November 2012

November 28, 2012

Today is Giving Tuesday, a response to Black Friday and Cyber Monday. HCFA is able to do the work we do because of the generosity of our supporters. Gifts from individuals, families, and organizations allow HCFA to continue to assist all Massachusetts residents in receiving the health coverage they need. Giving to Health Care For All has never been so easy. On this “Giving Tuesday,” please consider making a donation to Health Care For All in one of the following ways: Make an Online Donation Mail a Contribution Mail donations to: Development Department, Health Care For All, 30 Winter Street, 10th Floor, Boston, MA 02108 Dial a Gift Make a pledge over the phone by calling 617-275-2926. Celebrate and Remember In Honor of - Celebrate the work of family and friends in health care for a notable achievement, or for a special occasion such as a birthday or anniversary. In Memory of - Remember a loved one with a gift in their name. Donate today!  Monthly Donations Support HCFA monthly by allocating an ongoing donation. Giving a specific amount each month has great impact on our work. Email freitas@hcfama.org to start the process today! Shop & Give to HCFA When making last minute, online purchases, shop through www.iGive.com, and designate Health Care For All as your worthy cause.  A portion of each purchase is donated to our cause. The site has over 1,000 + stores and it’s easy to use:

1.Visit and register with www.igive.com 2.Select your favorite cause (Health Care For All). 3.Shop at brand name online stores through the iGive Mall.

Thank you so much in advance! Your gift will have an immediate impact on our work. --From all of us at Health Care For All

November 21, 2012

Despite widespread opposition among Council members, the Public Health Council voted this morning to enact final regulations on meals provided by the drug and device industry to doctors and other prescribers. The regulations approved today keep intact the expansive, subjective definition of "modest" meals, as whatever a doctor would order on his or her own. The regulations also permit drug sales teams to provide free alcoholic beverages to doctors at drug industry "educational" sessions. Although a number of motions were made to ban alcohol and limit the amount spent on meals, they were not voted on during the somewhat chaotic process of discussing the regulations. (see the Boston Herald coverage)

We were deeply disappointed by the outcome, which ignored extensive evidence that pharma industry marketing practices distort prescribing and raise drug costs for everyone.

By state law, all DPH regulations must be approved by the Public Health Council, comprised of 14 members of the public, in addition to the Commissioner of Public Health. This was the first meeting chaired by Interim Commissioner Dr. Lauren Smith.

The new regulation tightens up some of the reporting requirements dropped from the earlier draft. The Council did approve an amendment authorizing the Commissioner to demand more information about meals provided as part of drug marketing programs, with the intent to revisit the regulation in light of the data received.

Before the meeting started, a representative of Senator Mark Montigny was permitted to speak. He conveyed Senator Montigny's outrage at the proposal. He asked for a count of the number of public comments received in favor of and opposed to the regulation, and was assured that the count would be presented later in the presentation. However, the tally for and against was never presented to the Council.

The discussion focused on two main issues: should the state permit free alcohol to be served at supposedly educational sessions hosted by the drug and device industry, and how should the state define what constitutes a modest meal?

Council member Dr. Muriel Gillick, a Harvard Vanguard physician, spoke eloquently against allowing alcoholic drinks: "Show me the medical school that offers beer before physiology class. Show me the hospital that gives a doctor a shot of vodka before he goes into the operating room to learn a new surgical procedure." She was echoed by Helen Caulton-Harris, Health Director for the City of Springfield:

I bring the perspective of a local public health official working on a community basis with teens and young people around the dangers of alcohol and drugs. To me, it does not send a good message to sanction the provision of alcohol at an educational session. Given what we know scientifically, we should make clear that alcohol does not promote learning.

Also joining the chorus against allowing alcohol were Lucilia Prates Ramos, Dr. Michèle David, José Rafael Rivera and Dr. John Cunningham.

Several motions were made to not permit alcoholic drinks to be provided or paid for, but none of these motions were brought to a vote.

Setting a fixed definition on the cost of modest meals was also discussed extensively. DPH staff argued that it would be difficult to set a fixed dollar amount, since the cost of meals can be mixed in with the cost of a meeting room or AV equipment. Under questioning however, the staff admitted that the drug industry is required now to separate out these costs for reporting purposes.

During the discussion, Harvard health economist Dr. Meredith Rosenthal described the basic meals served at faculty meetings, and eloquently decried the priorities reflected by the regulation, saying "it is poor economic policy to sell out prescriber integrity in the name of economic stimulus." Dr. Gillick asked, "What is the point of the food provided at one of these sessions sponsored by a drug company or medical device firm? Is it to allow physicians to conveniently be able to attend an educational session or is it providing a social occasion desired to promote good relationships between physicians and the sponsor?”

Motions were made to limit spending on meals to $25, or to the federal reimbursement standard. These motions were also never voted on by the Council.

Several times, Lucilia Prates Ramos expressed dismay at the proposed regulations, arguing for limiting the definition of allowable meals and against allowing alcohol. She also raised the issue of the proper location for drug company marketing sessions, moving to not allow meetings at resorts, casino and country clubs.

Dr. Alan Woodward proposed that the regulation be amended to permit the Commissioner to specify additional reporting requirements. He asked specifically that the Department require data on how much is spent on alcohol as opposed to food, a break-out of how much for meals and for meeting places, and the qualifications of speakers presenting at the drug marketing programs. He urged that the regulation be examined in 6 months in light of the data. On the vote to accept the regulation with the change to allow more reporting, 4 members voted no, and another member abstained. Seven members voted yes, along with Commissioner Smith.

We hope the Department takes seriously the heartfelt objections raised by many members today, and commits itself to relook at the regulation next year.

November 21, 2012

On Friday, the Connector Board met to discuss customer service and business operations changes needed for ACA implementation and voted to release draft regulations on the small business wellness program. Materials from the meeting are here.

November 20, 2012

Tomorrow morning (Wednesday 11/21), the Public Health Council will be voting on final regulations implementing the changes to the pharma gift ban and marketing regulations. Over the summer, the legislature changed the law to allow drug and device companies to provide "modest" meals to doctors and other prescribers. The initial rule, which was widely criticized by consumer and medical groups (but supported by restaurants and pharma industry) defines modest as anything a doctor might order on his or her own tab, including alcoholic drinks.

State law empowers the members of the Public Health Council to review and make amendments to proposed regulations - they are the final authority. We hope they use their power if the regulations are not amended.

The cost of meals is also passed on to consumers in the form of higher drug prices. If such wining and dining didn’t work, the drug industry wouldn’t spend $6 billion a year on direct marketing to physicians. In addition, marketing expenses such as meals are tax deductible for the pharmaceutical or device companies, lowering their tax bill, reducing state and federal revenue, and ultimately increasing the tax burden on the remainder of the state residents.

MODEST MEANS MODEST
There's been no public discussion of the issue since the DPH hearing on the regulations. We've called for a strict dollar limit ("modest means modest"), and think that free alcohol is utterly incompatible with educational meetings.

At the hearing, testimony was overwhelming in favor of changing the emergency regulation. For example, the National Physician's Alliance testified that

As physicians, we are deeply disappointed that these regulations undermine the State’s leading commitment to evidence-based prescribing and to the protection of patients from the dangers of undue marketing influence in our profession. The new emergency regulations accommodate industry interests at real expense to patient safety and will result in a high financial cost to the state’s health care budget.

Representing physicians across medical specialties, the National Physicians Alliance (NPA) is united in support of unbiased, evidenced-based education and clinical practice. Marketing interests should not supersede this foundational obligation to patients.

Senator Mark Montigny, a national leader in prescription drug policy, wrote that "allowing medical companies to spend lavishly on meals and entertainment for health care providers means higher costs to the companies which are then passed on to consumers. It is estimated that the medical industries spend over $6 billion a year on marketing to providers. It has also been shown that such marketing predisposes providers to prescribe the products offered by those that feed them. The end result- patients pay more for drugs that they may not need."

Similarly, Reps Jason Lewis and Ruth Balser testified that "The FY13 budget explicitly included language stating that meals and refreshments must be 'modest' in nature. The Legislature chose this language deliberately, and rejected other proposed budget amendments that would have allowed for any and all meals with no restrictions. We feel that the current emergency regulations lack specificity in the definition of 'modest,' and should be rectified through the establishment of clear, concrete and enforceable terms, such as specifying a monetary limit for modest meals."

Specifically, we urge DPH and the Public Health Council to amend the current regulations to:

November 19, 2012

[caption id="attachment_8243" align="aligncenter" width="550"]Members of the Health Policy Commission pose with Governor Patrick at their first meeting Members of the Health Policy Commission pose with Governor Patrick at their first meeting[/caption]

All of the state’s diverse health care hangers-on were present at 9:30 am on Friday for the first meeting of the Health Policy Commission (HPC), with all of the board members in attendance: Chair Dr. Stuart Altman, Marylou Sudders, Dr. David Cutler, Dr. Carole Allen, Jean Yang, Sec. JudyAnn Bigby, Dr. Paul Hattis, Richard Lord, Veronica Turner, Dr. Wendy Everett, and Sec. Jay Gonzalez.

Gardner Auditorium was crowded, but not full, as the eleven board members stood for a photo and to be sworn in by Governor Patrick. Gov. Patrick welcomed everyone and noted that this meeting was the beginning of the future of health reform. The HPC is central to the cost containment law and vital to sustaining the Commonwealth’s central value statement: health is a public good and everyone deserves access to affordable care. Gov. Patrick acknowledged the difficulty of health care cost containment but noted that the administration will not be defeated by the difficulty of this endeavor. He then swore in the commission, and the members took their seats.

(For a few of us, it contrasted dramatically with the first meeting of the Health Connector Board, which the Romney administration scheduled for a cramped, windowless basement room of 1 Ashburton, without enough chairs and with the members facing away from the public.)

We live-tweeted the meeting, and you can see ours and others instacomments at hashtag #MAHPC. The meeting was also covered by WBUR’s CommonHealth Blog and Boston.com’s White Coat Notes blog.

The Commission has a web page at at www.mass.gov/anf/hpc, and the main presentation from the meeting is here (pdf), including an overview of Chapter 224, the HPC, and CHIA. Our full report on the meeting is after the flip.

November 16, 2012

The Massachusetts Public Health Association (MPHA) held its annual conference in Westborough today. Lots of happenings, so I'll just hit the high notes.

This was the first major public event for MPHA's new Executive Director, Toby Fisher. Toby is a long-time friend of many of HCFA, having headed NAMI Massachusetts and recently working with SEIU. HCFA is looking forward to continuing our partnership with MPHA under Toby's leadership.

Senator Richard Moore and Representative Steven Walsh received MPHA's legislative leadership award for their tireless work on payment reform legislation over the past session. Although Representative Walsh was unable to attend due to a family emergency, Senator Moore had interesting comments about where health care in Massachusetts is going.

Looking ahead, the Senator projects that hospitals and doctors will become more involved in community health under the newly reformed health care payment delivery system. He was optimistic about funding for the Public Health Trust, and believes that policy makers need to work to ensure permanent, expanded fiscal support.

Moore is also pleased with the appointments to the Health Policy Commission. We've done a lot over the past decade, he said, but there is still more to be done.

Yesterday, the Senate President appointed Senator Moore to a new commission examining various methods to regulate compounding pharmacies. Look for policy recommendations and new legislation in the next few months.

Former Department of Public Health Commissioner John Auerbach was also honored by MPHA for his work. Auerbach has moved on to work at Northeastern University and said that he looks forward to the University being even more active in public health policy development.

New Interim DPH Commissioner Lauren Smith also spoke on the future of the Department. Calling out critics who have characterized the agency as "embattled" (or worse), Dr. Smith spoke of the long list of DPH accomplishments, including high rates of childhood vaccination, low HIV infection rates, successful tobacco prevention, the integration of population-based health initiatives, and effective substance abuse programs. Giving credit to Commissioner Auerbach's leadership, Dr. Smith looked forward to many more successes to come by the Department.

Finally, MPHA launched its new priority focus on Health Equity. Dr. Brian Smedley of the Health Policy Institute at the Joint Center for Political and Economic Studies gave a keynote address, laying out the challenges and opportunities facing the effort. Stay tuned for an exciting policy initiative.
-Matt Noyes

November 15, 2012

If you see Administration & Finance Secretary Jay Gonzalez tomorrow (Friday, Nov. 16), have some sympathy for his full day of health care meetings.

The same applies to lots of other people who live and breath Massachusetts health policy. In the morning is the first meeting of the Health Policy Commission (HPC), the new board set up by Chapter 224 to administer much of the state's cost control policy. Yesterday, the Governor, Attorney General and Auditor announced their appointments to the Commission. Their press release with the names and the backgrounds of the appointees is here. The first full board meeting of the Health Policy Commission will be at 9:30 am on Friday at Gardner Auditorium in the State House, and should go to noon.

(By the way, we neglected last week to post that the Blue Cross Foundation released a very helpful series of 1-pagers explaining the impact of Chapter 224 on hospitals, health plans, consumers, and clinicians. Get them here.)

Then the Health Connector board meets from 1 pm until 4 pm on the 21st floor of One Ashburton Place, Boston. The meeting agenda is here (pdf).

We'll continue our practice of posting detailed summaries of both meetings here on A Healthy Blog. And we'll tweet anything particularly interesting from the HPC meeting. I'm thinking hashtag #MAHPC, but others may emerge.

Gonzalez is a member of both boards, of course. He'll barely have time to catch up on emails at a rushed lunch. The rest of us just get to sit through lots and lots of health policy stuff we crave. So be nice to Jay, OK?
-Brian Rosman

November 15, 2012

MassHealth Strategic Plan Cover

Last week, MassHealth presented to a group of advocates their draft strategic plan (download pdf), a detailed presentation of the top priorities for the Commonwealth's Medicaid program. Medicaid Director Dr. Julian Harris emphasized that the document is still a work in progress, but MassHealth has allowed us to share the draft with the public.

There's a lot of meaty substance here. For those who pay close attention to MassHealth, there's nothing dramatically unexpected. But the plan includes some digestable updates on the program's coverage and spending, a bold statement of overarching goals, and details of new initiatives to make sure the care provided to MassHealth members is integrated, coordinated, and focused on health. There's also a focus on building an administrative structure that serves members, and uses state funds efficiently. The presentation also puts MassHealth's goals in the context of the larger goals of the EOHHS Secretariat and the even larger goals of the Patrick administration.

We are well aware that proclaiming goals and objectives is just the first step towards action. Our motto as always is that implementation is everything. The divine is in the details. Still, this plan organizes disparate activities into a thought-out structure, and provides a level of transparency and accountability that is very welcome. We commend Dr. Harris for this step and look forward to collaboration for a new new MassHealth.
-Brian Rosman

November 9, 2012

As Glen Shor put it, the Connector is moving full steam ahead with Affordable Care Act (ACA) implementation. Today, the Connector Board discussed possibilities for updating the Connector’s health plan offerings to meet ACA requirements and offer products with “market appeal.” Materials from the meeting are here.

November 6, 2012

Today, Chapter 224, the state's cost containment and health delivery system reform law takes effect. It's the law's 0th birthday (except in some east Asian cultures).

The Patrick administration sent out a long list of implementation steps already taken. Since the law's signing, they have:

 

  • Held two special sessions at the Division of Insurance on the implementation of mental health parity provisions.  (more)
  • Held two special sessions at the Division of Insurance on the certification of risk-bearing provider organizations. (more)
  • Held a cross-secretariat Informational Forum on all implementation efforts related to Chapter 224. (more)
  • Launched a one-stop implementation website and e-mail outreach service to keep stakeholders informed.  (more)
  • Launched the Massachusetts Health Information Exchange, that allows for secure electronic health information to be transmitted between health care providers and organizations to better coordinate care, increase patient safety and lower health care costs.  (more)
  • Released a Request for Proposals (RFP) from the Group Insurance Commission that shows government leading by example in adopting new payment and care delivery models. (more)
  • Established the Center for Health Information and Analysis as the successor agency to the Division of Health Care Finance and Policy. (more)
  • Announced, with the Attorney General and the State Auditor, the unanimous selection of Áron Boros as the first Executive Director the of the Center for Health Information and Analysis. (more)
  • Announced the appointment of Dr. Stuart Altman as the Chair of the Health Policy Commission Board and the first full board meeting on November 16th, 2012. (more)

In addition, today the DCHFP morphed into CHIA - Center for Health Information and Analysis - with a new website at www.mass.gov/chia, and their former @MassHealthCare twitter feed now @Mass_CHIA (I wonder if they'll update their old RSC → DHCFP mugs with the new twitter handles?)

Today's effective date got national notice, as the Washington Post Wonkblog's Sarah Kliff posted an interview with Stuart Altman, titled, "Meet the man Massachusetts thinks can crack its health spending problem."

It's just by chance the groundbreaking law's effective date falls the day before the elections, but there's some justice, as the future of health care in the US will be decided on Tuesday, just as the future of health care in Massachusetts takes off.
-Brian Rosman

November 5, 2012
Globe article on the policy positions of Scott Brown and Elizabeth Warren From Boston Globe, 11/4/12

Did you see the Globe's Sunday Metro-front box, on the key positions of Senate candidates Scott Brown and Elizabeth Warren? Did you catch the huge mistake, in the very first line?

Under the issue topic "deficit" (which is shorthand for how do we reduce the federal budget deficit), Brown lists "repeal Obama’s health care law" as the first entry.

What's wrong with this picture?

Obama's health care law reduces the deficit - substantially. Repeal would increase the deficit. The Congressional Budget Office is the official, non-partisan, expert, scorekeeper on deficit impact of federal legislation. They reported in late July that repeal of the Affordable Care Act ("ObamaCare") would increase the federal budget deficit by $109 billion from 2013-2022. Just click here to read the official letter to Speaker Boehner (pdf), with all the numbers.

The article leaves the mistaken impression that repeal of the ACA would help the deficit, when the opposite is undeniably true. Will the Globe publish a correction?
-Brian Rosman

November 2, 2012

Stuart Altman speaking at HCFA book event 7-22-11

The Patrick administration announced today that Brandeis University health economist Stuart Altman will chair the Health Policy Commission (HPC), the central new policymaker under the Chapter 224, the cost containment law (press release). As expected, the appointment of DHCFP Commissioner Áron Boros to head the Center for Health Information and Analysis, or CHIA, was also announced today (don't worry, Áron already has a chia pet in his office).

Altman is renowned for his work on federal health policy, from his work running the Nixon administration's health cost containment policy, to his 12 years (1984-96) chairing the Prospective Payment Assessment Commission which advised on Medicare payment policy, to his work on the Clinton and Obama health care plans. His long experience led to a book detailing the history of US efforts to reform health care.

But he has also been close to state health policy. From 2000 to 2004 he chaired the state's "Government/Legislative Health Care Task Force," called the "Blue Ribbon Commission," that brought together all state health care stakeholders to look closely at state health policy. He was consulted by all parties in the run-up to chapter 224.

Altman has been a long-time friend of HCFA, and understands the role consumers must play as we reform health care delivery and payment structures. In an interview with WBUR's Commonhealth blog, he emphasized the need for consumer involvement and patient education:

... I think patients need to be part of this equation and we need to be balancing their needs with the people that pay the bills, so that’s one side.

...I don’t think patients really understand these limited networks and tiered networks and ACOs and the like. I think there needs to be an expanded consumer education program. Also I think we need to do it smarter and I think tiered networks that are a better model than limited networks, in the sense that you don’t force a patient into any one delivery system, you just make it more expensive if they jump out of one to the other, which continues to gives them the choice. What happened in the ‘90s is that often they had no choice, they had to be at a particular network and they couldn’t jump out.

So I think we’ve learned something in the last 20 years. If we’re going to ask organizations to have responsibility for total spending of a particular patient population, [the patients] need to know they’re in a particular group, but they also need to have the flexibility if for some reason they want to get out. I think we need to better educate our consumers and patients, but I think we’ve also learned from the ‘90s, so I’m hopeful.

We welcome Altman's appointment. The other 10 members of the HPC Board should be appointed in the next few weeks, leading up to their inaugural meeting on November 16 (Gardner Auditorium, 9:30 to noon; other details will be posted on the state's Chapter 224 implementation website).
-Brian Rosman
(Full Disclosure: I worked for Altman at Brandeis from 1998-2003)