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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

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: https://www.mahealthconnector.org/about/leadership/board-meetings.

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

November 24, 2015

On November 18th, the Health Policy Commission (HPC) Board met to discuss a number of new developments that relate to rising healthcare costs and quality improvement in the Commonwealth. The full slides from Wednesday’s presentations can be found here.

The meeting started with a presentation from Executive Director David Seltz summarizing recent activities at the HPC. Mr. Seltz outlined recent successes from the CHART Investment Program – a program to improve hospital outcomes through an aggressive series of awards, coaching, and technical assistance. This month, eight new awards were launched focusing on reducing emergency department reutilization.

HPC Slide on Performance Improvement Plan process 11-18-15

Two Commission staffers introduced the payer and provider Performance Improvement Plans (PIP). A unique feature of the Massachusetts 2012 health care cost control law, PIPs provide a mechanism for the HPC to identify and respond to payers and providers who exceeded the state’s health care cost growth benchmark. For 2015, that benchmark is 3.6 percent. The Center for Health Information and Analysis (CHIA) has provided a confidential list of potential offenders to the HPC. HPC then will notify the identified entities and may require them to file a PIP to implement options to reduce cost growth such as investing in efficiency measures, changing prices or referral practices, and more. The HPC revealed that CHIA has already created this list based on data from September 2012 to September 2013 along with preliminary 2014 data and identified under twenty providers and under five payers who may have exceeded the cost growth benchmark.

Health and Human Services Secretary Marylou Sudders voiced concern that payers and providers would be automatically blacklisted if they went even “0.0001 percent” over the cost growth benchmark and urged the Commission to instead look at the trends and stories behind the numbers to determine their validity. Secretary Sudders also pointed out that certain factors out of payer and providers’ control, such as rising drug costs, could present a warped image of actual cost growth. Secretary Sudders also reiterated the importance of having regulatory guidance prior to notifying identified payers and providers.  After a brief back and forth with Commissioner Stuart Altman who emphasized the need for transparency with the public, the Board agreed to an amended version of the process that included drafting regulatory guidance and conducting preliminary screening and analysis of payers and providers identified by CHIA.

HPC PCMH Prime process slider 11-18-15

Next, the board briefly discussed their criteria for Patient Centered Medical Homes 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. After months of stakeholder design feedback, the HPC settled on behavioral health integration as their initial additional domain for PCMHs, going one step beyond the national PCMH standards. Of the thirteen preliminary criteria, PCMHs will have to meet at least seven to become certified by the state. The criteria were approved unanimously.

The final action item was another standards-related vote, on preliminary ACO certification criteria. After explaining the process used to develop the initial criteria and outlining the goals of the certification program, HPC staff discussed some of the common themes they encountered throughout their stakeholder engagement. Many agreed that there was a balance between being too prescriptive and allowing providers to innovate the best ways to improve care while lowering costs. At the same time, many stakeholders reiterated the importance of incorporating behavioral health and long term support services into ACO criteria. Notably missing was the inclusion of oral health or dental benefits. The full criteria will be released for public comment in January and hopefully finalized by February of next year.

HPC slide on OPP case resolutions 11-18-15

October 28, 2015

Advocates for health and child well-being gathered at the Massachusetts State House on Tuesday, October 20th, to support H.429/S.94: An Act Relative to Ensuring the Wellbeing of All Children in the Commonwealth, sponsored by Senator Montigny and Representative Livingstone. The bill aims to integrate assistance for children and families who need improved access to food, housing, and medical care. Support for the legislation is led by the Healthy Food, Healthy Homes, Healthy Children (HHH) Coalition, a group of service providers, researchers, and advocacy groups who take a holistic approach to childhood wellbeing, with the belief that housing, health care, and hunger are all inextricably linked.  The legislation aims to promote childhood wellbeing by improving access to – and integrating – food, shelter, and medical care.

Prior to the hearing, HCFA hosted a press event to highlight the importance of the bill, and introduce the legislation to the public. At the press event, supporters of the bill spoke about how in order to address health problems among children, it is necessary to tackle poverty as the root cause. The event featured several speakers, including HCFA Executive Director Amy Whitcomb Slemmer,  Representative Jay Livingstone, Dr. Megan Sandel from Boston Medical Center and Children’s HealthWatch, and Diane Sullivan, the Policy Director of Homes for Families, who spoke about the issue from personal experience. Ms. Sullivan had previously been a homeless mother, and spoke about how, without access to proper resources and support, families cannot be expected to lift themselves out of poverty. Representative Livingstone, the lead sponsor of the bill in the House, spoke about how although so many children have health coverage, that does them little good if they lack the basic necessities to lead healthy lives. By viewing access to health care, housing, and food as integrated issues, the bill aims to provide children the necessary foundation to lead healthy lives.

Following the press event, a number of experts testified in support of the bill at the hearing before the Joint Committee on Children, Families and Persons with Disabilities.  Testimony covered the various sections of the bill, including:

  • A ‘common application’ for core Massachusetts safety net benefits, including MassHealth and SNAP benefits
  • Establishing a working group to assess methods for providing meals to homeless families temporarily housed in hotels and motels
  • Changing administrative processes to reduce ‘churn’ – the closing and reopening of benefits eligibility due to recipients’ income fluctuation

Particularly compelling testimony came from Dr. Lois Lee, a physician in the Division of Emergency Medicine at Boston Children’s Hospital, and an Assistant Professor of Pediatrics at Harvard Medical School. Dr. Lee spoke about family eligibility for emergency shelter. Currently, families must spend one night in a setting not meant for human habitation before they can be eligible for placement in emergency shelter.  Dr. Lee spoke about how this rule puts unnecessary stress on both the families that must satisfy this requirement, and the hospitals that end up assisting them. These families seeking shelter are almost always single mothers with children under the age of 5, and the hospital is obligated to provide them with a room. When space is scarce, the obligation to provide these families with a room often means that there is not a room for another patient that may be in need. Dr. Lee also noted that while in these rooms, families are confined and limited in their ability to move around because a hospital is not suited for the needs of sheltering children and their families. For many, it’s not just a question of short-term or situational health: “Homelessness affects not just physical health, but can cause long-term developmental issues”, she said, emphasizing the importance of this comprehensive bill.

Led by Health Care For All, advocates across the spectrum of health and children’s wellbeing will continue to work to move this legislation forward so families and children have the resources to lead healthy lives. If you would like more information about the HHH coalition or the legislation please visit the coalition website.

                           - Ben Koller

October 15, 2015

At Tuesday’s Joint Committee on Health Care Financing public hearing, legislators heard testimony from advocates, consumers and health providers on a number of important bills, including three of HCFA’s priority bills:

  • H. 984/S. 606, An Act to keep people healthy by removing barriers to cost-effective care;
  • H. 964/S. 595, An Act to preserve affordable health coverage for Massachusetts residents; and
  • H. 1025, An Act relative to preventing unnecessary medical debt.

Senator Lewis and Representative Farley-Bouvier testified first in support of H.984/S. 606, An Act to keep people healthy by removing barriers to cost-effective care, also known as the No Co-pay Bill. The bill, which is one of HCFA’s main legislative priorities, would eliminate co-pays for certain high-value, cost-effective drugs and treatments for people with chronic conditions. As Senator Lewis explained, cost is a major barrier for many patients. While price tiering is a useful method to prevent overutilization, it harms those with chronic conditions who have no choice but to take multiple medications to stay healthy. In the long run, Representative Farley-Bouvier stated, this approach, based on the premise of value-based insurance design, will provide a large health benefit for consumers at a comparatively low cost.

Next to testify in support of the No Copay bill was Ruthie Liberman from the Crittenton Women’s Union (CWU). As Ms. Liberman noted, CWU, whose mission is to promote the economic independence of women through housing and employment programs, doesn’t typically testify on health care bills. However, a study by CWU based on surveys and interviews found that medical debt was a critical factor keeping many families in the cycle of poverty. Specifically, the prohibitive cost of copays and deductibles was a source of debt for over one third of survey respondents. Ms. Liberman emphasized the importance of affordable medical care in eradicating poverty for Massachusetts residents.

Finally, we heard from a panel of HCFA grassroots activists introduced by HCFA senior health policy manager Alyssa Vangeli. Their personal stories illustrated the devastating effect high co-pays can have on patients and made a strong case for eliminating cost-sharing for certain high-value drugs and treatments. Mercy Nunez, for example, has a number of different conditions, including high cholesterol, congestive heart failure, and type I diabetes. She has to take over 14 medications, and her poor health prevents her from holding a job. Struggling with the high cost of her copays, Mercy was unable to afford all of her medications; as a result, she had a medical emergency that landed her in the ER, where she was admitted to the hospital for two months. The cost of her entirely preventable hospital admission was far higher than if she had been regularly taking her medications.

Maria Melendez is another patient who, burdened by exorbitant copays, tried to take her health into her own hands because of high out-of-pocket costs. Maria has type I diabetes and has to pay over $200 each month for daily treatments to manage her disease and stay healthy. A few months ago, feeling pinched economically, she began undereating in order to reduce the amount of insulin she needed. After an appointment where her doctor detailed the devastating effects her behavior could have on her health, she began adhering to her medication plan. The added cost, however, forced her to move back in with her mother. Valerie Spain also shared her story of struggling to pay for diabetes supplies due to high copays.

In addition to oral testimony, HCFA submitted written testimony, a policy brief, and a sign-on letter, with support from a number of organizations including Atrius Health, Boston Children’s Hospital, Health Law Advocates, Joslin Diabetes Center, National Alliance on Mental Illness MA, AIDS Action Committee, Crittenton Women’s Union, 1199 SEIU and American Heart/American Stroke Association.

September 28, 2015

The recent Blue Cross Blue Shield of Massachusetts Foundation “State of Health Coverage for the Elderly in Massachusetts: Affordability, Access and Satisfaction” event included a productive discussion about the current state of health care affordability and accessibility for seniors in Massachusetts.

Nancy Turnbull, professor at the Harvard T.H. Chan School of Public Health and a Health Connector Board member, gave a presentation describing how supplemental coverage often is needed to cover benefit gaps and high cost-sharing in Medicare. She also pointed out that many Massachusetts seniors are not eligible for, or – if eligible – are not aware of, programs intended to help them overcome these deficiencies.

One finding of a survey of over 500 Massachusetts seniors conducted by Robert J. Blendon (also a faculty member at the Harvard T.H. Chan School of Public Health) is that 18% of Massachusetts seniors in poorer health have had to resort to not filling a prescription due to the cost of prescription drugs.

A panel comprised of representatives from Blue Cross Blue Shield, the SHINE Program, Centers for Medicare & Medicaid Services and Mass Senior Action Council, as well as Nancy Turnbull and Bob Blendon, discussed the survey findings and current efforts to address the gap in health coverage for seniors. The Mass Senior Action Council is leading a legislative advocacy effort to help close coverage gaps for seniors. Let’s keep this vital conversation going!

  -- Wayne Jones (*Updated 9/30/15)

September 17, 2015

Yesterday, the U.S. Census Bureau, as part of its annual report on income, poverty and health insurance, announced that the percentage of people without health insurance fell rom 13.3% in 2013 to 10.4% in 2014.  This means a reduction of the number of people without insurance from 41.8 million to 33 million.

The report notes that between 2008 and 2013, the uninsured rate was relatively stable; but in 2014, the uninsured rate sharply decreased. This decrease occurred during the first year that key coverage provisions of the Affordable Care Act (ACA) were in effect, and it was most dramatic in states that took up Medicaid expansion. Between 2013 and 2014, individual direct-purchase of health insurance, Medicaid and Medicare saw the greatest enrollment increases. According to the report, even "national leader" Massachusetts saw a decrease in the uninsured rate in 2014.

The next open enrollment period for the ACA’s health insurance marketplaces (the Health Connector in Massachusetts) runs from November 1, 2015 though January 31, 2016, providing a new opportunity for the millions of Americans who still lack health insurance to shop for a plan -- and for those who have insurance to review their options and re-enroll.

To learn more about the health care gains made by Massachusetts residents, as revealed by the census report, read this fact sheet created by the Massachusetts Budget and Policy Center.

September 14, 2015

On Thursday, September 10, the Health Connector  Board discussed  readiness for Open Enrollment (OE) 2016,  including outreach efforts, and to deliver the final award of the 2016 Seal of Approval.  Materials from the meeting are posted here

Chief Operating Officer Vicki Coates provided consumer experience updates.  Coates first noted that total Non-Group Medical Enrollment stands at 175,605 members, a 1.2% increase from last month.  Non-Group Dental enrollment is 45,240 members, a 0.8% increase from last month.  Non-Group Enrollment for ConnectorCare is 129,657 members, an increase of 1.4% from last month.  Coates then said that the call center continues to hold the gains made in the last several months, with a lower call abandonment rate and average speed to answer than February and March.  Issue resolution has increased by 5% after holding steady for a few months and there are significantly fewer people reporting that they called more than three times without resolution.  First contact resolution, Coates reported, has increased 4.1% since May.  Overall satisfaction has increased 7% from July to August as lower wait times have resulted in higher satisfaction levels.  Coates also re-iterated that staffing is on track to match the anticipated increase in call volume associated with OE and staff are being trained to support customers’ shopping needs.

2016 Open Enrollment Readiness Update

During Open Enrollment, which runs from November 1, 2015-January 31, 2016, individuals in the non-group market can enroll in or switch plans for any reason without needing a qualifying event.  Currently, the Connector is in the final stages of determining eligibility and renewals for the upcoming OE.  118,000 households that applied for help paying for coverage and are eligible for a Qualified Health Plan (QHP) received eligibility notices.  The notice, it was noted in the meeting, is very “high level” and does not include information on the amount of tax credits an individual is expected to receive.  However, consumers will receive notices of their tax credit values before November 1st.  Once members receive their eligibility notices, they have 30 days to take action to update and finalize their eligibility if they choose. 

2016 Open Enrollment Outreach Update

The Connector performed a comprehensive consumer survey in July, surveying 1,086 residents representing those  currently enrolled in subsidized and unsubsidized health plans, dental plans, and a group of former enrollees.  The Connector also conducted several focus groups aimed at uninsured, current, and former members.  They held sessions in Lawrence, Lynn and Brockton, areas with high uninsurance rates, to learn about barriers to obtaining coverage and whether people felt comfortable using the Health Connector.

The survey found that, overall, the majority of insured respondents are satisfied with their experience as Health Connector members but room for improvement exists.  Dental plan enrollees were significantly less satisfied than health plan enrollees.  Additionally, satisfaction rates were skewed between lower-income subsidized members and upper income unsubsidized members - with lower income enrollees more likely to be satisfied. 

Uninsured respondents perceived that cost was the biggest barrier but insured members of similar income levels find their coverage to be generally affordable.  Uninsured individuals are more willing to risk not having coverage and show an inherent distrust in the health care system.  Individuals with families, however, were more interested in enrolling in health insurance.  Lastly, respondents emphasized that the process is still often confusing and expressed that having help with their application was useful.  To illustrate this point, the satisfaction rating of Navigators is relatively high compared to those of the Health Connector website or customer service. 

Survey and focus group data on plan selection and enrollment indicate that the top reasons people select the plan they enrolled in are to keep premiums low and have a plan that includes their doctor or provider.  More people report not understanding their benefits than understanding them.  Respondents noted that the enrollment process could be improved through better website design, better trained Customer Services Representatives (CSRs), simpler web navigation, and the ability for more plan comparisons. 

The top customer service issue appears to be linked to phone services, as shown by the number of respondents dissatisfied with long wait times and the fact that some CSRs appear to lack sufficient knowledge.  The Connector is addressing these problems by proactively hiring and training staff to add to the number of available CSRs during OE.  Fortunately, the Connector is emphasizing in-person assistance throughout the state through Navigators, Certified Application Counselors, Issuer Enrollment Assisters, Broker Enrollment Assisters, and new locations for support with trained CSRs.  Springfield, Fall River, Brockton, and Lowell will all be additional in-person centers staffed with trained Health Connector CSRs.  The permanent Boston and Worcester Centers will also have extended evening and weekend hours.

Final Award of 2016 Seal of Approval