The new leader of the Medical Society of the State of New York grew up in a family of pharmacists in Buffalo.
His grandfather and father owned pharmacies on the West Side. His mother, a sister and a couple of cousins worked in the profession, too.
“I think it’s been helpful in terms of practicing as a physician,” said Dr. Thomas J. Madejski, who graduated from the University at Buffalo School of Pharmacy before attending medical school in Syracuse.
Madejski this spring became president of a society that represents roughly 20,000 physicians. It is charged with defending patient rights and advancing evidence-based public health policies with lawmakers in Albany and residents across the state.
“I am honored,” he said.
His eyes glimmer as he recalls eating lunch as a boy at the Main Place Mall, riding his bike to the Central Library and on the grounds of the Buffalo Psychiatric Center, and graduating from the former Calasanctius School in 1977, after just three years.
“One of the sadnesses that I’ve had was watching Buffalo go through its decline,” he said. “I’m excited to see it coming back.”
Madejski (pronounced Ma-day-ski) has become an old hand at advocating for physicians and patients. He joined the medical society in the late 1980s, after he graduated from SUNY Upstate Medical University, and over the years became involved in roles both with the society and American Medical Association.
Still, most of his time involves serving patients at General Physician PC, a regional primary care practice managed by Kaleida Health. He leads offices in Medina and Albion as an internist who specializes in geriatric and palliative care, and he has become a key provider for the sickest patients at Medina Memorial Hospital, three nursing facilities and Orleans County Hospice.
His upbringing, and career, inspired his interest in trying to improve a national health care system with plenty of warts.
Madejski is among physicians who successfully advocated for HIV testing and treatment for newborns, electronic health record advancement with privacy protections, and bringing mental health care insurance coverage more in line with other medical reimbursement.
During a series of recent interviews that included a sit-down in his Ohio Street office – off the back parking lot of Medina Memorial – he raised concerns about the current and future state of health care, but also sounded inspirational notes.
“Every age thinks they’re living in the golden age of medicine, but I really think that we are,” Madejski said. “I’m excited that we have more and more information to be able to find genetically what a person has in terms of their risk of disease, how their body will potentially use medication, and also on the biology of some of the illnesses we deal with – particularly cancers – that already are beginning to radically change how we treat people.”
He also talked about personal responsibility at a point in time where medical improvements have extended life, while also raising costs.
“One of the things that’s changing right now is the approach to prevention and treatment overall,” Madejski said. “We have data that a lot of what causes people to develop disease is not something I can help them with in the office by giving them a pill, doing diagnostic testing or fixing something.”
Here’s what he had to say about several of the pressing issues in state and national health care.
Rural health care
Though he marvels at the resurgence of his hometown in recent years, Madejski has grown to love a much more rural existence the last quarter century, one he embraced moonlighting on weekend shifts at A.L. Lee Memorial Hospital in Fulton, in Oswego County, while attending medical school 30 miles to the south.
Madejski and his wife, Sandra, a retired respiratory therapist, raised five children in the Orleans County hamlet of Eagle Harbor, along the State canal system about halfway between Medina and Albion. The couple has become part of the fabric of the county with roughly 41,500 residents – 10 times fewer than the population of Buffalo when he was growing up in the 1960s and '70s.
Madejski became a Boy Scout leader, developed a love for fly fishing and enjoyed golf on less crowded courses in these surroundings. He also grew to enjoy regular interaction with patients.
“As a physician in a small community, you’re always on duty,” he said. “As a doctor, it’s great to see how your patients are functioning out in the community.”
Madejski was among five internists and two family physicians when he came to Medina in the early 1990s. A urologist, two general surgeons, an ear, nose and throat specialist and a rehab doctor also worked in the village. Today, he, another family doctor and one general surgeon remain – and rural hospitals not far afield in Newfane and Brockport have closed.
As in other rural communities, Madejski and his patients have learned to lean on physician assistants and nurse practitioners in recent years, as primary doctor recruitment has become a major challenge, and luring specialists all but impossible.
“We’re very appreciative of the skills and talents of our colleagues in the practice of medicine,” Madejski said. “We think things work best when we work together as a team.”
Madejski also is among the growing number of doctors once in private practice who, during the last decade, decided to focus on patient care and leave management headaches, including paperwork and high technology costs, to health care corporations. The closer connection helps streamline the need to transfer extremely sick patients to hospitals more than 40 miles away in Buffalo.
Health insurance requirements
Madejski called the health insurance prior authorization and utilization review process “impediments to a joyful practice.”
“Unfortunately, due to the cost of medications, there are a number of hurdles to get through something that should be relatively simple,” he said. “For instance, if you come in with abdominal pain and I think you have appendicitis, it shouldn’t be that hard for me to send you next door for a CAT-scan, because that’s the best test to diagnose it. While that used to be the case, now most insurance companies won’t let you do any CAT-scan without having to do some extra paperwork and forms. There can be some delay in care that could put you at risk. A lot of these things look to reduce costs by creating a rationing by inconvenience.”
He said he finds himself “with some frequency” advising patients they will want to consider something that will cost them money out of pocket. A big example is a low-dose CAT-scan lung cancer screening for smokers and former smokers, which has been proven to detect earlier forms of the biggest cancer killer in America. Some insurance coverages set a 25-year smoking minimum for adequate coverage, Madejski said, a benchmark the society sees as arbitrary and seeks to change.
Health insurance system
The society periodically studies different health care systems in New York. Madejski also has been involved in doctor-related advocacy on the national level.
“Generally, we are most in favor of a pluralistic system that has multiple options,” he said. The society looked at a single payer system about a decade ago and, at that time, it wasn’t well received. “We have some limited single payer in the country with workers compensation and the Veterans Administration, and while there’s some satisfaction, there are substantial issues in a large minority of people in those systems,” Madejski said.
Prescription drug costs
Madejski is part of the American Medical Association Council on Medical Service, which soon will release a report on the structure of insulin pricing, and what can be done to bring it down.
“If a patient can’t afford their medicine, it makes the implementation of what needs to be done much less effective,” he said. “There are some strategies but it is a really complicated problem with a number of moving targets. One of the things that would be really helpful is full transparency of prices. We talk about that in this report that’s going to come out.
“The other drivers are some of these pharmaceutical benefits managers who were ostensibly there to save money for somebody – either the patients or the insurance companies – but if they’ve done that, seem to be retaining most of the savings. We’re not seeing the costs come down for patients, which is the bottom line.
The state society has done much to bring reimbursements for mental health care in line with other medical care, Madejski said, but a number of health insurance plans have used federal exclusions to prevent more progress. The society will continue to support greater parity, he said, as well as the growing movement to imbed mental health specialists into primary care offices. His rural practice, as well as others across the state, also are looking into mental health telemedicine as a means to better serve patients.
Physicians in the society have worked with state legislators to implement an opioid prescription drug monitoring program “which overall has been a good thing,” Madejski said. “Prescriptions are down about 20 percent nationwide in terms of the amount of opioids prescribed now that there’s better knowledge about how to use them.”
The society remains concerned about people who have turned to street drugs as prescription opiates have become harder to get. Meanwhile, Madejski and others with the society continue to conduct doctor trainings in the midst of the continuing epidemic.
“The goal is trying to get the right medicine to the right patient at the right time,” he said, “and try to minimize side-effects and bad consequences of chronic pain medicine.”
Madejski in his practice, and the society in general, has taken a “very cautious” approach to medicinal marijuana. The state two years ago approved use for conditions whose symptoms include severe chronic pain, nausea, seizures and muscle spasms. Nearly 1,700 health providers statewide have registered to write prescriptions and more than 58,000 patients have been certified to use medicinal marijuana.
Anecdotally, physicians who have prescribed drugs have seen improvement for some patients.
“This is me personally thinking, not the medical society,” Madejski said. “I think we got slightly ahead of ourselves trying to put through products that have not been well vetted. I believe we are accumulating some data now and I have to say that I’m relatively pleased with how this experiment has gone thus far.”
The society has long advocated that marijuana – now scheduled by the federal government in the same class of Schedule 1 drugs as heroin and cocaine – be scheduled a less dangerous Class 2 drug, so it can be more easily studied in scientific research laboratories.
Madejski also expressed concern with the fallout of the legalization of recreational use of marijuana in several states.
“There’s a lot of concern about the effects on kids and younger adults in terms of brain maturation,” he said. “I’m not sure we know it is as benign a drug as it is postulated to be by some people.”
“We advocate strongly for preventing disease rather than finding and treating disease where that’s possible,” Madejski said. “We think that patients do better when diagnosed earlier and having access to treatment at an earlier stage of their disease process.”
Madejski said that the Geisinger Medical Center, north of Harrisburg, Pa., has announced it will implement genetic testing with all of its patients within the next two years to develop more individualized treatments.
“It’s a really exciting time.”
He sees this becoming an ongoing issue with health insurers as precision medicine becomes more common. In this impending form of care, health care providers will be able to get much more detailed genetic information in helping to decide which patients are more prone to cardiovascular disease (heart attack, stroke and COPD), diabetes and cancer, and more intensively treat and screen those at greater risk.
“The medical society thinks that investment is well worth making,” Madejski said, “but there is a cost and we have to figure out how to pay for it."
“There is very good data that going to a plant-based diet and avoiding animal fat is healthier in terms of avoiding vascular disease,” he said. “If society did a better job of sharing that, we would prevent a lot of vascular disease and probably cancer, as well. Physicians know this well. I believe we do tell our patients that.”
Madejski and fellow providers in his practice routinely talk with patients about the dangers of smoking and excessive alcohol intake. Doctors also regularly provide nutritional advice and refer heavier patients to dietitians or nutritionists – but in the end, it’s up to those patients to act on these important medical recommendations or face health consequences, Madejski said. He said insurance companies have stepped up by providing nutrition counseling coverage for those who are obese.
End of life
Despite our best efforts – and those of doctors and other health providers – human beings have a lifespan that can range from a few seconds to a dozen decades. Recent gatherings of society members have included talks about an Assembly bill on physician-assisted suicide. The society has had a long-standing view against this approach but recently re-surveyed members to see if that view has changed. It already has become clear that a growing number of state health advocates favor the idea, Madejski said.
“The question is whether the majority has changed enough that we would change our position,” he said. “That has not happened yet. I think it’s really important that we continue to have discussion. People on both sides of the issue are committed to patients being cared for well at the end of their lives. My goal as president is to have us focus on that.”
Twitter: @BNrefresh, ScottBScanlon