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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

April 18, 2016

Last week, the state House of Representatives unveiled their draft proposed budget for fiscal year 2017 (which begins this July 1). Like the Governor's proposal, the House budget proposes spending just under $40 billion, with about $15.4 billion going to MassHealth, a increase of below 5% (note that in figuring the cost to the state for MassHealth, one needs to subtract from the $15.4 million appropriation the some $7 billion in federal Medicaid revenue that we receive as a result of our MassHealth program). The budget proposes no major cuts in eligibility or benefits for MassHealth, though it also does not restore adult dental benefits eliminated a number of years ago. A major House initiative funds expanded steps to combat opiate abuse, with a 65% increase in funding for these services over the past 5 years.

Representatives have proposed over 1300 amendments to the budget, which will be voted on the week of April 25. HCFA is supporting a number of these amendments. We urge you to contact your Representative and urge support for the amendments on this fact sheet (pdf), or listed below:

Protect Health Safety Net Eligibility & Funding

The Health Safety Net (HSN) reimburses hospitals and community health centers for providing care to low-income uninsured and underinsured Massachusetts residents. Recent eligibility cuts and funding reductions impose barriers to care for individuals without access to affordable health coverage.

  • Support Rep. Barber’s amendment (#1119) to protect Health Safety Net eligibility and continue investing $30 million in the program, ensuring continued access to care for low-income uninsured and underinsured residents.

Close the SNAP Gap

Most MassHealth recipients are eligible for SNAP (food stamps), but the number of MA residents that get SNAP is just 41% of those with MassHealth.  A common application will reduce application barriers and help close the “SNAP Gap” in Massachusetts.

  • Support Rep. Livingstone’s amendment (#1041) to create a common application portal to allow MassHealth applicants and recipients to also apply at the same time for federal SNAP nutrition assistance.

Healthy Food for Families in Motel Shelters

Even when a family is eligible for food assistance, they often do not have access to cooking devices other than the microwave, no cold storage, and no convenient way or healthy place to purchase food.

  • Support Rep. Scibak’s amendment (#943) to create a working group to find ways to provide meals to homeless families temporarily housed in hotels and motels.

Ensure Access to Oral Health Services for People with Disabilities

Individuals living with disabilities have particular oral health needs, including adaptive facilities and equipment, as well as providers with specialized training.

  • Support Rep. Garlick’s amendment (#571) to allocate an additional $500,000 for the dental program for individuals with intellectual and developmental disabilities (line item 4512-0500). 

Invest in the Office of Oral Health

Charged with preventing dental disease and improving oral health in all Massachusetts communities, the Office of Oral Health at the Department of Public Health (DPH) is an essential component of our state’s public health infrastructure.

  • Support Rep. Scibak’s amendment (#1057) to adequately fund the DPH Office of Oral Health (4512-0500).

Provide Unbiased Prescription Drug Information to Doctors

Drug company promoters market their drugs directly to doctors by providing biased information touting their most expensive drugs. To counter this, trained educators can offer objective evidence-based information to educate doctors on cost-effective uses of prescriptions, lowering the cost of health care.

  • Support Rep. Benson’s amendment (#698) to fund "Academic Detailing," the physician education program on cost-effective prescription drugs.

Ban Drug Company Marketing “Coupons”

April 12, 2016

According to the leading crowd-sourced online encyclopedia, the traditional gift for a tenth anniversary is tin. So here's a brief bulletin on how folks marked the tenth anniversary of Governor Romney's signing of Chapter 58, the Massachusetts health reform law.

WBUR's Martha Bebinger was one of the go-to reporters covering health reform in 2005 and 2006. Today, she produced a 6-minute report on people's reactions to the law, talking to ordinary people, including Madelyn Rhenisch, the first enrollee in Commonwealth Care, who calls her insurance coverage "a lifesaver."

Also from Bebinger and WBUR is a handy list of "12 Things to Know" on the law's anniversary, with source links. My favorite: "Three-hundred and twenty fewer people died in each of the first four years of mandatory health insurance in Massachusetts." Appended to the list are 13 short essays on law's birthday, from across the spectrum of views. Among those writing are Nancy Turnbull of the Harvard School of Public Health, Jon Hurst of the Retailer's who critiques the merging of small groups with the individual market, and Elizabeth Browne, of the Charles River Community Health Center, on the need for a renewed focus on primary care. And, WBUR's Radio Boston included a discussion on the legacy of the law, with HCFA Executive Director Amy Whitcomb Slemmer lined up with Jon Hurst.

10 YEARS OF IMPACT: A LITERATURE REVIEW  OF CHAPTER 58 OF THE  ACTS OF 2006For the more wonky among us, the Blue Cross Foundation released a comprehensive bibliography of dozens and dozens of studies looking at Massachusetts reform. In addition to the detailed compendium of studies, prepared by Kelly Love and Robert Seifert of the Center for Health Law and Economics at the University of Massachusetts Medical School, there's a fact sheet summarizing the findings. Some highlights:

COVERAGE

  • Massachusetts became the state with the highest rate of insurance coverage soon after 2006 and maintains that status today.
  • The coverage gap among racial and ethnic groups narrowed post-reform.

ACCESS TO CARE

  • Coverage expansion led to overall improvements in access, but gains were uneven across different groups.
  • Unmet need among Latino, black, and middle-income individuals and those in fair or poor health continued to be a challenge post-reform.

HEALTH CARE UTILIZATION

  • The overall use of preventive care in Massachusetts rose, but increases in the use of specific preventive care screenings varied.
  • Hospital readmission rates rose slightly in the early years post-reform; readmissions for some diagnoses, such as substance use disorder treatment, grew while readmissions for others, such as psychoses, fell.

HEALTH OUTCOMES

  • Health care reform has been associated with overall improvements in health, particularly for people of lower incomes.
  • The greatest gains in health status were among racial and ethnic minorities, women, those with low incomes, and adults ages 60 to 64.

ECONOMIC IMPACTS

  • Chapter 58 helped reduce financial distress, most significantly among people who had limited access to credit markets pre-reform.

AFFORDABILITY FOR CONSUMERS

  • Immediately following 2006, increased coverage contributed to fewer reported problems paying medical bills, particularly for low-income adults.
  • Chapter 58’s individual mandate made insurance more affordable for those purchasing it individually, by bringing healthier people into the pool across which costs are spread.
  • Overall, however, Massachusetts has not escaped the long-term national trends in health care costs, and affordability challenges remain. A significant percentage of insured Massachusetts residents continue to report that health care spending causes them financial problems, that they go without needed care because of health care costs, and that they are worried about their ability to pay medical bills in the future.

Finally, former HCFA ED John McDonough blogged today with his take on the anniversary. John marveled at the strange evolution of conservative opinion on health reform, reminding us first, that the conservative Heritage Foundation spoke warmly of the policies embodied in our bill at the signing ceremony 10 years ago; and second, that this all changed with the advent of Obama and the ACA. He concludes,

April 11, 2016

Ten years ago today, April 12, 2006, we all made history in health care. Just look (and you can click on the picture for the video):

Romney signing the health care law - Click to see the signing ceremony video

Since 2003. HCFA had been working on assembling a broad coalition in support of what was originally known as just Chapter 58, and later “RomneyCare.” Looking ahead then, we figured that 2006 was going to be the year of opportunity. We built the ACT! (Affordable Care Today) coalition of religious activists, the health care industry (hospitals, doctors, community health centers, insurers, nurses and more), labor unions, citizen activists and political leaders that really did make history. What’s more, the coalition stayed together after the reform law passed (becoming ACT!! – or, Act 2), and continues to be a force for effective implementation of access programs.

RomneyCare and Obamacare as identical twins?This cartoon overstates it – RomneyCare and ObamaCare are not identical twins (contra an exuberant Jon Gruber, and more on this below). But there’s no question that our achievement became the template for the ACA, and we would not have over 20 million more people nationally with insurance, and additional millions with more affordable coverage, without our law's success.

Another Anniversary

Today also marks another important anniversary. Exactly nine years ago, on April 12, 2007, the Connector Board approved its premium schedule for subsidized people in Commonwealth Care (now called ConnectorCare). The fight over the level of premiums was the first major implementation battle. We worked closely with the Greater Boston Interfaith Organization to bring real family budgets to the discussion, demonstrating the tight finances of low-income people struggling with the high cost of living in Massachusetts. We were pleased that, in the end, on 4/12/2007, the Connector board ended up agreeing with us. As we said then, “We have achieved affordiosity.” These affordable premiums, along with no deductibles and modest copays in the subsidized plans, led to a surge of enrollment, bringing the coverage rate here up to around 97%.

But when the ACA was being designed, they deviated from the Massachusetts experience. Subsidized Obamacare plans have much higher premiums, and included deductibles and larger copays. In large part, this was due to the need for Congress to meet overall federal spending targets. The result is a stark difference in affordability:

Higher premiums under the ACA

We think this explains in part why Massachusetts enrollment has been better than the rest of the country - even states that have expanded Medicaid. The next frontier for Obamacare after Obama is more affordable coverage for low income people.

Still More To Do

We’re not done, though. This call from the Blue Cross Foundation points to continued challenges for all of us:

Health Reform at 10: Still must address access and affordability gaps

March 25, 2016

Safety Net

Yesterday, the legislature began a process to extend a temporary reprieve to low-income residents concerned about planned cuts to their access to health care.

Last month, the Executive Office of Health and Human Services (EOHHS) proposed changes to regulations governing the Health Safety Net (HSN) program. The HSN provides payments to hospitals and community health centers (CHCs) for providing care to low-income uninsured and underinsured Massachusetts residents. The program is primarily funded by an assessment on hospitals and insurers.

The proposed changes would significantly impact both the Commonwealth’s residents who rely on the program and providers who care for these residents by:

  • Reducing overall eligibility from 400% of the federal poverty level (FPL) to 300% FPL;
  • Charging deductibles for HSN users at or above 150% FPL (instead of 200% FPL); and
  • Limiting retroactive coverage to 10 days prior to application (instead of 6 months).

These cuts were scheduled to take effect on April 1, but are now being delayed until June 1 thanks to advocacy efforts. Also, the Governor’s proposed FY2017 state budget also does not include the customary $30 million investment in the HSN program.

Consumer advocates, hospitals and CHCs testified at the public hearing on February 26th in opposition to these changes. You can read the ACT!! Coalition’s comments here.

Dozens of legislators have also taken up the fight to preserve current HSN rules and funding. Yesterday, the Senate unanimously voted to approve an amendment to a FY2016 supplemental budget bill to preserve current HSN eligibility rules through June 30, 2016. The bill now must be reconciled with a House version that does not include the HSN provision, before enactment in both chambers.

We urge the Legislature to include this amendment in the final version of the FY2016 supplemental budget and the Administration to accept the budget language, and reconsider the proposed changes to the HSN program.

              -- Suzanne Curry

March 24, 2016

Boston Globe headline: Drug bill calls for student screening

Last week Health Care for All stood with policymakers, law enforcement, families, and advocates to watch Governor Baker sign Massachusetts' comprehensive opioid bill into law. It was an emotional yet hopeful moment as the Governor said “May today’s bill passage signal to you that the Commonwealth is listening and we will keep fighting for all of you.”

The new law has several key provisions aimed addressing the opioid epidemic including:

  • Limits on first-time prescriptions for opioid drugs to a seven-day supply, with exceptions for treating cancer or chronic pain.
  • Requiring doctors to check a state Prescription Monitoring Program (PMP) each time they prescribe an addictive opioid
  • Establishes civil liability for anyone administering the anti-overdose drug naloxone
  • Allows patients to fill a lesser amount of an opioid prescription.
  • Establishes a drug stewardship program to dispose of unneeded drugs and allows patients to fill a lesser amount of an opioid prescription.
  • Requires that a mental health professional provide a substance abuse evaluation to anyone who enters the emergency room suffering from an opioid overdose within 24 hours

The Children’s Mental Health Campaign, which HCFA helps lead, is proud to have worked hard to make sure prevention is central to the conversation around substance abuse. The campaign worked with Massachusetts State Senator Jennifer Flanagan to include a provision within the legislation that establishes a process for schools to verbally screen students to identify those at risk of drug addiction. This set of tools, called Screening, Brief Intervention, and Referral to Treatment (SBIRT), helps identify alcohol or drug use and guides follow-up counseling and treatment if a problem exists. With adolescents, SBIRT is an effective prevention and early intervention strategy.

HCFA and the Children's Mental Health Campaign will be closely following the implementation of this important strategy to improve the health of children in Massachusetts.

       -- Jamie Gaynes

March 23, 2016

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

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

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

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

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

Health status and income affect ability to get care

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

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

     -- Brian Rosman

March 14, 2016

Call Center Satisfaction Survey

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

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

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

Risk Adjustment Data Validation

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

2017 Affordability Schedule

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

 

2017 QHP Product Shelf

2017 Seal of Approval

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

Connector considering "Value Based Insurance Design" for 2018

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

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

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

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

                     -Sara O’Brien & Suzanne Curry

March 10, 2016

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

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

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

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

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

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

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

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

March 10, 2016

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

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

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

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

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

                          - Sara O'Brien

March 3, 2016

Dentists to be trained on opioid abuse care

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

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

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

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

                                    --Kate Frisher & Sara O'Brien

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