April 2015

April 30, 2015

Report - Rising Health Care Cost in MA: What it Means for ConsumersThe Blue Cross Blue Shield Foundation just released a blockbuster report on the impact of high health costs on Massachusetts consumers.

The stark conclusion should have strong policy implications:

Though the Commonwealth leads the nation in health coverage, with 95 percent of Massachusetts adults insured, a significant number of people struggle with the affordability of health care.... [N]early one of five reported problems paying medical bills or reported paying them off over time. People who have low incomes, those who are in poor health or have chronic conditions needing regular care or medication, and those who are only intermittently insured experience even greater difficulties with the high cost of health care.

Massachusetts consumers have many problems due to high health care costs

The report, prepared by Carol Gyurina, Jennifer Rosinski and Robert Seifert of UMass Medical School, is full of compelling statisical analysis to back up its findings. The findings are based on the Foundation's Massachusetts Health Reform Survey. Looking at the annual surveys, they found that:

  1. Consumer health care costs are increasing much faster than incomes. From 2006 to 2012, median incomes went up 15%, while consumer-paid health care spending went up 38%.
  2. High deductible plans are growing in Massachusetts - now around 45 percent of those with individual plans, and 38 percent of those with coverage through a small (under 50 workers) employer. As a result, nearly one in ten adults spent over 10 percent of their income on out-of-pocket health care costs.
  3. And so, an increasing number of people in Massachusetts are avoiding needed health care due to cost. Around one in seven of all adults who were covered all year report avoiding needed care because of the cost. The most frequently avoided services due to costs are dental care and prescription drugs. The problem is worse for younger adults, parents, people who identify themselves as Hispanic or Latino, and those buying coverage on their own.

In addition to the analytic conclusions, the report ends with four moving, personal stories detailing how Bay Staters are responding to these high out-of-pocket costs. HCFA assisted the UMass team in finding the people profiled, using our HelpLine and other contacts to locate them. The stories personalize the difficult real-world choices they face and make them relatable and real. So, beyond the detailed charts, in the report you will meet:

  1. Katharine Jackson, from Plymouth, who came down with a rare inflammatory disease and ended up with some $10,000 in medical bills just for doctors' visits and tests, despite having employer-sponsored health care insurance.
  2. Ronald Boisvert, from Newbury, whose in-network doctor sent a biopsy to an out-of-network lab, resulting in a bill of $1,900. This was on top of co-pay charges for surgery, imaging and consultations he received as part of his cancer treatment.
  3. Marisabel Melendez, a Lawrence mother with employer coverage, whose high cost of caring for her diabetes led her to tempt malnutrition in an attempt to lessen her need for diabetes drugs. Later, she  moved in with her mother to save enough rent money to pay her copays.
  4. Stephen Slaten, from Worcester, who started taking just half the prescribed dose of his Crohn's disease medication when he became unemployed. The result was a major flare-up, causing him to need more medication and tests.

HCFA has long been concerned with the impact of high out-of-pocket health care costs on Massachusetts consumers. Our "No-Copay" bill (S. 606 / H. 984, An Act to keep people healthy by removing barriers to cost-effective care) would eliminate cost-sharing for cost-effective preventive care for people chronic disease. This report should spur all of us to action on the issue of ever-growing health care costs.

     - Brian Rosman

April 29, 2015

USA Today article on growth of PFACs in Massachusetts

USA Today and Kaiser Health News published an article about the spread of Patient and Family Advisory Councils across the US and their deepening involvement in improving care and patient and family experiences. Brigham and Women’s Faulkner Hospital and MGH are among those highlighted with examples of how they engage patients and families in their work. Massachusetts is the first and only state to mandate PFACs in all acute-care and rehabilitation hospitals. More than 90 PFACs have been established across the Commonwealth, and 2015 marks five years since all PFACs were required to be in place.

HCFA and its Massachusetts PFAC Advisory Board are celebrating this five year mark, and looking to the future, with this year’s 3rd Annual PFAC Conference, taking place May 12 at the College of the Holy Cross. More than 200 PFAC members and others will gather to share best practices, hear from inspiring speakers, and network.

The USA Today article describes several efforts to engage patients and families. In addition to those efforts mentioned in the article, there are PFACs in Massachusetts that have initiated projects and partnered with their host institutions to make a true difference in care within the hospital and in the community. From working to improve behavioral health care in the E.R. to spearheading a community campaign promoting the use of medication cards to educating the community about palliative care and hospice care, the patient and family members of PFACs bring their unique perspectives and experiences to inform and advance life-changing initiatives. As the article touches on, strong support from hospital leadership and a culture that welcomes patient and family involvement are vital to ensuring the PFACs feel empowered to speak up and make change.

HCFA and the PFAC Advisory Board are working to advance this work through the annual conference and in many other ways. All PFACs are required to write annual reports highlighting their efforts during the previous year. HCFA and the Advisory Board collect all of those reports, which can be found on the HCFA website. If you want to learn more about a particular PFAC’s work, just click on the name of the hospital. Soon, HCFA will release its PFAC summary report, giving an overview of the work that is taking place across the Commonwealth.

April 28, 2015

The state House of Representatives began its budget debate yesterday, for fiscal year 2016, which starts on July 1. Over 1000 amendments have been filed (see the budget and amendments here).

As usual in the House, the amendments are being considered in groupings by subject matter. The health care bundle is expected to come up tomorrow or Thursday. Tonight, a group of HCFA citizen activists will fan out across the State House, meeting with Representatives to discuss HCFA's priorities. Here's some of our top amendents for support in the budget - we urge you to contact your Representative today on these:

Oral Health

MassHealth only provides a limited dental benefit to adults. More than 800,000 people, including 120,000 seniors and 180,000 people with disabilities, are without access to dental care beyond cleanings, fillings, extractions, and full dentures.  Left untreated, dental disease can lead to systemic infection, hospitalization, and in the worst cases, death.  No one should die because of a toothache.

  • Support Rep. Scibak’s amendment (#298) to fund full restoration of MassHealth adult dental benefits. 
  • Oppose Rep. Jones amendment (#296) to allow restrictions on MassHealth adult dental benefits

Individuals living with disabilities have particular oral health needs, including adaptive facilities and equipment, as well as providers with specialized training.  The Tufts University School of Dental Medicine partners with the state to operate the Tufts Dental Facilities (TDF), which provide oral health care for persons living with disabilities in sites across the Commonwealth.  Budget cuts to DPH’s Office of Oral Health since 2008 have made the continued viability of the TDF precarious. 

  • Support Rep. Scibak’s amendment (#291) to allocate $500,000 in additional resources that will allow TDF to provide much-needed dental services

Prescription Drugs

Faced with an overwhelming amount of new clinical research, health care providers often rely on pharmaceutical sales representatives for information about medications they prescribe. This can result in higher costs for patients and the Commonwealth, as representatives promote their newest, most expensive brand-name drugs. “Academic Detailing” provides independent, evidence-based information on prescription drugs, supporting doctors in making the best decisions for their patients, based on balanced data rather than biased promotional information.

  • Support Rep. Benson’s amendment (#734) to provide $500,000 for DPH’s evidence-based prescriber education program.

Children’s Health

Early Intervention is the state’s most cost-effective program in the Commonwealth dedicated to serving children from birth to three years with developmental delays and disabilities. The program has a remarkable track record of limiting the need for more expensive, less effective services in later years with more than $27 million in special education savings attributed to EI services. The program serves more than 35,000 children and families each year through 60 Early Intervention programs statewide.

  • Support Rep. Kafka’s amendment (#686) to provide $28.4 million for Early Intervention services.

Health Reform

Today, federal revenue to Massachusetts due to our expanded health care coverage programs now goes into the broad General Fund. Establishing a segregated, distinct MassHealth and Healthcare Reform FMAP Trust Fund will provide a foundation to ensure that new Affordable Care Act federal Medicaid funding is used for MassHealth and subsidized health insurance programs. A robust trust fund would ensure resources for services to low-income residents, support providers, and provide transparency in how the federal funds are spent.

  • Support Rep. Benson’s amendment (#614) to establish the MassHealth and Healthcare Reform Trust Fund.



April 15, 2015

Please join Representative Jennifer Benson and the Alosa Foundation this Thursday, April 16th from 11:30 to 12:30 in Statehouse Room 437 for a legislative briefing on Academic Detailing: Helping Combat the Opioid Epidemic.

Health care providers today are constantly bombarded with an overwhelming amount of new clinical research on different prescription drugs and treatments, making it difficult to stay current about which are most effective. At the same time, the pharmaceutical industry spends billions on marketing directly to doctors to promote their products. This disproportionate influence results in worse outcomes for Massachusetts patients and residents, as providers are likely to over-prescribe or needlessly prescribe more expensive, less effective drugs.

"Academic Detailing" remedies this issue by offering providers evidence-based educational information about the therapeutic benefits and cost-effectiveness of various drugs. This allows doctors to make decisions based on balanced research data rather than biased promotional information, ultimately leading to better and more informed care decisions. It is an especially important tool in combatting the over-prescribing of prescription opioids.

Unfortunately, both Governor Baker and the House Ways and Means Committee have chosen to forgo funding for this critical program. We hope that you’ll join us on Thursday to learn why funding for this program must continue and show support for a new budget amendment that will be introduced by Representative Benson.

       -  Kate Frisher

April 14, 2015

What's a medical homer?A "Patient-Centered Medical Home" (PCMH) is not an institution or nursing home, but a primary care medical practice that offers coordinated, comprehensive care that is personal and focused on the patients' needs. PCMHs have the potential to both improve patient care and reduce costs. By engaging the patient at the center of his or her own care, a medical home can focus on improving overall health and wellness in partnership with the patient.

At least that's the theory. But what practically is required of a medical home?

The state's Health Policy Commission (HPC) is charged with figuring that out. They have issued a draft framework for their medical home certification standards, based on national standards advanced by the National Committee for Quality Assurance. The hope is that strong standards will send a signal to patients that they can get the highest quality medical care by choosing a practice that meets the state's definition.

Health Care For All and the Massachusetts Public Health Association jointly submitted comments to the HPC on their medical home standards. In our comments, we expressed strong support for the direction taken by the HPC in their draft. We also emphasized a number of points where we urged the HPC to further advance the goal of medical homes through a number of provisions, including:

  • demonstrating cultural and language proficiency in the practice
  • coordination with coummunity-based resources, like community health workers
  • feedback from patients on their experiences with the practice
  • measure, and work to improve patient engagement in their care

There's a lot of wonkiness here, but we invite you to read our full PCMH comments here, and let us know what you think.

           - Brian Rosman

April 12, 2015

Administration officials from the Governor on down have been repeating the mantra over the past few months - MassHealth is "unsustainable."  Last Monday, EOHHS held a big public input session, titled, "Creating a Sustainable MassHealth Program."

Yes, MassHealth takes up a large portion of the state budget (but not as large as you think). And yes, MassHealth has seen spending increases over the years (but what part of the health care system hasn’t)?

But, does that make the MassHealth program unsustainable?

Let’s look more closely at the facts.

MassHealth is the foundation of the Massachusetts health care system. The program covers approximately 1.9 million low-income Massachusetts residents – providing access to critical medical, behavioral health and community-based services. It brings in about 80% of all federal revenue the Commonwealth receives and has a large impact on the economy.

MassHealth’s spending increases have been primarily driven by enrollment. The Commonwealth wisely expanded coverage through several reforms over the years, most recently by implementing the Affordable Care Act (ACA) Medicaid expansion to cover low-income adults. Many of these new enrollees were simply switching to MassHealth from Connector-based programs. So MassHealth spending grows, as Connector spending goes down. And, as a bonus, we collect more federal revenue.

While these points were acknowledged at last Monday’s MassHealth stakeholder meeting, the conversation was framed around a single focus: MassHealth is unsustainable. The centerpiece was this complex chart, which mixes lots of disparate numbers:

EOHHS chart - MassHealth "Unsustainable"

While this chart seems to be all bad news, with costs soaring, that's not what it says.

From a state fiscal point of view, the key number of consequence is the net state cost - the actual cost of the program to the state budget. That's the total cost, minus the federal revenue, shown in the dark blue line at the bottom of the chart. And the growth rate in net state costs is declining sharply. The dark blue circles above, isolated in the chart below, is good news:

MassHealth Net state cost growth rate declining

Here's what's happening in the charts. Due to the ACA, we're covering more people in MassHealth. But increasingly, more of the added cost is coming from federal sources, not the state budget. So MassHealth is becoming more, not less sustainable from a state budget point of view.

And, the increasing federal share is a big bonus for the overall state economy. Many studies have looked at the multipler effect of Medicaid spending. They all show that Medicaid spending increases leads to increased economic activity, including more jobs and increased state and local revenues.

This is not say MassHealth should not look for efficiencies. Of course - it must always. And improving overall health and patient outcomes through more care coordination, by changing how providers are paid to reward value, and by imtegrating mental and behavioral health as appropriate for patients are the right things to do regardless of the impact on spending. We strongly support these initiatives started by the Patrick administration and being carried forward now.

But when one looks at the ability of the state to afford, say, full restoration of dental benefits for adults on MassHealth, it's clear that the "MassHealth is unsustainable" catchphrase does not add any clarity to the analysis.

        - Suzanne Curry and Brian Rosman


April 9, 2015

Today, the Health Connector Board welcomed two new members: Dr. Michael Chernew, a health economist from Harvard Medical School, and Dimitry Petion, a small business owner. With these additions, the Connector Board membership is complete.

Connector Executive Director Louis Gutierrez provided an overview of health and dental enrollment through the Health Connector as well as priorities moving forward. Approximately 142,000 individuals are enrolled in non-group health plans and 35,000 in non-group dental plans. The Connector is intensely focused on improving operations, including call hold times and abandonment rates, back-end IT problems, and payment system upgrades.

Gutierrez also stated that corrected 1095-A tax forms have been mailed to 28,000 Health Connector enrollees who previously received forms with inaccurate federal advanced premium tax credit (APTC) information. 1095-A forms are filed with one’s federal taxes to ensure receipt of the correct level of Affordable Care Act (ACA) premium subsidies. Due to the technological difficulties, only 711 Massachusetts residents received APTCs in 2014.

Vicki Coates, the Health Connector’s new Chief Operating Officer, is conducting a top-to-bottom review of the Health Connector's back office functions. Patricia Wada, the Special Assistant to the Governor for Project Delivery (aka health reform czar) is working with Coates and looking to broadly build an implementation schedule for the eligibility and enrollment system within three categories of work:

  • Better solutions to back office errors;
  • New functionality for May (for example, ability to easily re-enroll in a plan, payment system improvements); and
  • Prioritization of defects.

Mark Gaunya, the broker representative on the board, asked whether this work includes development of decision support tools. Gutierrez responded that yes, there is some work happening in this area, but the final product will be very modest for 2016.

Board member and 1199SEIU Vice President Celia Wcislo asked when the provider search tool would be up and running. She had heard from the Attorney General’s office that consumers who chose Tufts – Network Health were surprised to find out their providers were not in the network. Gutierrez stated that that provider search capabilities are in mind when thinking about user interface, although the Connector will not have a robust provider search tool ready soon.

The meeting then turned to the repeal of some obsolete regulations, and an important discussion of risk adjustment regulations (honest, this actually is important). Meeting materials are posted here, and our full report on the rest the meeting just takes one easy click.

April 9, 2015

A huge crowd packed a MassHealth open meeting on Monday, April 6 to talk about fundamental reforms of the MassHealth program. There were seats for maybe 100 people at the DPH Council room, but some 200 people showed up, resulting in lot of folks standing, with some trailing down the hall outside the door, straining to hear. Inside, EOHHS Secretary Sudders and Assistant Secretary/MassHealth Director Tsai announced the beginning of a public discussion process on the challenges facing MassHealth, looking at restructuring how systems work and how care is paid for and delivered.

The slides from the presentation are posted here, and you should bookmark the new MassHealth site that we were told will be the hub for the ongoing reform discussion, www.mass.gov/hhs/masshealth-innovations.

After going over some background on the financial picture and opportunities for improvement, they listed the state's priorities and principles:

MassHealth principles for restructuring 4-6-15

The state speakers were open about the need for focused improvements, and broke up the discussion into four topics:

  • Member and provider experience
  • Payment reform
  • Integration of physical and behavioral health
  • Approaches for improving care/ sustainability for LTSS (long term services and supports)

 Audience members brought up other issues as well, with many comments focusing on how MassHealth can address social determinants of health such as housing and social supports, and better use community resources to combat poverty. A MassHealth member raised the issue of the program not providing a full dental benefit.

Tsai announced that MassHealth will be holding multiple sessions on the four topic areas, and then plans to synthesize comments and produce a timeline for public comments this summer. He warned that not everything would be able to be accomplished right away. He urged everyone to be engaged in what he called a "collaborative mindset." Stay tuned!

        - Brian Rosman

April 8, 2015

Coverage for 130,000 children and pregnant women. A $166 million hole in the state budget. Those are the stakes for Massachusetts in the upcoming Congressional vote to extend federal funding for the CHIP program.

For over 17 years, CHIP has helped millions of children get the health care they need. CHIP keeps children healthy, allowing them to get consistent care and timely, appropriate treatment. The outline of CHIP was born in Massachusetts. In 1996, the state, with a strong advocacy push from Health Care For All, passed legislation expanding Medicaid and transforming it into the MassHealth program. Among the provisions was a substantial increase in coverage for children, funded by an increase in our cigarette tax. After the legislature overrode Governor Weld's veto of the bill, our law came to the attention of Senator Edward Kennedy, who took the idea and formulated the original federal CHIP law in partnership with Republican Orrin Hatch.

But, federal spending authorization for the CHIP program ends this fall. The U.S. House passed a bi-partisan bill in late March to extend funding for the program for an additional two years, attaching it to a fix of the Medicare physician funding system. The law also extends funding for community health centers, the Maternal Infant Early Childhood Home Visiting program, and family to family information centers. All Massachusetts Representatives voted for the bill. The U.S. Senate is expected to vote on the bill when it returns next week.

Now, the Mass Medicaid Policy Institute of the Blue Cross Blue Shield of Massachusetts Foundation released a report analyzing the impact of the federal CHIP program for Massachusetts. The report was written by Robert  Seifert of the Center for Health Law and Economics at University of Massachusetts Medical School.

The report lays out the stark impact on Massachusetts if CHIP funding were to end:

All told, if federal CHIP funding is not continued and Massachusetts opts to continue to provide coverage to all of the 130,000 children currently covered, it will do so at an additional cost of about $166.3 million in SFY 2016.

Alternatively, fiscal pressures could lead Massachusetts to amend its 1115 waiver to eliminate MassHealth coverage for as many as 58,000 CHIP children and to choose not to cover the 7,000 unborn children. Some of these children might obtain more expensive, less comprehensive coverage through an employer or the Health Connector, but a significant number of them could become uninsured. This would reverse a long-running trend in Massachusetts and tarnish what has been one of the state’s great health policy triumphs: reducing the number of uninsured children in the state to a minuscule level.

Today, there were some rumblings that the law that was overwhelming passed by the House (the vote was 392 to 37) may be in trouble in the Senate, mostly from conservative Republicans. We strongly support the federal extension proposal, and urge the Senate to support the bill. CHIP is critical for kids' health in Massachusetts, and for our state budget.

     - Brian Rosman