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Massachusetts health care – wonky with a dose of reality

September 11, 2015

On September 9th the Health Policy Commission (HPC) Board met primarily to discuss the release in early September of the Center for Health Information and Analysis (CHIA) Annual Report on the Performance of the Massachusetts Health Care System and the upcoming annual Health Care Cost Trends Hearing.  The full slide deck can be accessed here.

Executive Director’s Report

First, Executive Director David Seltz delivered a report to summarize recent activities at the HPC. He began with an update on Material Change Notices, noting that of the types of transactions documented from April 2013 to the present, the most frequent were physician group merger, acquisition, or network affiliation transactions at 26% (Slide 7).

Notices received since the last HPC meeting include an acquisition of Saint Francis Care, a hospital system in Hartford, CT, by Trinity Health Corporation, which owns Mercy Medical Center in Springfield, MA..  Additionally, the HPC received notice of a new clinical affiliation between Tufts Medical Center Parent (Tufts) and Cape Cod Hospital (CCH) under which Tufts physicians will provide substantially all pediatric services at CCH (Slide 8). 

The HPC elected not to proceed with Cost and Market Impact Reviews (CMIR) for the following:

  • Acquisition of Braintree Rehabilitation Hospital and New England Rehabilitation Hospital by HealthSouth Acquisition Holdings. Their analysis indicated there is limited scope for a CMIR due to the fact that the hospitals in question primarily serve Medicare patients.
  • Acquisition of Saint Francis Care by Trinity Health Corporation. The proposed transaction would have a limited impact on operations, prices, and contracting practices at Mercy Medical Center.  While the transaction may result in a small increase in referrals between MA and CT providers, their analysis did not find that such changes would likely have a negative effect on spending or on the competitive market. 
  • Affiliation between Tufts Medical Center Parent and Cape Cod Hospital. The analysis indicated that rates and referral patterns are unlikely to change as a result and, in fact, may improve quality, access, and the ability of CCH to provide consistent pediatric coverage (Slide 9). 

Seltz then gave an update on the HPC’s Registration of Provider Organizations Program, a project meant to create a database to capture ongoing changes in the provider market Thus far 59 provider organizations have completed the first part of initial registration and are expected to complete the second part this Fall. The registrants represent behavioral health, hospital systems, physician groups, and an “other” group solely including Quest Diagnostics (Slide 11).  The provider organizations must submit their part 2 materials to the HPC by October 30, 2015.  Provider organizations can now access the online submission platform and the HPC encourages providers to schedule one-on-one meetings with them.

Next Seltz turned to the HPC’s Community Hospital Acceleration, Revitalization, & Transformation (CHART) Investment Program, which is progressing with both Signature Healthcare and Berkshire Health Systems moving into the contracting and launch phases respectively.  At Northern Berkshire Neighborhood of Health, part of Berkshire Health Systems, the $4M project has now launched and is serving patients from Northern Berkshire County.  The project primarily aims to reduce 30-day readmissions by 20% and, secondly, reduce 30-day returns to the emergency department from any bed by 10%.  They hope to achieve these goals by utilizing a number of strategies like individual care plans, addressing underlying social issues, and investing in technology to support care coordination.  The project also hopes to integrate many services into the community (Slides 17-18).

Lastly, Seltz reported on an important amendment passed in the FY2016 budget that strengthens consumer protections for patients who face medical bills and who exercise their rights to pursue internal or external appeals of certain health insurance coverage decisions. The amendment prohibits health care providers and their agents from providing information about unpaid charges for health care services to a consumer reporting agency while an internal or external review is pending or for 30 days (increased from 15 days) following the resolution of the internal or external review. The amendment further prohibits health care providers and their agents, including any collection agency or debt collector from initiating debt collection activities relative to unpaid charges for health care services while an internal or external review is pending or for 30 days following the resolution of the internal or external review (Slide 20).

CHIA Annual Report

Executive Director of CHIA, Áron Boros, began by delivering the major finding of CHIA’s Annual Performance Report that total health care expenditures (THCE) per capita rose 4.8% from 2014, which amounts to $8,010 spending per person. The greatest source of the percentage change is reported to be MassHealth/Commonwealth Care spending. However, there was much debate among the Board members as to what this fact actually meant when examined more closely and its impact on the total spending change number. 

September 2, 2015

The headline leads today's Globe's front page: Health care costs jump, a setback for Mass. There's no question that today's report from CHIA, with its topline finding of a 4.8% per capita growth in total health care spending in 2014, might lead to the perception that our progress in controlling health care cost growth has hit a bump. Certainly 4.8% exceeds the state's goal of holding spending growth to 3.6% or less. But digging into the report, there's a complex mix of good and bad news, and the report defies simplistic conclusions. So here are a few of our takeaways:

Components of rate of increase leading to composite rate of 4.8%

Racial and ethnic disparities in reported patient experience

  1. MassHealth (Medicaid) spending growth drove the all of the excess spending. MassHealth spending grew by 19%, compared to much lower growth rates in other forms of coverage. Commercial insurance spending grew by only 2.9%, Medicare grew by 2.1%, other public coverage grew by 2.0%, and insurance overhead grew by 1.7%. Except for the MassHealth spending (more on that below), 2014 should be counted as another success story in the state's efforts to control health care spending.
  2. The MassHealth backstory is almost all due to (a) the breakdown last year in the state's implementation of the ACA, and (b) the expected shift into MassHealth of people formerly covered by the Connector. As the Connector's online eligibility system failed, state officials (appropriately) kept people in coverage by shifting people who applied into stopgap, unmanaged MassHealth coverage. Many of these people were formerly in the Connector's Commonwealth Care plan, which was being phased out. Meanwhile, CommCare enrollment (in member-months over the year) decreased by 55% for the whole year as people shifted to MassHealth. By the end of the year, CommCare was gone. Bottom line: while MassHealth enrollment soared 23% during the year, spending grew by only 19%. 
    (and note that the federal government picked up 75% of the cost of the newly eligible, with the federal share increasing over time.
  3. The report highlights ongoing racial/ethnic disparities in care. In every category - access, provider communication, integration, and so on - quality was rated lower by Blacks, Hispanics and Asians compared to Whites in the survey. We have long called for an Office of Health Equity in state government and this report drives home the need for more attention to this issue.
  4. Growth in the cost of prescription drugs is the looming health cost issue in Massachusetts. Commercial plans had a whopping 13% increase in pharmacy spending. This is roughly double national projections of 6.8% spending growth for prescription drugs. HCFA has a broad agenda to control drug costs, including more transparency around drug pricing, objective information for doctors to counter marketing claims, and eliminating cost-sharing for cost-effective preventive drugs. And this afternoon, Senate President Stanley Rosenberg raised the issue of the state using bulk purchasing to negotiate larger discounts from drug companies. Lowering the cost for prescriptions is the imperative for state health policy in 2015.
  5. Cost shifting to patients continues. The number of Bay Staters in high deductible plans increased, and overall cost sharing (deductibles and copayments) increased 4.9% for people in commercial insurance plans. This trend, too, is problematic as insurance becomes less a collective sharing of the cost among everyone with coverage, healthy or sick.

There's lots more of good wonk in the report, on adoption of alternative payment systems, growth in employers self-insuring, and more. Go read it.

                     -- Brian Rosman

(UPDATE: mistaken statsitic on Medicaid spending growth removed)

August 27, 2015

Chip Joffe-HalpernHealth Care For All’s long-time friend, former Board President and board member, Chip Joffe-Halpern, is retiring as Executive Director from Ecu-HealthCare in North Adams this week. Chip has led Ecu-HealthCare for 20 years, during which time he and his team have been responsible for helping countless North Berkshire County residents get and stay covered.

Chip also played a vital role in implementation of Massachusetts’ 2006 health reform law, serving as the consumer representative on the Health Connector Board from 2006-2007. Chip and Ecu-HealthCare exemplify the importance of community-based on-the-ground outreach and enrollment work. 

And, he’s done all this with kindness and good humor.

Chip, thank you for your many years of service to the residents of North Berkshire County and the Commonwealth at large. We look forward to hearing about your next adventure. From the entire staff at HCFA, thank you, Chip!

(You can get a sense of the sense of Chip's wide-ranging thoughts on health reform from our blog posts covering his essays, from 2007 here and from 2014 here.)


August 19, 2015

Globe editorial in support of EOB confidentiality bill

Today, the Boston Globe added its voice to the chorus of supporters for the bill currently up for consideration in the state legislature that would strengthen confidentiality protections for patients who are dependents on someone else’s health insurance plan. 

The bill is “An Act to protect access to confidential healthcare” (S.557 and H.871), sponsored by Senator Karen Spilka and Representative Kate Hogan. This bill fixes 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.

After you get care, insurers send out documents, called Explanation of Benefits forms (EOBs), with details about the cost and type of services or treatments provided, as well as what is covered. The form is sent to the main policy subscriber, even when the medical information relates to other patients covered by the same plan, like an adult child up to age 26. As a result, the forms can disclose private medical information that should be kept between the insurer and patient.  This practice, the Globe affirms, is “at odds with the fundamental principle of privacy.”  

Currently, there is no standard way insurance companies in Massachusetts deal with patient privacy and the confidentiality of information. The bill requires insurers to send forms to the patient who received the care, rather than to the subscriber, and only if money is owed (details are here).

The Globe concludes by noting that the principals of health care transparency and patient privacy can both be achieved without sacrificing confidentiality. Health Care For All is encouraged by the tide of positive support for the bill and believes, as succinctly stated by Rep. Hogan, its passage would “alleviate fears of being punished, traumatized, or stigmatized for health care decisions.” 

HCFA leads a broad coalition called the Protecting Access to Confidential Health Care (PATCH) Alliance in support of the bill (see the PATCH website here). Some 40 members (see the list) include provider, advocacy, and community-based organizations, particularly those concerned with mental health care and reproductive health. Other groups active in the coalition include organizations serving survivors of domestic violence and sexual assault, transgender health groups, and HIV/AIDS service organizations.

The full Globe editorial can be found here.


August 17, 2015

We've come a long way since 2006, but still have a distance to go. That's the message of an opinion piece in the Tauton Daily Gazette by Audrey Shelto, President of the Blue Cross Blue Shield of Massachusetts Foundation. She notes that census data indicate that, still, four percent of Massachusetts’ population – more than 250,000 people – remain uninsured.

The number of uninsured is much higher in some areas of the Commonwealth. In April, the Foundation released a report that found that uninsurance rates are sharply higher in certain pockets of the state. In one section of Framingham, the average estimated rate was 19 percent, while a slice of East Boston stood at 24 percent uninsured.

Shelto also discussed the 2013 Massachusetts Health Reform Survey report released this June, which found that:

  • While many Massachusetts residents who previously lacked insurance have obtained public coverage, barriers remain in obtaining access to health care services that offer the quality and affordability that all Bay State residents deserve.
  • Those with public insurance plans are nearly three times more likely to have difficulty finding a provider who is accepting new patients. They are nearly five times more likely to struggle to find such a provider who accepts their insurance. And even when they do, they are nearly three times as likely to face delays in finding a primary-care doctor.
  • Even when those using public insurance plans do manage to get the care they need, they often report a lower quality of care and lower satisfaction with that care than do those on employer-sponsored plans.

Shelto concludes by emphasizing that Massachusetts is noted for its medical expertise and excellence, as well as for being a “national leader in moving the uninsured onto the rolls of the insured,” but “serious gaps persist in delivering quality health care, at affordable rates, to all.... The commonwealth hasn’t yet reached its goal of truly universal coverage, but that day is closer than ever.”

The full article can be found here.

             -- Michelle Savuto

August 13, 2015

Connector 2015 open enrollment timeline

Today, the Health Connector met to:

  • approve readiness and outreach plans for this fall's Open Enrollment; and
  • approve the decommissioning of Dell 2.0 Financial Management System.

Materials from the meeting are posted on the Connector's board meetings page. Our full report takes just a click.

August 12, 2015

The Gallup Poll does big national surveys asking people if they have health insurance. It's not as rigorous as our state surveys, but it's more frequent and provides a good snapshot that allows one to compare states.

Their latest results for the first half of 2015 were released this week. Nationwide, the uninsured rate fell from 17.3 percent in 2013 to 11.7 percent through the first half of this year. Here's the amazing bottom line:

Through the first half of 2015, there are now seven states with uninsured rates that are at or below 5%: Rhode Island, Massachusetts, Vermont, Minnesota, Iowa, Connecticut and Hawaii. Previously -- from 2008 through 2014 -- Massachusetts had been the only state to be at or below this rate.

It's all about the ACA. The poll notes that, collectively, the uninsured rate in states that chose to expand Medicaid and set up their own state exchanges or partnerships in the health insurance marketplace declined significantly more since 2013 than the rate in states that did not take these steps.

Poll shows a bigger decline in uninsurance rates among states that implemented the ACA

According to their numbers, the uninsured rate in Massachusetts is 3.0%, putting us second best, behind Rhode Island at 2.7%. Now in reality, the margin of error for the survey ±1 or 2 percentage points for us, and ±3 or 4 points for small states like Rhode Island. So, Massachusetts continues to set the pace for other states to lower their uninsured rates through expanding coverage.  There are no losers in the movement towards universal coverage. 

        - Michelle Savuto

August 7, 2015

Today the Division of Insurance (DOI) held a public listening session as part of its review of state regulations, as directed by Governor Baker through Executive Order 562 from March of this year. Executive Order 562 is the Governor's controversial directive requiring state agencies to review every state regulation. The Division of Insurance, as part of a statewide effort under the order, is undertaking a review of all of its existing regulations to determine whether there is a clearly identified need for continuing to retain the particular regulation, including: 

  • whether any costs associated with the regulation exceed the benefits that result from the particular regulation;
  • whether the regulation exceeds federal requirements or duplicate local requirements;
  • whether less restrictive alternatives to the particular regulation exist;
  • and whether the regulation unduly and adversely affects Massachusetts citizens and consumers, or the competitive environment in Massachusetts.

A few weeks ago, a broad coalition of 75 business, labor, consumer, public health, energy, environmental protection, elder care, housing, poverty and social service organizations sent a letter to the Governor, urging him to embrace more transparency and stakeholder involvement in the process. HCFA has joined the "562 Coalition" in support of their call to promote fairness and transparency in the process. 

Today's was DOI's turn to hear public comments on 23 separate health care regulations, totaling some 394 pages.

Very few speakers chose to comment during the meeting. The Massachusetts Association of Health Plans and Blue Cross Blue Shield of MA both expressed concerns about burdensome and duplicative data filings with the DOI and recommended that information should instead be obtained from state agencies when available. 

Alyssa Vangeli from Health Care For All and Laura Goodman from Health Law Advocates also testified. Vangeli stated that she understands the need to revise regulations in need of updates and avoid duplication, but cautions that wholesale changes to all rules should go through a more deliberative process that informs the public, considers the impact and includes stakeholders.  Vangeli also said that certain criteria in the Governor’s Executive Order 562 are not consistent with state and federal administrative law, citing the following concerns:

  • most regulations are required by state or federal law and cannot be legally sunsetted by an Exective Order without full regulatory review;
  • a provision that state regulations “not exceed federal requirements or duplicate local requirements” appears to violate the key federal principle where states are encouraged and expected to go beyond federal minimums.  There should not be a broad, unilateral limit on state regulations that go beyond federal regulations, especially in the area of health care and health insurance policy.  Massachusetts should be proud of its more protective health care laws and consumer rights in the area of health insurance.

Lastly, Vangeli requested that the DOI continue the review process in a transparent and inclusive manner, including ensuring that all regulations subject to amendments go through the formal public comment process with adequate notice to the public and opportunity to testify orally and in writing.

Laura Goodman of Health Law Advocates noted that Massachusetts has one of the most comprehensive mental health parity enforcement schemes in the country, due in large part to the Division’s careful efforts over the last several years to promulgate regulations and guidance. These regulation, developed in 2013, has strong public support. In some respects, our state parity regulation goes beyond what is required under the federal parity law, and puts additional obligations on health plans to ensure parity compliance. However, the regulation offers vital protections for consumers against potential health plan practices or policies that are discriminatory.   

Health Care For All also issued a public statement on the regulatory review process. In the statement, HCFA Executive Director Amy Whitcomb Slemmer warned against taking actions that hurt consumers: 

Health insurance regulations are essential to protecting public health and the welfare of some of the most vulnerable people throughout the state. These provisions should be reviewed and evaluated with the most transparent process possible. Widespread changes could place undue burdens on consumers and we urge the Division of Insurance to continue with the implementation of laws which are vital to protecting Massachusetts consumers.

HCFA's statement reminded the Division of Insurance that their groundbreaking work implementing the 2006 health reform law paved the way for federal passage of national reform, expanding coverage for millions. “Rolling back state regulations of this nature would set the Commonwealth back in its efforts to find new and innovative ways to improve our health care delivery system and manage growing costs.” 

                                   -- Michelle Savuto

August 2, 2015

MassHealth, the state's Medicaid program, is dramatically ramping up its process for the public to contribute ideas for its restructuring and payment reforms. And you're invited to participate.

During the spring, the agency held listening session forums throughout the state on a number of key issues. They plan to soon issue a summary of what they heard at those meetings.

Now, the next step is for an open, participatory process to advise MassHealth on implementing major changes to the program. In their announcement, the agency set out a multi-level outline for input into their planning:

MassHealth is committed to a fully transparent process that includes:

  • Public meetings (approximately every 4-6 weeks) between now and March 2016 to solicit broad public input;
  • A standing member forum for members and/or their families and caregivers to provide ongoing guidance and feedback to EOHHS on the development, implementation, and performance of its MassHealth reforms;
  • Continued use of the MassHealth.Innovations@state.ma.us email address to accept written testimony; and
  • Eight work groups to solicit focused input on specific topical areas

People are encouraged to apply to participate in the 7 workgroups, which will start meeting in mid-August and go though December. The workgroups will look at:

  •  Strategic Design
  •  Attribution
  •  Payment Model Design 
  •  Certification Criteria
  •  Health Care Homes
  •  Quality Improvement
  •  LTSS (Long-Term Services and Supports) Payment and Care Delivery Models
  •  BH (Behavioral Health) Payment and Care Delivery Models

Note that the topics of the workgroups have changed slightly since they were originally posted last week. In addition, MassHealth simplified the process of submitting your name, removing the requirement of a letter of support.

We're very encouraged by the open, public process, and encourage interested people to apply. HCFA will try to be at most of the meetings, and we'll report on any significant developments here on our Healthy Blog. 

Applications to the workgroups are due at 5:00 pm on Wednesday, August 5. More information on the workgroups and the application form can be downloaded on the state's clunky CommBuys site here, under "file attachments."

[ Note- the updated forms were put on the state's CommBuys website around 2:30 pm on Monday, August 3 ]

                           -- Brian Rosman



July 30, 2015

Remember "academic detailing?" We wrote about it last week - does that help?

How about this:

Governor Baker vetoes all Academic Detailing funds

We called on you to contact your legislator, asking him or her to support a vote to overturn the Governor's veto, and restore funding for the program.

Today, the legislature listened, and followed through. The House voted this afternoon to override the veto by a 121-33 vote, and this evening the Senate followed with a 32-5 vote. Both were way over the 2/3 necessary to reject the veto.

In talking to legislators about the program over the past few days, we emphasized how their objective education of physicians on prescriptions is focused on a critical concern, the proper use of painkillers, including avoiding overprescribing of opioides.Here's an example of the kind of education supported by the program, a Mass Medical Society course on "Managing Pain Without Overusing Opioids." 

We applaud the legislature for swiftly restoring funds for the program, and thank the many friends of HCFA who contacted their legislators to support the program.

            - Brian Rosman