January 2012

January 31, 2012

National poll shows little public awareness of Massachusetts health reform provisions
WaPo Wonkblog's Sarah Kliff found this group of questions about chapter 58 included the latest Harris poll on health reform attitudes.

The poll itself found modest increases in public support for the components of the ACA, with the exception of the individual mandate. The questions on Massachusetts health reform show that the vast majority of the public is unaware of what's included in our health reform law:

  • 65% are unsure that the Massachusetts reform law requires that everyone has or buys health insurance.
  • 69% are unsure that everyone in Massachusetts now has health insurance. Another 10% say this is false.
  • 69% are unsure that the health care reform bill is popular with most people in Massachusetts. And 13% think this is false.

We need to tell our story to the country.

And we have an important story to tell. The latest Massachusetts Health Reform Survey, compiled from a large random sample of Bay State adults, shows the state of Massachusetts coverage, access and affordability as of fall, 2010. Lead researcher Sharon Long has been conducting these surveys annually since 2006, tracking the impact of Massachusetts health reform.

Highlights from the report include:

Access and Usage of Care
There were sustained gains in access to and use of health care between 2006 and 2010.

  • Gains in Usual Source of Care: Nonelderly adults were more likely to have a usual source of care. They were also more likely to have had a preventive care visit, specialist visit and dental visit.
Adults with souce of care increased from 2006 to 2010 in Massachusetts

Health Care Use, Fall 2006 to Fall 2010 - Percent Reporting Type of Care

  • Declines in Hospital Use: First-time reductions in emergency department visits and hospital inpatient stays suggested improvements in the effectiveness of health care delivery.
  • Declines in Unmet Need for Care: Between 2006 and 2010 there were reductions in unmet need for care for nonelderly adults including reductions in unmet need for doctor care, medical tests, treatment, follow-up care, and preventive care screening.

Affordability of Care
In Massachusetts and nationwide, rising health care costs continue to raise concern about the affordability of care. More than a quarter of adults in Massachusetts reported financial problems due to health care costs.

Still, the study found significant declines in out-of-pocket spending as the share of nonelderly adults in MA who spent 10% or more of family income on out-of-pocket health care costs decreased from 10% in 2006 to 6% in 2010. The study also reported declines in unmet need due to costs.

Unmet need due to cost declined in Massachusetts

Unmet Need Due To Cost, Fall 2006 to Fall 2010 - Percent Reporting Unmet Need

Support for Reform

  • 66% of nonelderly adults in MA remain supportive of health reform. This level of support has remained steady since the implementation of reform.
  • However, among the remaining adults, there has been a marked shift from a neutral position toward opposition (17% opposed to reform in 2006 versus 27% in 2010).
Support For Reform has declined only slighlty since 2006

Support for Health Reform in Massachusetts, Fall 2006 to Fall 2010 - Percent Reporting Outcome

Employer Response to Reform
According to the study, there was no evidence that employers of nonelderly adults in MA were dropping or reducing the scope of coverage for their workers.

January 30, 2012

This exchange from last Thursday's Florida Republican debate was the most extensive discussion of health care so far in the primary season:

Romney gave a cogent, articulate defense of Massachusetts health reform (which of course goes just as well for national health reform under the ACA). Romney offered his standard defense of the individual mandate as reducing the number of "free riders" - "[I]f you don’t want to buy insurance, then you have to help pay for the cost of the state picking up your bill, because under federal law if someone doesn’t have insurance, then we have to care for them in the hospitals, give them free care. So we said, no more, no more free riders.”

But Santorum responded with something that had a lot of us scratching our heads:

SANTORUM:So what is happening in Massachusetts, the people that Governor Romney said he wanted to go after, the people that were free-riding, free ridership has gone up five-fold in Massachusetts. Five times the rate it was before. Why? Because…
ROMNEY: That’s total, complete…
SANTORUM: I’ll be happy to give you the study. Five times the rate it has gone up. Why? Because people are ready to pay a cheaper fine and then be able to sign up to insurance, which are now guaranteed under Romneycare, than pay high cost insurance, which is what has happened as a result of Romneycare.
ROMNEY: First of all, it’s not worth getting angry about. Secondly, 98 percent of the people have insurance. And so the idea that more people are free-riding the system is simply impossible. Half of those people got insurance on their own. Others got help in buying the insurance.

After the debate, policy analysts and fact checkers agreed that Santorum didn't know what he was talking about. The Washington Post's Wonkblog explained it well:

Here’s one reason we don’t hear much about free-riding in discussions of Massachusetts health reform: It’s barely happening. About 0.6 percent of Bay State adults under 65 paid a fine for not carrying health insurance in 2009, the most recent year for which data are available from the Massachusetts Department of Revenue. That was back when 96 percent of the population had health insurance, a number that has since risen (as Romney pointed out last night) to 98 percent. The number of free riders would presumably drop as coverage increases, although we’re still waiting for data on 2010 numbers.

But a few days later, the Santorum campaign clarified what he was referring to. Santorum's "free riders" are different than the "free riders" that most people worry about. He was harking back to the DOI actuarial study (pdf) comparing 2006 and 2008 figures for people buying individual coverage and dropping it within 6 months. The numbers did almost jump five-fold.

Whether or not these people were free riders, in any case it's not a problem in Massachusetts anymore. Two years ago, the legislature enacted legislation setting up annual enrollment periods for individual coverage. We've been critical of some of the details of how this provision is implemented, but this issue that Santorum raised is no longer a concern here.

So groups like FactCheck.org amended their original call, that Santorum was completely wrong, to just point out that he's behind the times.
-Brian Rosman

January 26, 2012

This week the Patrick administration reaffirmed its commitment to health care in the Commonwealth. First, the Governor's State of the Commonwealth speech focused on payment and delivery system reforms that will stem the rising costs of health care:

The market is moving in the right direction and that’s very good news. But it is not enough. Too many small businesses and too many working families still go through an annual ritual that starts with notice of another premium increase, and too often ends with a new plan costing the same or more for less coverage. Slowing the rate of increase is critical, but unless that slowdown is sustained, health care costs will continue to squeeze everything else – including job growth itself. We need to put an end to the “fee-for-service” model. We need to stop paying for the amount of care, and start paying instead for the quality of care. We need to empower doctors to coordinate patient care and to focus on wellness rather than sickness. And we need medical malpractice reform. All of this is addressed in the bill I filed last year. ... The Legislature has done considerable work on our proposed reforms, and I want to congratulate your care and thoughtfulness. Now it’s time to act. Before you take up next year’s budget, pass health care cost containment legislation. This is another hard decision. But for the good of the Commonwealth, let’s do this and do it now.

Over the last year and half our Campaign for Better Care has been meeting with legislators, presenting all around the state, and offer public comments regarding the issues of payment and delivery reform. We emphasized that curbing costs must be tied to measures that improve the quality of care and protect the vulnerable as we redesign care. We must make a serious and robust investment in public health and prevention. We need to ensure transparency in all aspects of the health system. The savings must accrue to us, so patients can reap the benefit of a less costly system. The Campaign for Better Care has offered specific legislative ideas (pdf) around each our patient-centered principles. If you would like to get involved with the Campaign please contact Paul Williams at pwilliams@hcfama.org. Second, yesterday's release of the proposed budget for fiscal year 2013 makes progress on health care coverage, public health, and cost control. While $545 million in MassHealth savings are imposed, the budget assumes no further cuts to MassHealth benefits. The administration's has posted write-up of their health cost and their public health initiatives on the state's site. As ususal, the Mass Budget and Policy Center put out their flash analysis last night, with more detailed analysis to come. The budget proposal fully funds Massachusetts health reform programs, including the re-integration of some 37,000 legal immigrants into the Commonwealth Care program. Full coverage for this group was required by a decision of the Massachusetts Supreme Judicial Court earlier this month, in a case brought by HCFA affiliate Health Law Advocates. The budget makes major progress in reducing costs through improvements in overall health and wellness. HCFA strongly endorses the proposed increase in the tobacco tax, and the ending of the loophole that exempts sugary soda and candy from the sales tax. These revenue sources will both improve overall health and provide needed funds for health programs. HCFA also supports the expansion of tobacco cessation benefits to Commonwealth Care, as called for in legislation HCFA has actively supported. The budget includes over $5 million desperately needed by MassHealth to improve customer service and begin implementation of national health reform. Service has deteriorated dramatically as cutbacks have reduced staffing at enrollment centers. Funds are also provided to implement a modern on-line integrated eligibility system for all health programs, scheduled to roll out in 2014. HCFA calls on the legislature to reverse a budget cut that substantially reduced dental benefits to adults in the MassHealth program. Good oral health is a requirement for good overall health, and we know that the reduction in dental benefits will lead to higher long-term costs. Truly the Commonwealth can afford to end the inexcusable pain and suffering affecting thousands caused by lack of dental care. We'll of course have more to say as the budget process continues. -Paul Williams, Ana Aguilera and Brian Rosman

January 26, 2012

Having discussions about care that someone would or would not want in the final stages of his or her life is difficult and emotional for all involved, including the individual, loved ones, health care providers, and others. But it is something that needs to be done, ideally before someone is at the point of not being able to express his or her wishes. A one-hour free webinar today hosted by the Institute for Healthcare Improvement will feature discussions about how people can broach these conversations. The webinar is titled “Have you had “The Conversation”? Helping Loved Ones Discuss End-of-Life Preferences” and starts at 2:00pm. You can sign up at www.ihi.org. This event will, among other things, introduce a new project at IHI called The Conversations Project.

In order for patients and family members to feel comfortable having these discussions not only with one another but also with their health care providers, it is necessary that providers also learn how to discuss end-of-life care. On that note, we applaud the MA Board of Registration in Medicine for its new requirement, effective February 1, that physicians must take 2 CME credits in end-of-life care.

Most of us have had personal experiences, or know others who have had personal experiences, with end-of-life care for loved ones or friends. Health Care For All would like to start hearing your stories about those experiences as we look at how we can help make a difference in this area. Please contact Deb Wachenheim at dwachenheim@hcfama.org if you have a story to share.
-Deb Wachenheim

January 19, 2012

A survey released today by the Kaiser Family Foundation's Commission on Medicaid and the Uninsured (KCMU) showcased experiences of four states - Massachusetts, Alabama, Iowa, and Oregon - at the forefront of the nation’s recent gains in children’s health coverage. The report’s findings were presented at a briefing held today in Washington.
The study reported that Massachusetts is the leading state for covering children in health insurance. Citing state figures, the report highlighted the 99.5% coverage rate for children in the Commonwealth. The report concluded that state officials and community partners showed a "deep and sustained commitment to children’s coverage." The report credited the role played by community organizations, and a strong, broad stakeholder partnership joining community groups, advocates, providers and state officials.

The briefing featured a presentation by HCFA’s Children’s Health Policy and Outreach Manager, Dayanne Leal. Leal discussed the recipe for Massachusetts’ success. “Our success came from Massachusetts’ choice to invest in kids, a real commitment to doing the work, and creativity to make it happen,” she said.

The report was prepared by the Kaiser Family Foundation in conjunction with the Georgetown University Center for Children and Families. A video  of the presentations is also available at the Kaiser Foundation website.

At the briefing staff from both institutions presented the main findings and then a panel of experts panelists discuss the survey findings and implications. Panelists included Cindy Mann, Deputy Administrator, Centers for Medicare and Medicaid Services (CMS); John Supra, Chief Information Officer for the South Carolina Department of Human Services; Dayanne Leal, Children’s Health Policy and Outreach Manager, Health Care for All Massachusetts; Tricia Brooks, a Senior Fellow at the Georgetown University Health Policy Institute Center for Children and Families; and Samantha Artiga, an Associate Director at the KCMU. who gave their perspectives. The panel was moderated by Diane Rowland, Executive Vice President, Kaiser Family Foundation.

Federal Medicaid administrator Cindy Mann recognized the work Massachusetts is doing to enroll children and keep them enrolled. “Massachusetts is the clear national leader in covering children,” she said. Leal thanked Mann for approving Massachusetts Express Lane Eligibility waiver to include renewals for parents, which will be crucial as Massachusetts move to the next phase which is improving its coverage retention.

January 17, 2012

Kate Nordahl and the Mass Medicaid Policy Institute keep churning out more good stuff.

Next up are two timely papers:

  1. First is a fact sheet (pdf) on the just-concluded extension of our Medicaid waiver, the agreement with the federal government that allows the Commonwealth to collect federal Medicaid funds for the MassHealth program, Commonwealth Care, and much more. The fact sheet focuses on what's new in this agreement, including the Pediatric Asthma Pilot, the Intensive Early Intervention Services for Children with Autism Spectrum Disorder, the Delivery System Transformation Initiatives, and Express Lane Eligibility, which allows the state to renew eligibility for children families based on their eligibility for SNAP (=food stamps).
  2. Second is a close look at "risk adjustment," (pdf) a wonky but critical detail to be included in the proposal to provide integrated Medicare and Medicaid for adults with disabilities who are in both programs, called the dually eligible. What is risk adjustment? Here's the report's clear explanation:

    Risk adjustment is a system for adjusting payments to health plans to reflect the differing health needs of enrollees, with higher payments made to health plans with members needing more care and lower payments to health plans with members needing less care. Without risk adjustment, providers of integrated care would face strong incentives to enroll the less needy among the duals. By contrast, providers that attract more than their fair share of enrollees with high needs would be underpaid, and could face large financial losses or have to reduce expenditures.

    Risk adjustment for programs serving the dual eligibles should take advantage of diagnostic data complemented by information on functional status.

    The paper explains how best to do this, and why it's particularly vital that functional status be added to the calculations.

Good winter reading, friends.
-Brian Rosman

January 16, 2012

The Health Care Quality and Cost Council is meeting January 18, 1-3 pm, at 1 Ashburton Place, 21st floor, Boston. Meetings are open to the public.

Agenda (pdf) items include follow-up from last month’s QCC annual meeting, including looking at enhancements to MyHealthCareOptions and improving quality measures. The Expert Panel on Performance Measurement will give a recommendation to the Council regarding public reporting of hospital readmissions.
-Deb Wachenheim

January 11, 2012

Tuesday’s NY Times reported on a research project called Open Notes, spearheaded by providers and researchers at Beth Israel Deaconess Medical Center, which looks at the impact of encouraging patients to view their outpatient medical records (doctors’ notes and all).

Providers and patients in three locations (Boston, rural Pennsylvania, and Seattle) were asked to participate in a one-year study, starting in the summer of 2010, during which patients would have electronic access to their full medical records and would be encouraged to view them. Before Open Notes began, the researchers looked at providers’ and patients’ expectations and attitudes about Open Notes. They surveyed participating and non-participating providers and patients.

In general, the patients were very enthusiastic about the opportunity to view notes and felt it would give them a fuller understanding of their care and what they needed to do to take care of themselves. Participating providers were also generally enthusiastic and had believed it would help improve patient-provider communication, patient education, and patient safety, while non-participating providers were more concerned about patient confusion and worry and reported that they may be cautious about what they write in the notes if they know patients will view them.

Privacy concerns did exist among a sizeable portion of patients but many patients also said they would share the records with others, such as family or other medical providers. Patients said they would be able to spend time digesting information that may be given to them quickly during a medical appointment. Some questions posed by the researchers include whether or not patients will withhold some information that they don’t want in the record and whether physicians’ notes will change if they know patients are viewing them. However, as the researchers point out, all patients in the U.S. have the right to view their records and their doctors’ notes if they so desire. And with more providers moving towards electronic medical records, it will become easier for patients to view the information. If it will help patients better understand their health and health care, and give them full information that they can carry with them to other doctors they may see, then it seems to fit right in with where MA and the country are going as we look to reform the way health care is delivered.

You can find the full research report in the Annals of Internal Medicine. The one-year project ended over the summer and we look forward to seeing the researchers’ final results.
-Deb Wachenheim

January 6, 2012

The state SJC just ordered the state to restore full Commonwealth Care coverage for legal immigrants. What's it going to cost?

For lots of people, the $30 billion state budget is just lots of unimaginable big numbers. But for those those of us who pay attention to budget numbers, and understand the relative scope and costs of stuff, we want to correct a cost misconception that's been floating around the press.

For example, the lede in today's Globe story says this:

Massachusetts lawmakers must quickly come up with about $150 million to provide health insurance to tens of thousands of legal immigrants, after the state’s highest court ruled yesterday that they were illegally excluded from subsidized coverage available to other residents.

That's not accurate.

The $150 million is the full cost for a full year. But if coverage is restored in February or March, the cost for the rest of this current fiscal year is much less, closer to $50 million. That's a much easier lift. The state does supplemental budgets every winter, and often adds much more than $50 million. Finding $50 million is not a piece of cake, but hardly insurmountable. (for example, what is the state saving in unused snow and ice removal so far?)

Also, there are some countervailing savings, from the ending of the Bridge program. The net cost is less than the full $50 million.

For fiscal 2013, the state will need to allocate around $150 million more than it would have otherwise, due to the ruling. [Update: We had originally reported that the full year cost of around $150 million did not take into account the savings from ending the Bridge program, leading to a net cost of $125 million. We've since been told by Administration and Finance staffers that the $150 million estimate includes Bridge program savings, and that is the net additional cost. So we've corrected the post.]

(And you know what raises around $125 million? - equalizing the tax on "other tobacco products," like little cigars and chewing tobacco so it matches the cigarette tax rate, and an increase in the cigarette tax to keep up with inflation. That would also improve health and lower overall health costs, too.)

But for fiscal 2014, the additional cost will only be half. That's because in January 2014, the ACA provisions that provide federal coverage for all legal immigrants kick in. After 2014, all legal immigrants, including the "aliens with special status" covered by the court ruling, will be eligible for federal tax credits that will replace most of the cost of Commonwealth Care.

So the $150 million figure is only for one year. It's not an ongoing cost. In fact, due to the ACA, the state will be relieved of hundreds of millions of dollars of costs that it took on as part of chapter 58. Yet another reason why we said for months that national health reform is good for Massachusetts.
-Brian Rosman

January 5, 2012

The MA Department of Public Health has issued its most recent reports on the occurrence of Serious Reportable Events (SREs) in Massachusetts hospitals.

Health Care For All and the Consumer Health Quality Council advocated for the law requiring public reports on SREs and Healthcare-Associated Infections (due to come out soon). We commend DPH, and particularly the dedicated staff at the Bureau of Health Care Safety and Quality, for its hard work compiling the data and publishing the reports, especially considering the budget cuts the department has endured the past few years.

You can find reports for acute and non-acute hospitals, for all of 2010 and the first half of 2011, on the DPH website). The reports list the numbers and types of SREs that occurred at every hospital. I also encourage you to view, on the same page, the Public Health Council presentation explaining the reports, SREs, and work related to reducing SREs.

In sum, there were 369 SREs in acute care hospitals in 2010 and 159 during the first half of 2011. About half of the SREs were serious falls which resulted in disability or death.  The next largest category of SREs was advanced pressure ulcers. At the non-acute hospital, there were 143 SREs reported in 2010 and 58 the first half of 2011. Again, about half were falls. As you can see in the presentation materials, there is a lot of work going on across the state to reduce falls and pressure ulcers.

Madeleine Biondolillo, the director of the Bureau of Health Care Safety and Quality, did say that there are some concerns with the validity of some data and the Bureau will work to make sure the data are valid. Serious medication errors was given as an example of an area in which the validity is uncertain since so few of them are reported as SREs. She said that the bureau will be investigating “near misses” as well to help further their understanding of hospital safety.

Public reports serve multiple goals. They provide the public with information about the quality of care provided at hospitals. They give health care providers a better sense of how they are doing and where they need to improve. And they can direct policymakers and advocates to areas that may need more attention. However, the information is also complex and it is not always possible to look at a table and draw immediate conclusions about quality and safety. While the goal should be zero SREs, we also want to make sure hospitals are reporting those SREs that do occur so that they can learn from them, and learn from one another, in order to prevent them from happening in the future.  And we want to encourage hospitals to be up-front with their patients and family members when SREs occur.  So look at the reports and ask your hospital for more information on what they are doing to prevent SREs. Ideally, public reports on serious reportable events, infections, and more lead to conversations within the hospitals, among hospitals, and between consumers and hospitals so that ultimately we can reach the goal of zero.
-Deborah Wachenheim

January 5, 2012

The SJC just issued their opinion in Finch v. Commonwealth Health Insurance Connector Authority, the case brought by Health Law Advocates contesting the denial of full Commonwealth Care benefits to legal immigrants who did not qualify for federal Medicaid reimbursement. The unanimous decision (link) requires the state to reinstate full coverage for all legal immigrants.

This will restore coverage for over 40,000 [update: we think it's around 37,400] legal immigrants. Most are uninsured, with access to some care through the Health Safety Net program. The remainder are in the Commonwealth Care Bridge program, which features fewer benefits and member higher costs than regular Commonwealth Care.

The court's decision is unambiguous: "The discrimination against legal immigrants that its [the state law's] limiting language embodies violates their rights to equal protection under the Massachusetts Constitution."

The decision will require the state to appropriate additional funds to comply with the decision. The court recognizes this, but understands that under our state constitution, financial concerns are not an excuse for discrimination:

We recognize that our decision will impose a significant financial burden on the Commonwealth. See Finch, supra at 675. Nonetheless, "the fiscal consequences of any . . . judgment on the merits cannot be permitted to intrude on consideration of the case before us. . . . '[M]inorities rely on the independence of the courts to secure their constitutional rights against incursions of the majority, operating through the political branches of government.'" Id., quoting Commonwealth v. O'Neal, [citation omitted]. If the plaintiffs' right to equal protection of the laws has been violated by the enactment of § 31, then it is our duty to say so.

The legislature has anticipated this decision, and we are confident they will appropriate the necessary funds.

HCFA gratefully thanks our partners at HLA, headed by Lorianne Sainsbury-Wong, and our board member Wendy Parmet of Northeasetern Law School who headed the legal team, for their magnificent, tenacious advocacy.
-Brian Rosman