March 2013

March 29, 2013

Boston without Mayor Menino at the helm?  Nearly impossible to imagine!  He's been Mayor for most of Health Care For All's history and he's been a terrific friend as he has made Boston healthier, safer and ready for success in the complicated 21st century.  Our Mr. Mayor is a determined champion of the underdog – which is clearly part of the attraction for HCFA and this political leader.  As we focus on creating a health care system that provides care for everyone, particularly the most vulnerable among us, Mayor Menino is in the streets talking with under-served people, listening to their challenges and helping shape city policies that make lives better.

The Mayor attracted wonderfully talented people to work with him and has been a champion of public health. For example, he endorsed the politically controversial, but clinically effective, needle exchanges that saved lives by preventing the spread of HIV infections among injection drug users. More recently, he decided to combat the thorny and complicated obesity epidemic by setting the outrageously ambitious goal of having Boston shed 1 million pounds.  To get us all moving in the right healthy direction, he founded Boston Moves For Health, which challenges all of us to improve our health through exercise like walking or playing more.  Because of Mayor Menino's leadership Health Care For All has 83% of our workforce enrolled in the Boston Moves program and just today we all participated in an hour of recess out on the Common.  Thanks, Mr. Mayor, for the first real recess most of us have experienced in years! We learned more about how exercise can improve our children's health, social skills, and provide a chance at a better education!

We are completely excited to see what our Mayor can accomplish in the next nine months, and we stand ready to support him.  Between now and the end of his remarkable public tenure, it will be Health Care For All's privilege and pleasure to honor the enduring legacy and wonderful work of Mayor Menino.  Please plan to join us at For The People on April 10th, where we will give Mayor Menino our Distinguished Leadership Award.  It will be wonderful to thank and pay tribute to the work of our friend and committed public servant.

--Amy Whitcomb Slemmer
Executive Director, HCFA

March 28, 2013

Anyone who has spent time in a hospital knows how much of a difference compassion and support from caregivers can make. Ken Schwartz, a Boston healthcare attorney who died at 40 after a struggle with lung cancer, believed in the central importance of compassionate caregivers, identifying their care as what made “the unbearable bearable.” Schwartz founded the Schwartz Center for Compassionate Healthcare in 1995 to ensure that such care remained a critical part of the healthcare system.

Since 1999, the Center has awarded the Schwartz Center Compassionate Caregiver Award, giving recognition to the exceptional efforts of New England caregivers. Nominations have opened, and are open to any patient or family member, as well as any health care professional who works with the caregiver. The award’s recipient is awarded with $5,000 dollars, and four other finalists will receive a $1,000 award. All will be honored at the Kenneth B. Schwartz Compassionate Healthcare Dinner on Thursday, November 21st.

If the compassion of a physician, nurse, therapist, social worker, psychiatrist, or any other health care professional has made a difference for you, consider nominating them for the award. More information is available on the Center’s website, located at www.theschwartzcenter.org. Nominations are due by Friday, May 3rd.
-Deb Wachenheim

March 27, 2013

Are you an adult who does not have health insurance, or didn’t until recently? Or do you know adults in this situation?

We are looking for people to be interviewed or take part in a focus group in April. Everyone who takes part will get a meal and a $15 gift certificate to a local supermarket. If you know someone who might be interested, please send them the link to this post.

What does it involve?  We’ll show you cards with words and pictures that explain health insurance words and terms (like premium, subsidy, and copay). We’re not testing the people who take part — we’re testing the cards. There are no right or wrong answers. We’ll be discussing whether the cards make health insurance easier to understand.

Where?    The location will be in Greater Boston at the most convenient site we can find.

When?    A morning, afternoon or evening in mid-April. The date and time will depend on what works for people taking part. The focus group will take 90 minutes.

Will I get paid? Everyone who takes part will receive a $15 gift certicate to a local supermarket. We’ll provide pizza and beverages. We’ll pay your costs getting there and back on the bus or T. If you need childcare at the same location, we’ll provide it.

Any other benefits?    You might learn more about health insurance and how to enroll yourself and your family. We’ll refer you to people and organizations who can help you enroll, if you want that.

Will I be identified?   We’ll use first names only (real or fake).

Do I qualify to take part in the focus group? 

Yes, if you answer YES to the following questions

  • Do you currently lack health insurance, or did you lack health insurance for at least 1 year out of the last 5 years? (For at least 6 months in a row.)
  • Did your formal education end at high school or sooner?
  • Are you age 18 or over?
  • Do you have a working knowledge of English? (You don’t have to be fluent)

What is this for?   The researcher is a graduate student at Tufts University School of Medicine. She is working with Enroll America, an organization that helps people get health insurance. When the cards are finished they will be available to people and organizations who can benefit from them.

Where can I sign up or find out more? Contact Lucy, researcher, (617) 969-1533 or (617) 359-7556. You can email Lucy at: ljdfamily@rcn.com

You can ask for more info without making a commitment. You can drop out at any time.

-Kate Bicego

March 26, 2013

Last week we celebrate the accomplishments of Distinguished Professor and former head of the Department of Public Health John Auerbach by creating the first ever “John Auerbach Community Leader Award.” John’s work is nationally recognized and has improved the lives of countless residents of Massachusetts. He reminds us that sustainable health care reforms require collaboration between public health officials, consumers, advocacy organizations, and all other sectors of our society.

Auerbach and Amy

His accomplishments are too many to list in a blog. But it’s worth mentioning just a few highlights.

Under his leadership the Public Health Commission and the DPH navigated and thoughtfully addressed some of the most serious health issues facing the Commonwealth’s residents while at the same time – doing so during difficult budget cuts and shrinking budgets.

John navigated the State’s response to the AIDS epidemic at its peak by speaking openly and honestly about the challenges, initiating common-sense interventions like needle exchanges and fighting for much-needed Medicaid coverage for the poor and the underprivileged.

John was instrumental to the implementation of the strongest tobacco control regulations in the country.

On April 10th at our annual event For The People we will award Monica Escobar Lowell of UMass Memorial with the “John Auerbach Community Award.” We hope that you join us on this joyous occasion.

-Ari Fertig

March 22, 2013

The Massachusetts Consumer Assistance Program (Mass. CAP), led by Health Care for All and Health Law Advocates, launched an outreach and education campaign training on March 15th to educate communities in Massachusetts about their new rights and responsibilities under the Affordable Care Act (ACA).

The campaign will focus its attention on limited English-speaking communities in Massachusetts, but will not only focus on this population. The Mass. CAP is partnering with ten community-based organizations throughout the state to assist with the campaign. (See below for list of CBO partners.)

HLA presents

Twenty individuals representing the ten regional partners came together for a full-day training that provided attendees with information about the Consumer Assistance Programs and Affordable Care Act implementation in Massachusetts. Representatives from the Executive Office of Health and Human Services were also in attendance.

Kate Bicego, Consumer Assistance Program Manager at HCFA, developed a rich and enthusiastic dialogue with the participants during most of the day. HCFA presented on the main provisions Massachusetts’ 2006 health reform law and the ACA, while HLA gave the regional partners and overview of the free legal services they offer clients seeking assistance filing insurance appeals and grievances.

kate presents

A small group exercise was held in order to identify issues and concerns that were in the minds of the participants with regard to ACA implementation. Some of the concerns and questions voiced during the training were: 

a) Benefits, costs, and eligibility
b) The level of confusion and misinformation regarding the ACA already present in    different communities
c) How to effectively reach immigrant communities
d) Investment in community-based outreach, education and enrollment assistance
d) Populations’ transition processes to new coverage options
e) Reconciling the national and state individual mandates

We look forwarding to working with the ten regional partners over the next few months to ensure ACA implementation in Massachusetts is a success!


REGIONAL PARTNER ORGANIZATIONS
: La Alianza Hispana (Roxbury, Boston); Centro Las Americas (Worcester); Cooley Dickinson Hospital (Northhampton); Ecu Health (North Adams); Greater Lawrence Community Action Council (Lawrence); Joint Committee for Children’s Health Care in Everett (Everett); Massachusetts Alliance of Portuguese Speakers (Cambridge); Outer Cape Health Services (Provincetown); PACE, Inc. (New Bedford); and, Stanley Street Community Health Center (Fall River).


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Francisco Ramos

March 15, 2013

Today the Connector Board approved the final 2013 Affordability Schedule and changes to Minimum Creditable Coverage (MCC) regulations; discussed the Health Connector’s proposed navigator program; and considered market feedback on the Health Connector’s sub-connector program model.

Materials from the meeting are here, and you know where to get our full report.

March 15, 2013

The Health Policy Commission met on Tuesday, March 12.  The Commission began diving into the substance, approving regulations and guidance documents on several fronts.

Meeting materials available here (pdf), and our complete report is after the break.

March 13, 2013

While Massachusetts has the lowest uninsurance rate in the nation (4.8% for adults age 19-64 and ~1% for children 18 and under), people continue to experience periods of uninsurance. We now know a lot more about the remaining uninsured in Massachusetts thanks to a brand new report issued by the Blue Cross Blue Shield of Massachusetts Foundation and the Urban Institute.

The report goes into impressive detail about who the uninsured are and what challenges they face.  Perhaps even more importantly, the report suggests outreach strategies that state agencies, policymakers, and other stakeholders can use in their efforts to insure hard-to-reach populations.

The most revealing statistic from the report shows that 10.6% of all adults (age 19-64) have been uninsured at some point during the past twelve months. At the HCFA HelpLine, we speak with thousands of uninsured Massachusetts residents every year who are seeking help obtaining health insurance, or assistance understanding their coverage options. Many of these people experience periods of uninsurance due to situations beyond their control.

I was presented with an example of one of these situations while fielding calls on our HelpLine last week. Laurinda, an uninsured woman reached out to us after her COBRA health insurance expired. She applied for subsidized health insurance through the state and was waiting for a response when she contacted me. During this brief period of uninsurance she had fallen and broken a bone. She went to the only place she could be seen right away – the emergency room – and was told she needed surgery that could cost her $15,000 up front. We assisted her in securing subsidized care so that she could get the surgery she desperately needed.

Here’s what Laurinda wrote to us when she finally got the insurance she needed:

"This injury and my inability to get health care have been depressing and distressing.My attempts to navigate the system had hit a dead-end and my lack of familiarity with the process was incredibly frustrating. Your knowledge, patience and understanding gave me hope during a very bleak time. I am grateful for you and your work--you do it well and with fabulous results quickly.”

That’s why we do what we do.

But what about the remaining uninsured that cannot access the health care services they need? The financial and health risks of uninsurance are well documented in this report and others. Affordable Care Act implementation gives Massachusetts resources to reinvest in outreach, education, and enrollment services for the hard-to-reach communities this report highlights as key to health reform’s success. We look forward to working with state partners (all of you!) to ensure (and insure) uninterrupted access to quality, affordable health care for all Massachusetts residents.

-Kate Bicego

March 11, 2013

Last Tuesday's Globe lead editorial ("Mass. needs an Obamacare waiver for small-business health plans") looked at an arcane issue that has turned into a big deal for some small business associations in Massachusetts.

If you just read the editorial, or coverage in the business press (sample: Massachusetts health care costs out of control as ObamaCare provision hits small business, from Boston Business Journal), one would think that some horrible provision of the ACA is leading to increased health costs in Massachusetts. What's going on here? Aren't we the blueprint for Obamacare?

But it's not so simple. In this particular area, there are winners and losers, and, like always, it's the losers that are making the most noise.

This stuff can be complicated, so here's an analogy, followed by the explanation.

Imagine an airline that sets a basic fare cost for flights from Boston to New York. So everyone pays that amount, right? Of course not, this is an airline we're talking about. In this example, imagine all the frequent fliers get a nice discount. They pay less. And everyone else? In addition to the base fare, the non-frequent fliers have to pay a "transit surcharge" imposed on top of the ticket price. They can't get out of it. So what would you think of the FAA prohibiting both the discount and the surcharge? Fair?

Here's what the health insurance issue is all about.

In Massachusetts, a provision of chapter 58, authorized a "group size rate adjustment" to small group (up to 50 workers) and individual premium rates. The provision was put in to mollify some small business groups who feared their premiums would go up when individuals were merged into the small group market.

Insurance premium prices start with the base rate - the average cost for the average person with the benefits in the plan. Then they are adjusted, based on age, geography and other factors. The law specifies the factors and the amounts. The way the group size adjustment works is that insurers, at their discretion, can provide discounts for larger small groups, and charge add-on surcharges for smaller small groups and individuals. The largest discount allowed is 5% off the base rate. The largest surcharge allowed is 10% added to the base rate.

So now, individuals and smaller small groups pay more than they should, and larger small groups pay less than they should. We've been told that the dividing line varies, but is around groups of 10 subscribers. Individuals and groups below 10 pay the surcharge, and groups above 10 pay get the discount.

The group size adjustment is not related to the actual cost of servicing smaller groups. The insurers don't have to justify their discounts or surcharges - DOI lets than do whatever they want as long as the discounts are no more than 5% and the surcharges are no more than 10%.

So here comes the ACA, which prohibits these kinds of adjustments in states, starting in 2014. When you forbid the group size adjustment, everyone starts with the base rate.  This ACA provision produces winners and losers. Smaller small groups and individuals are the winners, and larger small groups are the losers, compared to before. So naturally, the losers are complaining.

The state has been trying to get out of the federal rule, and has asked the federal government for a waiver, or for the ability to phase out the group size adjustment rather than eliminate it (you can read the state's letter here (pdf)). So far the answer from the feds is no, the law is the law. But it's still being pursued.

The worst outcome would be to divide up individuals and small groups. Insurance works best when the pool being insured is as large as possible. Slicing and dicing would create more losers, including low and moderate income people who in 2014 will be getting premium assistance through the individual market.

The ACA rule just gets rid of artificial discounts and artificial surcharges. Everyone will pay premiums based on the average cost of everyone in the pool. It's a one-time adjustment. The gain of those who are losing their surcharge should roughly match the pain of those losing their discount. The total amount collected in premiums for individuals and small groups will not change because of the implementation of the ACA rule.

The real victory is to keep people healthy, and reduce the cost of medical care when people get sick. That, in the end, is what determines the affordability of health coverage.The state is moving on many fronts to reduce health costs, including more prevention, oversight over providers, more efficient payment systems, and malpractice reforms. Small group base rates are going up on average just 2.7% this April, which is the key renewal month for most small firms. The Health Policy Commission, EOHHS, CHIA and all the stakeholders in health cost containment need to focus on the real prize.
 -Brian Rosman

March 9, 2013

Our fourth Patient Safety Week guest post is by Paula Griswold, Executive Director, MA Coalition for the Prevention of Medical Errors:

We should all be very worried about whether there will be continued improvements in patient safety. Then we should all take action and make sure there are.

I became very afraid when I read Dr. Robert Wachter’s excellent blog post “Is the Patient Safety Movement in Critical Condition?” This expert and commentator on patient safety wrote:

“…. I’ve never been more worried about the (patient) safety movement than I am today. My fear is that we will look back on the years between 2000 and 2012 as the Golden Era of Patient Safety, which would be okay if we’d fixed all the problems. But we have not.

So what’s the problem? I see two major forces slackening the response to patient safety: clinician (particularly physician) burnout and strategic repositioning by delivery systems to deal with the Affordable Care Act. Like a harried parent rushing out to the car to drive the school carpool, only to discover that he’s left his child in the house, we risk leaving behind our precious safety cargo if we fail to ensure that everybody is onboard as we rush headlong into the future.”

It’s a great post; I recommend you read the whole thing.  Here’s more…..

“The (first) problem, of course, is that nobody freed up the time to do all this new stuff….. Although many clinicians have been gratified by their work in safety and quality, I’m afraid this additional work has contributed to high levels of burnout…… seeing physicians and nurses so overwhelmed that getting them to think about anything else – safety, quality, teamwork – is nearly impossible…

“…..My second major concern about patient safety stems from the Affordable Care Act (ACA), one of whose main goals, paradoxically, is to place a premium on value over volume. You’d think that the patient safety field would benefit from such a law (which also includes significant new spending on safety), and perhaps it will… eventually. But in the short term, the ACA is yet another speed bump on the road to a safe system.

Just as physicians are overwhelmed and distracted, so too are hospital CEOs and boards. As the healthcare system lurches from its dysfunctional model to a (God willing) better place, healthcare leaders are scrambling to be sure that their organizations have seats when the music stops. The C-suite and boardroom conversations that, a few years ago, were focused on how to make systems better and safer now center on whether to become Accountable Care Organizations, how to achieve alignment with the medical staff, what the insurance exchange will mean for our reimbursement, and the like. To the degree that people remain interested in improved value, here too the emphasis has shifted from the numerator of the value equation (quality, safety, patient experience) to the denominator: cutting costs.

We simply must reorganize our healthcare systems to deliver the highest-value care. Of course, this will require big picture, strategic planning – new relationships, new institutions, new IT systems, and more. It will also depend on the creation of a bottom-up culture that allows those who deliver the care to improve it. ( my emphasis) Together, this is an awfully full agenda for both leaders and clinicians, and it is a noble one.

But as we proceed, we must remember that healthcare is delivered by real humans, working in organizations that are led by other real humans. Ignoring the pressures that both groups are under may lead us to create lovely systems and dazzling org charts for organizations that continue to harm and kill.”

Last year I wrote a guest blog post about a collaborative improvement project led by our organization, the Massachusetts Coalition for the Prevention of Medical Errors.  It demonstrated the tremendous improvement in quality and safety that can be achieved by leadership support and active engagement of front-line clinicians and staff.  I wrote:

“I am passionate about improving healthcare, to prevent harm to patients and to ensure that doctors and nurses, who entered the field to care for patients, are not devastated by their involvement in an event that instead caused harm.

What’s even more exciting is the same approach that makes healthcare safer will produce healthier patients who are happier with their care, while significantly reducing the costs of care. Hard to believe perhaps, and certainly not easy to accomplish, but true.

If we combine leadership commitment to these goals with effective engagement of front-line staff in improving processes of care, we’ll see extraordinary improvements. If we add policy and payment system changes which reward these efforts, there’ll be no limit to our achievements.”

So it is time for all of us to take action. 

March 8, 2013

[vimeo http://vimeo.com/27450676]

Must see TV: The award-winning documentary Escape Fire will be broadcast on CNN this Sunday. The movie will air on Sunday night March 10th at 8:00pm on CNN. It will re-air at 11pm ET and again on March 16th. Set your DVR.

Join Me in watching Escape Fire
From the producers:

American healthcare costs are rising so rapidly that they could reach $4.2 trillion annually, roughly 20% of our gross domestic product, within ten years. We spend $300 billion a year on pharmaceutical drugs – almost as much as the rest of the world combined. We pay more, yet our health outcomes are worse. About 65% of Americans are overweight and almost 75% of healthcare spending goes to preventable diseases that are the major causes of disability and death in our society.

It’s not surprising that healthcare is at the top of many Americans' concerns and at the center of an intense political firestorm in our nation's Capitol. But the current battle over cost and access does not ultimately address the root of the problem: we have a disease-care system, not a healthcare system. The film examines the powerful forces maintaining the status quo, a medical industry designed for quick fixes rather than prevention, for profit-driven care rather than patient-driven care.

ESCAPE FIRE also presents attainable solutions. After decades of resistance, a movement to bring innovative high-touch, low-cost methods of prevention and healing into our high-tech, costly system is finally gaining ground. Filmmakers Matthew Heineman and Susan Froemke interweave dramatic personal arcs of patients and physicians with the stories of leaders battling to transform healthcare at the highest levels of medicine, industry, government, and even the U.S. military.

ESCAPE FIRE is about finding a way out of our current crisis. It’s about saving the health of a nation.

The film includes substantial commentary from Don Berwick, and draws its title from a talk he gave in 2002. There's lots of information about the film on their web site, including the ability to set up a viewing party and get a discussion guide (pdf).
-Brian Rosman

March 7, 2013

Our third guest blog explains how patients can get better care by changes in the medical liability system. The post is by Alan Woodward MD, chair of the Massachusetts Medical Society's Committee on Professional Liability and a past MMS president, who was involved in the changes to state malpractice law contained in Chapter 224.

Every day patients seek treatment in health care facilities across the country, and every day, a few of those patients will suffer harm because of that treatment. These situations are called adverse events.  Patients who experience adverse events often feel unsupported, uninformed, and angry. Physicians’ primary goal is to give each patient the best care possible, every day. But when that goal isn’t achieved, it is hard to know how to respond to what has happened – whether it is because of a mistake, or just a complication that wasn’t expected –approaching the patient about it can be difficult. For a long time, the culture of health care denied patients information, empathy, and needed support after adverse events because health care providers were advised not to speak openly and had a debilitating fear of admitting fault and “getting sued” by the patient. But it is now clear that that strategy was damaging for everyone involved. In fact, many studies show that the primary reason that patients file lawsuits is not negligence, but ineffective communication between patients and providers. (see this Making Patient Safety The Centerpiece of Medical Liability Reform, a 2006 New England Journal of Medicine article by Hillary Clinton and Barack Obama)

Now there is a new approach gaining acceptance in our state. The Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) was founded this past year to change the culture of avoidance and fear, and to promote Communication, Apology, and Resolution (CARe) as a model to approaching adverse events. The CARe approach includes the following:

First, communicate with the patient about what happened and what it means for his or her care, and offer an expression of empathy. The patient will be given an assurance that the event will be investigated and support will be offered to the patient through a patient relations specialist, or outside support entity.

Second, after a full investigation, the patient will learn how the hospital plans to prevent the adverse event from happening again. Finally, if the health care group finds that they were at fault, they will formally apologize to the patient for making the error, and if the patient sustained significant harm, will offer the patient compensation for their injuries without having to resort to litigation. Patients will be encouraged to be represented by an attorney in discussions about compensation, to be assured that the health group is making a fair offer. Through the CARe system, health care groups give patients the support and information they need, take responsibility for their mistakes and learn from them, and offer the patient support and fair compensation in a timely manner.

This initiative is so important, not only to repair the culture around adverse events, but to improve patient safety by looking hard at our mistakes and finding ways to prevent recurrences.  I am thrilled that the CARe approach is currently being formally piloted in six hospitals, and used by multiple other groups and institutions in the commonwealth, and we hope more will join us in using CARe in the near future.

MACRMI has an informational website for patients, providers, and administrators with free CARe resources, testimonials, and interactive features, which can be found at www.macrmi.info. We invite you to visit the website, and share it with friends or colleagues who might be interested. Thank you to Health Care for All for supporting the CARe program’s principles and consistently advocating for patients, and for inviting me to be a guest-blogger for Patient Safety Awareness Week.
-Alan Woodward, M.D.

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