State auditor Suzanne Bump is auditing the MassHealth program, saying it lacks safety measures to verify applicants’ income, or that they live in Massachusetts.

The audit says MassHealth, which provides care to low-income residents, cost the state $6.5 million in 2010 alone by treating patients who may have lived outside Massachusetts. It also does not verify an applicant’s supplemental income, such as lottery winnings.

And State House News reports:

Income verification shortcomings in the state’s massive MassHealth program make it possible for ineligible applicants to receive health insurance benefits for a year before being removed from the program, according to an audit released Wednesday.

According to Auditor Suzanne Bump, MassHealth’s first verification of an applicant’s self-reported earned income occurs a year after applicants are enrolled and receiving benefits.  Bump also reported that MassHealth does not verify information about unearned income of applicants, or resources derived from lottery winnings, for instance, or stock dividends, pension payments or rental income.  While Bump did not conclude that the procedures are leading to benefits being awarded to ineligible individuals, she said her audit results show the need for improvements in the verification process and may be costing the state millions of dollars a year.

At a cost of about $12 billion per year, about a third of the state budget, MassHealth provides health insurance coverage and access to services for about 1.3 million low and moderate-income individuals in Massachusetts.   Bump also concluded “thousands” of individuals who are not residents of Massachusetts may be receiving MassHealth benefits inappropriately because MassHealth does not have a process to effectively verify the state residency of applicants and only verifies residency in cases where conflicts are found in applications.

Mike Bush is 45, unemployed and struggling with paranoid schizophrenia. But he has an even more pressing problem at the moment: lunch.

Bush’s teeth are so bad that he eats only one meal a day to avoid chewing.

“I shy away from meats and things. I told my dad that I’m running out of teeth to chew with. No big deal,” he said. “I’m probably going to end up with dentures.”

Bush, who lives in Bedford, Mass. started seeing a dentist three years ago for the first time in decades.

But his timing wasn’t ideal. In 2010, just after getting his initial dental exams and cleanings, MassHealth, the state’s program for low-income residents, cut its budget dramatically. Critical dental benefits were eliminated from the plan: fillings, crowns, root canals, and dentures were no longer covered. Extractions, for better or worse, were spared.

The problem isn’t isolated to Massachusetts. In states across the country, adult dental services provide an easy target for cash-strapped lawmakers looking for cuts, according to a 2011 report by the Institutes of Medicine, “Access to Oral Healthcare for Vulnerable and Underserved Populations.”

One reason, the report points out, is that Medicaid requires dental coverage for children, but not for adults. It referred to a February 2011 letter to states from the U.S. Department of Health and Human Services reminding them that Medicaid savings can be achieved via adult dental cuts.

“While some benefits, such as hospital and physician services, are required to be provided by State Medicaid programs, many services, such as prescription drugs, dental services, and speech therapy, are optional,” the HHS letter said.

So, many states are scaling back on the adult programs. Others are already moving to restore certain dental services after struggling with some unintended consequences due to earlier cuts.

Heading To The ER Instead Of The Dentist

For example, some states that track dental-related emergency room visits are seeing much higher costs. And physicians unable to treat dental problems are generally handing out opiate painkillers and antibiotics, according to Centers for Disease Control data cited in The New York Times.

Dental problems are sometimes perceived as less important, or somehow distinct, from overall wellness and good health, studies show.

But the 2011 IOM report advised governments and universities to integrate oral health into overall health programs in order to improve access to services and remove disparities.

“The enduring separation of oral health care from overall health care has marginalized issues related to oral health,” the report said.

An aside: I know this from personal experience. A close relative who is mentally ill and on MassHealth has black front teeth due to multiple, untreated cavities and old fillings that are falling out. After waiting two years for a dental appointment, she recently had the two most painful teeth pulled, though they could have been saved with fillings. (She also has 40-year old fillings that need replacing, but has no disposable income to pay for treatment.)

Another close relative, an elderly woman, also on MassHealth, has been trying to get dentures for several years because she only has five teeth left. She can’t afford care, though, and today I’m taking her to my own dentist for an emergency appointment, paying out of pocket, because her teeth became so jagged they were stabbing her in the tongue.

As for Mike Bush, even though he is now going to the dentist, he can’t afford the treatment. He’s done his best to keep from breaking his decaying teeth. And after the last dental visit he learned he needs six fillings, and something has to be done about his 10 missing teeth – mostly molars.

His gums hurt when he chews, he says, but he’ll live with it until he can find a way to pay for the dental work.

“If I hit the lottery, I’d get implants,” he said.

Requesting The “Soft Menu Option”

Carrie Endicott, the director at Elm Brook Place, a rehabilitation facility for the mentally ill in Bedford, said that all of the dental cuts have had profound impact on the members’ nutritional health – and on their ability to get jobs.

“People come here for vocational reasons to get back into the job market and you know it’s hard to go on an interview when you are missing half of your teeth,” she said. “They are self conscious about smiling.”

Endicott added that salads and raw vegetables are often left untouched. “It’s tough. Members have asked for a “soft menu option” for people who can’t chew…You can’t push raw vegetables on people who are missing half their teeth,” she said.

The Mentally Ill More Likely To Suffer

About 20% of Masshealth subscribers are physically or mentally disabled adults – not including those living in nursing homes.

People suffering from mental illnesses are 3.5 times more likely than the general population to go without teeth, and also have significantly higher rates of tooth decay, according to a 2011 meta-analysis published in the British Journal of Psychiatry.

Mark Etheridge, 47, suffers from Bipolar disorder.

At Elm Brook, he’s discovered a passion for cooking. Another thing he’s learned: how to conceal the fact that he has no “uppers.”

“I stick my tongue out to kind of hide it a little bit when I smile,” he said.

A Fix In The Works
After intense lobbying by consumer advocacy groups like Health Care for All, and complaints from dentists and patients, Massachusetts lawmakers devised a plan to partially address the problem.

Last month, the state Senate passed an amendment to reinstate some of the dental services that were cut from MassHealth in 2010. If the Senate amendment survives, an infusion of $7.2 million would be added back to cover anterior fillings.

State Representative John W. Scibak of South Hadley said that by addressing front teeth as a first step, it would at least help people who are interviewing for jobs.

This won’t get Etheridge his uppers, and Bush will have to wait for his molars.

Coverage for cleanings and extractions will continue, but anything beyond those services would require out-of-pocket payments.

Pulling Teeth Instead of Filling Cavities
Scibak supports full reinstatement of services, and views the amendment as a first step toward that goal. He says the current system of emergency-room dental care is not only expensive but it’s also bad medicine, with the wrong specialists working on the wrong problem.

“Clearly if you go to the emergency room for a dental problem, A: It’s going to cost far more than if you saw a dentist. And B: In many situations the person in the emergency room may not be able to address your problem other than perhaps giving you pain medications or treating what may be a localized infection,” said Scibak

He says he’s heard from dentists and constituents that some of the 700,000 adults on MassHealth are having teeth pulled that could be saved with fillings, while others use hospital emergency rooms for tooth pain and infections. While the overall number of poor patients seeking out such services because they can’t pay for more appropriate dental care is unknown, a spokesperson for Health Care for All says in the last two months alone, the nonprofit has received 71 calls specifically about problems related to dental care.

Elm Brook’s Endicott said her clients’ bad teeth continue to haunt her. She told the story of one man she has known for 17 years:

“While we were having lunch together one of his teeth just snapped and fell out of his mouth,” she said. “Then another one chipped…his mouth was disintegrating while we were having lunch. And to look at his teeth now they, I mean they are just kind of like stalagtites; they’re just a fraction of normal teeth.”

Dianne Finch is a freelance journalist and multimedia producer in Rockport, Mass. She’d like to thank Leslie Johnson for helping with reporting at Elm Brook.

Diagnosed with an immune system disorder, sarcoidosis, Bollinger has near-constant joint pain, trouble breathing, deafness in one ear and a slew of other symptoms that prevent her from holding a job, she says.

She’s on MassHealth, the state’s subsidized Medicaid program for low-income residents. But Bollinger says that as soon as she steps into the doctor’s office, she enters a world in which she feels inferior — rushed, ignored and discounted at each step. “I call it assembly-line health care,” she says. Doctors have abruptly stopped her from talking by putting a hand in her face, suggested she’s addicted to painkillers and left her alone in an exam room in the middle of a medical history, seemingly too busy to take her myriad symptoms seriously, she says. Although Bollinger reports that she was assigned a primary care doctor five years ago, she’s never seen her: that doctor’s schedule is always full. So Bollinger says she just takes whichever provider happens to be free.

“I’m treated horribly,” she says. “I want my doctor to be thorough even if it takes more than five minutes. Frankly, I’m embarrassed to be on MassHealth — they think, ‘Oh, you’re poor, you must be a drug addict.’ Or, like, ‘Your insurance doesn’t pay me enough to be thorough.’ ”

Despite nearly universal health insurance coverage in Massachusetts, which has clearly helped residents, mainly the poor, gain access to medical care, disparities persist.

Bollinger says she has a friend with renal cell cancer who is covered by private insurance and experiences health care in an entirely different, more humane manner. “She has Blue Cross and they treat her like a queen,” Bollinger says. “They pay for her transportation, and her primary care doctor, on days off, calls her just to check in.”

It’s tough enough being sick, but when you’re sick and poor, you’re far more likely to experience long waits and care that leaves you unsatisfied and feeling discriminated against because you’re on Medicaid or other public insurance.

In our poll, Sick in Massachusetts, we asked residents who said they had a serious illness, medical condition, injury or disability requiring a lot of medical care, or spent at least one night in the hospital within the last year about their experiences. We found that sick people with lower incomes (under $25,000) are significantly less likely than middle-income (from $25,000 to $74,999) and higher-income folks (over $75,000) to say they are very satisfied with their care. And more than one-fourth of the lower-income sick report that they were treated worse than others because of their insurance status, a significantly higher proportion than for middle-income (13%) and higher-income (2%) sick.

Robert Blendon, of the Harvard School of Public Health conducted the poll and this morning told WBUR: “…in a world where we’re so pleased with universal coverage, beneath the surface there are still people who think they’re being treated differently based on their insurance.”

A Snarky Tone And A Long Wait

“I felt I was treated like a second class citizen,” said Charlene Wallace, 61, who is on Medicare (due to disability and death benefit income, she earns $4 too much to qualify for MassHealth, she says). Wallace used to visit a clinic in Lowell for her Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, high blood pressure, arthritis, restless leg syndrome and recent heart attack, for which she takes a total of 20 medications. “When I asked why I had to get a urine test every month, the nurse raised her voice and said ‘Because you have to, that’s why.’ You have an appointment at 11 and you’re there for three hours,” she said. “Even just to pick up a prescription, I’m there an hour and a half.”

Indeed, according to our poll, half of the lower-income sick said they had to wait longer for an appointment than they thought reasonable, a significantly higher proportion than for middle-income (32%) and higher-income (27%) sick. The poll was conducted by the Harvard School of Public Health, the Blue Cross Blue Shield of Massachusetts Foundation and WBUR.

What the poll, which surveys 500 “sick” residents of Massachusetts, shows overall is that despite widespread insurance coverage here, patients still experience serious problems related to the cost and quality of care. The poll found that about one third of sick adults report that the cost of their medical care has caused a “very serious” or “somewhat serious” financial problem for their family; and one in seven sick adults say there was a time in the past year they couldn’t get the medical care they needed, either because they couldn’t afford it or their insurer didn’t cover it.

Collection Agency Blues

Bonnie McGhee says the quality of her care is fine, but even on Medicare, she can’t pay for everything she needs. At age 67, she’s got severe, “brittle” diabetes, neuropathy, acid reflux and heart problems. Medicare pays 80% of her drug costs, but she still has a hard time paying the other 20%, she said, and has already stopped taking certain medications to save money. Two years ago, she was admitted to Cape Cod Hospital six times due to extreme spikes in her blood sugar levels and other problems related to the diabetes. She still owes about $2,000 for those visits. “The collection agency keeps writing me.”

To pay for her insulin, McGhee works summers as a parking lot attendant in Provincetown — 10 hours a day, four days a week. “Physically it’s hard,” she says. “I get very tired easily — I have neuropathy in my legs, so I don’t walk right. I can do this job because I can sit in a booth.”

Nancy Turnbull, an associate dean at the Harvard School of Public Health, and not involved in the poll, said she thinks the survey shows the effects of insurance coverage expansions in the state because “there are very few significant differences between lower and higher income people [when it comes to] access, financial barriers to care and almost every other measure.”

But,” she says, “while insurance coverage reduces disparities in care for lower income people, it doesn’t eliminate them. So it’s not surprising that there are still differences in the survey. Lower income people are more likely to be in limited network plans, and so have less choice of doctors and hospitals. Rising co-payments and deductibles lead people with less income to delay care, get sicker and then need appointments more urgently, appointments that might be hard to obtain in a timely way. They could be more likely to live in areas that have worse access to care than in richer areas. Poorer people encounter bias and prejudice in the health care system — against the poor, against people who have Medicaid, against people of color (who are more likely to have lower incomes). So while insurance is tremendously important, it does not equalize the health care system for lower income people.”

You can view the report, Sick in Massachusetts, here and the detailed results here. And here’s this morning’s WBUR interview with Blendon, who conducted the poll.

The Blue Cross Blue Shield of Massachusetts Foundation, the Harvard School of Public Health (HSPH) and WBUR worked in partnership to produce “Sick in Massachusetts.” The Foundation commissioned and funded the HSPH poll. An independent research firm, SSRS, conducted the telephone interviews and provided WBUR with the names of poll participants. WBUR met with the partners to review the poll questions and analyze the results. WBUR shared story scripts with Robert Blendon at HSPH for fact checking purposes. WBUR, using internal editing procedures, decided how to frame and expand on issues raised by the poll results.

The form lay on my desk for weeks, untouched. I knew exactly why I didn’t want to fill it out: doing so would start the ball rolling toward a significant change in my health insurance – and how much I pay for it. However, these changes were coming whether I liked it or not, and ignoring the form meant my coverage would disappear altogether. With time running out, I gritted my teeth and grabbed a pen.

The focus of my procrastination: the eight-page MassHealth Eligibility Review Form. A short back-story: I moved to Massachusetts in 2008 after losing a job, and qualified for the state’s version of Medicaid after my unemployment insurance ended. In practical terms, being on MassHealth has meant I haven’t had to pay a monthly insurance premium or co-pays when I go to the doctor. Due to a chronic condition (that’s for another story), I take at least four medications a day, which currently cost $3.00 each per month. But I’ve only been able to get this coverage because I haven’t had an income – something that changed over the last year when, at 35 years old, I started working as a freelance writer in the WBUR newsroom.

Because I’m now earning something, I’m almost guaranteed to be cut from MassHealth and be required to pay a portion of my health care costs. Budget cuts on Beacon Hill mean that some MassHealth members will be dropped this year – the cover letter that came with the form warned of that. I’m completely okay with being one of them. The scary part is the uncertainty of how much I’ll be paying, and I had a hard time trying to get an estimate.

After 2006, when Massachusetts began requiring almost all residents to have health insurance, it established the “Health Connector” to oversee the new law and help people find the coverage they need. The Health Connector’s website is relatively easy to use and informative, whether you are new to Massachusetts or a change in circumstances means you’re looking at new insurance options.

That’s not exactly the case for MassHealth. Although there’s one eligibility form whether you’re applying for MassHealth (the fully-subsidized, no-cost program) or Commonwealth Care (a low-cost insurance with a sliding scale based on income), finding information online is tricky if you go to mass.gov/masshealth. Through that route, you reach the Office of Health and Human Services, which oversees MassHealth. Trying to find out how much I might have to pay each month, I went to the site… and became completely lost. I spent a lot of time clicking from one list to another, without finding any solid information. That has to be frustrating to other people who just want a simple answer (as I did) and discover a complicated, confusing maze of menus instead of a user-friendly and helpful tool.

Which leads me back to the form. After the unsuccessful search, and feeling even more in limbo (if possible), I started filling in the information. My situation is pretty straightforward – single, no kids – so it didn’t take as long as I’d feared. However, for someone whose income picture is, shall we say, “flexible,” it’s a bit daunting.

As a freelancer, some weeks I work every day, some weeks not at all. That’s been tough to handle the last few years, and is about to get more complicated. Adding fixed monthly expense like health insurance (plus co-pays and prescriptions, which are mandatory for me) without a fixed monthly income means I may have to make some unwanted lifestyle changes. For example, I spend a lot every month on gas, since my boyfriend lives in Providence and I’m in Boston. Will this mean we don’t get to see each other as often?

For now, all I can do is wait. It all comes down to how the state calculates my income – and that’s out of my control. But all in all, I’d rather pay and keep my insurance than have no coverage at all. Having no health insurance is what truly scares me… which is a reality for far too many people.

Don’t miss today’s important story by WBUR’s Martha Bebinger about the recession’s effect on health insurance in post-reform Massachusetts. It’s here, and here’s the gist: “The latest numbers show that virtually all Massachusetts residents who have gained coverage since the landmark 2006 law passed are now in a government health care program.”

This wasn’t supposed to happen, Martha recalls. The early mantra of the state’s health reform was “shared responsibility,” meaning that individuals, employers and state government would all share the burden of getting more people insured.

But here’s my analogy: If Massachusetts is the country’s laboratory for health care reform, the recession has contaminated our test tubes, and skewed our results. Martha reports:

Many experts agree the recession has played an enormous role in this shift from private to public coverage. Since the coverage law passed in 2006, 411,000 more residents of Massachusetts have health insurance; it’s the largest insurance expansion in the country. In the first few years, the expansion was fairly evenly divided between private and public insurance. That’s no longer the case.According to Nancy Turnbull, an Associate Dean at the Harvard School of Public Health, “virtually everyone” of the Massachusetts residents who have received health care coverage with the implementation of the new law are enrolled in a public plan.

“It’s virtually everyone because the number of people who have employer coverage has gone down,” Turnbull said. “That’s not at all surprising, that’s happening all over the country.”

All this is very politically sensitive, Martha notes: “There’s concern these numbers will reinforce the view that Massachusetts, and by association, the national health reform law, is launching a government health care takeover.”

But it ain’t over till it’s over — that is, the recession is over. The Patrick administration tells Martha the very latest state numbers, still unpublished, will look better. And one more important point, from Harvard’s Nancy Turnbull: “The good effect of our law is that we have not had the large increases in the number of people without health coverage.”

The Disability Policy Consortium filed suit Tuesday against MassHealth, contending that the Medicaid agency that insures more than 1 million Bay State residents has failed provide disabled applicants with adequate communication options.

The suit, filed in U.S. District Court by the consortium and eight plaintiffs – four blind residents, two deaf residents and two with other disabilities – concludes that MassHealth violated the Americans with Disabilities Act by failing to provide Braille or electronic forms that can be filled out without assistance, failed to offer materials in American Sign Language, and that the agency generally makes it difficult to contact a live customer service representative.

Several plaintiffs – MassHealth members for decades – argue that their health care services were canceled or suspended as a result of their inability to fill out required paperwork and because of the agency’s inability to offer assistance, despite requests for interpreters, accessible forms or other forms of help.

“Defendants have committed multiple ongoing and continuous violations of the ADA and the Rehabilitation Act, and unless restrained from doing so, Defendants will continue to violate the ADA and the Rehabilitation Act. Said conduct, unless enjoined, will continue to inflict injuries for which Plaintiffs have no adequate remedy at law,” according to the suit.

The consortium is asking a judge to force MassHealth to ensure that its disabled clients receive all “forms, materials and other communications in an accessible format of their choice within a reasonable time,” and to require that the agency permit callers to bypass its automated system for a live representative.

A spokeswoman for the Patrick administration’s Executive Office of Health and Human Services said the agency is still reviewing the complaint.

In addition, the group is seeking “monetary damages to each individual Plaintiff in an amount that will fairly and adequately compensate each Plaintiff for his or her endurance of great mental, psychological, and emotional pain, suffering, and anguish, shame, mortification, indignity, disgrace, embarrassment, humiliation, anger, discomfort, stigma, demoralization, inconvenience, delay, worry, distress, anxiety, nervousness, depression, powerlessness, and other injuries to his or her feelings and sensibilities and continued suffering of all of the foregoing for an indefinite period of time.”

One plaintiff, Donald Dawes, a blind West Roxbury resident and MassHealth member for 25 years, received a letter from the agency in April 2010 notifying him of changes to his services, but he was unable to read it, according to the suit. Although he used a scanner to convert the letter into a format that could be read aloud to him using software known as Open Book, the letter included “non-text characters, symbols and graphics” that made it unreadable. When Dawes received a recertification form from MassHealth later that year, he notified the agency that he could not read it and asked for a deadline extension to fill it out. The agency refused, the suit alleges.

Another plaintiff, Michelle Pirog, an Arlington resident with neurological and cognitive impairments, as well as a MassHealth member for 23 years, contends that earlier this year, she attempted to contact MassHealth to help understand a certain form. Because the agency failed to provide her with necessary assistance, the suit argues, she missed a deadline to recertify her health insurance. In June, her insurance was suspended.

The consortium contends that efforts to work with the Patrick administration to address concerns without litigation went unheeded.

The Department of Public Health sent out a news release yesterday about the study, and trumpeted the smoking cessation benefit, which includes access to nicotine patches and a prescription anti-smoking drug. The DPH also suggested that the 46% drop in heart attack risk was a direct benefit of the state’s health reform law. But Cooney quotes an expert discussing some of the study’s flaws:

Dr. Michael Siegel, a tobacco specialist at the Boston University School of Public Health who was not involved in the study, said the study’s methodology gave him pause. While there was clearly a drop in heart attacks among the people who used the stop-smoking program, there was no control group of other MassHealth members who did not participate. He said that makes it difficult to conclude that the decline in heart attacks is caused by the program itself rather than being a reflection of falling heart disease rates in general.

Siegel also said flat rates of respiratory illnesses were puzzling because asthma and pneumonia are among the first diseases to fade away when someone quits smoking.

Siegel’s third objection involves the gap between the actual heart attack rate — 8 percent — and the adjusted rate — 46 percent — arrived at after the researchers took into account such factors as other illnesses, including flu, and implementation of the state’s smoke-free workplace law. He said such a drastic difference makes him question the model the
researchers used. “I feel more work needs to be done,” he said.

As of July 1, about 700,000 poor adults statewide lost their dental coverage through MassHealth, the public health insurance program, as a result of budget cuts. CommonHealth asked Christine Keeves of the advocacy group Health Care For All how the cuts were playing out.

Q:What are you seeing as a result?

A:  Health Care For All has a HelpLine that can answer general insurance questions, tell folks what free and lower-cost programs they may be eligible for, and help them to apply all in quick and easy telephone call. They have experienced a spike in calls now that the cut has been made. Our Helpline counselors have already collected stories from every corner of the state from MassHealth members who are in pain, unable to eat, sleep, or work because of dental pain, and who are getting sicker and sicker while they try to find care.

· A Worcester woman, pregnant and on disability, needs two root canals that she cannot get because the procedure is no longer covered, which is endangering the health of her and her unborn child.

· A Mattapan man who has had 8 extractions cannot get the dentures he needs not only to go on job interviews (which we all know is incredibly important, especially in the current economic climate), but also for such basic functions as eating and speaking.

· Our Helpline counselors are in the process of assisting a Springfield woman who is mentally ill and diabetic. She had to have all of her teeth pulled in June. In light of this cut she is unable to get dentures. Her doctor warns that she will die without the dentures.

These are just three stories that represent a much larger problem. Oral health is overall health and with the implementation of these cuts we are already hearing from people across the state experiencing undue, and preventable, pain and suffering.

Q: Are people finding any alternatives for dental care?

A: There are 48 community health center dental clinics in the state where people can access care. Over 700,000 individuals were affected by these cuts. The health centers are doing remarkable work and trying hard to expand their reach to these new clients. Because of the cut, a huge number of people need care, and the number of options for services available to them has decreased dramatically.

Q:  Why was this particular chunk of state spending targeted?

A: When Massachusetts passed health reform, dental services were determined fundamental. However, these benefits are the only piece of MassHealth that is not legally mandated by the federal government. Cutting adult dental benefits is a step backwards for health reform in the Commonwealth.

Q: What’s the outlook?

A: We have been here before, when MassHealth adult dental benefits were cut in 2002. The legislature and administration recognize the impact of these cuts — restoring the program just comes down to money. The state will be receiving additional revenue from the federal government in the form of FMAP funds, and this is a great option to restore these critical benefits. We urge the legislature to allocate these funds to the MassHealth dental program.