February 2013

February 28, 2013

The Mass Nonprofit Network is starting a series of forums this week to look at the state budget and the need for new revenue. The first forum is in Westborough for the Metrowest and central regions, and will be held this Friday. Other forums will be in Boston, Easton, Northampton, and Lowell over the next two weeks.

The discussion will look at how budget cuts have resulted in the inability to meet our state’s critical needs; discuss ways nonprofit groups can be effective spokespeople for our constituents; and strategize on how to mobilize the nonprofit community around progressive revenue reform. These issues are critical for health care if we are to reverse the deep cuts made in the past decade to public health and other health needs, and make needed investments in improving our health.

Health Care For All is among the many groups sponsoring the forums, and we hope interested people will attend. For more information, check out the MNN web site.

February 25, 2013

State taxpayers spent about $760 million for health benefits for workers of large firmsillon

Friday afternoon, the Center For Health Information and Analysis (CHIA) quietly released their annual “Employers Who Had Fifty Or More Employees Using MassHealth, Commonwealth Care, or the Health Safety Net in State Fiscal Year 2010” report, also known as the “50+” report. This annual release, mandated by HCFA-led legislation from 2004, provides information on the number of workers in large firms enrolled in state-sponsored health coverage in FY10, as well as the state’s costs in providing for these workers.

Some key findings:

  • Taypayers spent $759,874,192 in FY10 on public health benefits for 361,725 employees of large firms
    • 264,790 employees in MassHealth, with a cost of $567,355,304 (75% of the total cost)
    • 79,014 employees in Commonwealth Care, with a cost of $142,243,749 (19%)
    • 53,325 employees in the Health Safety Net, with a cost of $50,275,073 (7%)
  • 1,548 employers in the state had over 50 employees on public health programs

These figures represent a reduction in publicly-covered employees from FY09, but a change in methodology complicates this comparison – the report no longer considers self-reported data from employees, and instead compares data from these public programs and DOR wage information.  And while this represents a significant reduction in the number of employees (from 532,155 in FY09, a 32% reduction), the change was not proportionate with the change in cost from these employees (from $793,700,000 in 2009, only a 4.3% reduction.) The number of employers with over 50 employees in these programs has also remained stable, with 1,553 employers appearing on the list in 2009.

The top employers with workers getting public benefits are the Commonwealth, Stop and Shop, Walmart and Target

The other change is that this year the Commonwealth takes first place, with 6,128 employees using public health benefits. As we said years ago, no one can call the Commonwealth stingy on employee benefits. Yet a huge number of full or near-full time employees categorized as “contracters” and are denied benefits. We repeat our call that the report should be a wakeup call to Massachusetts state government to look at its own practices and make appropriate changes.

The report emphasizes that Massachusetts is still a leader in employer-provided health benefits, with 77% of all employers offering health insurance and 97% percent of firms with over 50 employees offering benefits. But to the 5,254 Stop and Shop, 4,327 Wal-Mart employees, and the 2,610 Target employees, this probably isn’t much consolation.

The Patrick administration has proposed repeal of the state's employer fair share law, which is scheduled to cover firms with 21 or more workers effective July 1. Under the federal ACA, firms with 50 or more workers will be subject to federal requirements beginning in 2014. This report demonstrates the critical need to continue to set a norm that firms are expected to cover their workers. The huge bill Massachusetts and federal taxpayers shoulder to cover workers of very profitable large companies is a scandal.

We couldn't help notice that the report was released at around 4:00 pm on the Friday of vacation week. We learned almost everything we know about how government works from The West Wing, as we're sure you did too. So we remember their first season episode, Take Out the Trash Day, where the White House releases a pile of information on a Friday to reduce attention (you can refresh your memory with this clip).

Was this taking out the trash?

There is no press release, and no mention of the report on the CHIA homepage. The report is long overdue, too. It covers fiscal year 2010. The last one, for fiscal 2009, came out in June 2010 (our coverage), 11 months after the end of the year. The fiscal 2008 report came out in April 2009, 9 months after. But it took 31 months to release this report.

We hope CHIA acts more efficiently in getting required reports out (see our comment from 2 weeks ago). We look forward to their new role in opening up the window on Massachusetts health care.
 -Devon Branin and Brian Rosman

February 22, 2013

MMPI-MassBudget-MLRI logos

How does one follow the complex state budget process?

As they did last year, the Massachusetts Medicaid Policy Institute (MMPI) will be issuing budget summaries produced by the Massachusetts Budget and Policy Center in partnership with the Massachusetts Law Reform Institute. The briefs look at the health care coverage budget, focusing on MassHealth (Medicaid) and other subsidized health coverage programs.

The first brief for fiscal year 2014 (pdf) was released today, looking at the Governor's House 1 budget proposal (our summary is here). The budget includes the changes stemming from implementation of the subsidized coverage programs in the ACA starting in January 2014. All the numbers are here, showing the anticipated increase in MassHealth spending as people move from Commonwealth Care and other programs into MassHealth.

The brief makes clear the interrelationship of the health spending plan and the broader revenue proposal:

The projected health care spending is part of a larger state budget proposal, and the administration has indicated that its ability to reinvest new federal dollars received under ACA implementation in health care, rather than diverting them for other budgetary uses, depends on approval of other aspects of the proposed budget, including a plan to raise new revenues through a variety of tax reforms. The House 1 health spending proposal also relies on approval of a plan to modify and repurpose an existing employer assessment currently used to fund a separate health coverage program and use the revenue to provide general support for subsidized health coverage available through MassHealth and the Commonwealth Health Insurance Connector.

These briefs are invaluable, and we highly recommend them to anyone seeking to understand the Massachusetts budget. Future editions will follow the budget process as it winds its way through the House, then the Senate, and finally to the Governor this summer.
-Brian Rosman

February 22, 2013

Massachusetts Sites Participating in Federal Health Innovation

The federal CMS announced today that Massachusetts is one of 6 states awarded a State Innovation Models initiative grant (press release, and grant information). The Massachusetts award is for a not shabby $44 million.

The grant program is part of the broader Center for Medicare and Medicaid Innovation, authorized as part of the ACA. They are supporting new health care payment and delivery models, evaluating results and advancing best practices. Click on the map above to see all of the projects they are supporting in Massachusetts.

These Massachusetts funds will support payment reform and the implementation of chapter 224:

In the Massachusetts model, primary care practices will be supported as they transform themselves into patient-centered medical homes—capable of assuming accountability for cost and offering care coordination, care management, enhanced access to primary care, coordination with community and public health resources, and population health management. The Massachusetts model will strengthen primary care through shared savings/shared risk payments with quality incentives based on a statewide set of quality metrics, as well as payments to support practice transformation.

This award will be used to support public and private payers in transitioning to the specified model; to enhance data infrastructure for care coordination and accountability; to advance a statewide quality strategy; to integrate primary care with public health and other services; and to create measures and processes for evaluating and disseminating best practices.

-Brian Rosman

UPDATE: The Patrick administration forwarded this release:


Funding builds on Massachusetts nation leading health care reform efforts; supports move from fee-for-service towards integrated care systems

BOSTON – Thursday, February 21, 2013 – Governor Deval Patrick today announced that Massachusetts has been awarded more than $44 million from the federal Centers for Medicare & Medicaid Services (CMS) to advance the Commonwealth’s nation leading health care cost containment efforts.

“In Massachusetts we believe that access to quality, affordable health care is a public good,” said Governor Patrick. “This funding will assist us in implementing the next phase of health care reform to provide better care, better health and lower costs.”

The award will further the Commonwealth’s efforts to transform its health care delivery system by moving the market away from fee-for-service payments and towards a system capable of delivering better health care and better value for all residents of the Commonwealth. This announcement also builds on Massachusetts’ record of health care innovation and multi-stakeholder engagement, its trailblazing work to expand coverage, and recent legislation that commits the Commonwealth and all of its payers and providers to an ambitious transformation of the health care delivery system.

“We thank CMS for recognizing the Patrick-Murray Administration’s dedication to health care cost containment,” said Health and Human Services Secretary John Polanowicz. “This award will advance our efforts to achieve billions in health care savings for governments, businesses and families.”

Massachusetts was one of six states to receive such funding under the Affordable Care Act’s State Innovation Models Initiative. The $44,011,924 award will be used to:

February 20, 2013

[vimeo http://vimeo.com/59602758]

Last week, the University of Michigan’s Center for Healthcare Research and Transformation brought together key business leaders from Massachusetts and Michigan and experts from the University of Michigan to explore lessons from Massachusetts' experience with health reform and what may be ahead as the Affordable Care Act is implemented in Michigan.

Rick Lord, President of Associated Industries of Massachusetts, and Michael Widmer, President of Mass Taxpayers Foundation, discussed how Chapter 58, Massachusetts' health reform legislation of 2006, was enacted and implemented with strong support and engagement from the business community. Over 300 people attended the forum with the audience engaging in a lively discussion of health reform in Michigan. The event was sponsored by our partners at Community Catalyst with the support of the Robert Wood Johnson Foundation.

Michigan announced today that they will build a "partnership" exchange in conjunction with the federal government. Republican Governor Rick Snyder is trying now to convince a Republican-led legislature to appropriate funds to support their exchange. The business community is key participants in this decision, and hearing from Massachusetts leaders surely was helpful.

February 15, 2013

The Health Connector is holding steady as they prepare for full implementation of the Affordable Care Act (ACA). Yesterday, the Connector Board voted on the draft 2013 Affordability Schedule, approved plans for the FY2014 Commonwealth Care renewal, and officially launched the 2014 Seal of Approval process.

Materials from the meeting are here, and our detailed report is after the break.

February 12, 2013

Last September we wrote about the crisis of uninsured veterans. A national study we helped with found that 1 in 10 veterans are uninsured (for more statistics, see this amazing graphic, excerpted below):

1 in 10 Veterans are uninsured

This was brought home today in an article in Esquire profiling the Navy Seal who shot Osama Bin Laden. Once leaving the service, he became ineligible for government-provided insurance:

 "I left SEALs on Friday," he said the next time I saw him. It was a little more than thirty-six months before the official retirement requirement of twenty years of service. "My health care for me and my family stopped at midnight Friday night. I asked if there was some transition from my Tricare to Blue Cross Blue Shield. They said no. You're out of the service, your coverage is over. Thanks for your sixteen years. Go <expletive> yourself."

The government does provide 180 days of transitional health-care benefits, but the Shooter is eligible only if he agrees to remain on active duty "in a support role," or become a reservist. Either way, his life would not be his own. Instead, he'll buy private insurance for $486 a month, but some treatments that relieve his wartime pains, like $120 for weekly chiropractic care, are out-of-pocket. Like many vets, he will have to wait at least eight months to have his disability claims adjudicated. Or even longer. The average wait time nationally is more than nine months, according to the Center for Investigative Reporting.

For us, there’s some good news. The study found that Massachusetts has the lowest uninsurance rate among veterans, at 4.3%. Our state Veterans Affairs office has launched a very user friendly website and created outreach programs to ensure that veterans are aware of their benefits and can get assistance navigating a system that is often overwhelming.

If the shooter (who is anonymous in the story, and doesn’t reveal where he lives) were in Massachusetts, he would be eligible for our affordable insurance options. Once the ACA kicks in nationally in 2014, he will likely be able to get federal assistance with his health costs.

Still, there is much more to do, both as a state and nation. The deficiencies in our mental health system, the holes in our public health infrastructure, and the vagaries of coverage will cost us both dollars and human life.

If you would like to join us or learn more about veteran’s benefits or want to get involved with our work on behalf of veterans and families, contact Paul at pwilliams@hcfama.org.
-Paul Williams

(UPDATE: A companion story by the Center for Investigative Journalism adds more details:

The Navy SEAL who says he killed Osama bin Laden is unemployed and waiting for disability benefits from the Department of Veterans Affairs. ...

But perhaps the Shooter’s most explosive revelation is that nearly six months after leaving the military, he feels abandoned by the government. Physically aching and psychologically wrecked after hundreds of combat missions, he left the military a few years short of the retirement requirement with no pension and no job. ...

Like 820,000 other veterans, the Shooter has a disability claim that is stuck in a seemingly interminable backlog at the VA, where the average wait time currently exceeds nine months, based on the agency’s own data.

The VA offers five years of virtually free health care for every veteran honorably discharged after serving in Iraq and Afghanistan, even when he or she leaves the military early. But the Shooter told Bronstein that none of the counselors who came to SEAL Command told him that. That coverage also would not extend to his family.

“Families aren’t being cared for,” said Barbara Cohoon, deputy director of government relations for the National Military Family Association.

Her group, based in Virginia, is expected to testify Wednesday before the House Veterans’ Affairs Committee to push for increased access to health care, particularly mental health services, for military families.

“Oftentimes, they lose their support systems the moment a service member leaves the military,” she said.

Nationwide, VA documents show that nearly 681,000 Iraq and Afghanistan veterans discharged from the military have not sought health care from the VA. According to a study last year from the Urban Institute, 291,000 are uninsured – with neither private health insurance nor VA coverage.

The Shooter says his disability claim is less about the money it would provide than the right to free health care it would bring. While the VA now provides five years of virtually free health care to all honorably discharged Iraq and Afghanistan veterans, they can face bureaucratic nightmares later on if their conditions are not deemed service-connected. ...

Even more reason to let vets know about the Mass Vets Advisor website, at www.massvetsadvisor.org.

February 8, 2013

As you hunker down for the storm, it’s a good time to catch up with some new health data falling down on us. The Center For Health Information and Analysis (CHIA, née DHCFP) issued its Massachusetts Health Insurance Survey and Massachusetts Employer Survey this week. The report combines data from two surveys. The household survey was completed by over 4000 families, and includes cell-phone only households, and Spanish and Portuguese questionnaires in addition to an English survey. The employer survey is based on responses from 749 firms with at least 3 employees.

The Health Insurance Survey shows that Massachusetts continues to have by far the highest insurance coverage rate in the country, with 97% of all residents having coverage. Although the rate fluctuates, the rate of coverage has been essentially statistically unchanged since 2008. The uninsurance rate is higher for Hispanics, 6%, is double the rate for whites. Uninsurance is also higher among low-income residents, with 7% of those under 150% of the poverty level uninsured.

Uninsurance rates by race - ethnicity 2011

There was a statically significant increase in the uninsurance rate among children, rising from around .2% to 1.9%. We always viewed the 2010 finding of 99.8% coverage for kids to be a statistical fluke. The rate increased the most among low-income kids, leading us to think that the increased uninsurance might also reflect the reduction in MassHealth enrollment staff, which worsened in 2011. MassHealth covers over 550,000 kids, and delays in processing forms has led to increasing churn of coverage.

The report also looks at access to care, with nearly all residents (91%) reporting a usual source of care, and 88% a doctor visit in the past year. The proportion of residents reporting difficulty in obtaining care in the past year stayed at 22% like last year, as was the percent in families with problems paying medical bills, at 18%.

Employer offer rates by firm size 2011

The report also looks at employers. The offer rate among employers remains high, and continues to exceed national offer rates.

Employer offer rates - comparison of MA and US 2005 and 2011

We’re pleased to see CHIA begin to release some of its pent-up data. The insurance survey report, released last week, is based on a household field work that was conducted in summer 2011. Previously, data was compiled much quicker. While this latest report is coming out 16 months after the survey, the 2010 report was released just 6 months following the survey.

The state also used to release a valuable quarterly “Key Indicators” report, presenting a snapshot of state health data. Those reports ended in May 2011, and were supposed to be replaced with less-detailed “Quarterly Enrollment Updates.” But those stopped after one much-delayed report. The March 2011 quarterly update didn’t come out until February 2012, and the June 2011 report has been listed as “available shortly” for over a year.

Other reports required by statute have just not been produced. The last report on employers with over 50 workers using state benefit programs is from 2009. Again, for a year the website has stated that the 2010 report will be available shortly.

As a result, some have charged that the delay in data reporting is an attempt to hide bad news from public scrutiny. While we don't think so, we hope that the new more independent, configuration of CHIA leads to more timely and complete reporting of health data that the public and policymakers depend on.
-Brian Rosman


February 7, 2013

Chart: Lower costs among patients with higher patient activation scores

Are you an “activated” patient?  A new study suggests that involving patients more deeply in their treatment decisions – an approach known as “patient activation” – is correlated with lower costs and better outcomes. Researchers considered data from a Minnesota healthcare system which encompassed over 33,000 patients, looking at impatient, outpatient, laboratory, and patient costs. The researchers then contrasted these costs with a measure of patient activation, which they derived from questionnaires about patient confidence in their doctors: for example, patients were asked to agree or disagree if they were "confident that [they] can tell a doctor [their] concerns, even when he or she does not ask."

These comparisons revealed that the least activated patients had costs which were 8 percent higher than those with the highest activation scores. These differences increased when considering patients with chronic conditions: a 12 percent difference for those with high cholesterol, and a 21 percent difference for patients dealing with asthma. In the 2011 study, which only considered outpatient care and laboratory work, researchers observed non-activated patients paying costs 21 percent higher than activated patients.

Chapter 224 includes a number of provisions to promote measuring, and acting on, patient engagement. The ACO and medical home certification standards in the law include provisions on shared decision-making, home-based patient activation, end-of-life decision supports, and community based public health interventions that include social determinants of health. We strongly support using patient engagement and confidence measures as a key quality indicator and basis for payment.

Efforts to involve patients in their own care are nothing new, but these arguments have generally been framed in an ethical sense. This new study adds a fiscal incentive for patient activation, which could be a strong motivator for providers to jump on board. The authors of the study suggest monitoring patient activation, using that data to provide support those patients who are less willing or able to make decisions about their care. In any case, these new findings offer the opportunity for new perspectives on treatment and provider-patient interaction, and provide new incentives to try a patient-centered approach.
-Devon Branin