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Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy “flawed and irresponsible.” Here’s Alford’s response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Dr. Dan Alford

Dr. Dan Alford

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program’s stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients. Continue reading

Report: In Mass. Health Care, System Skewed So Rich Get Richer

A report released today by the Healthcare Equality and Affordability League (H.E.A.L.) — a partnership between the for-profit Steward Health Care System and the union, 1199 SEIU United Healthcare Workers East — finds that disparities in hospital costs and financing across the state are driving “a vicious cycle” of inequality in health care.

The result, according to this analysis, is that medical care is becoming less affordable for lower-and middle-income families in Massachusetts, and the disparities in hospital financing are “compromising the viability of community hospitals.”

The group is calling for new, and what they call more “fair” reimbursement rates so that poorer, community hospitals (with a greater proportion of Medicare and Medicaid patients compared to the higher-cost Boston teaching hospitals) can continue to serve the lower-income patients, among other financial recommendations.

David Williams, president of the Boston consulting firm Health Business Group, who was paid by H.E.A.L to research and co-author the report, says: “What hasn’t been demonstrated before is what impact these financing disparities have on communities and community hospitals.”

He notes: “The hospitals that have the highest percentage of publicly funded patients, they get paid less, but in addition to that, those hospitals also get the lowest commercial rates — because they’re not in as strong a position to negotiate — so that means that they’re doubly disadvantaged…it means that the hospitals serving middle-class and lower income communities don’t have the resources to compete effectively with those hospitals that get higher reimbursements.”

Clearly, the group’s recommendations would benefit the Steward-owned hospitals, Williams acknowledges, but, he adds: “it would also help with the state’s overall approach to cost containment.

I asked Nancy Turnbull, an associate dean at the Harvard School of Public Health, to take a look at the report and here’s what she had to say:

…This report looks to be raising critical issues regarding payment disparities. We’ve known for years, from the work of the [Attorney General], [Center for Health Information and Analysis] and others that these disparities exist and are, in many cases, getting worse. So far, we’ve done little to address them, and the effect these disparities have on lower paid providers and the patients for whom they care. However, I don’t think the solution is, in most cases, to just increase the rates of payment for poorly paid providers, although that is a needed action for some. We also need to talk about reallocation of existing payments, and about costs. I am supportive, to some extent, of giving consumers reasonable financial incentives, based on their income, to use lower cost providers—although lower paid is not the same as lower cost–but we also need approaches that are systemic. Consumers in tiered and high deductible health plans aren’t going to solve this problem without tough action by state government and other payers, including, in my opinion some regulation of rates of payment. And most tiered networks available so far are regressive — they impose higher costs on lower-and moderate-income people. They address one form of inequality by creating another.

Among the findings, according to the H.E.A.L press release:

“The rich get richer as highest cost hospitals attract a greater proportion of patients with commercial insurance, which have higher reimbursement rates than Medicare and Medicaid.”

(H.E.A.L report)

(H.E.A.L report)

–“Patient migration for routine care from community hospitals to high cost Boston teaching hospitals increases total medical costs and contributes to higher premiums for all individuals and families with commercial insurance (non-Medicare nor Medicaid). Additionally, low-income patients, forced to travel greater distances to receive routine care are more likely to forgo treatment until conditions become acute and require more expensive interventions.”  Continue reading

Updates, But No Solutions, From Today’s Connector Board Meeting

If you have or have tried to sign up for health insurance through the Massachusetts Health Connector, you know the website is a mess. Last week, Gov. Deval Patrick brought in a special assistant, Sarah Iselin, and and IT oversight group, Optum.

Today we had the first of what are to be weekly updates, with graphics that map the problems many of you are having.

0213_connector-workaround

Click to enlarge this slide prepared the Massachusetts Health Connector

If you are expecting a quick fix, you can stop reading here. But there are some important updates that might be helpful:

1. If you are one of the 50,000 or so residents who submitted a paper application for subsidized insurance, hang tight. The state has several dozen people (adding another 36 this week) who are going through these applications by hand at the rate of about two hours per application. If you do the math you’ll see it may take a while to get to you. The state hopes to add software that will speed up this process.

2. If you are one of the 124,000 Commonwealth Care members whose coverage was extended through March, you might want to hang tight too. The state has clearance from the federal government to extend your coverage again, through June 30. Now the state must negotiate with your insurance plan.

Eric Linzer, with the Massachusetts Association of Health Plans, said “each plan will make its own decision about whether to participate in the extension. There have been financial challenges in continuing coverage at last year’s rates, but plans are committed to making sure these folks have coverage.”

And be prepared for another extension of your current coverage into the fall or beyond. Continue reading

Report Blames Mass. Health Website Troubles On Lack Of Skills, Leadership

In the months after President Obama signed the Affordable Care Act (ACA) in 2010, officials in Massachusetts started planning for a new Health Connector website that would be compatible with the new federal regulations. UMass Medical School, the Massachusetts Health Connector and MassHealth came together to work on the project. They hired a Canadian firm, CGI, to build the site which launched in October 2013, but “was not fully operational,” according to a report released Thursday by the technology firm MITRE. Residents who’ve tried to apply for insurance through the site use words like “disaster.”

The MITRE report, which was commissioned by the state, says CGI did not have the expertise to create or maintain the site. Functions were not tested. Data was lost. Tools to fix bugs were not in place. So who from the state should have spotted and corrected these problems? MITRE concludes that it was never clear which of the three state partners was in charge. Gov. Deval Patrick says the shared leadership structure would have been fine if CGI had done its job.

But, Patrick added, “It turns out that this vendor has required and will require a much, much shorter leash. And that’s hard to do by committee.”

The lack of clear authority created other problems, according to the report. The website never had a baseline set of requirements. There was no master schedule. Decisions were not explicit and were not communicated clearly. CGI received conflicting instructions and deadlines from the three parties in charge.

Continue reading

Can This Woman Fix The Health Connector? Please?

Screen shot 2014-02-06 at 11.27.38 AM

WBUR reports that Gov. Deval Patrick is appointing an executive from Blue Cross Blue Shield of Massachusetts to help fix problems with the state’s Health Connector insurance website, which has recently been plagued with technical and other glitches that have frustrated and infuriated users:

Blue Cross chief strategy officer Sarah Iselin worked for the state during the rollout of the 2006 health care law. In addition, the state will also hire a Minnesota-based health care systems firm to help with fixes to the Connector site.

The governor says Massachusetts residents who are on temporary health insurance coverage will know by next week if they can be moved to a permanent plan. (The temporary plans were needed because of technical problems with the Health Connector website.)

In addition, State House News reports:

The administration is also hiring Optum to advise them on short-term and long-term fixes to the site and to help clear the backlog of people who have tried to sign up for insurance but encountered technical barriers. Patrick was discussing the administration’s efforts to repair the site Thursday morning at the state office building at One Ashburton Place. Iselin is chief strategy officer of Blue Cross Blue Shield of Massachusetts and was previously president of the Blue Cross Blue Shield Foundation of Massachusetts. The Connector Authority on Thursday also released the findings of MITRE, a consultant hired to examine the site and ways for the authority to move forward.

WBUR’s Martha Bebinger was at the governor’s news conference and reports:

The Health Connector site is still not working properly four months after it was revised to meet new federal rules. Governor Patrick has hired a special assistant to guide the fix and an outside IT firm to review progress. Patrick apologized to everyone who has tried to sign up for coverage. He says he knows people are frustrated.

“We’re not going to let anybody go without insurance. It’s not going to happen,” the governor said. “We have a moral obligation and an obligation in the law and a commitment to doing so.”

Patrick says he doesn’t expect the state will need to spend more than the $69 million already budgeted. He says starting from scratch at this stage would be difficult.

Stay tuned for more developments. At 3 today, Radio Boston’s Carey Goldberg will try get into the details of how Iselin plans to tackle the Connector problems.

Heroism At Home: An Intimate Look At Growing Ranks Of Caregivers

Screen shot 2014-01-31 at 10.38.03 AM

If you’re an adult living in the U.S., it’s a good bet that you (or your neighbor or close friend or colleague) are caring for an elderly family member. Indeed, more than 43 million Americans — about 18 percent of adults — care for a family member or friend 50 or older, according to the Family Caregiver Alliance; 15 million of these caregivers tend someone who has Alzheimer’s disease or some form of dementia.

Currently, family (read: unpaid) caregivers are the largest source of long-term care in the U.S. and health scholars expect that by 2050 the demand for such care will nearly double — and that family caregivers will have to continue meeting the greatest part of that need.

But the statistics don’t reveal the intimacy of such caregiving relationships: the terror of a mind slipping away, the humiliation and messiness of chronic illness, the often violent and shocking ways that bodies unravel. In her new book “The Caregivers: A Support Group’s Stories of Slow Loss, Courage And Love,” journalist Nell Lake details her two years observing a caregivers support group that includes a 50-year-old botanist who moved in with her aging mother to care for her, and a survivor of Nazi Germany who devotedly tends to his ailing wife, and others in the group (some of whom are dealing with serious health problems of their own). While documenting their lives, Lake offers views into the complexities of caregiving: the profound stress, the upheaval of family roles, the slow, often excruciating grief, as well as the graceful humanity of it all.

Here, lightly edited, is my Q & A with Lake, who lives with her family in Northampton, Mass.

RZ: You begin your book on a personal note, with a memory of your grandmother. Can you tell us a bit about her and how her story moved you to write about the larger issue of caregiving in America?

Journalist and author Nell Lake (photo: Sarah Prall)

Journalist and author Nell Lake (Courtesy Sarah Prall)

NL: My grandmother was a poised woman who lived her life with great energy. She had raised three children, kept a beautiful home, was active physically and also politically—involved in environmental causes and in the nuclear freeze movement in her community. She prized her independence and physical vitality, and, as she aged, she expressed a fear of ending up frail and in a nursing home. She kept materials from the Hemlock Society in a kitchen drawer.

In the summer of 1984, when I was 18, she found out from a doctor that she might have cancer. That night, she went to her garage, sat in her car, and turned it on. A neighbor found her the next day.

While my grandmother’s suicide didn’t directly spur me to pursue a story about long-term care and family caregiving, once I was sitting in on the caregivers support group, it was clear to me that I was immersing myself in the stage of life, an experience, that my grandmother had feared and successfully avoided. It became especially moving, then, for me to follow others who were making their way through the “shadow part of life,” as I put it in the book.

My memories of her shaped my lens: I wondered, Can we find ways to embrace this part of life, to meet it with less fear? Can we also try to make it better for everyone?

How did you connect with the hospital caregiver support group?

In late 2009, I went to a dinner party, a birthday celebration for a friend. I ended up seated next to a man whom I call Ben in the book. He told me that he was the lead behavioral health counselor at our local hospital, and that he also facilitated a weekly support group there for family caregivers. I told him I was a journalist interested in healthcare and mental health issues. He suggested I might want to sit in on the group, and later he asked the group members’ permissions. Before long I was listening to their stories.

Is there any particular quality you discovered about these caregivers that you didn’t expect?

It may sound surprising, but spending two years with the support group gave me a new and better sense for what constitutes heroism. I saw heroism in Penny, who had taken her forgetful mother, Mary, into her home. Caring for Mary was not easy, but Penny met Mary’s needs as best she could, sought to provide her mother with as much comfort, care, and happiness as seemed possible. I saw heroism, too, in Daniel, a caregiver who was himself quite frail, and whose wife was bipolar and in pain. Daniel also bravely did his best to meet his wife’s needs.

Their heroism, to me, was a willingness to keep returning to difficult circumstances, to persevere and act compassionately, to try to ease others’ suffering.

This idea of heroism is similar to the notion that bravery is not the quality of being free from fear; rather, bravery is a willingness to act in spite of fear.

Some (many?) caregivers are reluctant to take on so much responsibility, but feel they have no choice. Is this true for most informal caregivers these days and how does our modern notion of caregiving differ from past generations?

In the most important sense, there was less choice a century ago. The word “caregiver” didn’t exist; the words “daughter” or “wife” or “sister” sufficed to describe a caregiving role. Continue reading

Mass. Launches A Grand Experiment: Pricing Health Care

There’s a grand experiment underway in Massachusetts and we are all, in theory, part of it.

Here’s the question: Can we actually list prices for childbirth, MRIs, stress tests and other medical procedures, and will patients, armed with health care prices, begin to shop around for where (and when) they “buy” care?

One of the first steps in this experiment is a new requirement that hospitals and doctors tell patients who ask how much things cost. It took effect Jan. 1 as part of the state’s health care cost control law and we set out to run a test.

Our sample shopper is Caroline Collins, a 32-year-old pregnant real estate agent from Fitchburg who is trying to find out the price of a vaginal delivery. Her first call is to the main number at Health Alliance Hospital in Leominster. From there, she is transferred to the hospital’s obstetrics department. A receptionist there tells Collins to call the billing office at UMass Memorial Medical Center in Worcester, Continue reading

Partners On Anti-Merger Report: ‘Misleading,’ ‘Flawed,’ ‘Inaccurate’

partners

Partners HealthCare does not hold back in the response it plans to file today with the state’s Health Policy Commission (HPC). The commission issued a report last month that marked a rare effort to crimp Partners’ dominance in the Massachusetts market. The commission said that if Partners adds South Shore Hospital in Weymouth to its growing network, costs will increase around $23-26 million a year.

Wrong, says Partners, in an 89-page rebuttal that includes dozens of letters and testimonials from South Shore area leaders who support the merger. The commission should withdraw its finding, concludes Partners, and not send the proposed merger to the state attorney general for further regulatory review.

Some key points from Partners’ response:

1) The merger would not “add $23-26 million in annual physician health care costs.”

Partners says the HPC doesn’t understand how Partners’ physician contracts work. The assertion that the merger “will result in significant annual physician cost increases is based on material misunderstandings of both the Partners payer contracts and the process and goals of the parties’ proposed physician development efforts” in the South Shore Hospital area.

2) If there are any cost increases, they would be “offset” by better value and more efficient care.
Continue reading

From DIY Death To Live-Longer Workouts: Juiciest Health Stories Of 2013

happy new year

When people ask what we cover here at CommonHealth, we tell them our beat is broad, encompassing everything from personal health and medical research to health-related policy and politics.

But looking back at our 2013 oeuvre, we could also say that our beat ranges from cradle to grave, from below the belt to above the neck, from big-world news to inner-world angst.

2013 has been a banner year for CommonHealth: We crossed the 1-million-hits-a-month mark. (A million thanks to all who clicked or shared or tweeted.) We partnered with Slate to launch a regular podcast called The Checkup, which is expected to resume next year. And WBUR listeners heard us more on air than ever, as we crossed back and forth between media platforms.

More soon on our hopes and goals for 2014, but is there anything you’d like to see more or less or just different? Please let us know in the comments below. For now, here are our top  CommonHealth posts from 2013, based on traffic, reader response and a little personal bias. Here’s to a health-filled 2014.

1. DIY Death: Natural, At-Home Funerals And Their Boomer Appeal
Death remains a topic that many of us would rather avoid. And when it comes to the actual nuts and bolts of caring for the dead, most of us tend to think it’s best — and furthermore, required by law — to let professional funeral arrangers handle the arrangements. Well, it turns out that in most states it’s perfectly legal to care for your own dead. And, with new momentum to shatter longstanding taboos and stop tip-toeing around death — from “death with dignity” measures sweeping the country to projects promoting kitchen table “conversations”about our deepest end-of-life wishes — a re-energized DIY death movement is emerging.

2. Is It Time To Rethink Co-Sleeping?
bedsharePediatricians and public health officials have long warned that “co-sleeping,” or sharing a bed with an infant, is unsafe. But let’s face it: almost everybody does it. So perhaps the time has come for the public health message to focus less on advising against it and more on advising how to do it more safely.

3. Caring For Kevin: An Autistic Man, An Exceptional Doctor, A Life Renewed
Institutionalized since childhood, Kevin, now 56, has been losing his sight for the past two years to the point that doctors said he can see little more than shadows. He’s here at Boston Medical Center awaiting cataract surgery, a fairly simple procedure that generally takes about 30 minutes in the operating room. But for Kevin, who has long feared doctors and has a history of aggressive, unpredictable behavior — like hitting himself or inadvertently hurting others or running away when he’s in distress — the procedure isn’t simple at all.

4. Long After Recession’s End, Deep Layoff Scars May Remain
Everybody knows it hurts to lose your job. But what has caught me by surprise is that even though my family didn’t suffer much financially from my layoff, and even though I tend to be pretty upbeat and resilient, and even though I’ve landed well, it still hurts. More than four years later, I’m still not fully over it. At work, I feel hypervigilant – as if nothing I do is ever enough, or good enough, to feel safe. At home, making life plans fills me with anxiety. Which makes me wonder: Are these feelings normal?

(Newbirth35/flickr)

(Newbirth35/flickr)

5. I’m Finally Thin — But Is Living In A Crazymaking Food Prison Really Worth It?
It shocks me to even write this, but after a zaftig childhood and a curvy-bordering-on-chunky early adulthood, I find myself, in middle age, after two kids, to have reached my “ideal” weight. But lately I wonder if it’s really worth it.

 6. Every Minute Of Exercise Could Lengthen Your Life Seven Minutes
If you play with the data of a recent major paper on exercise and longevity, you can calculate that not only do you get the time back; it comes back to you multiplied — possibly by as much as seven or eight or nine.

7. The Scariest Reason To Get The Shingles Vaccine
The reason my heart dropped when I saw my rash — and the reason I am now going to pay out of pocket for the vaccine because my health insurance covers it only for those over 60 — is an affliction even less familiar to most people than shingles. It is called postherpetic neuralgia. Think of it as “Extended Release” shingles. Or as the closest thing to the trials of Job for an unlucky few.

8. ‘Thigh Gap’: Reflections On Teenage Girls’ Latest Obsession
That extra layer of influence is coming from the Internet and social media, and the way I see it, it’s like peer pressure on steroids — a vehicle for immediate feedback about you, the way you look, or what you think of others. And those opinions are so widely broadcast. Depending on a teen’s social media prowess, that can mean hundreds, even thousands of extra eyes.

(Photo: Robin Lubbock/WBUR)

(Photo: Robin Lubbock/WBUR)

9. Why A Sex Therapist Worries About Internet Porn
You may have seen the recent film Don Jon, featuring Joseph Gordon-Levitt as Jon, an Internet porn addict whose habit hurts his love life. I see too many Jons in my office…I see a sexual and relational train wreck happening, and I need to speak out.

10. A Doctor’s Decision To Quit 
When I introduce myself as a physician who left clinical practice, non-physicians ask me why I left. They’re generally intrigued that someone who sacrificed many years and many dollars for medical training would then change her mind. But physicians, almost universally, never ask me why I left. Instead, they ask me how.  It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health.

Special thanks to WBUR’s Martha Bebinger, CommonHealth’s founder, whose deep grasp of health care’s Byzantine ways is unmatched by any reporter we know. Her knowledge and humanity continue to enrich the site immeasurably. A few of her notable 2013 reports:

Web Glitches Snarl Health Insurance Enrollment In Mass.
Mass. Employers May Sue Feds Over Obamacare Small-Business Premiums
Marathon Bombing Victim Makes Strides Toward Her New Normal
Medicare, You Can Do Better (Or Why You Need A Translator For This Post)
Searching For The Best Colonoscopy In Town

And just some personal faves:
My Son, The Dragon Slayer: Risks And Rewards Of Growing Up Gaming
Proof In The Pants: A Pivotal Moment In Pre-Viagra History
How Gardening Is Better Than Parenting: Let’s Count The Ways
When A Patient Asks: Why Won’t Anybody Just Talk To Me?
High Anxiety: How I (Sort of) Overcame My Fear Of Flying

What were yours?

Nonprofit? Really? Big Salaries For Chiefs At Mass. Charitable Hospitals, Health Plans

A sample chart from the Attorney General's report showing compensation details for the top paid hospital executive in 2011, John O'Brien.

A sample chart from the Attorney General’s report showing compensation details for the top paid hospital executive in 2011, John O’Brien.

Compensation for CEOs of the top 25 nonprofits in the state, including hospitals and health plans, ranged from more than $487,000 to approximately $8.8 million, according to a new report released today by Attorney General Martha Coakley.

“Massachusetts is unique,” Coakley says, “in that many of our largest employers are non-for-profit institutions.”

These hospitals, health plans (and universities included in Coakley’s report) “must compete with national for-profit companies for CEO talent while staying true to their charitable mission.”

So do these CEO salaries achieve that balance?

Coakley suggests these organizations could be more balanced by paying more attention to the difference between executive and non-executive pay and by considering “the level of public support the organization enjoys in the form of exemption from property tax, corporate excise tax, sales tax and other forms of taxation.”

The numbers below, from 2011, look big and they are, just keep in mind they include retirement, bonuses and all other compensation.

HOSPITALS

1) John O’Brien at UMass Memorial Health Care $2,350,992.00 (retired earlier this year)

2) Gary Gottlieb at Partners HealthCare $2,163,199.00

3) Betsy Nabel at Brigham and Women’s Hospital $1,939,479.00

4) Peter Slavin at Massachusetts General Hospital $1,758,691.00

5) Mark Tolosky at Baystate Health $1,636,004.00

6) James Mandell at Children’s Hospital $1,503,885.00

7) Linda Shyavitz at Sturdy Memorial Hospital $1,496, 532.00

8) Edward Benz at Dana-Farber Cancer Institute $1,406, 432.00

9) Kate Walsh at Boston Medical Center $1,378,292.00

10) Howard Grant at Lahey Health $1,045,479.00

11) Dianne Anderson at Lawrence General Hospital $674,042.00

12) Kevin Tabb at Beth Israel Deaconess Medical Center $360,877.00 (partial year)

HEALTH PLANS

1) Jim Roosevelt at Tufts Health Plan $2,116,683.00

2) Eric Schultz at Harvard Pilgrim Health Plan $1,460,982.00

3) Andrew Dreyfus at Blue Cross Blue Shield $ 1,111,075.00 (Dreyfus declined some compensation) Continue reading