June 2013

June 27, 2013

Slides descriving Patient Reported Outcome Measures

The Statewide Quality Advisory Committee (SQAC) met on Monday, June 17th (see the meeting materials). The Committee is working to align health care performance metrics to promote uniform collection and reporting of a Standard Quality Measure Set in order to support improvement in the health status in Massachusetts. HCFA is a member of the Committee

At the meeting, Chair Áron Boros, Commissioner of the Center for Health Information and Analysis (CHIA), reported on his staff’s preliminary evaluations of 5 new HEDIS measures.  One of the staff’s major concerns in evaluating the measures was insufficient sample sizes at Massachusetts primary care provider practices for 4 of the measures. These 4 measures look at screening and treatments (some related to diabetes or cardiovascular disease) for individuals with schizophrenia.  Staff proposed downgrading their recommendation level from strong to moderate. Committee members expressed concern about downgrading the measures, seeing as how they relate to the SQAC’s goal of looking at behavioral health, especially the intersection of behavioral and physical health.

The discussion that followed these preliminary evaluations focused on “what is SQAC’s purpose” and “is the purpose of measures such as these to look at population health, in which case sample size would not be an issue, or to look at individual provider performance?” Above all, there are different uses for different measures and they are tools to engender conversation, so what should SQAC be working on?

Massachusetts Health Quality Partners (MHQP) discussed work they have been doing on Patient Reported Outcome Measures (PROMs) stakeholder outreach.  Linda Shaughnessy, MHQP project director, delivered a presentation on PROMS as critical for ensuring patient- and family-centeredness and provider accountability for health outcomes. Discussion around these outcomes-based measures, which engage patients rather than the clinical process, are thought to be useful and valued by consumers.  Committee staff evaluated a broad range of PROMs (and tools) available and recommended multiple measures be considered for evaluation and inclusion in the SQMS. There will be further discussion about PROMs after there is more discussion about goals and purpose.

The next meeting, currently scheduled for August 19th, will involve discussion about a framework for evaluating the proposed SQMS measures. Over the summer, the SQAC will solicit nominations to be considered for the Standard Quality Measure Set.
 -Lisa Buchsbaum

June 27, 2013

Today's Supreme Court decision holding part of the Defense of Marriage Act unconstitutional will have a number of impacts on health insurance eligibility and costs for same-sex married couples. It also might impact the state budget.

Attorney General Martha Coakley quickly put together today a FAQ page, at mass.gov/doma looking at many of these issues. It includes analysis and answers to questions like:

  • I am part of a married same-sex couple in Massachusetts.  Can I add my spouse to my health insurance plan?
  • Will my MassHealth coverage be affected by the Supreme Court's decision?
  • I am a Massachusetts state employee and I have already added my same-sex spouse to my health insurance.  When will my paycheck reflect that the federal government is no longer taxing my spouse's health insurance coverage?

The last question is an important impact of today's decision. Until now, married same-sex couples had to pay federal income tax on the amount spent by employer's to provide health benefits to their spouse. This added cost, called the "imputed income" tax, will end.

There's also a hotline phone number and links to other resources, including a great series of detailed fact sheets by our downstairs neighbors and friends at GLAD, Gay & Lesbian Advocates & Defenders.

On the policy front, lots of analysts are looking at the impact on insurers and subsidized health coverage. Washington Post health care blogger Sarah Kliff concluded that it will be complicated. Married couples who were considered two single individuals for federal benefit purposes because of DOMA will now be considered a family of two. Depending on their incomes, the decision might make them both now eligible, or both ineligible for coverage assistance.

In Massachusetts, the state was already treating same-sex married MassHealth and Commonwealth Care applicants as married, and forgoing federal reimbursements if they qualified for coverage solely due to our marriage laws. Thus the DOMA decision may slightly help our budget, as we will now get federal revenue for part of their subsidy costs.

HCFA hopes the Supreme Court decision will provide more Massachusetts residents access to quality, affordable, comprehensive health insurance coverage.
 -Brian Rosman

June 26, 2013

The Massachusetts state Senate is planning to vote today on legislation to implement the Affordable Care Act in Massachusetts.

The bill (H. 3452) was approved by the Senate Ways and Means Committee yesterday. The Committee recommended several technical amendments, and one curious symbolic amendment that purports to address a lingering, bogus issue that apparently cannot be put to rest.

The issue is the gradual phase-out of a number of state premium adjustments that are banned by the ACA. We've written about this several times (here, and here), and yet the meme keeps spreading that the ACA will cause premiums to spike for small businesses in Massachusetts.

You can look at our original post for a fuller explanation, but in essence state law has allowed insurance companies to tack on a surcharge on top of base premiums for individuals and smaller small businesses, with up to about 35 employees. The same law has allowed insurers to give a discount to larger small businesses, with from around 35 to 50 employees. The surcharges and discounts balanced each other out, but distorted the market.

The ACA bans both the special surcharges, and the special discounts. They are supposed to go away on January 1, 2014, but the state got a waiver letting us have a 3-year transition period where they phase out in stages.

So those firms that now get an unjustified discount will lose their discount over the next 3 years. Their rates will go up. And those companies that now have surcharges will stop having to pay the extra surcharge. Their rates will go down. In the end, everyone will be at the standard, fair base rate, without artificial discounts and surcharges.

Here's the bottom line: A study commissioned by the DOI found that on whole, three-fourths of all people in individual or small group plans will either see a premium decrease, or a modest premium increase (under 3.3% a year).

Those firms facing "increases" are really only losing a discount they didn't deserve. And this analysis doesn't take into account new wellness tax credits, as well as the federal ACA small business tax credit.

Anyway, the Senate Ways and Means amendment demands that Governor Patrick try again to get a waiver from the federal law (we were the only state to get a 3-year phase-out), which, if granted, would mean higher premiums for thousands of individuals and smaller small businesses.

We will be advocating for some other amendments during the floor debate, including extending current affordability protections now part of the Commonwealth Care statute, and ensuring transparency for new federal funds Massachusetts will be getting due to the ACA.

We congratulate the Senate on its strong support of the ACA, and expect a bill to be at the Governor's desk shortly. Friday would be a fitting day, the anniversary of the Supreme Court's decision to uphold the ACA.
-Brian Rosman

June 25, 2013

Our fiscal year ends on June 30th – there are just five days left to help Health Care For All this year!

June 30

Health Care For All (HCFA) needs your support to fully fund our HelpLine. Will you make a donation today? HCFA’s fiscal year ends June 30, 2012 and we need your help to continue to reach and assist residents of Massachusetts.

Here’s how your gift helps:

  • $50 Helps a consumer better understand their health insurance options.
  • $150 Screens a caller for eligibility for lower-cost and free health insurance programs, fills out an application for benefits, assists him/her in enrolling into a health plan, and schedules their important first doctor’s appointment.
  • $250 Helps to provide health care access to non-English speaking individuals across the state by providing culturally competent and linguistically appropriate outreach materials.
  • $500 Connects a family with the care they need during a serious health crisis, such as a child’s mental health diagnosis.
  • $1,000 Organizes a community meeting to bring residents together to talk about the problems they are facing and act to improve health outcomes in their community.

HCFA’s HelpLine is an underfunded and vital direct service program that assists Massachusetts health care consumers navigate the health care system and enrolls residents directly into coverage.

Thank you for considering a donation today to Health Care For All!

To make a tax deductible donation, click here , call 617-275-2936 to make a pledge over the phone, or mail a donation to: Health Care For All, 30 Winter Street, 10th Floor, Boston, MA 02108

Thank you for your support!

The Staff and Board of HCFA


June 25, 2013

Serious Reportable Events chart

Thanks to the reforms of Chapter 58 and Chapter 305, the Department of Public Health now conducts a regular review of efforts to control infection in Massachusetts hospitals. The department released its third annual report on the progress of hospitals in battling hospital-spread illness, and the overall message seems to be “slow but steady.”

The report primarily focuses on two litmus tests of the pervasiveness of infections: those spread by central line replacements in ICUs (central-line associated blood stream infections, or CLABSIs) and those spread in certain common surgical procedures (surgical site infections, or SSIs.) The department determined hospital progress in these areas by comparing hospital progress in reducing the spread of illness with predicted figures. In terms of CLABSIs, most types of ICUs hovered around the same proportion of infections. However, both pediatric and neonatal ICUs reported a significant reduction in illness spread by central lines.

Many types of ICUs were also making efforts to reduce usage of central lines, a critical step in curbing infection. Every insertion of a central line is a chance for infection to spread, so reports that neonatal, medical, medical/surgical, and burn ICUs had reduced utilization of central lines by more than 7% mark a promising path for further infection reduction. It’s also encouraging that Massachusetts continues to have infection rates which are significantly lower than national rates.

Reports on SSIs were mixed. Data from 2011 shows infection rates decreasing for coronary artery bypass and hip prosthesis procedures, but 2012 data is not available for these procedures yet. 2012 data focused primarily on hysterectomies. While abdominal hysterectomies had infection rates which were in line with predictions, vaginal hysterectomies ended up showing higher infection rates than predicted. A task force is at work to fight further infections.

Additionally, DPH released its June report on Serious Reportable Events (SREs), reporting statistics on serious errors in the medical setting through FY2011, along with predictions for 2012. Data from 2011 shows the most commonly reported SREs include falls resulting in death or serious disability (188), advanced pressure ulcers (bed sores, 70), a retained foreign object from surgery (33), and surgery to an incorrect body part (19). The report’s predictions for 2012 are relatively in line with data from 2011, but the department expects an increase in reports of serious medication error (16 predicted in 2012), which is likely related to last year’s outbreak of fungal meningitis.

The report demonstrates a continuation of a decrease in the incidence of serious medical errors. A good deal of this relates to improved hospital policy around falls and bed sores. However, the report also predicts an increase in SREs relating to surgery in 2012.

The transparency of this data helps patients around Massachusetts hold their hospitals accountable. You can check your local hospital’s number of SREs in each category from the first half on 2012 here, or read the full report from DPH here. You can also check how your hospital measures up with infection prevention here.
 -Devon Branin

June 21, 2013

The Health Policy Commission (HPC) convened this past Wednesday, June 19 for its 6th meeting. Materials from the meeting are available here, and can you read on for our full update below.

June 19, 2013

Today the Massachusetts House of Representatives passed legislation required to implement the ACA. The bill passed on a 116-32 vote that was almost all along party lines. Every Republican voted no, and all but two Democrats voted in favor of the bill.

The vote was preceded by a spirited, if somewhat misguided, debate. Rep. Jeffrey Sanchez, chair of the Public Health Committee, began the debate by emphasizing that the ACA would improve coverage by building on our earlier expansions, and save money for state taxpayers: "We’ve been innovators here in this building, and everyone is looking at us. All the states in the nation, even those who aren’t participating, are looking at us to see how we improve the delivery of health care to our citizens."

He was joined in support of the bill by Rep. Steven Walsh, chair of Health Care Financing. Walsh engaged in a discussion with a number of Republican representatives about the costs of the bill. Republican opposition seemed to be based on misconceptions about the impact of the ACA and the cost to us. The House turned down an amendment proposed by Rep. Daniel Winslow, which would have declared that no state workers or other resources could be used to implement the ACA unless it was fully paid for by the federal government.

Also speaking out eloquently for the ACA was Ways and Means Vice-Chair Rep. Stephen Kulik.

The House approved only a few minor amendments in the process, including a clarifying amendment we supported offered by Rep. Jason Lewis supporting coverage for pregnant women.

We congratulate the House for its support, and look forward to Senate acting on the bill, possibly next week.
 -Brian Rosman

June 19, 2013

In a recent New York Times Op-Ed, “Healing the Overwhelmed Physician,” Harvard Medical School professor Dr. Jerry Avorn highlights how "academic detailing" can both save money and improve patient care.  The House-Senate conference now meeting to finalize the state budget should support the Senate's move to fund this program, which could save some $3 million for MassHealth. Avorn explains how busy physicians struggle to keep up with the steady influx of medical information that is published each week. Modern medicine offers many choices—but this puts a burden on doctors to sort through the available options and identify the best course of treatment.

For years, the pharmaceutical industry has taken advantage of this “information overload” by sending out sales representatives to promote their products. These sales representatives, called detailers, travel to physician practices to deliver sales pitches lauding the benefits of their drugs. Often, detailers provide a free meal and drug samples as an enticement for providers to listen to their spiel. Various medical groups create clinical practice guidelines to aid physicians in their treatment decisions.

Unfortunately, these guidelines may also be tainted by financial conflicts of interest. For instance, some guidelines are developed by practitioners simultaneously serving as industry consultants to a particular pharmaceutical company. Thus, the recommendations can be biased—much like the promotional pitches that pharmaceutical detailers give.

Independent guidance, such as that produced by the Cochrane Collaboration, does exist.  While this is valuable, further steps are necessary to disseminate this evidence-based information. That is where academic detailing comes in. Academic detailing helps doctors stay abreast of current information while avoiding the biases of pharmaceutical-sponsored education. How does it work? Doctors, nurses, or pharmacists are trained to understand comprehensive and unbiased clinical data. They then visit physicians’ practices to pass this information on to practitioners. Academic detailers do not have a financial stake in the drugs that they are recommending, and thus serve as a counterweight to industry-sponsored information. Academic detailing has the potential to achieve two goals, both of which are good for Massachusetts:

  1. Promoting better patient outcomes. Academic detailers will present a more complete view of the available clinical data. This stands in sharp contrast to the selective marketing techniques used by pharmaceutical representatives, who focus on highlighting a drug’s strengths while glossing over its weaknesses.
  2. Reducing healthcare costs. Academic detailers recommend off-patent drugs when evidence shows that they are a safer and more effective treatment option. Pharma has no incentive to market off-patent drugs because, for them, that’s not where the money is. One study from Harvard Medical School and Brigham and Women’s Hospital found that each dollar spent on academic detailing saved two dollars in prescription drug costs. This means substantial savings on prescription drug expenditures statewide— potentially big enough for Massachusetts to recover most or all of what it spends to fund an academic detailing program.

Improved outcomes and lower costs? Sounds like a no-brainer, and we hope our legislators will agree. The Senate budget included $500,000 for academic detailing. No funds were allocated in the House proposal. The Senate Ways and Means Committee calculated a $3 million savings payoff from the measure, making it a smart investment.

Although Massachusetts initially emerged as a leader in academic detailing, in recent years, it has failed to maintain funding for this program. We are now presented with an opportunity for Massachusetts to once again foster a robust academic detailing program and, in turn, encourage a patient care environment that is based on science, not sales pitches.  -Claudia Kraft  

June 17, 2013

Today the state House of Representatives gave preliminary approval to Governor Patrick's legislation to implement the ACA in Massachusetts.

The bill, H. 3452 (text, section-by-section (pdf), and topical summary (pdf)), is expected to come up for a final House vote on Wednesday.

We urge legislators to support the bill. In addition to a passel of technical changes, the bill expands the ability of workers and young adults to get coverage, and reconfigures the state's coverage assistance programs to fit the ACA requirements. The new subsidized coverage programs protect the gains established since 2006, and allow additional low-income families who are now locked out of coverage to get the assistance they need.

We do support a number of clarifying amendments consistent with the intent of the bill and current practice. For example, we propose that the bill carry over some consumer affordability protections that now exist in the Commonwealth Care program. These include the ability to establish payment plans and request premium hardship waivers if someone gets behind on premiums.

We also support writing into law the administration's decision not to allow insurers to add surcharges on to the premiums of tobacco users (background here), and provisions strengthening the role of the Office of Patient Protection. We also are working to establish a transparent, accountable budgetary fund to receive and allocate the additional federal funds Massachusetts will be getting through the ACA.

We will be calling on legislators to support these and other amendments as the bill progresses. Contact Suzanne Curry for more information or to get involved.
-Brian Rosman

June 17, 2013

The Connector Board met on Thursday to review and award conditional Seal of Approval (SoA) for plans to be offered on the Connector in 2014, present the Connector’s Outreach and Enrollment strategy for the Open Enrollment period, and vote on extending the Connector’s contract with its advertising vendor Weber Shandwick. Materials from the meeting are available here. Just click on for our full report.

June 17, 2013

Giving a child with a bad cough or an adult with sinusitis an antibiotic, getting a CT scan or MRI for low back pain, having a Pap test done every year…these are all examples of tests or treatments that are over-used and about which patients should have conversations with their providers before they are done. We  all know that some tests and treatments, when done unnecessarily, can lead to further anxiety or harm.

So how do we address this issue? Patients need to be educated, sure. But so do physicians and hospitals, who order the inappropriate tests and procedures. And because economic incentives often influence these choices, we need to change those as well.

The ABIM Foundation's  started its Choosing Wisely campaign focuses on patients. The Massachusetts Health Quality Partners (MHQP) will be working to advance the Choosing Wisely campaign in the Commonwealth. Choosing Wisely is an effort to ensure patients are receiving evidence-based, effective care. The program compiles materials and resources patients can use to be more engaged in their care and have conversations about their care with their doctors and other care providers.

Going forward, the campaign plans to work with MHQP’s members, which include employers, health plans, consumers, and other interested parties, to raise awareness about specific procedures and tests patients should question.

There are many good reasons to be skeptical about the value of this approach. Change needs to happen at the physician level as well. So we're particularly pleased that the campaign will also reach out to the Massachusetts Medical Society to disseminate resources about unnecessary care. Additionally, the campaign will work to integrate Choosing Wisely with MHQP’s statewide Practice Pattern Variation Analysis program, which provides the opportunity to educate providers directly about what tests and practices can cause problems and waste.

This campaign is a large step forward for making health care more efficient and coherent for patients and advancing the partnership that should exist between providers and patients when making care decisions. Many of us have been in situations where we are not sure if a test or treatment is right for us but we often don’t have the tools to speak up. Choosing Wisely can empower patients to be true partners in care.
-Devon Branin

June 12, 2013

The Framingham-based company that owns the Cumberland Farms convenience store chain and all Northeast Gulf gas stations just announced a smart, reasonable step that will be seen as bold, and confounds conventional wisdom about implementation of the ACA.

Effective January 1, 2014, the Affordable Care Act requires that full-time employees working at a company with at least 50 workers have access to affordable health insurance through their employer. Full-time is defined as working 30 hours a week or more. If the company chooses not to offer full-time employees affordable health coverage, the firm pays a penalty.

So the conventional assumption is that the new law will drive employers to cut workers hours, to avoid having to either provide benefits or pay the mandate penalty.

Not so fast.

Here's how Convenience Store News (did you know there was such a thing?) put it:

Although many retailers are considering cutting employee hours in response to the Affordable Care Act employer mandate, The Cumberland Gulf Group, operator of 589 convenience stores, is taking the opposite approach -- one that may send shockwaves throughout the c-store industry. The company announced this morning that it will expand its health care program to cover an additional 1,500 employees approximately as of Oct. 1.

The company press release provides more details:

The Cumberland Gulf Group currently employs about 3,000 full time employees at 40 hours per week and 4,200 part-time employees. In order to aggressively pursue the extension of benefits to its part-time population, the Company is reclassifying 1,500 part-time employees to full-time status, which will bring the mix of employees to approximately 4,500 full-time and 2,700 part-time.

Additionally, while many companies are waiting until 2014 to implement their solutions to the new mandate, the team was charged with implementing the new program as of October 1, 2013 of this year, a full year ahead of when they would be required by the IRS to be in compliance.

Why are they doing this? The Wall Street Journal has the answer:

“We sketched out all the options, which included paying the penalty or having employees work fewer than 30 hours,” said Ari Haseotes, Cumberland Farms’ president and chief operating officer. The company has decided to make employee satisfaction and retention a corporate priority, and that meant expanding access to benefits. “We’ve been moving in this direction, but the ACA galvanized us to move more quickly,” he said.

The primary metric the company considered was its employee turnover ratio. Full-time employees stay, on average, three to four times longer than part-timers do, said Haseotes. Longer-tenured workers deliver a better experience for the customer—especially in the convenience-store business, where the customer is often in a hurry, he added.

“Our people know how to speed a customer through checkout quickly, how to use our ovens to make a pizza or sandwich right.” When turnover is high, he said, customer satisfaction suffers.

The ACA gives employers a unique opportunity to think about employee satisfaction, retention, and the long-term implications of how they handle the health reform law. Cumberland Gulf Group has taken advantage of the circumstances and devised a plan that helps their workers and puts customer and employee satisfaction first.

We congratulate Cumberland Gulf, and expect many other employers to make the same business decisions they did.
-Zoe Burns