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Worcester Medicine
Physician Tiering
Tiered Insurance
Products: Buyer Beware Payer Perspective Why Change? As I See It Science Corner Off Call Book Review: The Biology
of Cancer by Robert A. Weinberg; Garland Science, 2007 Legal Consult Financial Advice of
Physicians In Memoriam Society Snippets Editorial: A Light at the
End of the Tunnel or an Oncoming Train? After reviewing the articles in this issue, three familiar sayings come to mind: “Everything is changing, even the status quo,” “Change is good…you go first,” and “When you come to a fork in the road, take it.” Physicians are now being tiered by a variety of measures. Bluecompare in Texas is using health care bills and health insurance claims, Regence Blueshield in Washington State used claims data as well. Other insurers are using outcome data in addition to claims data. Is the data accurate? Is the data based on enough patients? Is it severity adjusted? If we wait until the data is perfected, it will be too late, but not doing anything is not an option. As insurers publish more information on providers and rank them according to “quality” and “efficiency” factors, the hope is that physicians and groups will change their behavior. But is all the information really transparent (transparency is the hot buzzword in healthcare these days)? The answer is that it’s not transparent yet. Do providers have the ability to see how the data was generated so they can help improve the quality of the information? The answer once again is not yet. The system is moving towards more transparency with hospitals and providers, but there is a black hole with payers. Do providers really know the cost of care when ordering a test? The answer is no. Do we know if we order test X at one facility if it is less expensive than at facility Y? The cost of care is blinded from the person ordering the test. It’s like ordering a PC off the Internet and not knowing what the cost is, then billing someone else for the cost, and then being told that you are inefficient and spending too much. Maybe each payer should also publish the various rates it has contractually arranged with each facility and ancillary services. This way the ordering providers and patients can make an informed decision of where to go, what medication to take and what the cost really is. Also, the brunt of “Pay for Performance” will be put on the shoulders of the primary care doctor, the highest volume, lowest paid provider in the healthcare system. If the primary care doctor is accountable for keeping the cost of care down, then primary care physicians need to know the actual cost of that care. Obviously, the system is not transparent at all. We have never really measured outcomes, therefore we are experimenting with the data to generate information and the real cost of that care is still hidden from those most affected ~ the patients and the ordering physicians using that service. So where does this lead us? P4P is happening, and so is tiering. Without question, we need better outcomes for our patients, but are we taking a collaborative approach? We are expecting providers to deliver better outcomes and efficiencies by creating a system based on partial information, unknown methodology ~ which is semi transparent ~ with no real data on the actual cost. And we are depending on the lowest paid, highest volume providers in the system to deliver these results…What is your definition of insanity?
Physician Tiering: Efficiency Rating or Economic Profiling? In an ever-changing market where the cost of healthcare is skyrocketing, a novel method to control health-care costs is “physician tiering.” In an attempt to marry cost and quality “efficiency,” the largest consumer of healthcare for the state of Massachusetts, the Group Insurance Commission (GIC), contracted with independent consulting firm Symmetry Health to use a proprietary technology they had developed, “Episode Treatment Groups” (ETGs), to categorize physicians into various classes ~ or “tiers” ~ depending on how efficiently they used resources to manage a particular episode or problem. The most significant criteria in this particular methodology are the cost of delivering care and the rating of a physician as more “efficient” if he/she is able to achieve the same outcome as another physician at a lower cost. The concept of lower-cost healthcare or cost-effective healthcare is not novel. With the increasing burden in the cost of healthcare both to the consumer and to the payor, it becomes incumbent on all who participate in the healthcare system to help responsibly manage assets and exercise fiduciary restraint on the utilization of resources. When tiering was introduced, physicians were opposed to the methodology and therefore were viewed as being against any form of quality improvement or cost constraints. Proponents of the current tiering system would argue that given the need to manage resources efficiently, consumers of healthcare should be given the option of choosing to have their care provided by a "more efficient" physician, ie one who is able to provide the same outcome at a lower cost than another physician in the same specialty and geographic location. Further, a number of consumers feel that they do not have the option to delay rising deductibles, co-insurance, and co-pays until perfect physician cost and quality measurement data is available. The inaffordability of rising healthcare costs makes it contingent on the healthcare system to provide any and all information to its consumers so that they can make informed decisions, albeit based on cost as a significant criterion. Opponents of the tiering system argue that the current methodology of measurement uses claims-based data which was only intended to provide a basis for reimbursement for services, not to represent the quality of the healthcare delivered. Consequently, there are serious limitations and opportunities for inaccuracies when using administrative data submitted primarily for reimbursement purposes to determine the quality and efficiency of care provided by physicians. The current methodology being used has several limitations, the most significant being the definition of a physician specialty, the attribution of an expected cost to an episode, the sample size in terms of the number of episodes being evaluated, and attribution rules such as which physician takes responsibility for the major costs in an episode given that care to a patient is provided by a multitude of physicians representing a variety of specialties. In addition to the inaccuracies of developing the ETG-based system of tiering, there are other difficulties with the concept as developed. Physicians with no prior practice history are placed in a higher tier by default. Thus, physicians in the same group may be in different tiers, purely because of the presence or absence of prior practice history. Of greater significance, new graduates starting a practice would be placed in a higher tier, making it virtually impossible for them to grow and survive in practice. Further, by having physicians within the same group belong to different tiers, patients would be left with the uncomfortable dilemma of having to break established relationships in order to migrate to a physician in a lower tier, even if that physician is a colleague in the same group. Lastly, in specialties where there is a relative dearth of physicians, patients would be forced to pay a higher premium to see such physicians irrespective of their tier due to geographic or other constraints. For these and many other reasons, physicians and other healthcare providers are concerned about the potential disruption to longitudinal care that this may represent, with all of its unintended consequences. Additionally, a number of health plans that contemplated following GIC’s footsteps have hastily rescinded their plans for implementation in response to such concerns. In summary, the concept of cost constraints and improved efficiency in the delivery of healthcare is absolutely vital to the survival of the healthcare system. There is no doubt that the advent of electronic technology, access to evidence-based resources on the web and attempts to create “electronic communities” between physician offices and hospitals so as to prevent duplication of resources all represent major advances in the efficiency and safety of the healthcare system. To that effect, any reluctance by physicians to embrace such progress would be viewed as unjustified. However, in the absence of such a "perfect" world, using whatever imperfect methodology exists to come to those same conclusions in efficiency and quality in the absence of a rigorous and transparent methodology runs the risk of creating further constraints on healthcare resources and an inequitable burden on consumers of healthcare. As we stand on the threshold of a challenging and "stressful" time in the healthcare system in the US today, I am reminded of the words of Henry Wadsworth Longfellow: “It's not joy and not sorrow that's our destined end or
way
Tiered Insurance Products: Buyer Beware Health insurance companies are introducing “tiered” insurance products in response to employers’ frustrations with ever-increasing insurance premiums. Essentially, tiering is the sorting of products and services into categories defined along cost or quality dimensions, or both. Tiering may apply to prescription drugs, hospital services, or physician services. Consumers ~ namely health insurance subscribers or patients ~ face financial rewards or penalties intended to drive them to choose products or services assigned to lower-cost and/or higher-quality tiers. These incentives may be in the form of higher or lower co-payments or deductibles at the point of service. These incentives may also appear when consumers choose a health insurance plan. Premiums may be higher or lower for plans depending on the cost or quality scores assigned to the hospitals or physicians covered by the plan. Tiering is grounded in the belief that market forces driven by consumer decisions can prod health care providers to become more cost efficient and to improve the quality of care. It is one variant of the broader “consumer-driven” health care movement. Tiered insurance products have sparked controversy about their promise, performance, and potential unintended consequences. It is not possible to address them all in this brief space, but among the most important issues for consumers and health care providers is the soundness of the quality and cost evaluations on which the tiers are based. If tiered insurance products are to be useful to consumers and effective in achieving their goals, they must be fair to health care providers. How so? Fairness to providers means they must be accurate in their assessment of provider costs and quality. But how are we to know that? First, health insurers must be transparent about the methods and data sources that they use to assess and classify providers. Proprietary, black-box methods should be rejected by employers, consumers, and providers. Detailed information about data sources and methodology used by insurers must be made available to providers and independent analysts, who may then assess the accuracy of the underlying data and scientific rigor of the evaluation and classification methods. Similarly, health insurers have a responsibility to seek the input of those they are evaluating and of independent experts in their tiering designs. Responsible challenges to the data and methods, and information about their strengths and weaknesses, should be made available to purchasers and consumers. Preconceived notions of a quota or share of providers per tier should not determine a provider’s assignment to a tier. Only meaningful differences should count. Researchers use accepted statistical standards to assess if observed performance differences among providers are due to anything other than mere chance. In this regard, it is instructive to note that scientifically rigorous assessments of hospital cardiac bypass surgery mortality rates in Massachusetts and heart attack and heart failure mortality rates nationally found that very few hospitals could be judged to have better or worse than expected patient outcomes. It should go without saying that assessments of the quality of care should be based on the most accurate information possible. The most accurate information about the care delivered to patients, and patients’ conditions or risk factors that affect the chances for good outcomes, comes from patient medical records. Yet, increasingly, provider assessments are based on computerized billing records that were not designed for assessing care delivery. These billing records are known to contain important gaps and inaccuracies. Consumers should be skeptical of assessments based on billing records, often labeled as “administrative databases.” There are ways to judge if quality assessments on which tiering assignments are based are fair and sound. Perhaps the best indicator is the extent to which physicians, hospitals, and health services researchers have had meaningful roles in the design and evaluation of the underlying quality measures and methods. Hospitals, physicians, government, and purchaser representatives have collaborated under the umbrella of the national Hospital Quality Alliance to endorse and report an ever-expanding set of over two dozen measures of the quality of hospital care. You can view these reports at www.hospitalcompare.hhs.gov. These quantitative measures provide useful insights about the extent to which care delivery meets evidence-based standards of care, patient care outcomes, and the perceptions patients have regarding their care. Promising national collaborative efforts also have begun for the design and evaluation of physician care measures. Closer to home, physicians have had meaningful roles in cardiac surgery quality measures reported by the Massachusetts Department of Public Health/Harvard Medical School, and in physician performance measures reported by the Massachusetts Health Quality Partners. Tiered insurance products may prove to be a benefit or a bane for our health care system. The best advice as we embark down that road is familiar old advice ~ kick the tires and look under the hood before driving off the lot. Payer Perspective In the somewhat testy conflict between purchasers and providers about performance measures, it might be useful to remind all the parties that our differences are over means, not ends. All of us want health care that is high in quality, accessible to all, and affordable to those who pay, as well as fair to those who are being paid for their services. That having been said, disputes over means can get almost as heated as those over ends. Rather than focusing on the technical details of physician profiling, report cards, and tiered networks, this article will focus on the means being adopted by many purchasers, and the reasons why they are moving in a direction that they knew would arouse concern in the medical community. It is based on the optimistic hope that if we understood each other’s problems better, we might try harder to work constructively together. Let me state the purchasers’ concerns with three short facts. One ~ the cost of covering a family for health care has gone up 87% since 2000. Two ~ last year alone, the cost of care went up 7.7%, twice the rate of inflation. Three ~ no one, in or out of the medical community, has refuted the findings of the IOM reports of 1999, 2001 dates and 2003, or the Rand Report on quality shortcomings. It is what are the right means to address these problems that are unraveling the employer-based health insurance system and damaging America’s position in the global economy that is in dispute. I think it is not unfair to note that it is purchasers, rather than providers, that have pushed for solutions with a real sense of urgency. While there are many laudable quality initiatives sponsored by various professional groups, none calls for immediate action to address unacceptable variances in quality and resource utilization. Time is not our friend. It is our enemy. And yet, the physician community has not made cost control a major organizational priority even though your help is desperately needed. Purchasers have gone ahead and adopted a range of programs to deal with cost and quality issues, but none of them has met with much enthusiasm from providers. Whether it is Pay for Performance, consumer directed health plans, report cards, or tiered networks, these proposals share the belief that making information about the cost and quality of provider services is essential if our employees and retirees are to participate in addressing either cost or quality issues. Whether labeled consumerism or transparency, all of these measures collect data about physician behavior ~ and make it available to employees so that they can use medical care better informed than they are today. Some physicians remain opposed to the idea of sharing quality data with the public. Most of the argument centers on the assertion that the data are not good enough, accurate enough, fair enough, or comprehensive enough to put in the public domain. This writer believes that until the data are in the public domain, whatever inadequacies they contain will never be identified and improved ~ physicians will have insufficient incentive to take the time to analyze their ratings and raise issues or disagreements, and purchasers will not keep on funding analytical studies that will not be put to practical use. The experience of the Group Insurance Commission in implementing its Clinical Performance Improvement Initiative over the past four years bears out this contention. It was only when the data were put into operation to tier physician networks by our six plans that they got any scrutiny that will make them better ~ more useful ~ more user friendly ~ as well as, I hope, more acceptable to physicians themselves. Physician comfort levels should go up as these various programs become more common ~ as they will. Ch. 58 ~ the Massachusetts Health Reform Act ~ mandates a Quality and Cost Council charged with publicizing cost and quality measures. CMS has pilot programs all over the country to the same end. NCQA is working on its own approach to physician profiling. And, of course, there are many commercial Internet sites of widely variable quality. It would seem to me that working with Massachusetts purchasers to participate in ongoing improvement of performance measures is a far more productive route than fighting them. Most purchasers want to offer their enrollees a broad choice of providers. They also want to pay for the highest quality at the most reasonable costs. Should their efforts to guide their enrollees toward these qualities fail, they will either resort to more cost shifting, select narrow networks that will exclude many providers, or drop coverage altogether. Those alternatives would surely not be in the interest of either patients or providers. I urge the readers of this journal to work with us to make provider profiling as good as it can be. Why Change? The ways that we deliver health care are changing ~ and for good reason. For generations, doctors have been accustomed to treating their patients one at a time and one visit at a time, usually for acute conditions. As a result of healthier lifestyles and better medicine, patients are living longer than ever, but they commonly have chronic diseases that require a schedule of care over years. Today about half of patients over 50 have at least one chronic ailment and twenty percent have five or more. Diabetics may see ten different providers of health care services- each at different times and in different locations. All of this means that there is a greater need than ever for information to move with the patient and for the primary care physician to provide a coordinating center for the patient’s care. This means not only knowing what services patients have had, but knowing what services they need and being able to conduct outreach to assure that patients have an opportunity to receive the best care possible. Today’s health care is based on an acute care model. A patient is seen by a physician, assessed and treated based on that physician’s knowledge of the problem at that time. To meet the challenge of treating chronic disease, we have to incorporate several different items into our routines. We have to agree on and update guidelines for the treatment of chronic conditions. We have to know who our patients are. We have to know what conditions they have. We have to know what services they are due to receive. And we have to conduct outreach to alert them and arrange for them to have the services. As it is, patients with chronic illnesses receive about half of the care that is recommended. Here in Massachusetts we are a bit ahead of the curve and tend to score at about the 90th percentile compared to the rest of the country ~ but that does not mean that 90% of our patients are getting recommended care; indeed, for some services the number may be well under half. About half of offices send reminders to patients and less than a quarter track testing and referrals to be sure that reports are received. Mostly we tend to depend on our patients to remember. A typical, healthy woman at age 50 may need a blood pressure check and breast exam every year, a mammogram every year, a Pap smear every three years, a cholesterol check every five years and a colonoscopy every ten years as well as a variety of vaccines at different intervals. All of these may need to take place at multiple locations and with different providers. Since patients, especially healthy ones, do not consider themselves to be patients, it is not hard to imagine that this testing is not on their mind very often and that things can be forgotten. Today, “Pay for Performance” is an attempt by insurers to incentivize physicians to put in place systems to enable primary care doctors to track and conduct outreach. There is no doubt that the measures and the methodology that they use contain flaws. But, the extra dollars in these programs, as well as the extra revenues resulting from timely appointments, can bring into offices the technology that is needed to upgrade the system. When physician offices are using their own data and running their own reports, both patient care and the data that insurers use for their programs will improve.
As I See It: A Medical/Art History/Mystery Story Looking out over New Jersey’s Ramapo Mountains, the air was unusually clear the night my mother told me her ghost story. Only this was not a camping trip in the 1960s when I might have been expected to have such a tale spun for me. This was one week after the death of my father, and I was a grown-up listening to my now widowed mom relate a tale that had been haunting her for over 60 years. She was feeling especially weary after a week of mourning during which many friends and neighbors had come to pay their respects after my Dad’s passing. My mother told me that she had seldom in her long lifetime felt this fatigued, but the weariness called to mind another time in her life when one particular image helped her cope with exhaustion. My Mom was 13 when her parents in Vienna, Austria, sent her away from the Nazi storm engulfing her native land to the presumed “safety” of the Netherlands on a “Kindertransport,” an evacuation of children by rail to a detention camp where refugees were clustered until the storm blew over. As part of that program, each refugee child was assigned a Dutch foster family, where at least on a weekly basis the host family would cook a decent meal for their foreign visitors. In return, these children frequently did chores for their foster family. From one week to the next, the children never knew if they’d be allowed to visit again. They also wondered if they’d ever again return to their native lands to see their parents. My Mom was assigned to one such foster family, the Bellenfantes, who were well-to-do Jewish booksellers in a seaside town of Scheveningen. At the close of her weekends at their large mansion-like abode, my mom would be told to wait in a study ‘til the transport back to her refugee camp arrived. There my Mom would stare at a painting hanging on the wall. It depicted an elderly woman wearing a red kerchief on her head and seated on a log in a forest clearing. On her back, she carried a quiver of twigs to help build a fire. There was a tremendous sense of weariness conveyed in the face of this elderly woman, and it was my Mom’s shared sense of exhaustion that comforted her back then. Though I had never seen the painting, Mom’s vivid description of this elderly woman made me feel that I could visualize it, and I became smitten with the notion of somehow seeing it for myself. I asked her what had happened to the Bellenfantes and the painting. My mom continued with her ghost story, and what came next shocked me. When the 2nd World War erupted, the Dutch Government locked down the camp so further trips to visit the Bellenfantes and the painting were made impossible. Later, in 1940, when the Nazis overran Holland, the camp was converted into a concentration and transport camp, with a direct rail line to Auschwitz to the East. Over the next 5 Years, 7000 Dutch, German, and Western European Jews ~ including, amongst others, Anne Frank ~ were shipped out weekly to their deaths in that camp. A total of close to 300,000 perished. What became of the Bellenfantes, my mom did not know. She and my dad were fortunate people, two of only 5000 who survived the camp by war’s end. She went back to Scheveningen to find them shortly after the war, but the house was empty. As for the “Old Woman,” my Mom did see her one more time. By 1943, my Mom had survived in Camp Westerbork (as it was called) because she had been trained as a nurse for the camp infirmary. She was sent to tend to some medical issues at the SS Headquarters in the town of Velp with a medical team. While waiting for a transport back to the camp, she was told to wait in the SS Commandant’s office. There on the wall hung the painting of the “Old Woman Carrying Sticks.” This told her that the likely fate of the Bellenfantes was that they had not escaped the trains East. That was the last time she viewed that painting, but its image was seared in her memory and somehow surfaced again now in this time of grief and pain here in New Jersey, where she had settled after emigrating to the U.S. in 1946. Now she could only wonder if the ”Old Woman Carrying Sticks” had also survived after so many years. After returning to Worcester to resume my own life as a UMass pediatric surgeon, Mom’s tale inspired me to try to learn some of the answers to the questions we had discussed looking out on the Jersey landscape that night. I “Googled” “Old Woman Carrying Sticks” to no avail, and could not get any more information about the painting or the Bellenfante family. One afternoon, I was enjoying a cup of coffee with my friend and colleague Kate Erwin, the Chief of the Child Psychiatric Liaison/Consultation Service at our Children’s Medical Center. Kate was having the kind of day that caused her to lament that some days she wished she had remained an art historian rather than pursuing medicine. “Art Historian?!?” I asked incredulously. “Why, yes,” she replied. “My grandfather was Grenville Winthrop, the art collector whose endowment of 4300 paintings to Harvard University founded the Fogg Museum there. I guess it’s in my blood.” I could barely contain myself as I realized that here in this wonderful medical colleague, I might very well have an individual with the skill-set to help me unravel my art history mystery. I related the tale to Kate. She barely let me finish before saying, “Mike, come with me, we’ve got to get to a PC.” We went from the Cafeteria to the first PC terminal we could find, and Kate eagerly sat at the keyboard Googling something different than I had. “Woman Carrying Faggots” she entered, taking advantage of her knowledge of the use of the term faggot for “kindling wood” in the 19th century. Lo and behold, a painting by Mihaly Munkacsy flashed up on the screen. Though I had never seen the painting before, this was the image I had conjured in my mind’s eye when my mom had told her haunting story. I learned the painting had been created in 1870, and that its creator was Dutch-born Johan Liep (1840-1900), who had eventually moved to Budapest and assumed a Hungarian name. He was widely considered the greatest Hungarian artist, making his fame from depictions of the life of Christ in his later years. The most astounding thing is that indeed the painting had, like my Mom, survived World War II! It was hanging in the National Art Museum in Budapest. I still could not be sure that the painting Kate had found was the one my Mom remembered, but that part of the mystery was cleared up when Mom came to visit us over Thanksgiving. I sat with her during a quiet moment together and asked her if she recalled our conversation about the “Old Woman.” She did indeed, and I told her of my forensic journey with Kate. I told her I thought we had found the painting and that it was OK. I pushed the button on my keyboard console to produce the painting for her. She gasped as she saw it, and a tear welled up in her eye as she said softly, “That’s her.” After gazing upon it for a while, my mom reminded me of the other part of this mystery. How did it get to Budapest? What happened to the Bellenfante family that owned it? Is this another case of stolen art that was hanging in a museum without proper compensation to the rightful owners? I had no answers for these questions, but any further Googling to find the answers would depend on a knowledge of Dutch. Believe it or not, just as the Worcester medical network had provided me with an art historian in the person of Dr. Kate Erwin, so too did the network provide me with a Dutch expert. My colleague and friend Dr. Stuart Weisberger is married to a native Netherlander, who, as it turns out, helps the Dutch government settle grievances for families wronged during the Second World War. Not only did Stuart lend his wife Lu’s expertise in this area, he himself is a talented photographer who used his considerable skill to provide me with a professional quality enlargement of the painting to present to my mother for the holidays. He not only created the enlargement, but had also helped me frame it in a museum-quality way. Though we still have not concluded our investigation into how the original painting made its way into the Budapest Museum, I am confident we will learn the answer soon. If there is an injustice to the Bellenfantes to correct, our little contingent of Worcester physicians will try to right the wrong. Meanwhile, in a condo in New Jersey hangs a beautiful replica that is once more providing comfort to an octogenarian who had been separated from this old friend for 63 years. You may wonder how this ghost story qualifies as an entry into the Medical History Column of Worcester Medicine. My life as a Worcester physician helped to unravel this mystery and provide this gift for my Mom. As I am sure you can guess, it was great to be able to ease the mind of the matriarch who has been “carrying the sticks” for my family for so many years. Science Corner: Tiered
Co-payment Systems and Their Impact on Drug Use and Expenditures Pharmacy benefit plans and payers use a variety of techniques to reduce drug use and expenditures; some are directed at prescribers, others at patients. Examples of tools aimed at altering providers’ prescribing patterns include formulary management, protocols for prescribing expensive medications, prior authorization for particular drugs, educational efforts, counter detailing and provider risk sharing.1 A tiered co-payment system (also referred to as tiered cost-sharing or tiered formulary) attempts to alter plan members’ prescription drug use. How does it work? A plan member pays a flat or fixed dollar amount (co-pay) for a prescription based upon the drug’s tier; the higher the tier, the higher the co-pay. A three-tiered formulary structure means that the drugs covered by a pharmacy benefit plan are divided into three categories with three co-pay levels, as shown below:
Several studies have shown that cost sharing mechanisms, such as co-payment programs, lead to cost savings for pharmacy benefit plans and payers.2-4,6-7 Co-payment systems encourage the use of drugs in Tier 1 as first-line therapy and discourage the use of drugs in the other tiers, especially Tier 3. Tier 1 primarily consists of generics that, on average, cost about 50% less than comparable brand-name drugs. Some plans require pharmacists to dispense generic drugs when they are available and legally permitted unless the physician specifies “no substitution” on the prescription or if a plan member requests the brand product. A plan hinders the latter by requiring the plan member to pay the difference in product cost plus the brand-name co-pay. For drugs that are not covered by the plan, a plan member may have to pay the full cost of the prescription. Plans also tweak the co-pay differentials among the tiers to drive the usage of lower tier drugs. Further, plans deter the use of Tier 3 drugs by requiring prior authorization or by encouraging therapeutic class switches. For example, prior authorization may be required before valsartan (Diovan®, a Tier 3 drug) can be prescribed for high blood pressure control. Alternatives to be considered include benazepril (a Tier 2 drug) or preferably captopril or lisinopril (Tier 1 drugs). The following table shows the average cost paid by MassHealth for selected prescription drugs in different tiers within the same therapeutic class, July-September 2006.5
* The co-pays for MassHealth are $1 for generics (Tier 1) and $3 for brand-name drugs (Tiers 2 and 3). Whenever more of the costs of prescription drugs are shifted to patients (through higher co-pays), there is always a concern that it may lead to decreased access and affordability of prescriptions drugs for some members, which in turn may lead to noncompliance with prescribed therapy, and, subsequently, to higher medical costs. Several studies have found that increased copayment requirements are associated with decreased use of prescription drugs and expenditures, even for chronic illnesses.3,4,6 Depending upon how much out-of-pocket costs increased, some plan members stopped filling their prescriptions for non-preferred brand-name (Tier 3) drugs such as ACE inhibitors, proton pump inhibitors (PPIs), and statins, as one study showed, although the researchers did not determine how this affected members’ health.7 Another study showed that adding another tier to a two-tier co-pay plan did not have an effect on the use of other medical resources (i.e., physician office visits, inpatient and emergency room use) at either the one-year or three-year follow up.3,4 A study of three-tiered pharmacy benefit plans found that patients who filled prescriptions for chronic illnesses with generic (Tier 1) or preferred brand-name (Tier 2) medications had greater adherence than those who received non-preferred brand-name medications (Tier 3).6 In summary, tiered copayment systems have been shown consistently to reduce prescription drug use and expenditures, primarily by steering patients (and physicians) away from non-preferred drugs toward preferred or generic drugs. What remains to be evaluated further are the unintended effects of such systems on the process of care (e.g. medication adherence, discontinuation) and health outcomes.8 References:
Off Call: Women in Medicine
Book Group “Be careful about reading health books. You may die of a misprint.” ~ Mark Twain In the fall of 2003, the Book Club of the Women’s Caucus of the Worcester District Medical Society convened for the first time, at the elegant District Headquarters in Mechanics Hall, to discuss Anne Fadiman’s The Spirit Catches You and You Fall Down. This beautifully written book provided a lively opportunity for women physicians to explore cross cultural medicine from both patient and caregiver perspectives. At that initial meeting we also considered what form the Book Group should take ~ what types of books would be appropriate, and how would we decide what book to read next? We operate with a consensus decision-making process, one that has worked surprisingly well. Initially, we intended to alternate strictly between medically relevant and more “secular” texts. Over time, we have found so many excellent books to choose from, and as physicians we somehow manage to make every text medically relevant. The Women’s Caucus Book Group presently has 22 members representing many disciplines ~ psychiatry, family medicine, internal medicine, pediatrics, pediatric cardiology, hospital medicine, Ob-Gyn, and ENT/surgery. We meet every two months or so (usually bypassing summer months altogether). Generally, 8-12 members attend a meeting, as our busy schedules do not permit all of us to be present simultaneously. The venue has also changed, due to the generosity of our members. We now meet in each other’s homes, and food has become nearly as important a feature as the book (not quite). For example, Annie Abraham recently hosted an evening where the book discussed was Rohinton Mistry’s A Fine Balance, a novel set in India in 1975. Annie’s hospitality included Indian cuisine ~ complete with a culinary lesson [see photo]. Other members who have hosted include Jane Lochrie, Anne Merritt, Lynda Young, Phyllis Pollack, Martha Waite, Ellen More, and the incomparable Joyce Cariglia. We meet to read books we would not otherwise know about or choose to read, and then to have the wonderful opportunity to discuss them. Some of books we have discussed include: Tracy Kidder’s book Mountains Beyond Mountains, about Paul Farmer’s quest from Boston to Haiti to build Partners in Health My Own Country, detailing Abraham Verghese’s experience as an ID doctor treating AIDS in rural Tennessee in the mid-1980s Hematologist/oncologist Jerome Groopman’s The Anatomy of Hope When You Don’t Fit the Mold, Make a New One, a collection of personal stories by and about women physicians, published by the Massachusetts Medical Society Every Mother is a Daughter, written by pediatrician Perri Klass and her mother, Sheila Solomon Klass My Sister’s Keeper, a novel by Jodi Picoult that examines the moral problem of being able to genetically engineer children to serve the health needs of others. As the NYU School of Medicine’s Medical Humanities mission statement notes, “Attention to literature and the arts helps to develop and nurture skills of observation, analysis, empathy, and self-reflection ~ skills that are essential for humane medical care.” We have found that reading literature allows us to deepen our sense of this connection between the humanities and the practice of medicine while enriching our lives personally and professionally. Here are some member comments, in their own words: “What I really liked was the opportunity to meet other women physicians outside of the work environment, to relax and enjoy each other’s company ~ to hear about their jobs and families, as well as their opinions about the book.” “I think the collegiality is wonderful. I so enjoyed discussing things on a different scale with colleagues, and was impressed by how well-read this group is!” “… a welcome time to be among other professional women in a very relaxed setting with good food and warm conversation even while we turn our attention to challenging moral and literary questions…” For me, the Book Group is a treasured group of colleagues and friends, bound together by books, ideas and medicine. In closing, I would like to share these words by the Canadian writer Margaret Atwood: “I suppose you could say that the real, hidden subject of a book group discussion is the book group members themselves. I think they are quite brave. They are ready to reveal, in semipublic, their own reactions, their own biases and doubts and convictions, and above all their own tastes; not everyone dares. The beauty of a book group for the members is that you don’t get passed or failed for your opinions.” Book Review: The Biology
of Cancer by Robert A. Weinberg; Garland Science, 2007 When a physician decides to communicate to basic biomedical researchers, the collective enterprise is rewarded (e.g. “Surgery of the Soul” by Joseph E. Murray). Like the phenomenon of counter-current distribution that underlies the physiology of kidney tubules, this goes both ways ~ sometimes a basic research scientist can cogently communicate to the clinician. Robert Weinberg is a cell biologist who studies cancer, and in this book he has undertaken to synthesize the subject both intra- and supra-discipline. The result is a work that is spectacularly sui generis, presenting an intellectually coherent view of cancer that is not only deeply analytical and broadly enabling, but derives even greater impact from the author’s extremely lucid expository style. Oncologists and pathologists know that cancers are progressive, going through stages of non-invasiveness (such as ductal carcinoma in situ, a relatively welcome diagnosis for thousands of women fearing worse), tumor mass expansion (sometimes interrupted by the beguiling phenomenon of indolence) and then, tragically all too often, frank metastatic disease. Weinberg advances a different concept of cancer progression, one rooted in gene action and the molecular biology of growth control. It is a framework that will provide insight for both the researcher and oncologist, and yet in no way collides with or diminishes the classical, clinical concept of tumor progression. Indeed, each of these two concepts, having distinct historical origins, now enables the other. Weinberg brings a Solomonic logic to cancer progression, presenting compelling evidence that these gene expression and cell biological stages are the causative factors underlying what surgeons, oncologists and pathologists see. All three such specialists should read this book; they will be richly rewarded. Reciprocally, basic cancer research scientists (of which I’m one) working on genes and molecules that control growth should not only read this book, but should also learn more about tumor biology ~ in order to properly bridge these two mutually reinforcing ways of viewing the cancer problem. The goal is not simply intellectual satisfaction in what was once a bicameral division of thinking. The goal is for us all to collaborate across the lab bench to the bedside in advancing the early detection and increasingly effective treatment of this scourge. The 1960s radical Abbie Hoffman grew up just down the street from my house, where I am writing this review in my study. To honor both him and Weinberg I paraphrase: Steal, borrow or buy, but by all means read this book. Legal Consult: Tiering
the Network The creation by insurers of “tiered” or selective networks of health care providers as an effort to encourage efficient and high-quality care is gaining momentum. As we know in Massachusetts, the Group Insurance Commission uses a variety of managed care entities’ tiered products for state employees, retirees and family members. The health care access and affordability law being rolled out currently also encourages the use of tiered networks for some of the new health insurance products that will be made available through the Commonwealth Health Insurance Connector Authority. These programs hold significant risk for physicians, and the experience of other states with similar programs is instructive. In Massachusetts, the GIC sponsors a number of so-called “Select & Save Plans” offered by various managed care organizations. Generally, these products impose a $5-$10 co-payment differential for office visits to physicians in different tiers, and a $50-$100 co-pay differential for inpatient admissions to hospitals in different tiers. There are no prohibitions on seeing providers in lower tiers. It is questionable that the co-payment differences themselves create a significant disincentive for patients to choose a particular provider, but placement in a disfavored tier may have a disproportionate impact on a patient’s perception of the provider’s quality and efficiency of care. Assignment of providers to a given tier in the GIC system is based upon quality and efficiency data. The quality data apparently is based on nationally recognized best clinical practices, e.g. annual eye examinations for diabetics. Efficiency is assessed by how many resources providers use in managing similar episodes of care. Similar measurements may be a significant part of Massachusetts’ health care reform. Although the new insurance products have not yet been specifically formulated, we can anticipate that the young adults coverage contemplated by the health care access law will likely include tiered provider networks, and that health plans receiving the Connector’s “Seal of Approval” will feature selective provider networks, mechanisms explicitly endorsed in the language of the new law. What can physicians do about being placed in a lower “tier?” Physicians in other states faced with similar programs have protested successfully to have such programs at least delayed. In Texas, Blue Cross and Blue Shield of Texas proposed a “BlueCompare” program which would assign physicians to one of three categories ~ “strongest performance,” “satisfactory performance,” or “threshold for recognition was not reached” ~ using evidence-based indicators for selected areas of practice. BlueCompare would also use an affordability scale comparing physicians in the same specialty and geographic area managing similar conditions as either less affordable, of average affordability, or more affordable than their peers. The Texas Medical Association complained that the quality ratings were based upon health care bills and health insurance claims and not upon medical record review. It also claimed that categorizing physicians as contemplated by BlueCompare would damage physician-patient relations. As a result of these complaints, Blue Cross and Blue Shield of Texas agreed to suspend the program and as of this writing it has not been implemented. In Washington State, physicians went further and sought legal redress against Regence Blueshield, which had sent letters last May to some of its patients informing them that their physicians were not going to be part of a new select network. The new network was to include only “…health care providers who deliver high quality, efficient care as determined by an assessment of the medical practice patterns and treatment costs, as compared to their peers.” The letter went on to say that Regence would evaluate the new select network annually, and “…providers will have the opportunity to improve the quality and efficiency of their practices, and become part of the network in the future.” The Washington State Medical Association filed suit, seeking an injunction to block implementation of the program as well as money damages. The Association claimed Regence’s program relied on claims data only and not on medical records, that some of the data used were as much as four years old, and that it relied on small sample sizes and did not distinguish adequately among differences in patient populations. Before the Association’s suit was filed, Regence announced that it would delay implementation of the select network but did not retract its characterization of some physicians as not meeting Regence’s quality and efficiency standards. The lawsuit claimed Regence had engaged in unfair and deceptive practices, thus violating Washington’s consumer protection statute; had libeled certain physicians; and had in effect de-credentialed certain physicians in violation of their provider agreements. The Association asked the court to prevent Regence from implementing the program and sought monetary damages for loss of good will, other economic losses related to the libelous statements and contractual breaches, and emotional distress suffered by physicians whose patients received Regence’s letter. At the end of last year, Regence announced it was discontinuing the select provider network, but not because of the lawsuit. The medical association praised the decision and announced that it would not drop the suit, instead continuing to seek monetary damages. Economic profiling, like pay for performance programs, seems to be an increasingly attractive tool for managing the efficiency and quality of health care. As Massachusetts rolls out new health insurance products under the health care access law, the need to offer affordable yet reasonably comprehensive plans will likely increase interest in this technique. Like PFP, however, the creation of tiered or selective networks may rely on quality and economic data that may be neither credible nor applicable. Physicians need to insist on early-stage involvement in the development of such programs and on increasing transparency on the part of health plans to explain and justify the data and methods used to place physicians in tiers. Failing that, physicians may have to seek legal redress. Financial
Advice for Physicians: Massachusetts Health Care Reform Plan: How It
Will Affect Your Group's Health Insurance On April 12, 2006, Governor Mitt Romney signed into law legislation that would provide nearly universal health care coverage to state residents. Full implementation of the Massachusetts Health Care Reform Plan is expected by July 1, 2007, though certain provisions (such as the fair share premium contribution requirement described below) may take effect sooner. Physicians who have thought about the changes this law will generate may have looked at it primarily from the perspective of its effect on practices as health care providers, but the Health Care Reform Plan will also affect physician practices in their capacity as employers. Much of this legislation is directed at businesses that have between ten and fifty full time employees. Physician practices are no exception. Practices with fewer than ten employees are exempt from most of the employer requirements of the law, but there’s a catch ~ your employees are still required to have health insurance coverage by July 1, 2007. Does that mean employers with more than ten full time employees are required to offer employer-sponsored insurance? No, but they are required to do certain things:
One of the key features of the new Massachusetts health care law is the creation of a quasi-government agency ~ referred to as the “Connector" ~ to facilitate the purchase of health insurance. If you want to offer an employer- sponsored health insurance plan via the Connector, you have the following options:
Many of the details of the new law are still being worked out and the information above may change. For updated information go to http://www.piam.com. In Memoriam: WDMS Remembers its Colleagues
Roland R. Caron, MD Dr. Roland R. Caron died Sunday December 10, 2006. He died after complications related to surgery for a brain aneurysm. During his last days his family gathered to comfort him and he died peacefully. His passing leaves a huge gap in the Worcester medical community. He was loved, respected and appreciated by the nurses, surgical and rehabilitation team members, physicians, and the thousands of patients he treated over his long and busy career. Almost everyone in Worcester had a family member or friend who was helped by Rollie. Everyone in the long line of those who came to pay respect at the funeral home had a story about his intelligence, wry good humor and kindness. He worked hard. He cared about his patients and treated them with dignity, honesty and respect. The medical community and his patients will miss him and honor him. He was married to Norma Caron, nee Tagliaferri, for fifty one wonderful years. He and Norma shared everything. They shared a love of caring for patients, their five children, their ten grandchildren, the French country home they lived in, their Pug dogs, their garden, gourmet food and wine collecting and tasting. Norma was the glue that held their family together and that made his office hum as a cohesive unit. They shared a love of life and a love of each other. Rollie was born and raised in Chicopee, MA and graduated from Massachusetts College of Pharmacy after attending Chicopee High School. He became a licensed pharmacist and then served overseas in the US Army. When he returned home, he attended Laval University Medical School in Quebec, where he got his MD degree. He came to Worcester in 1959 and completed a residency in orthopedics and stayed to build an enormous clinical practice. He worked at City Hospital, Hahnemann Hospital, and then UMass Memorial Hospital. After he phased out surgical orthopedics he continued to give valuable guidance to patients with bone and muscle illnesses. He was an esteemed resource for both lawyers and insurance companies because of his honesty and fairness. Despite the long hours he spent taking care of patients, he had other interests. He was an active member of St. Anne's Parish in Shrewsbury and was involved in many charitable events throughout the Worcester Diocese. He and Norma established the Christopher R. Caron scholarship fund at Assumption College. He joined Dr. Robert Ouellette in the founding of the prestigious Massachusetts Chapter of the Burgundy Wine Society, of which he was an officer. He is remembered fondly by the many charities, friends and medical coworkers with whom he shared his wine collection. He was an active member of the International Wine and Food Society and the Worcester Art Museum and was a founder of the Edna Hibel Society. He loved his garden and his Pug dogs. Rollie will be missed by those who knew him but he will be remembered by those of us who are physicians as a man who made us all a little prouder of our profession. By Ronald Dorris, MD Kenneth Farbman, MD Dr. Kenneth Farbman passed away on December 12, 2006 after a 2 ½ year battle with pancreatic cancer. Dr. Farbman practiced Internal Medicine with a subspecialty in Infectious Disease at Worcester City Hospital and then at UMass Memorial Health Care. He had a gentle and caring manner and was well loved by his patients, staff and colleagues. Dr. Farbman lectured on Infectious Disease at the University of Massachusetts Medical School and he precepted medical students and residents in his practice at 291 Lincoln St. He volunteered at the Worcester County House of Correction, treating AIDS patients and seeing other inmates for medical consultations as well. Dr. Farbman grew up in Revere, son of Benjamin and Pearl (Rickler) Farbman, immigrants from Russia and Lithuania. He attended Boston Latin School and then Brandeis University, where he decided to enter the field of Medicine. He attended Boston Latin School and then Brandeis University, where he decided to enter the field of Medicine. He graduated from Boston University Medical School and served his internship and residency at Maimonides Hospital and Boston City Hospital. He did his Infectious Disease fellowship at New England Medical Center. Upon the advice of his friend, Dr. Leonard Morse, he decided to start his practice at Worcester City Hospital, where he was a key figure on the medical staff until that hospital closed. He was an active member of the medical staff at UMass Memorial until he retired in 2004. Dr. Farbman married Marlene Glick and they enjoyed 46 years of a wonderful marriage. Dr. and Mrs. Farbman had three children: Deborah, David and Jeffrey. These children were fortunate to benefit from the integrity, honesty and love of their loving parents. In 2005, Dr. Farbman’s family honored him with a Lifetime Achievement Award. His colleagues also honored him in 2004 for his outstanding contributions to the practice of medicine at Worcester City and UMass Memorial Hospitals. Dr. Farbman was an active member of the Congregation Beth Israel and served for many years on its Board of Directors. After retirement, he devoted time to his family and also took up art and writing. During his battle with pancreatic cancer, he maintained an optimistic outlook and was an inspiration to those who cared for him. Dr. Farbman leaves his wife, Marlene; children, Deborah and Eric Rubenstein, David and Karen Farbman, and Jeffrey and Mary Farbman. He also leaves a brother, Albert Farbman, and six grandchildren. He will be greatly missed by his family, his colleagues, and by his many grateful patients. Memorial donations may be made to Rachel’s Table at 1160 Dickinson St., Springfield, MA 01108 or to Congregation Beth Israel at 26 Jamesbury Dr., Worcester, MA, 01609. By Mary Hawthorne, MD
Dr. Martin T. Feldman, pediatrician, of Leominster Dr. Martin T. Feldman of Leominster and Great Barrington died Sunday, July 30, 2007 after a courageous battle with cancer. He was 61 years old. He leaves his beloved wife and dearest friend, Geraldine (Garber) Feldman; his children, Joshua and Wendy Feldman of New York City, Sara and Jonathan Jacobson of Worcester, and Riva and Darren Wolkow of Atlanta, Georgia; his grandchildren Sophia Grace and Andrew Lev Jacobson of Worcester; his brother, Sol Feldman of Chicago; his parents-in-law, Max and Eleanor Garber of Lakeland, Florida; his brothers-in-law and their families; an aunt and uncle; and many cousins and nieces and nephews. He also leaves a very special friend, Amy Fishman of Cincinnati, Ohio, whose gift of blood stem cells gave him an additional eighteen months to enjoy his family. Dr. Feldman was born August 30, 1944, in New York City. He was the son of Noel and Lillian Feldman. A graduate of the school’s strenuous six-year program, he received a bachelor of arts and a medical degree from Boston University in 1968. He completed both his internship and residency at Boston City Hospital, and then, with the rank of Major, served as Chief of Pediatrics and Chief of Hospital Services at Little Rock Air Force Base in Arkansas. In 1973, Dr. Feldman and his wife moved to Leominster, where he joined the staff of Leominster Hospital (later HealthAlliance Hospital), an association that continued until his death. He became the chairman of the Department of Pediatrics in 1985. Over the years he also held many other positions at the hospital, including president and treasurer of the medical and dental staff. He was a longtime member of the hospital’s Quality Assurance Committee which he chaired from 1982 to 1985; he also chaired its Credentials Committee and was a member of its Long Range Planning Committee and Child Abuse Committee, serving on its Executive Committee for more than twenty years. He was a trustee of Leominster Health System from 1988 to 1991 and was appointed a trustee of the hospital in 1993. He was a board member (from 1994) and president (2000) of HealthAlliance with Physicians. And in 2001, he was appointed a trustee of Central New England Healthcare System. In June 2002, Dr. Feldman received the hospital’s Distinguished Physician Award in recognition of his “…setting the standard for the practice of medicine.” Shortly after coming to Leominster, Dr. Feldman formed Medical Associates Pediatrics, a medical practice that grew from two pediatricians in 1974 to eight pediatricians and three nurse practitioners in 2006. He was president of the group until 2003, when illness forced him to curtail his duties. Dr. Feldman’s commitment to children in Central Massachusetts was also evidenced by his role as school physician in Leominster, Lancaster, and the FLLAC Collaborative, and by his participation in Project FIND, HeadStart, and the North County Neurodevelopment Clinic. In addition, he was a member of the Governor’s Council on Mental Health and Retardation (1975–1978) and a physician advisor to Friends of the Retarded (1976–1977). In the thirty-plus years he practiced medicine, Dr. Feldman witnessed enormous change in the health care environment. Aware of the impact those changes would have on his patients, he took an active part in protecting them. He was a board member of the Central Mass. Health Care Foundation (1983–1993) and a trustee of the Central Mass. Health Maintenance Organization (from 1982). In 2004, he received the Community Clinician of the Year Award from the Worcester North District Medical Society, a division of the Massachusetts Medical Society. At the ceremony, the society cited Dr. Feldman’s thirty-year contribution to children and the community. In 2005, he received a citation of merit from the Spanish American Center of Leominster for his devotion and service to the community. Finally, Dr. Feldman recognized the importance of passing on knowledge to new generations of medical practitioners. For twenty-three years, he was a preceptor of third-year students at Boston University School of Medicine and was appointed an assistant clinical professor at the school in 1995. In 1988 he began a long-term association with the University of Massachusetts Medical School as an assistant professor and then an associate professor of clinical pediatrics, and as a preceptor of its residency program. In 2001, the medical school recognized Dr. Feldman’s skills as an educator with its Award of Excellence. Dr. Feldman was a longtime member of Congregation Agudat Achim in Leominster. He and his wife established a fund at the Leominster Public Library for the purchase of children’s books. Marty had enormous curiosity: he was an avid reader and traveled all over the world, including to Russia, the Far East, and Iceland. When he died, he was planning a trip to New Zealand. He enjoyed theatre and dance. He took pleasure in good food and good wine, and, with Geri, loved opening his home to family and friends for holidays and special celebrations. But what mattered most to him was his wife, his children, and his grandchildren. Marrying Geri, he once said in an interview, was “…his greatest accomplishment in life.” And his “proudest” was his children.
Obituary submitted to Worcester
Medicine by The First Annual Louis A. Cottle Medical Education Seminar From Socrates to S.O.D.I.U.M.*: The Dying Experience in Worcester Wednesday, March 21, 2007 Speakers Dennis Batey, M.D., Chair of the
Central MA Partnership to Improve Care at the End of Life, Inc., and Recognition of H. Brownell Wheeler, M.D. on this 10th anniversary of Dr. Wheeler’s 1997 WDMS Oration, entitled “Socrates, Einstein & the Worcester District Medical Society” Seminar Goal Registration Fee One AMA PTA Category 1
Credit™ To Register Sponsored By |
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