A Massachusetts Physician Offers a View of Healthcare Reform

Massachusetts enacted universal healthcare three years ago, and since then many have looked at us as a potential model for the nation. We've insured close to 98% of our population, adding nearly 450,000 to the insurance roles—an enviable achievement. But the strains are evident.

With physician shortages, especially in primary care, we've discovered that universal coverage does not mean universal access to care. Some patients are having difficulty finding a primary care doctor, and long wait times exist. And like others, we struggle mightily with the cost issue, exacerbated by a shrinking budget battered by a severe recession.

But the will to succeed exists, and we move ahead. A special panel on payment reform has recently recommended a new way to pay hospitals and physicians, with the goal of reducing costs.

Reforms at the state and federal levels aim to improve quality, reduce costs, and make healthcare more affordable. Physicians know that rising costs are unsustainable for the individual, the employer, and governments. We also know plenty of opportunity exists to improve the quality of care.

Physicians want to be—and should be—part of the process to build a better healthcare system. We are, after all, those who deliver the care. But this willingness is tempered with a certain degree of concern, born of experience. The last two decades have produced many big ideas to improve quality and affordability, launched with high hopes and great expectations. But most of these notions have failed, often making matters worse and driving a wedge between patients and their physicians.

Our hope for reform, at all levels, is that efforts, besides enhancing care and cutting costs, will restore dignity to the patient-doctor relationship.

Physicians believe there must be four cornerstones to healthcare reform, each patient-centered and each as important as the other:

• Healthcare spending must be affordable and sustainable. Volumes of evidence prove that when people can't afford healthcare, they don't take their medications, see their doctor, or engage in preventive care. People who defer their care get sicker, and treating them becomes more expensive and more difficult.
• Spending levels must be sustainable and realistic to provide the care that patients need. One important lesson from past efforts is that cutting hospital and doctor payments alone doesn't create long-term savings, even if they succeed in squeezing out short-term savings. There needs to be a systemic approach to developing sustainable spending, or the short-term savings cannot be sustained.
• Reform must support and promote high-quality care. Cutting costs without promoting quality will not be accepted by patients or physicians and would doom any effort.
• Reform must support a diverse, pluralistic healthcare system—large and small hospitals, independent practices, community health centers, nursing homes, rehabilitation facilities, home healthcare, mental health, dental care, and all venues where high-quality, high-value care is delivered. Patients value choice, a value deeply embedded in our culture. Any reform that deprives people of meaningful choice will not succeed and will hinder progress.

Current proposals could make things better, but only with great care and extreme diligence. Moving to a new system will require a careful, orderly transition taking many years. Physicians will need time, funding and training to acquire the technologies, to learn how to manage this new financial risk, and to acquire expertise in new areas of the law and governance. Further, practices are not equally ready to move to a new system, and some areas of the country are better equipped to do so than others. In particular, practices in the less-populated would be especially disadvantaged by an overly rapid movement to a new system.

In a similar way, patients will also need time to familiarize themselves with a new system. They will have new roles and responsibilities, and their transition needs must be designed just as carefully.

We all know that the status quo in healthcare is not an option, and much hope has been placed in these new efforts. We subscribe to President Obama's statement that we should keep what works and improve what isn't working. Let's use the wisdom we've gained from past experiments to guide us to effective, long-lasting reform.