December 2008

December 31, 2008

Today Governor Patrick announced that continued revenue declines will mean more midyear budget cuts. As much as $1 billion in further cuts may be needed. “There’s a lot of pain, and it’s going to have to be spread around,” Patrick said.

But there's one area where tax revenue is up, and it's improving Bay State health as well.

In July, the legislature and governor increased the cigarette tax by $1 a pack, enacting a key priority of HCFA, the ACT!! Coalition and Tobacco Free Mass. The additional revenue goes to fund health reform. At the time, we said the increase would both decrease smoking and increase revenue - a win-win for Massachusetts.

Soon after the increase was put into effect, calls to the Mass Tobacco Control Program 1-800-TRY-TO-STOP quit-line soared.

Now the sales and revenue numbers are in, demonstrating the win-win policy is working. For the four months before the increase (Mar-Jun 08), cigarette sales totaled 92.2 million packs. For the 4 months following the increase (July-Oct 08), cigarette sales dropped to 80.7 million packs. The drop in sales was 12.5%.

The revenue numbers show the opposite effect. For the same 4 months before the increase, revenue was $139 million. For the four months following the increase, revenue was $201 million, an increase of 45%. The roughly $60 million increase will go to the Commonwealth Care Trust Fund, used for health reform coverage expansions.

With all the bad news around, this is something to celebrate.
Brian Rosman

December 31, 2008

With a national focus on e-health as a piece of the national health reform puzzle, and President-elect Obama looking to spend $50 billion on the adoption of e-health technology, the New York Times Business section featured an article this past Saturday about the use of e-health at the Marshfield Clinic in Wisconsin, a large doctors' group with 790 doctors seeing more than 365,000 patients per year at 43 locations.

The article discussed the potential for the technology to increase the use of evidence-based medicine and to help patients manage chronic diseases. It also pointed out how e-health can reduce medical errors. The Marshfield Clinic system warns doctors, when they electronically prescribe medicines, of possible allergic reactions and dangerous interactions with other drugs the patient is taking. A survey published in the New England Journal of Medicine found that 71% of doctors using e-health records with a feature that included such warnings said they had been alerted of medication errors. As the article states, most of the medical groups across the country that have adopted e-health are large and are often insurers as well as providers, while 3/4 of physicians' practices in the country have 10 or fewer doctors and would need financial assistance to successfully implement the technology.

The article did not talk about the steps taken at Marshfield Clinic to educate the patients about electronic health records and their policies regarding privacy protections and notification of security breaches. It is also not clear if Marshfield includes a patient portal in its system, allowing patients to play a role in their care via their health record. Both the privacy protections and the patient portals are pieces of e-health that, from the consumer perspective, are important and should be part of the discussion as e-health moves ahead in Massachusetts and nationally.
Deborah Wachenheim

December 30, 2008

The season of giving is almost over and there’s only one day left to donate to HCFA in 2008. We, like others in these difficult economic times, are struggling to meet our fundraising goals. In order to continue the important work we do and improve the quality and accessibility of health care for all Massachusetts residents, we depend on your generosity. We invite old and new friends to consider making a gift today. If you have not already made a donation to our annual fund and appreciate the work we do, please help out. Click here to make a fully tax deductible contribution. Thanks to you, HCFA’s good work can continue. Melissa S. Freitas

December 29, 2008

Former NEJM editor Marcia Angell lays out the whole range of pharma industry control over medicine in a review, Drug Companies & Doctors: A Story of Corruption in the New York Review of Books. Angell's conclusions bear directly on the research loophole in the draft DPH drug payment disclosure regulations.

She estimates based on their annual reports that pharma provides tens of billions of dollars a year to US doctors: "most doctors take money or gifts from drug companies in one way or another. Many are paid consultants, speakers at company-sponsored meetings, ghost-authors of papers written by drug companies or their agents, and ostensible "researchers" whose contribution often consists merely of putting their patients on a drug and transmitting some token information to the company. Still more doctors are recipients of free meals and other out-and-out gifts. In addition, drug companies subsidize most meetings of professional organizations and most of the continuing medical education needed by doctors to maintain their state licenses."

She examines how the industry manipulates research to support its marketing goals:

Because drug companies insist as a condition of providing funding that they be intimately involved in all aspects of the research they sponsor, they can easily introduce bias in order to make their drugs look better and safer than they are. Before the 1980s, they generally gave faculty investigators total responsibility for the conduct of the work, but now company employees or their agents often design the studies, perform the analysis, write the papers, and decide whether and in what form to publish the results. Sometimes the medical faculty who serve as investigators are little more than hired hands, supplying patients and collecting data according to instructions from the company.

In view of this control and the conflicts of interest that permeate the enterprise, it is not surprising that industry-sponsored trials published in medical journals consistently favor sponsors' drugs—largely because negative results are not published, positive results are repeatedly published in slightly different forms, and a positive spin is put on even negative results.

This, in turn, leads to more expensive, and less effective health care:

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.

One result of the pervasive bias is that physicians learn to practice a very drug-intensive style of medicine. Even when changes in lifestyle would be more effective, doctors and their patients often believe that for every ailment and discontent there is a drug. Physicians are also led to believe that the newest, most expensive brand-name drugs are superior to older drugs or generics, even though there is seldom any evidence to that effect because sponsors do not usually compare their drugs with older drugs at equivalent doses.

We urge DPH to re-examine the research loophole, and allow consumers to see the full extent to which drug company funds are flowing to prescribers in Massachusetts.

December 24, 2008

We promised we would never let this false information go unanswered. Once again, someone has misused the DHCFP study on the cost of mandated health insurance benefits in Massachusetts to make the false claim that mandated benefits add up to 12% of insurance costs. Once again, it's our job to correct the misinformation. (See our original blog here, and our followups correcting the Herald, and HPHC CEO Charlie Baker.)

This time it's the Massachusetts Association of Health Plans (MAHP). In their 2008 annual report, they devote a page to mandated benefits. They claim that "Mandated benefits are one reason the cost of coverage in Massachusetts is so high. A state report tagged the cost of current mandated benefits at $1.3 billion or 12¢ for every dollar paid for health insurance."

No, that's not the conclusion of the DHCFP study. The DHCFP properly takes out from the impact of state mandates the cost of federal mandates and benefits that would be provided even without a mandate. Their conclusion: “mid-range estimates in the three to four percent of premium range (roughly $300 million to $400 million annually) may be a reasonable estimate of the mandate laws’ marginal impact on health care costs directly associated with the covered benefits described in the laws.”

That's three to four percent. Not 12%.

People can disagree over whether specific new mandates are in the public interest or not, and understanding the cost of a mandate is helpful for that discussion. MAHP says we should put a moratorium on new mandates until medical costs remain flat for two years. We might disagree on some mandates, agree on others.

But MAHP along with everyone else has an obligation to be honest with what the authoritative study has concluded.
Brian Rosman

December 23, 2008

Yesterday afternoon, the Department of Revenue (DOR) released their draft penalty guidelines for the uninsured in 2009 as well as an updated report on insurance mandate compliance in 2007.  Click here for the press release, here for the draft penalties and here for the report.

The implementation of the Individual Mandate in 2009 will look very much like 2008, and we thank DOR for releasing the penalties in advance of their January 1st start date and for maintaining last year's simple and fair model.  For those tax-filers under 150% of the federal poverty level, there is no tax penalty.  For tax-filers between 150.1 and 300% fpl, the penalties will remain largely the same as last year, changing only by removing $0.50-an unexpected surprise.  For those above 300% fpl, the penalty is based on the lowest-cost plan available (the penalty is half the monthly premium).

For young adults, the 2009 monthly penalty actually decreases $4 to $52/month, based on lowered premiums.  The penalty for those over age 26 increases $13 to $89/month, largely due to the minimum creditable coverage requirement for prescription drug coverage.

DOR is holding an open public comment period through January 23rd.  Comments can be directed to the Department's Rulings and Regulations Bureau at rulesandregs@dor.state.ma.us.

The ACT!! Coalition has been interested in learning more about who the uninsured are in Massachusetts.  Early this past summer, DOR released preliminary data on the uninsured, based on tax-filing season; the new report is an updated and more detailed version, including late-filers.  The report is mostly consistent with what we already know about Massachusetts uninsured: the state is making incredible progress in covering residents with health insurance.  And those who remain uninsured are more likely to fit in certain demographic categories.  A unique puzzle piece this report adds is how the Affordability Schedule functions.  This data is not a complete picture, since it only reflects information from those who file taxes.

By approximately a 2:1 ratio, uninsured are more likely to be under 40 years of age, male, single, and low-income (62% under $25,526/year).  Interestingly, almost all regions of the state reported an uninsurance level of 2.5-3.3%. The outlier is the Cape and Islands. Nantucket's rate was the highest at 12.6%, with Dukes County (Martha's Vineyard) at 7.5%, and Barnstable County at 4.3%.

According to the DOR data, 5% of Massachusetts adult tax-filers are uninsured.  (This data is 3-4 months older than the recently released Sharon Long/DHCFP report, and it also doesn't include children, who are more likely to be insured.)  Three percent of tax filers were uninsured but deemed able to afford insurance and nearly 2% were uninsured and unable to afford health insurance.  Including individual exemptions, just over 2% of tax filers were exempt from the mandate.  The Affordability Schedule and exemption process offers protection to those 76,000 who cannot afford insurance.   And for those 118,000 who were deemed able to afford insurance, the state collected approximately $16 million.  The state reached out to these individuals, letting them know of the mandate and health insurance options.

Happy holidays, all.
Lindsey Tucker

December 23, 2008

The Congressional Budget Office (CBO), the non-partisan gold standard in evaluating the economic impact of policy change, has determined that requiring disclosure of drug industry payments to physicians will lead to lower health costs.

Throughout our long night of July 31, waiting for the House and Senate to finalize the cost/quality bill that included the prescription reform provisions, a lobbyist for the drug industry kept needling me, "You don't actually believe that this will save costs?"

I said yes back then, and now there's even more evidence. The CBO findings are part of a detailed analysis of over a hundred health policy options released last week. Here's what CBO concluded:

At this time, the Congressional Budget Office cannot estimate how this option might affect spending for Medicare but believes that, over time, disclosure has the potential to reduce spending. For example, hospitals and health plans could use the data collected under this option to ensure that relationships between physicians and manufacturers did not influence decisions about which drugs became part of a formulary (a list of preferred drugs) or were recommended in practice guidelines. Public reporting and disclosure of industry–physician relationships might also encourage physicians to monitor and modify their own behavior. The reporting system that this option would implement and the data that would be collected as a result could become a building block for further regulations that might reduce future costs below the level that they otherwise would attain.

This report follows the strong recommendations of MedPac, the expert group that advises Congress on Medicare policy. Back in June, they put out an in-depth report on public reporting of physicians’ financial relationships with drug and device manufacturers: "studies have shown that physician interactions with the pharmaceutical industry are associated with rapid prescribing of newer, more expensive drugs, decreased prescribing of generic drugs, and physician requests to add drugs to a hospital formulary."

Now, they have put out their recommendations, calling for public reporting.

DPH will hold two hearing on their draft regulations, on January 9 and 12 (details). We will be joining a long list of individuals, groups and experts urging DPH to strengthen their proposed regulations, and thereby reduce health costs.
Brian Rosman

December 23, 2008

A celebration in honor of legislators and community leaders committed to improving the state of oral health in Massachusetts. Sponsored by Watch Your Mouth Massachusetts and the Legislative Oral Health Caucus. Contact Czarina Biton at biton@hcfma.org for more information or click here.

December 23, 2008

This is it - no more short term extensions. This morning federal CMS officials and the Commonwealth reached agreement on a 3-year MassHealth waiver. You can read the official documents here (big pdf).

According to EOHHS, the agreement includes all the elements announced in late September as part of the agreement in principle. Here are the key points from the state's notice to stakeholders:

Key features of the agreement include:

1. The total spending authority granted by the federal government is approximately $21.2 billion, which is $4.3 billion more than in the last three year term.

2. All eligibility and benefit levels are preserved. The agreement secures the ability to claim federal financial participation (FFP) to match state spending on all programs as currently designed, including Commonwealth Care at 300% FPL.

3. The agreement allows the state to meet all of its health care obligations for Fiscal Year 2009. In Fiscal Year 2009, the state will be able to claim $150 million for programs for which it was unable to claim matching funds for in Fiscal Year 2008.

4. The agreement expands the Patrick Administration’s authority to bill for programs in the Safety Net Care Pool by $1 billion over the current waiver period. The Safety Net Care Pool (SNCP) represents authority for federal reimbursement for Commonwealth Care payments, Health Safety Net (the “free care pool”) spending and hospital supplemental payments.

5. A flexible Cap in the Safety Net Care Pool. The federal government has proposed a three-year cumulative cap on Safety Net Care Pool expenditures, instead of the current annual cap. This flexibility allows the state to meet all of its commitments for Fiscal Year 2009 and to plan ahead to meet all Fiscal Year 2010 and Fiscal Year 2011 commitments.

We congratulate all of the Office of Medicaid and EOHHS staff who have been working very long and very hard to get to this point. The agreement allows health reform to continue with federal support through June 2011.

We haven't read through the documents yet, and look forward to the always informative analysis by the Mass Medicaid Policy Institute, due soon.

December 22, 2008

In January, the Legislature will start a new session and will welcome 21 new members of the House and Senate. This moment offers a unique opportunity for many advocates to educate the new members, as well as some of the returning members. Working with the legislative Joint Committee on Children, Families, and Persons With Disabilities, the Children’s Health Access Coalition (CHAC) is organizing a January 26th State House education event on a range of issues related to children called “Health, Housing, and Hunger: The Building Blocks of Childhood Success.” Taking a holistic approach to children’s welfare, CHAC solicited participation from a number of other organizations to bring their expertise in the areas of housing and nutrition. Precarious housing and inadequate nutrition have direct links to poor health outcomes, which in turn stack the deck against children being able to do well in school.

The January 26th event has the potential to help set the tone for the work of the Children, Families, and Persons with Disabilities Committee for the session. Although the Commonwealth is facing difficult financial times, there is still an opportunity to pass meaningful legislation that will make improvements in the lives of children across the state.

In putting together this event, CHAC has an exciting opportunity to collaborate with other organizations who we do not traditionally work with. CHAC has been working closely with several organizations outside the traditional children’s health network including Horizons for Homeless Children, Homes for Families, Project Bread, and the Greater Boston Food Bank.

To learn more about the event contact Matt Noyes at mnoyes@hcfama.org.

December 21, 2008

Every week we highlight the voices of real people that contact our Helpline every day. Once a week you will be introduced to a family whose life has changed for the better due to health reform. If you or anyone you know needs assistance applying for free or low-cost health care coverage, please contact our Helpline online, or call 1-800-272-4232. Here’s this week’s story:

Barbara was born with a health condition called hip dysplasia, causing severe pain which affects her life in many ways. She works as a secretary at a landscape company and is a 22-year-old single mother. She can’t walk well unless she takes a high number of very expensive medications.

She had been uninsured for two years and suffering without the medications that allow her to function normally when she was helped by a counselor at the Helpline. A few weeks after she filled out an application over the phone, she started her Commonwealth Care health insurance coverage and was finally able visit a specialist to take care of her health issues.

Barbara has been in treatment ever since. Pain medication is keeping her comfortable until her surgery scheduled for next month. She will have a hip replacement and the chance of success of her surgery is 98%. She is so excited about her new hip and stresses the important roll that Health Care For All played in helping her through the whole process. Here is what Barbara has to say:

“We are so lucky to be Massachusetts residents. My daughter is 1 year-old and she was born with the same problem I have. But thank to all the health care we receive, her health condition was diagnosed as soon as she was born and she had all the care necessary to fix her hips before she started having severe problems. She used a harness for a period of 4 months which helped to cure her problem. And through MassHealth she has the opportunity to go to the doctor for regular checkups until her situation is normalized. So I couldn’t be happier about the health reform in Massachusetts and all the assistance and care I receive every time I call the helpline.”

Monika Lira Malhoit

December 19, 2008

The Connector Board sneaked in a Friday morning meeting before the anticipated snow storm to vote on the revised Managed Care Organization (MCO) procurement RFP. The Board discussed revisions to the proposed procurement process at length. The Board was also updated on the FY08 Audit Report and the FY09 Administrative Budget. Materials for the meeting can be found here. Full details, after the jump.

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