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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

February 7, 2014

Between Governor Patrick’s press conference this morning (press release; and in-depth report from the Springfield Republican) and the Health Connector Board meeting this afternoon (Connector meeting presentation (pdf)) , today has been a busy day for discussing the key challenge of Affordable Care Act (ACA) implementation in Massachusetts – namely, how to fix the MassHealth & Health Connector’s flawed website and underlying IT system. Our full report is below:

Governor Patrick was emphatic about the goal of keeping everyone in coverage: “Those who have coverage will not lose it,” he said, “and those who are seeking coverage will get it…. We’re not going to let anyone go without insurance. It’s not going to happen. We have an obligation that is an obligation in law, and we have a moral obligation and a commitment to doing so.”

In late January, the Health Connector – in consultation with federal officials at the Centers for Medicare and Medicaid Services (CMS) – hired the non-profit technology firm MITRE to complete an assessment of the existing IT system.  The MITRE report (pdf), submitted on Tuesday, cites the IT vendor’s (CGI) lack of sufficient resources and poor project management and communications structures as major drivers of the deficient IT system.  The report also brings to light the lack of unified vision among the Commonwealth’s HIX (Health Insurance Exchange) project team, including EOHHS/MassHealth, the Health Connector and UMass Medical School, resulting in project oversight challenges.

MITRE suggests three main options to move the HIX system forward:

  • Sever the contract with CGI and work with a new vendor to start over building a new system
  • Work with a new vendor to continue incrementally improving the current system
  • Break the current system down into distinct technical segments and re-engineer each segment as to complete the system with a combination of CGI and new vendors

In response to these recommendations, Governor Patrick appointed Sarah Iselin to oversee efforts to repair the website and IT system.  Iselin, who is taking a four-month leave of absence from her role as chief strategy officer at Blue Cross Blue Shield of Massachusetts, will report directly to the Governor and act at the point person for the project. She committed to holding weekly briefings on the project’s progress.

Connector Board 2-6-14 Next Steps

NECN has a good summary of today’s news, including comments by Health Care For All Executive Director Amy Whitcomb Slemmer. Iselin was a guest today on WBUR’s “Radio Boston” program, and we think this 10-minute interview is the best summary of where we are and where we are going. Click below to listen:

February 6, 2014

With the continuing issues with the Health Connector/MassHealth enrollment website, we get asked the following questions constantly:

The old web site worked just fine. Why did they need to build a new one? Why can’t they just go back to the old one?

It’s a fair question. It’s also being asked in a more accusatory manner by some political candidates, who are claiming that we should have asked for a “waiver” from the whole ACA and just kept our old system.

What most people who ask this question don’t realize is that the Connctor and MassHealth are trying to build more than just a website. The web interface is just the visible tip. Underneath is a whole new processing system for health program applications, eligibility and enrollment.

So, here’s part of the answer, based on what we know:

1. Until now, there was no enrollment website for most people. The Connector’s web site only allowed people seeking unsubsidized coverage to fill out an online form to enroll and select a health plan. That was for just around 40,000 people out of the over 250,000 people covered by the Connector. For everyone else, there was no public enrollment website.

To enroll in subsidized coverage, one had to go to a community health center, hospital, or a few community groups that were authorized to use the state’s “Virtual Gateway.” It was not open to the general public. We’ve been told that once, by accident, it was open for the general public for a few hours on a weekend. A number of people filled out applications while they could, and all of the applications were filled out incorrectly and had to be redone. That’s why the state only allowed trained people to fill out the form.

The new system will allow the general public to set up an account, fill out their own forms, and submit it themselves.

2. The old “Virtual Gateway” form did not process verifications. If you had a hospital worker fill out the form for you, you still had to fax in separately the income,  residency and other verifications required for state programs. Then state workers had to manually associate the faxed-in documents with the form transmitted by the Gateway.

The new system will perform these functions automatically, in the background and in real time, by checking information already known to the state or federal government. For example, the system will check your wages with the Department of Revenue to see what your income is. Only if there’s a substantial discrepancy will the enrollee have to submit verifications.

3. The old system that determined eligibility was antiquated and difficult to update and maintain. Decisions took a long time to process. Under the old system used to process Connector and MassHealth applications, the determination of which program an applicant was eligible for was made by a system called “MA-21.” This 1980s era mainframe-style system was slow and very difficult to update. Changes in eligibility rules required lengthy, complex programming changes. The system produced awful form letter notices that were locked into a format that made it hard for people to understand. Decisions often took weeks.

The new system is designed to make instant real-time eligibility decisions. It will be easier to upgrade as program needs change. It also will be a platform for applications for other programs beyond health care.

Our HelpLine staff’s full-time job is enrolling people into coverage, so the current dysfunctional system makes us frustrated and furious at time (but note: the past few days we have had reports of substantial improvements in the system, with some people successfully applying, being determined eligible, and enrolling at one sitting). But the old system wasn’t so wonderful either.

We have two goals. First, everyone eligible for insurance must have a temporary solution, even if it means creatively working around some rules while the systems work is in progress. Then second, if we can get to a system that meets the goals outlined by the state, we will have made enormous strides to building a responsive, modern eligibility system that should last for a long time.

We’re looking forward to Thursday’s Connector Board meeting, just announced today, where we hope more progress can be made on system improvements.

-Brian Rosman

February 6, 2014

The Health Connector has scheduled a board meeting for Thursday, Feb. 6, from 9:00 am to noon. (UPDATED UPDATE: The meeting will start at noon, and is scheduled to go to 3 pm.)

According to the agenda (pdf), the only topic is the current open enrollment period. The agenda indicates that a vote is scheduled.

Because the meeting was not on the previously established schedule, it will be at Gardner Auditorium, in the State House.

When Things Go Wrong in the Ambulatory Setting

February 3, 2014

HCFA is one of a number of organizations involved in the PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) Project in Massachusetts. This project, which was funded through the federal Agency for Healthcare Research and Quality (AHRQ) Medical Liability Reform and Patient Safety Demonstration Grants, has been working to test interventions to improve safety in 16 ambulatory primary care practices.

The focus is on improving safety through improvement in test results management, referral management and medication management, with an overarching goal of improving communication (among staff, between providers and practices, and between staff and patients).

One of the areas that the PROMISES group, including HCFA, worked on was developing guidelines for primary care practices to follow when there has been harm caused to a patient. In 2006, Harvard hospitals came together to develop a document called When Things go Wrong which focused on the inpatient setting and the importance of disclosing errors to patients and families. The PROMISES group discussed the need for similar guidelines for the outpatient setting and together developed When Things Go Wrong in the Ambulatory Setting. HCFA is a co-author for an article about this document which was recently published in The Joint Commission Journal on Quality and Patient Safety.

This article will give national attention to these carefully considered guidelines, hopefully spreading their use not just in Massachusetts but across the country. These guidelines will be extremely useful as health care providers strive to carry out the apology and disclosure sections of the Massachusetts 2012 payment and delivery system reform law (Chapter 224).

You can see the guidelines on the PROMISES Project website, which includes the video above, featuring Dr. Lucian Leape, lead author of the original When Things Go Wrong document, and Dr. Gordon Schiff, lead primary care physician for the PROMISES Project, and case study videos.

-Deb Wachenheim

disparities bill cover
February 3, 2014

 

The State House News Service reported on Friday that the House Ways and Means Committee is voting on legislation to create a permanent Office of Health Equity within the Executive Office of Health and Human Services.

Health Care For All has long supported this legislation, working with a broad coalition of disparities advocates in the Disparities Action Network to draft the bill back in 2009. This session's bill, H. 2071, was introduced by Representatives Jeffrey Sánchez and Byron Rushing, along with 30 co-sponsors. It was already approved by the Public Health and Health Care Financing Committees (which offered a minor amendment).

In addition to creating an address in state government focused on health disparities, the bill would create a framework for a comprehensive approach to health disparities. The approach encompasses all the activities of state government, such as housing, transportation, education and economic development. It requires that each state budget submission identify major state initiatives that affect health and health care, and their impact on health disparities. It also calls for an annual report card on progress in reducing disparities.

HCFA urges the House and Senate to approve the legislation. The state has made important strides, creating a Health Disparities Council and an Office of Health Equity within DPH. Passage of this legislation would make health disparities an institutional concern at the highest levels of state government.

- Brian Rosman

January 30, 2014

Normally, the retirement of a member of Congress representing a district nearly 2,000 miles from Massachusetts would not be mentioned on this blog.  But Congressman Henry Waxman’s announcement today that he will be leaving public life at the end of this year is a notable exception.

During his 40 (yes, 40!) years in the House of Representatives, there was scarcely any piece of health care legislation that did not have his fingerprints on it.  As Chairman of the Health and the Environment Subcommittee, Waxman held the first hearings into the emerging HIV/AIDS crisis, exposed deceitful practices by the tobacco industry, and authored legislation that created the generic drug industry.

Expanding health coverage was a passion.  He is responsible for expanding Medicaid coverage to millions of low income children, pregnant women, and seniors, and along with our own Senator Ted Kennedy, he worked to ensure that children of working families had health coverage through the Children’s Health Insurance Program (CHIP).

In 2009, Congressman Waxman became chairman of the Energy and Commerce Committee, giving him a pivotal role in an effort to achieve one of his lifelong goals: guaranteeing that all Americans would have access to health insurance through the Affordable Care Act.

One would be hard pressed to find a more effective or dedicated policy maker to the principle that the health care system must work for consumers.  In countless ways, Massachusetts residents have benefited from the work of a congressman from California.  Our country is a better place for his efforts and Congress will have very large shoes to fill when he leaves.

(Full disclosure: I had the incredible honor and privilege to work for Congressman Waxman from 1999-2002 as a junior aide in his Washington office.)

-Matt Noyes

January 30, 2014

Huge news.

Today the Department of Public Health announced the first grant awards to nine recipientsfrom the $60 million Massachusetts Prevention and Wellness Trust Fund. This marks a historic milestone in Massachusetts health reform, as we expand our focus on preventing disease and keeping people healthy.

The awards will focus on combating tobacco use, pediatric asthma, hypertension, and falls among older adults. According to DPH, the nine partnerships will serve a total of 978,000 people, with a focus on reducing health disparities based on race, ethnicity, income, and other factors.

Health Care For All was part of a broad coalition of health, civic, business, and labor leaders – led by the Mass Public Health Association – that pushed for the Trust as part of the 2012 cost containment legislation.

Massachusetts is the first state in the nation to pioneer this investment in community-focused prevention.

The lead grantees (each of which are partnering with numerous other groups) announced today are:

Barnstable County Department of Human Services
Berkshire Medical Center
Boston Public Health Commission
Holyoke Health Center
City of Lynn
City of New Bedford Health Department
City of Worcester
Manet Community Health Center
Town of Hudson

Each grantee will receive up to $250,000 for a planning grant, and, may receive $900,000 to $1.5 million annually over the next three years to implement their plan.

The MPHA release and Patrick administration announcement, with lots of details, are below:

January 24, 2014

HPC slide showing major components of cost trends report

The Health Policy Commission (HPC) met Wednesday, January 8, for its first meeting of 2014.  Following suit from the last full meeting, the 2013 Cost Trends Report was a main topic of discussion. Also on deck was a presentation about the award recipients for the Community Hospital Acceleration, Revitalization, and Transformation (CHART) program and an update on the registration of provider organizations.

Materials from the meeting are here, and our full report is on the back side.

January 16, 2014
DPH Chart
Source: Mass Budget and Policy Center

Details here.

These are the weeks that the final decisions on the governor’s budget proposal for next year are being made by the administration.

We have a number of budget requests for health care, starting with full restoration of dental benefits for all adults on MassHealth.

But we also want to highlight the ongoing, cost-foolish, crisis of inadequate funding for the Department of Public Health (DPH).

DPH has been asked to do more and more with less and less funding in recent years. Last year spending was up a bit from the year before, but public health is still way behind. According to the Massbudget Budget Browser, adjusted for inflation, overall public health spending in FY 2014 is down $77 million, around 12%, from where it was in 2008.

DPH does not have adequate staffing and resources to fulfill all of its duties in a timely manner. For example, the Quality Division of DPH has been working hard on a new responsibility – implementation of the medical marijuana law. In the meantime, they are continuing their work on hearing complaints about care in nursing homes, hospitals, and clinics, and investigating those they deem most pressing. No doubt they could investigate more of the complaints if they had the funding to fully staff that team. They have been asked to start work on educating the public about end-of-life care and palliative care. The quality division also collects, analyzes and reports on Serious Reportable Events and healthcare-associated infections in hospitals. While these reports are supposed to be issued annually, providing relatively up-to-date information for both consumers and providers, they have fallen behind because of the need to keep up with the more immediate demands on their time. New reports on both SREs and infections may be coming out in the late winter/early spring, much later than had been anticipated.

Another example: the ambitious provision in chapter 224 for a comprehensive health planning effort has been dramatically scaled back. Instead of looking at a wide range of health services, to figure where there is either an oversupply or undersupply, the project is limited to looking only at one service, mental health.

Certainly every legislator and state budget official knows that public health is a core funtion of state government, and that investments in public health pay back profusely in lower medical costs for everyone, including the state.

As we move into the budget season, we strongly encourage the Governor and the legislature to ensure that DPH has enough funding to fulfill its mandates and serve the public by improving care for all residents of the Commonwealth.

-Deb Wachenheim

January 13, 2014

HPC slide showing major components of cost trends report

The Health Policy Commission (HPC) met Wednesday, January 8, for its first meeting of 2014.  Following suit from the last full meeting, the 2013 Cost Trends Report was a main topic of discussion. Also on deck was a presentation about the award recipients for the Community Hospital Acceleration, Revitalization, and Transformation (CHART) program and an update on the registration of provider organizations.

Materials from the meeting are here, and our full report is on the back side.

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