Massachusetts

IN THE STATES: Massachusetts Doctors Strongly Support State Reforms

Joanne Kenen — Wed, 21 Oct 2009 22:17:00 -0400

Massachusetts doctors strongly support their state's three year old health reform initiative, according to a study appearing in the New England Journal of Medicine.

Seventy percent of practicing physicians in Massachusetts -- specialists and primary care doctors -- support health reform, and 75 percent want to continue the policies (although nearly half want some changes), according to the Harvard School of Public Health study funded the Robert Wood Johnson Foundation and the Blue Cross Blue Shield of Massachusetts Foundation.

Only 13 percent of physicians in the state oppose the health reforms created through the legislation, and just seven percent believe the policies should be repealed.

The findings suggest that it is possible to provide near-universal coverage of the population and have a resulting system that most physicians believe improves care for the uninsured without undermining their ability to provide care to their patients," said Harvard professor Robert Blendon, one of the study's authors, (and as our regular readers know, a favorite go-to guy for insights into to the politics of health reform.)

More than half the doctors surveyed said reforms had no impact on their practices, and 22 percent said reform made it better. Half reported an overall worsening of their practice in recent years -- but not because of the Massachusetts health reforms. Most rated the Massachusetts health care system as better than the overall national system.

"What is particularly impressive is that on almost every question in which physicians were asked about the impacts of the law on their own practice and patients, a majority reported that it is having either no impact or a positive one," said Gillian SteelFisher, Ph.D., M.Sc., co-author of the study and research scientist at Harvard School of Public Health.

While we're at it ... the RWJF's health reform blog, Users' Guide to the Health Reform Galaxy, has had several good posts recently on Massachusetts, that we have had on our "write about when we have time" list so now is as good a time as any to give you at least a brief rundown.

Derek LeLia and Joel Cantor of Rutgers have been looking at how health reform might affect emergency room use. Massachusetts has not found expanded coverage to be a magic wand for ER utilization, but the second phase of the state's health reform effort (focused on cost and delivery system changes) is taking a closer look at where and how ERs fit in, particularly for people with chronic disease who end up in ERs (often appropriately) when they have serious flare-ups.

Sharon Long of the Urban Institute offers this observation about fears -- in the national debate -- that reform could undermine our current employer-sponsored insurance system:

The bottom line? ESI was not weakened once health care reform took hold in Massachusetts, which now enjoys the country's lowest rate of uninsurance. Indeed, ample evidence suggests that the 2006 health care reform law significantly boosted ESI coverage, countering the trend toward lower ESI coverage in the rest of country

And speaking of employer sponsorship -- our own employer has someplace we're supposed to be right now...

IN THE STATES: Massachusetts Health Reforms Are Bold, But Will They Succeed?

Tom Emswiler — Mon, 10 Aug 2009 13:36:00 -0400

With Congress on its summer break, it seems like a good time to take a look at what's going on in Massachusetts. The state is covering 97 percent of its people. Costs remain a challenge -- but Massachusetts is moving diligently and creatively toward solutions.

The New York Times noted in an editorial this Sunday:

Massachusetts' experiment in universal health coverage has become a favorite whipping boy for opponents of health care reform. They claim the program is a fiscal disaster and that the whole country will be plunged into similar disaster if President Obama and Congress' s Democratic leaders have their way.

That is an egregious misreading of what is happening in Massachusetts. The state's experience so far suggests that it is more than possible to insure almost all citizens, and stay within planned budgets -- although it will take great creativity and political will to hold down risings costs so that the program is sustainable.

The people of Massachusetts would probably welcome some good news right now. In addition to a major baseball controversy, a fund for helping unemployed residents purchase insurance running dry, and a partial cut to health funding for legal immigrants, Bay State residents were reminded the other day by NPR that their health costs were the highest in the country.

At least it's nice and mild on the Cape.

The state made huge headlines three years ago when it became the first in the country to require individuals to purchase health insurance (recent update here). It made more headlines last month when an expert panel recommended a movement away from fee-for-service and towards global payment. This is without question the biggest news in health reform outside of Washington in 2009. Let's give it a closer look.

It's helpful to remember that the panel's major recommendation is not the only delivery system reform news coming out of Massachusetts. As I wrote recently, their Senior Care Options program is an innovative strategy for providing coordinated care to beneficiaries dually eligible for Medicare and Medicaid. The state is also using grant money to convert 14 community health centers into patient-centered medical homes. The sites will use a team approach: a primary-care physician working with a nurse or health educator to ensure patients understand their treatment, are more closely monitored, and have more contact with their clinicians than just "15 minutes every three months."

The payment commission originated in a bill passed last summer, aimed at protecting Massachusetts' historic achievement of insuring 97percent of its citizens. As supporters at the time noted, soaring costs could threaten to undo this milestone -- just as soaring costs are threatening the coverage of all middle class Americans, making comprehensive reform at the national level a necessity this year. A commission was needed in their state to determine what steps could be taken to bend the cost growth curve.

As stated above, Massachusetts has the highest health costs in the nation. What's even more troubling is what the picture looks like if nothing is done. The chart below shows health spending in the state doubling (!) by 2020.

But Massachusetts isn't sitting back and doing nothing.

Here's a quick refresher for why global payments are being considered as a possible solution. In a system of global payment, insurers pay a set rate on a per member per month basis to an integrated delivery system or Accountable Care Organization for all services needed by that individual. Providers will make money by keeping their patients healthy, thereby reducing the health services they require, instead of making money off of providing services. A variety of risk adjustments will be introduced to ensure fairness. Our ability to measure, monitor, and reward quality is much better than during the HMO heyday of the 1990s.

The report issued in July states that the transition should take place within five years. This will allow time for hospitals, physicians, and other providers to form Accountable Care Organizations -- either real (incorporated) or virtual (networked). And while an oversight body will determine the global payment methodology, it is anticipated that the market will set the payment amounts.

No one thinks this will be easy, but the physicians seem tentatively on board. Twenty percent of Massachusetts physicians are already paid via global budget, so great responsibility falls to them to work with their colleagues to champion the new system. This can be thought of as a "nice guy" cost control initiative; global payment with market rates will require all providers to work together to provide care efficiently and effectively. If, on the other hand, costs continue to grow beyond our ability to pay, cost containment 20 years from now could be ugly and involve price controls. Avoiding that through smart and comprehensive health reform now would be good for the country.

As for the next steps, the proposal must be approved by the legislature and the governor. Although not a foregone conclusion, the commission that voted unanimously for the recommendations were appointed by the legislature and the governor, and there is a clear consensus that the current spending trajectories are unsustainable.

So can we consider the news of the proposed movement to global payment ‘good'? We've clearly got to do something about health care costs that grow faster than the economy as a whole every year. Global payments are a potentially innovative approach, and Massachusetts' willingness to explore this option will provide a natural experiment from which future reforms can learn.

IN THE STATES: The Massachusetts Good, Bad, and Ugly

Tom Emswiler — Wed, 22 Jul 2009 16:30:00 -0400

We all know that Massachusetts has come further than any other state in covering everyone. We also know that it's cost more than expected, and the state is now exploring some significant payment changes to make sure that it spends smarter on health care that actually improves health. It's also worth paying attention to an innovative program called Senior Care Options that deals with both the medical and long-term care needs of the elderly -- in a way that saves money, which Massachusetts needs to keep its health care coverage commitments.

Remember that the federal Medicare program covers all Americans from age 65, insuring hospital and physician services and now pharmaceuticals. It doesn't pay for long term care or most nursing home care, which can easily run to $70,000 a year. Medicaid, a joint federal-state program, pays for nursing homes -- for people who are poor enough to quality, or who become poor enough after paying some of those nursing homes on their own for a while. Many people in long term care are "dual eligibles," on both Medicare and Medicaid. But the two programs have different funding streams, so financing gaps, lack of coordination, and red tape can be a problem.

Enter "Senior Care Options." As Douglas S. Brown describes in an opinion piece in the Boston Globe, Senior Care Option organizations receive the funding for dual eligibles from Medicare and Medicaid but provide care in a unified manner, cutting down on bureaucracy. The results? With 11,000 enrollees in Massachusetts, they've achieved high patient satisfaction and a 25 percent lower nursing home admission rate compared to those not in the program. That saves money and leads to higher quality. It's also completely voluntary; patients choose to be part of it. And they don't need to be so sick or frail that they required nursing home level care, as in the PACE programs.

Massachusetts Medicaid could really use the money. As the only state in the nation with an individual mandate law, Massachusetts has added hundreds of thousands who were previously uninsured to the health care rolls. But because of the recession and resulting budget crunch, they've had to cut 30,000 legal immigrants, who are tax-paying residents, from the Commonwealth Care program. The Times recently profiled Laura Porto, originally from Venezuela, who will lose coverage for treatment and medication for her bipolar disorder because of the change. (Whether that will actually save money if she ends up in ERs in crisis is a whole other story...)

In addition to the cut for legal immigrants, "Commonwealth Care will save an estimated $63 million by no longer automatically enrolling low-income residents who fail to enroll themselves." While this might save money overall, it will result in cost shifting to providers. The uninsured will seek care from emergency rooms and clinics, and hospitals and physicians will either absorb the cost or receive a portion of it in transfer payments from the government.

With an aggressive possible move toward Accountable Care Organizations, the Bay State is currently dealing with the good, the bad, and the ugly in health reform. It could be the first state to move away from fee-for-service medicine, widely perceived as an expensive and inefficient way to deliver health services. Health policy folks would be wise to stay tuned to what's going on up there.

The California Supreme Court Offers A Suggestion for Constitutional Convention

Joe Mathews — Tue, 26 May 2009 18:58:00 -0400

The California Supreme Court's decision today to uphold Prop 8 is more about the California constitution and the initiative process (the true winner in the case) than it is about same-sex marriage. In effect, by a 6-1 vote, the court makes plain that it would have loved to overturn Prop 8--but couldn't because of the constitution.

And in the following passage from today's decision, the court seems to offer a suggestion to advocates of a constitutional convention: that the state needs provisions limiting the ability of the people to change certain parts of the constitution by initiative. The political problem with this is, of course, that advocates of such a convention desperately want to avoid having issues like same-sex marriage brought into the debate over a convention.

Anyway, here's the relevant passage:

"The constitutions of a number of other states contain express provisions
precluding the use of the initiative power to amend portions or specified
provisions of those states' constitutions (see, e.g., Mass. Const., amend. art.
XLVIII, pt. II, § 2 ["No proposition inconsistent with any one of the following
rights of the individual, as at present declared in the declaration of rights, shall be
the subject of an initiative . . . petition: [listing a number of rights, including the
rights to just compensation, jury trial, and protection from unreasonable search,
and the freedoms of speech, assembly, and of the press]]; Miss. Const., art. 15,
§ 273, subd. (5) ["The initiative process shall not be used: [¶] (a) For the proposal, modification or repeal of any portion of the Bill of Rights of this Constitution"].) In contrast, the California Constitution contains no comparable limitation. In the absence of such an express restriction on the initiative power, and in light of past
California authorities, we conclude that the California Constitution cannot be
interpreted as restricting the scope of the people’s right to amend their
Constitution in the manner proposed by petitioners.

Here's An Economic Stimulus Idea: Overturning Prop 8

Joe Mathews — Mon, 18 May 2009 21:11:00 -0400

Two new studies from the Williams Institute at the UCLA School of Law look at the economic impacts on Massachusetts five years after that state legalized same-sex marriage.

One study, which looked at data from the American Community Survey, found that same-sex marriages had a small but positive impact on the caliber of the workforce. "This study shows that in Massachusetts marriage equality resulted in an increase of younger, female, and more highly educated and skilled individuals in same-sex couples moving to the state."

The other study, based on a survey and the crunch of state-collected tax revenue data, estimates that same-sex marriages produced a net economic benefit to the state of $100 million.

Unintended Marijuana Consequences

Joe Mathews — Wed, 25 Mar 2009 15:39:00 -0400

Last year, Massachusetts voters decriminalized the possession of small amounts of marijuana. But several cities and towns have responded by adding or increasing penalties for marijuana use in public, the Boston Globe reports.

IN THE STATES: Economic Crisis, Fire, Can't Prevent Health Reform From Moving Forward

Paul Testa — Thu, 12 Mar 2009 20:24:00 -0400

Even in this economic downturn, Massachusetts continues to move forward in its efforts to provide affordable health coverage to all its citizens.

The 10-member board which runs the state's subsidized health insurance program, Commonwealth Care, unanimously approved an update to the program's affordability schedule. That means that people in the lowest-cost plans will not have to pay higher monthly premiums. Individuals that choose a higher cost plan may actually find themselves paying less, Secretary of Administration and Finance Leslie Kirwan told the Boston Globe.

Commonwealth Care provides low-cost or no-cost coverage to roughly 164,000 of the Massachusetts who make too much to qualify for Medicaid, but would be unable to acquire health insurance on their own. Currently, residents making less than 150 percent of the federal poverty level (about $15,606 for an individual living in the Bay State), pay no monthly premium. Those with higher incomes pay on a sliding scale.

Health Care for All live-twittered the packed event, which was apparently interrupted halfway through because of a fire alarm.

Massachusetts' decision should serve as a reminder that the need for health reform has only grown stronger during the economic crisis. Furthermore, while Massachusetts remains committed to keeping health insurance affordable for its residents, the state recognizes that simply subsidizing premiums is not enough.

Last summer, Massachusetts passed legislation to promote cost containment, transparency and efficiency in the delivery of quality health care. With provisions for payment reform, quality initiatives, health IT and more, the bill takes a comprehensive approach to make health care more affordable and sustainable for the long run.

The success and struggles of Massachusetts are an important guide for our nation going forward, and should serve to remind us that meaningful health reform must address the issues of cost, coverage, and quality together.

COVERAGE: Jobless Scramble to Find Massachusetts Insurance Niche

Joanne Kenen — Mon, 02 Feb 2009 21:32:00 -0500

Our readers know that we give Massachusetts a lot of credit for forging ahead with its program to cover everyone, although we recognize the economic and logistical challenges. The Boston Globe takes a closer look at how families are cobbling together coverage, even in Massachusetts, where unemployment has reached a 15 year high. Here are three stories that the Globe's Kay Lazar found when she looked "at the people behind the statistics."

Vivian Izuchi, 53, a married mother of three, lost her job as director of a church after-school program. She got another similar job fairly quickly, a blessing in this economy. But the last one had health coverage. This one doesn't. "I am investigating everything and anything I can," she told the newspaper, as she sorts through a "maze of state-subsidized programs" to see if her family qualifies. Her husband is now unemployed, so no on-the-job insurance option there.

Cynthia MacPherson, 46, lost her part-time job as a manager at a restaurant and her husband Jim, 50, lost his at a construction equipment firm. She estimates she has spent 100 hours calling around trying to get coverage for their family of five. It's particularly frustrating because they thought his severance package had them covered through May for $300 a month. But a paperwork mix-up got in the way, and they have received huge bills for their diabetic daughter's treatment. The paperwork snafu seems to be fixed now, and a state-subsidized MassHealth will fill in some of the coverage gaps. They hope. "It's scary to think that this could still fail," she said.

Aria Weissman is a recent college grad who had been working at a nonprofit helping troubled kids. Then the economy crashed, and she was laid off. She's now facing $30,000 in student loans, $500 in unpaid medical bills, plus the usual day-to-day expenses. She is "waitressing full time, sending out resumes, and hoping she doesn't get sick."

The stimulus bill being considered in Congress would help some of the newly-jobless get coverage through COBRA subsidies or Medicaid eligibility. SCHIP expansion can also help some of these families. Those are stop gaps though. Long-term solutions will be found in the entwined tasks of reviving our economy and repairing our health care system.

HEALTH REFORM: The Way We Are is the Way to Where We Could Be

Joanne Kenen — Tue, 27 Jan 2009 22:08:00 -0500

We are a bit late getting to Atul Gawande's New Yorker article on health reform, and we wondered whether to post, or whether many of you had read it. But then we remembered a lesson from a complicated pregnancy: even during three months of strict bedrest, it's impossible to keep up with the New Yorker. So for those of you who still have the magazine with this excellent piece on your bedside table, here goes:

The essay, "Getting There From Here," starts with the obvious: people who don't have health insurance have sad stories to tell, and sad stories can compel a society to change. At least it compelled every other major industrialized democracy (and some non-industrialized, non-democracies, but Gawande doesn't dwell on those) to make sure people get health care. But maybe we are at the point finally when we, as a society, with a new leader, will find those stories not just sad but unconscionable.

Gawande makes the case for pragmatism, for building on the current system. Not because the current system is flawless. It is deeply flawed. But it works well for some people. And it's what we have. And contrary to what many believe, other countries including postwar France and Britain built their health systems on what they had, not through radical changes imposed by a bold legislative stroke. Their systems evolved because of the peculiar quirks of history, geography and circumstance, what social scientists call "path-dependence."

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

In our country, however, we get sidetracked in part because we get polarized, caught between different visions of an ideal system.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn't mean that ambitious reform is beyond us. But we have to start with what we have.

In the real world, radical change isn't always better; Gawande reminds us of the mess at the start of the Medicare drug benefit, which was a complicated market structure rather than a natural graft onto existing Medicare. He reminds us that our modern phone system is a jerry-rigged antique, "shaggy" and convoluted. It keeps getting fixed and patched, but it "made the twenty-first century possible. A health care system built on the current one, dependent on our own historical path, "will undoubtedly be messier than anything an idealist would devise," he says. "But the results would almost certainly be better."

Gawande lives and practices medicine in Massachusetts. And we all know the strengths of that state's experiment (it is covering people) and the weaknesses (it is costing more than expected, due in part though not completely to health cost trends outside the control of a single state.) It is imperfect. But since it was implemented Gawande has not had a single patient put off cancer surgery because he or she was uninsured. "That's a remarkable change: a glimpse of American health care without the routine cruelty."

"We're not going to get perfection," he writes. "But we can have transformation—which is to say, a health-care system that works. And there are ways to get there that start from where we are. "

COST: We're Hooked!

Joanne Kenen — Fri, 09 Jan 2009 17:10:00 -0500

Maybe we need to stop thinking of health spending as a policy problem and start thinking of it as an addiction. Maybe we need a 12-step program. No, we're in a nasty recession, better make it a 6-step program.

That's how Nancy Turnbull of Harvard's School of Public Health has begun to think about health spending. She posted her "Six Step Program for Controlling Health Care Costs in Massachusetts" on the Commonhealth blog of WBUR public television. (Hat tip to Elizabeth Cooney of the Boston Globe's health blog for spotting this) Massachusetts is facing some unique cost problems as it pushes ahead with its full coverage program, but a lot of what Turnbull writes is widely applicable. It's also a fun read.

Here's the gist:

Admit that health care costs have become unmanageable
Embrace a greater power to help restore us to sanity and strength: (hint hint she means the government)
Examine past errors with the help of experienced people:
Admit the nature of our wrongs and make amends to those we have harmed:
Learn to live a new life with new behaviors:
Have a spiritual awakening and lead the way for others.

Hmm. We're having a little trouble getting our heads wrapped around that last one (Health reform. Congress. Spiritual Awakening?) But this is the kind of post people either love or hate, so go decide for yourself.