December 2009

December 29, 2009

Senate candidate (and current state senator) Scott Brown stuck his foot in the mandated benefits issue yesterday with legislation and a statement that shows his serious misunderstanding of the cause of high insurance premiums and how to cut health care costs. Brown filed legislation concerning health insurance mandated benefits - the state laws that require insurers to cover specified benefits.

This has been a long-time bugaboo for us (see our take-downs of Jeff Jacoby, Charlie Baker, and MAHP, among others). We've explained at length that while we don’t defend every existing mandated benefit, and we rarely take a position on proposed new ones, mandated benefits make sense by setting a common floor so that all insurers provide adequate coverage. Otherwise, insurers would decide not to offer treatments for an expensive disease (like diabetes, for example), so they would not attract patients with that disease. The insurers would game the system by avoiding high-cost patients. The result would be a race to the bottom, with all insurers trying to avoid the expensive patients. Ultimately, everyone is worse off.

Even the Boston Herald's State House blogger takes Brown to task for his proposal. And even Tom Finneran scoffed on the radio this morning, saying the proposal is not a game changer. On the broadcast, Brown admitted that he voted for a lot of these mandates.

Brown's approach blames coverage mandates for the high cost of health coverage in Massachusetts. But a study done by the Division of Health Care Finance and Policy found that at most, mandates add no more than 3%-4% to the cost of coverage. Eliminating mandates would result in a small 1-time drop in the rate of premium growth, but would do nothing to stop the ongoing rise of premiums.

We know why health costs are climbing. Multiple studies have shown that the rising cost of medical care, both increased utilization of expensive services, and higher prices for all services, is driving premium cost growth in Massachusetts. To get at the cause of the problem will require making comprehenisve changes in how care is delivered and paid for. That's why all the stakeholders and experts on the Payment Reform Commission and the Quality and Cost Council agree that a fundamental approach is required to reduce costs.

Looking at the actual text of Brown's bill (pdf) leads one to wonder if he understands Massachusetts health policy. The first section authorizes the Connector to eliminate state mandated health benefits. It's very curious that Brown, a state senator, would propose to take power away from the legislature and give it to a board where 3 out of 10 votes are appointed by the Governor, and another 3 out of 10 are appointed by his current opponent, the Attorney General. It was the Connector, in any case, that added prescription drug coverage that he opposes to the minimum creditable coverage requirement, which fits on top of mandated benefits for people seeking to comply with the coverage mandate.

The bill's second section authorizes DHCFP to study coverage mandates. However, current law already has DHCFP studying mandates, and new mandates cannot be considered without a DHCFP analysis.

Finally, Section 3 of Brown's bill declares it to be the policy of the General Court that a moratorium on new mandates be observed. This provision, which has no legal authority whatsoever, mirrors a similar declaration that was part of the 2006 health reform law (section 127 of chapter 58). That provision was quickly ignored when, less than 5 months later, the legislature passed a mandate for coverage of prosthetic arms and legs. The bill passed through the Senate during informal sessions when any Senator could have held it up; did Senator Brown support or oppose this bill?

December 29, 2009

The season of giving is almost over and there are only a few days left to donate to HCFA in 2009. Please help us provide health care education, enrollment services and advocacy that the people of Massachusetts deserve. 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 22, 2009

It's only fair. Under the original Senate health reform bill, states will get substantial federal assistance for increasing their Medicaid eligibility to 133% of the federal poverty level. Except for states that already cover people up to that level, like ... Massachusetts.

So Senator Kerry spoke today at Children's Hospital Boston and announced that he has secured additional federal funds for Massachusetts in the Senate manager's amendment, which was adopted this morning. CBO estimates the total amount at $500 million, although there is some uncertainty around the total. Also speaking at the event were HCFA Executive Director Amy Whitcomb Slemmer and MIT Economist Jonathan Gruber.

Senator Kerry listed a number of other benefits in the bill for Massachusetts, including increasing subsidies to 400% of poverty (CommCare now only goes to 300%), tax credits for small business, Medicare improvements like closing the drug doughnut hole, and support for comprehensive children's coverage through CHIP. He pledged that he had secured assurances that the federal bill would not interfere with the success of Massachusetts health reform.

Maybe it's just me, but we very much like the way they drafted the formal amendment language to boost the state's federal reimbursement rate for three calendar years starting in 2014. In the amendment, it's section 10201, starting on page 98. I've bolded the cool part; for those not familiar with legislative language this is somewhat unusual:

‘‘(z) EQUITABLE SUPPORT FOR CERTAIN STATES.—
...
‘‘(2)(A) During the period that begins on January
1, 2014, and ends on December 31, 2016, notwithstanding
subsection (b), the Federal medical assistance percentage
otherwise determined under subsection (b) with respect to
all or any portion of a fiscal year occurring during that
period shall be increased by .5 percentage point for a State
described in subparagraph (B) for amounts expended for
medical assistance under the State plan under this title
or under a waiver of that plan during that period.

‘‘(B) For purposes of subparagraph (A), a State described
in this subparagraph is a State that—
‘‘(i) is described in clauses (i) and (ii) of paragraph (1)(B); and
‘‘(ii) is the State with the highest percentage of
its population insured during 2008, based on the
Current Population Survey.

The House bill also recognizes Massachusetts has going ahead of the rest of the country and provides substantially more federal reimbursements for people we are already covering.

We know Governor Patrick and his staff have been working hard with our Congressional delegation to provide them with the ammunition they need to advocate on behalf of Massachusetts. We thank Governor Patrick and the delegation for their ongoing work to give us our fair share, too.
- Brian Rosman

December 22, 2009

Health reform is stimulating all kinds of creativity, particularly in the "poetry" department.

A few weeks ago, there was a twitter storm of health care reform haiku. Of course, twitter's 140-character limit is ideal for haiku. You can read them all by searching twitter for "#hcr haiku." If I say so myself, I was proud of my contribution: Lieberman flip flops / No miracle in these days / Hanukkah shanda.

Now a new genre has emerged, parodies of "'Twas the Night Before Christmas," (officially titled, "A Visit from St. Nicholas.") While the final health reform vote has just been moved from literally the night before Christmas, to 8:00 am on Thursday, the seasonal juices are still a wonder to behold.

(UPDATE: The NY Times Prescriptions blog noticed the same thing, and held reader a contest for the best poem.)

On the Senate floor was Senator Burris (video below, click to read his poem), whose best line was "What in the world would be quite so raucous / But a mandate for change from the Democratic caucus" (so much better than the obvious rhyme of "caucus" with "Baucus").
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From the other side there's Missouri Senator Kit Bond, reading on his couch in his Republican Red sweats and his dogs jumping all over him:

There's also this screed response from a Republican lobbyist, who takes his ire out on poor Rahm Emanuel, and this from a far-right tea-bagger type ("They mumbled in unison, as the tally rolled in / “Bah Humbug America! Let the Death Panels begin!”), and another wing-nut .

This from White House press corps is good, though not really about health reform, but the best came from Families USA Executive Director Ron Pollack:

'TWAS THE NIGHT BEFORE CHRISTMAS

'Twas the night before Christmas and all through the Senate
The Democrats were working for a fundamental tenet:
All Americans should have health care at a reasonable price
By forcing insurance companies to finally play nice.

The reform bill they pushed took some very strong positions,
Like no one denied coverage due to pre-existing conditions.
Premiums, in the future, would need to be fair
With no differences for women and people needing care.

The Democrats made sure that the bill they designed
Would give folks 'cross the nation some real peace of mind.
Health care would not end if jobs changed or were lost
As all could choose health plans at an affordable cost.

For seniors needing medicines, the bill had much to extol:
It plugged gaps in their coverage, like the bad "doughnut hole."
And for empty-nesting parents, there was reason to rejoice
Kids could keep family coverage, this was now a parent's choice.

But all Republicans scoffed and persistently said "no"
With the sometimes exception of their colleague, Ms. Snowe.
With obstructions and filibusters, they tried every delay
To stop the bill and kill reform, before Christmas day.

So Leader Reid called his colleagues from left and from right,
For all 60 to join him, lest they lose this big fight.
Now Nelson, now Lincoln, now Franken and Wyden,
On Lieberman, on Bingaman, on Harkin and Cardin.

Christmas eve turned to night, and when the votes were all counted,
The filibusters and obstructions were completely surmounted.
The vote was inspired by the memory of Ted
Who'd applaud the victory for the cause he had led.

The work isn't over, there's much yet to be done
The Senate and the House bills must be merged into one.
But the vote on Christmas eve offers reason to cheer
'Cause health care reform will pass in the new year.

So call your fine leaders, and let your voice be heard,
With letters and emails, we must spread the word.
Our message is clear, and it shines a bright light:
"Health care coverage for all, and for all it's our right."

-Brian Rosman

December 22, 2009

Yesterday President Obama signed the Defense Appropriations bill, which included a provision extending federal COBRA subsidies. Here's how Phyllis Borzi, Assistant Secretary of the Employee Benefits Security Administration describes the provision:

The act extends the eligibility period for the ARRA premium reduction for an additional two months (through Feb. 28, 2010) and the maximum period for receiving the subsidy for an additional six months (from nine to 15 months). Millions of unemployed Americans and their families will be better able to afford and keep their health benefit coverage because of this new law.

Individuals who had reached the end of the reduced premium period before the legislation extended it to 15 months will have additional time to pay the reduced premiums related to the extension. To continue their coverage they must pay the 35% of premium costs by (60 days after date of enactment) or, if later, 30 days after notice of the extension is provided by their plan administrator.

We encourage you to subscribe to our COBRA Web site, www.dol.gov/cobra, to get information on new notice requirements, updated guidance, fact sheets, and frequently asked questions as they become available.

Individuals should contact their plan or health insurance provider for information regarding the extension under their health plan. If you need further assistance contact an EBSA Benefits Advisor toll-free at 1-866-444-3272.

This is particularly good new for low-income Massachusetts unemployed workers, who can add the federal 65% COBRA to their Medical Security Program (MSP) benefit, reducing their cost to just 7% of the premium. The funding will also save some costs in the MSP program. Three weeks ago we reported that our HelpLine has already received several calls from folks shocked to see their COBRA bill triple from last month.

December 21, 2009

We have recently blogged about the Medical Security Program (MSP): a plea to find state funding to save the program and a discussion of streamlining possibilities to prevent gaps in coverage. We’re pleased to report that the program is funded for another calendar year, thanks to creative thinking from the Administration. We can thank the Governor and legislature for a $30 million dollar appropriation. Additional funds will come from employers, though the employer assessment is still below the rate it would have been had it kept up with medical inflation, as called for in the statute (on this point, see law professor and bill language drafter Peter Enrich's response to Mike Widmer's claims to the contrary on the CommonHealth blog).

To cover the remainder of the shortfall, the Executive Office of Labor and Workforce Development, who runs the program, is making some administrative and programmatic changes. Yesterday, they sent updated information, posted on their website, to current enrollees.

Here’s what we know about the programmatic changes:

-- Co-pays and deductibles will be tiered depending on provider and hospital, based on quality and cost measures

-- Co-pays for primary care visits will move from $15 to $15/25/50

-- Co-pays for specialist visits will increase from $30 to $50

-- Co-pay for an emergency room visit will increase from $100 to $150

-- Co-pays for prescription drugs will increase from $10/20/35 to $15/30/50

-- Co-pays for inpatient/day surgery will change from $250 or $600 depending on the hospital to $150 with varying deductibles, depending on the hospital

-- The out of pocket maximum will increase from $2,000 for an individual and $4,000 for a family to $5,000 and $10,000 (includes deductible, co-insurance and co-pays under $100)

More information on tiering:

-- 8% of current enrollees live within 8 miles of 2 doctors at the $15 level, and 100% live within 8 miles of 2 doctors at the $25 level

-- There are 39 hospitals statewide in the "enhanced" (cheapest) category; 14 in the "standard" (mid-level) category; and 23 in the "basic" (most expensive) category

Here's what will stay the same:

-- Income eligibility for the program is still to 400%

-- Enrollee premiums are still $0

Here’s what we know about the administrative changes:

-- Currently, an individual must be eligible for premium assistance for just one day of a month to receive coverage for that month. Now, one must be eligible for at least 10 days.

-- Currently, those under 200% of the federal poverty level are given presumptive hardship waivers. Now, the presumptive level is 150%. (Anyone else may still apply for a hardship waiver.)

-- Regulations will preclude those with access to spousal coverage to be eligible for MSP.
-Lindsey Tucker

December 17, 2009

Back in August, we wrote a blog about young people with mental health needs ending up in prison for lack of community resources.

While it doesn’t take much of an intellectual leap to imagine how inappropriate this setting would be for mentally ill youth, earlier this week, the New York Times published a story highlighting the conditions faced by these young people.

Most official estimates of the numbers of young people involved with the juvenile justice system who have mental health needs are typically in the 75% range. Talk to anyone who is familiar with the system, and they will tell you the percentage is much higher.

Locking up a mentally ill young person does not address the underlying reason why they were imprisoned in the first place, and without adequate treatment while incarcerated, the reasons are not going to go away.

As the Times article shows, youth correctional facilities are dramatically unsuited to address mental health needs of inmates.

We must get out in front of this issue – not only should we improve treatment for those behind bars, but we have to do more to identify and treat mental health needs early. Only then can we hope to reduce the numbers of young people involved with the juvenile justice system.

Matt Noyes

December 17, 2009

In a stirring Senate floor speech yesterday drawing on the legacy of Senator Kennedy, Senator Kirk again brought up the HCFA Helpline as an example of why we need health reform:

Senator Kirk told the Senators about Carol, who was uninsured and suffered from seizures. Carol's story, taken from a HCFA blog post, continued:

She learned about the assistance of Health Care For All, the Massachusetts organization dedicated to making quality, affordable health care accessible to everyone. She applied and was declared eligible for Commonwealth Care. She immediately went to see a specialist and was given the health care she needed. Carol expressed her gratitude in these words:

I definitely feel blessed to be a Massachusetts resident. I can’t thank Health Care For All and MassHealth enough for all the support given to me. The Helpline counselors literally held my hands and brought me to live a healthy life, where there is no fear or embarrassment, but there is knowledge and a total control of my seizures. So, thank you so much all of you who make this happen in people’s lives

Senator Kirk ended with a call to pass a health reform bill that honors Senator Kennedy's lifelong quest for justice:

Senator Kennedy understood that we are all connected to one another. He often referred to President Lincoln’s words about our common humanity and the good that can come to us all when touched ‘‘by the better angels of our nature.’’ And he knew that on no issue are our futures more connected than on health care. Ted Kennedy’s voice still echoes in this Chamber. His spirit of hope and strength, of determination and perseverance is still felt here. He said:

"For all my years in public life, I have believed that America must sail toward the shores of liberty and justice for all. There is no end to that journey, only the next great voyage. We know the future will outlast all of us, but I believe that all of us will live on in the future we make."

Let each of us in this Senate be moved by the better angels of our nature and make that future a better one for our generation and for generations to come. As Ted Kennedy said 40 years ago: ‘‘All we need is the will.’’ This is our time, Mr. President. Let us pass this legislation now.

December 17, 2009

Nicole Hall and Bing Chen, two students at the BU School of Public Health, have created two Public Service Announcements highlighting the stories of members of the Consumer Health Quality Council.

The 30-second version is above; there's also a longer, 1:41 version.

The Consumer Health Quality Council brings together Massachusetts residents who have been impacted by poor quality care, including medical errors and infections, and who want to advocate for public policy change to improve the quality of care provided across the Commonwealth. The PSAs take clips from videos featuring Consumer Council members’ stories. All of the stories can be viewed on the HCFA website, at www.hcfama.org/quality/stories.

Powerful stories can make a big difference, and the stories from the Consumer Council have helped to bring about new laws and regulations aiming to improve care and empower patients and family members. Your story can make a difference too. If you have a story to share about poor quality care or difficult experiences with the health care system, please contact Deb Wachenheim at dwachenheim@hcfama.org. And please share the PSA links with others to help spread the word about the Consumer Council.
-Deborah W. Wachenheim

December 17, 2009

This week’s Healthy Aging Forum featured Dr. Walter Leutz’s results from his study on how to create an environment where people achieve healthy aging. The report, Healthy Aging in the Commonwealth:
Pathways to Lifelong Wellness
(pdf) includes several recommendations to help all of us get there.

Importantly, Dr. Leutz equated health with ‘going and doing’ based on numerous surveys with older adults. The goal is patient-centered care. This is accomplished through organizing the community (senior centers, arts organizations, etc…) to be supportive of patient empowerment. The medical profession and the community then implement evidence-based programs that have been shown to benefit this population.

His recommendations are simple in theory, yet challenging to implement as was evident in the presentations of the remaining speakers. Nancy Whitelaw focused on the challenges of treating chronic conditions. She described a scenario where we usually think about the medical diagnosis and treat that, however in order to treat the whole person - and thereby increase the chances of healthy aging - we need to look at a whole host of community-related issues people face. These include the financial burden of aging, isolation, having less to ‘do’, pain and suffering, and not being asked for input about their own care. She drove home Dr. Leutz’s point that healthy aging is a systems change and it is our collective issue - it will not get solved by the medical system alone. Because it is a collective issue, it cannot be owned by any one person or entity - a profound statement made in the packed room.

The morning was rounded out by a panel discussion describing the current landscape in Massachusetts. Secretary Hartstein, of EOEA, emphasized that the status quo is not good enough. If we fail in this initiative the Commonwealth will lose not only lives, but employment growth opportunities. Anita Albright, from DPH, discussed DPH’s work in the community and their use of Stanford’s Chronic Disease Self Management Program, entitled “My Life, My Health.” Dr. Robert Schreiber, from Hebrew Life, drilled down into the details of what the community needs to offer people to encourage healthy aging. He noted that the community needs to work together and that the health system needs to embrace the community. Interestingly, he highlighted the need to market the programs smartly- as simple, accessible and available. Lastly, Rosa Palacios from Commonwealth Care Alliance described another aspect of the work being done in the community- training people to be champions in a culturally competent way.

There will be a second installment of the Healthy Aging Forum in 6 months- this time focused on how we build on the successes we started.
-Georgia Maheras

December 17, 2009

Today the Joint Committee on Financial Services held a hearing for An Act to Include Fluoride Varnish Service in All Health Insurance Coverage in the Commonwealth (H. 1032 / S. 463).

MassHealth began offering a fluoride varnish benefit through medical providers in 2008. These physicians are now able to apply fluoride varnish in the course of a well child visit to prevent dental disease. Currently, twenty-five states reimburse physicians for providing basic preventive oral health care for children during well child visits, the most common reimbursement being fluoride varnish application.

Senator Chandler opened the hearing, testifying that fluoride varnish is an important preventive measure, stating that the bill would bring private insurers up to best practice standards and make a huge difference for children. She urged the committee to report the bill out favorably.

Dr. Andrew Balder of Springfield testified next. He noted that as a pediatrician, he sees the links between oral health and overall health every day. He explained that poor oral health has a negative impact on a child’s ability to eat, sleep, and pay attention in school, and that it has been linked to a multitude of other health issues. He stressed the importance of preventive care, and how easy and effective it is for health care providers to apply fluoride varnish; just yesterday he provided the service for two siblings and it took approximately two minutes to complete.

Dr. Ana Zea, a dentist and instructor in the Community Health Programs division at the Boston University Dental School was the last to testify on the Fluoride Varnish bill. She drove home the importance of fluoride varnish as a preventive measure, and urged the committee to pass the bill to expand access to the benefit. She stressed that children often visit pediatricians long before they see a dentist, and that makes it essential for the benefit to be reimbursed through private health insurance.

If enacted, 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 will also increase access to preventive measures and improve the oral health and overall health of vulnerable populations, such as persons with special health care needs.
-Courtney Chelo

December 15, 2009

The Health Care Quality and Cost Council will be meeting on Wednesday, December 16, from 1:00 p.m. – 3:00 p.m. at 21st Floor, 1 Ashburton Place, Boston.

The agenda includes:
- Committee reports and discussion on
A.Quality and Safety
B.Cost Containment
C.Communications and Transparency
D.Advisory Committee

- Vote on adopting changes to CMR 3.00 – Disclosure of Health Care Claims Data and Proposed Fees for Health Care Claims Data

- Discussions
a.Briefing on the Expert Panel on Long Term Care Financing – Jean McGuire
b.Implementation Update on the Roadmap to Cost Containment: Healthy Behaviors – DPH
c.Presentation from Julie Lewis on Potential Savings from ACOs -- Dartmouth

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