June 2010

June 29, 2010

The Health Disparities Council met yesterday. Facilitated by EOHHS Secretary JudyAnn Bigby and Co-Chair Representative Byron Rushing, the meeting opened with an update on Senate 810, which is still pending in the Senate Ways and Means Committee. The Council has formally endorsed the legislation which makes permanent in statute the EOHHS Office of Health Equity.

The meeting featured an update from the Council’s Report Card Group, who continues to develop the state’s first report card to examine racial and ethnic health disparities. The Council initially worked through overweight and obesity data, looking at the best ways to present trends between 2001-2009. As the Council examined the data, members debated the practice of using the white population as the reference group for comparing health outcomes, even when white outcomes are not best. Secretary Bigby acknowledged that for the majority of indicators, whites usually fare best, although Asians can often have similar or better outcomes as well. The Council discussed other alternatives to present the data including measuring subpopulations against the population as a whole, or against a standardized outcome standard such as a Healthy People 2010 goal. Secretary Bigby reiterated that regardless of the comparison standards, the report card would not overlook the health concerns of sub populations who are performing relatively better such as Whites and Asians, as there are still a number of health indicators (including obesity) where improvement is needed.

The Council also worked through outstanding issues related to social determinants of health disparities that will be included in the report card. The Council discussed the importance of finding additional data sets that illustrate the resources and barriers related to health in communities. For example, the Council wants to demonstrate the availability of full-service food markets in different areas as a possible determinant of overweight and obesity. The members discussed partnering with agencies outside of the Department of Public Health to obtain such data. The Council report group will continue to work through the summer on the report card’s completion.

The meeting ended with presentations regarding workforce diversity and development efforts in the Commonwealth. In prior council meetings, the members discussed the need for additional data on race, ethnicity, language for the state’s health care professionals. EOHHS’s Yashira Peppin updated the council on the Board of Registry in Medicine and other professional licensure group’s data collection efforts to date. She also briefly discussed the state’s current loan repayment efforts and work to support the designation of health professional shortage areas. She noted DPH’s Primary Care Office currently has available $450,000 in funds dedicated to loan repayment programs for medical professionals serving in physician shortage areas, and noted the Commonwealth will also examine opportunities in the federal health reform legislation, to develop the health care workforce and improve access to providers in shortage areas.

The next Health Disparities Council meeting will take place on Monday, September 27, 2010.
-Qiong Lin

June 28, 2010

My experience with that huge medical file of mine is that nobody has time to look at it.

Our fragmented health care system is inefficient and wastes resources. The system is organized around the needs of the institutions, not the patients. Moreover, the growing cost of health care is crowding out funding for other areas that also affect health status, such as education, transportation, and housing.

What we need is better care at a lower cost. Payment reform is critical to reducing waste, helping patients become partners in their own care, and freeing up doctors from time-consuming paperwork so they can be there for their patients. We want a health care structure that delivers more for patients and protects the most vulnerable among us, such as the disabled, the chronically ill, immigrants, low and moderate income people, seniors and children. A coordinated care system, with high quality care can drive down the overall costs of health care.

Our Campaign for Better Care is educating consumers to advocate for a comprehensive, coordinated health care system through guiding principles such as: transparency, patient activation and empowerment, protections for vulnerable consumers, and patient-centered primary care. The campaign is launching a video series that includes stories from cancer survivors, care givers, and patients about how a coordinated care system can improve lives and health outcomes. These are straightforward stories that are told by people who have been personally touched by the health care system and strive to make it better:


-Georgia Maheras

June 26, 2010

State House News Service is reporting that some in Senate leadership are looking to reverse the 24-15 vote yesterday to ban smoking in Massachusetts casinos.

The Senate paused their gambling debate for the day just before 5 pm Friday without taking a final vote. The Senate will be returning for a rare Saturday session to continue working on the bill.

For the Senate to cave to the tobacco lobby and permit smoking in casinos would be a major step backwards in our efforts to advance public health. We urge everyone to call their Senator and ask him or her to oppose allowing smoking in casinos.

Six years ago, Massachusetts led the nation in implementing a comprehensive workplace law to protect employees and the public from the impact of secondhand smoke. The same considerations should apply to employees and customers in casinos.

Since the workplace law in Massachusetts was passed in 2004, both the Surgeon General and the Institute of Medicine have issued comprehensive reports on the risks of secondhand smoke and the need to protect employees and the public. The Surgeon General has stated that there is no safe level of exposure to secondhand smoke.

The Department of Public Health has demonstrated the impact of the Smoke-Free Workplace Law on a reduction in cardiovascular deaths and cost savings.

Casino workers and customers are at greater risk for lung and heart disease because of secondhand smoke exposure, even those in a "well-ventilated" casino. Studies have shown that these workers have cotinine (metabolized nicotine) levels 300-600% higher than in other workplaces.

June 25, 2010

In a recently published report by the Parent/Professional Advocacy League (PAL), parents of children with mental health needs and mental health providers were asked to identify and describe barriers to accessing treatment for kids. Results of the study showed a common trend: parents struggled most with out-of-pocket expenses, access to specialists, and finding community support for their child.

While national and state health care reform laws have addressed many problems preventing access to health care overall, improvements to access for mental health services still lag behind.

Expenses and coordination of care were reported most problematic.

Out-of-pocket expenses are high for essential treatments and services for children with mental health needs as compared with those costs for physical illness. Parents reported that copayments associated with frequent therapy, multiple specialists, and medications were prohibitively high. Additionally, expenses associated with travel to providers who accepted the child’s insurance plan, on top of an initial deductible, was a significant burden.

Cost alone is not the only issue. Long waits to get an appointment, obtaining an accurate diagnosis, coordinating care between providers, and insurance coverage limitations on treatment options were also mentioned. In addition to problematic access to medical services, the study revealed that school programs for children with disabilities were often inadequately tailored to address special needs, and the stigma attached to a mental disability often lead to isolation.

Federal and state health care reform laws have improved some access problems to mental health care. New federal laws will eliminates discriminatory practices insurance companies often use against individuals with mental health needs. Minimum Creditable Coverage laws in Massachusetts require compliant insurance plans to offer certain mental health benefits. While these are significant improvements for access to mental health care services, results from the PAL study demonstrate that payment for services is only part of overall access problems.

The Commonwealth has made significant strides over the past few years to improve access to care for children with mental health needs. However, as PAL’s report shows, we still have a long way to go.

The time is NOW to make changes.
-Elizabeth Arnold

June 25, 2010

The state Health Disparities Council holds its next meeting on Monday, June 28th from 2-4PM on the 21st floor of Ashburton Place.

The meeting will be the last to take place before the Council’s summer reccess. The agenda includes reports from the EOHHS Office of Health Equity, including an update from the Report Card Group, and a presentation from the Legislative Group.

June 25, 2010

On Thursday, the House Ways and Means Committee released its version of S. 2380, legislation to reorganize the state's economic development apparatus.

Buried in the 100+ pages of legalese was this simple provision:

SECTION 105. Chapter 111N of the General Laws is hereby repealed.

The pharma industry hoped nobody would notice these 8 words, that nobody would make any noise about this obscure provision.

But we did, and we will.

Chapter 111N is the state's historic drug and device marketing restrictions law, passed overwhelmingly in 2008 after a bitter struggle between consumers, doctors, hospitals and employer groups seeking lower health care costs, and the drug industry seeking to protect their sky-high profits on brand-name drugs. The law imposes reasonable restrictions and transparency on the inherent conflict of interest set up when drug companies pay off doctors to prescribe drugs. (Background info here, here, here, and here.

Now industry is pushing back, tacking on an unrelated provision onto a complex bill, a provision that never had a hearing or any public discussion during the last weeks of the session. This is a hail-mary pass by an industry that only looks out for its bottom line, without regard to ethics or patient needs.

The Boston Globe today called Chapter 111N "one of the smartest steps Massachusetts has taken to get health costs under control." DPH bent over backwards in its regulatory process to accommodate industry's pleas to avoid burdening legitimate interactions, while making sure the public interest came first. The first public reports under the law are due next week.

The House debate on S. 2380 is scheduled for next Wednesday. Call your Representative, and urge him or her to support the amendment to strip out section 105. This is not the time to undo a decision made just 2 years ago.
-Brian Rosman

June 25, 2010

Massachusetts Health Quality Partners today released survey data on patients’ experiences with care in primary care practices across the Commonwealth. (press release, link to reports and search)

This is the first patient experience survey since health reform was enacted in Massachusetts in 2006. Also, this survey took place in the midst of national health reform debates and discussions in Massachusetts about reforming the health care payment and delivery systems.

Many of these patient experience measures provide valuable information to health care providers and to public policymakers as they seek to make care more patient-centered, through models such as medical homes and chronic disease management programs, for example. As the press release describes with concrete examples, care providers look at this data to determine where they are doing well and where they need to improve, and then they take steps to make those improvements. The information also serves to inform consumers as they seek to choose providers or assess the quality of care provided by their current providers. There is data on both adult and pediatric practices.

One can check out ratings from a patient's point of view on doctors by name, or by geographic location. Results on seven quality of care measures, and patients’ willingness to recommend their doctor are reported.

Overall, there are a few areas that stand out as needing improvements: physicians’ knowledge of patients’ and their medical history, how often patients are informed of test results, and primary care physicians’ knowledge of care received by specialists to whom the patients were referred. Congratulations to MHQP for once again providing important, unbiased and insightful data for patients to use to improve their care.
-Deborah W. Wachenheim

June 25, 2010

This evening the US Senate voted yet again to try to end the Republican filibuster on a jobs package that included extending enhanced FMAP - federal Medicaid reimbursements - to Massachusetts and other states. The Senate leadership had slimmed down the package, reducing the aid that would come to Massachusetts, and so reducing the cost (and effectiveness) of the bill. Again, Senator Brown voted no. While a strong majority - 57 Senators - voted yes, this was not the 60 votes needed to allow the issue to come to a vote.

Today's budget laid out starkly what will happen in Massachusetts without the FMAP funds - cuts to health, education, public safety, children's program and more.

Responses were swift and furious. Governor Patrick:

"Senator Brown isn’t in favor of extending unemployment benefits for Massachusetts citizens or getting relief to states to avoid more harmful cuts to health care, education and public safety. Because of that, more people will lose jobs and the safety net will be in jeopardy at the very time people need help the most.

"He has a right to his opinion. But he isn’t just expressing an opinion, he is preventing a final vote on the merits – a vote that if taken would be successful. The thousands of Massachusetts citizens who are going to be impacted by his decision deserve to have an up or down vote on the merits of the bill. The fact is both the U.S. House and the U.S. Senate have passed extensions to FMAP, every other member of our congressional delegation supports it, and the President included it in his budget. That is why Massachusetts, along with close to 30 other states, included it in their budgets.

“We have already made $4.5 billion in cuts to programs and services that our constituents rely upon, and eliminated over 2600 state jobs. People are feeling the impact of those unavoidable cuts already and if Senator Brown stands in the way of an up or down vote on this bill even more people and families will be hurt."

Senator Kerry:

The vote was "one of the worst moments I've seen in 25 years in the United State Senate.

"In times of economic trouble, our country expects Democrats and Republicans to pull together and do the basics. Now, after eight weeks of debate and after every effort to make changes and find common ground, the Minority Leader has again found a way to unify his caucus to block legislation that extends unemployment benefits, creates jobs and provides hundreds of millions of dollars in desperately needed assistance for states. This is a terrible blow to Massachusetts. Even cutting our original proposal nearly in half wasn’t enough to secure even one Republican vote today. This can cost our state half a billion dollars in Medicaid funding, jeopardize our seniors’ access to Medicare benefits, and strip unemployment benefits from almost a hundred thousand laid-off workers in Massachusetts.”

It's time to raise our voices. On Monday at noon, join us outside Scott Brown's Boston office (at the JFK Federal Building, adjoining City Hall Plaza on Cambridge Street) to demand loudly that Senator Brown vote for the needs of Massachusetts, not politics leaders.

You can download a flyer here. Please share this with your friends and colleagues, and join us Monday.

June 25, 2010

A number of articles in the past few days have brought attention to the need to reduce hospital readmissions and improve quality of care within, and during transitions between, care settings.

An article in Monday’s Globe looked at preventable readmissions. According to the Institute for Healthcare Improvement, which is coordinating a national program to improve transitions and reduce readmissions, more than 10% of Massachusetts patients are back in the hospital within a month of being discharged. Twenty-two Massachusetts hospitals are participating in the IHI initiative to examine why this happens and what can be done to prevent such readmissions. Nationally, one in five Medicare patients returns to the hospital within a month of being discharged, costing over $15 billion.

The upside down financial incentives, where hospitals now profit from readmissions, inhibits hospitals that want to do the right thing from putting enough resources into preventing readmissions. We continue to believe that the quickest, most effective low-hanging fruit to improve quality and lower costs would be for Massachusetts to join other states in reducing payments to hospitals with high rates of preventable readmissions. This has been mulled over by state policymakers, but no firm steps have been taken beyond a task force working on recommending a measure of preventable readmissions.

There are many reasons why readmissions occur, but more broadly it is often because of a lack of coordination and oversight of care once the patient is discharged, whether the patient goes back home, with or without home health care, to a nursing home or rehab center, or to another hospital. The Globe article describes some of the pilot projects around the country that seek to improve transitions and reduce readmissions. One of these initiatives, the Care Transitions Program, is also cited in a NY Times article last week. The article focuses on the need to improve transitions of care especially for older adults with chronic conditions. The article points out that discharges from hospitals are often rushed and poorly coordinated, often leaving the still-vulnerable and recovering patient to manage his or her own care, including new medications, follow-up appointments, and keeping track of new or worrisome symptoms, with little coordination from a designated care provider. As the article points out, discharge planning often falls in the space between “billable events” and therefore does not get the time and attention it deserves. The Times article offers advice for patients and caregivers who are dealing with transitions, from making sure they know about new medications and how to take them, to putting together their own discharge plan, to making sure the primary care physician is fully informed about the patient and ready to begin his or her care post-discharge.

A second NY Times article looks at hallucinations that occur in hospitalized patients. Often called “hospital delirium,” it mostly affects older adults. It is estimated that one-third of patients over 70, and more often those in ICUs or post-surgery, experience hospital delirium. There are many potential causes, including infections, surgery, pneumonia, new medications, and also disorienting changes like sleep interruptions, isolation, changing rooms, and being without eyeglasses or dentures. As the article points out, patients experiencing delirium are hospitalized longer, more often sent to nursing homes, and more likely to develop dementia later on (and also, though not specifically mentioned, probably more likely to be readmitted to the hospital). Some 35%-40% of these patients die within a year. A number of hospitals have put processes in place to try to prevent delirium, including making sure patients have eyeglasses and hearing aids, making adjustments to schedules, light and noise so patients can sleep, and helping patients to engage in physical and cognitive activities.

The takeaway from all of these articles is that there are many hospitals and other care providers looking at how to improve quality of care within settings (eg. reducing delirium in hospital patients) and during transitions between settings (eg. thorough and coordinated discharge planning with fully informed care providers and patients/caregivers) but, for the most part, financial incentives in a fee-for-service system are still not aligned with making sure this work gets done. The goals of pilot programs in national health reform and of payment and delivery system reform in Massachusetts are to always put the patient at the center of the care process so that the patient’s health and well-being come first. Once that starts happening, health and quality of life will improve and costs will come down as fewer patients are unnecessarily readmitted to hospitals and their care is properly provided for in a coordinated outpatient setting.
-Deborah Wachenheim

June 24, 2010

The House and Senate conferees reported their FY 2011 budget last night (full text; Globe coverage). Facing no good choices, the conference budget makes deep cuts in health programs, along with many other areas of state government we all rely on. The House and Senate are scheduled to vote on the budget this afternoon.

This post summarizes our initial read of the budget document; we'll update it during the day as we better understand the implications of the budget.

[Update - the always authoritative Mass Budget and Policy Center analysis is here, and their health care discussion is here.]

Among the cuts is elimination of the Commonwealth Care Bridge program, which covers some 24,000 legal immigrants. Another 13,000 or so are currently on the waiting list. The program itself represents a budget cut, since it has reduced benefits and higher copays than the Commonwealth Care program that covered them before this year. Also, the budget imposes a further $68 million cut to MassHealth, and the already-planned elimination of most dental care for adults.

Many of these cuts would be reversed if Congress approves the 6-month extension of enhanced FMAP - the additional Medicaid reimbursements pending in Washington. The Bridge program and many of the Medicaid cuts would be reinstated if FMAP funds are approved.

HCFA is co-sponsoring, along with many other allies, including SEIU and other unions, GBIO, and other groups, a mass rally Monday at noon outside Senator Scott Brown's Boston office, demanding that he support extending FMAP funding. Meet us outside the JFK Federal building, next to City Hall Plaza, Monday at noon. We'll have more details on the blog later.

The budget is not all bad news. The conferees included some important initiatives and took some more steps on disparities, payment reform, kids coverage and other areas.

Here are some other budget highlights:

  • Section 190 of the budget creates an "FMAP Budget Relief Fund." That fund would receive the additional FMAP money if Congress extends our expanded Medicaid match rate. Numerous line items are partially funded from the General Fund, and part from this FMAP fund. Under section 190, for those line items the agency may only spend at the annual rate provided by the General Fund appropriation until the FMAP money is secured.

    So rather than a blunt, across the board cut, the budget provides for varying levels of cuts if the FMAP money is not approved.

    For example, in the MassHealth CommonHealth program for the disabled, .2776% is held back and funded by the FMAP fund, while in the DPH HIV treatment program's budget, 4.98% can only be spent from the FMAP funds. Some programs, like the CommCare Bridge program, academic detailing and the Betsy Lehman center, are 100% dependent on FMAP funds.

  • the MassHealth cuts are not specified beyond authorizing the administration to reduce adult dental benefits (section 145) and other optional benefits. Language directs EOHHS to provide a plan to cut $15 million in state costs from MassHealth, which would require about $33 million in total cuts, since the state would lose the federal reimbursements. The plan, due by October 15, "may include, but not be limited to, limiting, eliminating or otherwise restructuring services delivered to adult members of the MassHealth program;" but "shall make all reasonable efforts to avoid proposing elimination of any MassHealth services." The language explicitly overrides the provision of chapter 58 restoring MassHealth benefits that had been cut earlier.
  • The MassHealth restrictions on immigrants was amended to eliminate the unintended consequences of the original Senate language. The new provision (section 73) codifies current practice. All MassHealth applicants must verify their immigration status, and benefits may only be provided to those here lawfully except where federal rules permit otherwise.

    UPDATE: We are grateful that the Conference Committee found a rational and reasonable solution on this emotional issue. We also want to thank Rep. Provost who sent a letter to Speaker DeLeo (pdf) on this issue which was signed by 33 other Reps. Each of these Reps should be thanked and commended for their leadership and dedication to immigrant issues. Thank you!

June 23, 2010

The restaurant industry and drug and device companies are trying to repeal the Commonwealth's landmark drug industry marketing restrictions. The gift ban prevents drug and device companies from wining-and-dining doctors to get them to prescribe brand-name drugs. Repealing this provision will gut a critical piece of Massachusetts’ cost containment efforts.

Although some argue that the gift ban is crippling profits in the Massachusetts restaurant industry, no empirical evidence has been presented to show that the ban is to blame. The Massachusetts Restaurant Association contends that "the ‘gift ban’ has been devastating to restaurants and thousands of middle-class employees.... Sales at many Massachusetts restaurants dropped at least 10%, while countless others were forced to close.” But the Association offers no data to support this allegation.

We'd like to see the objective numbers, but even if this is true, the reason for the sales drop experienced by Massachusetts restaurants is surely the ongoing economic recession. The losses seen by Massachusetts restaurants mirror similar recession-caused losses in the restaurant industry throughout the country — despite the fact that most states do not have a pharmaceutical gift ban. For example, in April, a trade paper reported that sales were down 10% at the top 100 independent restaurants in the U.S. in 2009. This is in line with the drop that was forecast for national fine dining sales at the beginning of 2009, when the Wall Street Journal reported that such sales were “expected to plummet 12% to 15% in 2009.”

We fully understand the challenges that restaurants are facing in this bleak economy and sympathize with their plight. But the individual patients, who are struggling to afford their prescriptions, and small businesses, which are crippled by the cost of insuring their employees, deserve better. Their healthcare costs are driven up by exactly the sort of conflict of interest that the gift ban eliminates. We cannot allow what is really an attempt to boost pharmaceutical profits to interfere with ensuring affordable, accessible health care for our entire community.

One other thing - if doctors value getting their drug sales pitches over a fancy meal, there's no prohibition on a doctor and drug sales rep dining together at an upscale restaurant. Just ask for separate checks.
-Rosemary Guiltinan

June 22, 2010

Health Care For All (HCFA) needs $15,275.00 to fully fund our HelpLine. Will you donate $100.00 or more today? HCFA's fiscal year ends June 30 and we need your help to continue to reach and assist the consumers of Massachusetts. Here's how your gift helps: · $100.00 allows a HelpLine counselor to intake and enroll one person in health coverage. · $500.00 collects data and identifies areas and populations in the state that need health coverage improvements. · $1,000.00 sends a HelpLine counselor to a community event to enroll consumers and provide bilingual consumer education on health reform issues. HCFA's HelpLine is an underfunded and vital direct service program that assists Massachusetts health care consumers navigate the health care system and enrolls residents directly into coverage. Click here for a recent HelpLine success story and here to track our year-end giving! To make a tax deductible donation, click here or call Melissa Freitas, HCFA’s Individual Giving and Events Manager at 617-275-2926. -Melissa Freitas