January 2013

January 31, 2013

Today, the Health Policy Commission’s subcommittee on Care Delivery and Payment System Reform met for the first time.  Present at the meeting were David Cutler, Marylou Sudders, Jean Yang, Carole Allen (by telephone), and David Seltz.  Wendy Everett was present as a guest.  Sudders facilitated the meeting.

The first order of business was to elect a Subcommittee chair.  Allen was nominated and unanimously approved.  Sudders continued to facilitate the meeting since Allen could not be physically present.  Sudders noted the five overarching responsibilities of the subcommittee:

  1. Establish a provider organization registration program
  2. Develop and implement standards for a certification program of Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) and develop model payment standards to support PCMHs.
  3. Administer a competitive grant program to foster the development and evaluation of innovative health care delivery, payment models and quality of care measures.
  4. Coordinate with public and private payers regarding the advancement, adoption and measurement of alternative payment methodologies.
  5. Coordinate with the Division of Insurance regarding the development of regulations related to the certification of risk-bearing provider organizations.

Next, David Seltz was asked to go over some pressing deliverables.  He said that this subcommittee would be guided by several overarching principles.  They are charged with moving away from fee for service and toward methods that support value, quality, are patient-centered, and integrate mental health.  One timely item Seltz noted was the development of regulations related to the certification of risk-bearing provider organizations.  DOI has already started this process but provider orgs will need to register with the HPC.  This subcommittee needs to contemplate what information it would like to collect from provider orgs and coordinate with other state agencies to develop a registration program.

Yang would like to spend time at the next meeting to fully define “risk bearing provider organizations.”  Cutler said he would like to focus on responsibilities 3 and 4 (noted above) and set up joint working groups to coordinate with other government agencies and would like to form working groups with the provider and insurance communities to develop common standards helpful to everyone’s goals.  Everett suggested that a senior analyst make a list of all public and private certification requirements.  Seltz noted that some of this information has already been collected by DOI.  Seltz said that the HPC must set standards for patient centered medical homes by January 1, 2014.  By July 1, 2012, the Office of Medicaid must set up a training program for PCMHs and HPC must develop a payment system for PCMHs.  Sudders noted that NCQA standards would provide a good starting point for PCMHs standards and that she would like to see different stakeholders define what “integration” means to them.

Seltz announced that the HPC is now staffed by four people and that he would introduce them at the next full HPC meeting.  Cutler would like to set up an internal process for creating standards.  Seltz agreed that this was a good idea, given that the January 1, 2014 deadline was fast approaching.  Seltz also intends to look outside the HPC to different experts for guidance on this matter.  Moving to responsibility 3 (noted above), Seltz said that HPC will have money for a grants when the first gaming license is sold.  He wants to create a grant distribution system In anticipation of this money so that HPC can hit the ground running.

Setting up agenda items for the next meeting: Cutler wants to create a timeline for the subcommittee and Yang wants some concrete steps added to the timeline.  Sudder noted that all future agenda items would have to be coordinated with the new chair—Allen.

Lastly, the floor was opened for public comment.  A consumer and patient representative commented that the subcommittee should coordinate with consumers and integrate consumers into decisions.  A representative from MAHP suggested that the subcommittee review alternative payment methodologies with CHIA.  A representative from Atrius Health suggested that, in advance of listening sessions with stakeholders, the subcommittee should send out specific questions.  A Partners Health representative suggested that the subcommittee form an advisory council to get information that subcommittee needs.  The Atrius Health representative added that the subcommittee should reach out to different organizations and actively inform them of developments.  Cutler suggested that she and other people send in lists of organizations to David Seltz for the subcommittee to contact.    An MHA representative suggested that the subcommittee use their website to clarify regulations, like through FAQs.
-Jessica Sanchez


January 29, 2013

Oral Health Advocacy Task ForceToday’s Boston Globe features a piece on the 31 licensed public health dental hygienists in the Commonwealth. Longtime readers of this blog know that oral health is inextricable for overall health. They also know that despite a large body of evidence pointing to a multitude of costly and complex health issues related to poor oral health, access to dental care remains an issue.

Chapter 530 of the Acts of 2008 was the result of a successful collaboration between Health Care For All, the Oral Health Advocacy Taskforce, the Massachusetts Dental Hygienists Association, and the Massachusetts Dental Society, along with the leadership of the Legislative Oral Health Caucus chaired by Representative Scibak and Senator Chandler.

A key component of Chapter 530 established a new role in the dental delivery system: the public health dental hygienist. The bill expanded access to dental care by allowing dental hygienists – in collaborative agreements with dentists – to provide care in health centers, schools, nursing homes, and other public health settings. Preventive services are the real foundation of good oral health and have long-term cost savings benefits for the Commonwealth. Hygienists have long been a bulwark of prevention, and Chapter 530 solidified their role.

According to today’s article, the US Health Resources and Services Administration estimated that in 2012 nearly 350,000 individuals in the Commonwealth were underserved when it came to dental care.  The Globe spoke with Dr. Brent Martin, MassHealth dental director,

“In the last state fiscal year, the hygienists served about 6,900 children. While that’s a help, he said, there’s plenty of room for the program to grow. “

The article also highlights the great work of longtime Oral Health Advocacy Taskforce members Dr. Mark Doherty and Kathy Eklund.

Health Care For All looks forward to the continued growth of the public health dental hygienist program as time goes on. Common sense solutions like this, paired with restoring MassHealth adult dental benefits, will go a long way in protecting the overall health of Massachusetts.
-Courtney Chelo


January 28, 2013
Representative Thomas P. Conroy talks with HCFA staff members. Representative Thomas P. Conroy talks with HCFA staff members.


Last Thursday, Health Care for All hosted its bi-annual legislative cosponsorship fair for the new session on Beacon Hill. HCFA invited senators, representatives, and their staff to engage HCFA policy staff in a dialogue about our legislative priorities this session (here's the list (pdf)). Legislators visited tables where they could learn about recent developments and our proposals in health reform, children’s health, prescription reform, oral health, and private insurance. Legislators could then agree to cosponsoring our bills in these fields. Representatives from HCFA’s Helpline were also available to inform legislators about the help they could provide to constituents. The event proved a success, with a steady stream of senators, representatives and their staffers engaging with HCFA staff. Representative Sanchez, who sponsored the event, began with praise both of the event and HCFA itself (specifically noting the utility of the Helpline), and encouraged attendees to spend time talking with HCFA staff. They took his advice: the room was lively for two hours with passionate conversation about policy. Both legislators and their staff found a great opportunity for an education on over fifteen upcoming legislative proposals, and by the end of the event many in attendance had put their names down as cosponsors. -Devon Branin

January 24, 2013

Budget Header from state website

Governor Patrick released his Fiscal Year 2014 budget proposal today, which continues this administration’s strong commitment to ensuring access to affordable, quality health care for everyone in Massachusetts.

Budgets have both a revenue side and a spending side. This budget uses both to improve the health of the Commonwealth and reduce health spending growth.

The targeted revenue includes a long-overdue increase in the tax on cigarettes and other tobacco products, which will reduce the use of tobacco and swiftly bring improved health results. Making our tax system more fair (by simultaneously increasing income taxes, cutting many corporate tax expenditures, reducing the sales tax and increasing the personal exemption) will reduce the tax burden on lowest-income residents, which will directly improve their health.

This revenue supports new spending targeted at restoring vital health benefits, like adult dental benefits for MassHealth members, repairing some of the damage done to our public health system, and beginning the process of implementing the delivery system transformations required to bring down health costs.

Of course, one can’t have the spending without the revenue. As the legislature considers this budget, every revenue increase they scale back or reject will lead to corresponding cuts in services.

And for subsidized health care, this budget is actually two budgets in one, as it straddles two very different health care systems. The fiscal year starts on July 1, but on January 1, the coverage programs of the federal Affordable Care Act (ACA) begin. So the second half of the fiscal year will bring a complete transformation of subsidized coverage programs. Gone will be Commonwealth Care, the Medical Security Program, and the Insurance Partnership. MassHealth expands, and the Connector covers more people than ever. The ACA also brings Massachusetts a healthy infusion of new federal funds that will allow the state to continue to provide the affordability protections for low-income people.

The online budget is in a new format, yet again, and very frustrating to navigate (here’s the utterly impenetrable user guide). It’s so bad that web pages with line item language mysteriously expire if one looks away for too long. In addition to line items, there’s a roll-up organized by function, which, alas, does not include a cross-walk to the line items. The summary for health coverage programs is here. Fortunately, most of the health care initiatives are described in prose, in a clear, detailed budget brief, here. Here are some of our highlights:

January 22, 2013

Blog For Choice Day 2012Today marks the 40th the anniversary of Roe v. Wade, the Supreme Court’s landmark ruling that legalized abortion nationwide. As I reflect on what that means for me personally and for women across the country, I am struck that even in a state like Massachusetts, where we tout ourselves as national leaders in health care access, there is still much work to be done.

But first, to highlight some of the positive -- we are unquestionably fortunate that when compared to other states, Massachusetts policies in large part support the availability and accessibility of abortion services. For example, Massachusetts does not fall under the category of states increasingly hostile to abortion rights, where women may find it more difficult to access abortion services due to recent passage of more restrictions, such as mandatory waiting periods and ultrasounds of the fetus. Massachusetts further doesn’t restrict coverage of abortion in private or public insurance plans. And in a recent victory, a federal appeals court upheld the state’s buffer zone law, which creates a 35-foot fixed buffer zone around the driveways and entrances of Massachusetts abortion clinics.

Despite these protections, abortion remains a highly charged political issue, both nationwide and in our state; and access to abortion, as well as family planning and comprehensive evidence-based sexuality education, is far from a reality for many Massachusetts residents.

According to a report from NARAL Pro-Choice Massachusetts, Massachusetts has experienced an overall decline in abortion providers in both clinics and hospitals in recent years, while regional disparities in access to abortion care are growing with the majority of providers concentrated in the metro Boston area. Beyond the numbers and geographic distribution, factors such as age, income level, stage of the pregnancy, and availability of culturally and linguistically competent care create obstacles to obtaining abortion care.

I was also shocked to learn recently that Massachusetts still has antiquated laws on the books which ban all abortions without exception; require that abortions after the twelfth week of pregnancy be performed in hospital as opposed to other clinical setting; and outlaw birth control for unmarried couples. While these laws are superseded by Roe v. Wade and other Supreme Court rulings, if these rulings were ever overturned, women in Massachusetts could face serious barriers to safe, legal abortion care and family planning. That’s some pretty scary stuff. There is pending legislation to repeal these three provisions.
Moreover, as Massachusetts shifts its health care policy agenda from access to issues of quality and cost, the conversation around reproductive health care will need to continue in a different arena. Under Chapter 224, the new state law to promote health care quality and curb rising health care costs, provider organizations are encouraged to become certified as Accountable Care Organizations (ACOs). Standards for ACOs may include ensuring patient access to health care services across the care continuum. While ACOs have the potential to improve access to care, enhance coordination and integration of care, and improve quality and outcomes, ACOs may also restrict patient choice of providers through limited networks. We will have to watch closely to ensure that patients who receive care from ACOs are able to access the full range of reproductive and sexual health services, including comprehensive family planning services, sexually transmitted infection diagnosis, treatment and counseling, and abortion services, including non-hospital based care.

So back to what the 40th anniversary of Roe v. Wade means to me.  I am disheartened that even after 40 years, the topic of abortion continues to be a highly politically charged and divisive part of public policy debates on the state and national levels. I feel fortunate to live in a state like Massachusetts which has been consistently supportive of abortion rights, particularly in light of increasing restrictions in other states over recent years. Yet I know that even in our state, the work to ensure that all health care policies reflect women’s self-determination and full control over our reproductive health is far from finished.
-Alyssa R. Vangeli

January 17, 2013

HPC Twitter Feed

The Health Policy Commission convened for the third time yesterday (1/16/13), in a packed room atop 1 Ashburton. The Commission is still mainly in the getting-up-and-running-stage, and discussion focused mostly on the Board’s responsibility to regulate the maximum cost growth level for health care costs in the Commonwealth. Executive Director David Seltz is still the sole staffer, alone in an office suit, and he only figured out his phone number a day earlier. But their Twitter account is up, at @Mass_HPC.

The place will be jumping soon. Materials from the meeting are here, and our full report is below the fold.

January 12, 2013

Yesterday was the first Connector Board meeting with the Health Connector’s new Executive Director, Jean Yang, and with the previous Executive Director, Glen Shor, chairing the meeting in his new role as Secretary of the Executive Office of Administration & Finance (ANF).  Before diving into the substance of the meeting, there was a lovely send-off for outgoing ANF Secretary Jay Gonzalez, as well as recognition to Shor for his work at the Connector and Jean for stepping up to lead the Health Connector. We join the entire Chapter 58 community in thanking Jay for his outstanding stewardship of health care reform, and wish him well.

Materials from the meeting are here. Read on for our full report.

January 11, 2013
US Map Showing State Grades on Dental Sealants How Are States Doing On Providing Dental Sealants

The Pew Center recently released a report on dental sealants across the country, grading each state (and D.C.) on its performance in providing sealants. The grades failed to impress: only 5 states (Alaska, Maine, New Hampshire, North Dakota, and Wisconsin) received the top grade of an “A,” and 20 states received either a “D” or an “F.”

The center awarded its highest grades to states which provided dental sealants in over 75% of high-risk schools with minimal restrictions. Forty states, as well as Washington, D.C., were unable to confirm that 50% of children had received sealants – a minimum standard set by the federally sponsored Healthy People program. And rules still persist in many states that require an examination by a dentist before children can receive sealants from a hygienist, a step that has been deemed unnecessary by research.

Massachusetts received a “B” under the metric. Although over 50% of high-risk schools in the state now have sealant programs, the state has not yet reached the 75% standard, and some unnecessary restrictions still remain in place.

This is an important reminder that we have a way to go before we can declare victory on dental disease. We have solutions to prevent this disease; yet more than one in four MA children enters school with a history of dental decay. By approaching this issue with community and state-wide solutions – providing access to screenings, fluoride, and of course sealants (which can reduce tooth decay more than 70 percent (PDF))– we can eliminate dental disease and give our children the healthy childhood that they deserve.

 -Devon Branin

January 10, 2013

On Tuesday, Governor Patrick announced his second business-related legislative proposal of the 2013-2014 session (see press release). The proposal is part of the process of adapting Massachusetts' health care system to the coming Affordable Care Act (ACA).

In addition to freezing Unemployment Insurance (UI) rates for businesses, HD 162, “An Act to Support Employers in the Commonwealth” makes several changes that impact workers’ access to health coverage:

  • Repealing the Employer Fair Share Contribution (FSC) program as of June 30, 2013.

    Chapter 58 was built on the foundation of shared responsibility. The law relies on contributions from all stakeholders, including individuals, government, insurers, providers and employers.  Currently, the FSC program requires employers with 11 or more full-time equivalent employees to provide coverage to their workers or pay an assessment of up to $295 per worker per year.  In July, the minimum number of employees to be exempt from the assessment is slated to increase to 20 workers and employees who have coverage through other sources would not be counted in the calculation.  The Affordable Care Act (ACA) employer responsibility requirements – which apply to firms with 50 or more full time employees – take effect January 1, 2014.

  • Eliminating the Medical Security Program (MSP) as of January 1, 2014.

    Established in 1988, MSP covers workers collecting unemployment insurance either through direct coverage or COBRA premium assistance.  The program has undergone several changes over the years and has been an important lifeline during the recent recession.  The state seeks to streamline coverage options through implementation of the ACA.  Most workers eligible for MSP will be able to access coverage through MassHealth or the Connector as of January 1st.

  • Creates the employer responsibility contribution trust fund.

    The Governor’s proposal maintains the current MSP assessment, at a slightly lower rate, and under a new name.  Revenue from the employer responsibility contribution will be directed to MassHealth and the Connector to fund subsidized coverage for low-income residents.  Funding from the employer responsibility trust fund is necessary to ensure we do not backtrack on the gains we have made in offering affordable, quality health care to Massachusetts residents.

We have long believed in the principle of employer responsibility. The Fair Share Contribution surely played a role in increasing the proportion of employers in Massachusetts who offer health care coverage to their workers. While offer rates declined in other states, ours went up in 2007 and stayed high though the recession. We were pleased that Massachusetts provided the blueprint for the ACA, even though the details differ substantially, including for the employer requirements.

So we understand the need to reexamine our policy, and we support the administration's determination to continue substantial employer responsibility for health care in Massachusetts. We look forward to working with the Administration and the Legislature on the details of this bill and plan to monitor the impact of these policy changes on Massachusetts consumers.
-Suzanne Curry

January 10, 2013

The Public Health Council at the Massachusetts Department of Public Health today voted in favor of an emergency regulation to enact a tax credit incentive for small businesses which create wellness plans for their employees. In encouraging preventative health measures within the workplace, the initiative promises savings to premiums, overall savings in costs, as well as “softer” savings in areas such as motivation and productivity.

The tax credit could cover 25% of the costs of wellness programs for smaller businesses (those with less than 500 employees) with a maximum of $10,000 per tax year. An annual cap of $15 million would be placed on the incentive, and businesses would be granted the tax credit on a first-come, first-serve basis, although a “two-track” system would be implemented to grant preference to businesses with less than 100 employees. The Department of Public Health is granted the ability to certify the programs of individual businesses, a certification dependent on a plan’s fulfillment of certain criteria:

  • Grounding of the wellness program within the workplace
  • Evidence-based activities
  • Alignment with Department of Public Health research
  • Educational and screening components
  • Individualized approach based on health risk assessment of workforce
  • Promotion of both physical and mental health, including behavior change measures, such as assistance with quitting smoking
  • Provision of a healthy working environment
  • Addressing of most prevalent and preventable conditions in respect to the workplace

The incentive program should encourage employers to tailor individualized plans which meet the specific needs of their employees. Employers will be provided with a checklist of suggested ways to fulfill each part of the requirements, and a guidance document should be made available for employers in the coming weeks.

It's not clear how successful the program will be. Indiana is the only other state with a tax incentive, and just 114 business applied for the credit there. Council member Meredith Rosenthal, a Harvard School of Public Health researcher, also noted that there is not strong evidence that employer wellness programs save money.

The Department of Public Health will hold public hearings regarding the initiative in February, and a final vote will be held mid-April.
-Devon Branin