March 2011

March 30, 2011

Community leaders in public health and prevention, including EOHHS Secretary JudyAnn Bigby, doctors at the frontlines of providing care, and public health experts, met at the State House this morning to celebrate the launch of the Prevention for Health Caucus, chaired by Senator Harriette Chandler and Representative Jason Lewis, and to stress the vital need for health promotion and prevention efforts here in Massachusetts. The takeaway message of the event was: Prevention efforts must be included in upcoming health care payment reform. Reiterated by all the speakers this morning was the critical need to transform our current health care system, which focuses on treating illness, into a system that focuses on keeping people healthy and preventing disease. Massachusetts spends 97% of its health care dollars to treat illness, leaving only 3% of those dollars to prevent diseases and promote wellness. However, 88% of individuals’ health is determined by one’s environment and behaviors, not the health care received. In Massachusetts, diseases related to smoking, obesity and physical inactivity are the leading causes of preventable death, and result in billions of state dollars lost to preventable medical costs and productivity losses. However, as a physician working at one of Lawrence’s community health centers emphasized this morning, our health care system’s current fee-for-service payment method doesn’t encourage him to help his patients change behaviors to improve their health. While it pays providers to diagnose and treat asthma or diabetes, it does not offer equal financial rewards for providing nutrition counseling or smoking cessation programs. Further, for community health centers, whose financial health is intrinsically linked to partner hospitals, prevention efforts can result in even greater loss of revenue due to reduced emergency department admissions at their partner hospital. Not only does the current system fail to reward providers for keeping their patients healthy, it does not address the environmental factors that drive health-influencing behaviors, such as nutrition and physical activity. Many patients in Lawrence have no local access to fresh, nutritious produce, with the closest supermarkets being in neighboring suburbs. Without a car, the cost of transportation creates a significant barrier for this community to access nutritious food. Valerie Basset from Massachusetts Public Health Association emphasized that addressing the environmental factors that influence people’s health behaviors is just as important as promoting clinical preventions. These primary preventions, including improving the walkability and safety of neighborhoods and providing more nutritious school lunch programs, can enable and encourage health behaviors that prevent illnesses before they even happen. Including primary prevention in payment reform, by strengthen DPH funding and linking funding to health care payers, Basset emphasized, is an opportunity to maximize prevention efforts. Further, she stressed, prevention makes good financial sense, with the potential to save Massachusetts nearly half a billion dollars each year with just a 5% reduction in diabetes and hypertension prevalence. Reorienting our health care system to promote prevention and wellness, rewarding physicians for keeping their patients healthy and enabling individuals to promote their own health in their own environment, are important steps towards improving the health of the Commonwealth and priorities of HCFA’s own Campaign for Better Care. The Prevention for Health Caucus is an exciting new leader and partner in efforts to ensure these prevention priorities are a key consideration as the legislature moves forward on the next phase of health care reform. -Lydia Mitts

March 28, 2011

Campaign for Better CareThe state's payment reform push continues to draw wide interest. The American Medical News talked to Massachusetts physicians, and the Cape Cod Times covered the, Cape angle, with some institutions expressing trepidation, and others looking forward:

Institutions such as Cape Cod and Falmouth hospitals most likely would end up partnering with a variety of health care providers, ranging from labs and imaging centers to physicians, nursing homes and visiting nurse agencies, health officials say.

"There is going to be a great coming together of health care providers," said Dr. James Butterick, chief medical officer at Cape Cod Hospital.

In our latest edition of our Campaign for Better Care round-up, we focus on how coordinated care and patient empowerment will create better care, at less cost. The key is integrated care, aligned incentives, and empowering patients.

  • Surprisingly, although the success rate of heart attack treatment differs among providers, there is little variation in the treatment protocol among high and low performing hospitals. Researchers from Yale School of Public Health wanted to find what distinguished the top-performing hospitals. They found that patients who received heart attack care in hospitals that embraced a high level of communication, coordination, and organizational vision for providing high quality care had better results. The fascinating study showing that coordinated care results in better care.
  • Mercy Medical Center in Cedar Rapids, Iowa, ranks among the top 3% of hospitals for low readmission rates for heart attacks, heart failure, and pneumonia. A case study looked at the reasons why. It turns out that the hospital does things a little differently. It targets high-risk patients on admission and maintains a telephone “lifeline” after patients leave the hospital. This has shown to improve patient safety and lower readmission rates. ()
  • Diabetes is one of the leading chronic conditions of Americans. It is a complicating condition and sometimes both patients and their doctors feel powerless faced with uncontrolled blood sugar levels. In this study, researchers showed that patients who created self-management action plans with their providers were significantly more successful in controlling their sugar levels that those who did not. The good results persisted for a year. We think it’s not surprising that patients who are empowered and involved in their own care do better.
  • The new Governor’s Payment Reform bill as well as the federal Affordable Care Act encourages providers to create Accountable care organizations (ACOs). The entities have the financial incentives to encourage high quality care while controlling costs. Federal ACO guidelines are expected any day now. An informative CBS business network blog post explains the basics of ACOs and gives a perspective on how ACOs may change provider dynamics. And today, the Wall Street Journal ran their explainer on ACOs, focusing on the success Atrius Health is having in Massachusetts.

-Shaun Yang

March 28, 2011

As former Governor's Romney's presidential campaign heats up, Massachusetts health reform will again become a beanbag for politicians to kick around to score points. Mike Huckabee's trashing in his book ("we should take a lesson from RomneyCare, which shows that socialized medicine does not work") is one of many examples we will surely see in the coming months. That's why we're so happy that FactCheck.org, a non-partisan, independent truth-seeker, put so much energy into setting out the facts on Massachusetts health reform, in ‘RomneyCare’ Facts and Falsehoods. FactCheck's managing editor spent some time in Massachusetts earlier this month, interviewing all the right people, including Connector staff, Connector Board Member Jonathan Gruber, Mike Widmer from Mass Taxpayers Foundations, former Romney HHS head Tim Murphy, Mike Doonan from Brandeis' Mass Health Policy Forum, and HCFA. The article sets the record straight, detailing the evidence of how 5 years after chapter 58 was enacted, the law has reduced the number of uninsured, not bankrupted the Commonwealth, not shown to affect waiting times, and maintained public support. The article explains the challenges experienced around serving small businesses, and focuses on the lack of direct connection between most of the premium increases in Massachusetts and the coverage expansion. The article is blunt in refuting some of the worst calumnies:

Huckabee was dead wrong when he said that the law "ended up having almost the polar opposite effect of what was intended." A major goal — if not the goal — was to reduce the number of uninsured. The state was very successful in that regard. We called and e-mailed the press office for Huckabee’s political action committee several times, asking for back-up for his claims. A spokesman told us he would get back to us, but we have not yet received a response.

We'll be interested in reading the response, too. In the meantime, we will continue to work on the ongoing implementation of our health reform law. -Brian Rosman

March 24, 2011

Protest Sign: Babies Can't Wait: Save Early Intervention

Yesterday members of the Children’s Health Access Coalition went to the State House to join over 300 parents, kids and supporters in a Stroller-In to support Early Intervention and protest the substantial budget cuts that Early Intervention faces in the 2012 budget.

The Early Intervention program (www.mass.gov/dph/earlyintervention) provides services to families with children between birth and three years of age. Children are eligible if they have developmental difficulties due to identified disabilities, or if typical development is at risk due to certain birth or environmental circumstances. The program provides cost-effective family-centered services to facilitate the developmental progress of eligible children.

Parents brought their children to the state house to lobby their legislators to oppose the proposed $8 million cut to Early Intervention. The 27% budget reduction would transform the program and dramatically reduce the ability of families to get needed services. Uninsured families would fare the worst, and an estimated 6,000 children would be placed on waiting list.

Channel 4 covered the event with a video report, as did the State House News, and the Save MA Early Intervention Facebook page is full of activity. CHAC will continue to support early intervention has a vital, cost-effective state obligation.
-Gretchen Scheminger

See

March 21, 2011

This week, the federal Affordable Care Act turns one. Groups all over the country will be marking the anniversary with events that celebrate people who already have been helped by the law, and the benefits to come. Stay tuned for details on a Massachusetts event.

To mark the occasion, a few interesting links for you all:

1. Massachusetts has already garnered over $159 million from federal health reform grant programs. This isn't chump change, but some needed assistance to the state in implementing health reform, The full list is on the grants page of the state site, mass.gov/nationalheatlhreform

2. A focus for today is small business. Small business groups have been very active is supporting health reform. In Massachusetts, some 70,000-80,000 businesses will be able take advantage of the federal tax credits provided to assist them with coverage. Small businesses that want to plug into national advocacy should look at the group Small Business Majority, that has a number of events planned for this week.

3. Take a quiz: The Kaiser Family Foundation has put together a 10-question quiz on the ACA. Have you bought into the misinformation on the law? Take the quiz and find out.

4. Debate: The Pioneer Institute hosted a serious, substantive debate on the Affordable Care Act, between two economists: McCain health adviser Douglas Holtz-Eakin, and Connector Board member Jonathan Gruber, who consulted on both the Massachusetts and national reform efforts. Given the Pioneer's right-wing take on things, the issue was not how the ACA will provide health coverage to the uninsured, or even whether the ACA will improve health care for Americans. Rather, the debate was framed on the narrow, rather peculiar issue of the budgetary impact of health reform. The debate video is over an hour and 20 minutes, but is worth the investment if you want to hear the back-and-forth on budget issues, like the reliability of CBO. The Pioneer Institute cut a 2:20 -minute highlight reel that captures the flavor, below:
[vimeo http://vimeo.com/21100075]

-Brian Rosman

March 18, 2011

A productive blog conversation is going on now about something fairly wonky, but fairly important. We've blogged before about the state's "All Payer Claims Database (APCD)." The DHCFP database, which will collect health transactions from every possible source in the state, will allow policymaker and researchers to dig into the details of health care costs and utilization in Massachusetts. We think it's critical that the state make the data available as much as possible to all interested persons, with appropriate privacy protections to assure patients that personal information will be not disseminated.

This morning, Paul Levy blogged that leadership on the project had dissipated, and that no one was working to make sure the data gets out. With David Morales leaving the post of DHCFP Commissioner, who will be steering the boat, he asked.

This afternoon, acting DHCFP Commissioner Seena Carrington responded in effect in a post on the state's Commonwealth Conversations blog. Carrington writes that the state continues to convene daily calls on the technical issues (summarized on their website), and will be holding open forums in April to get wide public input on the project. She reaffirms the Division's commitment to public availability of the data, which is not yet in the state's hands.

The conversation highlights the value of our fast social media world in learning and discussing the issues.
-Brian Rosman

March 17, 2011

Lessons from Massachusetts Health Reform

The Blue Cross Foundation has released a helpful review of the Lessons from the Implementation of Massachusetts Health Reform (PDF). The report draws out eight lessons that are useful for other states as they begin their ACA implementation process. These lessons are also useful reminders to us as guides for ongoing implementation success. Each lesson is accompanied by a recommendation.

The key lessons and recommendations are:

  1. Ongoing stakeholder engagement in health reform facilitates implementation and helps overcome inevitable obstacles.
    Recommendation: Bring health care stakeholders to the table as quickly as possible to find common ground and keep them engaged.
  2. Strong, centralized coordination among government agencies helps to overcome the fragmentation often inherent in the health care system and in government functions.
    Recommendation: Create processes to facilitate collaboration and accountability among all parties responsible for the implementation of health reform.
  3. Close coordination between Medicaid and new public insurance programs is needed to maximize enrollment and retention while also reducing redundancy and administrative costs.
    Recommendation: Build on existing public programs, and structure eligibility and enrollment rules and processes in ways that will maintain continuity of care and coverage for people at all income levels, and as their income changes.
  4. Connecting uninsured residents to coverage and care requires an intense, state-wide effort that draws upon the knowledge and experience of local service groups and organizations.
    Recommendation: Develop and support a broad array of community-based outreach, enrollment, and retention activities that help uninsured residents sign up for, and maintain, health coverage.
  5. Successful implementation requires high levels of awareness and understanding among individuals and businesses about their opportunities and responsibilities under health reform.
    Recommendation: Create a comprehensive, ongoing communications campaign that draws on both public- and private-sector resources.
  6. No matter how successful health reform proves to be, there will still be uninsured and underinsured people who need access to medical care.
    Recommendation: Maintain a strong safety-net system that can meet the needs of patients who remain uninsured and that supports safety-net providers who provide care for low-income patients.
  7. Health reform implementation is an ongoing process that requires continuous improvement based on feedback from consumers, employers, providers, and other stakeholders.
    Recommendation: Track the impact of health reform, report results, and make changes in policies, processes, and operations as needed.
  8. Moderating future growth in health care spending is far more difficult than achieving nearly universal coverage, but without cost control, coverage expansions are unsustainable.
    Recommendation: Press for continued health system reforms that will reduce the burden of health care costs while supporting expanded access to coverage and care.

The report includes examples illustrating the lessons, and is good summary of health reform achievements so far. It concludes with our central challenge:

After almost five years of experience with health reform, Massachusetts policymakers and advocates have confirmed that implementation is a complex, ongoing process. It has taken a sustained, community-wide effort to enroll virtually all eligible residents, help connect them to the health care system, and maintain unprecedented levels of coverage, even in the face of the worst recession in decades.

....

Massachusetts has demonstrated that nearly universal coverage is a realistic and achievable goal. Now, the foremost challenge for Massachusetts is to find ways to gain greater control of health care costs without adversely affecting access or quality of care.

-Brian Rosman

March 17, 2011

The Health Care Quality and Cost Council met Wednesday with a full agenda (pdf). Administrative Director Jessica Moschella updated the council on the status of the Annual Report, which has been submitted, her presentation to the Rhode Island Senate on Massachusetts’ experience on quality and cost, and the recent release of the report on “Patient-Centered Care and Human Mortality” (pdf) by the Massachusetts Expert Panel on End of Life. DPH Commissioner John Auerbach stated that the Public Health Council will be coming up with a few quality measures based on the report.

One issue that aroused a lively discussion was the proposed 2011 quality measures for the states health quality rating website, MyHealthCareOptions. A handful of new measures were proposed. At one point, there was a discussion regarding the consumer-friendly nature of the available measures and whether patients will be able to use the information that is provided to them. We were glad to see that most members were supportive of quality and cost measure transparency and believed that people will be able to make good use of such measures in making their health care choices. The measures were approved with a unanimous vote, after Secretary Bigby’s thoughtful comment that people normally don’t consider themselves as a collection of organs and that the measures will, at some point, need to be categorized according to illnesses rather than organs.

Another round of discussions occurred during the overview presentation of the Governor’s new payment reform bill. Kevin Beagan of the Divison of Insurance explained to the Council the authorities it will have under the current language of the bill, which includes rate review. Beagan clarified that rate review is not rate setting, because providers and payers would still be able to negotiate the rates as long as it is within the boundaries of what the DOI determines as appropriate based on the estimated parameters. Some council members raised concerns on how the DOI would perform rate review under global payment and other alternative payment models.

One clarification that was a welcome news for consumers was that the current Governor’s bill does not intend to curve out mental and behavioral health from the coordinated health care services that need to be provided under the new payment models. All the council members, including the Secretary, agreed that any payment reform must include mental and behavioral health as a part of the services that are provided under models such as ACOs.

The Secretary ended the meeting by stating that any cost savings that result from payment reform must be shared with the consumers and other purchasers of coverage.
-Jekkie Kim

March 15, 2011

The Health Care Quality and Cost Council is holding its monthly meeting on Wednesday, 1-3pm, in the Café Conference Room in the basement level at 1 Ashburton Place (walk through the cafeteria to get to the conference room).

Agenda items (pdf) include discussions about quality measures to put on the website My Health Care Options, the revised goals from the Committee on the Status of Payment Reform Legislation, and Governor Patrick’s payment reform bill. Meetings are open to the public.
-Deborah W. Wachenheim

March 11, 2011

The 2010 National Healthcare Quality Report and National Healthcare Disparities Report were recently released by the federal Agency for Healthcare Research and Quality (AHRQ). The annual reports are mandated by Congress to examine progress and opportunities for improving health care quality and reducing health care disparities. The data presented in these reports are based on approximately 250 health measures, each falling under one of six categories including effectiveness, patient safety, timeliness, patient-centeredness, efficiency and access to care. The reports also incorporate recommendations made by the Institute of Medicine (IOM) to ensure that awareness regarding performance in the U.S. health care system is raised. Although the quality and disparities reports have been published separately in the past, this year they have been coalesced to reinforce the necessity of viewing these issues jointly when assessing the health care system.

The 2010 NHQR and 2010 NHDR stress four main points of consideration, if the nation is to improve the quality of the health care system and decrease health disparities. The first finding, a very apparent and recurring theme, is that health care quality and access are suboptimal, especially for minority and low-income groups. Amongst the piles of data, one finds that poor people receive worse care than high-income people for about 80% of core measures. (This unbelievable stratification truly makes you wonder if we live in one of the richest countries in the world).

The second point highlights the improvement in overall quality of care, combined with the stagnant progress in access and disparity measurements. Of the 179 health quality indicators tracked, two-thirds have shown improvement with a 2.3% median rate of change. Indicators regarding access and disparities remained relatively unchanged.

The third theme urges that attention be paid to ensuring improvements in quality and progress on reducing disparities with respect to certain services, geographic areas and populations. Areas of top priority include cancer screening and management of diabetes, states in the central part of the country, residents of inner-city and rural areas and disparities in preventive services and access to care.

The final principle the reports focus on is the uneven nature of the progress being made in respect to the eight national priority areas. (1) End-of-Life Care and (2) Patient and Family Engagement are improving in quality; however (3) Population Health, (4) Safety, and (5) Access are all lagging. Area (6) Care Coordination, (7) Overuse and (8) Health System Infrastructure all require more data to assess. Nevertheless, all eight priority areas did have one theme in common; they all showed disparities related to race, ethnicity, and socioeconomic status.

The publication of the eighth NHQR and NHDR will serve as the core data for a continued effort to improve the U.S. health care system. The documents go on to identify arenas in health care where innovative strategies have been used to increase quality of life for patients as well as areas where more work must be done. Conclusively, the report should serve as a foundation for stakeholders to design and target strategies and interventions with the intent of improving the overall health care system and the quality of life for the U.S. population. The quality and disparities reports are available online, by calling 1-800-358-9295 or by sending an E-mail to ahrqpubs@ahrq.hhs.gov.
-Courtney Mulroy

March 11, 2011

Some major departures in state personnel this week and last. David Morales has long been a leader in health care policy through service in the Senate, the Prescription Advantage program, the Governor's office, and as Commissioner of the Division of Health Care Finance and Policy. Last Friday was his last day, and we want to thank him for his outstanding service and friendship with HCFA. Under David, DHCFP dramatically expanded its data analytic role. Last spring's groundbreaking Cost Trends hearings set the stage for dramatic steps forward in transforming our health care system.

Today, David's replacement (for now), Seena Carrington, posted on the states' health blog that "It’s full steam ahead at the Division of Health Care Finance and Policy (DHCFP)." Seena has been a close collaborator with HCFA while she's served as David's deputy, and in her post she pledged today to continue to engage the public in health policy. We welcome Seena as we thank David for his commitment.

We also want to thank another old friend who's leaving state service this week. Melissa Shannon also came from the Senate, and then worked for us as HCFA's private market manager and our first director of government relations. She left HCFA for EOHHS and the Office of Medicaid, heading up the team on national health reform implementation and the Massachusetts federal MassHealth waiver process. Melissa has done an outstanding job in advancing state health policy, and we thank her profusely and wish her all the best.

At time when state employees are under the gun in Wisconsin and elsewhere, we stand up for those who work much harder and for less rewards because of their devotion to public service.
-Brian Rosman

March 10, 2011

The Connector Board met today to discuss results of the CommCare member survey; vote on the 2011 Affordability Schedule, and vote on the contract with a vendor to run the small business wellness initiative (download materials from the meeting).


Commonwealth Care Member Survey

Stephanie Chrobak of the Connector staff presented results of the CommCare member survey (pdf).

The survey was conducted by phone and email between mid-October through November 2010. The overall survey response rate was 40%. The survey results show a very favorable member experience in the CommCare program.

Here are some highlights:

  • 84% of members are satisfied with CommCare; satisfaction rankings were high (80% +) across all plan types
  • Choice of health plans, quality of care, and broad range of services covered by plan were the top three drivers of satisfaction
  • 68% of respondents reported they have a good understanding of their insurance
  • 80% reported they were able to pay their medical bills and/or did not experience any problems paying
  • In the past 12 months, or since joining CommCare:
  • 81% or respondents have a usual source of care with a physician, clinic or health center and 81% visited a general doctor
  • Very few respondents said they postponed or did not get needed care
  • Some respondents had problems scheduling doctor visits; among these members, 42% cited problems trying to see a general doctor, and 28% had problems trying to see a specialist
  • While two-thirds of respondents have not visited the ER since joining CommCare, 39% of those who have visited the ER could have been treated by a regular doctor if one were available
  • 85% of respondents thought the application process was very or somewhat easy
  • 20% of respondents lost coverage at least once since joining CommCare
  • 59% of respondents contacted CommCare customer services since becoming a members; of those, a vast majority had favorable experiences with customer service
  • A majority of respondents find the member materials and communications helpful
  • 74% of respondents have access to the Internet; of those, 52% have visited the CommCare website
  • While the survey showed that members are mostly satisfied with CommCare, Chrobak cited areas for improvement. CommCare staff will work to clarify plan benefit materials, increase understanding of the renewal process among members, and improve the website. In the long term, they will work to address the concerns around ER use and difficulties accessing doctors.

    Many Board members requested that CommCare staff provide data broken out by plan type; plan (MCO); and health status. Board members also requested comparisons of the CommCare survey results to those in the commercial/employer-sponsored insurance market. Chrobak responded that CommCare staff will be sending Board members a more detailed report that breaks out a lot of this information.

    Affordability Schedule
    Connector staffer Kaitlyn Kenney reviewed the proposed Affordability Schedule for 2011, which is unchanged from the 2010 schedule, with the exception of adjustments made for changes in the federal poverty guidelines. The Connector only received comments from the ACT!! Coalition. ACT!! supports the proposed 2011 schedule (our comments(pdf)) . The Board voted unanimously to adopt the proposed 2011 Affordability Schedule.

    Small Business Wellness Initiative
    Scott Devonshire presented the Connector staff’s recommendation of a vendor for their small business wellness initiative, which is a requirement in Chapter 288 of the Acts of 2010. The Connector will offer a 5% premium subsidy for small businesses that successfully participate in the program.

    To qualify, businesses must:

    • Purchase small group health coverage through the Connector
    • Be eligible for federal health care tax credits through the Affordable Care Act (have fewer than 25 FTE’s, average employer salary less than $50,000, and employers contribute 50% of employee’s premium)
    • Offer evidence-based employee wellness program that meets certain minimum criteria and employee participation, as defined by the Department of Public Health.

    The Connector’s vision for the wellness initiative is a primarily web-based program that offers literature and resources on healthy living. While the information will initially only be offered in English, the Connector will work with the vendor to explore translation of materials into other languages.

    After a procurement process with six bidders, the Connector chose PayFlex as their vendor for the wellness initiative. According to Devonshire, PayFlex scored highest on the service metric. PayFlex subcontracts with Live Healthier. Dolores Mitchell expressed concerns about contracting with a company that subcontracts with another company, as opposed to contracting with Live Healthier itself. She encouraged the Connector to look closely at the relationship between PayFlex and Live Healthier.

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