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Massachusetts health care – wonky with a dose of reality

July 26, 2016

In mid-June, MassHealth took another step towards payment and care delivery systems reforms with the release of their 1115 waiver proposal (background: section 1115 of the Social Security Act allows the federal government to authorize state demonstration projects to improve Medicaid). Through the 1115 waiver, MassHealth is requesting authority from the federal Centers for Medicare and Medicaid Services (CMS) to restructure MassHealth care delivery through implementation of Accountable Care Organizations (ACOs) and expand substance use disorders services. MassHealth is asking CMS for a $1.8 billion up-front investment over five years to support transition toward ACO models, including direct funding for community-based providers of behavioral health and long-term services, as well as funding for for safety net programs, including the Health Safety Net – this is important, as under the current waiver, a significant portion of Safety Net Care Pool funding is set to phase out by June 30, 2017.

The public comment period closed on July 17th, with many stakeholders weighing in. Health Care For All helped draft and submit several sets of comments on a range of issues covered in the waiver proposal, with common themes around ensuring access to care, member choice, consumer protections, and monitoring and oversight. One set of comments we organized included these 29 organizations:

Logos of groups commenting on 1115 Waiver

Use these links to read our submitted comments:

The next step is for MassHealth to submit their 1115 waiver proposal to CMS. CMS will send MassHealth a notice of receipt within 15 days of submission, and that notice initiates the start of a 30-day federal comment period.

 

 

July 25, 2016

It’s a horrible name, but a great program. And with HCFA’s support, the Massachusetts state legislature just saved its funding for this year.

“Detailing” is the term used to describe the marketing of prescription drugs to doctors, pressing them to prescribe specific drugs for their patients. Detailers are sales representatives who travel to physician practices to deliver sales pitches lauding the benefits of their drugs. Often, detailers provide a free meal and drug samples as an enticement for providers to listen to their spiel. Detailers only work for name brand drugs; there are no detailers for generic alternatives.

“Academic detailing” is just the opposite. Independent experts meet with doctors, and go over current scientific information on a class of drugs, informing doctors on all the research, and making unbiased recommendations based on comparative evidence, including cost-effectiveness. The result is better patient outcomes, and lower health care costs. One study from Harvard Medical School found that each dollar spent on academic detailing saved two dollars in prescription drug costs.

For several years, Massachusetts has operated an academic detailing program, operated by the Department of Public Health. For this coming fiscal year, the plan was to focus the $150,000 program on how to best prescribe pain killers, to avoid the over-prescribing of prescription opioids. But when the fiscal year 2017 budget was presented to Governor Baker, he vetoed the funding for the program.

Last week, the legislature overrode the veto, by a 122 to 31 vote in the House, and a 36 to 3 vote in the Senate. During the override debate, Senator Mark Montigny spoke out passionately in favor of the program:

“We're not only fighting the opiate crisis, we're also fighting price-gouging by the pharmaceutical companies. This is exactly what should be done. Instead of having folks running around offices selling things they aren't even qualified to sell half the time. I think this is a great program.”

HCFA continues to press for effective prescription drug policies that save money and improve care. In addition to support for academic detailing, our prescription drug policy agenda includes greater transparency around drug prices, and eliminating copays for cost-effective preventive care. We’re very pleased that the academic detailing program survived, and will continue to press for a consumer-focused policies in this area.

-Brian Rosman

July 20, 2016

The Oral Health Advocacy Taskforce (OHAT) has a new initiative: integrating oral health into the rest of the health care system. OHAT’s new Oral Health Integration Project (OHIP) kicked off this past May and has hit the ground running. Over the past couple of months, OHIP members and stakeholders have put their heads together to think about what oral health that is fully integrated with the rest of the health care system could look like.

There is currently a significant opportunity to elevate oral health in health care here in Massachusetts. As explained in previous blog posts, MassHealth is proposing substantial changes to its program with the renewal of its 1115 Demonstration Waiver, to be approved by the federal government. At stake is 1.8 billion dollars over five years to support MassHealth’s transition to Accountable Care Organizations (ACOs). ACOs are a new way to pay for and deliver care that works by bringing together providers to coordinate high quality health care – care that we believe should include oral health.

MassHealth’s released Waiver Proposal touches upon oral health in a few important ways, and briefly outlines the inclusion of oral health metrics in the ACO quality measure slate as well as contractual expectations for ACOs around oral health. OHIP is pleased to see that oral health is included in MassHealth’s future plans for restructuring and is urging MassHealth to expand its efforts in this area.

OHIP submitted formal comments to MassHealth pushing for more robust ACO standards that would facilitate increased integration of oral health. A summary is listed below:

  • ACOs need to have accountability for oral health and dental services, and dental services should be phased into ACO total cost of care
  • Dental providers should be allowed to join ACOs and take part in risk-sharing arrangements starting in the first year of ACO roll-out
  • ACO payment methodologies for dental and oral health services should incentivize high-value, evidence-based, preventative care
  • Delivery System Reform Incentive Payments (DSRIP) funds should be used to transition the delivery system to adequately address oral health
  • Oral health quality metrics can help tie oral health into overall health in ACOs and should be strengthened
  • Oral health should be integrated into all aspects of care coordination
  • Roll-out of dental services inclusion in ACOs should first consider piloting
  • ACO governance, quality, and clinical committees should have representation from oral health clinicians
  • There should be adequate consumer protections built-in throughout the ACO structure

Take a look at OHIP’s full set of comments here.

Kelly Vitzthum

July 19, 2016

Last Thursday, the Health Connector Board met to update their bylaws, award conditional Seal of Approval to health and dental plans, and review the Health Connector’s FY2016 final and FY2017 proposed administrative budgets. Materials from the meeting can be found here.

Executive Director’s Report

Health Connector Executive Director Louis Gutierrez provided updates on Connector activities.

  • July enrollment increased by 10,500 members
  • 7500 members were overcharged for their premiums; the Connector has worked with Dell to rectify the situation and ensure members receive refunds
  • Risk adjustment payment to carriers increased by $84 million, largely due to an increase in Qualified Health Plan (QHP) member months
  • The Health Connector is considering their options to the Small Business Health Options Program (SHOP) and employee choice program. The Health Connector cancelled the SHOP procurement after not receiving any good options.
  • Preparations for 2017 Open Enrollment are under way.

In response to the SHOP updates, Board members discussed and inquired as to whether implementing a SHOP system would be a waste of time and money and whether this feature of the ACA is able to be waived. Gutierrez responded that it is waivable under Section 1332 authority, but it would be very difficult to obtain approval. The Health Connector is considering a shared platform with other states such as Connecticut, Rhode Island and Washington DC as an alternative.  

Patricia Wada provided an update on the roadmap for IT systems upgrades. The next release in August will focus on repairs and user experience upgrades to prepare for 2017 Open Enrollment, allow for Spanish language notices, and plan management features. The HIX system is a joint effort between the Health Connector, MassHealth and Mass IT. One Board member questioned whether the IT system will be impacted by MassHealth’s delivery system redesign and implementation of Accountable Care Organizations (ACOs). Gutierrez responded that this is on their radar and they are planning very far ahead.

Update to Bylaws

Ed DeAngelo and Ashley Hague presented proposed updates to the Health Connector Board bylaws, which have not been updated since the Connector’s inception in 2006. Updates focused on the designation of the Secretary of Health and Human Services as the board chair, the allowance of Board members to be notified of scheduling matters via email, the shift of responsibility from Executive Director to a Health Connector employee to be responsible for meeting minutes, and the allowance of the election of a vice chair to occur any time during the final quarter of the year, depending on each monthly agenda were each enacted.

There were also a few contractual updates to the bylaws. This included the an update to the minimum dollar value (from $5,000 to $15,000) for contracts that do not require a formal vote, but do require a written notice to the Board 5 days before execution. The type of “contract” requiring Board vote was then specified as “any and all types” except for extensions, amendments and work orders that cost less than a quarter of the original contract, as long as the cost is noted in the most recent Board approved fiscal budget. The Board voted unanimously to approve the amended bylaws.

Conditional 2017 Seal of Approval

In response to the 2017 Seal of Approval RFR, there will be a 25% decrease in health plans offered through the Connector when compared to 2016. Unlike 2016, when only non-standardized Bronze plans were offered, the Health Connector created, two new Standardized Bronze plans - one MCC-compliant and the other  has-compatible. All carriers opted for the MCC-compliant Bronze  plan design. In addition, the second standardized Gold plan was also eliminated. In total, 10 medical carriers responded to the 2017SOA ,submitting 62 QHPs for both non-group and small group shelves.

Notably, one of the new goals of the SoA expressed by the Health Connector is  enhanced substance use disorders treatment 2017 ConnectorCare plans will offer enhanced access to Clinical Stabilization Services and reduce the cost burden for key MAT (medication-assisted treatment) and associated services.

Another change is the requirement for QHPs to include pediatric vision and dental services, as per the State’s updated Essential Health Benefits (EHB) requirement Requiring Pediatric dental EHB coverage would move the Health Connector into parity with the off-exchange market, increasing the accessibility of these services. While one carrier cited operational challenges as a barrier, most opted to include pediatric dental benefits into their plans. On the dental carrier side, there were not many changes to the requirements and offerings of Qualified Dental Plans (QDPs).

The Health Connector voted and approved the 2017 Conditional Seal of Approval for  recommended QHPs and QDPs from the following carriers:

  • Altus Dental
  • Blue Cross Blue Shield of MA
  • Boston Medical Center HealthNet Plan
  • CeltiCare Health
  • Delta Dental of MA
  • Fallon Health
  • Harvard Pilgrim Health Care
  • Health New England
  • Minuteman Health
  • Neighborhood Health Plan
  • Tufts Health Plan – Direct
  • Tufts Health Plan – Premier

Health Connector FY2016 & FY2017 Administrative Budgets

July 19, 2016

This blog post was originally published on Community Catalyst's blog Health Policy Hub

I recently attended Health Care for All’s (HCFA) 4th Annual Patient and Family Advisory Council (PFAC) Conference in Massachusetts, which was incredibly informative and inspiring. HCFA was a major force behind the passage of the 2008 law that required all Massachusetts hospitals to establish PFACs, and for the past eight years, has provided technical assistance, training and networking opportunities to strengthen patient and family engagement in hospitals.

So, what are PFACs and why do they matter? According to the Agency for Healthcare Research and Quality, PFACs are bodies made up of individuals who have received care at a hospital (or their representative family members) and are able to offer feedback and insights to inform and improve hospital care delivery, policies and operations to most effectively address patient and family needs and preferences. PFACs have the potential to help improve overall systems and processes of care, which can lead to better health outcomes for patients, as well as improve financial performance of health care organizations.  PFACs are a great example how to actively and meaningfully engage consumers in order to realign the health care system and place consumers at its center.

But establishing a PFAC is only the first step. Learning how to make it meaningful is an entirely other story. And that’s what the HCFA conference was all about. It began by offering a three-part vision of what constitutes authentic engagement: First, engagement is purposeful; second, engagement is effective; and, finally, engagement isequitable. The conference covered a lot of ground across these three themes, providing the nearly 300 participants with opportunities to discuss everything from building internal credibility for PFACs, to creating effective meeting agendas, to understanding why PFACs should care about and provide their perspectives around quality measures. Most importantly, the conference provided PFAC members from across the state with an opportunity to network with – and learn from -- one another.

One cross-cutting theme of the day was the importance of consumers being engaged at every level, and from beginning to end of all hospital processes. Examples abounded, including in sessions focused on engaging patients in research as partners rather than subjects, integrating patients into hospital committees, and identifying the PFAC’s role in shaping hospital community health assessments and activities in order to best address identified needs.

Another theme was the importance of recruiting a diverse PFAC membership that represents the patient population by race, ethnicity, language spoken, sexual orientation, gender, age, disability status, employment status and so forth. One PFAC’s approach to recruiting and retaining diverse members included developing a Diversity, Equity and Inclusion Council that supports other PFAC members in understanding how to be more inclusive of people from different racial and ethnic backgrounds. Another PFAC in the state is working to adapt educational materials for different age groups, particularly older adults, by ensuring materials are printed in large, bold text and colors that are easy to read. Several PFACs are changing their meeting times or incorporating virtual meetings and social media in order to accommodate members who are working parents or others who have difficulty getting to in-person meetings.

The conference helped me better understand some of the challenges and opportunities PFAC members face as they continue to develop and establish their roles within health care organizations here in Massachusetts. I also walked away from the conference with an increased appreciation of the role consumer health advocacy organizations like HCFA can play – through convenings, trainings and providing a space for PFAC members to connect – in supporting these councils so that their engagement is truly purposeful, effective and equitable.  

- Angela Jenkins, Project Manager at Community Catalyst 

July 12, 2016
New residents at BMC attend orientation, which includes a workshop on the social determinants of health. (Martha Bebinger/WBUR)
New residents at BMC attend orientation, which includes a workshop on the social determinants of health. (Martha Bebinger/WBUR)

Last week WBUR reported on an effort to improve doctor-patient relationships by training medical professionals in social determinants of health. These recognize that our health is largely determined by our access to social and economic opportunities, not direct medical care. Some of these factors include access to housing, nutritional food, education, and income supports, among many others. This piece highlights a program that is being implemented at Boston Medical Center, in which resident doctors are being trained to find out what kinds of barriers their patients may face when it comes to being healthy and staying healthy. In an effort to improve patient-centered care, similar trainings to the one at BMC are also being offered to doctors at various hospitals around the country, including Johns Hopkins in Maryland and at Dell Medical School in Texas.

Everyone in Massachusetts deserves the opportunity to lead a healthy life, and it is in our best interest for all doctors to be trained in how health may be affected by social factors. By looking at health from a more holistic perspective, health care professionals can aid in the transformation of the medical system and improve health outcomes. Health Care For All strongly supports the move to address social determinants of health. We believe that there is great value in this approach, as it helps to build patient-centered care and has the potential to positively impact our communities by promoting health equity. 

--Angela Swanson

June 30, 2016

Meals influence doctors' prescibing of brand name drugsRecently, a study (read about it in our post here, and see the Wall Street Journal chart at right) found an unsurprising correlation: doctors receiving free food from pharmaceutical companies are more likely to prescribe higher-priced brand-name drugs; even when the food costs less than $20. So of course, that's how the drug companies market their pills.

Now, a Boston Globe/ProPublica analysis provides insight into the scale to which doctors are receiving payments from both the pharmaceutical and medical device industries. Bottom line: a lot of docs are getting a lot of meals paid for by pharma. A few highlights:

  • Over 50% of affiliated doctors at some Massachusetts community hospitals received payments.
  • At some hospitals, almost everyone was on the take: 77% of doctors at Baystate Noble Hospital in Westfield received payments, mostly in the form of meals. At Mercy Medical Center in Springfield, it was 74%; at Harrington Memorial in Southbridge, it was 71%.
  • Most meals were provided while drug industry representatives provided information on brand name medications for asthma, high cholesterol and blood clots.

The Globe reached out to two doctors who each reported over 200 meal payments during 2014 for comment, but they refused to return multiple emails and phone calls from the paper. At Mercy Medical Center, the Globe reported this non-answer answer:

Mercy Medical Center said it monitors company payments to doctors and has “confidence in our physicians to do the right thing.’’ When they don’t, its statement read, “we take action.” The hospital declined to comment further.

While state law limits drug marketers to providing "modest meals" as part of educational forums, we reiterate our call to tighten the state regulation of what's modest. After all, the state definition was drafted in consultation with pharma lobbyists, and it essentially imposes no real limits. And this new research points to the need to also curb the number of meals provided, as well as the cost per meal.

                                                                                                          - Mike DiBello

June 25, 2016

The room - actually 3 rooms combined - was packed as MassHealth held its first listening session for its federal waiver application which includes its ACO proposal and much more. The session was held in conjunction with the regular meetings of two MassHealth advisory panels. Despite it being a late Friday afternoon before the first weekend of the summer, interest in the proposal was very high. Given the number of speakers, the session, which started at 2:30 was supposed to go to 4, dragged on until almost 5. A second session will be held in Fitchburg on Monday, June 27.

MassHealth staff started with this powerpoint presentation, which summarized the waiver application.  A lot of money is at stake. MassHealth is seeking $1.8 billion over 5 years from the federal government to be used for Delivery System Reform Incentive Payments (DSRIP). These funds will support the transistion to ACOs (Accountable Care Organizations - see our blog post here for more on ACOs). Money will go to provider groups seeking to become ACOs, allowing them to pay for social services as well as medical care. Funds will also go towards integrating behavioral health and long-term care services, and other investments, In addition to the DSRIP money, the state is seeking $6.2 billion over 5 years for safety net providers and to pay for care for the uninsured.

Many speakers focused on the opportunity to expand MassHealth to provide assistance with the social determinants of health, like housing, nutrition and other social services. People representing YMCAs, the Housing and Shelter Alliance, the Pine Street Inn and other groups talked the critical role housing and other services play in promoting health. Similarly, Action for Boston Community Development suggested creating social service "hubs" to connect medical ACOs with smaller agencies which can focus on particular needs. The Boston Center for Independent Living and the Transformation Center talked about the needs of people with disabilities.

HCFA's Oral Health Integration Project spoke about the need to fully connect dental care and oral health with the primary care offered through ACOs. 

HCFA's organizational comments, copied below, focused on three areas of immediate concern. Written comments are due by July 17. In the coming weeks, we will be circulating a sign-on letter for groups to join us in expressing broad community reactions to the waiver proposal. If you are interested in this, please contact Suzanne Curry of HCFA's staff. 

Here are the comments we offered:

Health Care For All Talking Points – MassHealth Waiver Listening Session (Boston 6-24-16)

We have heard the strong emphasis from the administration on ACOs as a way to improve MassHealth’s “sustainability,” which, of course, is code for saving money.

We understand and support this goal, and we also understand the need to secure federal DSRIP funds. But we see ACOs as more than cost savings. It’s an opportunity to restructure care so that the focus is on promoting the health of MassHealth members. Health is more than just what doctors and hospitals do, though they are important. ACOs open the door to a MassHealth system that treats the member as a whole person, rather than as disconnected symptoms.

We’re pleased that the proposal is aimed at:

  • Enacting payment and delivery system reforms that promote integrated, coordinated care and hold providers accountable for the quality and total cost of care;
  • Improve integration of physical health, behavioral health and long-term services and supports, and related social services;
  • Maintain near-universal coverage;
  • Support safety net providers to ensure continued access to care for Medicaid and low-income uninsured individuals;
  • Address the opioid crisis by expanding access to a broad spectrum of recovery-focused substance use disorder services.

Our comments today will focus on 3 areas where we think the waiver can be strengthened, consistent with the goals of the project.

Before I get to our three categories, I want to mention that we also have critical thoughts on the integration of oral health and dental care within the ACO structure. Those issues will be addressed by representatives of the oral health integration project which we lead. We also strongly support the comments you will receive from groups concerned with community health workers, the disability community and the public health community.

Transparency and Oversight

Our first category is transparency and oversight

We’re pleased that the proposal calls for ACOs to include members in their governance, and includes PFACs – patient and family advisory councils – as a requirement for every ACO.

June 21, 2016

Why do pharmaceutical companies pay for doctors’ meals? The answer is simple – it is a not-so-subtle form of bribery designed to influence prescribing practices. If it didn’t work, it is hard to imagine why it would be done. A recent study in JAMA Internal Medicine supports a fairly intuitive notion. Doctors who are wined and dined – even when it costs less than $20 – are more likely to prescribe brand name, highly expensive medications.

Headlines: Study showsmeals influence prescribing

The study found that doctors who received industry sponsored meals were significantly more likely to prescribe brand-name medications, compared to doctors who did not receive industry sponsored meals. Sure enough, doctors who were better fed, receiving either more or pricier meals, displayed an even higher likelihood of prescribing the advertised drug. The association held for four brand-name medications, including rosuvastatin, the third most expensive drug for Medicare Part D.

At HCFA, we are dedicated to advocating for high-quality healthcare at the lowest possible cost to the consumer, which is why we were steadfastly opposed the weakening of our gift ban law in 2012. The original law forbade pharmaceutical companies from providing doctors with free meals or other forms of payment, with the goal of preventing doctors from being tempted into prescribing more expensive drugs with no additional clinical benefit. The weakened law allows for "modest meals," but the regulations effectively put no limits on what can be provided. This new research demonstrates that even modest meals are pernicious. They are not only unnecessary, they are ethically dubious.

The first issue pertains to how doctors are getting their information. Pharmaceutical companies say that the free meals are a component of educational sessions. Should doctors be learning about medications from big-pharma over a pricey steak dinner? Or should they be relying on the latest peer-reviewed scientific studies, weighing the evidence of a multitude of more objective sources? Clearly, for patients to trust their doctors, the integrity of medical information dissemination must be preserved.

The second issue regards costs. Consider a Medicare patient who is prescribed an expensive brand-name drug when a cheaper, equally effective alternative is available. We, the taxpayers, pick up the tab for that drug. Therefore, in return for a small investment in the form of free meals, pharmaceutical companies receive a generous taxpayer subsidy. The same concept applies when insurers are forced to pay for more expensive drugs. That is, they pass on the costs to their members.

With costs of MassHealth rising steadily, it is crucial we find patient-centered ways to control costs. It is time for Massachusetts to reconsider the pharmaceutical gift policy.

                                                                  - Mike DiBello

June 17, 2016

Helen Hendirckson of HCFA at Dental Hygiene Practioner Rally 6-15-16

On Wednesday, HCFA was excited to join with over 60 others gathered in Nurses Hall at the State House to advocate for the creation of a mid-level dental provider in Massachusetts, the Dental Hygiene Practitioner (DHP). The event was attended by people representing those with disabilities, seniors, immigrants, and dental providers.

A provision to authorize DHPs is before the House-Senate conference committee debating the final state budget for fiscal year 2017.

Endorsed by twenty-seven organizations across the state, DHPs are dental hygienists who – after completing additional training – are able to deliver basic but critically necessary care to underserved populations. Services include filling cavities, placing temporary crowns, and extracting loose teeth. DHPs will work under the general supervision of a dentist, using telehealth technology to share X-rays and patient records with the dentist and consult on complicated cases. This will allow DHPs to bring care directly to people in schools, nursing homes, and other community settings.

The bill’s sponsors Senator Harriette Chandler and Rep. William “Smitty” Pignatelli both spoke passionately about the importance of passing this bill to Massachusetts residents. Both legislators represent areas of the state that experience a disproportionate burden of dental disease and face significant challenges in dental care access.

Maura Sullivan, government relations director at the ARC and mom to two children with autism, spoke of the difficulty she’s had accessing dental care for her kids.  Finding a provider who is trained to treat a patient with autism is difficult – but Amendment EHS # 479 includes a requirement that DHP are trained in strategies to treat patients with developmental disabilities.

HCFA’s Oral Health Manger, Helen Hendrickson, stressed the strong and diverse support for this bill by a broad and diverse set of groups who see the need for better dental care for all. 

For more information, check out this post by HCFA Oral Health Policy Analyst Kelly Vitzthum, on the Harvard Petrie-Flom Center's blog, Bill of Health, and read the letter delivered to the legislative leadership by 30 organizations supporting this bill following the rally.

 

                                                                                                                       - Kelly Vitzthum

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