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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

May 11, 2015

2015 PFAC report coverHealth Care For All, in partnership with its Massachusetts PFAC Advisory Board, released its 4th annual summary of the efforts of Massachusetts Patient and Family Advisory Councils (PFACs). HCFA was the lead advocate for the 2008 law requiring all Massachusetts hospitals to establish PFACs. The PFAC regulations require all hospitals to write annual PFAC reports outlining their activities over the previous year. All Massachusetts hospitals' 2014 annual reports are posted on the HCFA website. The latest HCFA report summarizes all of these individual reports, giving a snapshot of Massachusetts PFACs' efforts and development.

This year's report highlights a number of impactful PFAC projects, with a focus on those that ar PFAC-initiated (and then implemented in partnership with the hospital), that involve patients and families in the hospital beyond the PFAC itself (eg. serving on hospital committees, serving on hiring committees, acting as co-trainers for staff), and that seek to engage diverse voices from the communities served by the hospital.

Over the past few years we have seen more PFACs become valued partners in improving care in their hospitals and in the communities, but many PFACs are still seen as separate from the rest of the hospital and are not empowered to initiate projects or to become deeply and meaningfully involved in hospital initiatives. A key ingredient to a successful PFAC is real and open support from the hospital leadership. The leadership needs to create a culture where patient and family involvement is a priority and is vital to any decision-making at the institution.  There are hundreds of PFAC volunteers across Massachusetts eager to bring their experiences and their perspectives to improving care. They can only make a difference when they have a true partnership with their hospitals.

On May 12, over 230 of those volunteers from 64 hospitals and health centers will gather in Worcester for the third annual Massachusetts PFAC conference. They will celebrate their accomplishments, share their challenges, and discuss how to work together to further PFACs' development and efforts.

        - Deborah Wachenhiem

May 11, 2015

Governor Baker grabbed a lot of attention last week over an arcane corner of health insurance regulation - small group rating rules.

We've written about this issue before. Here's the quick skinny: when Chapter 58 in 2006 merged the individual and small group health insurance markets, larger firms complained that they would face premium increases, due to the addition of the typically sicker-than-average individuals to their pool. So Massachusetts allowed insurers to offer discounts to the larger small groups. But, the discounts are matched by surcharges added to premiums paid by individuals and smaller small groups. So larger small groups (typically companies with 35-50 workers) pay less than they should, and individuals and small firms pay more than they should. The spread resulted in the winners saving around 10% on average, with some companies saving over 18% of the fair premium.

Massachusetts also allows discounts and surcharges based on the industry, so some groups of companies, typically those with older workers, pay more than the average premium, while others get a discount.

The whole system is a zero-sum game, with every discount matched by a surcharge imposed on someone else.

Then along comes the ACA, which bans all of these distortions and adjustments. The Patrick administration complained that moving from our system directly to the ACA would cause big premium shifts. So the state worked out a deal with the federal officials to phase out our system over four years. In 2014 and 2015, we can only use 2/3 of the state factors, and next year, 1/3. The plan is for them to be gone by 2017.

Now the Baker administration has asked to freeze the phase-out and lock in our current system indefinitely (here's his letter).

We disagree.

Here's our counter letter to federal HHS Secretary Burwell (pdf). We're urging the federal government to continue on the path of phasing out the state-specific rating rules:

Our state-specific rating factors are discriminatory and unfair, and result in unwarranted premium rate increases to individuals and many small businesses. The artificial surcharges and discounts tilt the playing field in the wrong direction. They should be phased out as agreed. ....

HCFA supports the HHS decision to permit Massachusetts to phase out the state’s rating factors over a transition period, as this will ease the gradual implementation of the premium impact of these rules for small employers in the state. We support the CMS rating rules because eliminating certain rating factors will lead to fairer health insurance premiums overall and lower premiums for individuals and smaller small group employers.
 

The business community is also on board with the administration, at least the larger small businesses that benefit now from their juicy discounts. What makes this issue so frustrating for us is that it exemplifies a standard poli sci conundrum: government policies that take from a broad group to benefit a small group get lots of support from the winners, and the losers in the deal don't even know they're losing. We hope the federal policymakers stick with their principles and make their decision in the whole public's interest.

      -- Brian Rosman

 

May 7, 2015

Our friends at the Parent Professional Advoacy Leage are longtime partners in the Children's Mental Health Campaign we help lead with them and others.

Their director, Lisa Lambert, just posted an insightful blog with observations about the never-ending role of parents in their childs's well being, even as their child grows up. She writes:

When providers, emergency services and mental health providers ignore parents of young adults, it can send a message. When adult mental health systems exclude family involvement, that message is even stronger. The message I hear when this happens is, We don’t value parents and family involvement. If I am hearing it, my son or daughter probably is as well. Sure, there are privacy concerns and it’s important that young adults learn to take the lead in treatment and life decisions. But they may not want to do that every time. Sometimes we all need a team and parents can be valuable team members.

Well worth reading the whole thing, here: Don’t call me an adult ally, I’m a parent. Always was, always will be.

May 5, 2015

CHIA, the state’s Center For Health Information and Analysis, released their Findings from the 2014 Massachusetts Health Insurance Survey today. The package includes a report, and chartpack (with powerpoint), along with detailed data tables and a methodology explainer.

The survey is back after not being conducted for two years, with a new methodology that probably reaches more low income and uninsured people. The new methodology means you can't directly compare the numbers in the 2014 results to past surveys; hence the different colors and break in the line in the chart below. The survey was conducted during May through July of 2014. They plan to resume annual surveys, with the 2015 survey being fielded starting in a week or so.

Lots and lots of numbers here. If you're into this blog, you'll probably want to look at the whole thing. Our big takeaways:

Insurance Coverage rates in MA

Coverage

  • Coverage rates high: Our health insurance coverage rate remains very strong. In total, 96.3% of all Bay Staters had insurance at the time of the survey. For kids, it’s even better, with 98.2% covered.
  • Churn and gaps are still problems for many. Adults surveyed reported that 12.3% of them had a period of being uninsured in the past year.
  • Who is left out: The remaining uninsured are working age adults, disproportionately male, single, Hispanic and lower income. Almost all are likely eligible for state assistance through MassHealth or the Connector.

 

Source and Use of Care

  • With high coverage comes high rates of people reporting a usual source of care other than an emergency room. Some 88% of the state’s residents reported having a usual source of care.
  • But real racial and ethnic disparities still exist in this measure. The rate was 90.3% for non-Hispanic Whites, but 78.9% and 80.7% for Blacks and Hispanics, respectively.

Types of care forgone due to cost 2014

Affordability

  • More than one in three adults are skipping care they need because of cost. Overall, the rate was 27.9%, and it was 35.2% for adults. While the rate of those reporting unmet need due to cost is very high among the uninsured, even those with coverage throughout the year had a 25.3% rate.
  • The biggest unmet need due to cost is dental care. For adults, 25.9% reported not getting dental care they needed due to cost.

The policy implications to us are clear from the data:

  • The expansion of public programs through state health reform and the ACA has been a huge success. But we must expand outreach and simplify the application and enrollment process to reach the uninsured and assure continuous coverage for those eligible.
  • Health disparities remains a problem, requiring serious, ongoing state responses.
  • Our success in controlling the growth rate in total medical spending as not led to relief for patients, who continue to ration their needed care because of high cost sharing. We need to reduce cost sharing for high-value services, and find ways to integrate oral health into broader medical care.

HCFA is working hard on all these issues, and we hope policymakers will take today's survey results as another wake-up call for the critical agenda facing the state on health care.

             - Brian Rosman

April 30, 2015

Report - Rising Health Care Cost in MA: What it Means for ConsumersThe Blue Cross Blue Shield Foundation just released a blockbuster report on the impact of high health costs on Massachusetts consumers.

The stark conclusion should have strong policy implications:

Though the Commonwealth leads the nation in health coverage, with 95 percent of Massachusetts adults insured, a significant number of people struggle with the affordability of health care.... [N]early one of five reported problems paying medical bills or reported paying them off over time. People who have low incomes, those who are in poor health or have chronic conditions needing regular care or medication, and those who are only intermittently insured experience even greater difficulties with the high cost of health care.

Massachusetts consumers have many problems due to high health care costs

The report, prepared by Carol Gyurina, Jennifer Rosinski and Robert Seifert of UMass Medical School, is full of compelling statisical analysis to back up its findings. The findings are based on the Foundation's Massachusetts Health Reform Survey. Looking at the annual surveys, they found that:

  1. Consumer health care costs are increasing much faster than incomes. From 2006 to 2012, median incomes went up 15%, while consumer-paid health care spending went up 38%.
  2. High deductible plans are growing in Massachusetts - now around 45 percent of those with individual plans, and 38 percent of those with coverage through a small (under 50 workers) employer. As a result, nearly one in ten adults spent over 10 percent of their income on out-of-pocket health care costs.
  3. And so, an increasing number of people in Massachusetts are avoiding needed health care due to cost. Around one in seven of all adults who were covered all year report avoiding needed care because of the cost. The most frequently avoided services due to costs are dental care and prescription drugs. The problem is worse for younger adults, parents, people who identify themselves as Hispanic or Latino, and those buying coverage on their own.

In addition to the analytic conclusions, the report ends with four moving, personal stories detailing how Bay Staters are responding to these high out-of-pocket costs. HCFA assisted the UMass team in finding the people profiled, using our HelpLine and other contacts to locate them. The stories personalize the difficult real-world choices they face and make them relatable and real. So, beyond the detailed charts, in the report you will meet:

  1. Katharine Jackson, from Plymouth, who came down with a rare inflammatory disease and ended up with some $10,000 in medical bills just for doctors' visits and tests, despite having employer-sponsored health care insurance.
  2. Ronald Boisvert, from Newbury, whose in-network doctor sent a biopsy to an out-of-network lab, resulting in a bill of $1,900. This was on top of co-pay charges for surgery, imaging and consultations he received as part of his cancer treatment.
  3. Marisabel Melendez, a Lawrence mother with employer coverage, whose high cost of caring for her diabetes led her to tempt malnutrition in an attempt to lessen her need for diabetes drugs. Later, she  moved in with her mother to save enough rent money to pay her copays.
  4. Stephen Slaten, from Worcester, who started taking just half the prescribed dose of his Crohn's disease medication when he became unemployed. The result was a major flare-up, causing him to need more medication and tests.

HCFA has long been concerned with the impact of high out-of-pocket health care costs on Massachusetts consumers. Our "No-Copay" bill (S. 606 / H. 984, An Act to keep people healthy by removing barriers to cost-effective care) would eliminate cost-sharing for cost-effective preventive care for people chronic disease. This report should spur all of us to action on the issue of ever-growing health care costs.

     - Brian Rosman

April 29, 2015

USA Today article on growth of PFACs in Massachusetts

USA Today and Kaiser Health News published an article about the spread of Patient and Family Advisory Councils across the US and their deepening involvement in improving care and patient and family experiences. Brigham and Women’s Faulkner Hospital and MGH are among those highlighted with examples of how they engage patients and families in their work. Massachusetts is the first and only state to mandate PFACs in all acute-care and rehabilitation hospitals. More than 90 PFACs have been established across the Commonwealth, and 2015 marks five years since all PFACs were required to be in place.

HCFA and its Massachusetts PFAC Advisory Board are celebrating this five year mark, and looking to the future, with this year’s 3rd Annual PFAC Conference, taking place May 12 at the College of the Holy Cross. More than 200 PFAC members and others will gather to share best practices, hear from inspiring speakers, and network.

The USA Today article describes several efforts to engage patients and families. In addition to those efforts mentioned in the article, there are PFACs in Massachusetts that have initiated projects and partnered with their host institutions to make a true difference in care within the hospital and in the community. From working to improve behavioral health care in the E.R. to spearheading a community campaign promoting the use of medication cards to educating the community about palliative care and hospice care, the patient and family members of PFACs bring their unique perspectives and experiences to inform and advance life-changing initiatives. As the article touches on, strong support from hospital leadership and a culture that welcomes patient and family involvement are vital to ensuring the PFACs feel empowered to speak up and make change.

HCFA and the PFAC Advisory Board are working to advance this work through the annual conference and in many other ways. All PFACs are required to write annual reports highlighting their efforts during the previous year. HCFA and the Advisory Board collect all of those reports, which can be found on the HCFA website. If you want to learn more about a particular PFAC’s work, just click on the name of the hospital. Soon, HCFA will release its PFAC summary report, giving an overview of the work that is taking place across the Commonwealth.

April 28, 2015

The state House of Representatives began its budget debate yesterday, for fiscal year 2016, which starts on July 1. Over 1000 amendments have been filed (see the budget and amendments here).

As usual in the House, the amendments are being considered in groupings by subject matter. The health care bundle is expected to come up tomorrow or Thursday. Tonight, a group of HCFA citizen activists will fan out across the State House, meeting with Representatives to discuss HCFA's priorities. Here's some of our top amendents for support in the budget - we urge you to contact your Representative today on these:

Oral Health

MassHealth only provides a limited dental benefit to adults. More than 800,000 people, including 120,000 seniors and 180,000 people with disabilities, are without access to dental care beyond cleanings, fillings, extractions, and full dentures.  Left untreated, dental disease can lead to systemic infection, hospitalization, and in the worst cases, death.  No one should die because of a toothache.

  • Support Rep. Scibak’s amendment (#298) to fund full restoration of MassHealth adult dental benefits. 
  • Oppose Rep. Jones amendment (#296) to allow restrictions on MassHealth adult dental benefits

Individuals living with disabilities have particular oral health needs, including adaptive facilities and equipment, as well as providers with specialized training.  The Tufts University School of Dental Medicine partners with the state to operate the Tufts Dental Facilities (TDF), which provide oral health care for persons living with disabilities in sites across the Commonwealth.  Budget cuts to DPH’s Office of Oral Health since 2008 have made the continued viability of the TDF precarious. 

  • Support Rep. Scibak’s amendment (#291) to allocate $500,000 in additional resources that will allow TDF to provide much-needed dental services

Prescription Drugs

Faced with an overwhelming amount of new clinical research, health care providers often rely on pharmaceutical sales representatives for information about medications they prescribe. This can result in higher costs for patients and the Commonwealth, as representatives promote their newest, most expensive brand-name drugs. “Academic Detailing” provides independent, evidence-based information on prescription drugs, supporting doctors in making the best decisions for their patients, based on balanced data rather than biased promotional information.

  • Support Rep. Benson’s amendment (#734) to provide $500,000 for DPH’s evidence-based prescriber education program.

Children’s Health

Early Intervention is the state’s most cost-effective program in the Commonwealth dedicated to serving children from birth to three years with developmental delays and disabilities. The program has a remarkable track record of limiting the need for more expensive, less effective services in later years with more than $27 million in special education savings attributed to EI services. The program serves more than 35,000 children and families each year through 60 Early Intervention programs statewide.

  • Support Rep. Kafka’s amendment (#686) to provide $28.4 million for Early Intervention services.

Health Reform

Today, federal revenue to Massachusetts due to our expanded health care coverage programs now goes into the broad General Fund. Establishing a segregated, distinct MassHealth and Healthcare Reform FMAP Trust Fund will provide a foundation to ensure that new Affordable Care Act federal Medicaid funding is used for MassHealth and subsidized health insurance programs. A robust trust fund would ensure resources for services to low-income residents, support providers, and provide transparency in how the federal funds are spent.

  • Support Rep. Benson’s amendment (#614) to establish the MassHealth and Healthcare Reform Trust Fund.

 

 

April 15, 2015

Please join Representative Jennifer Benson and the Alosa Foundation this Thursday, April 16th from 11:30 to 12:30 in Statehouse Room 437 for a legislative briefing on Academic Detailing: Helping Combat the Opioid Epidemic.

Health care providers today are constantly bombarded with an overwhelming amount of new clinical research on different prescription drugs and treatments, making it difficult to stay current about which are most effective. At the same time, the pharmaceutical industry spends billions on marketing directly to doctors to promote their products. This disproportionate influence results in worse outcomes for Massachusetts patients and residents, as providers are likely to over-prescribe or needlessly prescribe more expensive, less effective drugs.

"Academic Detailing" remedies this issue by offering providers evidence-based educational information about the therapeutic benefits and cost-effectiveness of various drugs. This allows doctors to make decisions based on balanced research data rather than biased promotional information, ultimately leading to better and more informed care decisions. It is an especially important tool in combatting the over-prescribing of prescription opioids.

Unfortunately, both Governor Baker and the House Ways and Means Committee have chosen to forgo funding for this critical program. We hope that you’ll join us on Thursday to learn why funding for this program must continue and show support for a new budget amendment that will be introduced by Representative Benson.

       -  Kate Frisher

April 14, 2015

What's a medical homer?A "Patient-Centered Medical Home" (PCMH) is not an institution or nursing home, but a primary care medical practice that offers coordinated, comprehensive care that is personal and focused on the patients' needs. PCMHs have the potential to both improve patient care and reduce costs. By engaging the patient at the center of his or her own care, a medical home can focus on improving overall health and wellness in partnership with the patient.

At least that's the theory. But what practically is required of a medical home?

The state's Health Policy Commission (HPC) is charged with figuring that out. They have issued a draft framework for their medical home certification standards, 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.

Health Care For All and the Massachusetts Public Health Association jointly submitted comments to the HPC on their medical home standards. In our comments, we expressed strong support for the direction taken by the HPC in their draft. We also emphasized a number of points where we urged the HPC to further advance the goal of medical homes through a number of provisions, including:

  • demonstrating cultural and language proficiency in the practice
  • coordination with coummunity-based resources, like community health workers
  • feedback from patients on their experiences with the practice
  • measure, and work to improve patient engagement in their care

There's a lot of wonkiness here, but we invite you to read our full PCMH comments here, and let us know what you think.

           - Brian Rosman

April 12, 2015

Administration officials from the Governor on down have been repeating the mantra over the past few months - MassHealth is "unsustainable."  Last Monday, EOHHS held a big public input session, titled, "Creating a Sustainable MassHealth Program."

Yes, MassHealth takes up a large portion of the state budget (but not as large as you think). And yes, MassHealth has seen spending increases over the years (but what part of the health care system hasn’t)?

But, does that make the MassHealth program unsustainable?

Let’s look more closely at the facts.

MassHealth is the foundation of the Massachusetts health care system. The program covers approximately 1.9 million low-income Massachusetts residents – providing access to critical medical, behavioral health and community-based services. It brings in about 80% of all federal revenue the Commonwealth receives and has a large impact on the economy.

MassHealth’s spending increases have been primarily driven by enrollment. The Commonwealth wisely expanded coverage through several reforms over the years, most recently by implementing the Affordable Care Act (ACA) Medicaid expansion to cover low-income adults. Many of these new enrollees were simply switching to MassHealth from Connector-based programs. So MassHealth spending grows, as Connector spending goes down. And, as a bonus, we collect more federal revenue.

While these points were acknowledged at last Monday’s MassHealth stakeholder meeting, the conversation was framed around a single focus: MassHealth is unsustainable. The centerpiece was this complex chart, which mixes lots of disparate numbers:

EOHHS chart - MassHealth "Unsustainable"

While this chart seems to be all bad news, with costs soaring, that's not what it says.

From a state fiscal point of view, the key number of consequence is the net state cost - the actual cost of the program to the state budget. That's the total cost, minus the federal revenue, shown in the dark blue line at the bottom of the chart. And the growth rate in net state costs is declining sharply. The dark blue circles above, isolated in the chart below, is good news:

MassHealth Net state cost growth rate declining

Here's what's happening in the charts. Due to the ACA, we're covering more people in MassHealth. But increasingly, more of the added cost is coming from federal sources, not the state budget. So MassHealth is becoming more, not less sustainable from a state budget point of view.

And, the increasing federal share is a big bonus for the overall state economy. Many studies have looked at the multipler effect of Medicaid spending. They all show that Medicaid spending increases leads to increased economic activity, including more jobs and increased state and local revenues.

This is not say MassHealth should not look for efficiencies. Of course - it must always. And improving overall health and patient outcomes through more care coordination, by changing how providers are paid to reward value, and by imtegrating mental and behavioral health as appropriate for patients are the right things to do regardless of the impact on spending. We strongly support these initiatives started by the Patrick administration and being carried forward now.

But when one looks at the ability of the state to afford, say, full restoration of dental benefits for adults on MassHealth, it's clear that the "MassHealth is unsustainable" catchphrase does not add any clarity to the analysis.

        - Suzanne Curry and Brian Rosman

 

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