March 2009

March 31, 2009

This past Sunday and Monday, the Center on Budget and Policy Priorities and the Georgetown Center for Children and Families gathered advocates from around the country to discuss the recently-passed Children’s Health Insurance Program Reauthorization Act (CHIPRA). The new law will be a major step forward in providing health coverage to millions of children who are currently uninsured.

The conference itself was jam-packed with information, but here are some significant take-aways:

  • Although everyone would like to see CHIPRA implemented as soon as possible, there have been delays as the new HHS secretary and CMS director have yet to be confirmed by the Senate. As soon as those posts are filled, expect RFRs and regulatory guidances to be issued quickly.
  • States have an opportunity to get an enhanced federal matching rate if they enroll more eligible kids into CHIP. However, to even be eligible for this higher rate, each state must adopt a series of administrative streamlining regulations, including establishing 12 month continuous eligibility under both Medicaid and CHIP. HCFA and the Children’s Health Access Coalition are supporting legislation that would make exactly this change.
  • Massachusetts stands to see significant cost savings due to the removal of the 5 year waiting period for legal immigrant children. Massachusetts already covers these children using state funds through the Children’s Medical Security Plan (CMSP), but according to EOHHS, there will be an estimated 500 children who will now be CHIP-eligible when the state takes up this option. In these difficult fiscal times, every dollar saved is important.
  • CHIPRA doesn’t just provide health coverage – it also attempts to improve child health quality. According to a 2007 New England Journal of Medicine article, only 53% of children received appropriate care for chronic medical conditions, 41% received adequate preventive care, and 68% got treatment for acute medical problems. CHIPRA contains $225 million in funding specifically targeted toward child health quality initiatives. We have a real chance to make significant improvements not only in health access, but also on health outcomes.

The conference was too full to allow for sight-seeing, but I am pleased to report that the Cherry Blossoms on Haines Point appear to be on schedule to bloom just in time for next weekend’s Cherry Blossom Festival – at least that’s how they looked out the window of the Metro …
Matt Noyes

March 31, 2009

Today HCFA hosted the consumer stakeholder engagement meeting with the Special Commission on the Health Payment System. The Payment Commission is holding a second round of meetings with stakeholders prior to their coming up with recommendations for revamping the health payment system in Massachusetts.

Their first meeting to begin discussing recommendations will be this Friday, April 3, from 12-5 (5 hours!), at 1 Ashburton, 21st floor, Boston. Materials will be posted here.

At today's consumer session, Commission consultant Michael Bailit heard from HCFA, consumers from the Consumer Quality Council, Mass Public Health Association, AARP, Mass Law Reform Institute and Community Catalyst.

We prepared a preliminary list of points for the Commission to consider. What do you think?

Health Care For All strongly supports reform of our health payment system. Our current system, built on a foundation of fragmented fee-for-service payments, does not promote high-value and high-quality care. We support an all-payer reform that rewards accessible, coordinated, patient-centered care that focuses on health and disease prevention. Payment methodologies should favor primary and preventive care, encourage collaboration among providers and include accountability for patient health. Payment systems must also take into account the role of public health, and the special health care requirements of those with particular needs, such as the disabled, those chronically ill, immigrants, low and moderate income people, seniors and children.

We ask that the Commission take into consideration the following points in formulating its recommendations:

1. Transparency. The payment system must be totally transparent. Measures of care and incentives built into payment system must be open, transparent, and understandable by patients, such that each patient can see how these incentives are related to him or herself. Consumers must have access to their own medical records. Transparency must take into account linguistic capacity and cultural awareness.

2. Phased-in approach to bundled/global payments. We believe that over time, payments should cover larger bundles of services in both time and number of providers. An immediate first step is to decrease payments for potentially preventable hospital complications and potentially preventable hospital readmissions.

Vulnerable consumers need to be protected. We must guard against any structure that would incentivize providers to avoid high risk or chronically ill patients. Any risk adjustment should include provisions for socio-economic status and other social factors affecting care. We need proven systems in place that achieve real care coordination.

3. Patient activation and empowerment. A number of patient activation and patient empowerment methods have been shown to lead to better health outcomes, reduced disparities, and better satisfaction with one’s health care, as well as reduced costs. Models such as chronic disease self-management, ideal medical practices, and others should be promoted by a payment system that supports medical homes and other patient-centered practice arrangements. Measurably and systematically increasing patient empowerment is key to improving quality and stabilizing health care costs

4. Value-based benefit designs that support prevention and primary care. We support benefit designs that reduce or eliminate cost sharing for cost-effective preventive services and primary care. We oppose tiering arrangements and high-deductible plans that place inappropriate burdens on consumers who are not equipped to understand or accept the risks these plans impose on patients.

5. Support the role of public health through the payment system. Public health concerns must be integrated with the payment system. Patient education by community health workers and others should be accounted for in payment models. Payers should contribute to cost-effective public health interventions that improve the health of the general population.

March 31, 2009

On Monday, the Department of Public Health held a public hearing in Springfield on the proposed amendments implementing certain provisions of chapter 305. Consumer Health Quality Council member John McCormack gave testimony on behalf of the Consumer Council regarding how Chapter 305 can advance patient safety and health care quality for all Massachusetts health care consumers.
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John’s story was one of four consumer stories released earlier this month at our Quality Care Saves Lives event at the State House. You can view the story of John’s daughter Taylor above, and see other videos at www.hcfama.org/quality/stories. Introducing himself at the public hearing as a father and an advocate for patients’ rights in hospitals, and speaking about the proposed Patient Rapid Response Methods (PRRMs), John said “I believe that had such a system been in place when Taylor was in the hospital, she would still be alive today.”

Urging hospitals to do their utmost to educate patients and family about how and when to active the rapid response method, John also asked that there be a requirement that hospitals report to DPH on the use of PPRMs by patients, family and staff so that DPH and hospitals can assess how and when they are activated and how successful they are at preventing further deterioration in patients’ health.

John and members of the Consumer Council advocated for Chapter 305 and have offered to DPH and others to serve as a resource as these regulations are implemented.
Kuong Ly

March 30, 2009

Check out the PBS Frontline special, “Sick Around America.” It airs Tuesday, March 31 at 9 PM and will follow individuals & families across the US as they recount their successes and failures with our health care system.

A few people have nothing but positive experiences, such as Mark and Melinda Murray, who happily found that 100% of costs related to a prolonged and complicated pregnancy was covered under Mark’s employee health plan at Microsoft. Others, like Jennifer Thompson of California were dumped by their insurer just when the insurance was needed the most. Georgetown University Professor Karen Pollitz explains that for many people, the current system is “like having an airbag in your car that’s made out of tissue paper: I’m so glad that it’s there, but if I ever get in a crash, it’s not going to protect me.”

Side effects of Massachusetts’ pioneering health reform will also be featured. The program will document the Abramses, a Massachusetts family struggling, to comply with the state’s mandatory health insurance policy since they can’t afford $12,000 a year to purchase private insurance, but make too much to qualify for Commonwealth Care.

The program will also investigate options for national reform and what assumptions and practices must change before any substantial systemic reform. In states unlike Massachusetts, which bans medical underwriting, keeping one's insurance means staying healthy. For those Americans who find health coverage in the private market, there’s no guarantee it will protect them. In 2007, Palm Desert, Calif., realtor Jennifer Thompson received a letter from Blue Cross accepting her for coverage that read: “Congratulations! You have been approved for coverage with Blue Cross of California. ... The immediate value of your coverage is peace of mind.” But then Thompson discovered she had a cancer that required surgery, and three days after leaving the hospital, she received a letter from Blue Cross saying that her insurance was “rescinded,” leaving her uninsured and owing more than $160,000 in medical bills. Blue Cross cited Thompson’s previous history of cancer and results from a recent doctor’s visit as the reasons for the rescission.
Caitlin Outterson

March 30, 2009

Please attend if you have an interest in how electronic health record systems will be implemented!
When: TODAY, March 30, 3:30 - 5:00
Where: 1 Ashburton Place, 11th floor, Matta Conference Room

March 27, 2009

Back after a brief vacation, 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 entry:

When Camila first contacted Health Care for All two years ago, her family had been uninsured for a period of almost two years when her friend suggested that she contact the Helpline. Her biggest concern at the time was trying to find help for her five-year-old son who had serious speech problems. At the age of five, Marcos wasn’t really able to speak and achieve the milestone behaviors of other kids his age.

A Helpline counselor helped Camila’s family to fill out the application form for MassHealth and Commonwealth Care, and within weeks she was notified of her family’s eligibility. Camila and her husband were eligible for Commonwealth Care and her son was determined to be eligible for MassHealth. Camila says that having access to quality, affordable health care coverage was such a great change in their lives.

Before having coverage, she says that she didn’t know how to deal with her son’s speech problems. She knew that she needed professional help, but she couldn’t afford to pay out-of-pocket to take her son to the doctor. Now, with his MassHealth coverage in place, Camila has the opportunity to bring Marcos to a specialist. She says that at the beginning it was hard to see her little one struggling to speak, but after some intense treatment, she couldn’t believe the great improvement her son was making. For the first time, she says that she could communicate with and better understand him. Here is what she had to say:

“I’m just so excited and immensely grateful for all the help given to our family. I really appreciate all the beautiful work that Health Care For All does in Massachusetts. I’d also like to give a big “thank you” to MassHealth for providing us with the state health insurance programs. It feels like a big window opened and let in the sun, now that I can communicate with my son. We know each other better because we can express ourselves, and it is just amazing seeing the growth of my son every day of his life.”

Monika Lira Malhoit

March 27, 2009

Earlier today MassHealth announced their return to a 45-day redetermination cycle for Eligibility Review Verification forms. In mid-December of 2008, this return time was shortened to 30 days as a cost-saving measure for the state. As part of the federal stimulus package, the state is receiving increased federal match money for our Medicaid program (FMAP). Since these funds are contingent on the state meeting maintenance of effort requirements, the state is moving back to a 45-day cycle. All households selected for annual review on or after March 30, 2009 for any public program will have 45 days to complete and return the form.

Advocates across the state had been concerned that 30 days was not sufficient time for many individuals to return their forms, and we thank the Governor, Secretary Bigby, and your staffs for this change.
Lindsey Tucker

March 27, 2009

Two Pharma-related items to report:

1. Data Mining Hearing at the State House

Yesterday the Joint Committee on Health Care Financing held a hearing on several bills related to data mining (S. 17, S. 19, H. 109, and H. 110). These bills prevent pharmaceutical companies from buying doctors’ prescribing records from pharmacies and using that information to target their marketing to physicians.

Here's our video describing the process:
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Representative Provost started us off with a wonderful description of why this ban is needed. Our thanks to her for such impassioned and clear testimony!

Next up was a panel from the Massachusetts Prescription Reform Coalition (MPRC) consisting of Jessica Hamilton of HCFA, Wells Wilkinson of the Prescription Project and Jasmin Weaver from the Change to Win labor coalition. Jessica Hamilton introduced the panel and reminded the Committee that this bill passed the House last year and emphasized the need to protect patient and prescriber privacy. Additionally, she explained that the bills only ban the use of data for marketing and not for any other purpose. Wells Wilkinson then explained the practice of data mining (see our video here for the details) to the Committee. He also discussed the harms that can come to patients through the use of this data for marketing purposes. Data mining allows pharmaceutical detailers to target potential prescribers and drive up the sales of brand-new drugs. The risks of new drugs are higher than older drugs- Vioxx being the preeminent example. Next, Jasmin Weaver spoke about the need to protect patient privacy and gave the example of CVS/Caremark marketing on behalf of Merck to their pharmacy patients. When asked, by Senator Candaras, Representative Grant and Representative D’Amico, why this practice was not a violation of HIPAA, Weaver and Wilkinson replied that this practice is a loophole under HIPAA and is actually allowed. This law will close that loophole for Massachusetts.

Industry got its turn with a panel of three: Randy Frankl from IMS Health, Prof. Ernie Berndt, from MIT and Steve Mulloney from Mass Biotech. They think there is nothing wrong with the use of this information and only harm can come from the passage of this ban. Interestingly, they argued without justification that since the rate of increase in pharmaceutical costs was declining (though costs are still increasing) during the expansion of data mining, than banning the process will not save money. Malone also said that “the authors of this legislation (they are Senators Montigny and Moore and Representatives Kulik and Mariano) have a fundamental misunderstanding” of the biotech industry.

After a small discussion about provider education, Senator Moore recommended that industry become non-profits and donate money to the state’s academic detailing program so providers could get comprehensive drug information. There were no takers….In the end, Senator Moore said he wasn’t convinced by their arguments about the "benefits" of data mining.

Next we heard from a second MPRC panel with Sue Kirby (Mass. Senior Action Council), Deirdre Cummings (MASSPIRG), and Debbie Banda (AARP). Bringing the consumer perspective, Debbie Banda first spoke about the need to ban this practice so we can constrain health care costs. Deirdre Cummings explained the potential risks new medications have for patients. Sue Kirby emphasized the impact of data mining on seniors. Senator Moore asked why so many brand name drugs are prescribed when there is an automatic generic substitution law in Massachusetts. As Sue Kirby explained, the problem arises when there are new brand name drugs that don’t have generic substitutions due to small molecular changes. This means that while there are therapeutic substitutions (many of which can be generic), there is no specific generic substitution. The state law only has mandatory substitution for the exact drug, not something that is even a little bit different.

Finally, the Committee heard from David Czekanski from the state’s Group Insurance Commission (GIC), another member of MPRC. He started off by discussing some of the GIC’s statistics: their members fill over 3 million prescriptions each year. He said that despite a high rate of generic prescriptions, the GIC is still very concerned about the use of brand name drugs. Brand name drugs cost an average of 9 times more than the generics- a huge impact on their bottom line. He said that these bills support the GIC’s goals of getting the best treatment for their members at the best cost. Czekanski endured some gentle ribbing by Senator Moore about the GIC’s generic percentage (slightly lower than the state average).

And with that the hearing closed.

2. Thanks, but no thanks says APA

Doctors are telling industry ‘no thank you’ in a big way. The New York Times reports that:

Amid increasing Congressional scrutiny of ties between doctors and drug makers, the American Psychiatric Association announced on Wednesday that it would end industry-financed medical seminars at its annual meeting. The association, the field’s premier organization, said it would also phase out meals at the meeting paid for with industry money.

March 27, 2009

The New England Journal of Medicine article, Use of Electronic Health Records in U.S. Hospitals, by Ashish Jha et al. (described here through WBUR's excellent story on the topic), reports on results of a survey of electronic health record (EHR) adoption in all acute care hospital members of the American Hospital Association. The authors' conclusion from analyzing the data is hardly surprising: U.S. acute care hospitals have very low levels of EHR adoption. The reasons -- the expense, lack of interoperability (so that records, even if electronic, can be difficult to share), lack of technical support and know-how, unclear return on investment and sustainability, and physician resistance for these and other reasons, are hardly surprising, either.

Some of the issues that the survey does not capture, from those mentioned in the article -- actual use, effectiveness, and satisfaction -- to those not mentioned -- nonphysician staff and patient concerns, satisfaction, and use (the latter through patient-facing web-based portals, for example) -- need to be studied as well.

The lack of clarity in this area as a whole -- the panel of experts undertaking the survey could not reach consensus about the definition of an EHR -- is also an enormous challenge.

There are glimmers of hope, however. VA Hospitals, have had fully implemented EHR records systems "for more than a decade with dramatic associated improvements in clinical quality." And just the fact that this survey was undertaken means that serious scientists are taking this issue seriously. After all, without a baseline, progress can't be measured, and the good news is: we can only go up from here!
Lisa Fenichel

March 27, 2009

“As far as health condition and medical care are concerned, [homeless] children are prisoners of their socioeconomic and insurance status.”- America’s Youngest Outcasts: State Report Card on Child Homelessness, The National Center on Family Homelessness

A recent report (www.homelesschildrenamerica.org) by the Newton-based National Center on Family Homelessness (NCFH) begins with a call to action: “It is unacceptable for one child in the United States to be homeless for even one day.”

Still, in the richest country in the world, 1.5 million children go to bed with out a home each year. Just as alarming, NCFH found that 1 in 50 American children experience homelessness at some point in their life.

Dr. Ellen L. Bassuk, NCFH president, states that we need to provide “equal opportunities for all American children to grow and thrive in the safety and security of their own homes.”

For Massachusetts, there is some good news: according to the report, the Commonwealth ranks 8th in the nation for well-being of homeless children. This ranking is based on the number of homeless children and how these children fare in various domains (food security, health, and education), the risk of children becoming homeless, and the state’s planning and policy efforts.

But while we can take some comfort in our overall ranking, the news on the health front is troubling – Massachusetts ranks 43 out of 50 for the percentage of homeless children reporting moderate to severe health conditions. Compared to middle-income families, homeless families in Massachusetts suffer proportionately more moderate to severe health problems, as well as more asthma, traumatic stress, and emotional disturbances.

Health insurance alone isn’t enough to guarantee good health. If that were the case, children in our state would be by far the healthiest in the nation (only 1.2% of our children do not have health coverage).

Good health depends on more than an insurance card.

If the NCFH report is a call to action for us to protect the health of our most vulnerable children, we should closely examine the impact that budget cuts will have on low income and homeless kids.

While no one can deny that these are unprecedented economic times and that difficult funding decisions need to be made, there are specific child health programs that must be held harmless.

The Healthy Start Program provides prenatal and limited post-partum coverage for low-income women not eligible for MassHealth. The program serves close to 4,500 pregnant women each year.

Healthy Start covers prenatal visits (including labs and radiology), outpatient mental health services, prescription drugs, medical nutrition therapy, durable medical equipment, amniocentesis, and postpartum care up to 60 days after delivery. Timely prenatal care is important to a healthy pregnancy and has been shown to produce better birth outcomes.

Early Intervention (EI) is the most comprehensive, family-centered program in the Commonwealth dedicated to serving children birth to three with developmental delays. The program serves more than 30,000 children and families in Massachusetts each year. EI is a range of services available to families of children up to three years old who have developmental delays or whose development is at risk because of particular birth or environmental factors. Services are based on the needs of the child and family, and can include home visits, child groups, parent groups, and services of specialty providers.

Current economic factors indicate that it would be irresponsible and short-sighted to cut Healthy Start and EI at a time when the demand for their services is likely to only increase.

The idea that children are our most valuable resource cannot be disregarded as simply another cliché – we must live this value by working to ensure that, in the words of Dr. Bassuk, there exists “equal opportunities for all American children to grow and thrive.”
Matt Noyes and Christine Keeves

March 27, 2009

Yesterday's news was that insurers are ‘offering’ to phase out their practice of charging higher premiums to sick people if national health reform includes a mandate for coverage. Skeptics denigrated the concession, particularly because it did not apply to small group coverage, claiming the key point of the insurers is their drive to prevent a public option competing with private plans.

In Massachusetts, these practices were eliminated in the early and mid-90’s. But in yesterday’s Commonhealth Blog, Nancy Turnbull reminds us that there is one area in Massachusetts where insurers are still allowed to discriminate - age rating. She thinks age rating's time may have passed:

“I’d been meaning to suggest that Massachusetts should think about abandoning the major discriminatory rating practice we do still allow, and that’s age rating. Our insurance laws permit health plans to charge older people as much as twice the premium rate as younger people for the same product. The classic argument in favor of age-rating has been that it’s necessary to have lower rates for younger people in order to convince them to purchase insurance. The ability of health plans to age-rate also creates a troubling inequity in the state’s affordability schedule at the highest income levels, where the schedule requires people to purchase insurance regardless of the cost...

But if we look back at the history of many insurance practices that were once common in the insurance market in Massachusetts but have been abolished—like rating based on race or gender, or not providing coverage for maternity care and mental health—we find the same initial opposition. We’ve done many innovative things under the state’s health reform law—let’s talk about whether eliminating age rating should be another one.”

We think this is an important issue to be raised now. ACT!! has long advocated for greater affordability protections for older people who are hard hit by the mandate. There's no magic about the current 2:1 rate band. New York has long required full community rating - no age discrimination allowed - for small groups. This should be on the health policy agenda for the near future.
Georgia J. Maheras

March 26, 2009

On Wednesday, the Kaiser Family Foundation hosted a live webcast that explored the national economic downturn’s impact on health in communities of color. Hosted by the Foundation’s Senior Policy Analyst Cara James, PhD, the forum facilitated the Massachusetts Department of Public Health’s Medical Director Dr. Lauren Smith, Howard University’s Chair of Economics William Spriggs, PhD, and the Consumer Union’s Senior Attorney Adrienne Hahn, Esq.

The diverse panel of experts discussed the impact of unemployment, housing forecloures, and state budget crises on communities across the country. Dr. Spriggs described the dramatic affects of the downturn on Black and Latino populations, noting the housing crisis hit Black communities early through unregulated sub prime loans. Spriggs further discussed unemployment impacts, citing a 14% unemployment rate for Blacks and a growing 8-14% rate for Latinos who have been devastated by construction job losses. Unemployment rates continue to rise across all education levels for these populations, and black wealth has experienced the largest decrease since the 1930s.

Dr. Lauren Smith discussed the influence of such job and housing losses on community health, describing the difficulties faced by families with smaller incomes, insecure housing and greater mental stress. Food insecurity, out of pocket healthcare costs, and unmanaged chronic disease conditions were all mentioned as challenges. Dr. Smith noted the discordance of greater community needs for social supports such as WIC, school lunch, and healthcare coverage, while states and philanthropy are making deep budget cuts and reducing services.

As the economic downturn continues, the panel of experts all noted the importance of partnership between the federal government and the states on these complex issues. Dr. Spriggs affirmed the federal recovery act’s inclusion of healthcare reforms, stating this effort is a vital investment in the health of all American communities. Dr. Smith remarked on the resources distributed to states through the legislation, needed to support wellness, public health and prevention programs.

The 1 hour webcast is available on the Kaiser Family Foundation website.
Camille Watson

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