September 04, 2008

Massachusetts Health Care Reform--Act 2

Why isn’t everyone talking about the new Massachusetts Health Care Reform law? Is it that the Governor signed the legislation into law during the dog days of summer? Is it that the act, which introduces cost containment measures and quality improvement measures, isn’t a single issue bill like the first health care reform law, which expanded coverage to almost all Massachusetts residents?
The “Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care,” (S2863) is an important piece of legislation which should be getting a great deal more local and national attention than it has. But for all its virtues, it also has some major flaws—and it won’t make much of a dent in the skyrocketing cost of health care.
The law calls for two new programs: a pharmacy drug detailing program and a health care workforce center. The detailing program is modeled on an intervention proposed by Harvard researchers Jerry Avorn and Stephen Soumerai 25 years ago: they wondered whether the same kind of clever strategies used by drug companies to promote their wares could be used to provide physicians with accurate information about the safety and cost-effectiveness of drugs by using trained pharmacists as “un-sales reps.” Their 4-state randomized trial found that academic detail men were accepted by the overwhelming majority of physicians—and that the program saved $2 for every $1 in costs (Jerome Avorn and Stephen Soumerai, “Improving Drug-Therapy Decisions Through Educational Outreach. A Randomized Controlled Trial of Academically Based ‘Detailing,” New England Journal of Medicine 1983; 308: 1457-63). With the new health reform law, the Massachusetts Department of Public Health has been charged with arranging face to face visits to “inform prescribers about drug marketing intended to circumvent competition from generics.” How effective this strategy will be in 2008 is unclear, now that drug companies are not only targeting physicians but are also pouring money into direct-to-consumer advertising.
The law also calls for the establishment of a Health Care Workforce Center whose main purpose is to increase the number of primary care physicians in the state. Specifically, the program will set up a loan repayment program for doctors who go into primary care. A related part of the bill requires the University of Massachusetts Medical School to increase its enrollment, to add residency slots for primary care, and to waive tuition for applicants who agree to practice in under-served areas. Taking steps to enhance primary care is laudable, but as demonstrated in the recent Institute of Medicine Report, Retooling for An Aging America: Building the Health Care Workforce (see my blog entry, “the Boomers are Coming, the Boomers are Coming,” from May 9, 2008), what we desperately need is not just primary care physicians and nurses, but also a diverse array of individuals equipped to care for our growing geriatric population.
One of the few provisions of the new law that did garner quite a bit of attention is the “gift ban,” which requires health care providers to publicly report any gifts they receive from pharmaceutical or medical device manufacturing companies and which bans certain kinds of gifts altogether. Drug companies protested loudly, but as Dr. Jerome Kassirer argued in his book, On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Life ( NY: Oxford University Press, 2005), the standards promulgated under the law constitute are not radical or draconian: they simply represent a basic, ethically justifiable set of guidelines for corporate and professional conduct.
Massachusetts Health Reform, Act 2 contains a hodgepodge of other provisions designed to improve quality and efficiency of care. It requires hospitals to develop rapid response teams for “deteriorating patients,” a measure that could lead to the installation of “panic buttons” in every patient room—not necessarily a good idea. The concerns of families need to be respected and addressed, but surely it should be professional judgment and not anxious families that dictate the summoning of an emergency response team. The act will require hospitals to implement computerized physician order entry systems by 2012 and electronic medical records by 2005—which is probably a good thing, but not as well-supported by hard evidence as I would like. As Drs. Pamela Hartzband and Jerome Groopman argue in their essay, “Off the Record: Avoiding the Pitfalls of Going Electronic” (New England Journal of Medicine 2008; 358: 1656-8), electronic medical records can “constrain creative clinical thinking” and computers can “become a barrier between patients and physicians.” And the act calls for new initiatives in end of life care and in home care—laudable but at this point vague and without substance.
All these components of the new law focus on improving the efficiency and quality of medical care. The only measure that seeks to control costs by actually changing the way we do things in medicine, not merely by ensuring that we do what we have been doing but with greater efficiency, is the requirement that physicians wishing to build ambulatory surgery centers apply for and receive a “Determination of Need” certificate. The engine that drives costs is technology and right now hospitals and medical groups can build new outpatient centers for doing procedures with essentially no restrictions. And in medicine, if you build a new machine, it will be used, regardless of whether one more scanner or surgical suite actually improves the population’s health. Dr. John Wennberg of Dartmouth, who has devoted his career to the exploration of regional variations in American health care, has found repeatedly that the number of elective procedures in various parts of the country depends not on need but on the capacity to perform those procedures (see for example John Wennberg and Alan Gittlesohn, “Small Area Variation in Health Care Delivery,” Science 1973; 182: 1102-8). Controlling the untrammeled growth of technology by evaluating the need for the centers that house that technology has the potential to have an enormous effect on the future cost of medical care. The caveat is that the legislation needs to have teeth, and it is unclear how the requirement that ambulatory surgical centers demonstrate “need” will play out: how is “need” to be defined and measured? Will the cost of the center be a consideration or if there is “need” (read “demand”), is any cost acceptable? Unfortunately, current Massachusetts Determination of Need regulations for hospitals include no such considerations.
Massachusetts Health Care Reform—Act 2 is an important step in the right direction. But if we want to truly change the way health care is delivered and provide high quality care at an affordable cost, we better start working on Massachusetts Health Care Reform—Act 3.

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