May 2013

May 30, 2013

Over 150 years ago, the Austrian physician Ignac Semmelweis discovered that, by washing their hands regularly, doctors could stop the spread of disease between patients. Now, a century and a half later, hand-washing is a common practice – but not nearly common enough. Studies have shown that doctors wash their hands as little as 30% of the times they interact with patients. With the rise of nasty antibiotic-resistant germs, hand-washing is more important than ever. And now that hospitals can be financially impacted if their patients are infected while in their care, they are paying more attention to the need to prevent their occurrence.

That’s why many hospitals are opting to use new technology to encourage doctors to boost their compliance with hand hygiene requirements. A New York Times article details recent efforts by hospitals to implement surveillance mechanisms to track just how often doctors wash their hands. At North Shore University Hospital, located in Long Island, hospital administration installed cameras near hand-washing stations. Workers in India were tasked with keeping track of how often each staff member washed their hands, and then reporting this data back to the hospital. Other hospitals have outfitted doctors with Bluetooth enabled badges, which vibrate when a doctor is about to treat a patient without washing his or her hands beforehand.

So why aren’t doctors washing their hands? Studies offer an array of reasons: dry hands, pressures on time, or a resistance to authority. But with $30 billion spent each year on hospital-acquired infections and nearly 100,000 annual deaths, it’s hard to be sympathetic to a doctor’s dry skin or resistance to colleagues or patients asking them to wash their hands. The efforts outlined in the article are a promising start to addressing hand hygiene, but they may only be a first step. “People learn to game the system,” said Dr. Elaine Larson, a nursing professor at Columbia University specializing in hand-washing. “There was one system where the monitoring was waist high, and they learned to crawl under that. Or there are people who will swipe their badges and turn on the water, but not wash their hands. It’s just amazing.”

In order for substantial change to occur, medical culture must change as well. As Danielle Ofri writes in her recent New York Times op-ed, doctors are too often attuned to a culture of shame, in which doctors keep their errors quiet unless their consequences are obvious. Ofri admits to a “near-miss” she made in her medical residency: declaring a patient in good health when a radiologist detected a cranial bleed in the patient a few hours later. In the current hospital environment, Ofri found it too difficult to speak about the factors leading to her mistakes – and she’s not alone.

Hospital leadership must move in a direction where doctors feel comfortable engaging in a dialogue about their mistakes. These conversations may be uncomfortable, but they provide a crucial path to averting future mistakes and near-mistakes. The same principles can be applied to hand-washing – there must be a greater sense of openness about hand-washing and a better understanding of the concerns on both sides. If these new tracking mechanisms can be used to provide doctors specific feedback on their hand-washing, hospital culture should also allow doctors to provide hospital administration feedback on hand-washing infrastructure. If doctors have dry hands, perhaps doctors might request gel with aloe, for instance: a small cost compared to that of hospital-transmitted infections.

Patients deserve the confidence that their doctors are treating them with clean hands. Hospitals can provide a critical role in this by making sure noncompliance in hand hygiene is not only addressed, but also discussed.

--Devon Branin

May 21, 2013

Tomorrow the state Senate will begin debating its version of the state budget for fiscal year 2014, which begins on July 1. Like the House budget did, the Senate Ways and Means version starts out with a strong commitment to building on the state's health coverage reforms through implementation of the ACA, and some substantial deficiencies in funding for health care programs. The best overview of the Senate budget comes, of course, from the Mass Budget and Policy Center. The overview notes the continued decline in support for public health:

More striking than these differences, however, is the extent to which support for public health activities has been cut over the past decade. Since FY 2001, funding has dropped by about 25 percent, after adjusting for inflation, a decline that has hampered the ability of the Department of Public Health to protect the health of the public through regulation of health facilities and other potential hazards. Cuts have also affected a variety of programs—such as smoking cessation and disease prevention—designed to promote health and wellness and reduce long-term health costs. The Governor's FY 2014 budget proposal drew on new revenue to make a modest step towards restoring these cuts; the lower House and Senate appropriations reflect the tighter revenue constraints under which the legislature is operating.

More details on the cuts to public health can be found on the Mass Public Health Association blog. Senators have filed hundreds of amendments to the budget. You can read them here, color-coded by topic. Over 200 amendments are classified as health and human services. We've poured through them all, and here are some of our recommendations. We urge you to contact your State Senator on behalf of these amendment positions:

Oral Health Cuts to the MassHealth adult dental services in 2010 left over 800,000 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 #601 (Chandler) to restore MassHealth adult dental benefits. 

Individuals living with disabilities often need specialized medical care, including adapted facilities and equipment, and providers with specific training.  Dental care is no exception.

  • Support Amendment # 569 (Chandler) to determine the need and the system capacity to provide dental health care to people with disabilities. 

Health Care Access 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 #546 (Jehlen) to provide $3.3 million for MassHealth operations staff.

Prescription Drug Marketing Last year, DPH ignored directives from the Legislature and failed to establish a meaningful definition of “modest meals” that pharmaceutical sales representatives can provide to physicians during drug marketing presentations.

  • Support Amendment # 668 (Montigny) to establish a meaningful definition for modest meals.

Health Care Reform The Affordable Care Act provides enhanced federal matching funds to states that expand Medicaid, including Massachusetts.  The new federal revenue is intended to be invested in MassHealth and other subsidized health coverage programs.  Establishing a Health Care Reform Trust Fund will promote transparency in health care spending and ensure federal health care dollars are spent on health care needs.

  • Support Amendment #634 (Joyce) to create a Health Care Reform Trust Fund.

As the state implements the ACA’s Medicaid expansion, we must ensure that no residents are left behind.  Gaps in coverage can occur when people move from one program to another.  MassHealth needs funds to reduce these gaps by funding coverage to the end of the month, when subsidized insurance coverage from the Connector starts.

  • Support Amendment #697 (Jehlen) to effectively implement the ACA in Massachusetts. 

The Health Safety Net (HSN) program generates federal matching funds which should be used to support care provided to low-income uninsured and underinsured patients. This is particularly important as the HSN has faced significant shortfalls for several years, which burdens hospitals that care for the uninsured and underinsured and destabilizes this important part of the Commonwealth’s safety net.

    • Support Amendment #584 (Welch) to reinvest federal Medicaid matching revenue claimed on HSN administrative expenses into the HSN program.

    Children’s Health Children have unique health care needs that must be addressed in age-appropriate ways.  For very young children with health and developmental needs, the Early Intervention program is a cost- and medically-effective way to address issues when they first arise.

    May 20, 2013

    PFAC Conference 5-17-13 Patient and Family Advisory Councils, or PFACs, are changing the way we experience care at our local hospitals, and also at some outpatient care centers. PFACs allow patients and family members to represent the consumer voice in health care, operating as a crucial link between patients and hospital administration, providing suggestions on making the patient experience more comfortable and less confusing. All acute-care and rehabilitation hospitals in Massachusetts have been required to have PFACs in place since October of 2010. On May 17th, Health Care For All brought together representatives from PFACs across the state to share their successes and challenges. Over 170 registrants from more than 40 PFACs signed up for the Westborough conference, gathering all day on a Friday to attend workshops and network with one another. Some members came to the conference eager to share their accomplishments, talking at length about, for example, their PFAC’s effort to reduce noise in the hospital at night. Other members used the conference as a opportunity to learn from the experience of others, asking other attendees about (among other things) their efforts to increase diversity in their PFACs. The conference opened with a fascinating keynote speech from Dr. John Wasson, a passionate health care advocate and the former dean of Dartmouth Medical School. Dr. Wasson urged those in attendance to buck the status quo and create a culture of change, one that utilizes the voices of patients and family members in day-to-day hospital operations. Through this, Dr. Wasson suggested, PFACs could increase patient health confidence and grant patients faith that they could take control of their health. The conference attendees responded enthusiastically and many of them were excited to also attend Dr. Wasson’s two workshop sessions. Other workshops focused on a variety of topics, from the basics of PFAC management and how to effectively partner with the hospital to PFAC involvement in the more specialized areas of care transitions and emergency departments. In each of these workshops, HCFA tapped members of especially innovative or ambitious PFACs to serve as workshop facilitators and presenters, allowing other PFACs to take away new ideas or share their own alternate approaches. Members left these workshops inspired and excited to start making change. Sixteen hospitals also brought posters describing some of their accomplishments. The posters were displayed outside the conference rooms throughout the day and gave a sense of the wide variety of projects that PFACs are working on across the Commonwealth. At the end of the conference, HCFA reaffirmed its commitment to helping PFACs succeed. A list of resources for PFACs can be found here. Continue checking this webpage because we will be encouraging PFACs to send resources to us that we can post for broader sharing. The webpage also includes a link to HCFA’s summary of annual PFAC reports, which details trends and achievements reported by PFACs in 2012. The first PFAC conference proved a great success, and as enthusiasm and passion among PFAC members continues to build, next year’s conference promises to be even bigger and better! Thank you to everyone who played a part in making this year’s conference so successful. -Devon Branin

    May 16, 2013

    Oral Health Advocacy Task ForceThe Senate budget released yesterday is a mix of good and disappointing, of course. We'll have a more detailed report, with all of our amendment recommendations, early next week.

    But for now we want to focus on the most glaring problem with the budget - no funds for dental fillings for some 800,00 low-income adults on MassHealth, including 120,000 seniors and 180,000 people with disabilities.

    Now, 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.

    The House budget included funds to cover fillings, starting on January 1, 2014. But the Senate did not follow their lead.

    Senator Harriette Chandler is filing an amendment to add funds to cover the $18 million cost of adding fillings to the MassHealth dental benefit. The deadline for other Senators to cosponsor her amendment is tomorrow (Friday) at noon.

    That's where you come in.  We need as many Senators as possible to co-sponsor her amendment. Here's an action alert from our Oral Health Advocacy Task Force:

    Five Minutes Can Make a Big Difference!


    Calling your Senator is easy and effective - here's how:

    • Call and ask to speak with your Senator. It is also okay to speak with an aide.
    • Tell them your name and that you live in the Senator's district.  They may ask for your address.
    • Say that you are calling to strongly urge them to cosponsor Senator Chandlers amendment to restore fillings to the MassHealth adult dental benefit.
    • Let them know the amendment would go into effect on January 1, 2014 and would cost $18 million.
    • Ask them if they will commit to signing on to Senator Chandler's amendment, restoring medically necessary health care services for more than 800,000 individuals in Massachusetts.
    • Thank them for their time.

    Thank you for taking the time to make your calls this afternoon!

    Please contact Courtney Chello at 617-275-2935 or and let us know how it went. The more we know about who has committed to sign on, the better we can target our efforts.


    (Not sure who your Senator is? Click here to find out.)


    May 13, 2013

    Last Thursday, the Connector Board discussed policy, programmatic and operational readiness for Connector 2.0, voted to extend their Affordable Care Act (ACA) project management contract with Deloitte, and approved the transfer of authority over several regulations from CHIA to the Health Connector, as required by Chapter 224.

    Materials from the meeting are here and our full report is a click away:

    May 6, 2013

    [From Mass DPH:]

    Help influence health care in Massachusetts.

    The Health and Disability Program, part of Office of Health Equity at the MA Department of Public Health (DPH) is conducting a health needs survey for people with disabilities in Massachusetts. The Office of Health Equity promotes the health and well being of minority populations, including people with disabilities throughout the Commonwealth. Results from the survey will be used to determine how best to address the current public health needs of the disability community.

    To that end, first, please take a few moments to complete the health needs survey at  Then, as we would like to get a broad range of respondents representing all the facets of the disability community, please forward the link to your friends and colleagues in the disability community and ask them to complete it.

    Who should complete this survey?

    • Residents of Massachusetts, over the age of 18 who have disabilities
    • Caregivers or guardians of adults or children with disabilities
    • Disability advocates
    • Staff at community based organizations or state or local government offices that serve people with disabilities
    • Academic researchers
    • Healthcare providers
    • Public health officials or professionals
    • Health and wellness promotion specialists
    • Health administrators
    • Health policy experts
    We also invite participation by anyone else who has an interest in the health of people living with disabilities in Massachusetts. Please forward as soon as possible, as the survey link will only remain active until May 31, 2013. We look forward to hearing from you!

    This is a voluntary and anonymous survey. The responses are compiled and we do not have knowledge of individual respondents.

    May 6, 2013

    The Health Policy Commission met on Wednesday, April 24, addressing a packed agenda. All the materials were just posted, here, so we can present our full report, after the break.

    May 4, 2013

    Governor Patricks cover letter filing the ACA implementation bill

    While ACA implementation remains contentious in many states, in Massachusetts the building blocks are being set in place in a routine and orderly way.

    On Wednesday, MassHealth released its revised ACA implementation plan, called the "Roadmap to 2014." Also released was the state's proposal to the federal CMS for an extension of our Medicaid waiver, along with supporting documents (the materials can be found on the MassHealth waiver documents webpage).

    And this afternoon, Governor Patrick filed legislation needed to implement the ACA in Massachusetts (here's the bill, H. 3452, the state's section by section summary; and here's their summary by topic).

    The Governor's cover letter sets out why he is looking for passage of the law:

    The legislation will allow Massachusetts to realize the full benefits of the Affordable Care Act, including expanded federal funding to support coverage for low and middle-income families and federal insurance reforms that will secure additional protections for Massachusetts residents.

    The bill proposes a number of technical changes to state insurance laws to conform with the ACA. Many of these changes will improve access to coverage. For example, current law prohibits individuals from buying individual coverage if they have access to employer-based insurance. The ACA does not allow these restrictions, so the bill eliminates the provision. Another section of the bill extends the ability of adult children up to age 26 to remain on their parent's coverage, because the federal law is more expansive than our provision, enacted as part of Chapter 58. The bill also eliminates obsolete references in current law to pre-existing conditions and waiting periods, and permits the phase-out of rating factors not allowed by the ACA (explanation).

    Other sections of the bill revamp the MassHealth and Connector statues to reflect the new subsidized insurance program starting in 2014. Statutory provisions for Commonwealth Care, Masshealth Essential, the Insurance Partnership program, and other programs are eliminated, replaced by expanded MassHealth eligibility.

    The legislation will need to be enacted within the next few months in order to get state laws in place for implementation by insurers and others. The legislature should move quickly on the bill, which will be tough given the difficult budget and revenue issues still to be resolved.

    At the same time, the state is asking the federal government to renew the "1115 Waiver" agreement with the federal government (background, and more, from BCBS Foundation). The waiver would permit Massachusetts to receive federal Medicaid funds for some of the cost of health reform programs, including funding for the "QHP Wrap" which is the state's supplement to federal premium and cost sharing subsidies. The goal of the wrap would be to prevent increases in costs for low-income people in the Commonwealth Care program.

    These and other changes are all explained in detail in the "Roadmap" transition plan. The state will be accepting comments on all the proposals, and will be holding an open meeting on Friday, May 17, at 3 pm at the DPH Public Health Council room (250 Washington St, 2d floor) to discuss ACA implementation.

    In our quick preliminary read, we don't see anything particularly new or controversial in these plans. State officials have been very open with advocates and other stakeholders about the plans for ACA implementation. For the public however, the drumbeat of national opposition cannot but raise anxiety. Even though we've gone through this before, a targeted public education campaign will be required. For example, the 200,000 some people transferring from Commonwealth Care will need to be guided through the steps required to switch their coverage. All together, around 560,000 people will see some change in their coverage. The reassurances necessary require the availability of one-on-one assistance to affected people.
    -Brian Rosman