Earlier this month, the Milken Institute released a report on the economic burden of chronic disease in America. The report considers the health care and financial effects of cancer, diabetes, high blood pressure, stroke, heart disease, pulmonary conditions, and mental disorders. The report adds to the growing base of information describing the impact of chronic disease on health care costs and provides detailed analysis about its influence on the labor supply and the economy through decreased worker productivity.

What is most striking and troubling is that Massachusetts ranks in the lowest quartile of states—at 40th overall. According to the Milken report, Massachusetts’ chronic disease ranking is attributable to high cancer rates and the high incidence of alcohol abuse and other mental disorders.

The ranking is surprising because Massachusetts is generally viewed as one of the healthiest states in the nation. We rank first among states in terms of the overall rates of obesity — 19% of all Massachusetts residents are obese, compared to 30% of residents of Mississippi, which ranks last. But, at the same time, we rank 27th in the percent of children who are obese. Read more…

The argument that it’s acceptable to exclude prescription drugs because some people will buy a plan without drugs is like allowing plans to exclude coverage for mental health services — if you don’t need it today and think you probably won’t need it tomorrow, why make you pay for it. You could do just that, and some people would buy a plan without mental health coverage — but we don’t allow it because it puts vulnerable people at risk and because it is contrary to the whole concept of insurance. Everybody pays a little more so that everyone is protected when and if they need help. We can try to keep costs down by requiring the use of generics; by excluding some “me-too” expensive drugs; by adjusting co-pays to encourage desirable utilization patterns, but we should not be encouraging people to be underinsured or, more importantly, to put themselves or their families in harm’s way by not taking the drugs necessary for prevention of serious health outcomes, for delaying treatment of current ailments, or by buying at full retail cost, the undiscounted drugs they absolutely must take. Remember what serious consequences can follow even an untreated strep throat in a child. That’s when being penny-wise can lead to life-long medical harm — that’s pound foolishness.

Dolores L. Mitchell, Executive Director of the Group Insurance Commission of the Commonwealth of Massachusetts, the agency that provides life, health, disability and dental and vision services to over 285,000 State employees, retirees and their dependents.

The most unprecedented aspect of Chapter 58 is about to get real. Many uninsured Massachusetts residents over 18 will face financial penalties if they don’t have health insurance by 12/31/07. Because insurers don’t sell coverage for a day, buying coverage for 12/31/07 requires buying coverage beginning 12/1/07, and that requires purchasing coverage by about 11/15/07.

The penalty for not having coverage on 12/31/07 will be loss of one’s personal tax exemption, about $220, when state income tax forms are completed next year. Beginning January 1, the penalties mount month by month, up to half the cost of the most affordable monthly Connector-approved premium.

Not every uninsured person will be penalized. Many have already been determined exempt because there is not affordable coverage available to them. Others may obtain individual waivers. And some unknown number will face penalties. No one knows how many will fall into these three categories.

Only two governmental entities on the planet, the Netherlands and Switzerland, place a similar requirement on their residents. Like the U.S, both rely largely on private insurers to provide coverage, though at no more than two thirds the cost of ours – the most expensive health coverage on the planet.

The individual mandate was not advanced by Health Care For All or the Affordable Care Today coalition. The Blue Cross Foundation’s Roadmap to Coverage project first advanced it as one possible component in June ‘04. Read more…

Today, Massachusetts hospitals and nurse leaders are taking another leadership step in their efforts to be open and transparent about the care they provide. Our hospitals are the first in the nation to voluntarily “open their books” if you will and let the public see how they are performing when it comes to falls and falls with injury in the hospital. When I told a national leader in improving falls, Pat Rutherford RN IHI Vice President, about this data release she told me that given the scarcity of public data in this area, it will be an enormous contribution to national efforts.

Data transparency by healthcare organizations can accomplish at least three goals: demonstrate the organization’s willingness to be held accountable for their practice, educate those they serve, and improve the service levels, satisfaction, costs, and outcomes of care. With release of this data, Patient’s First and Massachusetts Hospitals continue to demonstrate a leading edge commitment to accountability, education, and improvement. Their work will also continue to inform a state and national journey.

Congrats to all involved in the release of the data and in the commitment to work to eliminate preventable harm from falls.

Jim Conway, Senior Vice President, Institute for Healthcare Improvement

Know, O people, the LORD has told you what is good,
and this is what he requires of you:
to do what is right, to love mercy,
and to walk humbly with your God.
(Micah 6:8, New Living Translation)

For the past month, GBIO leaders have been holding Outreach and Enrollment Sessions for our members throughout Greater Boston. These sessions give us direct contact with uninsured residents struggling to secure their own health. By conducting these sessions we are learning several important lessons about health reform and the challenges that lie ahead.

Lesson 1: This law is helping many people get access to quality health insurance.

Here are just two stories that highlight this success:

Sabrina Knights is a family child care provider in Dorchester. She has three children on MassHealth but is uninsured herself. At a recent Outreach and Enrollment workshop organized by GBIO and the American Family Child Care Network, she was surprised to find out that there was a new option for her, Commonwealth Care with a $35 a month premium. After the session she visited her local health center to apply. She’s waiting to hear the results, but they look positive.

Pat Maye-Wilson from People’s Baptist Church is currently between jobs and uninsured. She is in her late 50’s and wants and needs health insurance that can allow her to access to vital prescriptions and doctor visits. After attending a session at her church, she discovered that she is most likely eligible to enroll in Commonwealth Care and recently submitted her application.

Lesson 2: Lots of people do not understand their new obligation under the individual mandate.

While many people have heard about the new law, few people have yet had the opportunity to think about how the new law will affect them, what new programs they are eligible for and if they will face a financial penalty for not having insurance. This is a brand new concept and the residents of the state need additional education about how this law affects their families. Read more…

A couple of weeks ago, my class of health science majors (pre-med, public health, possibly nursing, pharmacy or physical therapy) in Bouvé College of Health Sciences at Northeastern University were privileged to have a presentation by Lindsey Tucker, Health Reform Coalition Coordinator at Health Care for All about Chapter 58, often mistakenly referred to as “Massachusetts health reform” and the availability of affordable health insurance for them as one of the key target populations, young adults ages 19-26. Partly motivated by another contributor to this blog this week I decided to follow-up with a class survey, and while “of course I’m not a researcher or a scientist” it’s subject to criticisms regarding scientific rigor, validity and reliability. Nevertheless, I think there are some interesting findings.

I’m pleased to report a 100% response rate and that 100% of the students responding to the survey are insured: 88% on their parents plan with 6% on Medicaid and another 6% that purchase the plan offered by the University. As future health professionals a substantial majority, 78% report that having health insurance is very to very, very important to them mostly for security as a way “to ensure payment for a catastrophic event or illness.” Only 30% reported feeling they understood enough about health insurance, coverage and benefits to make an informed decision in selecting from among the “too many” Commonwealth Choice(s). Many, 66% were discouraged by the complexity and lack of information available. Try here. Read more…

Part of the stated mission of the Health Care Quality and Cost Council, established by the health care reform law, is “to develop and coordinate the implementation of health care quality improvement goals that are intended to lower or contain the growth in health care costs while improving the quality of care.”

One approach that I feel should not be used to accomplish this mission, as it relates to physicians, has become known as “tiering,” a process that, in theory at least, is supposed to improve physician performance as it relates to efficiency and quality. This program, currently using claims data from health plans, is being used now by the State’s Group Insurance Commission for its 285,000 state employees and retirees. Similar physician rating programs have come under fire (and the object of lawsuits) by physicians in Washington state and Connecticut. And New York’s Attorney General has called the practice into question, saying it could be deceptive and confusing.

I am not opposed to cost and quality measurements. Indeed, I welcome whatever information that will help me improve patient care and outcomes. But I am concerned about unintended consequences of the current system of tiering; I believe it is simply the wrong approach.
Some of the flaws: Read more…

There is a new term in the lexicon of quality and safety that refers to errors in medical care that are “clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility” (definition by the National Quality Forum). The term is never events. The idea is that certain events should never happen in hospitals and that establishing a zero tolerance for these problems and requiring public reporting will help eradicate them. Another related idea is that economic disincentives will help reduce the incidence of “botched hospitalizations,” a commonly used term for the never event concept. In a recently released, 2,000-page report, Medicare announced it will not pay hospitals for the care needed to treat patients after certain preventable medical complications. The concept is that non-payment removes the financial “reward” that currently comes with complications and will get complacent doctors and hospitals to make more of an effort to improve.

The problem is that some the events on the list really are “never events” (like wrong site or wrong patient surgery) that can and should be eliminated. But the other end of the spectrum includes conditions that may never be eliminated, although having zero as a goal is a worthy aspiration. An example of this latter category is mediastinitis, a hospital-acquired infection involving the sternum or breastbone that can occur after heart surgery. The only way there will ever be a zero incidence of mediastinitis is if heart surgery were to become obsolete or some sort of fundamental breakthrough in infection control were to occur. Read more…

On Friday I met with Lindsay, one of our students at the Harvard School of Public Health and her boyfriend, Andrés, who is a graduate student at another local university. When he enrolled in graduate school, Andrés bought the student health plan offered by the school, since he was required by state law to have health insurance. (Students enrolled in colleges and universities in Massachusetts have been subject to an individual mandate since 1990.) The health plan offered by Andrés’s school meets the state requirements for qualified student health insurance (QSHIP).

Earlier this year, Andrés was diagnosed with cancer. He had surgery and completed radiation therapy treatments. Once the bills started coming in, Andrés discovered that his health insurance plan had a variety of legally permissible but devastating limitations: a $100,000 overall cap on benefits for any one illness, a limitation of $5,000 for high-cost procedures (which included his MRIs and radiation treatments), a severely restricted benefit for anesthesia, and many others. As a result, Andrés now has at least $40,000 in uncovered medical bills. Not the kind of added stress he needs when he’s fighting cancer.

Andrés is exploring whether the Uncompensated Care Pool/Health Safety Net Trust Fund can be a source of financial assistance for some of his bills. And maybe he’ll be able to get some relief from the Boston teaching hospital where he’s being treated.

At least Andrés did get one piece of good news: as a result of health reform, he was able to enroll in a Commonwealth Choice plan that has much more comprehensive coverage than his QSHIP plan, so he now does have the coverage that he needs.

But many other Commonwealth Choice enrollees may find that they aren’t as lucky: one quarter of them have enrolled in the new Young Adult Plans (YAPs) that were modeled in part after the QSHIP regulations. Read more…

Some of you (Dave, read on) have asked about applying for an exemption to the requirement that all adults have health insurance.

As mentioned in July, the first time you will have to prove that you either have health insurance, or qualify for an exemption, will be on your 2007 state income tax return.

If you want to make sure you are exempt in advance of signing your state tax return, click here to find out how to file for an exemption. Many waivers will be based on income. There is also a list of hardships the state will consider. And, residents who believe that faith, not medicine, heals, will not be required to purchase health insurance.