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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

October 11, 2016

Policy Forum on Oral Health Integration

Last Thursday the Massachusetts Health Policy Forum hosted a forum entitled “Integrating Oral Health into ACOs.” This event brought together researchers and stakeholders to discuss the importance of oral health integration.

The context is the state’s proposal to set up ACO’s – Accountable Care Organizations – for our MassHealth program. ACOs are structured to provide more coordinated care, and the state is planning to better integrate behavioral health and long-term care services into the plans. At issue is how best to integrate oral health as well.

The morning started with a brief presentation by Dennis Heaphy, an analyst at the Disability Policy Consortium and a leader in Disability Advocates Advancing our Healthcare Rights, the leading health disability advocacy organization in Massachusetts. He spoke on the critical role good oral health and dental care has played in his own life.

The research panel presented with compelling evidence supporting coordination between oral health and overall health services and how that could fit into ACOs.  The first speaker was Yara Halasa, a dentist and PhD candidate from Brandeis’ Heller School. She provided a summary of her paper, demonstrating that including oral health care into the ACO model foster comprehensive and better quality care. She brought attention to the fact that 29% of adults in Massachusetts rated their oral health status as poor to fair. Yet, oral health is closely linked to overall health, with poor oral health leading to issues with diabetes and respiratory or cardiovascular conditions. She ended her discussion with a number of policy recommendations on how to best get to achieve integrated oral health. See her presentation here.

Chief Economist and Vice President of the Health Policy Institute and member of the American Dental Association, Marko Vujicic said that IT challenges are the top barrier for oral health integration. There are numerous benefits to oral health integration, particularly for diabetics and pregnant women. He also reported that $153 million could be saved if dentists were included in the general medical screening process.

Oregon CCOs integrate oral health

While Massachusetts prides itself on being number one in all things healthcare related, Oregon is leading the country in integrated care through ACOs. Representing the Oregon Health & Science University, Dr. Eli Schwarz discussed the successes that Oregon is having with integrating oral health in its ACO model, known as CCOs (see his presentation here). The program has reduced ED visits and hospital admissions for congestive heart failure and pulmonary disease, and increased used of effective dental sealants. It is estimated that the government will have saved $1.7 billion over the waiver period though better care.

The session ended with a panel of stakeholders, who discussed the importance of oral health integration, perceived barriers to integration and how to tackle those challenges. Members of this panel included the moderator Michael Monopoli of the DentaQuest Foundation, State Senator Harriette Chandler, MassHealth dental director Dr. Donna Jones, HCFA’s Brian Rosman, Dr. Hugh Silk, a primary care physician and instructor at UMass Medical School, and Dr. Raymond Martin, president of the Massachusetts Dental Society.

Senator Chandler, who co-chairs the legislature’s oral health caucus, passionately remarked that the state of Massachusetts is a “long way” from providing what we do for oral health than what we do for physical insurance, and pledged to continue working for full integration.

-- Chelsea Canedy and Angela Swanson

September 15, 2016

Our friend Vicky Pulos, attorney and advocate at the Massachusetts Law Reform Institute, has a blistering letter in today's Boston Globe, objecting to the reasoning used by the Connector in suddenly raising subsidized ConnectorCare premiums (see our post for background).

Here it is:

A safety net frays as Mass. health plan premiums spike

THE MASSACHUSETTS Health Connector’s decision to raise most premiums for subsidized insurance in 2017 represents a change in its longstanding policy of protecting the poorest of the poor from the full effects of premium increases (“Subsidized health plan raises rates 21%,” Page A1, Sept. 9). For the lowest-income ConnectorCare enrollees, including the destitute and the homeless, the cost of remaining with their current plan may increase by as much as $165 per month.

Massachusetts’ 2006 health reform law prohibited premium contributions for those living below the poverty level. Until last week’s board meeting, the Connector had honored the spirit of state health reform by fully subsidizing all plan choices for the very poor.

Several board members objected to this practice of what they called “cross-subsidization.” However, the Connector is not a private insurance company. It has no profitable or unprofitable product lines. It’s a public authority, and ConnectorCare is a public program. The fiscal constraints driving the Connector have more to do with declining state tax revenue, and the need to transfer funds back to the general fund to support other state spending, than with any other cause. Now that’s cross-subsidization.

Victoria Pulos
Senior health law attorney
Massachusetts Law Reform Institute
Boston

We agree. The Connector is a public entity, tasked with administering a public insurance program, for the benefit of the low-income people in the Commonwealth. We urge the Connector to re-examine its decision.

Thanks, Vicky, for a great letter.

                                                                                                                     -- Brian Rosman

September 13, 2016

We're number oneToday the federal Census Bureau released its annual statiscal report on “Income, Poverty and Health Insurance Coverage in the United States: 2015” (link). This is their annual survey based on the Current Population Survey and the American Community Survey.

And so, it's time for our annual blog post (e.g, 2014, 2010, and 2009) on the continuing progress Massachusetts in making in expanding health coverage.

First, the encouraging national headlines:

  • Fewer uninsured: The percentage of people without health insurance coverage for the entire 2015 calendar year was 9.1 percent, down from 10.4 percent in 2014. The number of people without health insurance declined to 29.0 million from 33.0 million over the period.
  • Both private and public coverage: Between 2014 and 2015, the increase in the percentage of the population covered by health insurance was due to an increase in the rates of both private and government coverage. The rate of private coverage increased by 1.2 percentage points to 67.2 percent in 2015, and the government coverage rate increased by 0.6 percentage points to 37.1 percent.
  • Kids better, too: In 2015, the uninsured rate for children younger than age 19 was 5.3 percent, down from 6.2 percent in 2014.

The Massachusetts headlines: (based on this state table)

  • We’re number one: The 2015 uninsurance rate in Massachusetts went down to 2.8% - again, the best in the country. (second best is a tie between DC and VT, each at 3.8%). So our coverage rate is 97.2%
  • Continuing Improvement: The uninsurance rate continues to decline - it was 3.3% in 2014, and 3.7% in 2013, and 3.9% in 2012

More analysis (including great charts) are available from the Mass Budget and Policy Center.

We cannot be complacent about the continuing progress. Our state's success relies on the aggressive outreach and enrollment efforts, which should not be curtailed. We do hear frequent reports of considerable churn in enrollment, as people shift between various programs and private coverage. And there is a big challenge coming in next year, as MassHealth (which covers 1.8 million in the state), begins rolling out ACO options for most of its members.

                                                                                                                                                                         -- Brian Rosman

 

 

September 12, 2016

On Thursday, the Health Connector Board met to award the final Seal of Approval (SoA) for plans to be sold through the Health Connector in 2017. This included a review of premium changes in the ConnectorCare program and plans for member communication and outreach for open enrollment. The meeting sparked big headlines, including the lead story in the Boston Globe (see below). Materials from the meeting can be found here.

Boston Globe: Subsidized Health Plan raises rates 21%

Due to an increase in rates offered by some health plans, the Health Connector reported that many members will have higher premiums upon their 2017 plan renewal. This will particularly impact individuals enrolled in Harvard Pilgrim HealthCare, Neighborhood Health Plan, and Health New England. Members receiving only premium tax credits or no subsidies will see a 19% premium increase.

That’s going to have a big impact on people. There’s going to be a lot of shifting and a lot of disruption.’Until now, the Health Connector “smoothed” the difference in premiums between the lowest and highest cost plans in the ConnectorCare program. After considering budget constraints and alternative solutions, the Health Connector has decided to discontinue most premium smoothing in the ConnectorCare program beginning in plan year 2017. However, the Connector will continue to “smooth” plans offering premium rates less than $35 different from the lowest cost plan for 2017 only.   Continuing smoothing as it has been implemented would cost $51 million ($35 million after federal reimbursement). The significantly reduced premium smoothing in 2017 will cost $4.2 million ($2.1 million net).  

The impact this decision has on the most vulnerable members of the Commonwealth is apparent. The starkest change if for “Plan Type I” ConnectorCare members, whose incomes put them below the poverty level (about $11,800/year in income for an individual). In previous years, these members could choose any ConnectorCare plan and not pay a premium. Starting in 2017, they will pay anywhere from $0 to $165 in premiums, depending on their choice of plans.  

While the Connector has other insurance plans that are less expensive and have comparable benefits, the individuals who choose to switch their plans will likely need to switch physicians and providers. The Connector Board stated that these changes are necessary in order to adhere to their goal of giving individuals options in light of their heavy budget restrictions.

The next Connector Board meeting is scheduled for Thursday, October 13th, 9am, at 1 Ashburton Place, 21st floor, Boston.

                                                                                                                                        -- Chelsea Canedy

September 4, 2016

MassHealth has pending before CMS - the federal Centers for Medicare & Medicaid Services - its proposal for a major redesign of its care delivery system. MassHealth is the state's Medicaid program, and covers nearly 1.9 million Bay Staters. 

The proposal (read the submission and supporting materials here) calls for creating Accountable Care Organizations (ACOs) as a new choice for MassHealth members. An ACO is made up of primary care providers who team up to provide integrated, coordinated care, with the goal of both treating patients when they are sick, and keeping members healthy. They will work with community organizations to assist members with social needs that keep us healthy, like nutrition or housing.

MassHealth is asking CMS for a $1.8 billion up-front investment over five years to support transition toward ACO models, including direct funding for community-based providers of behavioral health and long-term services, as well as funding for safety net programs.

HCFA coordinated the submission of 5 sets of comments to CMS on the proposal, from various coalitions that we coordinate. All together, 96 different organziations signed on to one or more of the comments that we coordinated. The comments reflect each coalition's particular concerns. The final set of comments below is from over 30 consumer groups, such as the Greater Boston Food Bank, Alliance of Massachusetts YMCAs, Easter Seals Massachusetts and the Massachusetts Association of Community Health Workers. Click the links below to see the submitted comments.

August 31, 2016

Globe letter - EpiPen pricingToday's Boston Globe's lead letter-to-the-editor is from Amy Whitcomb Slemmer, HCFA's Executive Director. The letter is call for action on high prescription drug prices, exemplified this week by the outrageous price increases Mylan is charging for their EpiPen injectible drug for allergic shock:

 

 

Re the Aug. 25 editorial “EpiPen maker sticks it to patients — again”: We agree. The price hikes of the EpiPen allergy-drug injector are “shameless” and “deceptive,” and another example of drugmakers pricing their products at whatever the market will bear.

Prescription drug prices are the fastest-growing cost in health care, placing life-saving therapies beyond the reach of consumers. Drugmaker Mylan’s initial response to the public’s EpiPen price hike outrage was to enhance its patient-assistance program, a marketing ploy that discounts the cost of EpiPens for individuals but does nothing to address the underlying cost gouging, or the resulting impact on insurance premiums.

We urge lawmakers and regulators to step in and shine a light on the true development and production costs of pharmaceuticals. This is a wake-up call. Let’s work together to place the EpiPen and other life-saving therapies back within the reach of the people who need them. Let’s stop underwriting exorbitant profits, drug marketing budgets, and lobbyists’ salaries.

Innovative new drugs and therapies will be worthless if no one can afford to buy and use them.

AMY WHITCOMB SLEMMER
Executive Director
Health Care For All
Boston

 

The public is demanding action on prescription drug prices. The Kaiser Health Tracking poll found overwhelming, bipartisan support for a variety of policy ideas to get tough on drug prices:

  • 86 percent support requiring drug companies to release information on how they set prices, including majorities of Democrats (90%), Republicans (82%), and independents (84%)
  • 83 percent support allowing the government to negotiate with drug companies to lower prices for people with Medicare, including majorities of Democrats (93%), Republicans (74%), and independents (83%)
  • 76 percent support limiting how much drug companies can charge for high-cost drugs for illnesses such as hepatitis or cancer, including majorities of Democrats (79%), Republicans (70%), and independents (77%)

HCFA has promoted a broad agenda to lower prescription drug prices, include price transparency legislation, restrictions on gifts and meals provided by drug marketing reps to doctors, support for "academic detailing," which provides objective, unbiased information to doctors to counter sales pitches from drug sellers, and reinstating the state ban on drug copay discount coupons, which, as mentioned in our letter, are ploys used to promote high-price drugs that end up costing consumers more in higher premiums.

We are planning to mount a major campaign for next year's legislative session to take strong action on prescription drugs. This year, Vermont passed major drug price transparency legislation, and bills are pending in other states as well. The tide on this issue is turning, growing larger and more urgent. Let us know if you would like to participate.

                                                                                                                                 -- Brian Rosman

 

August 17, 2016

HPC: Preventable Oral Health ED Visits Report

Reducing the number of preventable emergency department (ED) visits has been an important measure of health care quality. According to the U.S. Agency for Healthcare Research and Quality, avoidable ED visits are not only costly, but may indicate poor care management and/or inadequate access to care, among other system failures in inefficient health care delivery and prevention.

Thus ED visits for avoidable oral health conditions are a marker of serious deficiencies in our health care. The Health Policy Commission released a policy brief Monday describing the extent and significance of preventable dental visits in hospital emergency departments across the Commonwealth, following their initial findings back in April. The stark findings: In 2014, there were over 36,000 preventable oral health ED visits in Massachusetts, which cost the health care system between $14.8 million and $36 million. Around half of all preventable dental ED visits were paid for by MassHealth.

HPC Chart: Preventable Oral Health ED visits by age - 2014

When regular dental care is inaccessible and/or unaffordable, people tend to delay needed care, often exacerbating a problem until it becomes an acute issue. Aside from being significantly more expensive, emergency departments are also ill-equipped to adequately address underlying dental concerns. Along with establishing dedicated ED diversion programs for oral health conditions, the HPC suggested that access to care could be improved by authorizing mid-level dental providers to provide routine care. These providers, known as dental hygiene practitioners or dental therapists in other states, are akin to nurse practitioners in medicine and have been shown to be a safe and economically viable option to reduce ED utilization and improve access. The HPC also suggested that the state consider supporting teledentistry initiatives to expand the “geographical reach of existing dental providers.” Complementary to establishing mid-level dental providers, teledentistry uses portable equipment and remote telecommunication technologies to reach those who live in remote or dental provider shortage areas and deliver care directly in community settings and has been found to be effective in other states.

The report also focused on cuts to MassHealth dental care:

Policy shifts may have affected oral health access. On July 1, 2010, MassHealth reduced dental benefits for its members age 21 and over, eliminating coverage for endodontics (root canals), periodontics (care for gums, such as plaque removal from below gums), crowns, and denture coverage for roughly 700,000 adults. Some of these benefits have since been restored, including fillings (March 2014) and dentures (May 2015). One retrospective study found that dental-related ED visits and costs at Boston Medical Center increased following MassHealth dental cuts. Of particular note, these dental visits increased 2 percent in 2011 and 14 percent in 2012, suggesting that higher ED use may be due in part to the cumulative effects of forgone prevention.

The general lack of integration of oral health into the rest of health care is also a root cause of preventable ED visits and overall poor oral health outcomes. Health Care For All believes that access to affordable, quality dental care is an important part of overall primary care, and enthusiastically supports the HPC’s policy recommendations as important steps to improved oral health in the state.

                                                                                                                            -- Kelly Vitzthum

August 10, 2016

When high-value care is delivered effectively, everybody wins. Patients experience better health outcomes, payers save money in the long run, and providers are better able to care for their patients. But the system needs to help patients focus on high-value care.

At HCFA, we are committed to breaking down barriers to high-value care. Our "No Co-Pay bill" would eliminate cost-sharing for high-value preventive care, like asthma inhalers or hypertension drugs. The Health Connector's decision last month to eliminate copays for medication-assisted treatment for addiction reflected a similar approach.

Who benefits from clinical nuance? - patients, payers and providers

The University of Michigan-based Center for Value Based Insurance Design has released a very cool infographic on what they call "clinical nuance" - structuring insurance to promote high value care, and discourage waste and unnecessary, inefficient low-value services. An excerpt is above, but click here for the full infographic

                                                                                                                              -- Mike DiBello

August 10, 2016

Originally posted by the Center For Health Care Strategies (CHCS)

Achieving health equity is a growing priority among health care stakeholders. However, until recently, many efforts to achieve equity have been focused on increasing access rather than addressing specific inequities. This is particularly true in oral health, where major barriers to access such as limited insurance coverage and insufficient workforce capacity persist. As a result, the Center for Health Care Strategies (CHCS), with support from the DentaQuest Foundation, led the Advancing Oral Health Equity learning collaborative to help oral health stakeholder organizations examine the impact their programs have on oral health equity and develop targeted strategies for disparate populations.

Health Care for All (HCFA), a nonprofit advocacy organization focused on achieving high-quality, affordable, and accessible health care for all Massachusetts residents, was one of five organizations participating in the collaborative. By listening to community and stakeholder groups, as well as hearing stories through its Health Insurance HelpLine, HCFA has adopted an equity-based framework and approach throughout its work. It sees inequities in oral health care as a social justice issue, believing that the social determinants of health and the intersecting issues of racism and classism affect overall health and well-being. To learn more about HCFA’s approach, CHCS spoke to two members of HCFA’s oral health care team: Kate Frisher, oral health coalition coordinator, and Kelly Vitzthum, oral health policy analyst.

Q: What kinds of activities is HCFA doing to advance oral health equity?

A: We focus primarily on policy opportunities. One example is supporting legislation that would create a new type of mid-level dental provider, the dental hygiene practitioner, also known as a dental therapist. Dental hygiene practitioners can help fill gaps in access for communities that are most in need of dental services, including rural parts of Western Massachusetts, elderly communities, and low-income urban communities of color. We’re hopeful that this new model will become a reality in Massachusetts and will also work to ensure that mid-level providers will serve the people who need them most. It’s one thing to get a bill passed, but it’s not enough to just stop there.

Q: Which populations are you focusing your equity work on?

A: It’s really easy to just say, “We’re focusing on the Medicaid population,” and leave it at that without thinking about the sub-populations that exist within the broader set of Medicaid beneficiaries. We’re finding that the population with developmental disabilities as well as individuals who live in the rural areas of western Massachusetts are both having trouble with access to oral health care.  Even just saying that we’re “narrowing down” our focus to western Massachusetts is obviously a bit of an oxymoron because it’s a huge region.

We also know that not having culturally and linguistically competent care is a big barrier to access in some places. We were really surprised to find that although there appear to be enough dentists who speak Spanish, severely lacking are dentists who speak Portuguese, the third most common language in the state. Thus, we identified Portuguese speakers as a potentially underserved group.

Q: Are there any obstacles to your oral health equity work?

A: The biggest obstacle is the separation of oral health care from the rest of health care. A lot of the oral health disparities could be alleviated if oral health care were better integrated into the health care system. We’re pursuing structural-level changes in the way that oral health care is financed and delivered to try to “bring the mouth back into the body.”

We also see diversifying the workforce to better represent Massachusetts residents as critical, especially when you look at who is going into the dental profession. Establishing more pathways into the oral health professions through outreach to minority students, recruitment of minority faculty, and targeted financial incentives such as loan repayment programs will help.

Q: How does HCFA plan to advance oral health equity in Massachusetts going forward?

A: Through the learning collaborative, we’ve highlighted an ongoing priority: oral health surveillance. There aren’t many oral health care datasets available, so we have identified collecting those data as one of our top priorities. We are also making sure that oral health is being addressed within Massachusetts’ new accountable care organizations. Ensuring that these new delivery and financing models establish equitable ways of providing care is a critical part of the implementation process. This is in line with a broader attempt to increase the prominence of oral health at the systems level.

Progression toward oral health equity will happen with interventions that address specific barriers identified at the community level. Health Care for All’s strategies to improve oral health data collection, diversify the dental workforce and improve cultural competency will increase the availability of oral health care for those whom need it most in Massachusetts — and may serve as a promising path for other communities across the country.

--June Glover, Program Officer, CHCS and Teagan Kuruna, Communications Associate, CHCS

August 9, 2016

This blog was originally published on Community Catalyst’s blog Health Policy Hub

As states across the country look for ways to combat the ongoing opioid crisis, one overlooked issue is how we address the impact of this crisis on our communities’ youngest. Infants exposed to opioids in utero may experience a variety of potentially debilitating symptoms associated with opioid withdrawal, collectively known as Neonatal Abstinence Syndrome (NAS). As the opioid crisis and NAS receive greater attention, children’s advocates and public health professionals have pushed for more focused strategies and greater resources to assist. Efforts have focused not only on those infants specifically diagnosed with NAS, but also on additional substance-exposed newborns (SEN) who may experience problems related to other types of prenatal substance exposure.

At the federal level, the Protecting Our Infants Act of 2015, sponsored by Rep. Katherine Clark (D-MA) and Sen. Mitch McConnell (R-KY), helped bring greater attention to the issue, particularly the need to gather data to comprehensively assess the impact on infants and their families over time. Increasing awareness is an important first step in reversing the rise in newborns exposed to harmful substances. And while there are numerous efforts on the ground to combat the epidemic and support infants and their families in recovery, many are reliant on finite resources and have yet to be integrated into a system that will ensure their long-term sustainability.  

In Massachusetts, over the past year, Community Catalyst’s New England Alliance for Children’s Health (NEACH)convened a working group of practitioners, early childhood specialists, advocates and public health stakeholders to help the state take the next step to advance uniform policies across human and health services to support infants and their families. With the help of the Children’s Health Access Coalition (CHAC), the working group pushed the state to take more concrete steps to improve care for substance-exposed newborns. These efforts produced a resounding victory last month – the state’s FY 2017 budget included language establishing an inter-agency task force dedicated to addressing NAS and SEN. The relevant section declares that “all executive agencies work in coordination to address the needs of newborns, infants and young children impacted by exposure to substances.”

Importantly, the taskforce brings together state agency leaders who play an important role in the care of children and their parents. This list includes the Secretary of Health and Human Services, the Attorney General, the Commissioner of Children and Families, the Commissioner of Mental Health, the Commissioner of Public Health and the Executive Director of the Massachusetts Health Policy Commission. Additionally, an advisory council of experts and community leaders was formed from across the continuum of care for infants and parents experiencing the effects of substance use disorders. The establishment of this task force is a major step forward and presents a considerable opportunity for improving the care and outcomes for parents with substance use disorders and their children throughout the Commonwealth.

While the establishment of the task force is but one step in addressing a very large problem, it does make significant progress around coordination and communication among state agencies – one of the greatest barriers to establishing comprehensive systems of care on a state-wide basis. Due to the multiple issues involved, NAS and SEN necessitate the involvement and interaction of several agencies and departments. As states look to address NAS and SEN, the ability to coordinate effectively will be critical to ensuring the development and implementation of successful plans.

--Ben Koller, Program Associate, Community Catalyst Aliiance for Children's Health

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