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Massachusetts Health Reform, From The Front Lines

Apr 12, 2012

For six years, my fellow physicians in Massachusetts have been working under a health reform law that, for better or worse, bears a strong resemblance to the national law that is two years old.

Young

While some commentators may be surprised that our health care system is still standing, I can assure you that things here are going reasonably well. We're still practicing medicine, patients are still getting good care and life is continuing without undue disruption.

Nonetheless, life has changed since the law took effect in October 2006 for those who provide care, those who receive it and those who pay for it.

Massachusetts Payment Reform

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The numbers are well known. Many more people are insured. While we struggle with a primary care physician shortage like the rest of the states, significantly more people, especially those in disadvantaged communities, have a regular health care provider.

We also continue to struggle with rising costs -- which is not a new phenomenon. Massachusetts has been a high-cost state for a long time, and it has nothing to do with our health reform law. But with many more people in the system, it's more important than ever to do something about it.

But aside from the numbers, what has it been like to experience the Massachusetts health care system since 2006? At first, we saw an upsurge in new patients -- people we had never seen before. We were concerned these new patients would overwhelm practices, especially those in urban areas, but it wasn't as huge a problem as some feared. It was very helpful that the state promised to close the gap between Medicaid and commercial insurer rates, because most of these new patients were covered by Medicaid.

These new patients frequently presented with complex, chronic health conditions such as hypertension, and many hadn't received the regular treatment they needed. So with these patients, we had some catching up to do, but this catch-up period didn't last forever.

To meet the new level of demand, many practices found it very helpful to hire physician assistants, nurse practitioners and other allied health professionals to help them improve the daily operations of the practice. Most patient visits require relatively simple interventions, while others are more complex. These health professionals can help physicians focus more of their time on the most complex and demanding visits.

Meanwhile, we initially thought that once everyone (or almost everyone) was insured, we would never have to talk about money with our patients again. In fact, these conversations are still happening, but they are of a different nature. More of our patients have high-deductible plans, high co-payments or limited network plans. These realities have prompted many of them to ask pointed questions about the cost of a procedure or a test, because they're on the hook for more of the cost. This trend can go too far in the other direction, but it's not always a bad conversation for a physician to have with a patient.

These conversations often lead patients to ask about the effectiveness and value of our interventions. Fewer patients are now willing to accept a physician's advice at face value. We often must provide evidence for why going to a different hospital, undergoing a simpler procedure, or getting a less expensive test, will produce the same or even better results.

Even if the Supreme Court overturns the federal health law, health care delivery in the United States will never be the same. Accountable care organizations are here to stay. Electronic health records won't go away, and they will get better and better. Hospitals, physicians and other health care providers are working together more, and market consolidation is occurring under our feet. The Affordable Care Act merely hastened the process, and added momentum to the changes we've been seeing in Massachusetts, too.

Will our experiences in Massachusetts be the same as physicians in other states? Maybe not. Health care delivery can be a local phenomenon, so experiences are bound to vary. But for us in Massachusetts, we are keenly aware that while health reform still presents many challenges, its benefits are very tangible.

Lynda M. Young, MD, is pediatrician from Worcester, Mass., and is president of the Massachusetts Medical Society, the state's professional association of physicians.

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