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…

For Massachusetts’ hospitals, I fear the light at the end of the tunnel may be an oncoming train.

The impact of the overall state fiscal crisis and Governor Deval Patrick’s emergency “9C” cuts is just beginning to be felt, and already the outlook for health and human services is grim. Governor Patrick had no easy choices, and tough cost cutting decisions absolutely had to be made. But hospitals and other health providers are hit especially hard, not only with a disproportionate share of the cutbacks themselves but also with losses of federal matching funds due to reductions in promised Medicaid payments.

Already several hospitals have been forced to lay off staff, and many other are delaying or abandoning planned investments in the facilities’ physical plants and infrastructure. There are dire warnings within the legislature that we may face yet another round of cuts when it reconvenes in January.

As the economy continues to unravel, I fear it could trigger an “every entity for itself” mentality that would spell disaster for the entire health care reform effort. One of the leading of health care reform in Massachusetts has been its collaborative nature. Hospitals and other providers with very different patient populations, market shares and agendas have joined together, along with insurers, businesses and the government to reach compromise. Everyone has made substantial sacrifices for the greater good.

Now, important health programs with long-standing track records and high utilization are disappearing, just as demand becomes even greater. Read more…

Transparency. Measures. Outcomes. Information for informed choices. Laying it all out on the table.

Call it what you want but the trend in health care, and certainly a main focus of the reform law and of “Reform II”, the cost-containment bill, is to generate more information, submit it to an ever-increasing number of sources, and ensure that it’s all posted online where it’s …. well, oftentimes it’s ignored.

Right now, the state is putting the finishing touches on a Cost & Quality website. The Massachusetts Hospital Association has had its Patients First website up and running since 2005, posting nurse staffing data and, now, data relating to “nursing-sensitive” measures, such as how often patients fall in a hospital or develop bed sores.

The national Hospital Compare website (operated by the U.S. Department of Health and Human Services on behalf of the public/private coalition known as the Hospital Quality Alliance) reports voluntarily-reported hospital-specific data on about two dozen best practices/processes of care – for example, does a hospital administer antibiotics one-hour prior to surgery? Or give a pneumonia patient a thorough assessment and influenza vaccination? More such measures will be added this year and next. Read more…

Amidst all the debate about the merits of the Massachusetts health reform law, it is easy to forget that its accomplishments have been nothing short of spectacular. A study authored by Sharon Long of the Urban Institute showed a fifty percent reduction in the number of residents without health insurance. Along with coverage came improved access to health care and a reduced financial burden associated with receiving care. These results were generated in just one year.

I can think of only two other state-level reforms that have had similarly dramatic effects. The first was Hawaii’s employer mandate, enacted in the mid-1970s with implementation delayed until the 1980s due to legal challenges. Under the Hawaii law, employers are required to provide health insurance coverage to their employees, but not their dependents. For more than a decade after enactment of the mandate, Hawaii had one of the lowest rates of uninsurance in the country. The second was Tenncare, implemented in 1994, which vaulted Tennessee from high levels of uninsurance typical of southern states to one of the lowest rates in the country.

Hawaii and Tennessee have lost their places of leadership in health insurance coverage. The Hawaii mandate is frozen in time due to federal law, making modifications that are more appropriate to the 21st century impossible. Tenncare has been dismantled and the number of uninsured in the state has grown.

Others draw the lesson from these two states and others that state-based reform is doomed to fail. While I would be the first to say that there are limits to what states can accomplish, it seems more valuable to seek to learn from the lessons of Hawaii and Tennessee. Read more…

The end of July may have marked the end of the Legislature’s formal sessions for 2007-2008, but it did not mark the end of our work for the year. In this and other public forums, discussion and analysis of the health reform law enacted in 2006 continues, as it should. The Legislature and the Patrick Administration have ongoing responsibilities and duties to health reform, and that work continues, too. The blueprint established by Chapter 58 is being followed and built upon by the Legislature, most recently through Chapter 305 of the Acts of 2008, “An Act to Promote Cost Containment, Transparency, and Efficiency in the Delivery of Quality Health Care.”

Chapter 305 makes good on the promise for sustainable health reform, by establishing policy priorities for containing health care costs, increasing transparency of what we get for our well spent health care dollars, and improving quality and creating efficiencies in our health care delivery system.

The new law puts in place provisions for a statewide system of secure and accurate electronic medical records, and a special commission on payment reform charged with making recommendations to the Legislature for incentives and payments to providers that encourage delivery of appropriate and coordinated care, with improved patient outcomes.

The new law also provides incentives for new medical school graduates to practice primary care here, where they are trained. Read more…

8-21-2008 – Statement from Network Health:

“Unfortunately, Network Health has determined that a recent a survey of former Network Health Commonwealth Care members, which was administered by a third party, was not conducted in a statistically valid manner.

Network Health remains committed to working with MassHealth and the Commonwealth Connector on the continued successful implementation of the state’s historic health reform law.”

7-29-2008 – Original Post:

As you know from my previous posts, the “churn” of still-eligible MassHealth and Commonwealth Care members on and off their coverage is a topic of great interest and concern of mine. I focus on it because it’s antithetical to what our commonwealth has embraced in creating the health reform law and mandating insurance coverage for all Massachusetts residents. And, not only does churn self-perpetuate the problem of the uninsured in Massachusetts, I also believe that it creates lost opportunities for care management and critical gaps in care, and is a waste of time, energy, and money for the state, for members, for health care providers, for health plans, and for taxpayers. In the words of one recently disenrolled Commonwealth Care member, “If the state is going to insist that you have health insurance, they should make it easier to keep it.”

The goal of reform efforts is continuous insurance coverage of nearly all Massachusetts residents. Yet, in a recent survey we conducted of nearly 400 recently disenrolled Network Health Commonwealth Care members, more than 40 percent told us they do not have health insurance since losing Commonwealth Care (!!). Of that 40 percent without coverage, nearly 20 percent said they did not know why they lost their Commonwealth Care coverage. As one survey respondent said, “I am very interested in knowing why I was cut from the plan. I never got a reason.” Read more…

If there was one thing that struck both observers of, and participants in, the creation of the Massachusetts health care reform law, it was how many seemingly diverse groups came together to make the unwieldy law work. Yes, there were disputes – and they continue today. That can be expected from a law that affects literally everyone in the Commonwealth. But in general, hospitals, insurers, physicians, regulators, consumers, religious groups, and others united and have remained together – a rarity in any state, but especially so in our often fractious Commonwealth.

Now that the reform law is well on its way of achieving its main goal – insuring the uninsured – its remaining challenge of lowering health care costs will require the same sort of collaboration. I’m happy to report that this May, the hospital community, under the leadership of the Massachusetts Hospital Association, brought together 80 key individuals to discuss diabetes management – a big cost center in our state’s health care system.

It was called a “charette” – an architectural word referring to brainstorming to develop solutions to a design problem within a limited timeframe. Read more…

Last month, the Massachusetts House of Representatives passed a nursing union bill, which simply put, threatens the future of health care reform. Indeed, the very groundbreaking initiative the Legislature helped craft, is now threatened by a bill that could add $250 – $500 million in new health care costs — a tab that health care reform simply cannot afford.

The added costs come in the form of a union backed bill, which would establish government-mandated nurse-to-patient ratios in Massachusetts Hospitals. This cookie-cutter approach would completely take away a hospital’s ability to tailor care to specific patient needs. Every hospital in the Commonwealth, prominent business leaders, nursing leaders, and many major newspapers are opposed to — and extremely concerned about — the impact of this legislation. Read more…

Rev. Hurmon Hamilton, his GBIO colleagues and a university gymnasium filled with 1700 of their leaders reminded us all last night of the shared responsibility that it took to achieve the gains in health coverage that we have shared so far, over a mere two-year period.

I was invited there by GBIO to affirm my commitment to sustainable health reform, and to repeat the promise that I made, back in December 2005, to a similar GBIO-assembled crowd, that I would stand firm until consensus was reached to achieve comprehensive health reform. I made that promise, and I’ve kept that promise.

I continue to work with my colleagues in the House of Representatives, Senate President Murray, and Governor Patrick to secure and strengthen the hard work that we began over three years ago with the essential partnership of the GBIO, along with a coalition of leaders from business, insurance, and health care.

The spirit of the event last night left no room for retreating from that work or from the commitment that carried it across the line to enactment. Read more…

Since the state’s budget for Commonwealth Care has been getting a lot of attention lately, I thought it would be helpful to hit on a few key points about how all the money gets spent. At Network Health, more than 94 percent of the Commonwealth Care premium is spent on paying for medical costs. For some Commonwealth Care members, like those in Plan Types III and IV, the percent of total member premium spent on medical costs is more than 160 percent.

The good news is that Commonwealth Care members are using services they have long needed and appear to be making up for years without consistent access to health care and preventive services. For example, Commonwealth Care members are utilizing surgery services at almost twice the rate of MassHealth members. Similarly, we see Commonwealth Care members use extensive office visits, outpatient specialty services, and pharmaceuticals.

I had hoped that this phenomenon of pent-up demand would lead to a regression to the mean after members gained some health plan tenure. Read more…