In today’s Globe (”Lost in the Labyrinth“), columnist Sam Allis explores “the labyrinth called Chapter 58″ and gets a “case of the vapors.” From all appearances, seems like he talked with Codman Square ED Bill Walczak and no one else. Bill is a dynamic health center director who’s done a great job at Codman; he’s also been a persistent critic of Chapter 58 since day one. In the process, Allis seriously misinforms his readers:

Walczak ran the numbers on a hypothetical 58-year-old woman who earns $32,000 a year. Under Commonwealth Choice, her cheapest option costs her $4,400 a year in premiums. There will also be a co-pay every time she sees a doctor, but she first must exhaust a $2,000 deductible to get anything back at all. If hospitalized, she’ll face a 20 percent coinsurance payment. …

Everyone in the state must have annual proof of membership in some health insurance program to avoid fines. Without proof, the state will come after you. The fine for not enrolling in a Chapter 58 program can run as high as $912 a year. Say I’m earning $31,212 - 300 percent of poverty and, like the hypothetical woman, am forced into Commonwealth Choice. But I don’t sign up for it because my company has dropped overtime pay, my wife’s salary has been cut in half, and my balloon mortgage just ballooned.

So what’s going to happen to a criminal like me, or the 26-year-old criminal struggling in a start-up, or the criminal restaurant cook? Will we be dragged off in the middle of the night by storm troopers and thrown in the clink? Will the state garnish our wages and hasten our descent into bankruptcy?

Well, no. In fact, the “hypothetical 58-year-old woman” will be subject to no penalties. And nobody will be “dragged off in the middle of the night by storm troopers and thrown in the clink.” Geesh, Sam, don’t let facts get in the way of a juicy line. Just a patina of fact checking here could have avoided misleading your readers.

There’s lots more to chew on here. Just one more thing for now, not for Sam, but for Bill. OK, Bill, we know you hate Chapter 58. What, please, after two years, is your alternative? It’s not like the State could have done nothing and kept the status quo. The “status quo” — to the extent there was one — was a status quo MINUS hundreds of millions in federal Medicaid dollars exclusively devoted to the Massachusetts health care safety net.

Lots of folks know the Christmas movie, “It’s a Wonderful Life,” where Jimmy Stewart as George Bailey gets to experience what the world we be like had he not been born. We need to envision a Massachusetts health care “Pottersville” that shows what the world would be like had we not done Chapter 58. Here are just a few elements — a massive financial crater right in the middle of our health care safety net (with community health centers in the middle of the bulls eye), rising numbers of uninsured, exploding uncompensated care costs, and providers screaming that the sky is falling.

And that’s the truth.
John McDonough

Leadership changes are in the wind these days. Two recent announcements of note:

Ali Noorani, the dynamic executive director of the MA Immigrant and Refugee Advocacy Coalition since November 2003, is moving to new challenges in Washington DC. Ali helped to turn around an organization in trouble and has been a respected and courageous advocate and spokesperson on immigration and refugee issues. He will be missed around town.

And Michael DeChiara, executive director of Community Partners, the Amherst-based health access organization, is also stepping down this summer. Here’s a bit of his statement:

I am very proud of the work that Community Partners has achieved during my time here. We have certainly contributed much to outreach and enrollment in Massachusetts (and nationally) ­ from piloting community outreach and enrollment in 1997 and the development of the Health Access Network in 1998 to our Moving Beyond Enrollment and Portable Electronic Enrollment programs that pushed the envelope how to make O&E more effective. And I know our email and website efforts are relied on heavily by people across the Commonwealth.

I am confident that Community Partners will be in good hands. I am pleased to say that Meg Kroeplin will take over as Acting Director upon my departure in July. Anne Rosen and Laura Anderson will remain as part of our expert health access team.

Congrats to Ali and Michael and best wishes to MIRA and Community Partners in their big transitions.

State House News Service report on a visit to Boston today by US Health & Human Services Secretary Mike Leavitt, who has final sign-off authority of renewal of Massachusetts Section 1115 Medicaid Waiver, the essential financing source for MA Health reform:

Citing fiscal constraints, the nation’s top health and human services official said Thursday that federal health care dollars for Massachusetts may be contingent upon “refinements” in the state’s delivery of health care. “I feel very confident that there will be refinements based on things we have learned,” U.S. Health and Human Services Secretary Michael Leavitt told reporters today.

In Boston to tout the city for its advances in health care technology, Leavitt said there are “financial constraints” on the federal level that may impact the amount of funds Massachusetts receives in its next three-year Medicaid waiver, a fiscal underpinning of the state’s 2006 health insurance expansion law. “We have to look at how best to meet our mutual objective but in the context of those financial constraints,” he said. The state’s current waiver expires at the end of June.

The secretary said he had had “lengthy discussions” with Gov. Deval Patrick and U.S. Sen. Edward Kennedy regarding the state’s Chapter 58 health care reform law, which has come under pressure in the wake of surging costs and enrollment in a heavily subsidized program and slower tax revenue growth. Asked whether the federal government was satisfied with Massachusetts’ spending of health care dollars, Leavitt said, “Those are the discussions we’re having right now with the state. We need to have data on this to draw those conclusions. We have not yet drawn them.” Asked about the greatest challenges to implementing Massachusetts’s increasingly costly law, Leavitt said they were the same challenges facing the rest of the country, “escalating costs and no capacity to measure cost or quality.”

Yesterday’s Globe included an editorial (”Managing Care the Right Way“) giving well deserved praise to Commonwealth Care Alliance (CCA) — NO relation at all to Commonwealth Care, health reform’s subsidized insurance program:

MANAGED CARE got a bad reputation in the 1990s. At its best, though, this method of organizing healthcare saves money while enhancing the quality of patients’ lives. In Massachusetts, the Commonwealth Care Alliance, which bills itself as a nonprofit care delivery system, is succeeding in its five-year-old experiment on whether treatment can be coordinated and improved for people with complicated medical histories.

CCA manages care for “dual eligibles” — elderly and disabled who are enrolled in Medicare and Medicaid. These are among the most expensive and difficult population anywhere. CCA enrolls duals through community health centers and manages comprehensive care to keep members healthy and functioning well in the community. They save real dollars by reducing hospital and nursing home admissions. They receive capitated payments from Medicare and Medicaid; they have saved the State millions; they have fantastic member satisfaction ratings; and they have a medical trend rate at about 3%.

HCFA and the Boston Center for Independent Living are the two “corporate members” and founders of CCA — meaning HCFA and BCIL Boards must approve all CCA board appointments and by-laws changes.

As we figure out ways to moderate health care inflation in Massachusetts, CCA is worth a look.

Closing in on health reform’s two year anniversary, some things are worth remembering. Many observers saw that the financing plan to sustain Chapter 58 over the medium and long haul was deficient. We saw it, and commented that the time would come when we would have to revisit the law’s financing structure.

We predicted the most likely time for the reckoning – spring 2008. For two reasons: first, the second contract period for Commonwealth Care would significantly raise the cost of covering CommCare enrollees; and second, renewal of the federal 1115 Medicaid waiver carries significant risks for the state’s financial exposure. On these two, the first shoe has dropped, and the second not yet.

We did not see the robust enrollment in CommCare, the major factor that has pushed costs beyond most expectations.

Right now, the cost of CommCare is being borne exclusively by taxpayers (state and federal) and by enrollee premiums and copays. Two years ago, the legislative crafters of Chapter 58 estimated CommCare costs at $750 million in FY09; in January, the Patrick Administration’s budget estimated FY09 costs at $869M. Now, according to Alice Dembner’s Globe article today, that may be as much as $100M short.

The cost of CommCare cannot be sustained by taxpayers and enrollees. It won’t work.

Are we in a financing crisis? A crisis is when your back’s to the wall and there are no acceptable alternatives. That’s not the case here. It’s reasonable and fair to ask insurers to bear some of these costs, especially when – by their own recent calculations – health reform has delivered them 111,000 new customers over the past year. It’s also reasonable and fair to ask some providers to sustain this important advance.

Business? Two propositions. First, it’s not fair to ask employers who are covering their workers to pay more. They are already paying their fair share. And it’s fair to ask employers whose workers are not covered, and especially employers whose workers are relying on CommCare for coverage, to pay part of the cost, in addition to taxpayers and enrollees.

This is not a crisis. Not yet.
John McDonough

No big decisions or developments in the past 24 hours on MA health reform. But a lot of comments and attention — all focussed on the state’s growing financial pressures in paying for health reform in general and Commonwealth Care in particular. Let’s review — and then add comments of our own in a companion posting.

First, Alice Dembner writes a first-rate analysis in today’s Globe: Healthcare cost increases dominate Mass. budget debate. No attention grabbing revelations, just a good overview of the current dilemma:

… But the state’s top budget official, Leslie Kirwan, last week suggested that the financial pinch might require increases in the contributions from coalition partners as well as “revisiting some of the original assumptions of healthcare reform.” Through a spokesman this week, she declined to elaborate, saying only that “the administration remains fully committed to healthcare reform.”

Murray also suggested the state should review the health law’s provisions as part of a “look at everything.” But House Speaker Salvatore F. DiMasi said he believed it was too soon to significantly modify the blueprint. The Patrick administration has asked coalition members for suggestions on how to raise money and cut costs, and dozens of proposals have been submitted.

Advocates are pressing the administration to expand the number of companies subject to a penalty for not insuring their workers, a step the administration could take without legislative approval but which would probably draw strong opposition from businesses. The penalty raised only about $6 million this year, far less than originally expected. DiMasi said he thinks the administration should consider this option.

Second, last night on Jim Braude’s NECN show, State Treasurer Timothy Cahill:

…floated the prospect that the state may not be able to meet the commitments it made under the 2006 health coverage expansion. “We might not be able to cover everyone,” Cahill said, adding, “The situation we’re in means that we’re not going to be able to do everything for everyone, and new programs or additional spending has to be under control, and that means we’re going to have to say no to some people.” Asked if he would consider cutting back on the reform if he were governor, Cahill replied, “I would certainly look at it.”

Third, at today’s session of the Legislature’s Health Care Financing Committee, co-chairs Sen. Dick Moore and Rep. Pat Walrath said:

…policymakers were not considering scaling back the state’s increasingly bank-breaking health care reform law. “Never crossed my mind,” said Rep. Patricia Walrath, co-chair of the powerful Committee on Health Care Financing.

A day after Treasurer Tim Cahill suggested the mandatory coverage law might have to be scaled back in the face of sharply rising costs, Walrath and her co-chair Sen. Richard Moore said lawmakers and the Patrick administration were not entertaining the idea of reducing the scope or ambition of the state’s health care law, Chapter 58.

“The leadership is committed,” Moore said. “And as far as I can tell, the governor is committed to the goal of full access to insurance and full access to care that they can pay for with that insurance.” Moore and Walrath told the News Service proceeds from a proposed cigarette tax and increasing corporate tax collections would help fund Commonwealth Care, the state’s subsidized insurance for low-income residents.

An important conversation on paying for health reform is now moving front and center.

Shahram Ahari, former Eli Lilly drug “detailer,” shared the tricks of the trade on NECN this week (two parts):

Shahram, who now travels the country testifying to legislatures considering measures to regulate pharmaceutical marketing and speaking to doctors and medical students, provided an insider view to the manipulative tactics that drug companies use to sell their products.

According to Ahari, drug reps are hired based on good looks and congeniality – no science background required. They are then encouraged to exploit sexual tension and to ply docs with gifts to foster a friendship and sense of reciprocity. Dr. Dale Magee, President of the Massachusetts Medical Society, echoed Ahari’s concerns over the industry’s sales practices – and gift-giving in particular:

Recognizing the cost and quality implications of these practices, Senate President Murray has taken these concerns head-on. Her cost control legislation, released this month, would prohibit pharmaceutical companies from giving gifts to doctors and would create an educational outreach program to provide doctors with an unbiased source of information about drugs. The Massachusetts Prescription Reform Coalition strongly supports this legislation.

In related news, a University of Chicago study found that consumers who get free drug samples actually face higher drug costs. On the heels of another study that found that samples rarely go to the uninsured and low-income, this once again raises the question of whether samples are charity or just another marketing ploy. What do you think?
Lisa Kaplan Howe

Today’s Wall Street Journal discusses the federal government’s own contribution to the problem of the uninsured through it’s use of contract employees who do not receive health benefits even when they function as pseudo-full time workers:

Covering the uninsured is a central issue in this year’s political campaign. Yet while politicians debate how best to cover the growing ranks of the uninsured, the federal government — by outsourcing service jobs — quietly is adding to those numbers. “As federal employees, we get great insurance,” says Dr. Rogers … “People who work as contractors often don’t enjoy those benefits.”

Federal contract employees, including cafeteria workers, security guards and cleaning crews, work on Capitol Hill and in federal agencies across the country. Under a 1965 law, called the McNamara-O’Hara Service Contract Act, most contractors with service contracts of more than $2,500 are required to pay locally prevailing wages, plus fringe benefits or the cash equivalent — $3.16 an hour this year, under a government formula.

Yet some contract employees don’t get either the health insurance or the extra cash. Under the law, employers in industries where health insurance typically isn’t offered are exempt. Other employers don’t comply with the law because they don’t understand it or assume they won’t get caught, say lawyers and consultants who work in the field. The law doesn’t allow contract workers to sue employers over alleged violations, but they can file a complaint with the Labor Department, which may investigate the claim. …

Outsourcing of federal-government jobs reflects the same cost-cutting imperatives that drive private businesses to outsource. The U.S. government keeps tabs on how much it pays contractors, but no government agency keeps a tally of the workers who are employed or how many have health insurance. Paul Light, a political scientist at New York University’s Wagner School of Public Service and a specialist on government employees, estimates that in 2005, there were 5.4 million federal service-contract workers, double the number in 1990.

This is also an issue in Massachusetts where a large number of full time state workers are classified as “03 consultants” and do not receive any benefits. One regular commentator on this and the WBUR Commonhealth blog, Ron Norton – a passionate critic of Chapter 58 — works full time teaching radiologic technology at Quinsigamond Community College, and gets no benefits for his labors.

This is one reason why the Commonwealth of Massachusetts (and the University of Mass.)shows up on its own report/list of employers with more than 50 workers accessing MassHealth or the Uncompensated Care Pool. It’s time for the Commonwealth to take a fresh look at some of its own employment practices.

HCFA’s 5th Annual Policy and Organizing Conference will be held this Friday!

The day will be packed with informative and interesting events, including a keynote address from A&F Secretary (and Connector Board Chair) Leslie Kirwan on cost control, a Community Organizer panel who will address the intersections of policy and organizing, and a ton of workshops on today’s most important healthcare issues.

Check out the day’s agenda and a list of conference workshops.

Online registration is closed, but you can still register on-site.

Check out this great Commonwealth Fund series of articles on preventable hospital readmissions. Right on the heels of conversations about hospital acquired infections (or “healthcare associated infections” as others like to call them), one of the next big quality/cost conversations, we predict, will focus on hospital readmissions that would not occur if care were done right the first time.

Some folks suggest all readmissions are preventable. Our advisers tell us no, and tell us that a whole heck of lot of them are. And the cost implications are serious:

An Agency for Healthcare Research and Quality study of patients admitted to hospital with preventable admissions found 19.4 percent had at least one preventable readmission within six months. The cost of those admissions, which occurred in four states in 1999, was $729 million, or $7,400 per readmission. The numbers are not much better in the commercial population. When PacifiCare Health Systems Inc. reviewed discharge data for its enrollees between 2005 and 2006, it found readmission rates at hospitals ranged from as low as 0 percent to as high as 44 percent, with an average around 10 percent.

And see the case study on how Catholic Healthcare Partners — by using “heart failure advocates” — reduced their readmissions rate by five times, with vastly improved outcomes for patients. And here’s the rub:

Better management of chronic conditions is likely to lower overall costs to the health system, but current payment policies create few incentives for hospitals to invest in it. In fact, hospitals may lose money by investing in programs that reduce the number of hospitalizations, because most are not reimbursed for their efforts and they stand to lose business as hospital admissions decline.

It’s not hospitals. It’s this screwed up system that has all the incentives backwards. That’s what we’ve got to change. Sen. Murray’s cost containment bill can be the vehicle to put us on the right track, or it can be a missed opportunity. Let’s hope it’s the former.
John McDonough

Canada’s Globe and Mail reports this week on the Canadian Patient Safety Institute’s new guidelines for disclosing medical errors to patients — click here. The guidelines encourage health-care workers to break news to patients within a day or two of discovering an adverse event. There’s controversy over whether or how caregivers should apologize.

These twin issues of mandatory disclosure and apology are priorities for HCFA’s Consumer Health Quality Council. When things go wrong in care, patients deserve honest and humanely-communicated information. The public has a role to play in encouraging hospitals to open these lines of communication. Legislation now pending in our Legislature’s Health Care Financing Committee would help clear the way to ensure patients are told the whole truth about their care.

In line with the theme, “it can happen to ANYONE“, the Globe and Mail reports that “one in 13 adult medical and surgical patients admitted to acute-care hospitals [in Canada] suffered at least one adverse event.” Hard to compare to studies of US rates, but this suggests things may be just slightly better in Canada.
James Madden,Consumer Health Quality Organizer

Every once in a while, a piece of survey research appears that is so “spot on” it blows my mind. That was my reac when I saw the new Bob Blendon survey on partisan differences in opinions about how good the US health care system is. Click here for the report. Bottom line:

A recent survey by the Harvard School of Public Health (HSPH) and Harris Interactive, as part of their ongoing series, Debating Health: Election 2008, finds that Americans are generally split on the issue of whether the United States has the best health care system in the world (45% believe the U.S. has the best system; 39% believe other countries have better systems; 15% don’t know or refused to answer) and that there is a significant divide along party lines. Nearly seven-in-ten Republicans (68%) believe the U.S. health care system is the best in the world, compared to just three in ten (32%) Democrats and four in ten (40%) Independents who feel the same way.

I remember gagging every time Republican Presidential candidate Rudy Giuliani went on one of his rants that the primary need is to preserve the high quality of US health care. Truth is, he’s just reflecting the attitude of the Republican voter base. Also interesting is that, while Independents are in the middle as usual, they definitely tilt toward the Dem perspective.

Damn, this is a fundamental disagreement. And it sure makes the case why it’s so hard to reform national health care policy.

By the way, if you want the truth about the US health care system versus other advanced nations, there’s no better source than the Commonwealth Fund’s extensive research on this topic.

Bottom line? Our system stinks! And, by the way, Canada’s only looks good in comparison with ours. Compared with other systems, they stink, too!
John McDonough

The Quality and Cost Council met Wednesday for its last two hour meeting (three hour meetings begin next month). The Council’s Annual report is completed. A cover letter will be highlight the Council’s achievements. The cover letter to the Senate President will note areas of alignment between Council’s recommendations and S2526 – the Senate President’s Cost Containment bill.

The Council continues collecting quality and cost measures to post on its website. It has entered an agreement with DHCFP to compile measures into one reporting dataset for the web application. The Council has hired a Clinical Consultant to help. The new launch date is now mid-June 2008. Website consultants presented initial designs. The Council discussed what measures will be acceptable to practioners and useful to consumers.

ED Katharine London proposed Committee structure changes. The current Committees are Patient Safety, Chronic Disease Management, End of Life and Communications& Transparency. Based on the 2008 goals, London recommended the following committees: Governance, Communications & Transparency, Cost Containment and Accountability. The Advisory Committee meets quarterly, but did not have a meeting in March.

The Council discussed their FY09 Budget:
o The Council’s FY09 budget request = $2.37M
o H2 FY09 budget for the Council= $1.89M

Member Greg Sullivan (Inspector General) moved to re-submit a budget request to the Legislature asking for $900K more then the initial request (totaling $3.27M). The money would assist the Council to achieve their goals and accomplish priorities included in the Senate president’s bill. Members spoke about the work the media and the legislature expected them to accomplish. The Council voted to send a letter to HWM and SWM informing them of the work the Council will be doing in the future without a specific dollar request. The vote was 10-2. Council Chair and HHS Sect. JudyAnn Bigby was one of the two votes against.

The Council will soon have a dataset ready for analysis. Data release regs will be proposed at the 4/16 Council meeting. A public hearing on the proposed regs will follow in late May or early June and adoption of a final proposal in July.

Secretary Bigby also suggested a Council retreat. More info to follow. Next full Council Meeting is 4/16 from 1-4.

The Patient Safety Committee met immediately after the Council meeting. Paula Griswold (MA Coalition for the Prevention of Medical Errors) is collecting data on all current patient safety activities in Massachusetts. She will present her findings at the next Patient Safety Committee meeting (TBA).

200+ people filled the room at today’s Connector Board meeting held at 1 Ashburton, and many more were turned away at the door by state troopers. Greater Boston Interfaith Organization, Neighbor to Neighbor, Coalition for Social Justice, SEIU 615, HCFA, and many more turned out to hear the Connector Board begin to discuss a new phase of health reform: shared responsibility and cost control.

Beginning last December, talks involving the renewal of Commonwealth Care contracts with the four Medicaid Managed Care Organizations (MMCOs) and proposals to increase the affordability schedule and copays in Commonwealth Care triggered opposition from advocates and consumers. Due to hard work and aggressive advocacy, the Connector approved premium and copay adjustments that lessened both and launched a broader discussion on sharing/broadening responsibility for costs.

Connector materials from the meeting are available here, and the Connector has posted a helpful summary of the decisions, here.

Key Decisions:
1. The CommCare copay structures was approved
2. The MMCO Contract rates were approved
3. The revised Affordability Schedule was approved
4. Recommendations for changes in the premium hardship waiver in CommCare received preliminary approval
5. The MassHealth Interagency Service Agreement (ISA) was approved

Executive Report
Jon Kingsdale, Connector ED, opened the meeting and thanked the MMCOs for their partnership and public service. Patrick Holland, Connector CFO, received special praise for his critical financial analysis. Kingsdale stressed that the proposals must be seen in the larger context of cost-control.

Connector Chair and Secretary of Administration and Finance Leslie Kirwan broadened the discussion further, stressing the “spirit for shared sacrifice and mutual commitment.” For months, the state was involved in MMCO negotiations. She said the cancellation of the 2/28/08 board meeting when the votes on copays and affordability was initially scheduled was due to unsatisfactory MMCO bids. The state also lacked an understanding of the “larger financial context,” thus postponing the meeting.

Commonwealth Care Renewal – VOTE:
MMCO Rates
Patrick Holland presented background on the MMCO bid timeline. The Connector received initial bids on 1/23/08, and bid discussions were finalized 2/22/08. Initial bids had an average increase of 15.4%, with significant variation among plans. Since then, progress has been made. The overall rate came down to 12.1% and new copay and premium changes lowered the increase to 9.4%.

Copays
Staff presented new proposed copays for CommCare. In the December proposal, copays increased across the board for plan II members (100%-200% FPL) and plan III members (200%-300% FPL). Advocates opposed the copay increase as well as the lack of out of pocket maximums for drugs in plan III.

Staff introduced new proposal features including:

• Plan Type III will have an out of pocket drug max at $800
• Plan Type III mental health outpatient copays decreased from $20 to $15
• Specialist copays proposed to increase to $25 from $20, were brought down to $22

The Connector is directing plans to tracks copay usage so once a member hits the out of pocket max, they will no longer pay copays. The current ‘shoe-box’ process requires members to track receipts; no member has claimed to reach the out of pocket max. Board member and actuary Ian Duncan expressed disbelief that a system requiring the participation of providers and others can be implemented by July 1.

Staff stressed the out of pocket max offer more protection than employer-sponsored plans. Nancy Turnbull said comparing CommCare to employer-sponsored plans is a poor standard because the employer plan itself may not be affordable. The Connector also is requesting vendors to have a system platform capable to implement Section 125 payroll deductions for CommCare members. Section 125 allows members to pay for health insurance with pre-tax dollars, leading to more savings.

Enrollee Contribution and Affordability Schedule
When the draft affordability schedule was first released, CommCare members saw a 14.3% premium increase. The schedule was revised and presented at the board meeting. The new schedule maintains a 10% increase in all income brackets.

Nancy Turnbull reiterated the issue of age discrimination in the affordability schedule. Older individuals and families above 500% FPL are not listed in the affordability schedule, meaning these individuals are subject to disproportionately high insurance rates because of their age. Turnbull proposed a 10% of income cap to the affordability schedule. The Board agreed to revisit this issue in the comment period. The board approved the affordability schedule with a comment period. The schedule will be finalized at the April 10 meeting.

Premium Hardship Waivers
Melissa Boudreault, CommCare Director, presented recommendations to improve the premium hardship waiver process. To date, the Connector has received about 300 hardship applications. One change will allow easier waiver renewal for up to 12 months instead of the current six months.

A debate centered on the recommendation to expand proof of medical/dental expenses from previous 12 months to previous 24 months of CommCare enrollment. This refers to the hardship criteria allowing enrollees to get a waiver from premiums when they incur more then 7.5% of their income in medical/dental expenses. Board Member Jonathan Gruber said this provision contradicts changes in the out of pocket max’s because the proposed amounts can exceed 7.5%. The Board decided to approve the initiation of a new administrative bulletin and leave room for comments and revision at the next board meeting.

Shared Responsibility Debate
After staff presentations, Secretary Kirwan made observations on the negotiation process. She was pleased to see the MMCO increase drop from 15% to 10%. The state heard many concerns about the impact of cost-sharing on low income populations and tried to balance those concerns with private insurance parity. Her key message was the “theme of shared responsibility must be accelerated.” CommCare faces budgetary challenges. Gov. Patrick has begun cost control talks with stakeholders and has engaged parties to work together to close health reform’s financial gaps.

Celia Wcislo, Board member, said more stakeholders must share the financial burden of health reform. “Today, consumers and taxpayers took the lead and first step to addressing cost control.” Stakeholders including hospitals, insurers, providers, and employers, and others who benefit from more uninsured being covered, should join. We need to look at employers who haven’t paid their fair share into the system.

Board member Rick Lord from Associated Industry of Massachusetts said businesses have been struggling with skyrocketing costs and employers are covering more employees after health reform. Employers are doing their part.

Nancy Turnbull said “consumers and taxpayers are making the sacrifice today,” and other stakeholders must get involved. Hospitals are receiving higher payments and insurers have more members. Turnbull recognized that more employers are covering workers but there are still many employers not offering coverage or offering inadequate coverage. Turnbull received applause from the audience. Turnbull and Wcislo said the state listened to consumer concerns and responded with reasonable concessions. The copay, premium and affordability structure was approved unanimously.

MassHealth Interagency Service Agreement (ISA)
The Board approved an interagency service agreement with MassHealth for $5.3 million. MassHealth is the behind the scene operational backbone for CommCare. MassHealth handles eligibility, internal MMCO coordination, data collection, appeals, IT support, and the Virtual Gateway enrollment system.

Commonwealth Care Redetermination Process
Melissa Boudreault walked the Board through the redetermination process, which is the process by which information that impacts a member’s eligibility, such as income, employment, etc, is updated. In November 2007, CommCare began a wave of redetermations, beginning with longest enrolled members, most of whom were autoenrolled from the Uncompensated Care Pool. Many groups have observed churning in CommCare. In February, 13,799 individuals were dropped from CommCare. Of these, 9,000 lost coverage through the redetermination process, almost all due to failure to return their redetermination forms. Another 4800 cases closed due to normal caseload activity. With the 13,799 members dropped, and the 12,961 members added during the month, CommCare enrollment as of March 1 was down from the previous month.
Diana Ong

The Massachusetts Association of Health Plans has released data today from 11 state health plans showing an increase in covered lives of about 111,000 between January ‘07 and January ‘08. In December, the State released data showing an increase of abou 60,000 in private coverage between the start of health reform in ‘06 and the fall of ‘07. Here’s the breakdown:

Individual Coverage: from 52,689 to 78,744
Employer-Sponsored Coverage: from 3,804,924 to 3,890,160
Aggregate: from 3,857,613 to 3,968,904
Change from 1/1/07: 111,291

Click here for the MAHP release. This would be on top of 177,000 in Commonwealth Care, and another 90,000 in MassHealth. Clearly, there’s some duplication here. And there’s also some undercounting — eg: people signing up for employer-based coverage in firms that self insure AND the firms do not use any of the 11 MAHP surveyed companies for third party administrator (TPA) services.

Anyone see any holes here?

We’ll have a complete report and analysis of today’s Connector Board meeting soon. Here’s the report from NECN: (if video embedding doesn’t work, see report here)

To mark the 30th anniversary of Urban Medical, and to launch a “Fund for the Future of Primary Care”, there will be a special symposium April 4 to discuss the future of primary care and the role models like Urban Medical model can play.

Keynote speaker will be Harvey Fineberg, M.D. Ph.D., president of the Institute of Medicine. Other speakers will include: Judy Ann Bigby, M.D., EOHHS Secretary, Thomas Bodenheimer, M.D., professor of Family and Community Medicine, University of California at San Francisco, Robert Master, M.D., president and CEO of Commonwealth Care Alliance, and Jeffrey Kang, M.D., MPH, senior vice president and chief medical officer, CIGNA Health Care.

The symposium will be from 8:00 a.m. to noon at the Conference Center at Harvard Medical School, followed by an evening gala celebration of Urban Medical’s 30 years at the Westin Copley Hotel. Click here for more info on the symposium and gala.

Agenda for tomorrow and recent board minutes now available on Connector website.

Many restaurants in San Francisco are adding surcharges to their customer bills to cover their mandatory assessments under the SF universal coverage law. The LA Times covers the new development “Social Policy on the Menu,” excerpt below:

In the hip South of Market neighborhood, the menu at Tres Agaves, a popular Mexican restaurant and tequila bar, has a small message at the bottom of the first page that says, “3.5% service charge will be added to all checks for the San Francisco affordable healthcare legislation.”

At issue is the city’s new effort, kicked off Jan. 9, to provide healthcare for all residents. Since then, employers with more than 20 workers are required to spend a minimum amount on health insurance, set aside money in health reimbursement accounts or pay a fee to the city’s Healthy San Francisco program.

A big city jumping into universal healthcare is unprecedented. The program is being watched closely as officials from Sacramento to Washington to invent ways to provide and pay for care for the uninsured.

Restaurant patrons so far don’t seem to mind footing the bill for expanded healthcare. “We haven’t noticed it, so I guess it’s not that big a deal,” said Stacy Wong, a Tres Agaves customer waiting with friends to lunch on Jalisco-style fish tacos.

Seems like a not-so-bad solution and makes one wonder why businesses oppose employer mandates so much. Providing health insurance to workers is part of the price of goods and services in any company that provides worker coverage. If all employers do it, whether explicitly or implicitly, that’s up to them.

The next Connector Board meeting is scheduled for Thursday, March 20th at 9am. An agenda has not yet been posted (update: it’s here), but we think there are four key votes to be held: the Commonwealth Choice contracts and “Seals of Approval”; the Commonwealth Care contracts; the 2008 Affordability Schedule (a preliminary vote before a public comment period); and the Commonwealth Care co-pays.

We hope the votes on the Affordability Schedule and the Commonwealth Care cost-sharing will be postponed until we go through a broader discussion exploring all options. We should not ask more of Commonwealth Care consumers without also asking more from other stakeholders in the shared responsibility community. We’re also waiting for data to understand better how the Affordability Schedule and co-pays are impacting those eligible for and enrolling in Commonwealth Care.

Members of the ACT!! Coalition will be attending for the meeting—please join us!

Health Connector Board Meeting
1 Ashburton Place, 21st floor

As we hear more information, we’ll post it here. Click here to learn more about the Coalition’s position.