In recent years, Massachusetts has led the nation by creating a new system to address our state’s health care needs. As we are increasingly used as a model for improving health care throughout the country, we must ensure that we protect some of the most critical pieces of this system, including oral health care.

With access to simple, cost-effective preventive care, we can keep our state and our nation healthy. Protecting these benefits is imperative for several reasons:
· Oral health is an essential part of overall health. Chronic oral infections are associated with complex health problems such as heart disease, stroke, diabetes, low-birth weight, and premature infant births.
· Lack of preventive care causes the state to waste millions in extensive and costly services in emergency and inpatient hospital settings.
· Lack of comprehensive and consistent dental care prohibits many adults form entering or remaining in the workforce. Currently, 164 million hours of work are lost in US each year due to dental disease.

By law, the governor must balance the state budget, and on Thursday announced a $600 million deficit. Currently, Governor Patrick can only make up these deficits by cutting from certain types of programs, including public health. Under these circumstances, we fear that the Governor will eliminate oral health coverage for nearly 700,000 adults, including more than 120,000 low-income seniors and 180,000 disabled individuals on MassHealth. This means that one in ten Bay Staters will lose access to services that are crucial to remaining healthy, contributing members of society.

However, Governor Patrick has requested that the legislature grant him authority to spread these cuts over wider arenas, sharing the burden more fairly across the state. There are several ways we can stand up to try save vital programs such as adult dental benefits in MassHealth. The governor must understand the importance of oral health to overall health, and the necessity of oral health care. We can also request that our state legislators grant the governor expanded authority to cut from a wider range of programs. Click here for more information.

As we are scrutinized by the country as an example of successful health reform, we cannot move backwards by cutting vital services. We must arm the Governor with the authority he needs to protect dental benefits to adults on MassHealth, and preserve our legacy of innovation and leadership.

Early in the meeting speakers identified competing pressures that will challenge the adoption of a different payment system. Speakers and meeting participants spoke of the need to maintain patient centered care, patient and doctor autonomy, while being mindful of limited resources in the face of unlimited need. There was near unanimous agreement that most physicians don’t actually know what things cost, and some very funny anecdotes about trying to find out cost information. (One doc asked a lab manager what a panel of tests cost only to be told that the manager was prohibited from sharing that info. When pushed, the manager suggested that the doc couldn’t handle the truth.)

Dr. Harvey Fineberg, the President of the Institute of Medicine gave the keynote address and opened his remarks by polling the physicians in the room about how they are paid. This simple exercise demonstrated that payment methods were all over the map. Some docs were salaried, some received fee for service, and some were paid under capitation. (There were no concierge providers in the room). As Dr. Fineberg explained each of these payment systems has its own peculiar properties with incentives and disincentives for particular behaviors.

Dolores Mitchell explained that the Special Commission on the Health Care Payment System had recommended the gradual move to a global payment system, which evoked lots of small group conversation about what systems and protections would be needed to avoid unintended consequences for providers and patients.

There was a good deal of conversation about physician salaries and how much money doctors should make. Several speakers pointed out that salary is always assessed in relation to others (the ideal salary being $15 more than your brother-in-law), with little consideration of what the cost is to generate a salary, or what salary represents a barrier or an inducement to join a particular practice area. There was vigorous agreement that primary care must be appropriately valued and paid for in a way that encourages more providers to join the ranks.

This was my first ABIM Foundation Forum, and I was delighted to be among the consumer advocates included in this conversation. Some of my consumer colleagues expressed frustration at feeling like “the skunk at the garden party,” but my small group conversations were eminently more cordial and accommodating. A couple of docs voiced frustration at having patients appear in their offices demanding a particular drug or test – commonly, these challenges arose from patients asking to have an MRI which the doctor judged to be useless. I suggested that these intersections are great teachable moments. If the doctor would have a conversation with the patient that explained that the MRI would yield no useful diagnostic information, and provide no additional insight into the case, I wagered that most patients would withdraw their insistence on a useless, time consuming, resource wasting, test.

Alternatively, I suggested that one thing that would enhance patient trust and improve system credibility would be to have more transparency so that patients could see if there were competing interests at work with referrals or prescription choices. My small group was in vigorous agreement about the role of transparency in a transformed payment system, particularly as this would mean that payers would share more complete information with providers.

I am grateful that the ABIM Foundation distributed the principles that Health Care For All has adopted for our work on payment reform, and I enjoyed discussing some of the immediate opportunities that Massachusetts has to be at the forefront of payment reform.

We discussed coordination of care as an important potential benefit of payment reform and there were some folks who were involved in systems of extremely coordinated care. However, it was helpful to hear from a consumer who has a host of medical conditions that require the coordination of 9 doctors and their support staffs. This consumer pointed out that she is the point of coordination, and that her continuity of care depends on her accurate description of all of her treatment. This is a source of endless frustration, and will not be effective for patients who are less well versed in their own medical conditions.

Health Care For All is cautiously optimistic about Massachusetts payment reform, and we think that engaging, empowering, or activating patients in new and different ways will be the bedrock foundation for its success. We know that in a fee for service system unnecessary care is very profitable care. We also know that many providers are frustrated at not having the time or incentives needed to work collaboratively with their patients in a way that improves outcomes. We think that payment reform and a gradual and deliberate move to some type of global payment offers real hope for improving our system of care delivery.

Doctors have an incredibly powerful role to play in national health reform and in payment reform. Consumers want to partner with our providers to improve our overall health and to improve our health care delivery system. The ABIM Foundation Forum was a terrific step toward that ideal.

Amy Whitcomb Slemmer, Esq.
Executive Director, Health Care For All

This week, for example, the legislature will be hearing a number of bills to strengthen both the quality and access threads of health reform.

On Tuesday, the Public Health Committee will be hearing three bills drafted by HCFA’s Consumer Health Care Quality Council. The Council gives a voice to people impacted by poor quality medical care. They have joined together to work for real improvements in our system. The bills are:

• An Act to Improve the Delivery of Healthcare (S. 878/H. 213), filed by Sen. Moore and Rep. Provost, directs the use of checklists in hospital procedures. The bill would reduce medical errors and infections in hospitals by requiring that a series of safety steps be explicitly checked off by healthcare providers to decrease patient harm for given procedures. Airline pilots always run through their checklist before takeoff, and when surgeons do it, death and complication rates reduce dramatically.

• An Act to Reduce Healthcare-Associated Infections (H. 2139), filed by Rep. Provost, calls for screenings of high risk individuals entering a hospital setting for the “superbug” MRSA, a highly-infectious bacteria that’s resistant to most anti-biotics. Two years ago, that CDC reported that more people in the US die from MRSA than AIDS. Screening will allow hospitals to take precautions to prevent the spread of infections.

• An Act to Reduce Medication Errors in the Commonwealth (S. 909/H. 2084), filed by Sen. Tucker and Rep. Khan, establishes an expert panel to determine the prevalence of medication errors and adverse drug events in the Commonwealth and make recommendations for how to reduce their occurrence across all health care settings.

The Committee will also be hearing An Act to Investigate the Use of Computed Tomography (CT) Scans in the Commonwealth (H. 2118), filed by Rep. Kulik, which asks the Department of Public Health to look into overuse of CT scans. CT scans subject patients to very high doses of radiations, 500 times that of an x-ray, and are suspected to be a major cause of cancer.

Then on Wednesday, the Health Care Financing Committee hears a number of bills, including the ACT!! coalition’s legislation, An Act Relative to Health Care Affordability (S. 549), introduced by Senator Montigny. As pointed out in Sunday’s lead Globe story, affordability is becoming a major concern for people with insurance.

The bill would require that the state’s affordability standard take copays, deductibles and other out-of-pocket costs into account. Right now, the standard only looks at premiums, leaving many unable to afford a policy that the state claims is affordable.

The bill also includes language, initially filed last year by Senate President Murray, to strengthen oversight over insurer premium increases. The provision requires insurers to file proposed rate increases 90 days before they are due to take effect. If any increase is for more than 7%, then a public hearing must establish sufficient justification for the increase. The hearings would allow the public and regulatory authorities to understand the basis for large increases, and give the state grounding to reject unwarranted increases.

Finally, the bill separates out the regulatory authority over health insurance from the Division of Insurance into a new Division of Health Insurance. With the current DOI’s attention divided among auto, homeowners, health and other types of insurance, this provision would assure that one agency has a singular focus on the critical issues of our health insurance market. Rhode Island recently set up a similar office, and it has allowed the new agency to devote all its resources to effective oversight.

Brian Rosman and Mehreen Butt, Health Care For All

ACT!! has significant concerns with student health plans, particularly the lack of comprehensive coverage and unaffordable cost-sharing. The skinniest of the skinny, student health plans often do not cover basic services such as prescription drugs and surgery. The Health Care For All Helpline receives many calls from students concerned with the poor coverage provided by their student health plans, primarily the lack of access to medication. Without prescription drug coverage students struggle to manage chronic conditions such as diabetes and asthma.

The cost of student health plans is prohibitively expensive for many students and acts as a barrier to education, especially for students from low-income families. Co-payments are often unaffordable leading to students forgoing both preventive and acute care. Student plans that include benefit caps, per service caps and lifetime caps expose students to financial risk and jeopardize access to care when students are most in need of coverage. The strengthened coverage requirements achieved by Massachusetts health reform have led to fewer residents avoiding necessary medical care because of costs. ACT!! hopes that Massachusetts is able to secure access to comprehensive, affordable coverage for students so that they are also able to follow this trend.

The ACT!! Coalition strongly supports the increased disclosure requirements for student health insurance plans. As students are new to navigating the complex health insurance system it is important that they have a complete understanding of the details of their health care coverage. We urge DHCFP to ensure that the information regarding benefits and services is clearly and effectively communicated to students and all coverage exclusions, limitations and cost-sharing is explicitly presented.

ACT!! greatly appreciates that DHCFP will gather performance and benefit information from student health insurance plans; this is an important first step in evaluating the adequacies and deficiencies of these plans. The data gained from these reports will be useful in improving student health insurance plans.

Another round of regulations is planned for this summer on substantive changes to the benefits and structure of student health insurance plans. ACT!! looks forward to this opportunity to continue voicing our concerns and working to strengthen student health insurance. We appreciate DHCFP’s transparency and willingness to engage us and other members of the public in their decision-making. If you would like to learn more please contact Catherine Hammons at chammons@hcfama.org.

Catherine Hammons
Health Reform Policy Associate at Health Care for All

In 2008, the HelpLine took a total of 37,472 calls and completed 1,870 health insurance applications over the phone. Behind each application is an individual or family who we have guided through the health care system. For each one of these clients, we have followed up individually and notified them of the status of their application and their next step. Our callers include those who need help making a doctor’s appointment or getting prescriptions filled at low- or no-cost; those who need assistance with medical debt or appealing a MassHealth decision; and those who have questions about private insurance or need assistance completing an application for the state programs.

The HelpLine calls have increased in the last few months, and we are hearing a lot of new stories from people who have never turned to the state for assistance before. Here are some of the changes:

– So far this month, the call volume has increased by 67% compared to same time-frame last year. There are huge increases in both Spanish and Portuguese calls: 216% increase in Portuguese calls and 124% in Spanish calls.

– We are getting calls from people who are collecting unemployment benefits and do not know about the Medical Security Program. This is creating a shift in how we are helping our callers since many of them are eligible for Medical Security Plan and we cannot fill those applications out over the phone. We are answering questions and e-mailing/mailing the applications to them.

– People who have been on COBRA for the past eighteen months are calling, since they have no idea where to look on their own.

– There are more gaps in coverage with the influx of callers who are unemployed; these people are calling because they have ongoing treatments and/or medications.

There are reasons, of course, for these changes. We know that in February of 2008, Massachusetts had about 151,600 unemployed folks (4.4%); in December, that number was up to 235,4000 (6.9%).

I cannot begin to emphasize the importance of outreach workers and HelpLine assistance. It is critical that proper funding be provided to do this work. Now that we have all these great health insurance options in Massachusetts, it is even more important the assistance is there for people who need it. The best way of ensuring continuity of coverage is with outreach workers. This is the only way Health Reform will be successful in keeping the uninsured rate down and utilizing the benefits of the new Health Reform law.

Hannah Frigand, Health Care For All

Prescription drugs are central to modern health care. Medications are the first line of defense in preventing and combating disease. The prices of the most widely used brand-name prescription drugs rose nearly 50% between 2000 and 2006, more than twice the rate of inflation. Research has shown that gifts and fees paid to prescribers influence their prescribing behavior and cause more brand-name drugs to be prescribed when cheaper, generic drugs are as effective. The billions of dollars spent annually place a huge financial burden on the entire health care system. According the Congressional Budget Office, disclosing industry payments could lead to health cost reductions.

In December, DPH issued draft regulations which contain a number of loopholes. The draft regulations only ban gifts given to prescribers that are designated for “sales and marketing” purposes. This means that gifts given labeled as educational, such as expensive textbooks and computers, are not banned. Also, undefined “modest and occasional meals” are still permitted.

All gifts and meals should be banned because they all create a sense of indebtedness. The unconscious social psychology rule of reciprocity pushes a recipient to repay the giver, even if the gift is small. This interferes with the ability of health care providers to make prescribing decisions based solely on the needs of their patient. Both Boston University School of Medicine/Boston Medical Center and UMass Memorial Health Care have banned all gifts and meals. These regulations should follow their lead.

The draft disclosure regulations exempt payments made to providers conducting research in Massachusetts. Despite the legislature and Governor rejected the industry argument that disclosing these payments would hurt medical research, the DPH regulations open up this loophole. In fact, all clinical trials are already registered at a public government website, ClinicalTrials.gov. Disclosing research payments will allow Massachusetts consumers to see if their providers have any conflicts of interest. This step is essential for cost control to work.

Public comment and hearings on the regulations begin Friday. We urge the DPH and the Public Health Council members, who vote on these regulations, to strengthen them so that the intent of the law is achieved.

Georgia Maheras, J.D. is the Private Market Policy Manager at Health Care For All

Across the country, other states are similarly feeling the pinch, and Congress has been considering options to help. One potential opportunity to lessen the impact of budget cuts on the health care system is a short-term increase in the Federal Medical Assistance Percentage, or FMAP. FMAP is the percentage that the federal government reimburses to the states for Medicaid expenses. Because Massachusetts is one of the richer states, we receive the minimum – 50%.

FMAP can be a powerful tool that the federal government can use to inject cash into the economy, protect jobs, and help states support their health care system during a recession. In 2003, Congress raised the FMAP rate by about 3% across the board. The increase worked out to more that $300 million for Massachusetts which helped the state preserve programs and maintain eligibility rules. T he legislature passed a provision earmarking the additional funds to health care programs.

In the effort to pass an economic stimulus package earlier in the fall, the House of Representatives included an FMAP increase in their proposal. That version died in the Senate, and the bill that eventually passed did not include raising the rate.

In the final weeks of the current Congress, there is a steady buzz about the potential of a new stimulus bill – either during the lame duck period before January, or after President-Elect Obama takes office. All of the Massachusetts health care stakeholders need to join together with the Patrick administration and press Congress to include the help we need. We also need to insure that the funding is used solely to keep vital health care programs afloat. The health care system is hurting, and help needs to come.

Matt Noyes
Children’s Health Coordinator, Health Care For All

The Connector is trying to find a solution to the problem. We draw three lessons from what’s happened so far:

1. The continued need for outreach and education: The state now provides modest grants to 45 non-profit community groups to fund outreach and education efforts statewide. For the past two years, much of their work has been oriented towards getting people to sign up. Now, the focus is helping people stay enrolled, with continuous access to care. Every MassHealth and CommCare member must re-enroll annually, and the system can be daunting. The community groups receiving the grants have built up the trust and expertise to work with people who need individualized help.

Renewal of the grant program (which is half federally reimbursed) is now pending before the legislature’s budget conference committee; we urge them to continue the program.

2. The need for effective communication: State officials learned about the delays in late May. Several networks exist for getting the word out, but that state initiated none of these so far. We discovered the problem from our Helpline, not any official source. State officials shouldn’t be wary about being open with advocacy groups about concerns. Early warning would have allowed those of us working with the program to collaborate, find answers and communicate them to the public.

3. The critical need for retroactive coverage in CommCare: Unlike MassHealth, the Commonwealth Care program is generally unable to retroactively provide coverage when someone is wrongfully terminated. Bureaucratic mess-ups are bound to happen, but under the current system, there’s no way to amend the mistake. Gaps in coverage also occur when someone transitions between coverage sources. For someone in the middle of vital medical treatment, this can have serious consequences. The Connector recognizes this as an issue, and has asked for patience while they work on the problem. We think this must be a top priority for the near term.

Brian Rosman
Research Director, Health Care for All