January 2009

January 30, 2009

Update: Listen here.

Today, WBUR's Radio Boston asks, "Can Mass Healthcare Be Used as a National Model?" The show airs at 1:00 pm today, and repeats at 1:00 pm tomorrow, Saturday. You can also listen online after the show airs.

Host David Boeri spent a good amount of time listening in at HCFA's Helpline, as we helped people get enrolled into coverage. His work on the story is making a difference for Jessica Alpert, an assistant producer of the show, who blogged about her experience.

Ms. Alpert works part-time, and is not offered coverage by BUR. When she moved to Massachusetts, she dreaded applying for good coverage, because she had a number of serious health issues. So she didn't inform the out-of-state insurer on her application for catastrophic-only coverage, fearing she'd be rejected if she told all the details.

What she didn't know is that Massachusetts prohibits insurers from asking about health status, and that low-income people like her are eligible for help in paying for quality comprehensive coverage. Through working on the story, she got connected to the Helpline, which filled out an application for her. She's promised to update her blog with the results.

The show this afternoon takes phone calls - let them here your story.
Brian Rosman

January 29, 2009

The Quality and Cost Council will hold another website launch event tomorrow, January 30, 2:00pm at Fallon Community Health Plan in Worcester (10 Chestnut Street, 9th floor).Speakers will include employers, physicians, and a consumer, in addition to Secretary Bigby, who will announce “My HealthCareOptions Week,” a week during which the public will be encouraged to visit the new website with healthcare quality and cost information (www.mass.gov/myhealthcareoptions).

Speakers include Fallon Community Health Plan CEO Eric Shultz, EOHHS Sec. JudyAnn Bigby, Elizabeth Capstick, Deputy Auditor of Administration and Finance, and Joseph Lawler, The Gaudreau Group.

January 28, 2009

Governor Patrick started the FY 2010 budget process today with the filing of House 1, the administration's budget proposal. Given the steep decline in existing revenues, the budget was bound to be a good news/bad news situation. The budget proposes no direct cuts to benefits or eligibility in health coverage programs. The Governor's deep commitment to health reform is maintained. But deep cuts in public health, along with ongoing cuts in provider rates for public programs, will stretch our health safety net and threaten gains made in the past years.

We're still looking at the details ourselves, and have a number of questions for the administration. But here's our initial take.

The extensive online materials include a helpful page summarizing the accomplishments of health reform, and an overview of the health access program budget levels proposed in House 1. The budget assumes a cut in MassHealth spending of $374 million. Without the cuts, MassHealth would grow about 7.3%; the cuts reduce the spending growth rate to 3.14%. Because of the loss of federal revenue, the $374 million in cuts saves the state only half of the amount, $178 million.

Speaking of federal revenue, it's not clear from a quick read how the Governor proposes to use the additional federal Medicaid reimbursements expected as part of the recovery package. The package is expected to include several categories of additional federal aid. The budget does count additional federal revenues, but we will seek clarification to make sure that all of the Medicaid revenue goes to health, as Congress has indicated.

No direct cuts were proposed to MassHealth services or eligibility levels. The cuts include the elimination of outreach and enrollment grants, which have been critical in helping people get connected to health programs and navigate the maze of health care programs. Assistance from local community groups has become more important as many people encounter difficulties staying enrolled once they initially sign up.  Other savings come from holding rate increases to around 1% on average, tightening some service management, and expanding the use of generic drugs. We were pleased to see a $10 million investment in expanding “medical homes,” a patient-focused primary care model for patients with chronic disease.  Details on the MassHealth savings can be found here  (scroll down to Medicaid Cost Controls and Savings).

The budget funds the Commonwealth Care program at $880 million, compared to spending this year  estimated at to be at $820 million (this is less than the $869 million originally budgeted, due to the stagnation in net enrollment growth).  This amount assumes some renewed growth in CommCare enrollment, based on the worsened economy.

The Health Safety Net program (formerly the Uncompensated Care Pool) is expected to continue its slow decline, as insurance coverage expands. Spending is estimated at $381 million, compared to $406 million this year. Because of the decline, the administration proposes that no General Fund  subsidy will be required for the program. The budget materials do caution, however, that there is uncertainty around the forecast and that a cushion has been built in the assumptions.

The outside sections include a welcome provision that allows benefits to be adjusted in the Children's Medical Security Plan. Under current law, many low-income kids exhaust their CMSP benefits, and the Children's Health Access Coalition is sponsoring legislation to bring CMSP benefits up to the MassHealth level. CHAC will work with the administration and legislature to strengthen the CMSP benefits to meet the goal of keeping kids healthy.

Several initiatives will cut needless spending and improve health quality. One outside section prohibits payments for healthcare-associated infections, and another authorizes a hospital payment demonstration that would creating incentives for hospitals to integrate services, manage costs and utilization, and ensure high-quality care. MassHealth will also expand its pay for performance contracting.

The steep public health cuts are worrisome, and ultimately counterproductive. The budget does propose some innovative dedicated revenue streams for public health, but these do not make up for the blunt cuts. For example, today the Governor made an additional $99,000 cut to the Department of Public Health's oral health services line item for FY09. Oral health programs funded through DPH were cut by $570,000 during the first round of 9C cuts in October. Therefore, approximately $670,000 has been cut from oral health programs since October, affecting the BEST oral health program, the Cape Cod Dentist Care program, the ForsythKids program, Taunton Oral Health Center and Tufts Dental Facilities. We will be working with the Mass Public Health Association and United We Stand for Public Health Coalition to reverse these cuts and prevent further cuts from going this deep.
Brian Rosman

January 27, 2009

CommonWealth Magazine's terrific CommonWealth Unbound blog recently highlighted how a safety checklist can reduce the number of deaths from hospital-acquired infections.

According to the author, a flight training manual developed in 1980s states the following, “[E]ven the most experienced professional pilots never attempt to fly without an appropriate checklist. The habit of using a written checklist … should be so instilled in pilots that they will follow this practice throughout their flying activities.” Some 80% of all general aviation accidents in the United States are caused by errors on behalf of the pilot. One missed step in the pre-flight process could cost a life and, therefore, the use of a checklist has become an industry standard. It is only recently that the medical community has discovered the benefits of using a checklist.

Now, 100,000 people die each year from hospital-acquired infections. It is the 10th leading cause of death in the United States. The author states, referring to Dr. Peter Pronovost, who created a checklist to prevent infections, “Dr. Pronovost found that making a habit of using this checklist every time, for every patient, by every caregiver, had dramatic results. He proved that use of this checklist in surgical ICUs had dramatically reduced the number of catheter-related blood stream infections in patients.” However, as the author observes, despite the success of a checklist, many hospitals around the country and in Massachusetts have not systematically implemented checklists.

As we've blogged, the Consumer Health Quality Council, a unique HCFA coalition of consumers who have been impacted by poor quality care, has worked with legislators to file three bills, one of which encourages the use of checklists of care in hospitals in the Commonwealth. Should the bill pass and become law, perhaps the high numbers of infections and medical errors will, as Brown suggests in the article, become “a thing of the past.”
Kuong Ly

January 26, 2009

“These are not bad people or lazy people suffering in this economy – All people are suffering” - Dr. Deborah Frank, Children’s Sentinel Nutrition Assessment Program (C-SNAP) Education had long been touted as the silver bullet to solve issues of poverty and inequality. But education alone is not enough – if basic needs are not addressed, the best school in the world won’t be enough. A child can’t learn if they are sick. A child can’t learn if they are homeless. A child can’t learn if they are hungry. At the start of the 2009-2010 legislative session, healthcare, housing, and hunger prevention advocates collaborated on a legislative briefing that connected all three issue areas to form a basis for childhood success. Hosted by HCFA’s Amy Whitcomb Slemmer, the forum featured remarks from Diane Sullivan of Homes for Families, Helen Caulton-Harris of the Springfield Department of Health and Human Services, Ellen Parker of Project Bread, and Dr. Deborah Frank of C-SNAP. Especially in the current economic climate, it is vitally important for advocates to work together on shared goals and missions. Health care, housing, and hunger prevention do not exist independently of each other – rather, we have to take a holistic view of children. This morning’s briefing marks the beginning of new collaborative work between HCFA and many new partners. To paraphrase what has become a popular political slogan: Together, we can help all children achieve success in school and in life. Matt Noyes

January 26, 2009

HCFA applauds the hard work of Speaker Sal DiMasi and his unwavering commitment to health reform in Massachusetts. DiMasi was a driving force behind the law. With just two years of implementation, over 440,000 previously uninsured people now have health insurance. The Speaker’s deep commitment to social justice shined through the countless hours and political capital he dedicated to making real reform a reality.

While health reform gets the headlines, we would like to take a moment to recognize other areas where the Speaker’s leadership improved access for the Commonwealth’s most vulnerable. Many thanks to DiMasi for his work on MassHealth Equality, which requires the state Medicaid program to provide equal treatment to same-sex couples; on reforming children’s mental health services to prioritize what is in the best interest of the child, and breaking down administrative silos; on Mental Health Parity, which requires insurers to provide the same coverage to mental health as they would to physical health; on expanding access to quality oral health services to those most in need; and, on legislation that requires more compassionate long term care, just to list a few of many initiatives he championed.

On behalf of the Commonwealth’s health care consumers, we thank you, Mister Speaker and your amazing staff, for your leadership and compassion.

January 26, 2009

Over the weekend we blogged that the tipping point on disclosure of payments by pharma and device makers has already been reached. Between state and federal initiatives, and the rush to get ahead of regulation by voluntary disclosures, the industry will have to change. Those trying to hold back the tide (like the hotel industry) don't see what's happening.

More evidence today of the tide becoming a flood, from the WSJ:

A medical society representing U.S. spine surgeons has taken the rare step of requiring that researchers disclose not just the existence of financial ties to medical-device companies, but the dollar amounts as well.

The initiative is a response by the North American Spine Society to pressure from lawmakers, prosecutors and lawsuits by companies' former employees. Prominent surgeons doing research have been found to have significant financial relationships -- sometimes to the tune of millions of dollars -- with medical-device firms.

NASS, which has more than 5,000 members, said the new disclosure policy will apply to doctors who present studies at future medical conferences.

The society said its policy "is not a voluntary guideline, but a binding covenant which applies to all relationships engaged in by all participants in all" activities of the spine society. Failure to disclose would be a "sanctionable offense," the spine society said. Sanctions could include suspension, expulsion or public letters of censure. ...

"It just became clear that more transparency is better," said the spine society's ethics-committee chairwoman, Marjorie Eskay-Auerbach, an orthopedic surgeon in Tucson, Ariz. She said she doesn't know of other professional groups or journals with similarly stringent disclosure rules.
In recent years, medical-implant makers Zimmer Holdings Inc., Stryker Corp., the DePuy orthopedics unit of Johnson & Johnson, and Biomet Inc. have paid more than $221 million to surgeon "consultants," according to a Senate committee.

Medtronic Inc. has been accused by former employees and the government of inducing surgeons to use its spine products through questionable payments. In 2006, the Minneapolis company agreed to pay $40 million to the government to settle civil charges in federal court in Memphis, Tenn., that it paid kickbacks to doctors, but denied wrongdoing.

UPDATE: 20 minutes after we posted this, we saw this item from the Des Moines Register:

Iowa City, Ia. — A new University of Iowa policy would prohibit physicians from giving free drug samples to patients, a long-standing practice that hospital leaders and consumer advocates say contributes to the ballooning cost of health care.

Other changes include barring U of I Health Care employees from accepting gifts and meals from private companies and requiring all doctors who do industry consulting to report who they work for and how much they are paid.
"Will I get a lot of tomatoes and rotten eggs? Yes," [Vice President for Medical Affairs Jean] Robillard said. "But this is absolutely the right thing to do. We have a responsibility to our patients."

January 26, 2009

Dr. Joel Pearlman has been working continuously with the Tufts Dental Facilities serving Persons with Special Needs since the late 1970’s. He has dedicated his career to improving the oral health of patients with developmental disabilities, where he ensures that his patients and their families are treated with the dignity and compassion that they deserve. In that time, in addition to the thousands of patients he has seen, he has served as a mentor to numerous post graduate dental students and 4th year dental students alike.

He has shared exceptional clinical skills, with his many students over the years, and mentored and inspired numerous clinicians to become experts in the treatment of individuals with special needs. Several of those individuals remain as clinicians in those facilities today. Many of his former students and colleagues spoke up to nominate Dr. Pearlman for this award. These individuals describe Dr. Pearlman as selfless, giving, committed, kind, compassionate, and a “true oral health hero.”

Watch Your Mouth will honor the relentless work of Dr. Pearlman, as well as Senate President Therese Murray and Representative William Smitty Pignatelli on February 2, 2009 at our Fourth Annual Oral Health Heroes Event. The event will take place in Nurses Hall at the Massachusetts State House from 1-2pm. Please join us in thanking Dr. Pearlman for his dedication to the health of our community.

If you can join us, please RSVP by January 27th to Czarina Biton at 617-275-2838 or Biton@hcfama.org.

To learn more about Watch Your Mouth, visit www.watchyourmouth.org.
Christine Keeves

January 25, 2009

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:

Ann had just learned about her family’s eligibility for MassHealth and Commonwealth Care when she first brought her 12-year-old-daughter to the pediatrician for a regular visit. She says that it was just essential for her daughter to get the best care because the doctor had just diagnosed her with scoliosis, a serious spine issue that if not taken care of in time can cause respiratory and heart problems.

Her MassHealth coverage allowed her to be seen by a specialist who started her treatment, which was to wear back braces for 20 hours per day. Ann says that her daughter has now been using the braces for a period of two years, and she has visited the specialist for regular check-ups very often. She’ll have to use the brace until she stops growing, which the specialist thinks might happen in about 1 year, when she turns sixteen years old.

Ann watches her daughter’s treatment closely and she feels terrified when thinking about the possibility of seeing her with any kind of health complication. She says that she can’t jut thank the Helpline and MassHealth enough for all the great treatment they have brought to their life. These are her own words:

“The Helpline has been always wonderful to us. I feel that I can’t be grateful enough for all the good they bring to ours lives. I’m always in touch with them whether I need help with a review form, questions about health reform, health resources, or even for advice. I’m so happy for the possibility offered to my daughter to take care of her health, in addition to the Commonwealth Care for all kinds of routines exams I need to go through. So, thank you to all of you that make this state a better place to live.”

Monika Lira Malhoit

January 24, 2009

Sometimes the world starts changing so fast, those wedded to the status quo don't even realize what's happening.

So today the Globe leads with the pleas of the pharma and device industry via their fronts, the hotel and convention industry. Over at DPH, over a dozen hotels submitted word-for-word identical testimony. The industry, wanting to cling to the old ways, doesn't understand that it's all changing.

Here's the best evidence of the shift. When you're mocked by The Onion, it's over. Read this:

Powerful Rest And Fluids Industry Influencing Doctors' Treatment Of Colds

WASHINGTON—A two-year investigation conducted in five major cities has exposed a widespread campaign by the formidable Rest and Fluids industry to infiltrate thousands of doctors' offices and dictate how they treat minor illnesses.

The investigation—the full details of which will be disclosed in this newspaper over the coming months—documented thousands of instances in which sick patients were repeatedly instructed, often verbatim, to "lie down and drink plenty of liquids." This treatment, recommended a staggering 4 out of 5 times on average, was in each case prescribed by a physician known to have recently enjoyed a golf vacation courtesy of Big Rest and Fluids.

The hotel industry is not being told by their industry puppetmasters what's really happening. In fact, the DPH regulations merely enforce the industry's own new codes of conduct. The agency that accredits medical education already requires full disclosure of corporate payments and prohibits industry control of programs (standards). The DPH gift ban echoes the restrictions in the new PhRMA code. Senators Grassley and Kohl introduced federal legislation yesterday that would make disclosure mandatory nationally. Senator Max Baucus’ recent position paper on health care reform and the Medicare Payment Advisory Commission have both recommended the disclosure of industry payments to prescribers. Other states are moving to pass similar legislation.

Today's New York Times article lays it all out. The tide has shifted:

There is little question that battles over how much companies, doctors and medical institutions disclose about their financial ties will continue. But some experts on medical conflicts of interest, seeing the rapid fall of resistance by most major companies, say that a turning point has arrived.

“We are definitely moving toward more disclosure and disclosure of information that is useful to people,” said Lisa Bero, a pharmacy professor at the University of California, San Francisco.

Recently, several big pharmaceutical companies have also said they plan to release the names of doctors they use as consultants.
Some hospital systems, including the big Kaiser Permanente network, bar physicians from taking industry money and now require device suppliers to compete on the same basis on which most medical products are purchased — price.

In recent months, the ground has shifted so rapidly under device makers that companies find themselves scrambling to keep up.

The article presents example after example of device companies deciding to report their payments to physicians, either voluntarily or under court order.

Or look at this week's New England Journal of Medicine. Correspondent Robert Steinbrook, M.D. reports that more and more academic medical institutions are requiring full disclosure of all financial ties between doctors and industry. The Cleveland Clinic, Duke, Univ. of Pennsylvania and others are making the move.

The train has left the station, but some of the passengers aren't even aware. It's almost sad.
Brian Rosman and Georgia Maheras

January 23, 2009

Over the past week, HCFA has been highlighting our 2009 legislative agenda. Parts one and two covered children's health and health reform. Our sthird and fourth topics covered quality and electronic health privacy, and disparities. Part 5 looked at prescription data mining. For part 6, we highlight the priorities of the Oral Health Advocacy Task Force. The Taskforce is supporting three important bills filed by the Chairs of the Legislative Oral Health Caucus, Senator Harriette Chandler and Representative John Scibak, each seeking to increase access to preventive oral health care and improve the overall health of the Commonwealth. Below is a summary of each bill: 1.Integrating Oral Health Care and Medical Care – Oral health is an essential part of overall health. Dental decay is caused by a bacterial infection in the mouth and is the most common chronic childhood disease. If left untreated, dental disease can interfere with basic life activities, such as eating, speaking, learning and working. Nationally, children miss more than 51 million school hours due to dental related illness. In adults, dental disease has been linked to a multitude of complex health problems such as heart disease, stroke, diabetes, and low-birth weight and premature infant births. Children have frequent contact with a physician early on, while many lack a dental home. This makes physicians a crucial resource in delivering preventive oral health care. Currently, 25 states reimburse physicians for providing basic preventive oral health care for children during well child visits. Many of these states already have training toolkits in place, as does Massachusetts. Applying fluoride varnish to children’s teeth is an easy technique for providers to learn, and is effective in preventing decay. In states where a fluoride varnish benefit is provided, it also serves as an opportunity to educate parents about the importance of oral health and to refer the child to a dental home to receive complete and consistent oral health care. MassHealth began offering a fluoride varnish benefit through medical providers during 2008. These physicians are now able to apply fluoride varnish in the course of a well child visit in order to prevent dental disease. This bill will bring private insurers in line with best practices and provide all children in the Commonwealth with access to this effective preventive measure. It is an easy and effective way to increase access to preventive measures and improve oral health and overall health. 2.Equitable Dental Reimbursement Rates – Dental rates, especially for adults, continue to fall far below the cost of providing care. As a result, MassHealth dental providers are forced to make up the difference between the cost of care and the rate at which they are reimbursed. Equitable reimbursement rates for MassHealth dental services are critical to increasing access to dental care and ensuring the health of vulnerable populations. States that increase these rates typically see a one-third increase in the number of providers accepting MassHealth, and sometimes the number has doubled. This significantly increases access to both preventive and restorative care. On average, every dollar spent on preventive care saves $38 in future treatment. Improved access saves money for both consumers and the state, while protecting overall health. This bill would require the EOHHS to develop a plan to index the child and adult dental fee schedule, to the 75th percentile of the most recent American Dental Association Survey of Dental Fees in New England by January 1, 2013. 3. Whole Body Commonwealth Care Coverage - Dental coverage is critical to maintaining overall health. The good news is that dental benefits for adults on MassHealth were restored as a result of Health Reform. Unfortunately, dental benefits are not offered to individuals with Commonwealth Care plans with incomes above 100% but below 300% of the poverty line. Lack of access to dental care causes needless pain, suffering, and illness, and wastes millions in extensive and costly services in emergency and inpatient hospital settings. Dental insurance is health insurance. As with medical insurance we know that children and adults who lack dental insurance and/or adequate funds to pay for services out-of-pocket often forego needed preventive and restorative care. Much like delaying medical care, delaying dental care can have profound and negative effects on a person’s overall health. The Connector has taken steps to evaluate the addition of this important benefit to all Commonwealth Care plans. We urge them to move forward with the addition of dental benefits. This step would prove to be both cost effective and essential in protecting whole body health in the way that health reform is meant to. This bill would require that Commonwealth Care plans offered to adults with incomes below 300% include comprehensive dental benefits.

January 23, 2009

Two separate State House rallies today made the case against further health cuts. And now an analysis of the proposed federal economic recovery package shows that Massachusetts should be receiving sufficient federal health funds to stave off further cuts -- and possibly reverse current cuts.

The first rally was sponsored by United We Stand For Public Health, a reborn coalition to protect our invaluable public health system. Several hundred people gathered in Nurses Hall to hear how public health cuts hurt - and how the strength of our community depends on public health. Later, the "Put Patients First" coalition delivered more than 5,000 postcards and letters to the governor, demanding the restoration of cuts to key safety net hospitals Boston Medical Center and Cambridge Health Alliance. HCFA participated in both events.

Here's NECN's coverage:

Today, the expert Center on Budget and Policy Priorities released their analysis (pdf, too) of the estimated new revenue Massachusetts and other states would receive under the proposed federal economic recovery package. The bill moved swiftly through the House committee process today, with full House approval expected next week. The Senate version has not been released, but action is due soon there as well.

The bill includes an $88 billion increase in Medicaid funds to states, through a temporary increase in the matching rate, for 2 1/4 years. Massachusetts currently gets a 50% matching rate (called FMAP), meaning the federal government reimburses the Commonwealth 50 cents for every dollar we spend on Medicaid. Under the House proposal, the rate would increase to at least 54.9%, and would go higher if we have a large increase in unemployment.

In addition to the health funds, the bill also proposes multi-billion dollar investments in specific state programs for education, infrastructure, human services, and $79 billion in general assistance to be divided between education and general state needs (apparently, Massachusetts doesn't subscribe to the service which publishes estimated state-by-state allocations of other funding, so we can't present a total for the other funds.)

The FMAP increase translates into lots of federal revenue:

FY 2009: $554,879,000

FY 2010: $1,361,344,000

FY 2011: $720,329,000

Total for 3 years: $2,636,552,000

To put the numbers in context, the Medicaid 9C cuts of last October was around $300 million. The Department of Public Health cut was $28.3 million, one of the highest percentage cuts of any EOHHS agency and among the highest percentage cuts for any area of state government.

Two key points:

First, although the final amounts may be higher or lower, the range will be close to the above numbers. With substantial help on the way, it is critical that state officials hold off on any more health cuts so that the new funds can be taken into account. Cuts to safety net programs and providers will result in the closing of facilities, the reduction of capacity, and the laying off of employees. The actions are difficult and time-consuming to reverse. Meanwhile, long-term health suffers, and we all will pay the cost. The administration should not put health programs through the painful cuts process when it is clear that funds will soon be available to allow the state to avoid much of the cuts.

Second, we must insist that the FMAP funds be reinvested into the health care system. To scoop these health funds for other purposes would violate Congressional intent, break precedent, and show bad faith. The Congressional intent cannot be more clear: "The bill would provide, on a temporary basis, additional federal matching funds to help states maintain their Medicaid programs in the face of recession-driven revenue declines and caseload increases." During the 2003 recession, funds from a similar FMAP increase were segregated in its own fund, and used to restore health budget cuts. Massachusetts will be getting lots of other new federal revenues designated for other purposes. Health money must be used for health.

The health community already agreed to major increases in premiums paid by low-income CommCare recipients, to increased assessments on insurers, employers and hospitals, and we spearheaded a $175 million cigarette tax increase. There is growing support for additional revenue dedicated to health, and broad revenue measures. With the federal funds likely to be approved, by mid-February, we urge the administration to delay implementing any addition cuts to health programs.
Brian Rosman