In Pa., facing two big challenges: Opioids, ACA

Want to know what's important in medicine today?

Ask Charles Cutler, an internal medicine specialist from Norristown who last month was sworn in as the 167th president of the Pennsylvania Medical Society.

The society's 16,000 members are physicians and medical students throughout the state. Among the issues it promotes are leadership, education, and public health.

Cutler, a member for 35 years, belongs to numerous other medical organizations, including the Board of Trustees of the Montgomery County Medical Society. He is a member of Einstein Physicians Norriton, a part of the Einstein Healthcare Network.

He spoke to us recently about where medicine is - or should be - headed.

What is one of the primary issues in health care today?

I would be negligent if I didn't lead off talking about the opioid crisis. To capsulize it, in some jurisdictions, there are more people dying of opioid overdoses or abuse than in automobile accidents. And look at all we've done for automobile safety with seat belts and air bags and cameras. The list goes on. In a different vein, but with the same intention, we have to do that for this crisis. Addiction is an illness. People didn't wake up in the morning to say, "Gee, how can I be sick today?" There are social and psychological and emotional issues that surround this.

This is a major issue for the medical society, and we're encouraged that it's being recognized by the Pennsylvania legislature, the governor's office, a lot of stakeholders around the state, and, for that matter, around the country.

The society has worked with others and created guidelines for prescribing opioids. There are some patients that legitimately need narcotics, and they should be able to get the products that they need to feel better and to get better. We've also created information for patients that can be distributed through physician offices, hospitals, and other venues.

You have been involved in efforts to make Montgomery County tobacco-free. Tell us about that.

This goes back a number of years, but I was the chairman of an organization for a tobacco-free Montgomery County. Funding from a tobacco settlement helped promote programs in Montgomery County. At that time, there was a general opinion that people wouldn't go to a bar if they couldn't smoke. Breaking down that perception was hard, but there were some bar owners who were willing to take it on. They discovered that business improved, that people were happy not to be inhaling all of the toxic chemicals that involve second-hand smoke. At the time, there were restaurants that had a smoking section and a nonsmoking section, which was sort of ridiculous, because the smoking section wasn't walled off. Now, I think most restaurants are smoke-free.

There's a lot more to be done. I stop at a local convenience store every morning to buy coffee. Folks are still buying a lot of cigarettes, despite the fact that they're $6 to $7 a pack. One of the pharmaceutical chains stopped selling tobacco products. As for the others, it's puzzling to me that a pharmacy that is there to promote health would sell tobacco products.

The society has a strong policy objecting to tobacco products of all sorts. One of the biggest deterrents to tobacco use is cost. The more tobacco products are taxed, the higher the cost is to the consumer. One of the interesting statistics of tobacco use is that if you don't start smoking by the time you're in your early 20s, you'll never be a smoker. The key for the next generation is getting people in their early teens - some kids start at 13 or 14 - to not start smoking.

You are a former president of the Victim Services Center of Montgomery County, one of many such centers throughout the country. Tell us about that.

This is an important service, and the medical society is behind this effort. A lot of what Victim Services does is to support women who are accosted, sexually assaulted, traumatized through unwanted sexual activity. It is a very, very painful experience. The workers sit side by side with someone and say, first of all, that it's not your fault, and second, it's OK to feel the pain. We will help you to ease that pain. And to work through the process of healing.

A lot of children are impacted by crimes. There may be an argument between two parents and someone may get hurt. The children are the innocent bystanders, and their feelings need to be addressed.

The medical society is behind these efforts. We've been out there on the front line, trying to support the agencies with increased funding.

What about the issue of high-quality care?

Within the last year, Medicare has decided to build in a quality factor for paying physicians. Historically, physicians and all health-care providers were paid fee-for-service. But in other areas, consumers pay for quality. You quality-shop when you buy a TV. Now, if you're a physician who is doing a good job with disease management, you're going to get an additional payment from Medicare. The new law, which went into effect about a year ago, is expected over the next generation to drive health-care delivery and payment, not only for Medicare, but also for Medicaid and the commercial insurers.

It's hard to measure quality, but it's a worthwhile effort. Patients deserve it. It's easy to tell if you like the doctor because he or she has a nice personality and a warm bedside manner. But are the medications going to make you better? Are the treatments you're getting really necessary? As a physician, if you're taking care of a diabetic, is the blood sugar coming down or staying normal? You can go through a whole bunch of diseases. Is the cholesterol coming down? Is the blood pressure in a healthy range?

Medicare is encouraging doctors to come together in what are called clinically integrated networks to provide patients with better care, lower cost, and a better experience. If you're a general internist, as I am, maybe you could work with a cardiologist and a kidney specialist and a surgeon. The medical society recently decided to help physicians across Pennsylvania to create these networks.

Any more issues you'd like to discuss?

The Affordable Care Act. The medical society and most other large physician organizations in 2010 were in support of it. It was not perfect, but one thing the act did was to provide insurance for millions of people who didn't have it. It's impossible to criticize the importance of that. It got rid of limits on what insurance will cover. The ACA has done a great deal to make America a healthier country.

Both Republicans and Democrats recognize that the flaws have to be corrected. Certainly, the medical society will advocate for addressing premiums in the marketplace - reducing the maximum premiums and reducing or eliminating co-pays, deductibles, and out-of-pocket expenses. There have been proposals - and the medical society would probably support them - for more tax credits when out-of-pocket expenses are very high.

Another issue is access to care. Every summer, hundreds if not thousands of medical residents graduate and go out into practice. The insurance industry now takes a very long time for credentialing. They would argue that there are safeguards and they need a lot of time. Certainly, we don't want people that are not doctors out there calling themselves doctors. But we think there are unnecessary delays.

Another insurance reform that's really important has to do with preauthorization. Physicians, to order certain tests, have to contact the insurance company and get permission. We need to create a system where there's not a bottleneck. A related problem is that people who are legitimately sick get a procedure, but then the insurance company denies the procedure retroactively. The medical society is lobbying for legislation that would streamline credentialing and preauthorization and address retroactive denials.

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