The
Massachusetts Medical Society, on behalf of over 25,000 physicians and medical
students, appreciates the opportunity to provide comment on this legislation.
The Medical Society applauds the Senate for continuing to promote policies that
support high-quality and high-value care in the Commonwealth. We have seen many
positive trends on the cost front, including attainment of the cost benchmark
again this year, and data suggesting that Massachusetts has exhibited some of
the strongest containment of rates of health care growth in the country over
the past five years. Physicians in Massachusetts play a central role in
containing health care costs. For example, this was the fourth consecutive year
that total medical expenses for physician services grew less than 2 percent,
and grew slower than overall spending, an important contributing factor in the
Commonwealth’s ability to beat its per capita health care cost growth
benchmark. However, despite these positive trends, we also appreciate the increasing toll that health care
costs are taking on physicians and their patients. Rising premiums,
deductibles, drug costs, and constraints on physician time with their patients all
point to the need for thoughtful health care cost containment policies.
The
Medical Society has long recognized that increasing the value of care—that is,
providing high-quality care as efficiently as possible—allows the healthcare
budget in the Commonwealth to stretch farther, thereby improving access to care
for patients throughout the state. The Medical Society commends the Senate’s
efforts to make legislative changes in pursuit of this shared goal. We urge
caution, however, in determining the degree of those changes, in light of both
the aforementioned positive trends in healthcare costs in Massachusetts and the
present uncertainty at the federal level, which has already caused significant
market instability. The legislature has already enacted a complex and
fine-tuned legal framework to ensure that patients in the Massachusetts receive
the high-value care for which the Commonwealth is renowned; and in such times,
using a scalpel rather than a sledgehammer is wise.
Quality Measure Alignment,
Prevention & Wellness Trust Fund, Drug Pricing Transparency
The
Medical Society commends the Senate, and offers its strong support, for
sections pertaining to quality measure alignment, the Prevention and Wellness
Trust Fund, and enhanced transparency for pharmaceutical manufacturers and
pharmacy benefit managers. We believe that each of these proposals represent
imminently thoughtful policies that address very specific areas of concern on
the health care cost front in Massachusetts.
The
establishment of a Task Force on Quality Measurement is an important step
toward improving quality and strengthening Massachusetts health system
performance. The Medical Society is grateful for your commitment to achieving
standardized quality measures across payers through Section 2 of the bill, as
this is an important step toward improved transparency, efficiency and,
ultimately quality, as we streamline the process and allow for comparisons
across plans and populations. We hear regularly about the burden on physician
practices that has resulted from the proliferation of competing quality
metrics, all with little benefits to patients. This Task Force represents an
important step forward, and we urge the Senate to continue to find ways to
promote the resulting aligned quality measure set as the exclusive or at least
predominant quality measure set across all payers in the Commonwealth.
The
Medical Society also commends the Senate for its longstanding commitment to
health care prevention, an essential component to evidence-based cost
containment. We strongly support Section 67 which reinstates the Prevention and
Wellness Trust Fund. The Medical Society believes that a far greater emphasis
should be placed on addressing social determinants of health. The
reestablishment of this Trust Fund creates the infrastructure for funding more
programs that focus on wellness and prevention, and which begin to address
social determinants of health- programs not often covered by traditional payers
and providers.
The
Medical Society has had longstanding, mounting concerns about the costs of
prescriptions drugs. Evidence shows rising pharmaceutical costs contribute
greatly to increases in total medical expenditures in the state; but, more
importantly, we also know that these increases are affecting patients and their
access to essential medications. We therefore strongly support the sections of
the legislation addressing pharmaceutical drug costs, and costs associated with
pharmacy benefit managers. While the state has made tremendous strides in
improving health care cost transparency and analysis over the past five years,
pharmaceutical cost analyses have always been shrouded in asterisks indicating
incomplete or insufficient data. The Medical Society therefore supports
sections 10, 12, 21, and 30, which all will make important improvements in
shining a light on pharmaceutical costs. Section 12, for example, which
requires individual pharmaceutical manufacturers and pharmacy benefit managers
to be required to participate, at HPC request, in the annual cost trends
hearings is an important step to ensure that pharmacy costs are no longer an
enigma. And the annual reports that will be put out by CHIA on pharmaceutical
and pharmacy benefit manager price and fee issues, and the commensurate
authority of the agency to obtain necessary data to complete these analyses, is
an essential step in deepening the understanding of this sector of healthcare,
to allow for further policy intervention if necessary.
Telemedicine
The
Massachusetts Medical Society wishes to express concern regarding the sections
of this bill dedicated to addressing telemedicine. The Medical Society was
dismayed to find that the telemedicine sections include neither a consistent
mandate for payers to provide coverage to patients for telemedicine services
when clinically appropriate, nor any assurances of adequate reimbursement when
those services are provided. Instead, the proposed language will largely codify
the status quo, and will only provide protections against issues that have not
been identified as problems in Massachusetts. This approach further contributes
to a patchwork system of insurance requirements in an already complex system
that many patients struggle to navigate and understand.
The
Medical Society was concerned to see the omission of a consistent telemedicine
coverage requirement for services that can appropriately be provided via
telemedicine. Such a provision would simply ensure coverage for telemedicine
services that would be covered if those same services were offered in an
in-person setting. Again, such policy would not constitute a mandate to cover
new services, but rather, a requirement to cover services across modalities,
regardless of whether those services are delivered in-person or via
telemedicine. The Center for Health Information and Analysis has determined
that a telemedicine bill with a coverage mandate, such as the one filed last
legislative session, would have a negligible impact on costs for insurers
because the number of services covered under such a bill would not increase, as
stated above.
Telemedicine
is an essential component of an efficient, high-quality, cost-effective
healthcare system truly serious about addressing the social determinants of
health and health inequity by providing access to care remotely for some of our
most marginalized populations. Unfortunately, the telemedicine provisions of
this bill represent a missed opportunity to expand access to telemedicine in
Massachusetts. Failure to propose laws that consistently assure coverage and
reimbursement for medically appropriate telemedicine services prevents
Massachusetts from realizing many possible improvements to access to high-value
medical care for persons with behavioral health needs, with mobility
challenges, for school age children, among many others.
Research
shows that ambiguous laws which do not provide coverage or reimbursement
mandates, such as the telemedicine provisions in this bill, impede the uptake
of telemedicine care. A recent report by the Milbank Memorial Fund, which
evaluated the impact on telehealth private payer laws, noted in its findings:
“Despite passage of telehealth private payer laws, expansion
of the use of telemedicine to deliver care has not moved as rapidly or
expansively as state policymakers may have envisioned. This could be due to the
ambiguous way most of these laws are written, often omitting critical language
that could encourage provider to utilize and be reimbursed for telehealth care.
This lack of clarity in the language of the private payer laws provides
discretion to the private payer to establish its own disparate policies that me
or not be restrictive, making it challenging for providers and patients to
understand and navigate.”[1]
This
point that telemedicine parity laws are needed to expand access to telemedicine
is further confirmed by a recent study in Health Affairs, which concluded that
states with telemedicine parity laws had a 20 percent higher rate of
utilization of telemental health than in states without such laws.[2] If
the legislature desires to expand access to telemedicine, data confirm that parity,
not ambiguity, is needed.
Specifically,
Section 99, which provides a coverage mandate for HMO products, is ineffective.
Coverage alone is not sufficient for facilitating an expansion of telemedicine,
as many insurers cover certain telemedicine services, but reimburse physicians
at a significantly reduced rate as compared to if the services were provided
in-person. These reduced telemedicine rates are not sustainable for clinical
practice, and cover neither the overhead costs of the technology nor the
physician time of the visit itself. With so many studies showing equivalent
quality outcomes for medical services provided via telemedicine as compared to
in-person, the reimbursement should not be substantially reduced simply because
of a differing modality.
The
Medical Society thus strongly supports reconsideration of the telemedicine
provisions in this bill to include consistent parity in payment for
telemedicine services, so that reimbursement is equivalent to the amount meted
out for medically appropriate care delivered in-person. That parity is needed
to correct present inequities in access to care, as reduced reimbursement for
care provided through telemedicine contributes to the limits to access to
high-quality care for vulnerable patients across the state of Massachusetts.
The
Medical Society urges the Senate to reconsider this approach to telemedicine,
and to instead revisit coverage and reimbursement provisions already put
forward filed, such as Senator Lewis’s Senate Bill 549.
Out-of-Network billing
The
Medical Society strongly opposes the out-of-network proposal contained in
Sections 22, 106, and 118 of this bill, which are unlike any other law passed
in the country. If passed, we believe that this legislation would have drastic negative
impacts on access to medical care in Massachusetts by giving payers unilateral
authority to underpay physicians for services provided to patients. The Medical
Society has long sought to end the situation whereby patients receive
unavoidable out-of-network bills. The Medical Society has crafted a legislative
proposal which we believe would achieve all of the patient protections laid out
in these sections, by establishing a formula that promotes the balance and
sustainability that this bill lacks. That proposal has been shared with Senate
staff and is attached to this testimony for your convenience.
In
particular, we believe that Section 118, which fails to provide any floor for
the rate of reimbursement by referencing rates “up to” the 80th
percentile of charges, is inconsistent with the Provider Price Variation Report,
which cautioned to not set a rate “at such a low level as to make a health plan
indifferent as to whether the provider is in-or out-of-network.” This section
of this bill, which would allow payers to pay physicians at any rate they
desire, would create far more than an “indifference.” It would remove all
incentives for payers to negotiate in good faith, and would thereby allow for
the underpayment of physicians in a manner that could significantly jeopardize
practice sustainability and, thus, access to care.
The
Medical Society also has concerns with the provisions set out in Section 22,
which would turn the Health Policy Commission into a rate setting entity.
Several states have crafted solutions to the out-of-network issue, such as our
neighbors in Connecticut and New York, which dictate a sustainable formula for
the rate in statute. The Medical Society urges that the legislature consider
enacting an analogous statute, which would be demonstrably effective and far
simpler than the alternative put forward in this bill, and which would not turn
a policy entity such as HPC into a rate setting body.
Lastly,
the Medical Society wishes to again point out important patient protections
already in place in statute that, with further awareness and enforcement, may
address at least in part the concerns over patient’s being subjected to large
bill for unavoidable out of network care. Section 6 of Chapter 176O includes a
provision that requires carriers inform insureds that, “the insured shall not
be responsible to pay more than the amount required for network services even
if part of the medically necessary covered benefits are performed by
out-of-network providers unless the insured has a reasonable opportunity to
choose to have the service performed by a network provider.”
Scope of Practice
The MMS
also wishes to be recorded in opposition the sections of this legislation that
grant independent practice to advanced practice nurses, and to those that
expand the scope of practice of optometrists and podiatrists. The MMS applauds
the Senate’s goal of decreasing health care costs in the Commonwealth through
this legislation, but these expansions to the scope of practice of the
aforementioned health care providers would not result in costs savings, and
could jeopardize the high quality of health care provided to citizens of the
Commonwealth through the current statutory framework.
The MMS
believes that the physician led team-based care model promotes integrated,
coordinated care that utilizes all appropriate health care professionals while
ensuring that physicians are available for consultation or collaboration when
necessary to promote the highest quality and safety of care for patients.
Physicians’ extensive medical education, required medical residencies, and, in
many cases, post-residency fellowships, provide them with unique expertise and
qualifications to manage care, particularly for the sickest, most complex
patients. Surveys indicate that patients prefer health care teams led by
physicians when care becomes complex and as patients age. The MMS supports
H.2437, An Act to Promote Team Based Health Care, as a model for cooperative,
integrated health care.
The MMS
shares the Senate’s commitment to finding solutions to the high costs of health
care in Massachusetts. We hold, however, that this legislation is an
ineffective means of lowering costs. While nurse practitioners and other
advanced practice nurses may be reimbursed at slightly lower rates, studies
have shown that their increased utilization, referral patterns, and
hospitalization rates often offset savings that might have resulted from the
reduced price. Additionally, many claims of cost savings from changes in scope
of practice laws put forward by the optometry community have been widely
accepted as significantly inflated.
The MMS
appreciates that the Senate has heard and responded to concerns regarding many
patient protections in statute for advanced practice nurses; however, a
significant gap remains between the patient safeguards in place to uphold the
standard of care for physician practice, and those in place to do the same for
nursing practice. The legislature, in fulfilling its duty to protect patients
of the Commonwealth, has over many years established a thoughtful,
patient-focused framework of policies and statutory requirements that apply to
physicians in light of their ability to independently provide medical care.
Specifically,
the Medical Society points to the statutory requirement that all physician
complete a two or three-year medical residency, to the 100 credit/hour per
license cycle continuing medical education requirement, and to the online
physician profile as important means by which the legislature has acted in the
name of patient protection and transparency. Care provided by independent
non-physician practitioners would be subject to fewer and less stringent
patient protections. While the Senate has made note of the importance of
these provisions for non-physician extenders, we do not believe that language
goes far enough to ensure patient protection.
Additionally,
the Board of Registration in Medicine, with its unparalleled requirements and thoroughness
in the licensure process, and through the unmatched sophistication and
resources of its investigatory unit, also provides important protections to
patients cared for by independently practicing physicians. The most important
patient safety protection that can be provided to patients is to ensure that
all care meets the same high standard, regardless of whether it is provided by
a physician, APRN, podiatrist, optometrist, etc. Therefore, licensure boards
would need similar expertise and resources to understand and uphold the medical
standard of care provided by physicians. The Board of Registration in Nursing,
for example, currently has seven vacancies, and only has three members trained
to understand the medical standard of care. The Medical Society is concerned
that patients seen by non-physicians would not have the same standard of care,
protections, or assurances guaranteed to patients seen by physicians.
Provider Price Transparency
The MMS
has partnered with multiple fellow stakeholders to address system-wide
mechanisms that control the forces responsible for the escalation in health
care costs. These include, among others, improving the market structure for
medical services through transparency of price and outcomes. The Society’s
policy is to work toward improving price transparency in our healthcare system
using a multi-stakeholder approach as outlined by the Institute of Medicine’s
(IOM) recommendation from their report, Crossing
the Quality Chasm, “that private and public purchasers, health care
organizations, clinicians, and patients should work together to redesign health
care processes” in the need for transparency whereas the “health care system should make information available to patients and
their families that allows them to make informed decisions when selecting a
health plan, hospital, or clinical practice, or choosing among alternative
treatments.”
Unfortunately,
section 69 of the Senate bill, abandons this multi-stakeholder approach and
mandates that health care providers bear the burden of transparency when
scheduling a procedure or service or referring a patient to needed medical
care. The information on health plans that providers are expected to
disseminate to their patients on cost and network status is very difficult and
time-consuming to obtain and fraught with inaccuracies. This undue burden
negatively impacts providers’ ability to provide timely, efficient care to
their patients, hindering patients’ access to high-quality care and further
exacerbating inefficiencies in the health care system that increase cost.
Therefore, the Society strongly opposes this section and instead recommends
that health plans work with physicians and patients to disseminate this
important information directly from its source.
New Plan options for Small Group
and Individuals
The
Medical Society supports access to affordable health care for all residents of
the Commonwealth, and has therefore watched with concern as insurance costs
have risen in the small group and individual markets in Massachusetts. While
the Medical Society appreciates the need for reform of this market, Section 101
of this bill proposes several complex, novel insurance plan designs that we
believe are concerning and could jeopardize patient health and market
stability. Proposing entirely new insurance market designs in 20-word bullet
points does not provide nearly enough detail to ensure that patients will be
protected, nor to determine the effect of such plans on physicians, hospitals,
and other stakeholders. We would need more details regarding each of these proposed
plans before they can be endorsed in statute.
60 days opt out
Section
106 eliminates the 60-day opt out provision for providers for the small group
and individual market for the new proposed plan -- (iv) of subsection (b) of
section 11 of Chapter 176J – which is “a plan in which a separate cost-sharing
differential is applied to shoppable health care services among the network of
providers”.
As
detailed in the section above, MMS has concerns about the actual nature of this
plan in general. No specificity is provided and one is left concerned that this
novel program could not provide insurance coverage to patients that meets the
standards and expectations we have set in Massachusetts. We therefore oppose
adding a provision to these newly proposed plans which eliminate a longstanding
provision that allows physicians to opt-out of the plans at certain
opportunities, such as after they are re-tiered, or in these cases, after
premiums are adjusted pursuant to their previous years’ cost metrics. The elimination of this opt-out option
appears arbitrary and inconsistent. The language in 176O, Section 9A gives the
plans options to pick and choose the providers who will be in their
networks. Similarly, providers can pick
and choose which new plans they will join. If the plan cannot make its products
attractive enough to the provider, the provider should not be mandated to
participate. Eliminating a provider opt-out on these new insurance plan
proposals that offer insufficient detail as to their implementation is unfair
and will not be in the best interest of physicians or their patients.
Alternative Payment Thresholds
Section
116 establishes Alternative Payment Model Threshold for APM penetration and for
downside risk assumption. The imposition
of a threshold for the downside risk is troubling. Assuming downside risk must
be voluntary and self-determined as the financial assessments and clinical
integration competencies physicians need to consider are complex. ACOs and
other provider organizations should not be mandated to accept down side risk
for which they are not adequately prepared to assume. This threshold for
downside risk acceptance from 25 percent to 65 percent over 6 years potentially
sets up requirements that could subject these organizations to assume
arrangements they are not capable of managing and that should not be enforced
for the sake of patients and providers alike. Further and to complicate
matters, it is unclear which threshold is being proposed by using the
MassHealth ACO as the base. The
statutory language about what rate of risk of the various MassHealth ACOS is
unclear.
The
Medical Society supports all insurance contracting arrangements, and supports
the continuum of risk arrangements currently in the marketplace. Downside risk,
for physician organizations with sufficient capital, risk reserves, and
population management infrastructure, is often an effective way to effectuate
high-value care. Forcing these arrangements on organization without the
financial or organization infrastructure to accept downside risk will
jeopardize the solvency of physician organizations, and could jeopardize access
to care. We therefore oppose blanket benchmarks for downside risk.
Tiering/ Aligned
Measures
The key principles used to tier
physicians should strengthen patient-physician relationships, involve
physicians in program design and implementation, use clinically relevant and
sound performance measures, rely on data-driven analysis, and be reviewed with
physicians prior to public release. However, given the complexity of our
current health care system, even those tiering programs with methodologies
rooted in these key principles, can result in errors. Therefore, it is
essential that the tiering program outlined in the bill must include an
appeals mechanism and should acknowledge the importance of consistency in the
use of standardized quality measures to simplify the process across payers to
improve accuracy. The Society applauds the bill’s proposal to standardize quality measures across
plans and urges the adoption of standardized measures in tiering programs as
well.
This legislation also requires plans to utilize the aligned
measure set established by the EOHHS and task force, may use the non-core set,
and sets up the core set to be the determiner of the tier. MMS strongly
advocates for simplicity, consistency, reliability and validity in measurements.
The core set identified should be the only set required. Every effort must be
made to synthesize the quality reporting space as it is has become a major
burden on practices and is contributing along with the Electronic Health
Records to physician burnout.
MMS also had significant concerns with the first two plans
proposed in Section 101 of this bill, as they are complex, novel and have the
concern of jeopardizing patient health and market stability. The last plan is also novel and complex and
can be greatly confusing for patients. The Medical Society urges the
legislature to develop these plans in more detail prior to encoding them in
statute.
MMS also has concerns about the legislature’s proposal to
eliminate the 60-day opt out provision for providers for the small group and
individual market for the new proposed plan, put forward in Section 106. The
lack of specificity regarding these concept insurance plans and the elimination
of this opt-out provision do not instill the proper amount of analysis and
insight that should occur before new insurance plans are implemented. Further, it is not at all clear why
participation would be required. This
requirement appears arbitrary and inconsistent. The language in 176O, Section
9A gives the plans options to pick and choose the providers who will be in
their networks. Similarly, providers can
pick and choose which new plans they will join. This elimination of the 60 days
opt out appears to be a legitimate option and if the plan cannot make itself
attractive enough to the provider, the provider should not be mandated to
participate.
The
Medical Society commends the Senate for its dedication to health care cost
containment. We support many provisions of this bill, as detailed at the
outset, including the quality measure alignment, Prevention and Wellness Trust
Fund, and attention to pharmaceutical costs. Other issues, such as telemedicine
and out-of-network billing, are also issues that warrant close attention by the
legislation. For these issues, we believe that alternative legislative
proposals would be a more prudent path forward, to assure the uptake of
telemedicine in Massachusetts, and to assure a sustainable solution for out-of-network
billing which protects patients and fairly reimburses physicians for their
services to ensure continued improvement in access to quality care in the
Commonwealth. The Medical Society appreciates the opportunity to provide
comment, and we look forward to continuing to engage on these issues and other
issues for the betterment of the health care system for all patients of the
Commonwealth.
[1] Milbank Memorial Fund, Telehealth Private Payer Laws: Impact and Issues. Available at https://www.milbank.org/publications/telehealth-private-payer-laws-impact-issues/
[2] Ateev
Mehrotra, Haiden A. Huskamp, Jeffrey Souza, Lori Uscher-Pines, Sherri Rose,
Bruce E. Landon, Anupam B. Jena and Alisa B. Busch, Rapid Growth In Mental
Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation
Across States, Health Affairs 36, no.5 (2017):909-917.
