December 2015

December 23, 2015

Last week Health Care For All submitted comprehensive recommendations to MassHealth regarding their development of Accountable Care Organizations (ACOs). ACOs represent a new way to pay for and organize health care delivery, by bringing together doctors, hospitals and other health care providers who work to give coordinated, high quality care to their patients. 

MassHealth is engaged in a process of consultation with health care stakeholders and the public to establish the contours of their ACO transition. You can read more about MassHealth's thinking on ACOs in this presentation. Here are two of their slides:

MassHealth ACO slides

We agree that MassHealth has an opportunity to promote approaches to payment reform that fundamentally transform the way care is delivered. ACOs should deliver high quality, high value care that treats the individual as a whole person and ensures coordination of care, improved communication, member support and empowerment, and ready access to health care providers, services and community-based resources and supports. The goal is not just better health care, but better health for the entire state.

There’s a lot of detail in our full recommendations (download the document here (warning: 29-page pdf)), along with examples from other states. Below is a much-abridged summary of our recommendations:

Member Protections

  • Monitor and track underutilization: ACOs should establish internal monitoring mechanisms for under-service to safeguard against potential incentives to deny or limit care, especially for members with high risk factors or multiple health conditions. MassHealth should monitor under-service by assessing claims data and health outcomes over time to identify patterns of variation.
  • Protect member choice of providers
    • Network adequacy: Members should have access to care across the continuum, which includes reasonable access to a sufficient number of primary and specialty care physicians, facilities, and other providers, as well as benefits delivered in a timely fashion within a reasonable distance. ACOs should have continuity of care provisions for contracting with providers outside of the ACO.
    • Attribution methodologies: Attribution methods should involve member choice to the maximum extent feasible. MassHealth should not establish a lock-in period forcing members to remain in their ACO for a particular period of time.
  • Ensure robust appeals and grievances procedures: ACO grievance and appeals processes should be easily accessible. MassHealth should establish a single source of information and accountability for under-service through an ombuds program model.

Member Engagement at Multiple Levels

December 16, 2015

Good dental care is critical for overall healthOn Monday, the bill to authorize dental hygiene practitioners was reported favorably out of the Joint Committee on Public Health. The bill (reported as a new draft, S. 2076), sponsored by Sen. Majority Leader Harriette Chandler and Rep. Smitty Pignatelli, establishes a new mid-level dental provider that would help increase access to needed dental care across the Commonwealth.

Known in some other states and countries as dental therapists, dental hygiene practitioners would be able to provide basic dental services, including fillings and simple tooth extractions, and help increase access to dental care for people who struggle to find dentists in their area and/or whom accept their insurance. Though MassHealth covers 40% of the state’s children, most dentists do not accept it, and a shocking proportion of children have untreated oral decay, affecting their ability to eat, learn, and play, and costing the state millions in expensive emergency room visits. Massachusetts also currently has 64 Dental Health Professional Shortage Areas (DHPSAs), with the problem only expected to get worse.

We need dental providers that can deliver care to those who need it the most. Dental hygiene practitioners could work in settings such as schools and nursing homes to make sure those who have a hard time accessing care can receive it. They may also work directly with dentists, allowing practices greater financial flexibility to see more MassHealth patients.

HCFA’s Executive Director Amy Whitcomb Slemmer recently published an Op-Ed in both Quincy's The Patriot Ledger and The Enterprise in Brockton discussing the importance of mid-level dental providers in improving access issues.

We are happy that our policymakers are pushing forward this bill and are excited to work with the Dental Care for Mass Coalition to support this legislation. The bill was referred to the Joint Committee on Health Care Financing, and we urge them to quickly report it out favorably.

    -- Kelly Vitzthum

December 11, 2015

Yesterday, the Health Connector Board met to discuss two topics: 2016 open enrollment and transitioning to the federal risk adjustment program. Materials from the meeting are posted here:

Over 180,000 enrolled, halfway through open enrollment window

2016 Open Enrollment Update

Half-way through open enrollment for 2016 health coverage, which runs from November 1, 2015-January 31, 2016, more than 180,000 individuals are enrolled in a qualified health plan (QHP) through the Health Connector for January 1, 2016 – inclusive of ConnectorCare, QHP with Advanced Premium Tax Credits (APTCs) and unsubsidized coverage.

One of the reasons Open Enrollment is going more smoothly this year is that the Health Connector is conducting auto-renewals. While members enrolled in Health Connector coverage in 2015 can switch plans at any time during Open Enrollment, members who did not actively choose a plan in November were automatically enrolled into a plan for 2016. Put simply, if a Health Connector member likes their plan, they do not need to do anything – except pay the updated premium – to keep that plan in 2016.

According to the Health Connector, customer service performance has greatly improved from the last Open Enrollment period, and the launch of additional walk-in centers throughout the state and the ombudsman services provide consumers with additional ways to get help with the eligibility and enrollment process.

Risk Adjustment Update

The Affordable Care Act (ACA) requires implementation of a Risk Adjustment (RA) program, which provides payments to health insurance carriers with plans that have higher-than-average risk (i.e., members with more health care needs) funded by transfer payments from health insurance carriers with plans that have lower-than-average risk. Both federal and state methodologies for RA result in significant transfers of money among carriers, as some will have to pay and others will receive payments.

Massachusetts is the only state to run its own RA program, administered by the Health Connector, in collaboration with other state agencies. The federal Centers for Medicare and Medicaid Services (CMS) runs the RA program for every other state. The Commonwealth’s authorization from CMS to operate a state-based RA program runs out at the end of 2017. Health Connector staff proposed that Massachusetts transfer over the RA program to the federal government after the state-based program ends.

Various factors played into this recommendation, including the requirement for a federal extension of authorization to operate the state-based program, federal approval of the payment methodology (which currently very closely follows the federal methodology and would need to be replicable in other states), and higher costs. The RA program is funded through an assessment on carriers, which is twice as expensive as the federal rate for the state-based program, the cost of which is ultimately passed on to consumers. Thus, the Health Connector is not planning  to pursue federal authorization to operate the state-based RA program for the 2017 benefit year and beyond. However, upon urging from Secretary Marylou Sudders and a few Connector Board members, the Health Connector will notify CMS that they may explore re-establishing a state-based program in the future.

The next Connector Board meeting is scheduled for Thursday, January 14th at 2:00pm at 1 Ashburton Place, 21st floor, Boston.

               -- Suzanne Curry

December 2, 2015

Good dental care

Last Friday (Nov 25) the Boston Globe published an Op Ed by Harvard University Dentist Lisa Simon supporting legislation, introduced by state Senator Harriette Chandler and Representative Smitty Pignatelli, that would create a new mid-level dental provider: Dental Hygiene Practitioners.  Dr. Simon describes the overwhelming need for dental services she has seen in her years treating vulnerable populations, explaining “Dental clinics in Massachusetts are tremendously overburdened” with long wait times for dental care. Many find it difficult to locate a dentist at all.  “The suffering is heaped disproportionately on the poorest and most vulnerable in our communities, including children and low income seniors.”

Dr. Simon supports creating a Dental Hygiene Practitioner to provide basic dental services, freeing up dentists to “focus on treating the more urgent and complex needs of their patients.”

Read the full article here

HCFA is participating in a new coalition, the Dental Care for Mass Coalition. The coalition is supporting the Massachusetts legislation, S. 1118 / H. 249, which would authorize dental hygiene practitioners, a midlevel professional that is similar to physician assistants on a medical team.

For a national perspective on creating midlevel dental providers, see a recent journal article published in Dimensions of Dental Hygiene.

      -- Helen Hendrickson