March 2010

March 31, 2010

The Division of Insurance held public hearings today regarding their emergency regulations promulgated last month in an effort to provide premium relief to small businesses. Several organizations testified including the Massachusetts Association of Health Plans and Blue Cross Blue Shield of Massachusetts (BCBS).

The most controversial part of the emergency regulation, 211 C.M.R. § 43.08, requires that HMOs file proposed small group rates (or changes to previously filed rates) at least 30 days before their effective dates. Along with the rates, HMOs must file actuarial support to justify any increases and they must also file a description of the basis for differing rates among similarly situated providers (including the quality of care, patient mix, geographic location of the provider, and complexity/intensity of services provided).

The Commissioner of Insurance will then evaluate the rates, including an analysis of the data supporting price increases. If the Commissioner then determines the rates to be unreasonable or excessive in relation to the benefit conferred, he may disapprove the rates. If the Commissioner disapproves rates, he must do so on or before the effective date (tomorrow, April 1 for the first filings made under the regulations). The HMO may then request a hearing on the disapproval to be held within 30 days.

The insurers argued that the regulations do not take into consideration market forces behind HMO pricing. As a result, caps on prices will be arbitrary and insurance companies will sustain losses which will be felt across the Commonwealth. HCFA, in its written testimony (pdf), lauds the Governor for prioritizing the rate issues facing the individual/small group market. To us, the public has a right to understand what is behind premium increases for individuals and small groups. The Division of Insurance has long had the responsibility of reviewing rates and disapproving unwarranted rate increases in order to ensure stability in the market.

We expect to soon learn of DOI's decisions for the next round of premiums.
-April Seligman

March 30, 2010

Dr. Atul Gawande was the featured speaker at Monday morning’s MGH Disparities Forum, organized by The Disparities Solutions Center at MGH. He spoke about the “bell curve” of care, with the best performers at the top, the worst at the bottom, and the majority in the middle. As Dr. Gawande pointed out later in his talk, those at the top are often providing the best care at the lowest cost, and, often, vice-versa for those at the bottom. Dr. Gawande said that we do not look closely enough at what is happening at the top that leads to the best quality care but we also pay even less attention to those at the bottom and how they can get better. He said those at the bottom are often where the greatest disparities are happening, and, as he related later in the talk when speaking about where he has seen the greatest adoption of surgical checklists to prevent surgical complications and deaths, often because of a lack of time and resources at hospitals that see many uninsured patients but also because there may not be an organization and leadership that is prioritizing improvements in care at those institutions. He did also point out that those in the middle and at the top also have much work to do on reducing disparities, even though it is often hard for those at the top to admit that they have disparities.

Dr. Gawande compared today’s national reform landscape with what happened after Medicare became law in 1965. Knowing that the road toward implementation of health reform will no doubt be rocky, he said that we also need to recognize that Medicare implementation was not smooth, though it is now a hugely popular program. He talked about resistance from the AMA at the time, which thought Medicare would lead to socialized medicine, and also resistance from hospitals in the South which had segregated patients by race and, if they wanted to receive Medicare funds, were required to stop such practices. Thus, as he said, Medicare had a major impact on dismantling disparities that existed at the time.

Dr. Gawande also spoke about his work with the Word Health Organization on developing a surgical checklist for care to reduce surgical deaths and complications. 
The pilot test phase of developing the checklist included the use of the checklist at 8 hospitals around the world with varying levels of resources and technology as well as poverty and need among patient populations. Surgical complications decreased by 36% and deaths decreased by 47% on average. The decreases were greatest in the poorest hospitals but there were significant decreases in the well-resourced hospitals as well. In the U.S., about 15% of hospitals are currently using the checklist, and most of them are the better-resourced hospitals.  Again, as mentioned above, those hospitals resisting its use are often, but certainly not always, those with larger populations of uninsured, minority patients. HCFA and the Consumer Health Quality Council are advocating for legislation on the use of checklists in MA hospitals. Learn more on the HCFA website.

Dr. Gawande closed his remarks by saying that work on improving the quality of health care IS the work to reduce the cost of health care.

Deb Wachenhein
Quality Manager

March 30, 2010

Given the current economic climate, states are searching for ways to cut back costs.  Eight months ago, California made drastic cuts to dental benefits for adult Medicaid recipients, leaving 3 million poor and disabled Californians uninsured for dental cleanings, exams, filings, root canals and dentures.  Massachusetts threatens to follow their lead with similar cuts. 

Oral health is an essential part of overall health. If left untreated, dental disease can impact other chronic health conditions such as heart disease and diabetes, and can interfere with basic life activities, such as eating, speaking, learning and working. 
Unable to pay for dental services out of their own pockets, California Medicaid patients are forced to delay care until dental pain is intolerable and their only option is extractions, the only dental service still covered.  A recent story on NPR reported that dental schools and free clinics in California have been overrun or have been forced to close and while dentists are offering discounts and payment plans, low income adults cannot afford these options. 

Proposed cuts in Massachusetts would leave almost 700,000 residents, including more than 120,000 low-income seniors and 180,000 disabled adults without critical oral health benefits.  Like California, many easily-solved oral health problems will instead become needless pain and suffering.  Extractions will remain the only option to prevent infections from spreading throughout the body. 

Massachusetts has led the country on healthcare reform and yet, threatens to cut oral health out of the picture despite the link between oral health and overall health.  Dental prevention and treatment services also reduce costs to the state by preventing costly emergency services and decreasing the severity of other chronic diseases. A Kaiser study found the 2002 elimination of dental services merely shifted the cost of care to other parts of the health care system.

Let’s learn our lessons from California’s experiences.  We must preserve MassHealth adult dental benefits to ensure healthy communities and avoid unnecessary healthcare costs. 

Tiana Wilkinson
Oral Health Intern

March 29, 2010

The National Alliance for Mental Illness (NAMI) had their annual lobby day at the State House on Monday. Consumers and advocates from across the state came to show their support for mental health services that are currently being offered in the state. Laurie Martinelli, Executive Director for NAMI, opened the event by sharing six recommendations for the state regarding mental health services. Budget cuts were a top priority at the lobby day, since so many mental health services are in jeopardy.

One of focus of the day was Emergency Service Providers (ESP). ESP is a program that offers around the clock services to individuals suffering from mental illnesses. Individuals are able to call, and a team of providers will respond in a timely manner, and offer critical services that the police or 911 operators might not be able to provide. ESP is designed to offer help to all individuals, regardless of whether they have private insurance, MassHealth, or no insurance.

Commissioner Leadholm stressed that both the Governor and Secretary realize that funding is needed in this area, and that it is critical that constituents make their voices be heard by their legislators. As a final note, the Commissioner stated that, “We must always remember the most important side of mental illness is the human side.” She asked everyone to keep that in mind while speaking with their legislators.

Many legislators were at the event, including Senator Jen Flanagan, who encouraged individuals to share their personal stories to their legislators to get their point across. Flanagan is one of the legislators who are working hard to get as many services as possible for individuals suffering from substance abuse issues and/or mental illnesses.

Representative David Sullivan vowed to continue to work for this issue in his years to come. He stated that mental illness programs always seem like an easy cut, which is why it is so important to advocate for mental illness. He concluded his remarks saying, “This is your house, so don’t be afraid to let your voice be heard!”

Consumers were encouraged by other mental health leaders to speak passionately to their legislators about mental health programs that are currently in jeopardy. Mental health services are expected to receive $621 million, a 3.6% decrease from last year, which is why this lobby day was so important.
--Brittany McDaniel

March 29, 2010

A state report released this past week indicated that Massachusetts led the country in the number of vaccinations against the seasonal flu and H1N1. 57% of the state’s population was vaccinated against the seasonal flu with 36% of individuals were inoculated against H1N1. Nationwide, only 37% of the population was immunized against the flu, and a meager 21% against H1N1.

Close to two million doses of the H1N1 vaccine was distributed in the state of Massachusetts over the course of this past flu season. HCFA played its role, with our Helpline working with the Department of Health to increase awareness of the flu and H1N1 to callers. In addition, local health departments in collaboration with schools and hospitals released public health messages, such as 30-second commercials, Facebook and Twitter messages, brochures, and transportation advertisements.

All cases of the flu are lower than normal for this time of the year, and the reason could be linked to the raised public awareness. The chances of contracting H1N1 are diminishing in the state, with a third having been inoculated and another third already contracting the virus. Officials plan to include the H1N1 strain into next season’s flu shot, and the hope is that even more people over the age of 6 months, will receive the shot.
-Brittany McDaniel

March 27, 2010
March 26, 2010

Dr. Don Berwick, the President and CEO of the Boston-based Institute for Healthcare Improvement, is rumored to have been chosen to head up the federal Centers for Medicare and Medicaid Services (CMS).

Though the appointment has not been publicly announced, Politico reports that the journal Inside Health Policy quotes several sources who say it could be announced as soon as next week, writing that "Berwick agreed to take the job ‘some time ago’ but only on the condition that health reform pass first."

Dr. Berwick is highly-respected for his work at IHI, one of the leading health care quality improvement organizations in the world, as well as his work as a professor at Harvard Medical School and the Harvard School of Public Health. National health reform includes many provisions relating to quality improvement and cost containment in the Medicare program, and there are few people more qualified to head up these efforts than Dr. Berwick, who also brings a personal and consumer-oriented perspective to his work and to IHI. HCFA has had the opportunity to work with IHI on many occasions and we eagerly anticipate an official announcement of Dr. Berwick's appointment.
-Deborah Wachenheim

March 26, 2010

Senator Kerry and members of the Massachusetts House delegation will speak today on benefits of health reform to Massachusetts this afternoon, at the East Boston Neighborhood Health Center.

Also, Congressman Markey released a summary of the fiscal benefits to Massachusetts (pdf) from the health reform law. In total, the Commonwealth and its residents will receive new federal support for health care worth approximately $7.7 billion over 10 years. The report finds that in Massachusetts, the heath care reform bill will:

  • Provide families with tax credits worth $2.4 billion to help purchase health care coverage.
  • Provide $2.3 billion in increased federal funding for Medicaid.
  • Provide small businesses with $1 billion worth of health care tax credits.
  • Fill the donut hole, saving seniors $1.6 billion in drug costs.
  • Provide $400 million in new funding to community health centers.

Here's the text of the press announcement for today's event:


BOSTON – Fresh from passing historic health care reform, Senator John Kerry and members of U.S. House delegation including Congressmen Ed Markey and Congresswoman Niki Tsongas will speak with members of the media on Friday about how the new reform passed by Congress will benefit Massachusetts.

The law passed this week by the House and Senate will strengthen Massachusetts’ health reforms, cut costs for families and businesses, bring new federal subsidies into the state, deliver new benefits to families and businesses across Massachusetts, and give the state billions of dollars to provide subsidized coverage and tax relief to small businesses who offer health insurance to their employees.

It also dramatically increases funding to community health centers throughout the state. Community health centers play a vital role in providing high quality care to underserved communities. This funding would help the 52 community health centers in the state that provide high quality health care to those in need regardless of their ability to pay. Community health centers in Massachusetts currently serve more than 760,000 state residents.

Members of the Massachusetts Congressional delegation recently announced $80 million in federal grants to Massachusetts Community Health Centers. Of the funding, East Boston Neighborhood Health Center received $12 million to construct a new facility. Last summer the center received $1.9 million to make improvements to its existing facility. The East Boston Neighborhood Health Center is the only health center in America with an emergency room that operates 24 hours and day, seven days a week.

WHO: Senator John Kerry
Congressman Edward Markey
Congresswoman Niki Tsongas
Members of Massachusetts State House delegation
Members of Boston City Council

WHAT: Press Conference to highlight how Massachusetts will benefit from the new federal health reform law

WHEN: Friday, March 26, 2010, 3:00pm

WHERE: East Boston Neighborhood Health Center
10 Gove Street, East Boston

March 25, 2010

CommonWealth Magazine's Michael Jonas has a thoughtful interview with John McDonough, former HCFA Executive Director who served on Senator Kennedy's HELP Committee health staff in 2008 and 2009.

Their talk yesterday covered the role of Massachusetts health reform, Scott Brown, Mitt Romney and the challenge of implementation. McDonough also brings a historical perspective: "This is the kind of thing that happens less than once in a generation. It seems like it’s every other generation or every third generation. If you think of Social Security, 1935, Medicare, 1965, 30 years later, and then this, 45 years later. It’s hard to underestimate the importance of it."

March 23, 2010

The Massachusetts Health Care Quality and Cost Council met to discuss the recommendations of the Expert Panel on end of life (EOL) care and to hear a presentation by Kevin Beagan, Deputy Commissioner of Insurance, regarding the health care components of the Governor’s small business bill.

Lachlan Forrow, M.D., Chair of the Massachusetts Expert Panel on End of Life Care, delivered the Panel’s recommendations to the Council. He noted that the goal of the Panel was to “develop processes and measures to improve adherence to patients’ wishes in providing care at the end of life” and to “ensure that health care providers ask about and follow patient’s wishes with respect to invasive treatments, do not resuscitate orders, hospice and palliative care, and other treatments at the end of life.” Dr. Farrow noted that health care should be capable of promising dignity, comfort, companionship, and spiritual support to patients and families at the end of life. He highlighted some of the Panel’s key findings, for instance, that on average 140 people in the Commonwealth die daily, the majority of which are not related to acute episodes or traumas. Additionally, 70% of people in the Commonwealth want to die at home (citing AARP statistics), when in actuality approximately 70% of people die in institutions. Dr. Farrow noted that the Panel’s central finding was that there is little to no accountability in the Commonwealth for ensuring that EOL care is anchored in patients’ wishes. There are also no standards or processes for eliciting, documenting, or honoring patients’ wishes.

In the Panel’s opinion, the two prerequisites for change are 1) to engage people in voicing, individually and collectively, what we want and need during serious advancing illness, through the end of life, and 2) to hold health care providers publicly accountable for delivering patient engagement and sharing best practices to drive ongoing improvement. The Panel’s recommendations toward these ends were ultimately split into five categories:

  1. Massachusetts residents must understand the full range of their options for EOL care;
  2. Health care providers must reliably identify and meet the wishes and needs of patients with serious advancing illnesses;
  3. Massachusetts must cultivate a skilled workforce to meet patients’ EOL needs;
  4. Financial systems must support the provision of care that patients want and need; and
  5. There must be a responsible body with existing credibility, which has the resources and authority to ensure achievement of the above requirements for excellence in EOL care, with measurable quality indicators and public accountability.

Each category contains several recommendations toward meeting the overarching goal of the category.

After Dr. Farrow’s presentation, there were a few very poignant comments. One comment came from Jim Roosevelt, President of Tufts Health Plan, in response to one of the Panel’s findings that the Commonwealth cannot improve EOL care by focusing on the identifiably “dying” but instead must address the trajectory of serious advancing, ultimately-fatal illness. Mr. Roosevelt noted that for most diseases from which people ultimately die, doctors are unable to predict when exactly the patient will die. Although much of a person’s lifetime health care dollars are spent in the final weeks of a person’s life, Mr. Roosevelt commented that, ultimately, hindsight is 20/20 and if we knew that certain weeks were actually the final weeks of a person’s life, then the patient’s medical decisions may be different.

Dr. Farrow responded that to improve EOL care, we must have discussions focusing on the patient’s wishes and values. When discussing an ultimately-fatal illness, the doctor should tell the patient that the illness will kill the patient unless something worse does sooner. Then, the doctor should frame the discussion as seeking to prolong life, but also eliciting the patient’s wishes regarding where and how they prefer to spend their final months (eventually) so that the doctor can then honor the patient’s wishes.

However, these open discussions between patients and physicians are not happening. An AARP study has reported that currently, EOL discussions are not taking place for the vast majority of patients (only 1 in 6 patients in the study reported talking about EOL issues with their doctors). Dr. Farrow commented that these discussions don’t occur because EOL care is not part of the current medical agenda. Therefore doctors are not taught in medical school how or when to discuss EOL issues nor do they get into the habit of having such discussions once they are actually practicing. However, in order to improve EOL care, patients must know their options and make informed decisions, just as is the case in all other realms of medical treatment. As such, doctors must start having these conversations about patients’ wishes for the end of their lives if they ever hope to get good at having such conversations. If doctors shy away from the issues because they are not accustomed to having discussions regarding end of life care, then the issue will never become part of the medical agenda in the Commonwealth.

The next presentation to the Council, given by Deputy Insurance Commissioner, Kevin Beagan, summarized the key health care components of the Governor’s small business bill, which was filed with the General Assembly on February 10, 2010. The bill responds to the huge rate hikes felt by small businesses in the past year. Some small businesses have reported up to 70% increases in their health insurance premiums. With increases this high, small businesses are struggling to keep afloat and are desperate for regulation and relief.

March 23, 2010

The Health Disparities Council held its bi-monthly meeting on Monday. Chaired by Representative Rushing, the members focused on legislative opportunities, interpreter services, and the Latino community to address health disparities in Massachusetts.

Hank Porten, President of the Valley Health Systems in Holoyoke, opened the meeting by discussing the current steps that are being taken by the legislative working group to improve access and quality of care. The group detailed a roadmap of how they plan on achieving this goal, including payment reform and support of a system-wide redesign. Once this goal is achieved, the group hopes to work towards the enactment of malpractice reform and peer review status and increased transparency.

Terri Yannetti from the Office of Health Equity updated the council on their ongoing recommendation of reimbursement for medical interpreters. Discussed were the limitations of MassHealth and the methodology of acute inpatient/outpatient payment amounts. The group is looking for sustainability when it comes to how the interpreters are paid.

The majority of the meeting focused on how to build a pipeline of linguistically and culturally competent mental health providers for the Latino community presented by the Masachusetts School of Professional Psychology. The Laria Mental Health Program through MSPP is a collaborative effort that offers students the opportunity to become linguistically and culturally competent before serving the 20% of individuals in the U.S. who are of Latino descent. One way they achieve this competency is by participating in a 5 week immersion program to Costa Rica or Ecuador during the summer. The main goals of this program are to increase the number of Latino mental health professionals in the U.S. and provide current psychologists with training that is needed to serve this population.

Please visit the Health Disparities Council webpage for more information.
-Brittany McDaniel

March 22, 2010

Health Care For All applauds the House of Representatives for voting YES on national health reform yesterday. And we thank the members of our Congressional delegation who supported this life-changing piece of legislation for their leadership, commitment, and perseverance. This critically important vote brings our country a giant step closer to passing national health reform. Millions of Americans are struggling to meet their daily needs, and they are now poised to gain affordable health care.

In Massachusetts, we see the positive effects of our own landmark health reform law for our residents every day. We have expanded access to care for more than 400,000 people, yet we know for many more, health coverage is still not yet affordable. National health reform will help close that gap and make health coverage affordable to nearly another 75,000 Massachusetts families.

We now look to the Senate for its leadership on this issue. We offer our steadfast support to Congressional members for moving national health reform over the finish line.