October 2013

October 30, 2013

Medically Induced Trauma Support Services (MITSS) will be holding its annual fundraising dinner the evening of November 14 at the Westin Copley Place Hotel (event details here).

This year they are also doing something new and adding a free educational forum that is taking place prior to the dinner. The forum, “Supporting Patients and Families Following Medical Harm - Are We Missing the Boat?” will take place at the Westin Copley Place Hotel from 1pm until 4:30pm. Learn more about the forum and how to register here.

MITSS continues to lead the way in supporting patients and families who have been impacted by medical errors, and with this event they will bring much needed attention to this area. Thank you to MITSS for all of your important work.
-Deb Wachenheim

October 29, 2013

Enroll America Blog - title

Enroll America is the national non-profit working to to maximize the number of uninsured Americans who enroll in health coverage made available by the Affordable Care Act. They are focusing on states with the highest numbers of uninsured, as you would expect. But a number of their senior staff members were in Boston last week to learn about our success in Boston and share ideas and strategies. We also discussed what we are doing now to pick up the remaining uninsured and help those transitioning to ACA coverage.

They just published a blog post written by Ari Fertig, HCFA's Information and Marketing Coordinator, about HCFA's aggressive education work to get the word out about the ACA  in Massachusetts:

When we talk with folks around the country about Massachusetts health reform, we’re proud to boast that over 97 percent of our residents—and 99.8 percent of children in the state—have health insurance. Sometimes, many people think that Affordable Care Act (ACA) implementation must not mean much here since we had our own health reform back in 2006 -- but that is not really the case.

Implementing the ACA here in Massachusetts requires a lot of outreach and education—people need to know how things will be changing. The analogy we like to make is that we’re renovating a house, rather than building the house from the ground up—so there are bound to be some challenges.

In partnership with the Health Connector—the Massachusetts Marketplace or “exchange”—and local community organizations across the Commonwealth, Health Care For All launched a public education campaign targeted to individuals, families and small businesses—paying special attention to the Spanish- and Portuguese-speaking communities—about the affordable health insurance options available in Massachusetts.

There’s a lot for Massachusetts consumers to know. People who were not on subsidized health coverage before may be eligible now for MassHealth, our Medicaid program, thanks to the Medicaid expansion. There are new dental options available on the Health Connector. Small businesses qualify for new tax credits. More people will be eligible to get help paying for health insurance. The Marketplace will offer more health plan options for residents.

We still have work to do to make sure that residents in Massachusetts know about their options. So here’s our grassroots approach:

  • We’re launching a door-to-door canvassing effort to knock on 40,000 doors across Massachusetts.
  • We’re reaching out to 1,000 minority-owned small businesses to talk with them about their health care options under the ACA.
  • We’re distributing door hangers, brochures, and other materials to make sure individuals and families know about their health care options and have updated information—this will help us enroll the uninsured.
  • We’re working with regional partners from cities like Worcester (the second-largest city in New England) to small towns to make sure that even in places where there are no navigators or other kinds of in-person assistance available, people know about their health coverage options.

But we know that we need both a bottom-up and a top-down approach to reach everybody. So we placed advertisements in ethnic media outlets across the state and engaged with key stakeholders garnering a number of front page media stories in newspapers and magazines.

Health Care For All’s HelpLine has already seen a significant uptick in the number of consumers calling to request our assistance due to these efforts. Our HelpLine is a free service that can answer any Massachusetts resident’s questions about health insurance and connect people with public programs. You can call our HelpLine at 1-800-272-4232.

We'll have further updates about our campaign soon.


October 28, 2013

The Statewide Quality Advisory Committee met last Monday and approved its year 2 final report. The report should be posted on the website soon, and you can see last year's report and meeting materials here.

Before approving the final report, the group heard a presentation from Dr. John Wasson, the creator of www.howyourhealth.org, a tool for measuring patient confidence in care.

HCFA had proposed that patient confidence and measures of shared decision-making be considered for the Statewide Quality Measure Set. Dr. Wasson came to the meeting to inform the group in more detail about the patient confidence measure. Thanks to his presentation and discussion  with the members, the final report, while not approving patient confidence or shared decision-making measures right now, will recommend that they should continue to be examined and considered as they become more widely used in Massachusetts.

The one new measure that was added to the measure set relates to obstetric trauma during birth with instrumentation.  The final meeting of 2013 will be on December 16, 3:00pm, at CHIA, 2 Boylston Street, Boston, 5th floor. The group will revisit its 2013 priorities (behavioral health, care coordination, and patient-centered care), discuss whether or not they were addressed, and talk about priorities for 2014.
-Deb Wachenheim

October 28, 2013

Last week, the Office of Consumer Affairs and Business Regulation held its second community conversation conference on “empowering healthcare consumers.” Click here  to read more about the conference and the featured speakers and to see information about the first conference held last spring in Boston.

The bulk of the gathering involved a panel discussion on healthcare price and information transparency and, later, facilitated table discussions on health care choices.  Panelists included representatives from insurance carriers (Harvard Pilgrim, Fallon), purchasers (GIC), health care providers (Steward, Reliant Medical Group, MHA), government (Office of Consumer Affairs and Business Regulations) and an employer group (Associated Industries of Massachusetts).

The panel, moderated by reporter and anchor Susan Wornick, discussed cost transparency tools and what needs to happen for consumers to utilize the information in a meaningful way. A few panelists mentioned the apparently often-held belief among consumers that if something is more expensive it must be better, including in health care, and that websites should be set up in a way to allow for that myth to be busted. This can only happen if websites present cost and quality information side-by-side in an easy to navigate and understand format.  One panelist made the interesting point that there is no quality measure for when something (a procedure, test, etc.) is not done, though this should often be one of the options discussed by the patient and provider, and that discussion in actuality does not happen often enough (as more provider use shared decision-making tools, hopefully those discussions will happen more often). Another panelist pointed out that cost and quality information is useful not just for consumers but for referring doctors, who would like to have that information easily available when they are making referrals. Panelists also commented on the difficulty of asking the consumer to take on the role of making decisions when they are sick and/or vulnerable, which is why this needs to be a partnership conversation involving the provider and the patient/family.

The table discussions involved a scenario in which you are undergoing physical therapy for a rotator cuff injury and during that time you are researching your options among 5 different hospitals in case you have to have surgery. Nicely laid out on a sheet of paper (unlike what can be found on-line) was an easy-to-understand chart showing things like rate of infections/complications, length of stay, number of surgeries per year, patient satisfaction, total cost and total out-of-pocket cost.  Even when out-of-pocket costs were the same at all 5, nobody chose the hospital that had the highest overall cost because they saw that length of stay and the patient satisfaction and infection/complication rates were worse than at some others. So at least for these well-informed consumers, when given clear information on quality, they are able to make a choice based on something other than the alleged myth that more expensive is better. However, for the general population this is much less true.  Even with this information in front of us, we wanted more details so that we knew what it meant that one hospital had, for example, a low and another a medium complication rate.

We look forward to seeing how this statewide empowerment campaign, to quote Barbara Anthony, will evolve. These first two conferences were a great opportunity to explore the issues but most of the folks in the audience were not there purely in their role as consumers. We hope the next steps will reach more of the general public, and we are happy to be one of a number of partners in this effort.
-Deb Wachenheim

October 21, 2013

Goals and Methods of the Massachusetts SIM grant

The Health Policy Commission (HPC) met on Wednesday, October 16, 2013 for its ninth full meeting. Several important issues were discussed at the meeting, including trends that emerged from the Annual Cost Trends Hearing; updates on the Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program; current activities under the federal State Innovation Model (SIM) grant program, and updates on cost and market impact reviews.

The consolidated meeting presentation is here (pdf), and our full report is below the fold.

October 19, 2013

As implementation of the Affordable Care Act moves forward, Massachusetts policymakers continue to update state laws and regulations.  Recently, the Health Connector released proposed regulatory changes to the Massachusetts Student Health Insurance Program (SHIP) (pdf). Since the 1988 Dukakis universal coverage law, students attending Massachusetts colleges and universities have been required to have health insurance. The state has required all colleges and university to offer a SHIP, and gives schools the discretion as to whether to require students to take the SHIP or keep or enroll in other comparable coverage. Many SHIPs had traditionally offered less than comprehensive coverage and the insurance carriers offering these plans made substantial profits off of the students. Many of the student plans had very low "medical loss ratios," meaning they spent less on medical care and more on administrative costs).   In recent years, the Health Connector collaborated with the Department of Higher Education and other agencies to improve benefits in SHIPs at state and community colleges. ACA implementation offers further opportunities to improve SHIPs and enable students greater access to health coverage, particularly those from low-income families.  For instance, today, low-income Massachusetts residents who are college students lose their MassHealth coverage upon turning 19.  With the ACA Medicaid expansion, these students will be able to continue or become eligible for MassHealth as long as they meet the income thresholds, no matter their age. More importantly, today college students are also locked out of Commonwealth Care coverage due to access to SHIPs. Starting in 2014, with the ACA, low-income college students not eligible for MassHealth may be able to get help paying for health insurance through the Health Connector. The Health Connector made further changes to the state’s SHIP regulations to both comply with the ACA and further strengthen and streamline the SHIP.  We appreciate that the Health Connector took many of HCFA’s suggestions into account when developing these rules. The proposed regulations include many improvements that will help low-income students with the cost of SHIP coverage, such as requiring schools to:

  • Give students the opportunity to enroll in partial year coverage, which may be prorated by term, which can help with the affordability of SHIP coverage;
  • Offer students a prorated premium refund to any student who paid to enroll in a SHIP for entire school year but who is not a student at the beginning of a term during the school year; and requiring that schools; and
  • Accept MassHealth or subsidized health insurance coverage through the Health Connector as comparable coverage.

In addition, the proposed regulations strengthen coverage by requiring that all SHIPs – both fully-insured and self-funded – comply with ACA insurance market reforms and consumer protections, including covering Essential Health Benefits (EHBs), eliminating annual and lifetime limits, and not charging cost-sharing for preventive services.  The regulations also require SHIPs to comply with cost-sharing provisions of the state’s Minimum Creditable Coverage standards. The SHIP regulations are open for public comment.  A public hearing is scheduled for Tuesday, November 19th at 9:00 at Asbhurton Café (in the basement of 1 Ashburton Place).  Written comments are due by November 15th to connector-legal@state.ma.us. We appreciate the Health Connector’s efforts to improve health insurance coverage for Massachusetts college students and look forward to providing more feedback during the public comment period. -Suzanne Curry

October 17, 2013

At Wednesday’s Public Health Council meeting the Department of Public Health presented its draft regulations (PDF) for implementing Section 227 of Chapter 224. This section focuses on providing information to appropriate patients about palliative care and end-of-life care options.

There are four parts in the section. The first contains definitions of terms. The second part directs the DPH Commissioner (for some reason the law was written this so that the Commissioner, rather than the Public Health Council, shall promulgate the regulations, so after the public comment period, the Commissioner will make the final decision on the regulations and bring those to the Council) to adopt regulations requiring hospitals, nursing homes and health centers to distribute information on palliative care and end-of-life care options to appropriate patients. It also mentions assisted living facilities, but DPH does not regulate those facilities. It will work with the Executive Office of Elder Affairs on this piece. The third part does not apply to DPH but to the Board of Registration in Medicine and the Board of Registration in Nursing because it speaks to attending health care practitioners offering to provide patients with information and counseling (DPH staff said they will be working with these Boards on implementation). The fourth part directs DPH to work with the Hospice and Palliative Care Federation to develop the related information, rules and regulations.
Under the draft regulations, the covered facilities will be required to:

  1. Have a process to identify appropriate patients;
  2. Ensure that appropriate patients receive information;
  3. Distribute information about hospice and palliative care in a timely manner;
  4. Inform all physicians and nurse practitioners of the requirement to provide end-of-life counseling to patients with a terminal illness or condition (This is the section that is under the Boards of Registration in Medicine/Nursing-and it should actually say that it is a requirement to OFFER to provide counseling to patients).

DPH can request to see the facility’s process and policy and to review it. One suggestion from a Council member was for DPH to develop a model policy to distribute to facilities.
The regulations require facilities to distribute to appropriate patients culturally and linguistically suitable information regarding the availability of hospice and palliative care. They can either use a DPH-issued informational pamphlet (which they are drafting) or a facility-created pamphlet. The pamphlet must at least include:

  1. Definition and explanation of advanced care planning, hospice care and palliative care;
  2. Other requirements defined in the guidance of the Department.

It is wonderful to see the specific requirement about culturally and linguistically suitable information. However, the actual implementation of this is not something to be taken lightly. Some cultures have very strong feelings regarding talking about death. Will facilities be able to conduct focus groups or hire consultants from specific communities who can assist them in developing this information in a culturally appropriate way? DPH may have to get further involved in this piece to ensure that this is done correctly.

DPH will issue guidance for facilities suggesting that they include the following components in an informational pamphlet:

  • FAQs about hospice, palliative care, and patient legal rights;
  • A MOLST form and explanation;
  • Conversation tools to encourage discussions with family and providers;
  • List of licensed hospice providers near the facility.

Other comments from Council members included asking about efforts to engage the faith community and also to get the information out to health care workers other than those in the covered facilities. For example, community health workers, home health workers, and many others interact regularly with patients who may want/need this information. Even within hospitals, it was mentioned that it should not just be the doctor or nurse who gets this information to distribute but social workers, chaplains, etc. Council members suggested that DPH work with the Department of Developmental Services and the Department of Veteran’s Services to reach populations who may not otherwise be reached. Council members talked a lot about the need to educate the public. For example, many individuals do not understand that receiving palliative care does not mean that you are stopping all treatment for your condition.

We hope that the Boards of Registration will work closely with DPH to ensure that the section covering individual health care practitioners is implemented. It is often in the outpatient setting that this type of information and counseling needs to be provided to patients and families.

October 15, 2013

The Public Health Council is meeting tomorrow (Wednesday 10/16) at the Department of Public Health, 250 Washington Street, 2nd floor. See the agenda here (pdf).

Topics to be covered include draft regulations on information for patients about palliative care and end-of-life care options (required under Chapter 224) and final regulations relating to pediatric immunization and BMI reporting on school children. Meetings are open to the public.
-Deb Wachenheim

October 11, 2013

Yesterday, the Connector Board met for the first time since the launch of open enrollment on October 1st, a significant milestone for Massachusetts and the nation as the coverage provisions of the Affordable Care Act (ACA) become reality.

Meanwhile, enrollment in current Health Connector program has continued to grow, with the highest enrollment seen to date: 210,219 Commonwealth Care members and 43,526 Commonwealth Choice members.

The Board discussed the open enrollment which began last week, new regulations for "ConnectorCare," which will replace Commonwealth Care for many current members, and student health insurance regulations.

Materials from the meeting should be available on the Connector website (try the About link at the top, then Leadership/Board Meetings on the side menu). You know what to do to read our full report.

October 8, 2013

Massachusetts has made progress in cost growth rates

Last week the Health Policy Commission (HPC) held the annual health care cost trends hearing. Chapter 224 transferred the responsibility to conduct the hearing to the HPC, in coordination with the Office of the Attorney General and Center for Health Information and Analysis (CHIA).

The two-day hearing focused on a public examination into the drivers of health care costs, including testimony from experts and witnesses and some tough questions from HPC Commissioners and state officials. Highlights included lots of discussion about the role inadequate behavioral health care plays in health care costs, the good and bad of provider consolidation, and much discussion about the impact of people moving from HMOs to PPOs. We were also struck by the incessant use of the cliché term, “right care in the right place at the right time,” which was always trivial, and has now become meaningless through constant repetition.

This was the fourth year of the cost trends hearing (see info on the previous years’ hearings here, and most of our reports here). The hearing used to be 3 and even 4 days long in past years. In HCFA’s testimony on the last afternoon, we dryly suggested that the hearing be lengthened again. Nobody laughed at our joke. We were kidding, but the hearing is an important opportunity for everyone in the state’s health care policy world to express their position, to listen to each other, and to think about the tough questions.

All the prepared testimony and presentations from the hearing are on the HPC site. We took notes and tried to summarize as best we can, but there’s obviously more that was said than we can report. But click on for our detailed take of all the discussions:

October 8, 2013

Governor Patrick published a piece in the Huffington Post today with the self-explaining title, "Health Care Reform Works in Massachusetts and It Will Work in America."

In the piece, the Governor goes beyond the statistics and presents some stories (that's how we roll, too):

I met a young woman named Jaclyn, a cancer survivor who got life-saving care through our version of an exchange. She had no way to afford care before health care reform -- it saved her life.

A self-employed man named Ken ignored his gastrointestinal symptoms for years because he couldn't afford to see a doctor or pay for possible treatments. Once insured, he was seen and treated for Stage III colon cancer and is cancer free today. ...

Expansion hasn't hurt our general economy. Unemployment has remained lower than the national average and economic growth has been higher. At one business incubator, a young entrepreneur told me he moved his start-up to Massachusetts because he wanted to be sure his young family had health insurance while his business got off the ground. Today that young man's company is employing others.

The Governor also connects health reform to broader concerns and our values:

In one form or another, health care significantly affects business, household and government budgets, people's ability to get a job, and a child's readiness to learn. Accessible, affordable, quality care in all cases improves lives and in many cases saves lives. It gives peace of mind and economic security to families. It increases productivity for large and small employers as well as for students. It creates jobs and contributes to our economic strength. It's a powerful statement of who we are.

The article ends with some political analysis and some well-deserved boosterism:

Tea Party Republicans don't want the Affordable Care Act. Do they really mean they don't want these kinds of improvements in the lives of millions of Americans? I don't think so. Would they rather we address these issues with a government program instead of through the market-based, individual choices that are the framework of the ACA? I don't think that's true either. Have they proposed an alternative way to accomplish these goals? Nope. Despite a presidential election, a decision by the United States Supreme Court, and over 40 failed repeal attempts, it's clear that what Tea Party Republicans don't like about Obamacare is the "Obama" part of it.

In Massachusetts we're proud to be home to many "firsts." The first Thanksgiving. The first battles of the American Revolution. The first public library, the first typewriter and the first subway. Even the first chocolate chip cookie. Recently, the first state to achieve universal health care, the model for the ACA.

Firsts are hard. There are and will be challenges. But it has been and will be worth it. Just ask Jaclyn or Ken or any of your neighbors.

We congratulate Governor Patrick. As the state transitions from Chapter 58 to ACA implementation, we are seeing many people who will be soon getting help that they could not get now. You know our slogan:

National H Reform is Good for MA (no dot org)

  - Brian Rosman

October 3, 2013
HCFA consumer testify before Public Health Committee 10-1-13 HCFA consumer testify before Public Health Committee 10-1-13

On Tuesday, three Health Care For All consumer advocates sat before the Joint Committee on Public Health to explain the damaging effects of out-pocket-costs and to lend their voices to making change.  Laura Hudson of Northhampton, Valerie Spain of Cambridge, and Dr. Steve Slaten of Worchester testified in support of H. 2084, “An Act relative to keep people healthy by removing barriers to cost-effective care."  The Health Care for All-authored legislation, sponsored by Rep. Carl Sciortino and Senator Patricia Jehlen, would set up an expert panel to make recommendations to DPH regarding which high value and cost-effective services and medication should not be subject to out-of-pocket cost sharing, like co-pays, deductibles, and co-insurance.

Barrier-Free Care in a Nutshell
The legislation draws from a concept known as Value-Based Insurance Design, which recognizes that out-of-pocket costs are intended to compel patients to reduce care, in an effort to contain costs.  However, rationing necessary care - especially cost-effective drugs or treatments connected with chronic illnesses like diabetes, hypertension, HIV/AIDS, asthma, and mental health conditions - puts patients at risk of developing bigger, more expensive health complications down the road. For these services, we don't want patients to limit their use. In these cases, out-of-pocket charges don't make sense.

Just as the ACA ended cost-sharing for many preventive screenings, this proposal would eliminate cost-sharing for cost-effective care that prevents higher cost acute illness.

Consumer Testimony
Laura, a caseworker and program coordinator with HIV/AIDS patients, stated that although her patients receive significant assistance through the HIV Drug Assistance Program (HDAP), “there are still significant barriers to care, such as annual deductibles and needing to pay a co-pay for each office visit.”  She told the story of a patient whose annual deductible was so high, he was forced to go without his inhibitor medication for an entire month.  She continued that the affordability challenge captured in his story has been compounded by more recent barriers, pointing to a recent Blue Cross Blue Shield policy that requires chronic illness patients to buy their medication in 3-month blocks.  As a result, patients must forgo HDAP’s month-by-month co-pay assistance and pay 3 months’ worth of copays upfront.  Laura noted that this barrier is particularly difficult for her patients, as many of them are prescribed more than one medication to deal with their illness.  She continued that being able to consistently access care would not only improve the health of her patients, but would go a long way towards preventing the spread of HIV, as the inhibitor medication helps patients maintain an undetectable viral load.

Valerie,  the director of Energize Everett, noted that her tiered network plan has exacerbated the challenges that out-of-pocket costs pose to her efforts to maintain responsible care for her Type 1 Diabetes.  “I make 50K and now pay $50 a month in co-pays for diabetes supplies,” Valerie stated. Valerie continued that reducing her copays would improve her ability to maintain the excellent control over her health that she has worked hard to cultivate for years.

Dr. Steve Slaten, a psychologist, concurred with Laura and Valerie’s statements, noting that, as a someone with Crohn’s disease, it is not difficult to fall into the habit of self-rationing medication.  “It is so easy to take it twice a day instead of the required 4 times a day to stretch out the money until the disease flares up again,” Steve stated. “I’ve had to deal with that.”

However, Steve really drove the point home when sharing the story of a friend in Worcester who lost his sister Sally to cancer.   While undergoing chemotherapy, Sally and her family were unable to afford the co-pays that came with the extra oxygen equipment she needed on top of all of the other expenses that came with her care.  When they were finally unable to pay, the company providing the equipment refused service and took back the equipment, leaving Sally to die weeks later from complications.  Steve directly addressed the panel of lawmakers, stating:

From their perspective the insurance companies will tell you that providing free high value, cost-effective care for certain serious diseases is going to cost them money…and they are partially right.  The savings of preventing ER visits and expensive care for acute episodes may not affect their bottom line this next fiscal quarter or in this fiscal year.  The cost savings and health benefits of preventive strategies add up over years, but that is not the time frame within which insurance companies evaluate their financial performance.  It is up to policy makers and legislators like you to decide that long term benefits are of greater value than short term costs.