"Health Care For All" in lights on a bridge

A Healthy Blog

Massachusetts health care – wonky with a dose of reality

March 23, 2016

This. The headline above topped the Blue Cross Blue Shield Foundation's annoucement of the latest results from the Massachusetts Health Reform Survey. The sobering report has some good news - overall, coverage is still very strong in Massachusetts, with 95.7 percent of nonelderly adults reporting having insurance.

But the report is newsworthy for the challenges it lays bare. Just having an insurance card is not nearly enough.

Almost half of insured adults (46.9 percent) reported a major access challenge: 1) difficulty finding a provider that would accept their insurance; 2) difficulty finding a provider that was accepting new patients; or 3) difficulty getting an appointment with a provider in a timely manner. Of these, 37% did not get needed health care in the past year.

Also, more Bay Staters reported going without care due to costs than in previous years. While this figure is 12.6% for those making more than 4 times the poverty level, it's 28% for those earning below 138% of the poverty level (around $16,200 annual income for an individual). We suspect many of these people are not in the MassHealth program, which has virtually no cost sharing, but are in employer plans with co-pays and deductibles that put a strain on low and moderate income people.

The situation is worse for those with a health limitation or a chronic health condition:

Health status and income affect ability to get care

HCFA is supporting the "No Copay" bill that would eliminate cost sharing for high-value preventive care treatments for chronic disease, like asthma inhalers or insulin for diabetics. This would go a long way in helping people with chronic conditions afford their care and prevent expensive acute episodes.

The survey also asked about dental coverage for the first time. Around 69% percent of us have dental insurance that includes coverage for routine dental care, leaving almost a third of the state without good dental coverage. We know that oral health care is integral to overall health, and we are working to make sure that the next generation of coverage and care coordination systems fully integrate oral health along with medical care. 

     -- Brian Rosman

March 14, 2016

Call Center Satisfaction Survey

Last Thursday, the Health Connector Board convened to discuss a variety of topics, including a recap of the Open Enrollment period, the 2017 Affordability Schedule, the Risk Adjustment Data Validation (RADV) contract and plans for the 2017 Seal of Approval. Materials from the meeting are here.

The meeting began with the Executive Director’s report on the consumer experience during the 2016 Open Enrollment period, which ended on January 31st. During Open Enrollment, the Health Connector assisted over 18,000 people across the state in their walk-in centers, with 93% overall customer satisfaction rate, and reduced average call-handling times, overall improving customer service.

As of March 1st, 208,374 members were enrolled in coverage through the Health Connector, including 156,679 in ConnectorCare and 51,695 in unsubsidized and Advanced Premium Tax Credit (APTC) coverage. 55,312 consumers are enrolled in dental plans through the Health Connector. Overall, the Health Connector was pleased with the progress during the 2016 Open Enrollment period, and is planning for additional improvements for the 2017 Open Enrollment period.

Risk Adjustment Data Validation

The Affordable Care Act (ACA) requires that a state that operates its own risk adjustment program perform Risk Adjustment Data Validation (RADV) to ensure the integrity of the risk adjustment program. The Connector Board approved a new work order with the Connector’s existing consulting company (FTI), to do a risk adjustment audit for 2015.

2017 Affordability Schedule

The Connector Board also voted to approve the 2017 Affordability Schedule, which determines what premiums are considered affordable for the purpose of enforcing the state individual mandate. The Health Connector received comments on the proposed schedule from one entity – our very own ACT!! Coalition. The ACT!! Coalition supports the proposed 2017 schedule, and encourages the Health Connector to continue to explore how to impact rising out-of-pocket costs.


2017 QHP Product Shelf

2017 Seal of Approval

Health Connector staff also provided an overview of the 2017 Seal of Approval (SoA) process.  The Health Connector hopes to make the consumer shopping experience more user-friendly by streamlining plan offerings and further supporting “apples-to-apples” comparison shopping. The Connector proposes to reduce the number of Qualified Health Plan (QHP) plan offerings and for the first time institute a cap on the number of allowable Qualified Dental Plans (QDPs). 

Connector considering "Value Based Insurance Design" for 2018

The Health Connector proposed eliminating the second standardized Gold plan design, standardizing the Bronze tier, and standardizing additional benefit categories. In addition, the Health Connector is “looking to leverage this year’s SOA to start influencing the way products in our marketplace address the health needs of our members, such as opioid use disorder therapy and chronic disease management through value-based insurance design.” For 2017, the Health Connector also proposes a requirement to embed pediatric vision coverage and encourages health plans to embed pediatric dental coverage.

The Connector Board had an interesting discussion about the impact of the state’s Minimum Creditable Coverage (MCC) requirements on plan offerings and the most appropriate standardized plan option for the Gold and Bronze tiers.

The Health Connector plans to release the QHP and QDP RFR on Monday, March 14th, award Conditional 2017 SoA at the July board meeting, and award final 2017 SoA at the September board meeting, to ensure completion prior to the start of the next open enrollment period on November 1, 2016.

The next Connector Board meeting is scheduled for Wednesday, April 20th from 1:00-3:00pm.

                     -Sara O’Brien & Suzanne Curry

March 10, 2016

"Confidential"Health Care For All applauds the decisive vote to pass An Act to Protect Access to Confidential Healthcare (S. 2138) by the Massachusetts Senate today. This legislation will prevent the disclosure of sensitive health care information through an Explanation of Benefits (EOB) form received by someone other than the patient.

The HCFA-led "Protecting Access to Confidential Health Care" (PATCH) Alliance, a broad-based group of provider, advocacy, and community-based organizations, led the advocacy for the bill. Also supporting the bill were the state's health insurers, including the plans of the Massachusetts Association of Health Plans and Blue Cross Blue Shield of Massachusetts.

Health insurers routinely send EOB notices detailing the type and cost of medical services received to the primary subscriber each time an enrollee on the plan accesses care. Confidential health information may be disclosed in an EOB, violating the basic right to privacy for anyone enrolled as a dependent on another's policy, such as a young adult, minor or spouse.

State Senator Karen Spilka spoke passionately in support of the bill during the brief Senate debate:

This is called the PATCH Act because it stands for protecting access to confidential health care. The genesis was working with Dr. Paula Johnson at Brigham and Women's and one thing that came to light is that there are women who would come to the clinic, or not, afraid their confidential health care information would not be kept confidential. Down the line, their explanation of benefits was not being sent directly to them, but to the subscriber, which could be a spouse. In cases of domestic violence it precluded a woman from seeking health care the woman really needed. In an attempt to remedy that and the issue with the ACA, children up to 26 can stay on their parents health care, they want their information coming to them, not their parents. This is basically what is involved in this bill. I ask that you vote yes.

Senators Welch and Eldridge also were instrumental in advancing the legislation.

An Act to Protect Access to Confidential Healthcare establishes mechanisms to ensure that, when multiple people are on the same insurance plan, confidential health care information is not shared with anyone other than the patient. These protections include sending notices directly to the dependent rather than to the primary policyholder; allowing patients to choose their preferred method of receiving EOBs; providing only general information about the service or visit; and providing consumers the option to opt-out of receiving EOBs if no remaining balance exists on the claim. More information about the bill is here.

But we’re not done yet. We encourage people to thank their State Senators, as well as to reach out to their Representatives in the House. We now urge the House of Representatives to advance this legislation so it can become law to effectively protect consumers throughout the Commonwealth when they seek care.

March 10, 2016

Patients who are engaged in their own care, and have the access and confidence to take an active role in their own health are sometimes referred to as “activated” patients. HCFA has long supported encouraging medical care providers to use patient activation or patient confidence measures, as they “result in better health outcomes, reduced costs, reduced disparities, and better satisfaction with one’s health care.” Our ACO recommendations urged use of these tools which encourage patients and clinical providers to be full partners in care.

Now, a new Health Affairs study has confirmed the value of these tools in the ACO context, and the implications are far-reaching.

ACO care managment targets high-risk patients for additional support. These high-risk patients are expected to need the most care, and high levels of support should result in the most cost savings, as well as better health outcomes. However, health systems generally look at past medical claims data for guidance on the likely future needs of high-usage consumers. For this new study, researchers posited that the missing element was the lack of consideration of a person’s level of “activation.” Knowing this can help predict how likely a person is to use costly services, and can help improve care.

In the study, researchers looked at people who were considered to be high-risk based on the standard measures which look at demographic characteristics, episodes of care, diagnoses, and pharmacy use. They then examined this population's activation levels, and divided them into 4 categories based on their specific level of activation. The study found that those who were more engaged in their care had a lower chance of being hospitalized or of having emergency room visits. The study also found that overall costs were generally lower for patients with high activation levels. The study found that "combining the costs associated with hospitalizations and ED visits, the differential between the patients at the lowest level of activation and the highest level was $5,168 in 2012 and $3,129 in 2014."

What does this mean for patient-centered care? Health care providers can use these tools to more accurately tailor their care based on the patient’s activation levels. Also, a number of interventions have been shown to effectively increase patient activiation levels. This study confirms the value of paying attention to the whole patient, and not just their medical test scores. HCFA will continue to press for more use of patient activation and confidence tools in Massachusetts health care.

                          - Sara O'Brien

March 3, 2016

Dentists to be trained on opioid abuse care

Highlighting the undeniable connection of dental services and medical care, three major dental schools in Massachusetts launched an initiative to combat the opioid crisis by teaching dental students skills in pain management and use of prescription pain killers. Notably, the program also trains and encourages dentists to collaborate with other health professionals in identifying and treating addiction. Governor Baker announced the agreement:

Dentists prescribe about 8% of opioids, the third-highest profession to do so. Because of this, dentists and oral health professionals are in a unique position to help combat opioid addiction. Not only do dentists regularly encounter patients experiencing pain, they are also unique in the amount of time they spend with each patient – on average, one hour compared to the primary care physician’s ten or twenty minutes. Dentists and other oral health providers are primed to play a strong role in prevention as well as education on a number of medical issues.

As the opioid crisis shows, greater integration of dental services into medical care and vice versa can yield powerful results, but training doctors and dentists individually to identify and address opioid addiction is not enough. Medical and dental providers must be regularly engaging and interacting to coordinate patient health, and every practice (both medical and dental) should have facilitated referral networks so that patients can access the care they need. This should also include inter-operational electronic health record (EHR) systems so that all providers can access a patient’s health history. What would it look like, for example, if a dentist identified a patient as being vulnerable to opioid addiction and was then able to relay that information to their primary care physician?

With regards to the opioid crisis, coordinated care means providers are more likely to avoid over-prescription and can readily assess behavioral risks based on a patient’s health history. This program is a strong step towards integrated health. Health Care For All applauds initiatives like this and we hope to see more collaborative, cross-professional thinking in the future.

                                    --Kate Frisher & Sara O'Brien

March 1, 2016

AAFP endorses oral health integration

At Health Care For All, we believe that oral health is integral to overall health. This belief is gaining more and more traction as mainstream organizations begin embracing it. Late last year, it gained even more support as the American Academy of Family Physicians (AAFP) endorsed a medical-dental integration framework.

The model, known as the Oral Health Delivery Framework, outlines the importance of including preventive oral health care as a component of routine medical care and reviews the social and economic consequences of poor oral health. The report also details five actionable steps that primary care providers can take to protect and promote oral health, including:

  • Performing basic oral health risk assessments for patients;
  • Training and educating other primary care providers on how to identify oral health conditions and the importance of oral health;
  • Offering preventive interventions like fluoride varnish or dietary counseling;
  • Having structured referral networks between dentistry and primary care;
  • Leveraging health information technology to facilitate oral health risk assessments.

Primary care providers, including family physicians, are positioned to play a strong role in promoting good oral health. As the oral health delivery framework explains, providers can make it a priority by screening for oral health behaviors and risk factors. We’ve seen similar initiatives with mental health, and now nearly every primary care visit includes a short survey and screening for depression. Oral health should be treated with equal importance.

Yet it is not enough to simply screen for poor oral health – providers must have an established mechanism for connecting patients with the appropriate care, too. Whether this comes in the form of co-located practices, structured referral networks, or another method, providers must be able to effectively help patients establish a dental home. Primary care providers can also play a strong role in patient education. In Boston Children’s Hospital’s primary care clinic, for example, every visit includes oral health education from a nurse practitioner or physician’s assistant during the intake procedure.  

This endorsement comes at a pivotal time for Massachusetts. As the state transitions to new payment and delivery models known as Accountable Care Organizations (ACOs), providers will be held accountable for improving patient health through coordinated care delivery. This moment represents a critical opportunity to elevate oral health as a priority for residents of the Commonwealth and to advocate for the integration and inclusion of dental care into new models. As more and more organizations like the AAFP recognize the importance of oral health and support for medical-dental integration grows, it proves: it’s time to put the mouth back in the body.

                                  -- Kate Frisher

February 29, 2016

Crowds gather at the State House for Elder Leap Day 2-29-16

Today, Health Care For All was delighted to join hundreds of seniors, advocates, and caregivers at the Grand Staircase in the State House to advocate for services that keep seniors healthy and living at home. Mass Home Care organized and AARP Massachusetts State Director Mike Festa emceed the event. Over a dozen senior and disability organizations sponsored the event.

According to Mass Home Care, the elderly population in Massachusetts will increase 40% by the year 2035, with nearly 40% of elder needing long term services for more than two years in their lifetime. Today’s lobby day was an amazing showing of energy around policies that will ensure seniors of today and tomorrow have the resources and community supports they need, including home care, adequate housing and transportation.

Issues highlighted include:

  • Eligibility and funding for home care services
  • Proposed passive enrollment into Senior Care Options
  • Supporting caregivers
  • Expanding MassHealth eligibility for seniors
  • Fair pay for home care workers and personal care attendants
  • Opposing EOHHS authority to restructure MassHealth benefits
  • Protecting the Community Choices program
  • MassHealth estate recovery

Mass Home Care has a good rundown of some of the issues raised. HCFA supports these efforts to help older Massachusetts residents remain independent and living with dignity in their homes and communities.

     - Suzanne Curry

February 28, 2016

S. 2138 - An Act to protect Confidential Healthcare

Last week, the Massachusetts Senate advanced S. 2138, An Act to protect access to confidential health care, a key priority for Health Care For All. The bill would fix a crucial barrier to accessing health care by ensuring that when multiple people are on the same insurance plan, confidential health care information is not shared with anyone other than the patient.

Health insurers routinely send out explanation of benefits (EOB) forms detailing the type and cost of medical services received to the primary subscriber of a health insurance plan, not the individual patient who accessed services. Sensitive health information may be disclosed in these forms, violating the basic right to privacy for anyone enrolled as a dependent on another’s policy, such as a young adult, minor, or spouse. S. 2318 would address this problem by allowing patients to choose where and how they receive explanation of benefits (EOB) forms.

During the Senate session, Senate Ways and Means Chair Karen Spilka, the bill’s lead sponsor in the Senate, spoke passionately in support of the bill’s passage. She explained that patient confidentiality is a fundamental element of the patient-provider relationship and is essential in helping patients feel comfortable accessing care and sharing information with their health care providers. Out of fear that a parent or spouse may see an EOB, young adults or survivors of domestic violence may not seek needed treatment at all, she said.  While some health plans already take steps to ensure confidentiality, this bill would ensure that all health plans do so and in turn would help many individuals across the Commonwealth.

Senator Eldridge, Chair of the Joint Committee on Financial Services, which had previously given the bill a favorable report, also spoke in support of the bill. He reminded his fellow Senators of the compelling testimony from a number of young people at the bill’s public hearing. He described the bill as an important way to work towards continuing to improve our health care system, as keeping health care information confidential is extremely important to every patient in Massachusetts.

The bill was then advanced on a unanimous voice vote and ordered to a third reading, and will likely taken up for a final vote next week.  We thank both Senator Spilka and Senator Eldridge for their leadership in ensuring critical confidentiality protections for patients in Massachusetts and urge the full Senate to pass this legislation next week.

      -- Alyssa Vangeli & Jessica Imbro

February 21, 2016

The remaining uninsured in MassachusettsLast week, the Blue Cross Blue Shield of Massachusetts Foundation and the University of Massachusetts Medical School released a report entitled “The Remaining Uninsured in MA: Experiences of Individuals Living without Health Insurance Coverage” (read the report here). Massachusetts continues to have the lowest uninsured rate in the nation, with some 97% of residents covered. However, about 200,000 people of diverse age, race and employment status remain uninsured. The goal of this study was to figure out the reasons why people remained uninsured and help inform policy suggestions which would help them receive coverage in the future.

The report authors spoke to a sample of uninsured people from seven counties in the state and developed the following key findings;

First, health care costs continue to be prohibitive. One of the most cited reasons that people gave for being uninsured was the cost. Some people weren’t eligible for their employer’s insurance, and other were not eligible for subsidies. Some 58% of respondents said they had had coverage at some point in their adult lives, but changing circumstances had dissuaded them from applying. Some said that they let their coverage lapse because they said they didn’t use it enough to justify the cost, while others simply became ineligible for employer-provided insurance. One respondent said that the cost of the penalty was less than the cost of insurance itself, and so they decided to simply pay the fine.

Another key point here is that a vast majority (73%) of the people surveyed said that they considered themselves to be in very good health, despite that slightly more than one third has one or more chronic conditions. Still, it would seem that some people were willing to hedge their bets by remaining uninsured, counting on good health to compensate for their lack of insurance.

Some other important aspects were related to communication; the process of applying was widely reported to be confusing and complex, and would be greatly simplified by having personal assistance, in people’s primary language. Having access to this would be even better if it is available in convenient location such as “health clinics, hospitals, nonprofit organizations, unemployment offices, and local businesses” that have evening and weekend operating hours, additional appointment times and more staff to assist.

Some respondents also reported losing their health insurance through state programs like MassHealth because they did not realize they needed to take any action to renew their membership. In this area, better communication with enrollees is necessary.

Secondly, the value of health insurance was lost on no one. Almost every person contacted indicated that they wanted health insurance coverage, and certainly understood the value of it to their overall wellbeing. Most people indicated that that the insurance provided a sense of security and that the lack on insurance was reflected in the way that people interacted with their care. People without insurance said that being uninsured limits “when they can get care, where they can get care, and what type of care they receive. Nearly a third said they were unable to get care when they needed it and that not having insurance limited their access to specialty care, routine tests, and preventive screenings”. Almost one third said that they were unable to get care when they needed it. While some people reported that they didn’t use it enough to justify the costs, the lack of insurance meant either not receiving or putting off necessary and preventative care.

The study notes that community health services such as free clinics and community health centers provide necessary access points for uninsured, especially undocumented, people in the Commonwealth. Additionally, the report supports the value of enrollment events and in-person assistance to help insure people and recommends possibly working with unemployment offices to help those who are looking for insurance outside of the open enrollment period.

The report closes with a note that lowering Massachusetts’ already low uninsured rate will be difficult, but that by learning from the experiences of those people, we can do what is possible to get the number down to 0% uninsured.

                  -Sara O’Brien

February 16, 2016

Last week, the board of the Massachusetts Health Connector met to discuss results from the 2016 open enrollment period and voted to release the proposed 2017 Affordability Schedule for public comment. Materials from the meeting can be found here.        

The meeting started with a warm send-off for Dolores Mitchell, who is retiring from a long career in public service. Mitchell ran the Group Insurance Commission (GIC) for nearly 30 years and served as a Connector Board member since its inception in 2006. Throughout her career, she has been leader in advancing access to affordable health care in the Commonwealth.

Health Connector Deputy Executive Director Ashley Hague and Chief Operating Officer Vicki Coates shared highlights from the 2016 Open Enrollment period, which ran from November 1, 2015-January 31, 2016. They started by looking at how the Health Connector made enrollment a smoother process by using direct mailing campaigns, logging additional call center hours, and setting up four additional walk-in centers across the state, among other efforts.

2016 Open Enrollment Update