Boston Medical Center is preparing for layoffs as early as this week and Cambridge Health Alliance will likely close one of its three hospitals and some health centers early next year. The state’s two largest safety new hospitals claim they are bearing a disproportionate share of state budget cuts…but the Patrick administration say it is time to rebalance the state’s health care spending.

(story transcript)

MARTHA BEBINGER: For decades, Boston Medical Center and Cambridge Health Alliance have made it their mission to care for Massachusetts residents who fall through the cracks of the health care system. They’ve created comprehensive programs of care for the uninsured, immigrants, drug addicts and the mentally ill. Representative Alice Wolf of Cambridge is leading a group of state and local elected officials worried about how her hospital will cope with 55 million dollars in state budget cuts this fiscal year.

ALICE WOLF: If there is a reduction in services, if an emergency room had to close or part of a hospital had to close, that would make a real difference. There isn’t any other place for those visits to be taken care of.

BEBINGER: Cambridge Health Alliance includes hospitals in Cambridge, Somerville and Everett as well as 20 community health centers. Administrators have not announced any changes …but the uncertainty is having an effect. Read more…

In 1993 the large national health insurance carriers contributed to the defeat of national health care reform by their association with the famous “Harry and Louise” advertising, which struck a cord with the entire country. While there are arguably many reasons for the failure of health care reform at that time, the opposition of most of the nation’s health plans helped to doom an idea whose time had not, apparently, come.

I’m pleased to report that times have changed. Last week, I represented the national association of health plans, America’s Health Insurance Plans, in a press conference in Washington to announce its series of proposals designed to support the national adoption of universal coverage.

The announcement said many things, but my quote that found its way to daily newspapers was this one, “The heart of our proposal is a public-private partnership that builds on the employer-based coverage that 170 million Americans rely on today. We have laid out a workable, realistic path to universal coverage and we want to ensure that no one falls through the cracks of our health care system because of age, health status, or income.”

While it is only the beginning of the national health reform discussion, the ideas put forth by AHIP have merit. No less an advocate than Sen. Kennedy has called for serious consideration of the AHIP proposals for a workable, realistic path to universal coverage. Read more…

Massachusetts health care consumers just got a whole lot savvier. As part of its commitment to improving health care quality and containing costs, the Commonwealth launched today an interactive websiteto help residents select high-quality, lower cost care and to encourage providers to improve quality and contain costs.

These efforts are particularly critical as Governor Patrick, his Administration, and our partners in the Legislature continue to move forward with health care reform implementation. Since 2006, more than 442,000 people have enrolled in insurance programs, making Massachusetts first in the nation in the percentage of uninsured. Care for the remaining uninsured, financed by the Health Safety Net, has decreased by more than 36% as enrollment has increased.

These are critical achievements, but the architects of Massachusetts’ historic 2006 health care reform initiative wisely recognized that controlling costs and improving quality are key components to ensuring the long-term sustainability of health care reform. The Health Care Quality and Cost Council has developed a consumer-friendly website that allows a diverse range of stakeholders to compare common health care procedures at different hospitals and outpatient facilities. A patient considering knee replacement surgery, angioplasty or a mammogram can now visit the new site to see how cost and quality measures might differ between various local hospitals for that procedure. Read more…

As the state looks for ways to improve health care and save money, the end of life is getting a lot of attention. 80% of the Medicare budget is spent in the last year of life but more than half of patients do not have the kind of death they’ve said the would prefer. One reason is that don’t explain their wishes to physicians or their loved ones.

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BEBINGER: Pam and Steve Rosenberg are in their family room, in Andover, trying to answer a questionnaire about what they want their last weeks or months of life to be like.

STEVE ROSENBERG: No.1 let me die in my own bed without any medical intervention.
PAM ROSENBERG: I agree with that.
STEVE: OK so, what if you can’t express your wishes? Is it up to me, in which case I’m never going to let you go. How do you know that science wont’ catch up to you in 5 years?

BEBINGER: Pam is 40. Steve is 53. Pam is pregnant with her first child. They have two sons from Steve’s first marriage. The Rosenbergs are both healthy. But Steve’s father’s death last year, was traumatic and both Rosenbergs hope that by being clear with each other now, they will avoid confusion and regret.

STEVE: I fall off a ladder and I am unconscious, on a ventilator, what are you going to do? Read more…

The dramatic cuts in funding proposed for Cambridge Health Alliance (CHA) and Boston Medical Center (BMC) are causing an increasing stir among caregivers and the communities these key safety net hospitals serve.

These cuts have local and national implications. With cuts looming, and with no apparent plan in place to ensure access and care, patients and caregivers in the communities where minority and low-income neighbors are served by BMC and CHA are feeling increasingly alarmed by a proposal which would be devastating for their community hospitals. Community, labor, and religious groups are taking measure of the impact the proposed cuts would have to essential care for minority and low-income neighborhoods. And advocates, safety net providers, and policymakers across the country are watching to see if Massachusetts can develop a plan to ensure the continued viability of its safety net system in the face of the dramatic changes wrought by health reform and the current economic and budget crisis.

A plan is essential because Massachusetts cannot afford to lose the vital services provided by BMC and CHA.

Consider:

CHA provides 150,000 visits annually for patients with behavioral or substance abuse problems. CHA provides 10% of all the state’s mental health inpatient stays, and 14% of all Medicaid mental health and substance abuse care. With the cuts proposed to CHA this year alone, it is possible that 10% of all the acute care psychiatric beds in Massachusetts could be closed. Read more…

Writing about what’s next in health care and health insurance during the next five or six months is going to be pretty much of a crap-shoot (If that’s a swear — sorry — I think of it as a gambling term) and most of us would be wise, not to do it. Who knows how bad the economy will get, or what help we will get from the next Congress and the next administration — or what that help will accomplish. And who knows what will come of the various health reform packages — Senator Baucus’s, Senator Kennedy’s or Secretary Daschle’s. And of course, in the great parlor game of musical chairs, we’re all waiting to see who gets on the short lists for CMS, for AHRQ, for CDC, for FDA, for Surgeon General — who from Massachusetts will get the nod — which incumbents get to stay — and who goes — what will it all mean for us in the Commonwealth as we watch the state’s revenues sink, along with those of our sister states. Misery doesn’t particularly enjoy this kind of company.

Although we can see the future only dimly, the one thing we know is that things will be different in Washington — and in Boston. So, with absolutely no inside knowledge to guide me — my predictions are the following:

- There will be a stimulus package, and it will pass quickly.
- There will be a health reform bill and it will pass during the first year of the new Congress. Read more…

Click here to listen to Dr. Atul Gawande talk about a wide range of issues including the Individual Mandate, reducing surgical errors and whether patients will shop for the best values in health care.

Codman Square Health Center has taken a number of financial hits this year. We started off the fiscal year in October with about $200,000 in cuts from a safety net program that was eliminated from the budget. We took another hit with the Governor’s 9C cuts in October. Just prior to writing this blog, I opened yet another envelope from the Department of Public Health containing a contract amendment reducing a grant for at risk women and adolescents from $90,000 to $76,500 for this fiscal year. Among other expenses, the grant supports a registered nurse who performs case management duties for pregnant women and girls. We have already received other reduction letters, and, combined with the expected lowering of reimbursement through cuts in Medicaid managed care, we are looking at about $250,000 – $300,000 in cuts from October’s 9C budget reductions. This is forcing managers at Codman Square to scramble to find new ways to increase revenue or reduce cost amounting to a combined total of $500,000 just to break even on a cash basis (meaning we would show an operating loss of nearly a million dollars, but it would be mainly from not funding depreciation).

This brings us to our 1400 problem. Read more…

A recent analysis by the actuarial firm Mercer on the Massachusetts Medicaid population (aggregate Medicaid managed care organization data) suggests that just over half of the emergency department (E.D.) expenditures in calendar years 2005 and 2006 were spent on low-acuity, non-emergent, (“LANE”) services. These are services that presumably could have been handled in a primary or urgent care setting, such as earaches, coughs, and viral infections, and that for whatever reason, the individual sought treatment at an E.D. Certainly, at more than half of the total cost of emergency visits, this non-emergent use of the E.D. is a significant contributor to the overall health care cost equation. To encourage more appropriate settings for needed care, MassHealth, as part of the annual rate setting process with the Medicaid managed care organizations (MMCOs), has actually worked with Mercer to quantify and apply to the MMCO rates a “LANE” deflation factor, a downward adjustment to reflect what that care would have cost if a portion of it had been delivered in an alternative setting. So the MMCOs have a real incentive to discourage inappropriate E.D. utilization. But to truly effect change in this regard, we need to understand the factors and behaviors that drive people to the E.D. for non-emergent care and then we actually need to be able to do something about it.

Although most people who receive state-subsidized insurance openly recognize that the intended purpose of emergency departments is for emergency care, many readily admit to using the E.D. for non-emergency medical concerns. During a series of focus groups Network Health conducted earlier this year, several of our members also said that they went to the E.D. because they felt that they would have a hard time getting an appointment with their PCP, or that if they sought care through a PCP, they would be sent to the E.D. anyway. Read more…