April 2013

April 29, 2013

It was hard to notice. But an obscure section in a the final, technical amendment during the House budget debate would allow over 800,000 low-income adults to receive dental fillings under the budget approved by the Massachusetts House of Representatives Wednesday night. The budget amendment added $17.2 million to restore coverage for fillings in the MassHealth adult dental plan, effective January 1, 2014. Those benefiting include 120,000 seniors and 180,000 people with disabilities.

Oral health is a crucial part of overall health. Left untreated, dental decay can spread throughout the body, causing serious and permanent health issues. Over 800,000 Massachusetts residents are impacted by the 2010 cuts to the MassHealth adult dental program. Some of the most vulnerable residents of our Commonwealth have faced daunting challenges in attempting to access oral health care in the wake of the cuts to MassHealth adult dental benefits.

The current program provides very limited services such as cleanings, screenings, extractions, and very limited fillings, for front teeth only. Access to complete fillings means that infections can be stopped before they become a systemic health issue, before teeth have to be pulled, and before individuals are forced to show up in the emergency room because of significant mouth pain.

The full restoration of MassHealth adult dental benefits is among HCFA's top priorities. We applaud House Ways & Means Chairman Brian Dempsey and House Legislative Oral Health Caucus Chair Representative John Scibak for their leadership.

The House did not include additional funds requested for administrative support for the MassHealth program. Without these funds, delays in MassHealth enrollment and member processing will continue to worsen.

Our friends at Mass Budget and Policy Center have a full report on the House final budget. For MassHealth, there are still major cuts coming if the House version prevails:

... [F]unding for MassHealth in the final House budget remains about $208.0 million below the amount proposed by the Governor. A portion of that overall gap can be explained by the following differences between the two budgets:

  • The House does not fully restore dental coverage ....
  • The House eliminates $11.7 million in funding, proposed in the Governor's H1 budget, that would allow MassHealth to maintain coverage for about 3,400 legal immigrants who will not be eligible for coverage under the ACA, and to extend MassHealth coverage to about 900 disabled adults by extending new ACA rules for calculating income eligibility to cover people with disabilities.
  • It appears that the House does not follow the Governor in allocating $10.0 million for primary care provider rate increases.
  • The House budget proposes to tap an off-budget trust fund (the Healthcare Payment Reform Trust Fund) to pay for some costs that were included in H1 line items. ...

After taking these differences into account, there is still a sizable gap—more than $100 million— between the funding levels proposed by the Governor and the House. While some of this difference may result from different assumptions about enrollment growth, the state's ability to control health cost growth, and the state's ability to employ cash management strategies that shift costs into subsequent years, administration budget writers indicate that it will be difficult — if not impossible — for MassHealth to implement this lower level of spending without affecting either rates for providers or services for low-income patients.

We have already begun working with the Senate to restore the full range of MassHealth adult dental benefits, along with other priorities, when they take up their budget proposal in May.
-Cortney Chelo and Brian Rosman

April 26, 2013

No one wants an exhausted doctor making decisions about their health. That’s why the Accreditation Council for Graduate Medical Education, which is charged with accrediting American medical residency programs, has continued to take steps to limit the time doctors in training spend on the clock. The most recent restrictions, established in 2011, target interns, limiting their work day to no more than 16 hours. It’s a common sense solution to a justified anxiety about fatigued doctors.

Yet the measure may not have been as effective as predicted. A New York Times article surveys emerging literature relating to these changes, and the results may cast doubt on the ultimate effects of hour restrictions. Since the changes, interns have not been getting more sleep, nor are they happier. Evidence suggests the regulations may even be stunting the educational progress of these doctors: interns have actually been spending less time in educational activities, as the time needed for these conferences and lectures contributes to the 16 hour limit on their time.

Patients haven’t been receiving better care, either – no significant improvements in patient care have been reported since the hour limits. One study reveals an increased concern among interns about making medical errors after the change.

The problem with the regulations? Demand for care stays steady, no matter how many hours doctors work, and hospitals haven’t matched this demand by hiring more interns. This means that interns find themselves spread thinner and thinner, as they struggle to complete all their responsibilities with less time to do them. “It’s as if you told airline pilots that they could only work a certain number of hours, but they had to fly 50 percent more flights,” said Dr. Lara Goitein, lead author of a recently published editorial in JAMA Internal Medicine.

Physician fatigue is a very real problem, but efforts to address it should not stop at blanket-level restrictions. Instead, hospitals need to devote money to hiring more doctors in order to ensure that each patient can receive quality care from an engaged and focused professional. There’s no denying that such an effort would result in short-term losses, but the payoffs in better patient care – and, perhaps, outcomes – would likely be well worth it.
-Devon Branin

April 26, 2013

A recent study has confirmed that methicillin-resistant Staphylococcus aureus (MRSA) is being transmitted from animals to people (NY Times story, and NPR story). While this has long been suspected, the University of Cambridge study uncovered more concrete evidence by studying cases of MRSA in Denmark – a country where a generally low incidence of MRSA means sources for exposure are lower than in the rest of the world. Geneticists were able to compare MRSA samples from both patients and the infected livestock they owned, and discovered a similarity in the genes of the bacteria indicating likely transmission.

These findings highlight warnings issued by those in agricultural public health for years, who have long suggested that the overuse of antibiotics on livestock could pose huge risks for humans. Managers of factory farms have been known to use antibiotics on all animals to encourage growth, a practice which may encourage the development of drug-resistant pathogens. This study demonstrates that these new hard-to-treat germs could easily make people very sick.

The FDA has moved for voluntary action from farms to curb the spread of drug-resistant pathogens, asking those in the food industry to phase out blanket application of antibiotics. Previously, the FDA has pushed for stronger restrictions on antibiotics, partnering with the CDC in a statement condemning the current state of their use in agriculture. However, in 2011, the FDA veered away from efforts to regulate antibiotics, choosing the voluntary path instead.

HCFA has worked extensively with MRSA prevention in hospitals, and this new research poses an additional challenge to those efforts. Farm workers, for instance, who are unaware that they have been infected, may be hospitalized and introduce MRSA to the hospital, risking the health of other patients, especially those with weakened immune systems. With so much at stake, responsible use of antibiotics in animals is essential.
-Devon Branin

April 25, 2013

HCFA Executive Director Amy Whitcomb Slemmer talks about health coverage issues after the Boston Marathon attacks

Health Care For All is getting the word out that our free HelpLine is available to assist Massachusetts residents with insurance issues following the Marathon attacks. The HelpLine counselors are unparalleled in their understanding of our health care system and the programs available and stand ready to answer questions in English, Spanish, Portuguese and Italian.

Yesterday morning HCFA Executive Director Amy Whitcomb Slemmer appeared on NECN (click to watch) to talk about these important issues.

People are encouraged to contact the HelpLine and Health Law Advocates through our toll free number 1-800-272-4232 if they need assistance.

Health Care For All wants Boston Marathon runners, spectators, family members or anyone affected by last week's violence to know they have a partner and free resource available if they are struggling with health care coverage issues. We want people to be able to concentrate on healing rather than worrying about their health care coverage, and we stand ready to help anyone who needs assistance to navigate the complexities of any insurance issues.

In addition, if patients or consumers find that they need legal assistance, our partners at Health Law Advocates provides free assistance with payment plans, coverage denial appeals or respite from crushing medical debt.

Coverage following the attacks raises a number of important policy issues. The Georgetown Center on Health Insurance Reforms posted a comprehensive post looking at these concerns (thanks to Community Catalyst's Health Policy Hub for cross-posting). The discussion looks closely at issues like coverage limits, benefit exclusions, and cost-sharing challenges. Already we are hearing about variations in coverage of prosthetics by different insurers.

This work is at the core of our mission, and it is our privilege to assist people affected by last week's events to alleviate concerns that might distract them from healing and reclaiming the health they enjoyed before the Marathon.


April 25, 2013

The Statewide Quality Advisory Committee met Monday and discussed priorities for the coming year as they prepare to solicit nominations for measures to be considered for the Statewide Quality Measure Set and as they consider experts they would like to bring in to meet with the group.  The SQAC members came to consensus on the need to prioritize patient-centered care and to have a particular focus on behavioral health and coordination of care. The group agreed that behavioral health is an area where there is the potential for the greatest improvement in quality of care and patient-centeredness of care. As part of the larger area of patient-centeredness, the group also talked about looking at measures relating to shared decision-making, patient confidence, and patient-reported outcomes.

We at HCFA are excited that this will be a focus of the group and we look forward to continuing to actively participate in conversations about quality measures and quality improvement activities.
-Deb Wachenheim

April 23, 2013

This week starts the budget process in the state House of Representatives. For the next 3-4 days, the House will deal with some 888 amendments. The full budget and amendments are here.  You can also download the "Amendment Book" which has the amendments summarized and categorized by topic. I counted 49 in the Health and Human Services category, another 27 in the Mental Health and Disabilities category, and 58 in the Public Health category. That's a lot.

HCFA has been working the House aggressively on behalf of a number of amendments. With the inadequate revenue proposal moving in the legislature, the House budget comes up short on health care in many ways. HCFA is supporting a large number of amendments to restore funding and invest in health care.You can see the amendments we are asking Representatives to support here (pdf).

Among our top priorities are two key MassHealth amendments:

  • Restore Dental Care For MassHealth Adults: Cuts to the MassHealth adult dental services in 2010 left over 700,000 people without access to dental care beyond cleanings and extractions, including 120,000 seniors and 180,000 people with disabilities.  Dentists can identify cavities during an examination, but with the exception of a small number of billing codes, fillings are not covered.  Left untreated, a simple cavity can lead to serious medical problems.

Support Amendment #204 (Scibak) to fully restore MassHealth adult dental benefits. 

  • Provide Adequate Administrative Support for MassHealth: Since 2008, MassHealth operations staff has been sharply cut at the same time the number of MassHealth members has risen dramatically, resulting in paperwork processing backlogs, gaps in health coverage, and delays in enrollment.

Support Amendment #158 (Brodeur) to provide $3.3 million for MassHealth operations staff.

The HesterPrynne blog has a good overview of the process, and what to expect on the hot button issues, here. As the post explains, the House budget contains several provisions aimed at "cracking down on fraud and abuse" in welfare programs, and a number of amendments would go even further. Many of them would interfere with or prevent people from getting benefits they need, including health care. We are working with a number of groups to oppose these provisions.

The Mass Public Health Association is supporting a number of public health amendments, listed in their blog post here, including reversing cuts to smoking prevention and cessation services, the successful Mass in Motion program, environmental health and health care quality. We are also lobbying hard on these public health issues, and urge people to work with MPHA to support investments in our public health system.

We are also focusing on mental health parity, on assuring full implementation of the ACA, and health equity. Many of the amendments we are actively supporting can be found here.

We urge our friends to contact their Representative today to voice support for these amendments.

April 23, 2013

This past week has been a tough one for all of us. Our thoughts go out to the families who are grieving the loss of loved ones and all those who are recovering from injuries.

But, a week after the Boston Marathon attacks, we are back. A week after our world was rocked by unexpected violence, days after the suspected perpetrators were apprehended and our first day back to work after what was an unprecedented week.

We will not be proceeding with business as usual. Our tasks before us may not have changed, but the experiences that we all shared last week will thread their way through our efforts henceforth.

Please consider what images and information you are consuming in the aftermath of last week. Be selective in what you consume – which images, which sources deserve your time and attention. Take care to edit. Given our proximity and the number of friends, co-workers and loved ones directly affected by this experience, you know and are surrounded by so much more than the talking heads could ever understand.

Today we observed the moment of silence at 2:50. It was just the first step on the road to recovery. That road will be a long one.

We want to make sure that all are aware of the many resources available to you, which you should avail yourself of if and when they are useful:

You can speak with a counselor on the Disaster Distress Helpline at
1-800-985-5990 or text "TalkWithUs" to 66746

TTY for Deaf/Hearing impaired 1-800-846-8517

Usted puede hablar con un consejero de la linea de ayuda de socorro de desatres
1-900-985-5990 o mensaje SMS Hablanos al 66746

SAMHSA guides for students, families, teachers and other caregivers as well as first responders and health professionals

Practicing Self-Care After Traumatic Events (pdf) - Riverside Trauma Center

How to Talk with Your Children about Boston Marathon Bombs - WBUR CommonHealth

Media Coverage of Traumatic Events - National Center for PTSD

5 Tips on Talking to Children About Scary News - CNN

Mayor's Health Line: 617-534-5050

--Amy Whitcomb Slemmer

April 12, 2013

Uninsurance comparison - US-MA 650

Today marks the 7th anniversary of the enactment of Chapter 58, the Massachusetts health reform law. For those of us who have followed our groundbreaking law through formulation, passage, enactment, and implementation, it’s been a long, wonderful journey (our previous birthday posts make an interesting record for the nostalgic: 1st; 2nd , 3rd, 4th, 5th (and 5th anniv. video) and 6th).

It’s also probably the last anniversary where we can take stock of the progress made by Chapter 58. A year from now, the Massachusetts health care coverage landscape will be as influenced by the ACA as it will be by Chapter 58. Obamacare will overtake and subsume Romneycare.

Even though the national law is built on our blueprint, the changes coming on January 1, 2014 will be so substantial that it will not make sense to measure the impact of Chapter 58. There will be no Commonwealth Care program, no state Employer Fair Share or Free Rider surcharge, and a very different MassHealth and Connector.

Chapter 58 was ostensibly all about coverage. The key numbers to remember are 439,000 – the number of newly covered people in the state; and 97% -- the percent of people in Massachusetts with health coverage. The Blue Cross Foundation has always been the essential repository for all things 58. Their annotated text of the actual law, along with amendments, is one of the best places to start. Their just-updated, essential chartpack, Health Reform in Massachusetts: Assessing the Results, provides most of the facts and figures one could need to answer how are we doing.

(By the way, the worst place to start would be the Wikipedia entry on Massachusetts Health Care Reform. It’s way out of date, filled with irrelevancies and errors. Does any health policy instructor want to assign their class a project to update the page?)

But although the law successfully boosted coverage, the key question has always been, has it improved health?

A number of studies are approaching this in different ways. These studies are difficult to do in a rigorous way, because one needs to use sophisticated comparisons for control and statistical techniques to isolate just the impact of the health reform law.

One of the most interesting studies is research by Courtemanche and Zapata, two economists (their 2012 paper is here (pdf), an update was published in 2013). They found that reform in Massachusetts led to significant improvements in self-assessed health, and objective health indicators. Improved health was comprehensive, encompassing physical and mental health, functional limitations, joint disorders, and body mass index. They found an increase in reports of “excellent” and “very good” health, and a corresponding decrease in reports of “good,” “fair,” and “poor” health. It was particularly promising finding that there was no substantial difference in short and longer-term trends. These improvements showed an especially strong effect upon minorities, those with low incomes, the near elderly, and women.

Courtemanche - Zapata health status graph

The chart above highlights their findings, which show that between 2001 and 2006, Massachusetts (at the top) and the rest of the US (on the bottom) moved in tandem, with a slight decline in health status. But since 2006, the Massachusetts numbers have improved, while the national experience remained stable.

April 12, 2013

Today (April 11, 2013), the Connector Board discussed the Commonwealth Care member survey, the FY14 Commonwealth Care MCO renewal, and efforts to enhance consumer health plan selection and decision support tools on the Health Connector’s website.  Materials from the meeting are here, and our full report is after the break.

April 11, 2013

Brigham and Women’s Hospital has been leading the way in transparency around medical errors, as a recent Boston Globe article reports.  The article details the implementation of an initiative to inform hospital staff about mistakes made in the hospital via a newsletter, distributed to the hospital’s 16,000 employees.  Issues of the newsletter include anonymous interviews with both patients and doctors concerning the issue, as well as information about recourse after these incidents.

The efforts of the hospital run against a long-standing trend of silence surrounding medical errors. Hospitals often are reluctant to circulate information about medical errors due to fears about malpractice lawsuits or fear from the public. Yet transparency efforts, like those demonstrated at Brigham and Women’s, can do much to foster a culture among staff which could focus on preventing future errors and modifying existing systems to ensure patient safety. And the particularly visceral effect of reading specific stories is likely to change the behavior of doctors far more than a long list of quality statistics. Patient advocates are optimistic as well – Linda Kenney, the executive director of MITSS (Medically Induced Trauma Support Services), appreciated the move towards a culture of openness. “I like the idea the Brigham is encouraging people to speak up,’’ she said.

Yet the impact of the newsletter has been more than theoretical: in fact, a “pretty dramatic experience” recounted in the newsletter concerning emergency room wait times pushed the department towards efficiency, reducing wait times to 20 minutes and expediting the process of bringing in extra help. A story about the damaging effects of a doctor prescribing contraindicated medications led to mandated doctor-pharmacist conversations about medication side effects.

These newsletters serve as a critical jumping-off point for Brigham’s troubleshooting process. Dr. Elizabeth Nabel, the hospital’s chief executive, created the program in an attempt to mitigate the shame around medical errors. And although specific data on changes in quality care since the implementation of the “Safety Matters” newsletter aren’t yet available, the increase in transparency marks a promising shift in the way providers can approach patient care.
-Devon Branin


April 11, 2013

It's all about the revenue.

Yesterday the House released its proposed budget for the upcoming fiscal year. With the House counting on much less revenue than the Governor called for, they used two strategies to bring the budget into balance: make lots of cuts, and use lots more one-time revenue sources. Although transportation and education face the biggest cuts compared to the Governor's proposal, there are some gaping holes in health care as well.

What follows is based on our first quick read of the House proposal. We'll update with some more details and links as our friends do their reviews. (UPDATE: the Mass Budget and Policy Center has very good coverage of the health care budget in their brief, here. Also, the very helpful Mass Law Reform Institute's summary is here (pdf).

ACA Coverage Mostly Funded
The House proposes to fully fund the ACA Medicaid expansion. The budget also includes the Governor's (and our) proposal to maintain affordability for people transferring from the Commonwealth Care program, by providing a "state wrap" to supplement federal tax credits. Without this wrap, these low-income adults would face major premium and cost sharing increases. We commend House Ways and Means Chair Brian Dempsey for keeping the state's promise of affordable coverage for those who need help paying for coverage.

The House also adopted the Governor's proposal to extend MassHealth coverage through the end of the month, to reduce gaps in coverage as people transition between plans, and to maintain our extended eligibility for pregnant women.

A few key items were left out of the House budget. First, the budget shortchanges the administrative staff MassHealth needs to process the applications and renewals under the complex changes that the ACA will bring. The House slices over 60% from this line item (4000-1602). Representative Paul Brodeur will propose an amendment to add back funds, which is critical to improve application and eligibility review processing times, reduce paperwork backlogs and decrease call-waiting times.

The total MassHealth budget is over $200 million less than the Governor wanted. We're not sure what the implications of this will mean for people who depend on MassHealth for their health needs. The budget also rejects coverage for a small number of legal immigrants who would not be picked up by the ACA, and a proposal to use the new, more favorable, income definitions for a group of people with disabilities who the state planned to include in standard MassHealth coverage.

Medicaid Dental Services Not Restored
The House budget continues the shameful policy of providing only limited dental benefits to adults in MassHealth, including 120,000 seniors and 180,000 people with disabilities. While the Governor proposed to restore these benefits effective January 1, under the House budget over 700,000 low-income people will face worsened overall health due to lack of good dental care. The cuts force people to use costly emergency and inpatient hospital settings and to seek temporary relief of pain caused by lack of access to restorative care. Cuts have also created a major cost shift to the Health Safety Net program. Representative Scibak will be filing an amendment to fully restore dental benefits in Masshealth, and we urge everyone to contact their Representative to support this amendment.

Public Health Takes It Again
In what has become a continuing refrain, the House again imposes more and more cuts on public health. For example, look at the DPH's funding for health promotion and disease prevention. In addition to keeping people healthy and improving the quality of life, this work is the lynchpin for reducing health care costs. In 2010 this line item received a bit over $6 million, a very small sum for the value it provides. This year, the Governor proposed just $3.3 million, a cut from last year's $3.4 million. The House proposal for this work: a paltry $2.3 million (full details from MassBudget tool here). Smoking cessation got cut, too (details), just as the state looks towards a long-overdue tobacco tax increase. The cut will reduce our capacity to provide cessation help, just when the tax increase drives  demand for people to try to quit smoking.

We will continue to review the budget, which will be debated the week of April 22. But the bottom line is that without sufficient revenue, the state will be forced to make real cuts and bad choices. The long-term health of the state requires adequate investments in a broad set of basic needs. We continue to call on the legislature to reverse the years of tax cuts and the systemic, structural imbalance in our state finances, and approve a progressive tax package that allows are state to grow and thrive.
 -Brian Rosman

April 8, 2013

Oral Health Advocacy Task ForceTomorrow (Tuesday, April 9), advocates will convene at the State House in support of Restoring Essential Dental benefits to MassHealth.

Oral health is full body health. So, why would Massachusetts – the state that pioneered universal healthcare for all residents – slash dental benefits for those that need it most? The answer is easy, budget cuts. Please plan to join HCFA and the Oral Health Advocacy Taskforce at the State House tomorrow at 1:00 pm as the Joint Committee on Public Health hears An Act to Restore MassHealth Adult Dental Benefits. To ensure that we are seen and heard, we are asking all of those who attend the event to wear RED in support of restoration.

Oral health is overall health, and dental insurance is health insurance! The legislative budget process gets underway on Wednesday, so tomorrow’s hearing is the perfect opportunity to tell the legislature that we cannot let budget cuts hinder health of Massachusetts residents!
-Courtney Chelo