June 2009

June 30, 2009

Only 10 hours until HCFA ends its 2009 fiscal year. This is our last fundraising effort before July first and your final chance this year to support our work.

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.

Please click here to make a fully tax deductible contribution.

Thanks to you, HCFA’s good work can continue
-Melissa Freitas

June 30, 2009

Kudos to the Governor and the Administration and Finance staff for the very informative "Health Care Policy Brief" issued along with the budget signing and vetoes today.

The document has full details of the spending levels approved for MassHealth, Commonwealth Care and the Health Safety Net. For the wonks among us, there are detailed spending charts and savings assumptions. It also explains the administration's reasoning behind the proposal for the legal immigrants proposed to be cut from Commonwealth Care.

Back in the old, old days, when I used to work at the Senate Ways and Means Committee, we used to produce a detailed book with narratives explaining each of the budget allocations, agency by agency. That went away in the mid 90s. It's good to see the Governor making more information available to the public.

Listen to excerpts from the Governor's speech.

-Brian Rosman

June 30, 2009

We hesitate to bring more attention to something that pretty much didn't make a ripple, but when the Herald picks up only the misleading part of a State House New Service story, leaving out our responses, and when right-wing blogs start spreading the news, it's up to us provide fairness and balance.

The issue is a poll released yesterday by the infamous Rasmussen Reports. The poll purports to show only 26% of Massachusetts voters think health reform is a success, while 37% think it's a failure (37% are not sure).

The poll was taken for the Boston Fox TV station, and the pollster is well-known for skewing results to the right:

"[P]olling is a crowded business. And Rasmussen doesn’t also have a daily newspaper or a television network to tout his results. His business, however, requires attention. So how does he get that attention? Well in part he gets it with issue polling that, while basically methodologically sound, has question-wording that’s designed to lead to conservative-friendly results." - Matt Ygelesias

"But the qualitative questions, in terms of their phrasing and so forth, are frequently skewed to give answers friendly toward GOP or conservative viewpoints." - Joshua Marshall

"Rasmussen is influential because its carefully crafted questions that produce answers that conservatives like. .. The result is that polls with extremely favorable numbers for Republican stances leap into the public arena every week, quickly becoming accepted wisdom." - David Wegel

This June 20 graph, from polling guru Nate Silver, shows how Rasumussen's polling on national health reform is an outlier compared to every other polling firm:

Rasmussen Poll is an Outlier compared to others

Like the polls in the graph, everyone else find that health reform has broad support in Massachusetts. The Rasmussen question was worded in terms of "success" or "failure," with no context or explanation.

The Urban Institute survey asked a much better-worded question in summer 2008:

“Now I have some general questions about health insurance in Massachusetts. As you may know, Massachusetts has a law that is aimed at providing health insurance for all Massachusetts residents. In general, do you support or oppose this Massachusetts law?”

The results were: Support: 74%;  Oppose: 14%   (Don’t know: 12%)

The Urban Institute poll used a sample that included cell phone-only households, unlike Rassmussen. The Urban sample exceeded 4,900 households, compared to the Rassmussen sample of 500. The sample was also weighted using a validated algorithm to correct for sample bias.

Similarly, the Harvard School of Public Health polled 963 residents last summer, and found 69% support and 22% opposition among people familiar with the law.

There's no question in our minds that the Rasmussen poll was done to influence the debate in Washington, and to provide speech fodder for those opposed to national reform.

Health reform has been enormously successful in its stated goal - expanding access to the uninsured. The remaining challenges of cost and quality are being addressed, but more remains to be done. We're not stopping.
-Brian Rosman

June 30, 2009

The Governor took out his metaphorical veto pen today as he approved the state's budget for fiscal year 2010.

Saying, "Health care for all means health care for all," at his press conference, the Governor proposed partially reversing the proposed cut to some 30,000 legal immigrants (listen Governor Patrick budget statement.

Under the Massachusetts Constitution, the Governor can "line item veto" individual items in the budget. The item is then not operative, unless the legislature overrides the veto by 2/3 vote in both branches. He can also return a provision to the legislature with a recommended amendment, which has the effect of blocking the implementation of the provision until the legislature either approves the recommended amendment or insists on its original language. All of these options were used on health-related matters today.

Outright vetoes
The line-item vetoes total $147 million. Among the funds reduced are the Betsy Lehman Center (about $1.2 million); the Quality and Cost Council ($133,000) and over $50 million in MassHealth spending, including $2.3 million for children's behavioral health. No cuts were made in MassHealth eligibility or benefits, including dental coverage. Funding was eliminated for the academic detailing program.

He also vetoed a provision calling on a raft of state authorities to continue to make contributions to state programs. One effect of this veto is to eliminate the requirement that the Connector and HEFA contribute $500,000 and $2 million respectively, for outreach and enrollment grants. If this veto is not overriden, no funds would be available for community outreach assistance.

Immigrant Provision Returned with Amendment

The Governor returned with a recommended amendment (text here) the legislature's provision ending Commonwealth Care coverage for some 30,000 legal immigrants who are not eligible for federal funding. The Governor highlighted his concern for this population:

The conference committee budget terminated Commonwealth Care health insurance coverage for approximately 30,000 legal immigrants, a successful feature of our health care reform experiment.  This would be a major step backwards from our progress at a time when the eyes of the nation are focused on this groundbreaking initiative.  I am accordingly proposing an additional $70 million in funding to continue state-subsidized health insurance for these residents - and ensure that our state continues to lead the nation in offering high-quality, affordable health care to all.

The provision as drafted by the Governor envisions the immigrants retaining their current coverage for the month of July. Their coverage would end for August. During that period, some would be eligible for MassHealth Limited, which covers emergency care only. Most would also be eligible for the Health Safety Net Program, which covers hospital and community health center services. Then in September, a new program, costing $70 million, a bit more than half of the current annual cost, would be made available for these immigrants. The program would either be run by MassHealth or the Connector. The provision is temporary, lasting only one year.

About half of the $70 million comes from increased federal Medicaid funds the state is now expecting as a result of the higher unemployment rate. The other half depends on the legislature sustaining some of the line item vetoes, thus freeing up other funds. The Governor filed a separate appropriations bill allocating the $70 million to this new coverage for these legal immigrants. What the program would cover and how it would run is left up to the Connector and MassHealth.

The next step is for the Connector and MassHealth to settle on a plan, while the legislature considers the Governor's proposal. While we strongly oppose ending coverage for these legal, taxpaying member of the community who meet all other eligibility standard for health coverage, if this plan is moving ahead we urge MassHealth, the Connector and the legislature to consider:

June 26, 2009

The Quality and Cost Council held its annual meeting yesterday in Shrewsbury, MA. A good crowd turned out for the event which included a keynote address by Cathy Schoen from The Commonwealth Fund and a responding panel made up of Senator Richard Moore; Dr. Charlotte Yeh, formerly of CMS and now with AARP Services, Inc.; Dr. Randy Wertheimer of Cambridge Health Alliance; and Eileen McAnneny of Associated Industries of MA. You can find meeting materials, including Ms. Schoen's presentation, on the QCC website.

A few facts from Schoen's presentation that have been public previously (many came from Commonwealth Fund reports from 2008) but still are shocking to see: In the U.S., 34% of patients with chronic conditions reported that they experienced medical errors, medication errors or lab errors in the previous year, a figure that was higher than other countries studied; U.S. patients are less likely to see a doctor quickly when needed and more likely to go to the E.R.; only 40% of providers in the U.S. have arrangements for after-hours care while 95% do in the Netherlands (thus, leading to E.R. use).

She talked about some of the examples in the U.S. of health systems doing innovative practices, like the medical home model at Geisinger in rural Pennsylvania. Because it is in a rural area, there are many small providers' practices spread out. So they use nurses who work with multiple practices and help with managing the care of elderly and frail patients. This decreased the use of the ER and hospital admissions and also decreased costs. While MA rates highly in terms of access and quality, the Commonwealth stands out in its high ranking on numbers of potentially preventable hospital readmissions and hospitalizations for ambulatory sensitive conditions (things that should be taken care of outside of the hospital). This speaks to the need to do more work on discharge planning and transitions of care and improving communication across providers and with patients.

The panelists all had interesting comments but the one that struck me the most was the piece of Dr. Yeh's talk when she mentioned areas where we should look more for improving quality and reducing costs. She said that there could be savings of $50-75 billion if health literacy issues are addressed. She also talked about Alzheimer's and depression/mental health and said that costs for care related to depression can be reduced 50% if it can be managed from home rather than the hospital. Dr. Wertheimer talked about the need to follow evidence-based medicine more often and gave the example of the use of electronic fetal monitors and that they don't need to be used with low-risk pregnancies. She also talked about guidelines for mammograms and whether women age 40-50 who are low-risk need them annually.

The presentations were followed by small group discussions on quality and cost measures that should eventually be included on the website. Congrats to the QCC for putting together a stimulating program and for including the audience in discussions.
-Deborah Wachenheim

June 26, 2009

Nearly 100 consumers, advocates, medical experts, healthcare professionals and legislators gathered at the State House on Tuesday morning to testify before the Joint Committee on Public Health on bills relating to patient safety, malpractice and medical errors prevention and reporting.

During the three hour hearing, many of those in attendance testified in support of the three priority bills of HCFA’s Consumer Health Quality Council. HCFA’s Executive Director, Amy Whitcomb Slemmer, introduced the Consumer Council’s three-person panel. The consumers told compelling personal stories as part of their testimony. Virginia Harvey testified in support of H. 2138 and S. 878 “An Act to Improve the Delivery of Health Care,” filed by Representative Provost and Senator Moore, which would require hospitals to use checklists to prevent serious errors that can lead to serious injury and possibly death. Checklists promote teamwork and collaboration among surgical teams and better surgical outcomes. The point was made that many other professions use them including construction companies and accountants, not to mention pilots. Ms. Harvey, who had to have her leg amputated because of an infection that she got during ankle surgery, said she hopes this gives patients a better chance than she had. The use of one particular checklist, a surgical checklist, has been found to result in approximately a 36% reduction in serious complications (including surgical site infections) and deaths.

Lucilia Prates testified on the importance of H. 2139, “An Act to Reduce Healthcare-Associated Infections,” filed by Representative Provost. This legislation would require hospitals to screen incoming high-risk patients for MRSA (Methicillin-Resistant Staphylococcus Aureus) - a bacterium that can be easily spread from person-to-person and cause infections among patients. Ms. Prates' father died from complications due to a hospital acquired infection which was preventable. Nearly 100,000 Americans die from a hospital-acquired infection each year and 19,000 of those are MRSA. Five other states have similar laws in place.

Consumer Council President Ken Farbstein testified in support of S. 909/H. 2084, “An Act to Reduce Medication Errors,” which was filed by Representative Khan and Senator Tucker. These bills would establish an expert panel to study medication errors in Massachusetts and develop a prioritized list of concrete recommendations and best practices for how the Commonwealth can reduce the prevalence of medication errors. Nineteen years ago, Mr. Farbstein’s wife was given the wrong medication for a number of hours while she was in labor. Their newborn son spent 3 weeks in the NICU. He and his family did not report the error then but he’s sharing their story now to encourage others to do the same. He testified that more oversight and reporting mechanisms are needed.

A number of legislators testified in support of the more than thirty bills being heard. Rep. Provost testified in support of the two bills she filed and that are mentioned above- MRSA screening and using checklists. Of the first she mentioned that as a former trial lawyer, she only knew of two ways to handle the problem: 1) legislative oversight and regulation or 2) the inefficiencies of the malpractice system. She urged the legislature to take the initiative to regulate versus leaving the problem to the more expensive option. Rep. Provost also urged her colleagues to support the checklist bill. She cited figures from the study on surgical checklists that found their use in all operating rooms in the U.S. could save $15-25 billion per year. Senator Tucker also testified in support of the quality bills, saying “this is exactly the right time” to do this in the Commonwealth.
-Jessica Hamilton

June 26, 2009

With the news this evening that the Governor will sign the sales tax increase as part of the budget package, due to be signed Monday, the likelihood of the Governor finding budget savings by vetoing spending for MassHealth adult dental coverage lessened substantially.

Still, the threat is there. The Governor's revised budget submission called for elimination of dental care for adults in both MassHealth and Commonwealth Care. This would affect over 700,000 people, including more than 120,000 low-income seniors and 180,000 disabled individuals. Secretary Kirwan reminded the public at the Connector Board meeting yesterday that even with the sales tax, the budget situation is precarious. Today's news that Treasurer Cahill neglected back in May to inform House and Senate budget writers that $25 million in anticipated lottery revenue would not be arriving adds to the ongoing crisis.

Oral health is an essential part of overall health, and it is also critical to health reform. Denying over 600,000 people access to oral health care leaves part of the body uncovered, and sends the wrong message about our commitment to health reform and access as the nation turns its eyes to Massachusetts to lead the way to health care reform.

The Washington Post wrote about this on Tuesday:

Among adults, oral cancer kills more Americans than cervical cancer, and research suggests that oral infections can affect pregnancy outcomes and complicate chronic diseases such as diabetes. Still, 82 million adults have no dental insurance.

As the Obama administration rolls out its massive health-care reform effort, many dental-health experts worry that a golden opportunity is being missed. "Is oral health care getting enough attention in the current health-care reform discussion? The fast answer is no, and the door is closing," said Yolanda Bonta, a New Jersey dentist who is active in the national Hispanic Dental Association. ...

Burton Edelstein, a professor of dentistry and health policy management at Columbia University, says it has been "very challenging" to try to join the debate: "The mouth," he said, "is the only body part or essential organ that is excluded from policymakers' routine consideration of health and health care."

Closing the gap between the worlds of dental care and medical care, with their separate histories and cultures, and their separate finance and delivery systems would be a formidable task. Edelstein, who is the founding chairman of the nonprofit Children's Dental Health Project, sees a glimmer of hope in the inclusion of several dental provisions in the 615-page first draft of the Senate Health, Education, Labor and Pension Committee's health-care reform bill.

The draft includes dental care in a list of benefits that children should receive and cites the importance of disease prevention and surveillance, safety net programs, and changes in the dental workforce and public-health infrastructure.

Cutting MassHealth dental coverage also means the loss of federal funds. With federal reimbursement exceeding 60% for next year, the loss of federal revenue will hurt our economic growth. When dental services were eliminated under Governors Swift and Romney, spending increased in other health accounts.

Call the Governor Today to Protect Basic Health Care Services

Call 617-725-4005 to reach Governor Patrick’s Office. You can find talking points here.
-Brian Rosman and Courtney Chelo

June 25, 2009

The Public Health Council led by Commissioner John Auerbach met the morning of Wednesday, June 25th to discuss and vote on a host of public health issues and regulations.

The meeting began with a discussion to codify a definition of the term “Public Health Provider” that would allow residents of the Commonwealth to choose nurse practitioners as their PCP’s rather than just physicians. The Council voted to approve this change in the regulations. Defining the term in this way will significantly ease primary care access for many Massachusetts residents while alleviating some of the costs of our health care system.

The Office of Patient Protections then discussed some of its work in monitoring insurance grievances and conducting external insurance provider reviews.

Next, an amendment was introduced to current regulations that force all college students to have up-to-date immunization records prior to matriculation. The amendment added kindergarteners, 7th graders, health science students, and considered adding community college students to this list. The amendment would also expand the list of the required immunizations these students would need to receive prior to beginning school.

Finally, the Council discussed the merits of requiring HIV screenings for all Massachusetts residents aged 13-64 regardless of risk. This discussion comes in the wake of a study demonstrating that screening in Massachusetts dramatically lowers the transmission of HIV, and that 54% of HIV transmissions are caused by the 25% of people who do not know that they are infected. Those at high risk for infection may be asked to get screenings annually.

The Public Health Council will meet again in August.

Brian Schon
Policy Intern

June 25, 2009

The Joint Committee on Health Care Financing held a hearing Wednesday afternoon on several bills including one of the ACT!! Coalition's priority bills on health care affordability.

An Act Relative to Health Care Affordability

Shanna Shulman, Director of Policy and Research at the Blue Cross Blue Shield Foundation of Massachusetts presented data relevant to S. 549/H. 1102 An Act Relative to Health Care Affordability. Dr. Shulman provided an overview of the Urban Institute survey of affordability of health care for consumers across the state. The survey explores medical debt and out-of-pocket costs with a focus on trends in affordability since the passage of health reform and disparities in affordability of health care. The survey found that 18% of residents report that their out-of-pocket costs are equivalent to 5% or more of their family income, 7% of residents report that their out-of-pocket costs are equivalent to 10% or more of their family income, 18% of residents report problems paying medical bills and 20% of residents report having medical bills they are paying off over time. The survey also found that 11% of residents report that they did not get needed care because of costs in the last 12 months. The percent of residents reporting high out-of-pocket costs has declined since health reform but the percent of residents reporting problems paying medical bills has increased slightly. Dr. Shulman informed the Committee that low-income residents report more difficulty affording medical care and residents in Western MA are more likely to report not getting needed care because of the costs. Dr. Shulman's full testimony can be read here.  During the discussion, Sen. Canderas highlighted disparities in affordability and access in Western Mass.

Lindsey Tucker voiced the ACT!! Coalition's support of An Act Relative to Health Care Affordability (S.549/H.1102).  This bill addresses cost and affordability in two ways: one, redefining the state's Affordability Schedule to include out of pocket costs and two, creating a new Division of Health Insurance with more power to regulate health insurance premiums.  The first will ensure consumers are protected from health costs they cannot afford, and the second will improve public accountability and transparency of health insurers.  Lindsey explained the disparate impact that co-pays have on the elderly and those with chronic diseases and how unaffordable cost-sharing leads to crippling medical debt. ACT!! urges the Legislature to consider out-of-pocket cost as part of the affordability schedule to protect consumers from unaffordable health coverage.  For more details read the ACT!! testimony here.

Dorcas Grigg-Saito, the CEO of the Lowell Community Health Center, shared the struggles many of her clients have with the costs of health care. Grigg-Saito informed the Committee that the Lowell Community Health Center serves one-third of the population of Lowell and 93% of the patients are below 200% fpl. Grigg-Saito explained that health reform has reduced the percentage of uninsured patients at her health center but health care costs still serve as a barrier to care especially for patients with chronic diseases, existing medical debt and those who have recently gained coverage after years of being uninsured.

Senator Moore raised concerns that exempting more people from the individual mandate would raise the number of uninsured residents and potentially increase hospital bad debt. Rep. Lewis questioned the Connector's reasons for not including all cost-sharing in the Affordability Schedule.

Rep. Scibak also testified in support of H. 1102. Rep. Scibak described the provisions of the bill which would create a new Division of Health Insurance. Without increasing costs or staff this new agency would focus on affordability, consumer protection and improving the health of the Commonwealth by ensuring solvency of plans, regulating rates, overseeing benefits, and enforcing cost control initiatives; assure that health insurance premiums are kept as affordable as possible and that insurers serve the public interest; and improve public accountability and transparency of health insurers.

Next, Eric Linzer of the Massachusetts Association of Health Plans testified in opposition to S. 549/H. 1102. MAHP raised concerns with creating a Division of Health Insurance when DOI already has the authority to examine rates. MAHP also argued that most of the premium dollar goes toward medical expenses and the percent of administrative costs has decreased from 2007 to 2008. MAHP raised concerns that the bill doesn't address the ability to change provider contracts if premium increases are found to be excessive

An Act Relative to Shared Responsibility in Health Reform

June 24, 2009

The Connector Board met on Tuesday afternoon to vote on a revised Affordability Schedule, the Seal of Approval for the proposed Commonwealth Choice plans, revised Commonwealth Care regulations, the FY10 Administrative budget and a contract with Perot Systems. The Board discussed the Commonwealth Care budget and proposed savings to the program. Meeting materials are available here.

Although it was widely reported that the Connector voted to eliminate dental benefits now provided to below-poverty members in Commonwealth Care, that did not happen. What did happen is the board made major changes to the CommChoice program for next year, and agreed to administrative changes that are estimated to reduce Commonwealth Care enrollment by 17,655 people. Details after the jump.

June 24, 2009

On Monday June 22, the Massachusetts Health Disparities Council held its monthly meeting. The meeting comprised of legislators, providers, and health care groups from across the state was chaired by Senator Susan Fargo and Representative Byron Rushing.

The meeting began with a review of the use and demand for interpreter services in Massachusetts Hospitals. The good news was that of the 72 hospitals surveyed for the study, 100% agreed to participate in the research. The bad news was the documented discovery that there is inadequate accessibility to linguistic services in clinical settings in the Commonwealth. These inadequacies can lead to a communication breakdown between patients and providers creating worse care as patients lose the ability to effectively communicate with their doctors and vice versa. With this in mind, the council reviewed some recommendations related to the study’s outcome including future advancement of linguistic training measures, regulations to certify medical interpreters, and standards for providing and reimbursing these interpreters.

The council then discussed some glaring statistics from the statewide distribution of racial and ethnic hospital care in 2007 and 2008. Some of the highlights of the findings were that in the FY 2008, 80.48% of those treated in inpatient care were white, while only 7.13% were Hispanic and only 6.79% were African American. The Council discussed how its proposed framework of policy recommendations can address the societal, policy, community, institutional, and individual factors that create these types of disparities.

The Council also spent significant time discussing and reviewing a template for a report card of the state’s performance on disparity matters. The report card aims to not only capture disparities data but effectiveness of interventions and opportunities for policy change. The Council wants to make sure that the report card provides a comprehensive and practical tool for the state to advance its disparities elimination efforts.

Finally, the members reviewed the new Council website, created to engage both members and the public in its activities. The Council will next meet on Monday July 27th at 2pm.

- Brian Schon
Policy Intern

June 23, 2009

The video below, produced by the New America Foundation (home of the outstanding New Health Dialogue blog), explains why health program budget cuts are bad for people and the economy. The video details are all about California, but the reasoning applies equally to Massachusetts. Watch it: