August 2011

August 25, 2011

Researchers at the British think-tank Demos released an eye-opening study this week, entitled the “Truth About Suicide.” The conclusion: at least 10 percent of suicides in Britain are linked to terminal or chronic illness.

Demos wanted to challenge the idea that taking one’s life was strictly about a patient’s mental health rather than physical health. Researchers stated that patients with chronic or terminal illness “should be considered a high risk group for suicide within national policy, and much greater attention should be given to providing better medical, practical, and psychological support.”

As we move forward in health care reform, studies like this bring to light the necessity to provide access to quality, affordable, and truly patient-centered care to those who are at the highest risk and the most vulnerable. For those who are dually eligible for Medicare and Medicaid, disability advocates have been working with the state, identifying ways that the health care delivery system can be improved in order to better address the needs of the whole patient, rather than focusing on one component of an individual.

Additionally, such initiatives as the Public Health Trust, focusing on community based prevention work, would increase the identification and response to public health issues such as suicide.

If you are aware of someone or you are struggling with thoughts of suicide please call the national suicide prevention hotline - 1-800-273-8255.
-Paul Williams

August 24, 2011

The end of summer has brought some notable staffing changes in MassHealth, Executive Office of Administration and Finance, and the Division of Health Care Finance and Policy.

Congratulations to Robin Callahan, who has been named as the new deputy Medicaid director for policy and programs. With more than 16 years of experience working at MassHealth, Robin gracefully works on implementation of various federal grants and waivers, and will now play a significant role in the implementation of national health reform. We at Health Care For All value Robin’s spirit of collaboration and transparency, and look forward to continuing to work with her in her new leadership role

Thank you and good luck to Alda Rego, who served as the Office of Medicaid’s Chief Financial Officer for several years. We deeply appreciate Alda’s hard work and dedication to the MassHealth program and her ability to see the real people behind the numbers.

Candace Reddy recently received a well-deserved promotion to Director of Health Care Finance at the Executive Office of Administration and Finance. Candace knows the state’s health care budget inside and out, and plays an important role in health reform implementation. We are excited to continue working with Candace in her new role.

Health Care For All thanks Seena Perumal Carrington for her leadership as Acting Commissioner of the Division of Health Care Finance and Policy (DHCFP) for the past several months, especially for her tactful oversight of this summer’s health care cost trends hearings.

Áron Boros has been named the new commissioner of DHCFP, beginning September 15. Previously, Boros worked as Director of Federal Finance for the Office of Medicaid and for the law firm Foley Hoag. The staff of Health Care For All welcomes and looks forward to working closely with Commissioner Boros in his role at DHCFP.

-Suzanne Curry and Kate Bicego

August 24, 2011

The Massachusetts Department of Public Health has received federal ACA funds to continue its life-saving work on preventing healthcare-associated infections.

An estimated 34,000 healthcare-associated infections cost Massachusetts up to $473 million per year.

The federal funding will go towards establishing a quality improvement initiative focused on the prevention of clostridium difficile infection (CDI), a potentially life-threatening infection. The Department of Health and Human Services announced funding to all 50 states for work on infections as well as immunization programs and enhancements to laboratories and technology. Massachusetts has made great strides in publicly reporting and preventing infections. With budget cuts at the state level, the state’s infection program would be unable to maintain and expand its work without federal funding. This funding will most certainly save many lives in Massachusetts and beyond.
-Deb Wachenheim

August 24, 2011

MITSS (Medically Inducted Trauma Support Services) is seeking nominations for its annual HOPE Award. The Award winner will be announced at the MITSS annual dinner and fundraiser on November 1 in Boston. Learn more about the award on the MITSS Hope Award website. Nominees can be individuals or organizations who exemplify the mission of MITSS, which is supporting healing and restoring hope to patients, families and clinicians impacted by adverse medical events, medical errors, or unexpected outcomes. The winner will receive $5,000 to be put toward their work.
-Deb Wachenheim

August 23, 2011

Oral Health Advocacy Taskforce logo“While cavities are on the decline in the general population, they are a fact of life for increasing numbers of young children, according to the Centers for Disease Control. They affect 10 percent of 2-year-olds and over half of 5-year-olds, causing everything from minor toothaches to missed school days to complications that require major surgery,” a recent article in the Boston Globe reports.

The message comes just in time for back-to-school season. More than 156 million school hours are missed due to dental disease each year. In fact, dental disease is the most common chronic childhood disease. It is five times more common than asthma in children all across the nation. Dental decay can affect some of life’s most basic activities, including speaking and eating, and can hinder kids’ ability to learn and advance in school. In adults, dental disease is associated with other health problems, such as heart disease and diabetes.

The article calls for parents to “manage cavity prevention as they would battle any chronic illness,” and that is sound advice. Measures such as dental sealants, fluoride treatments, and early childhood screenings can almost entirely prevent dental disease. These are simple, cost-effective interventions that go a long way. Oral health is overall health, and it is essential that kids and adults alike have access to quality oral health care here in the Commonwealth.
-Courtney Chelo

August 17, 2011

Former DHCFP Commissioner David Morales once used an an analogy to make the point that Massachusetts' implementation of the ACA is easier than in other states. We just have to do a renovation, while other states have to do new construction.

But it's not clear to me which is more difficult. Massachusetts has major, complex issues to figure out. A key goal is to not lose the gains we have made through Chapter 58.

Affordable Care Act stakeholders in Massachusetts have a seat at the state implementation planning and design table. Last Friday afternoon was the first meeting of the Subsidized Health Insurance Work Group Advisory Council. Attendees included advocates, providers, organized labor, members of the Health Connector Board, representatives from the MassHealth Policy Advisory team, and community outreach grantees.

The objective of the Council is to give state policymakers input and insights regarding the subsidized coverage options under consideration (see materials (pdf) overview presentation; and timeline) Council meetings will allow EOHHS and Connector staff to share their progress and work with us throughout the process of planning around four key issues affecting low-income people: Medicaid expansion, Basic Health Plan option, tax credits, and Essential Health Benefits.

We thank Secretary Bigby, Secretary Gonzalez, and Connector ED Glen Shor for requesting that their teams convene the Advisory Council and for the hard work and dedication of the Council’s leaders.
-Kate Bicego

August 17, 2011

Campaign for Better CareAn editorial in the Taunton Gazette, and other GateHouse papers (like the Milford Daily News, Wrentham Country Gazette) lays out the urgent need to move on comprehensive payment reform:

A new report from the Kaiser Family Foundation confirms what we already knew: Health insurance premiums are high in Massachusetts. Along with Vermont, Massachusetts leads the nation in individual health premiums, averaging $400 per month, including employers' contributions.

The finding is no surprise, because health care costs have been higher in Massachusetts for a long time. There are several contributing factors at work here, including a higher cost of living in general and the presence of some of the world's top teaching hospitals, which tend to charge more even for routine procedures.

Some are quick to blame the state's 2006 health care reform law, but we've seen no convincing evidence that making health insurance available to thousands of otherwise uninsured pushed up costs. The Kaiser report attributes some higher costs to requirements put on insurers by the state, including covering patients with pre-existing conditions, but some of those costs are offset by getting more people in the insurance pool.

What counts is what the 2006 law didn't do. The authors of that law never promised to restrain health costs, and included no provisions that would keep costs down. That shortcoming has been criticized for years on this page and by political leaders, including Gov. Deval Patrick.

There's actually been relatively good news of late on health care premiums. Thanks to market pressure from competitors, new policies with higher co-pays and deductibles, and a tougher stance by regulators in the Patrick administration, the latest round of rate hikes is lower than the state has seen in many years. State House News Service reported Thursday that the rate hike requests filed July 1 average no more than 5.9 percent for any insurer.

That's still higher than the overall rate of inflation, of course, and 5.9 percent only looks good compared to the double-digit increases we've seen for years. When the underlying problem is ever-increasing health care costs, pressuring insurers can only go so far.

For over a year, Patrick has been pushing for health care payment reforms to take away some of the incentives for excessive health care spending. Legislative leaders have resisted, saying there's not enough time to take up the complicated issue this year. Patrick hasn't been taking "wait until next year" for an answer, nor should he.

The Kaiser report should remind all the state's elected leaders that health care costs are a priority for Massachusetts businesses and families. The Bay State led the nation in addressing access to health insurance; now we should lead in taming health care inflation.

We understand the Joint Committee on Health Care Financing is working diligently on a comprehensive payment reform bill. We look forward to the legislature acting decisively to enact reforms that improve care and reduce costs.
-Brian Rosman

August 16, 2011

Insurance rates are going up slower than they have in a long time, but they are still going up more than they should.

Late last week the Insurance Commissioner announced the approved increases in base health insurance rates for individuals and small businesses starting October 1. The increases were lower than had been approved in many years: Blue Cross Blue Shield, Tufts, Harvard Pilgrim and United all received an average 5.9% increase in their base rates. CeltiCare received a 5.7% increase, Fallon a 5.4% increase, Neighborhood Health Plan a 4.8% increase and Health New England - amazingly - a 1.4% decrease in premiums.

This is the lowest increase in over a decade. Yet health insurance premium growth continues to far outstrip wage and income growth.

While the administration was justifiably proud of the results, they recognize that more needs to be done. The State House News Service talked with Consumer Affairs & Business Regulation Undersecretary Barbara Anthony today:

"It’s no secret that the Patrick-Murray administration has been urging and encouraging insurance companies and providers to reduce health care costs because of the drag that these costs are on our economic recovery here,” Anthony said in a phone interview. “We’re not going to be satisfied, quite frankly, until there’s an actual decrease in costs."

Insurers are getting the message. Blue Cross said “We understand that the expectation of the community is improving affordability of health care.” Tufts said there decisions in part were "because of an environment in which controlling soaring health care costs has become a key goal of public policymakers." Yet insurers warn that the rates were unsustainable and called on providers to take more actions to reduce the cost of care.

For the short term, HCFA and GBIO renew our call to the entire health care system - providers, insurers, employers, consumers and government - to take actions to freeze rates for 2012. Rates for coverage starting in January 2012 will be filed on October 1, and final decisions should come in mid-November. We will be watching.

The breathing room provided by a premium rates time out will allow the state to enact comprehensive reforms in our payment and delivery system that reduces the cost of health care by emphasizing health and wellness, and rewarding quality and value.

One other thing: The Division of Insurance was able to use its regulatory authority under state law to temper premium increases. Governor Patrick vetoed proposed changes to the law that would undermine the ability of DOI to oversee premium charges (see background, here). The House overrode the veto, but the Senate has yet to act. We urge the Senate to not override these provisions.
-Brian Rosman

August 15, 2011

The Health Care Quality and Cost Council is meeting this Wednesday, August 17, 1:30-3pm, 1 Ashburton Place, 21st floor. Meetings are open to the public. The agenda (pdf) includes an update from the Advisory Committee and from the Acting Director, a recap of the cost trends hearings and final report by the Division of Health Care Finance and Policy, and a report by the Harvard Medical School’s Department of Health Care Policy on health care spending and quality in year 1 of the BCBS Alternative Quality Contract.
-Deb Wachenheim

August 11, 2011

“An ounce of prevention is worth a pound of cure.” Yes, it's so cliché, but it intuitively makes sense for health care; if we take care of ourselves today, we’ll save big by avoiding huge medical bills tomorrow. This is the basic premise of public health, whereby investing in widespread prevention efforts will prevent sickness in thousands of people, and save millions of dollars in future medical expenses.

Yet our health care system highly rewards the life-saving medical services that treat people once they’re already sick, and invests little in cost-effective public health programs. Consequently, while state spending on health care services continues to grow, public health has endured significant budget cuts in recent years. The Mass Budget and Policy Center's Budget Browser, shows that since 2008, public health spending in Massachusetts has decreased around 20%.

But the cliché is true. A new article published in the journal Health Affairs demonstrates that a greater investment in public health produces substantial health gains in communities. The thirteen year (1993-2005) study examined spending changes in 3,000 local public health agencies across the nation, and their impact on community health in terms of preventable causes of death, such as infant mortality and deaths due to heart disease, diabetes, and cancer. The most striking results: for each 10% increase in public health spending, researchers observed statistically significant decreases for infant mortality (6.9% decrease), cardiovascular disease mortality (3.2%), diabetes mortality (1.4%) and cancer mortality (1.1%).

The authors conclude “additional spending, such as the $15 billion in new federal funds authorized under the Affordable Care Act’s Prevention and Public Health Fund, would be expected to generate substantial improvements in population health over time. At the same time, our results suggest that the recent recession-driven reductions in state and local support for public health activities are likely to have adverse health consequences over time unless they are offset with new spending.”

Before these spending cuts impact the health of the Commonwealth, we should urge legislators to increase our investment in public health. Increased funding can allow local public health agencies to tailor health programs that will best suit the unique problems facing individual communities. The Prevention and Cost Control Trust (H. 1498), sponsored by Representative Lewis and Senator Chandler, would allocate funds directly to local projects for cost-saving community prevention programs that will bring about sustainable health improvements.

The Health Affairs article provides strong evidence that investing in our community health will yield huge payoffs in the future. Not only do public health initiatives benefit a greater number of people, they are also less costly than comparable health care services that target the same diseases. In an economic downturn, policy-makers must confront difficult choices regarding program funding cuts. While public health has consistently made it to the chopping block, we hope this study will encourage policy-makers to reverse this trend, and increase funding to public health programs.
-Amelia Russo

August 11, 2011

Children's Mental Health Campaign logoOn June 27, the Joint Committee on Mental Health and Substance Abuse held an Oversight Hearing on parity implementation and the causes for "boarding" mental health patients in the emergency rooms of local hospitals. The Children's Mental Health Campaign (CHMC) was called upon to talk about this problem from a children's perspective and we put together an outstanding panel of experts including Marylou Sudders from MSPCC, Matt Selig from Health Law Advocates and Kate Guinness from Children's Hospital Boston.

Senator Keenan and Rep. Malia, the Chairs of the Committee, wrote a commentary that appeared on August 4 in the Quincy Patriot Ledger about this important issue and referenced Marylou Sudders' testimony provided to the Committee during the oversight hearing:

It’s becoming clear that, despite state and federal statutes to the contrary, there remains a stark difference between how physically ill and mentally ill patients receive treatment in Massachusetts. Or as Dr. Luis Lobón, of the Cambridge Health Alliance, put it during his testimony: mental health parity does not exist in Massachusetts.

There is no one reason for this failure.

We agree with Marylou Sudders, the well-respected former Massachusetts Department of Mental Health commissioner that the boarding problem was caused by the failure of the system as a whole.

The Commonwealth does bear some responsibility, as budget cuts have forced the closure of 200 state hospital beds, which then creates backups elsewhere in the system. However, of greater concern is the apparent failure of our state’s public and private insurance plans to meet their new obligations under federal and state parity laws.

Diabetic patients aren’t kept on gurneys in hallways over a weekend because the hospital can’t get authorization for treatment from insurance companies that turn off the lights Friday at 5 p.m. And oncology units aren’t closing because they’re losing money. But these are the realities for mental health services.

Failure to properly treat mental illness comes with a staggering financial cost. As a society, we pay for it through increased demands on our police, our courts, and our jails.

Insurance companies may balk at the upfront costs, but they pay in the end, as studies have consistently shown that consumers with mental illnesses also have higher average medical costs. In addition, hospitals recover from health insurance companies the money they lose through boarding mental health patients for days at a time by shifting costs elsewhere.

Efforts are ongoing to reconstruct our state’s health care system under a global payments model. It is important that this new model also include revamping our state’s mental health system. Individuals who are suicidal, schizophrenic, psychotic, or even homicidal need and deserve proper medical treatment, just like someone suffering from a heart attack, stroke, or broken hip. We need to make mental health parity a reality.

The CMHC has also been asked to provide input to the Committee on what parity reform or improvements would entail and we will continue to work towards full parity implementation over the course of the next year. This is a very important issue for the Committee and we look forward to working together on the next stage of parity regulations.
-Erin Bradley, coordinator of the Children’s Mental Health Campaign

UPDATE: See this letter further emphasizing the issues from Sudders in the Patriot Ledger.

August 9, 2011

About 98,000 people die every year from medical errors. A recent article in the New York Times describes the recently improved work schedules of medical residents, and how shorter working hours, in combination with other crucial changes in our health care delivery system, can help to reduce medical errors.

In 2003, a policy change required that medical residents work no more than 80 hours per week, cannot provide direct patient care after 24 hours of continued duty, and must get at least one day off per week.

What really spurred this change of rules was the death of 18-year-old Libby Zion, 27 years ago. Within 7 hours of being admitted to the hospital for uncontrollable thrashing and a high fever, Zion was pronounced dead. The patient had been given several different medications, two of which were powerful sedatives to control her body movements. Libby’s father, a writer, learned that his daughter’s doctor had been on duty for almost 24 hours, which he believed contributed to her untimely death. He proceeded to sue the hospital and publicize the situation, prompting a “60 Minutes” episode.

Just last month, a new policy further restricts working hours, abolishing 30-hour overnight shifts for first year residents that have been commonplace in US teaching hospitals. For many years, the medical community has struggled with the issue, with some doctors fighting to preserve long hours for interns because they believe it’s a necessary component to doctor training, and others who believe long shifts cause errors, and are unnecessary because many doctors will go on to practice in the outpatient setting.

Dr. Christopher Landrigan, an associate professor at Harvard Medical School, ran a study published in 2004 that examined the performance of interns in different work schedules, where one group worked the traditional 30-hr every other night schedule, and the other group worked on a staggered schedule, working no more than 16 hours per day. His results were shocking: Interns working the 30 hour traditional schedule made 36% more serious medical errors than the group with more limited, staggered hours.

However, this study was small and uncontrolled, and more large-scale studies that have examined doctor fatigue and medical errors have failed to come to the same conclusions. Most have shown that reduced working hours produced no major improvement in preventing medical errors. These studies lead many believe the core problem is not long hours.

What is it, then? Sleep deprivation seems like an obvious culprit for causing young doctors to make mistakes, but it seems the issue is more complex. One reason may be that as many as 2/3 residents violate the policy, working more than 80 hours per week. Many doctors believe that lack of supervision and reliable computerized records have been overlooked at other possible contributors to medical errors. In addition, shorter shifts may have caused less continuity of care between a patient and their doctor, and when one doctor leaves and another takes over, the patient’s information is often poorly communicated and the handoff becomes a large risk factor for error.

Ted Sectish, a pediatrician who runs the residency program at Children’s Hospital in Boston is committed to improving the handoff process, which he says is not a standardized procedure nor one that is typically taught to students. So far, Sectish’s pilot project which includes computerized patient summaries and a structured verbal handoff has reduced medical errors by almost 40%.

Rather than blame one factor, sleep-deprivation, the article’s author provides some food for thought on how to better understand the underlying structure that allows medical errors to occur: “In 2000, the British psychologist James Reason wrote that medical systems are stacked like slices of Swiss cheese; there are holes in each system, but they don’t usually overlap. An exhausted intern writes the wrong dose of a drug, but an alert pharmacist or nurse catches the mistake. Every now and then, however, all the holes align, leading to a patient’s death or injury.”

So while sleep deprivation may not be the only cause, when lined up with poor supervision, bad handoffs, or insufficient medical records, it undoubtedly plays its part in avoidable errors.

It turns out that Zion died of something known as serotonin syndrome, which was likely brought on by the combination of an antidepressant she had been taking for weeks, and one of the sedatives administered to her in the hospital. A well-rested doctor at the time would have likely made the same mistake. Unfortunately, this mistake would also likely occur in an inpatient setting today, as about 2/3 of US hospitals do not have computerized prescribing systems that alert doctors of such potentially fatal interactions between medications.

What we need is an innovative way of delivering care such that well-rested residents, and all doctors for that matter, have more time to meet with their patients, and that better communication between providers can prevent medical errors. Some simple measures like checklists, electronic medical records/ prescribing systems, and improved communication between health care providers will go a long way toward reducing medical errors. But let’s also let residents catch some Z’s.

-Amelia Russo