Michael Preston

Q&A// T.



For the past decade, T. Michael Preston, though not a physician, has been the face and voice of the state's doctors as executive director of MedChi, the state medical society.

Before that, he was a lawyer handling malpractice cases - on the defense side. Reform of the malpractice system has been a key issue during his tenure.

Other issues, too, have centered on questions of quality and accountability. He was a key player when the state restructured its Board of Physicians in 2003. The board investigates cases in which physicians are accused of harming patients. Despite the changes, debate has persisted over what should trigger an investigation of a physician and over how much information about physician problems should be public. The debate is likely to heat up again next year, when the board is scheduled for reauthorization.

Many of Preston's battles haven't been legislative or regulatory. The doctors have also faced off against HMOs and other managed care insurers over issues of payment and how much oversight the insurers should exercise over treatment decisions.

A few weeks ago, Preston announced he would be leaving MedChi this month. His wife, Margaret Preston, an executive at Mercantile Bank, is taking a position at Bank of America in New York.

Preston recently sat down to discuss the evolution of quality and accountability issues over his tenure.

You've been doing this for about ten years. When you arrived, what were the problems facing the medical profession.

Ten years ago, the business of being a doctor was just entering the throes of managed care, and doctors were widely ambivalent about it. They were suspicious, but there was also sentiment that there really was a need for reform. The costs were beginning to escalate to a point where they were getting out of control. The new version of the solution, instead of being called managed care, is being called "pay for performance." And doctors are not ambivalent about that. They're pretty consistently unfriendly to what they perceive to be a new name for the same approach.

What does "pay for performance" mean to the doctor? Does that mean if the patient has optimal outcomes, you get $3,000, but if the patient still limps you get $2,000?

No. There are many variations on what pay for performance actually may be. It may be a series of administrative actions that are expected by a physician's office. One version is the so-called high-performance network from Aetna. As far as the doctors can tell, it's a sort of a black-box process by which doctors in their network are being categorized. If you make the cut, you're in the high-performance network and you get the patients, but you don't necessarily get any more money.

So what kinds of things are doctors expected to do to get the stamp of quality?

See, that's the problem - it's not clear. The measures on which doctors will be judged either haven't been communicated well or haven't been communicated at all.

Would this or should this be transparent to the patient? Would there then be a list somewhere that says, "These are the cardiologists who meet the standard"?

That's the goal. In general, doctors don't contest that notion, that transparency and the ability of patients to understand what they're getting in quality is a good thing. The key problem at this early stage is: Are the tools and the measures by which we get there valid? And there's great suspicion that if it's done wrong, they won't be valid.

You've been involved over the last couple of years in the liability issue. A bill was passed with a state subsidy for malpractice insurance. Malpractice premiums have leveled off. Claims have leveled off, even declined a little. Where do you see that headed?

There's a temporary lull in the roar over medical liability, but I think, definitely, the levels are going to go right back up when the subsidy disappears. From the public policy standpoint, it's hard to be optimistic that we're going to see much progress. It's been at a stalemate so long, and the interests are very entrenched. Many physicians believe that a public policy solution, tort reform that will have a meaningful impact, will only come when there is sort of a breakdown. As several doctors have put it, when some senator's kid can't get surgery.

Speaking of accountability, the Board of Physicians is up for reauthorization next year. What changes, if any, would you like to see?

One thing's certain - the disciplinary process is not a quality improvement process. The crossover between litigation and credentialling actions is the source of all the friction about this, because of the widespread belief that lawsuits, and even payment on lawsuits, is necessarily a good indicator about whether or not somebody should be examined.

I don't think anybody's saying, "Three claims paid and you're de-licensed," but some people are saying, "Three claims paid and the board ought to look at you."

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