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

August 1, 2016

The purpose of health insurance is twofold. First and foremost, it serves to protect a person’s health. Without coverage, people are more likely to delay getting needed care. But, almost as importantly, coverage ensures financial security. Even a routine procedure like an appendectomy could mean financial ruin for the uninsured. An important new study, The Effects of the Massachusetts Health Reform on Household Financial Distress, published in the American Economic Journal, sheds light on the economic impacts of the 2006 Massachusetts health reform. The conclusions suggest that the effects of sweeping health reform extend far beyond better health outcomes; expanding coverage may actually help to lift people out of the hole financially, ultimately driving opportunity for economic growth.

The study compared financial characteristics of people under age 65 in Massachusetts to other New England states, before and after full implementation of the Massachusetts health care law in 2008. The model took into account which subgroups were most heavily affected by the reform. Before the reform, from 1999-2005, Massachusetts followed the same financial trends as other New England states. After the expansion of coverage in 2008, Massachusetts suddenly deviated. The authors concluded that higher coverage rates directly and significantly contributed to the following outcomes through 2012:

  • improved credit scores,
  • reduced total debt,
  • reduced total amount and percent of debt past due, and
  • reduced probability of personal bankruptcy.

Just to be sure about health reform’s causal effect on improved financial well-being, the authors conducted an analysis of individuals over age 65 in Massachusetts, since this age group was essentially unaffected by the reform. Confirming the findings, seniors’ financial outcomes did not change relative to those who gained access to insurance under the reform.

The authors conclude:

Our analysis shows that health care legislation has implications that reach beyond health care providers and the uninsured, and extend into credit markets, benefiting not only uninsured households who gained coverage, but also creditors who served these households. Our finding that credit scores improved as a result of the reform indicate that the reform increased future access to credit for those individuals who gained coverage. These results show that health care reform legislation has pervasive effects not just on health and the use of health services, but across many measures of household well-being.

Chart adapted from paper, showing decline in Mass residents with over $10,000 in debts.

Particularly striking is the fact that these financial improvements took place in the midst of a serious economic recession. It prompts the question: did the 2006 health reform help mitigate some of the recession’s worst effects for the state of Massachusetts? Common sense economics says that if people have less bad debt, less likelihood of declaring bankruptcy, and better credit, they will have better economic opportunities. Greater numbers of economically healthy individuals means a more prosperous economy as a whole. A higher credit rating means better prospects of home ownership. Less unpaid debt means more money flowing through various sectors of the economy. Less personal bankruptcy means – well, let’s just say we know what happened in the 2008 financial collapse.

Again, Massachusetts leads the way in demonstrating the far-reaching beneficial impacts of universal healthcare. The nation should take note.

                                                                                                                                                                         -- Mike DiBello

June 13, 2016

Pie chart of state budgetThe House-Senate conference committee on the Fiscal Year 2017 state budget held its first meeting last week to negotiate a final budget based on the House and Senate budgets passed in each branch. The new state fiscal year will begin on July 1.

HCFA is pleased that each budget proposal includes a number of provisions that fund MassHealth and other key health programs, and advance consumer health interests. However, there are important differences between the two versions, and HCFA distributed the following statement to the legislative leadership indicating our priorities for the budget process:

The challenges facing our Commonwealth are significant. Recent revenue declines mean difficult funding decisions. The budget proposals put forward by both the House and the Senate reflect the commitment by the Legislature to not retreat from effective, innovative government policies that promote the health of all Massachusetts’ residents, and we should collectively be proud of the many provisions that will benefit health care consumers.   

As you work to develop the final FY 2017 budget, HCFA urges you to prioritize these goals:

  • Protect the Health Safety Net Program;
  • Expand access to dental care through Dental Hygiene Practitioners;
  • Provide unbiased information about the cost and efficacy of prescription drugs;
  • Streamline public benefit program applications to improve health and decrease health costs;
  • Plan care improvement for infants exposed to substances;
  • Complete the study on drug copay coupons before changing policy;
  • Examine the impact of limited MassHealth dental coverage; and
  • Adequately fund the statewide dental program for people with disabilities.

Protect the Health Safety Net Program

The Health Safety Net (HSN) lives up to it name. It is our last resort program to meet critical health needs of low income residents of the Commonwealth without any other source of assistance. Senate Section 77A (redrafted amendment 369) delays proposed eligibility reductions through April 1, 2017, giving the Legislature, Administration, and stakeholders the opportunity to better understand the impact of the cuts and develop appropriate policy responses. HCFA opposes the cuts proposed by the Executive Office of Health and Human Services (EOHHS), and urges reconsideration of their implementation. The eligibility cuts would shift costs to providers and leave many low-income people with substantial medical debt.

The HSN is primarily funded by an assessment on hospitals and payers, while the state customarily contributes $30 million of federal reimbursement it receives from revenue generated by the assessment. The Administration’s FY2017 budget did not include any state funds for the HSN. Both the House and Senate provide $15 million in funding, though the House budget includes “up to” language that could potentially result in less funding being transferred to the Health Safety Net (House Section 42). We urge the conference committee to support the Senate budget approach that specifies a firm $15 million for the program (Senate Section 72).

We urge the Conference Committee to include a provision delaying implementation of eligibility cuts in the Health Safety Net program until April 2017 and specify $15 million in state funding for the HSN.

Expand Access to Dental Care through Dental Hygiene Practitioners

One in ten Massachusetts residents does not have access to a regular dental provider. Only 35% of dental providers accept MassHealth, making it even harder for seniors, children, and other vulnerable populations to access basic dental care. Dental care must be more easily accessible.

A dental hygiene practitioner is similar to a nurse practitioner and would improve access to dental care. Dental hygiene practitioners could work in settings such as schools and nursing homes to make care accessible. They may also work directly with dentists, allowing practices greater financial flexibility to see more MassHealth patients. Sections 35A-35D and Section 77A of the Senate budget (redrafted amendment 479) authorize dental hygiene practitioners in Massachusetts.

We urge the Conference Committee to include provisions authorizing Dental Hygiene Practitioners to be licensed as a new midlevel dental provider.

Provide Unbiased Information about the Cost and Efficacy of Prescription Drugs

Health care providers are confronted with an overwhelming amount of new clinical research, making it difficult to stay current about which treatments are most effective and have the best patient outcomes. At the same time, the pharmaceutical industry spends billions on marketing directly to doctors to promote their products. This influence results in higher costs for patients and the Commonwealth as pharmaceutical representatives typically promote their newest, most expensive brand-name drugs, regardless of whether or not they offer improved outcomes.

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.

February 21, 2016

The remaining uninsured in MassachusettsLast week, the Blue Cross Blue Shield of Massachusetts Foundation and the University of Massachusetts Medical School released a report entitled “The Remaining Uninsured in MA: Experiences of Individuals Living without Health Insurance Coverage” (read the report here). Massachusetts continues to have the lowest uninsured rate in the nation, with some 97% of residents covered. However, about 200,000 people of diverse age, race and employment status remain uninsured. The goal of this study was to figure out the reasons why people remained uninsured and help inform policy suggestions which would help them receive coverage in the future.

The report authors spoke to a sample of uninsured people from seven counties in the state and developed the following key findings;

First, health care costs continue to be prohibitive. One of the most cited reasons that people gave for being uninsured was the cost. Some people weren’t eligible for their employer’s insurance, and other were not eligible for subsidies. Some 58% of respondents said they had had coverage at some point in their adult lives, but changing circumstances had dissuaded them from applying. Some said that they let their coverage lapse because they said they didn’t use it enough to justify the cost, while others simply became ineligible for employer-provided insurance. One respondent said that the cost of the penalty was less than the cost of insurance itself, and so they decided to simply pay the fine.

Another key point here is that a vast majority (73%) of the people surveyed said that they considered themselves to be in very good health, despite that slightly more than one third has one or more chronic conditions. Still, it would seem that some people were willing to hedge their bets by remaining uninsured, counting on good health to compensate for their lack of insurance.

Some other important aspects were related to communication; the process of applying was widely reported to be confusing and complex, and would be greatly simplified by having personal assistance, in people’s primary language. Having access to this would be even better if it is available in convenient location such as “health clinics, hospitals, nonprofit organizations, unemployment offices, and local businesses” that have evening and weekend operating hours, additional appointment times and more staff to assist.

Some respondents also reported losing their health insurance through state programs like MassHealth because they did not realize they needed to take any action to renew their membership. In this area, better communication with enrollees is necessary.

Secondly, the value of health insurance was lost on no one. Almost every person contacted indicated that they wanted health insurance coverage, and certainly understood the value of it to their overall wellbeing. Most people indicated that that the insurance provided a sense of security and that the lack on insurance was reflected in the way that people interacted with their care. People without insurance said that being uninsured limits “when they can get care, where they can get care, and what type of care they receive. Nearly a third said they were unable to get care when they needed it and that not having insurance limited their access to specialty care, routine tests, and preventive screenings”. Almost one third said that they were unable to get care when they needed it. While some people reported that they didn’t use it enough to justify the costs, the lack of insurance meant either not receiving or putting off necessary and preventative care.

The study notes that community health services such as free clinics and community health centers provide necessary access points for uninsured, especially undocumented, people in the Commonwealth. Additionally, the report supports the value of enrollment events and in-person assistance to help insure people and recommends possibly working with unemployment offices to help those who are looking for insurance outside of the open enrollment period.

The report closes with a note that lowering Massachusetts’ already low uninsured rate will be difficult, but that by learning from the experiences of those people, we can do what is possible to get the number down to 0% uninsured.

                  -Sara O’Brien


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