Today Governor Patrick announced that continued revenue declines will mean more midyear budget cuts. As much as $1 billion in further cuts may be needed. “There’s a lot of pain, and it’s going to have to be spread around,” Patrick said.

But there’s one area where tax revenue is up, and it’s improving Bay State health as well.

In July, the legislature and governor increased the cigarette tax by $1 a pack, enacting a key priority of HCFA, the ACT!! Coalition and Tobacco Free Mass. The additional revenue goes to fund health reform. At the time, we said the increase would both decrease smoking and increase revenue - a win-win for Massachusetts.

Soon after the increase was put into effect, calls to the Mass Tobacco Control Program 1-800-TRY-TO-STOP quit-line soared.

Now the sales and revenue numbers are in, demonstrating the win-win policy is working. For the four months before the increase (Mar-Jun 08), cigarette sales totaled 92.2 million packs. For the 4 months following the increase (July-Oct 08), cigarette sales dropped to 80.7 million packs. The drop in sales was 12.5%.

The revenue numbers show the opposite effect. For the same 4 months before the increase, revenue was $139 million. For the four months following the increase, revenue was $201 million, an increase of 45%. The roughly $60 million increase will go to the Commonwealth Care Trust Fund, used for health reform coverage expansions.

With all the bad news around, this is something to celebrate.
Brian Rosman

With a national focus on e-health as a piece of the national health reform puzzle, and President-elect Obama looking to spend $50 billion on the adoption of e-health technology, the New York Times Business section featured an article this past Saturday about the use of e-health at the Marshfield Clinic in Wisconsin, a large doctors’ group with 790 doctors seeing more than 365,000 patients per year at 43 locations.

The article discussed the potential for the technology to increase the use of evidence-based medicine and to help patients manage chronic diseases. It also pointed out how e-health can reduce medical errors. The Marshfield Clinic system warns doctors, when they electronically prescribe medicines, of possible allergic reactions and dangerous interactions with other drugs the patient is taking. A survey published in the New England Journal of Medicine found that 71% of doctors using e-health records with a feature that included such warnings said they had been alerted of medication errors. As the article states, most of the medical groups across the country that have adopted e-health are large and are often insurers as well as providers, while 3/4 of physicians’ practices in the country have 10 or fewer doctors and would need financial assistance to successfully implement the technology.

The article did not talk about the steps taken at Marshfield Clinic to educate the patients about electronic health records and their policies regarding privacy protections and notification of security breaches. It is also not clear if Marshfield includes a patient portal in its system, allowing patients to play a role in their care via their health record. Both the privacy protections and the patient portals are pieces of e-health that, from the consumer perspective, are important and should be part of the discussion as e-health moves ahead in Massachusetts and nationally.
Deborah Wachenheim

The season of giving is almost over and there’s only one day left to donate to HCFA in 2008. We, like others in these difficult economic times, are struggling to meet our fundraising goals. In order to continue the important work we do and improve the quality and accessibility of health care for all Massachusetts residents, we depend on your generosity.

We invite old and new friends to consider making a gift today.

If you have not already made a donation to our annual fund and appreciate the work we do, please help out.

Click here to make a fully tax deductible contribution.

Thanks to you, HCFA’s good work can continue.
Melissa S. Freitas

Former NEJM editor Marcia Angell lays out the whole range of pharma industry control over medicine in a review, Drug Companies & Doctors: A Story of Corruption in the New York Review of Books. Angell’s conclusions bear directly on the research loophole in the draft DPH drug payment disclosure regulations.

She estimates based on their annual reports that pharma provides tens of billions of dollars a year to US doctors: “most doctors take money or gifts from drug companies in one way or another. Many are paid consultants, speakers at company-sponsored meetings, ghost-authors of papers written by drug companies or their agents, and ostensible “researchers” whose contribution often consists merely of putting their patients on a drug and transmitting some token information to the company. Still more doctors are recipients of free meals and other out-and-out gifts. In addition, drug companies subsidize most meetings of professional organizations and most of the continuing medical education needed by doctors to maintain their state licenses.”

She examines how the industry manipulates research to support its marketing goals:

Because drug companies insist as a condition of providing funding that they be intimately involved in all aspects of the research they sponsor, they can easily introduce bias in order to make their drugs look better and safer than they are. Before the 1980s, they generally gave faculty investigators total responsibility for the conduct of the work, but now company employees or their agents often design the studies, perform the analysis, write the papers, and decide whether and in what form to publish the results. Sometimes the medical faculty who serve as investigators are little more than hired hands, supplying patients and collecting data according to instructions from the company.

In view of this control and the conflicts of interest that permeate the enterprise, it is not surprising that industry-sponsored trials published in medical journals consistently favor sponsors’ drugs—largely because negative results are not published, positive results are repeatedly published in slightly different forms, and a positive spin is put on even negative results.

This, in turn, leads to more expensive, and less effective health care:

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.

One result of the pervasive bias is that physicians learn to practice a very drug-intensive style of medicine. Even when changes in lifestyle would be more effective, doctors and their patients often believe that for every ailment and discontent there is a drug. Physicians are also led to believe that the newest, most expensive brand-name drugs are superior to older drugs or generics, even though there is seldom any evidence to that effect because sponsors do not usually compare their drugs with older drugs at equivalent doses.

We urge DPH to re-examine the research loophole, and allow consumers to see the full extent to which drug company funds are flowing to prescribers in Massachusetts.

We promised we would never let this false information go unanswered. Once again, someone has misused the DHCFP study on the cost of mandated health insurance benefits in Massachusetts to make the false claim that mandated benefits add up to 12% of insurance costs. Once again, it’s our job to correct the misinformation. (See our original blog here, and our followups correcting the Herald, and HPHC CEO Charlie Baker.)

This time it’s the Massachusetts Association of Health Plans (MAHP). In their 2008 annual report, they devote a page to mandated benefits. They claim that “Mandated benefits are one reason the cost of coverage in Massachusetts is so high. A state report tagged the cost of current mandated benefits at $1.3 billion or 12¢ for every dollar paid for health insurance.”

No, that’s not the conclusion of the DHCFP study. The DHCFP properly takes out from the impact of state mandates the cost of federal mandates and benefits that would be provided even without a mandate. Their conclusion: “mid-range estimates in the three to four percent of premium range (roughly $300 million to $400 million annually) may be a reasonable estimate of the mandate laws’ marginal impact on health care costs directly associated with the covered benefits described in the laws.”

That’s three to four percent. Not 12%.

People can disagree over whether specific new mandates are in the public interest or not, and understanding the cost of a mandate is helpful for that discussion. MAHP says we should put a moratorium on new mandates until medical costs remain flat for two years. We might disagree on some mandates, agree on others.

But MAHP along with everyone else has an obligation to be honest with what the authoritative study has concluded.
Brian Rosman

Yesterday afternoon, the Department of Revenue (DOR) released their draft penalty guidelines for the uninsured in 2009 as well as an updated report on insurance mandate compliance in 2007.  Click here for the press release, here for the draft penalties and here for the report.

The implementation of the Individual Mandate in 2009 will look very much like 2008, and we thank DOR for releasing the penalties in advance of their January 1^st start date and for maintaining last year’s simple and fair model.  For those tax-filers under 150% of the federal poverty level, there is no tax penalty.  For tax-filers between 150.1 and 300% fpl, the penalties will remain largely the same as last year, changing only by removing $0.50-an unexpected surprise.  For those above 300% fpl, the penalty is based on the lowest-cost plan available (the penalty is half the monthly premium).

For young adults, the 2009 monthly penalty actually decreases $4 to $52/month, based on lowered premiums.  The penalty for those over age 26 increases $13 to $89/month, largely due to the minimum creditable coverage requirement for prescription drug coverage.

DOR is holding an open public comment period through January 23^rd.  Comments can be directed to the Department’s Rulings and Regulations Bureau at rulesandregs@dor.state.ma.us.

The ACT!! Coalition has been interested in learning more about who the uninsured are in Massachusetts.  Early this past summer, DOR released preliminary data on the uninsured, based on tax-filing season; the new report is an updated and more detailed version, including late-filers.  The report is mostly consistent with what we already know about Massachusetts uninsured: the state is making incredible progress in covering residents with health insurance.  And those who remain uninsured are more likely to fit in certain demographic categories.  A unique puzzle piece this report adds is how the Affordability Schedule functions.  This data is not a complete picture, since it only reflects information from those who file taxes.

By approximately a 2:1 ratio, uninsured are more likely to be under 40 years of age, male, single, and low-income (62% under $25,526/year).  Interestingly, almost all regions of the state reported an uninsurance level of 2.5-3.3%. The outlier is the Cape and Islands. Nantucket’s rate was the highest at 12.6%, with Dukes County (Martha’s Vineyard) at 7.5%, and Barnstable County at 4.3%.

According to the DOR data, 5% of Massachusetts adult tax-filers are uninsured.  (This data is 3-4 months older than the recently released Sharon Long/DHCFP report, and it also doesn’t include children, who are more likely to be insured.)  Three percent of tax filers were uninsured but deemed able to afford insurance and nearly 2% were uninsured and unable to afford health insurance.  Including individual exemptions, just over 2% of tax filers were exempt from the mandate.  The Affordability Schedule and exemption process offers protection to those 76,000 who cannot afford insurance.   And for those 118,000 who were deemed able to afford insurance, the state collected approximately $16 million.  The state reached out to these individuals, letting them know of the mandate and health insurance options.

Happy holidays, all.
Lindsey Tucker

The Congressional Budget Office (CBO), the non-partisan gold standard in evaluating the economic impact of policy change, has determined that requiring disclosure of drug industry payments to physicians will lead to lower health costs.

Throughout our long night of July 31, waiting for the House and Senate to finalize the cost/quality bill that included the prescription reform provisions, a lobbyist for the drug industry kept needling me, “You don’t actually believe that this will save costs?”

I said yes back then, and now there’s even more evidence. The CBO findings are part of a detailed analysis of over a hundred health policy options released last week. Here’s what CBO concluded:

At this time, the Congressional Budget Office cannot estimate how this option might affect spending for Medicare but believes that, over time, disclosure has the potential to reduce spending. For example, hospitals and health plans could use the data collected under this option to ensure that relationships between physicians and manufacturers did not influence decisions about which drugs became part of a formulary (a list of preferred drugs) or were recommended in practice guidelines. Public reporting and disclosure of industry–physician relationships might also encourage physicians to monitor and modify their own behavior. The reporting system that this option would implement and the data that would be collected as a result could become a building block for further regulations that might reduce future costs below the level that they otherwise would attain.

This report follows the strong recommendations of MedPac, the expert group that advises Congress on Medicare policy. Back in June, they put out an in-depth report on public reporting of physicians’ financial relationships with drug and device manufacturers: “studies have shown that physician interactions with the pharmaceutical industry are associated with rapid prescribing of newer, more expensive drugs, decreased prescribing of generic drugs, and physician requests to add drugs to a hospital formulary.”

Now, they have put out their recommendations, calling for public reporting.

DPH will hold two hearing on their draft regulations, on January 9 and 12 (details). We will be joining a long list of individuals, groups and experts urging DPH to strengthen their proposed regulations, and thereby reduce health costs.
Brian Rosman

A celebration in honor of legislators and community leaders committed to improving the state of oral health in Massachusetts. Sponsored by Watch Your Mouth Massachusetts and the Legislative Oral Health Caucus. Contact Czarina Biton at biton@hcfma.org for more information or click here.

This is it - no more short term extensions. This morning federal CMS officials and the Commonwealth reached agreement on a 3-year MassHealth waiver. You can read the official documents here (big pdf).

According to EOHHS, the agreement includes all the elements announced in late September as part of the agreement in principle. Here are the key points from the state’s notice to stakeholders:

Key features of the agreement include:

1. The total spending authority granted by the federal government is approximately $21.2 billion, which is $4.3 billion more than in the last three year term.

2. All eligibility and benefit levels are preserved. The agreement secures the ability to claim federal financial participation (FFP) to match state spending on all programs as currently designed, including Commonwealth Care at 300% FPL.

3. The agreement allows the state to meet all of its health care obligations for Fiscal Year 2009. In Fiscal Year 2009, the state will be able to claim $150 million for programs for which it was unable to claim matching funds for in Fiscal Year 2008.

4. The agreement expands the Patrick Administration’s authority to bill for programs in the Safety Net Care Pool by $1 billion over the current waiver period. The Safety Net Care Pool (SNCP) represents authority for federal reimbursement for Commonwealth Care payments, Health Safety Net (the “free care pool”) spending and hospital supplemental payments.

5. A flexible Cap in the Safety Net Care Pool. The federal government has proposed a three-year cumulative cap on Safety Net Care Pool expenditures, instead of the current annual cap. This flexibility allows the state to meet all of its commitments for Fiscal Year 2009 and to plan ahead to meet all Fiscal Year 2010 and Fiscal Year 2011 commitments.

We congratulate all of the Office of Medicaid and EOHHS staff who have been working very long and very hard to get to this point. The agreement allows health reform to continue with federal support through June 2011.

We haven’t read through the documents yet, and look forward to the always informative analysis by the Mass Medicaid Policy Institute, due soon.

In January, the Legislature will start a new session and will welcome 21 new members of the House and Senate. This moment offers a unique opportunity for many advocates to educate the new members, as well as some of the returning members. Working with the legislative Joint Committee on Children, Families, and Persons With Disabilities, the Children’s Health Access Coalition (CHAC) is organizing a January 26th State House education event on a range of issues related to children called “Health, Housing, and Hunger: The Building Blocks of Childhood Success.” Taking a holistic approach to children’s welfare, CHAC solicited participation from a number of other organizations to bring their expertise in the areas of housing and nutrition. Precarious housing and inadequate nutrition have direct links to poor health outcomes, which in turn stack the deck against children being able to do well in school.

The January 26th event has the potential to help set the tone for the work of the Children, Families, and Persons with Disabilities Committee for the session. Although the Commonwealth is facing difficult financial times, there is still an opportunity to pass meaningful legislation that will make improvements in the lives of children across the state.

In putting together this event, CHAC has an exciting opportunity to collaborate with other organizations who we do not traditionally work with. CHAC has been working closely with several organizations outside the traditional children’s health network including Horizons for Homeless Children, Homes for Families, Project Bread, and the Greater Boston Food Bank.

To learn more about the event contact Matt Noyes at mnoyes@hcfama.org.

Every week we highlight the voices of real people that contact our Helpline every day. Once a week you will be introduced to a family whose life has changed for the better due to health reform. If you or anyone you know needs assistance applying for free or low-cost health care coverage, please contact our Helpline online, or call 1-800-272-4232. Here’s this week’s story:

Barbara was born with a health condition called hip dysplasia, causing severe pain which affects her life in many ways. She works as a secretary at a landscape company and is a 22-year-old single mother. She can’t walk well unless she takes a high number of very expensive medications.

She had been uninsured for two years and suffering without the medications that allow her to function normally when she was helped by a counselor at the Helpline. A few weeks after she filled out an application over the phone, she started her Commonwealth Care health insurance coverage and was finally able visit a specialist to take care of her health issues.

Barbara has been in treatment ever since. Pain medication is keeping her comfortable until her surgery scheduled for next month. She will have a hip replacement and the chance of success of her surgery is 98%. She is so excited about her new hip and stresses the important roll that Health Care For All played in helping her through the whole process. Here is what Barbara has to say:

“We are so lucky to be Massachusetts residents. My daughter is 1 year-old and she was born with the same problem I have. But thank to all the health care we receive, her health condition was diagnosed as soon as she was born and she had all the care necessary to fix her hips before she started having severe problems. She used a harness for a period of 4 months which helped to cure her problem. And through MassHealth she has the opportunity to go to the doctor for regular checkups until her situation is normalized. So I couldn’t be happier about the health reform in Massachusetts and all the assistance and care I receive every time I call the helpline.”

Monika Lira Malhoit

The Connector Board sneaked in a Friday morning meeting before the anticipated snow storm to vote on the revised Managed Care Organization (MCO) procurement RFP. The Board discussed revisions to the proposed procurement process at length. The Board was also updated on the FY08 Audit Report and the FY09 Administrative Budget. Materials for the meeting can be found here. Full details, after the jump. (more…)

The U.S. Surgeon General has identified the mouth as an early warning system, signaling trouble in other parts of the body. Oral health is inextricably linked to overall health. In fact, dental disease is caused by a bacterial infection in the mouth. Left untreated, it can lead to life-long health problems, from respiratory disease, to heart disease to diabetes.

In Massachusetts, nearly half of all children have experienced this disease by the time they reach third grade. Left untreated, dental disease can impact a child’s ability to eat, sleep and concentrate in school. It is no surprise, then, that the American Academy of Pediatrics (AAP) has released a policy statement that encourages pediatricians to include oral health to be included in routine care.

The paper, from the AAP’s Section on Pediatric Dentistry and Oral Health, states that pediatricians should periodically assess the oral health of all children, and all patients should have a dental home by their first birthdays. The inclusion of oral health in routine pediatric visits will surely help promote the health of all children in Massachusetts.

To read the full article, click here.

For more information on how to speak up for children’s oral health, please visit www.watchyourmouth.org.
Christine Keeves

The Health Care Quality and Cost Council (QCC) met on Wednesday and approved its budget request for level funding of $1.182 million. Before this year’s 9C cuts, the QCC had proposed an FY10 budget of $3.2 million, so its new proposed budget took into account the deep 9C cuts that hit the QCC.

The meeting also included an overview of how the new quality and cost website (www.mass.gov/myhealthcareoptions) has been utilized since it went live on December 10. The site had its highest traffic level on December 11, when there was quite a bit of media coverage on the launch of the website. The homepage was viewed close to 13,000 times on that day alone. A small number of comments were sent by users via the website, including a request to allow a search of hospitals within 100 miles (it currently allows only up to 20 miles). Charlie Baker also mentioned that he received comments that consumers should be able to compare more than 4 hospitals at a time, as is currently the case on the website. A grassroots communications plan was presented at the meeting and will involve engaging partners to do viral on-line marketing of the site on a given day in January. Also, MA Health Quality Partners was selected as an analytic consultant for the QCC.
Deborah Wachenheim

Congratulations to Massachusetts! Our rate of uninsurance is down to a remarkable low of 2.6%. The Division of Health Care Finance and Policy just released their annual report, “Health Insurance Coverage in Massachusetts: Estimates from the 2008 Massachusetts Health Insurance Survey.” A survey of Massachusetts households was conducted this past July and August by Sharon Long and colleagues at the Urban Institute. This report focuses on health insurance coverage, and a second report with data on access to health care is forthcoming.

The good news is great: an extraordinary 97.4% of our residents are insured. Nearly all kids (98.8%) and virtually all elderly adults (100%) are insured. The uninsurance rate is 3.7% for non-elderly adults (19-64 years of age); it’s under 2% for those with incomes above 300% federal poverty level (fpl) and just 0.3% of those above 500% fpl. These numbers have improved since 2007, when over 5% of the population was uninsured (2-3% for kids and 7-8% for non-elderly adults). The majority of residents (68%) are covered by employer-sponsored insurance, with 15% on Medicare and the remaining 17% on public coverage or other care. A full 80% of non-elderly adults have employer-sponsored coverage.

A remarkable three-quarters of the Commonwealth support health reform, with just 14% not supporting. This is up from 64% supporting two years ago.

What’s the downside? Those still uninsured are more likely to be non-elderly adults, those under 300% of the federal poverty level, and Hispanic. The numbers are most stark for the Hispanic population. Among non-elderly adults (the age group with a higher rate of uninsurance), Hispanics are more than 4 times as likely to be uninsured as white, non-Hispanics and nearly three times as likely to be uninsured as non-white, non-Hispanics. In terms of income, those non-elderly adults under 300% fpl have an average 7.9% rate of uninsurance, twice that of those non-elderly adults between 301% and 499% fpl. (The rate of uninsurance of non-elderly adults above 500% fpl is just 0.2%.)

Of particular concern, nearly 1/5 of households are unaware of the Individual Mandate, showing that more outreach and education is still needed.

So, champagne for all—and keep funding the outreach grantees!
Lindsey Tucker

Tomorrow, the Connector Board will meet at 10:00 am–in the 21st floor conference room of One Ashburton Place, Boston. The Board is scheduled to vote on the revised CommCare reprocurement plan. For the ACT!! Coalition’s reaction to the CommCare reprocurement process, check out Lindsey Tucker’s blog. Materials for the meeting can be found here.
Catherine Hammons

The Council on Racial and Ethnic Health Disparities reconvened on Monday, after a two month hiatus. The meeting was chaired by Representative Byron Rushing and new Co-Chair Senator Susan Fargo. In collaboration with EOHHS Secretary Bigby, the two chairs led the council members through a discussion of the council’s mission, and developing a broad framework for the group to make recommendations to eliminate disparities in the Commonwealth. Council members emphasized the importance of making recommendations that address disparities in a comprehensive way, and are reasonably possible to accomplish through the legislature, administration, or community.

Secretary Bigby and Commissioner Auerbach noted that some efforts are underway in their agencies, including a draft disparities report card evaluating the state’s progress (EOHHS), and development of a grant program to support community based disparities reduction projects (DPH). Senator Fargo noted her ability to file legislation that supports the council’s recommendations.

DPH Director of Research and Epidemiology Bruce Cohen also joined the meeting and shared a number of disparities data points, describing areas where the disparities gap has worsened, improved, or remained stagnant. The council may identify some of those areas to address through their forthcoming recommendations.

The council will shortly announce a regular meeting time for the new year. Stay tuned to the HCFA disparities web site for updates.
Michele David
Co-Chair, Disparities Action Network

The Division of Health Care Finance and Policy recently released two reports that provide an in-depth look into the Health Safety Net and the financial performance of Massachusetts’ hospitals.
The Health Safety Net 2008 Annual Report gives an overview of payment experience, utilization patterns, and user demographics in the first year of the Health Safety Net. From Pool Fiscal Year 2007 to Health Safety Net Year 2008, HSN payments to hospitals and community health centers were reduced by 38%.

The first 6 months of HSN08 compared to the same period in the prior year revealed a:

• 36% reduction in HSN volume for hospitals and community health centers
• 31% reduction in HSN users
• 28% reduction in ER bad debt

Findings on HSN user demographics demonstrated that:

• Nearly 90% of inpatient discharges and payments were for emergency or urgent care
• The largest share of hospital volume (76%) and payments (88%) were for services for individuals who have the Health Safety Net (HSN) as their primary and only payer.
• Mental diseases and disorders and alcohol/drug use represented the top two diagnostic categories among inpatient claims.
• Men used fewer services than women, but payments for their care were higher.
• Users with no income received the most costly services, comprising 32% of service volume that generated 42% of payments.
• Single adults account for 70% of hospital volume and 76% of hospital payments.

This report provides comprehensive data on how health reform has reduced residents’ reliance on free care, and valuable insight into how the safety net is currently utilized and funded.

The second report, Massachusetts Acute Hospital Financial Performance: FY04 through FY08 Q3, thoroughly examines the financial status of hospitals across the state over a 5 year period and compares trends among teaching, community and disproportionate share hospitals (DSHs). Overall, Massachusetts acute hospitals experienced declining financial performance during the first three quarters of FY08, with community hospitals suffering the most. Highlights from the report include:

• While both teaching and community hospitals reported declines in total gains, community hospitals reported steeper operating declines than teaching hospitals.
• Non-operating margins declined significantly more for teaching hospitals than for community hospitals during the first 3 quarters of FY08
• Teaching hospitals had significantly higher profitability than community hospitals in each of the past five years. However, both teaching and community hospitals experienced declines in median total margin during the first three quarters of FY08 compared with FY07.
• Teaching hospitals’ median current ratio improved, but declined for community hospitals suggesting a more difficult time meeting current obligations for community hospitals.
• DSHs and all other hospitals as a group were less profitable overall during the first three quarters of FY08 than in FY07; however, DSH operating profits improved while all other hospitals as a group experienced steep declines in non-operating profits during the first 3 quarters of FY08.

DHCFP has also included a break down of the individual financial experience of each hospital in the state.

We thank DHCFP for compiling and analyzing all of this important data on the financial situation of Massachusetts hospitals.
Catherine Hammons

I’m feeling anxious about the Commonwealth Care reprocurement process, and it doesn’t feel seasonally appropriate. At last week’s Connector Board meeting (click here for the Powerpoint), Connector staff Patrick Holland offered to the Board a presentation on the Commonwealth Care FY10 MCO reprocurement process. The Connector is looking at a new bidding process that is designed to achieve several goals. Among these are minimizing the differential in enrollee premiums, maintain current co-pays, and increase MCO promotion of wellness visits—and we commend them for innovation.

It was the middle of this conversation that prompted my anxiety, a section entitled “Plan Type I Enrollee Incentives.” The Connector is looking for ways to move PTI members—who pay no premiums—into the lowest-cost plan, thereby saving the state money and encouraging new MCOs to bid in the formerly closed system by creating the possibility that more existing members might switch plans. I fear two of the three proposals will negatively impact enrollees.

1. Shorten the auto-enrollment look back period from 12 months to 3 months. Currently, if a PTI CommCare member is terminated from the program and re-enrolls within 12 months and does not self-select an MCO, the Connector auto-re-enrolls him or her to the former MCO. This means that the enrollee will be familiar with the plan and have access to the same providers as last time s/he was enrolled. The Connector is proposing limiting this look-back period from 12 to 3 months. Under the proposal, a prior enrollee who comes back to the CommCare program (or from MassHealth) more than three months later and does not self-select a plan will be auto-enrolled into the lowest-cost MCO plan. These individuals are the poorest in our state and often slide between the two programs. We could cause unintended confusion as one program looks back 12 months (MassHealth), and another would look back only 3 months (CommCare). We would place an additional burden on consumers by asking them to self-select a plan in this re-enrollment process.

   How many folks are we talking about here? The Connector says there are about 2,400 average monthly re-enrollees. 70% of these people are re-joining the CommCare program after a gap of less than 3 months and 90% re-enroll after a gap of less than 6 months. Based on these numbers, why do all this disruption for about 8,640 members a year (30% of 2,400×12)?

   If we think that this proposal will, by itself, create a significant incentive for plans to bid lower overall, it might be worth it in terms of overall savings. But if we think this change isn’t enough of an incentive to alter overall pricing behavior, then it needs to be assessed in terms of the potential savings it will produce.

   In terms of the actual state savings from simply being able to enroll people in the lowest cost plan, it’s not that much. If you assume the lowest cost plan will be 2% lower than the plan the person would otherwise be in (though some of the re-enrollees will already be in the lowest cost plan), it saves the state $8 PMPM on each member, which is $829,000 per year (though many of these folks won’t be in the plan for a full year).

   Why not make the look-back period 6 months to capture a high percentage of re-enrollees? A 6 month look-back means that only 10% of members (2,880) are affected. Is this enough to make the plans bid lower? If you assume not, and therefore it’s just a cost-saving measure, it means that state saves only $275,000 (assuming a 2% discount). Is this enough savings to warrant all the confusion that will result from the change?

   We know most members come back within 3 months, the result of “churn”, according to the Connector. This strengthens our argument that these individuals are inappropriately terminated from the program; the redetermination process is complex and difficult, and we want to make it as easy as possible for those eligible to be enrolled as quickly as possibly in the plan they know, with providers they know.

2. Active enrollment process. CommCare has an open-enrollment period each year, and this past year enrollees who didn’t want to change plans weren’t asked to take action. Only individuals who want to change plans need to take action. (This is the same as the process for most people with employer sponsored insurance when their employer has an open enrollment period, including state employees.) This proposal would require all CommCare members to select a plan during open enrollment, even if they want to say in their current MMCO, and even if they have recently gone through the re-determination process. If they don’t make a choice, they will be reassigned to lowest-priced MCO (but have 60 days to change plans).

   I understand the financial concerns of the state and the program. I also understand the Connector’s desire to create incentives for new MCOs to enter the system, incentives that would ensure that any new MMCOs have a reasonable chance of attracting existing CommCare members. But it’s our job to consider the members the program serves and how to meet their needs.

   One of the important benefits of the Commonwealth Care program is the coordinated way it interacts with MassHealth. Any disconnect between the two programs must be considered carefully. CommCare PTI is a program that serves very low income people, who often have complicated and difficult lives. The arguments against the first proposal fit this one as well; only here, we’re talking about more enrollees—perhaps 24,000 to 40,000 per year. This active open process would effectively be a second redetermination period, not establishing eligibility but still demanding participation and the return of mail. Many of these folks may not receive Connector mailings, either because of homelessness or the fact that they live in neighborhoods where mail delivery is unreliable. This proposal does not consider the complex realities that the very poor face in their day-to-day lives.

   Churning has administrative costs as well. Reassigning individuals to a new plan costs money for both MCOs and providers: new ID cards, welcome calls and packets, changes in billing. It imposes significant and largely unfunded costs on the community-based organizations and workers who will be the ones trying to help CommCare members navigate these complex and changing processes.

   As a community, we are worried about people’s ability to develop and maintain relationships with primary care providers. We are asking the MCOs to manage chronic conditions better and decrease inappropriate use of emergency rooms—both of which require a trusted provider. Why purposefully disrupt these bonds with care givers?

We have a shared goal with the State to cover all eligible individuals. I know that the current churn in the Commonwealth Care program is higher than any of us expected, and we aren’t quite sure why. The first proposal would take advantage of this churn, and both would add administrative as well as enrollee burden. I hope the Connector rethinks these proposals before Friday’s vote.
Lindsey Tucker

The Berkshire Eagle joined numerous other objective experts in calling for tougher DPH regulations on public disclosure of drug industry payments to doctors. The Blue Mass Group has been all over this issue, too (Lack of disclosure still doesn’t add up).

The Eagle rejects the industry arguments straight up:

The regulations are necessary because patients have a right to know if drug companies are attempting to influence their doctors to prescribe drugs that may be more costly than those elsewhere on the market. ….

The pharmaceutical industry, however, claims that if it is forced to disclose consulting fees and research grants it provides to physicians, proprietary information valuable to competitors will be exposed. This danger, however, has not emerged in any other state in the nation. A far greater concern is that physicians whose research work is funded to a large degree by the pharmaceutical industry will have their objectivity compromised by the grants and fees paid them by the industry.

Also check out NoFreeLunch.org, a site set up by doctors and other medical professionals to support kicking out biased drug industry promotional marketing from the medical profession. There’s lots of information on how even modest gifts, like free lunches, impair prescriber objectivity. The DPH regulations would permit drug marketers to provide “modest and occasional” in-office meals. This loophole needs to be closed.
Brian Rosman