February 2011

February 26, 2011

We have blogged several times about the new open enrollment period that has been created for individuals who buy private health insurance coverage for themselves individually or for their families.  We have created a flow chart that explains the new law.  It is quite technical and full of legal terms.  If you have any questions, please contact our HelpLine at  1-800-272-4232.

- Jekkie Kim

February 25, 2011

Campaign for Better CareThis week, Governor Patrick held a series of meetings with health care providers in Hyannis, Brockton and Jamaica Plain to discuss his recently-filed payment reform bill.  Grateful to be a part of these candid conversations, HCFA thanked the Governor for filing his legislation and ensuring consumers have a seat at the table in these conversations.

The discussions covered a range of topics - from the need to improve communication between insurers and patients to how to increase the number of primary care physicians practicing in Massachusetts.  But the most pronounced part of these meetings was the consensus among the diverse stakeholders that the status quo is unsustainable and meaningful cost and quality improvements must be made.

Patrick Administration officials stressed the importance of treating the entire patient and emphasized that more health care is not necessarily better health care. "We get what we pay for,” said EOHHS Secretary Dr. JudyAnn Bigby. “We pay for ICUs. We pay for hospital beds. But we have one of the most under-resourced hospice care system in the country. We have way too many families who say, 'my father never wanted X, Y, Z and he died 3 weeks later in the ICU anyway.' What we pay for doesn't necessarily pay for what the communities want and need.”   The Governor also pointed out the cost savings associated with coordinated care and talked about the importance of not getting lost in health care jargon.  He told attendees that the health care community must discuss reforms in a way that is understandable to the average consumer.

In the coming weeks and months, patient voice and advocacy will be a critical part of the debate around payment reform.  We encourage you to get involved and join our Campaign for Better Care to ensure these changes work for all consumers.  Please email me at afertig@hcfama.org to get involved.
-Ari Fertig

February 25, 2011

The Connector Board met yesterday to discuss revised Commonwealth Care regulations and the Connector’s FY11 plan of operations.  Board Vice-Chair Dolores Mitchell chaired the meeting in Secretary Jay Gonzalez’s absence.

Materials from the meeting are here.

Glen Shor began the meeting with a quick report on the Connector’s activities:

  • Procurement: The Connector received RFR responses for Seal of Approval contracts, which are effective July 1, 2011.
  • Student Health Program Procurement: The SHP Steering Committee – of which the Connector is a key member – received bids for Academic Year 2011-2012.  They anticipate final selection of a plan(s) in March.
  • The commercial non-group insurance market is closed as of February 16.  The Connector website includes updates about the closed enrollment period as well as information for people whose circumstances may allow them to purchase insurance outside of the open enrollment period.
  • The Connector applied for and received an Early Innovators Grant for their proposal to create exchange IT infrastructure with UMass Medical School on behalf of a consortium of New England states.  Shor recognized Connector Chief Operating Officer Bob Nevins for his work on this grant.  The grant provides the Connector with resources to create reusable and transferable information technology related to exchanges, in order to help other states establish exchanges quickly and efficiently.  The Connector is working with UMass Medical School and the Blue Cross Blue Shield of MA Foundation on certain aspects of this initiative.
  • The Connector plans to reserve time at Board meetings to discuss Affordable Care Act implementation on a quarterly basis.

Commonwealth Care Regulations
Connector General Counsel Ed DeAngelo presented the Board with highlights of revisions to the Commonwealth Care regulations.

The changes are necessitated for primarily three reasons: to implement FY12 MCO procurement bidding rules; to accurately reflect current practice; and to strengthen the Connector’s program integrity measures.

CommCare MCO Procurement

  • Assignment of certain new and returning Plan Type I (below poverty) members to the lowest-cost plan.
  • Permits Connector to implement an active open enrollment for Plan Type I members, with assignment of Plan Type I members who do not actively choose a plan to the lowest cost plan.
  • Limits Plan Type I members’ ability to transfer from their assigned health plans.  Members will no longer have 60 days to switch their plan.

Clarify Current Practice

  • First month’s premium must be paid in full before enrollment.
  • Premium payment due date is the 25th of each month.
  • Members disenrolled for failure to pay premiums must pay their arrears before re-enrollment.

Program Integrity

  • Members are disenrolled if they owe two months of premiums.  Members get a warning after missing one payment along with an application for a hardship waiver and payment plan information.
  • Members on payment plans to pay back arrears must keep up with both the payment plan and the current monthly premium.
  • Members who have been out of CommCare for more than two years must pay their arrears before re-enrolling.

Nancy Turnbull requested information on how many members are disenrolled for failure to pay premiums, and how many members are on payment plans.  DeAngelo said the Connector staff will look into this.  In response to Celia Wcislo’s question, DeAngelo also noted that members can call the Connector’s customer service to talk about setting up a payment plan or applying for a hardship waiver.

The Connector also proposes two miscellaneous amendments to reflect the current economic climate:

  • Eliminate reference to the Fishing Partnership, which is being discontinued.  Previously, residents with access to the Fishing Partnership were ineligible for CommCare.  Income-eligible former Fishing Partnership members are being transitioned to CommCare (with the help of the HCFA HelpLine).
  • Premium and co-pay hardship waivers will also be available for members who have declared bankruptcy.

The Board voted unanimously to release the CommCare regulations for public comment, with a public hearing planned for April 5.  The Board will vote on the final regulations at the April 14 meeting.

FY2011 Plan of Operations Update
Connector COO Bob Nevins updated on the Connector’s progress in meeting their FY11 plan of operations goals.  According to Nevins, the Connector identified 49 key strategies across 4 planning categories: program, policy, administrative/organizational, and national health reform.  For the most part the Connector work is on schedule.

February 23, 2011

Consumer Health Quality CouncilIn a recent 2-part series (Part I), (Part II) in the Boston Globe we read a number of chilling stories about patients who died in the hospital because an alarm set to warn nurses of their critical condition was accidentally missed, handled incorrectly, or failed to go off.

According to the article, between 2005 and mid 2010 more than 200 patients in the US died due to problems with alarms on monitors that track heart function, breathing or other vital signs. And research suggests these numbers are underreported.

Why is this happening? One possible reason is what researchers call “alarm fatigue.” With the use of monitors increasing, the rising number of beeps and lights can cause stress and fatigue for nurses. Additionally, high rates of false alarms cause nurses to become desensitized to alarms, leading them to develop a decreasing sense of urgency for addressing these alarms. In one unit at Johns Hopkins Hospital staff document 942 alarms in one day and one critical alarm every 90 seconds

Another major concern is technical problems and improper use of the alarms This includes issues such as dying batteries, disconnected cables, alarms that are not turned on or set properly, and volumes that are set too low. In some cases nurses lower the volume on alarms to give themselves and patients a break from the constant noise.

Currently there are limited federal level interventions in place to address this issue. Additionally, there are major disagreements between staff in hospitals and medical device companies that make monitors as to what the most important causes of the issue are. The article suggests some solutions that address both nursing and device specific issues. They include:

Hiring nurses and techs to do nothing but monitor alarms - In MA, Massachusetts General Hospital and South Coast Hospital have both been using this approach. Unfortunately this solution is very costly (South Coast spent $1Million) and can lead to alarm fatigue in the nurses hired to monitor the alarms.

Improving monitoring technology to decrease false alarms. - A number of companies are working on designing smarter monitors that follow multiple physical indicators at once and consider them all together before sounding an alarm. Paul Hickey at Children’s Hospital Boston is collaborating with engineers at MIT to develop this type of smart monitor. However, Dr. Hickey points out that a finished product is far off.

Strengthening standards for monitor design and use. – This approach can be used to regulate device characteristics, such as minimum volume, and the thresholds for alarms being sounded.

Stricter monitoring criteria - There is some concern that the number of patients being monitored has increased unnecessarily in recent years. Creating stricter guidelines for who gets hooked up to a monitor could help reduce alarm fatigue, however some providers are concerned this will create serious safety issues.

How can you protect yourself as a patient?
James Kelley of the ECRI Institute (a non profit institute focused on improving medical care) suggests that patients and families ask doctors and nurses to explain what monitors are being used for, what types of alarms to expect, and which signals to be most concerned about.

- Margot Schwartz

February 21, 2011

If you need individual insurance, the open enrollment period during which anyone can purchase coverage is over. The enrollment periods only applies to people who buy private health insurance coverage for themselves individually or for their families. It does not apply for those who get health insurance through work, school, or a government insurer such as Medicare, Commonwealth Care or MassHealth.

From now on, the annual open enrollment period for individuals to purchase insurance will be between July 1st and August 15th. Until then, the individual insurance market is in a closed enrollment period.

However, under the following circumstances, individuals may not have to wait until July and may be able to buy insurance during closed enrollment. Here are the rules

1. You can buy coverage if you can answer yes to all of the following questions:

  • Did you have a prior health plan that was terminated less than 63 days ago?
  • Were you terminated for reasons other than you committing a fraud or not paying your premiums?
  • Was that plan a group health plan (including COBRA or mini-COBRA), government health plan (including Commonwealth Care), church plan?
  • Did the plan provide “creditable coverage” as defined in HIPAA (ask your insurer)?
  • Did you have the insurance for 18 months or more?
  • Are you not eligible for coverage under a group health plan, Medicare Part A or B, Medicaid?

2.You can buy coverage if you or your dependent have experienced any of the following events.

  • Marriage (and establishment of domestic partnership, if available under the terms of the policy).
  • Birth of a child.
  • Adoption of a child or placement of that child for adoption.
  • The dependent’s loss of creditable coverage from another group or government plan.
  • Upon court order.

3.You can buy coverage if you experienced any of the following events.

  • Dis-enrolled from individual creditable coverage due to loss of status as a dependent.
  • Dis-enrolled from individual creditable coverage due to the carrier’s termination of the plan.
  • Moved to a place in Massachusetts that is outside the original plan’s service area.
  • Lost eligibility for a qualified student health insurance plan or a Young Adult Health Benefit Plan.

The rules are complex, but the HCFA HelpLine is also available to anyone who needs assistance at 1-800-272-4232.
-Jekkie Kim

February 19, 2011

The House and Senate Ways and Means Committees held their budget hearing on health programs this morning, and heard testimony from Secretary of the Executive Office of Health and Human Services (EOHHS), Dr. JudyAnn Bigby, and the state Medicaid Director, Terry Dougherty.

In her testimony Secretary Bigby emphasized that the EOHHS will maintain its commitment to providing services and support to the Commonwealth’s most vulnerable, despite budget cuts. Secretary Bigby noted that the Governor’s plan will maintain a commitment to advancing health reform, finding savings through re-procurement of MassHealth contracts and reducing administrative expenses. A main strategy for reducing administrative costs, Secretary Bigby noted, is moving towards consolidating EOHHS agencies into shared locations. For example, agencies in Barnstable will be co-located to save administrative costs and EOHHS is looking to further consolidate child service agencies.

Representative Swan spoke out on his concerns as to how such consolidation would impact the delivery of services and the cultural sensitivity of service delivery, particularly in the urban communities he represents. Secretary Bigby agreed that different communities within the state definitely have unique needs that should be considered. She specifically highlighted ensuring rural communities’ access to services and making sure that interagency expertise, such as that in the children's behavioral health program, should not be disrupted.

Governor Patrick’s recent payment reform proposal was also at the top of everyone’s talking points. Representative DeMaceo, who had many questions for Secretary Bigby, highlighted that his local community hospital believes payment reform is necessary and that he’s looking forward to working with the administration to find cost containment solutions. He specifically highlighted the need for quality and cost transparency so that consumers can be informed when making health care decisions. Bigby took such opportunity to invite the committee and hearing attendees to check out the website mass.gov/myhealthcareoptions.org, where they can compare cost and quality of specific health services across Massachusetts.

In his testimony Director Dougherty detailed MassHealth’s new procurement initiative, aimed at not only reducing costs but also better integrating care. MassHealth MCOs will soon have to develop strategies for integrating services, such as behavioral and medical services, and better coordinating patient care. Director Dougherty also shared with the committee MassHealth’s new policy of not reimbursing providers with above average preventable readmission rates, for preventable hospital readmissions within 30 days of discharge. He noted that these new regulations are all part of the administration’s larger effort to move towards a health care system that emphasizes quality and coordination of care over quantity of services.

Senator Flanagan voiced her concern over the proposed cut of 10-day bed holds, noting that when most people leave to go to the hospital, they also don’t pack a bag prepared to move out of their home. She directly asked where people are supposed to go after being discharged?

Multiple committee members, including Rep. Sciortino and Rep. Balser, also commented on the detrimental impact of continuing to cut many dental services for adults in MassHealth, and proposed cuts in adult day health and adult foster care services would have on already vulnerable individuals.
-Lydia Mitts

February 18, 2011

With a strong call to be “bold,” Governor Patrick released his payment reform proposal today that linked better care to cost reductions, though reform of the health payment system. In a speech this morning (press release/summary; speech text), and in a meeting with health care stakeholders this afternoon, the Governor started the ball rolling on a process that he hopes leads to landmark legislation by the end of the year. Check out our written response, and the video interviews with us and Blue Cross’ Andrew Dreyfus from the CommonHealth blog.

HCFA welcomes the proposal as our Campaign For Better Care will be deeply engaged in the legislative process, working to make sure all of our principles are reflected in the final bill.

The discussion going forward will surely center around how many and how strong must the “carrots” and “sticks” be to get to the desired results. While some see the bill as mostly getting there through voluntary actions, with state government leading by example, the Governor made clear that real pressure must come from government:

The market has made tremendous progress in the last year or so, but much of it only after the regulatory hammer came down and new legislation was passed. As exciting as the progress we have made is, it’s not enough. We must maintain a sense of urgency to our work. If the legislation I file today feels like pressure on the market, good. Good. That’s exactly what it’s intended to do. The goal is not to punish any part of the industry or to return to the days of price regulation. I believe that everyone in the Massachusetts health care industry is sincere in their efforts and desire to deliver lower cost and better health care.

The goal of this proposal is to keep the pressure on all of us – including the state – to move as fast we need to move in order to bring the cost savings we need to keep our economy growing.

We echoed this point in our statement:

If consumer needs and voices are respectfully considered and addressed, we know payment reform holds the potential to yield healthier outcomes for Massachusetts residents.

When lawmakers crafted Massachusetts' landmark health reform bill, they included provisions to encourage private industry and individuals to buy health insurance. In this next phase of health reform, Health Care For All believes it is equally important to again promote shared responsibility, accountability, and engagement from private sector and consumer stakeholders. We look forward to identifying constructive incentives for participation in this next wave of health reform.

We’re going to be reading the bill closely over the next few weeks, but a few little-mentioned features got our notice in a quick scan. First, the bill requires that behavioral health services be available through ACOs, and sets up a special behavioral health task force to make strong recommendations for how to include behavioral health under payment reform. Second, the bill explicitly requires ACOs to ensure access by disabled and other people with chronic or complex medical conditions to appropriate specialty care. Both of these provisions will be welcomed by us and our CBC partners.

Third, the law sets up a Health Planning Council within DPH, charged with conducting an inventory of health facilities and technologies, and assessing the need for these services in the future. The plan is to be used by DPH in making “determination of need” decisions about new projects. This is a "back to the future" idea that is critical if the state is to make rational allocations of resources and control supply-induced spending growth.

Lots more to come on this. Watch this space.
-Brian Rosman

February 17, 2011

Yesterday’s duo of QCC meetings included the long anticipated conclusion of the QCC Status Committee on Payment Reform. In case you missed it, the QCC created this subcommittee to do something about payment reform legislation. Through a series of meetings this subcommittee’s members have staked out bright lines about what is (and isn’t) important to their constituency. The Secretary began this meeting by emphasizing that the work and discussions of the subcommittee had been expressed to the Governor as he developed his proposals for payment reform.

The familiar arguments were briefly reiterated at today’s meeting as the group agreed to a one page set of goals. In quiet tones, the committee members expressed appreciation for the work-product as well as delivering one final push for key issues. This list of goals reflects consensus from the group on a substantial number of issues- no easy feat as was recognized in the meeting. It was also acknowledged that we could not reach consensus on many issues such as: is this a voluntary transition and if so, how voluntary; what is the role of government rate regulation; and how can we deal with payment disparities. These goals reflects a sense of shared responsibility for working towards these goals. And while more work needs to be done in payment reform by policymakers, it is clear that the work of this committee is concluded and the hopes, concerns and goals will need to be carried forth into a new table set by the Governor at tomorrow’s Chamber of Commerce Breakfast.

The second QCC meeting was of the full committee and the abbreviated agenda included discussions of ambulatory care measurements, an update on the annual report, and an update on the payment reform subcommittee meeting of that same day.

The QCC will be participating in the Aligning Forces for Quality grant with MHQP and the Brookings Institute for the ambulatory care measurement work. They are starting off by working on the diabetes measure with the potential to add other measures in the future. There will be more on this in the future. The QCC’s annual report is in its final draft stage and will soon be released to the public.

The bulk of the second meeting was spent discussing the payment reform subcommittee’s process and goals. It was recognized that the goals need a little more tweaking based on conversation in the earlier meeting. The larger QCC (half of whom had been in the earlier meeting) absorbed the overview with little comment except for the Inspector General recommending they not adopt the goals because they are not specific enough. There was much discussion about how they should adopt these goals. To broach a slight concern about the amendments, the process will be for Jessica Moschello to distribute the amended document to the entire QCC and then they will determine how to vote and adopt these goals at the next meeting.

-Georgia Maheras

February 16, 2011

Campaign for Better CareWhen Blue Cross and Blue Shield (BCBS) began its "Alternative Quality Contract," to move from a fee-for-service system to one that pays practices a fixed sum for each patient’s care, patients questioned how this would impact care. Would this experiment truly improve quality? Would it actually reduce costs?

Today, economist and business consultant Ed Moscovitch penned an op-ed for the Boston Herald detailing his review of global payments to three AQC practices. How did they do? Well, Moscovitch concluded that if you change the way the money flows, you can change behaviors.

Under the global payment structure, docs are paid a set amount of money for each patient they care for, rather than for each procedure or test they provide. So, the providers have incentive to increase efficiency and better coordinate care between nurses, primary care physicians (PCPs) and specialists. Moscovitch notes that this new payment structure has been boon for patients at these hospitals. He writes:

Each of these groups has built an extensive network of nurses and data people to help doctors make sure patients get needed care. This includes making sure primary care physicians (PCP) know when patients use the emergency room, are admitted to the hospital or see specialists — and making sure that the PCP follows up quickly.

Blue Cross collects data on 18 quality measures, including patient blood sugar, blood pressure and cholesterol, whether patients receive timely mammograms and colonoscopies, and how satisfied patients are with their care.

The six participating medical groups scored far higher on these measures than other providers in their first year; their rate of improvement on monitoring for diabetes and cardiovascular disease was more than four times what they’d accomplished prior to the contract!

Tomorrow, Governor Patrick is expected to shed light on his plan to restructure the way we pay for health care in Massachusetts. We are hopeful his payment reform plan will yield healthier outcomes and better quality care for all Massachusetts – much like these hospitals have done.
-Victoria A. Bonney

February 16, 2011

Consumer Health Quality CouncilIn his recent blog post, Dr. Bob Wachter (a national leader in patient safety and health care quality), expressed his concern about the overuse and safety of CT scans in the U.S.

HCFA and the Consumer Health Quality Council (www.hcfama.org/consumercouncil), are supporting legislation filed by Representative Stephen Kulik that will require the Department of Public Health to investigate the use of CT scans in Massachusetts and make suggestions for tracking and reducing CT scan use.

Dr. Wachter’s concern was sparked when he recently attended grand rounds at UCSF, lead by Dr. Rebecca Smith-Bindman, and learned that a 20 year old woman who gets an abdominal-pelvic CT has a 1 in 250 chance of developing cancer from that single scan. According to Dr. Wachter, any young woman who goes to an ER for stomach pain is likely to receive an abdominal-pelvic CT.

Dr. Wachter reported a few additional eye opening statistics in his article including:

  • In 2011 there will be approximately 17 million CT scans performed. In 1980 this number was only 3 million.
  • Experts suggest one third of CT scans performed are unnecessary.
  • A recent study found that radiation from CT scans causes 29,000 cancer cases each year in the U.S.

With data emerging about the risk of CT scans, little has been done to regulate their use. In her research, Dr. Smith-Bindman found significant variations in the amount of radiation being emitted for the same test from different scanners in the same geographical area, and also found that some were emitting 66% more radiation than is standard.

Massachusetts General Hospital has already begun to address this issue by developing CT scan appropriateness protocols, which have significantly reduced their use of CT scans. While this is a great start, Dr.Wachter points out that the most important and greatest challenge is to change the culture around and over-reliance on CT scans.

To help advance our effort to track the use of CT scans in MA, call your Massachusetts State Representative and Senator and ask them to support to H. 597, HCFA’s bill directing DPH to examine the use of CT scans in children and adults and recommend changes to reduce risk to health. Please read our fact sheet (.doc) on the bill for more details.
-Margot Schwartz

February 16, 2011

Campaign for Better CareThe Campaign for Better Care, the public voice in the payment reform debate, is eagerly waiting for the Governor's payment reform plan, expected Thursday.

We're also still glowing from last Friday's "Patient Empowerment: More Than A Slogan" conference last Friday (see WBUR's CommonHealth report). The morning highlighted the need to ‘meet patients where they are’ and build patient confidence. The event also demystified the amorphous phrase “patient empowerment” by showing that it is something real. In order for payment reform to succeed, we need to empower patients and Friday’s event showed us some tools to get there. The program and discussion strengthened our belief that patient confidence is the key metric in assessing patient-centered care, and ought to be connected to the payment system. We strongly encourage everyone to try out the patient engagement tool from HowsYourHealth.org. On the second screen, enter the code ZKS507, which will allow us to aggregate and report on all the people filling out the survey based on our event.

In this latest news update, we bring you interesting developments from Vermont to Texas regarding payment reform, and our own patient empowerment event from last week. Read on for more news:

  • As accountable care organizations will become the chief ingredient in payment reform, analysts explain that informed patients and transparency within the ACO’s will be essential to their success in the fight to control costs. Read one doctor's prescription in the NY Times for the missing ingredient in accountable care - the patients.
  • In Texas, the legislature strives to create a variety of outcomes-based health initiatives in efforts to cut back on health care costs, however some legislators disagree with these programs and the 2012-2013 budget may be incapable of supporting such initiatives. Read more about the Lone Star primary care conundrum.
  • The Boston Globe ran a good summary of the benefits to patients of more coordinated and higher quality care through a global payments system that puts doctors on set budgets to care for patients.
  • This past Monday, Vermont Governor Peter Shumlin proposed a bill that would eliminate most private forms of insurance, taking advantage of the federal assistance that will kick in during 2014, yet leaving out details of how the plan would be funded. Read more about Vermont's proposed single-payer health care system.
  • We also liked CommonHealth's report on a new study found that storytelling has the ability to measurably improve the health of some patients. Read more about the health benefits of storytelling.

-Courtney Mulroy

February 15, 2011

The Quality and Cost Council is holding its monthly meeting this Wednesday, February 16, 2:00-3:00pm (NOTE THE CHANGED STARTING TIME) at 1 Ashburton Place, 21st floor, Boston. The agenda includes approval of the QCC’s annual report and the final report from the Committee on the Status of Payment Reform Legislation. See full agenda (pdf) for details. Meetings are open to the public.

Before that, from 12:30-1:30, the "Committee on the Status of Payment Reform Legislation" will meet in the same space. According to the agenda (pdf), the committee will be concluding its work after reviewing payment reform goals and recommendations.
-Deborah W. Wachenheim