Here are some we picked out, roughly in order of amendment number.

• Employer Fair Share Assessment: a large number of amendments make various changes to the Employer Fair Share Assessment, the payment made by employers with 11 or more workers who do not provide fair and reasonable coverage to their employees. Among these are amendments 15 (M. Moore) and Tarr amendments 175, 176 and 185. The Fair Share system will need to be changed with the coming of ACA implementation in 2014, and the administration plans to convene a broad stakeholder process, including employers, to find a consensus on systemic updates to the statute. The Senate should allow this process to go forward, and not short circuit it by using payment reform as a vehicle for random changes.
• Count Broker Commissions as Medical Costs: Amendment 17 (M. Moore) would allow insurers to count broker commissions as part of their medical expenses, as part of the requirement that insurers spend a minimum amount of premium dollars for medical care. Broker commissions are a marketing expense, and we don’t see any reason to consider them part of medical care.
• Prevention Strategy: Amendment 52 (Chandler) would require the state to have a comprehensive strategy for promoting prevention. This would help guide coordinated efforts by state and private groups to keep the population healthy. We support this idea.
• Culturally and Linguistically Appropriate Care: The Culturally and Linguistically Appropriate Services (CLAS) standards are principles for better health care services so that everyone in the health care system receives equitable and effective treatment in a culturally and linguistically appropriate manner. We support Amendment 102 (Fargo), which would commit the Commonwealth to living up to these standards. Senator Fargo filed a whole package of amendments sponsored by the Disparities Action Network. These amendments would make sure that disparities reduction is a top goal of health reform.
• Palliative Care and End of Life Options: Senator Richard Moore filed amendment 121 directs caregivers to provide dying patients with information and counseling on palliative care and end-of-life options, including the patient’s legal rights to comprehensive pain and symptom management at the end of life. Similarly, Senator DiDomenico proposed amendment 129 to add hospice and palliative care to ACO benefits, and Senator Jehlen filed amendment 135 to add hospice benefits to two MassHealth plans. These are compassionate, appropriate reforms, that we support.
• Same Rules For Co-ops: Amendment 127 (Welch) would remove a section that gives an unfair advantage to new co-op plans. The section in the bill would fragment the individual and small group market by allowing co-op plans to offer discounts not justified by actuarial factors. The result would be higher premiums for everyone else. We support Senator Welch’s amendment.
• Report Checklist Compliance: The Senate bill includes language supported by HCFA’s Consumer Quality Council to encourage the use checklists during surgery and other procedures, which improve care, save money and reduce errors. But the bill does not let patients learn which hospitals use checklists as part of their procedures. Amendment 137 (Jehlen) would allow the public to learn about hospital compliance with the standard. We support this amendment.
• Paperwork Delays Shouldn’t Delay Enrollment: Senator Tarr’s amendment 170 provides that enrollment in Commonwealth Care not be terminated if requested documentation has been provided by the recipient and received by MassHealth. Paperwork processing delays in MassHealth enrollment centers is leading to many people losing coverage for no good reason, and we support Senator Tarr’s amendment to fix this problem. We also support his amendment 172, which directs the Division of Unemployment Assistance to provide information about termination of unemployment benefits to help Medical Security Program members switch to other health coverage programs.
• Strengthen Mental Health: Senator Keenan has a package of amendments that strengthen the integration of mental health, behavioral health and substance abuse care into our health care system. We support his amendments, including 222, 227, 228, 241, 247 and others.

There’s more we can report on, but this is a good list of key amendments that we’re watching.
-Brian Rosman

Debate starts Tuesday, and if necessary, will continue on Thursday.

HCFA and the Campaign For Better Care worked closely with Senators on a number of amendments to strengthen the bill. These amendments reflect our 10 principles, which we blogged on last week.

We urge the Senate to support these amendments from the Campaign, among many other positive ideas:

• Don’t Sunset Prevention: Amendment 30 from Senator Chandler doesn’t let the Prevention Trust Fund expire after 5 years, as provided in the Senate bill.
• Patient Centered Care: Amendment 9 from Senator Chang-Diaz adds several important provisions to requirements for ACOs, including patient confidence measures, cultural competence, use of community health workers, and support for chronic disease self-management.
• Reward Good Outcomes: Amendment 45 from Senator Montigny encourages ACOs to reward providers who achieve good outcomes, like reducing potentially avoidable admissions, readmissions, or complications.
• Protect Vulnerable: Amendment 81 from Senator Rush extends protections for vulnerable patients to those in private plans, by encouraging them to use socio-economic factors in risk adjustment, integration of mental health, and providers serving underserved populations. These are only voluntary for private health plans in the Senate bill.
• Patient Choice: Amendment 134 from Senator Creem allows patients to choose their providers within a health plan.
• Accessible Web Site: Amendment 151 from Senator Rodrigues aims to make the consumer information web site more accessible, by including other languages, having it tested out by consumers, and including accessibility information for people with disabilities.
• Protect Appeals and Second Opinions: Amendment 10 from Senator Brownsberger provides for external appeals of ACO and provider organization decisions, and lets a patient seek a second opinion to support an appeal.
• No ACO conflicts of interest: Amendment 46 from Senator Montigny makes sure that no conflicts on interest exist on ACO governance boards, and that ACO governance is transparent.
• Savings shared With consumers: Amendment 171 from Senator Jehlen provides that shared savings programs include consumers, too.

There are a number of other amendments strongly supported by HCFA, including

• Senator Eldridge’s amendment 123 to improve MassHealth enrollment for children, by authorizing 12-month eligibility, pre-populated renewals and electronic signatures;
• Senator Fargo’s package of amendments to support disparities reduction, in particular amendment 42 to create an Office of Health Equity;
• Senator Petruccelli’s amendment 32 to require GIC and CommCare plans to cover tobacco cessation.

Please let your Senator know today if you support one or more of these amendments. Our organizers, Ari Fertig (afertig@hcfama.org; 617-275-2913) and Celia Segal (csegal@hcfama.org; 617-275-2904) will be happy to help you figure out who to call and what to say.
-Brian Rosman

Materials from the meeting are posted here and our full report is after the fold.

Glen Shor began the meeting with the Connector’s program enrollment numbers as of Enrollment as of May 1, 2012:

• Commonwealth Care: 184,281 (increase of over 9,000 people, mainly due to the transition of legal immigrants from the Health Safety Net to Commonwealth Care).
• Commonwealth Choice: 39.382 (a slight decrease from April, largely attributable to payment activity).

In addition, the Connector is preparing for both Commonwealth Care and Commonwealth Choice open enrollment, which is June 1-22 and July 1-August 15 respectively.  On the Commonwealth Choice side, the Connector is working to make it easier for consumer to enroll in and switch plans through their website.  Letters will be mailed out in subscribers’ invoices beginning this week, and the Connector has staffed up their call center.

The Connector is also continuing their Affordable Care Act (ACA) implementation work.  This past week, staff from the Connector, EOHHS, and MassHealth met with representatives from CMS, CCIIO and the IRS to discuss Massachusetts’ progress in transitioning to the ACA.  The Connector also met with staff from Rhode Island and Vermont for a tri-state IT session.  Last but not least, on Wednesday the Massachusetts House of Representatives passed an FY12 supplemental budget that included language authorizing the Connector as the Commonwealth’s ACA-compliant exchange.  The Connector expects the Senate to take up this bill today.

Commonwealth Choice 2013 Seal of Approval

Roni Mansur (Chief Operating Officer) and Sarah Stephany (Program Coordinator) presented the Connector staff’s 2013 Seal of Approval recommendation.  The Connector puts their Seal of Approval on plans that meet their standards for quality and value.

The current Commonwealth Choice Seal of Approval contracts run from July 1, 2011 through December 31, 2012.  During this time, the Connector:

• Achieved full health insurance carrier participation in the Connector’s small business program through re-launch of Business Express;
• Added a new carrier, BMC HealthNet Plan;
• Implemented Wellness Track;
• Launched a provider search tool on their website;
• Implemented Chapter 288 provisions, including non-group open enrollment; and
• Removed the annual benefit maximum for all new sales of Young Adult Plans (per the ACA).

The Connector’s main goal in 2013 is to keep pace with health benefit design changes in the private health insurance market while continuing to offer small businesses and individuals plans that meet their needs and avoiding significant operational disruptions while the Connector plans for changes required by the ACA.

Therefore, the Connector recommends:

• Extending current carrier contracts for an additional 12 months beginning January 1, 2013 through December 31, 2013, and
• Issuing a Request for Responses (RFR) for new carriers for the term beginning January 1, 2013 through December 31, 2013.

Carriers must continue to meet current Seal of Approval requirements by participating in all product offerings (small and non-group) and providing products that meet the current standardized plan designs in all benefits tiers on the broadest commercial provider network offered.

In addition to offering standardized products, the Connector is inviting carriers to offer one or more of the following effective January 1, 2013:

• Narrower network products on all standardized plans designs for at least one benefit tier (Gold, Silver, or Bronze) and/or
• One or more other popular/innovative products (i.e. do not need to meet standardization) – this could include tiered networks.

According to Shor, the Connector is proposing this strategy in response to market changes, feedback from small businesses, with the overall goal of adding value to the Commonwealth Choice product “shelf.”

All proposed products will be subject to the Connector’s review and approval based on criteria including but not limited to:

• Meeting MCC standards;
• Including federal and state mandated benefits;
• Bringing value to consumers; and
• Achieving premiums cost savings for consumers.

Depending on what new products are proposed and subsequently approved, the Connector may need to introduce a new tier or benefit package.  According to Shor, the Connector will issue broad guidance to carriers on what criteria the Connector will use to evaluate new products and will work closely with the Board to assess proposals to promote clarity and comprehensiveness.

Jon Gruber commented that if the Connector moves away from standardization, they “need to provide more cutting edge decision support for consumers.”  Celia Wcislo commented that the Connector needs to not just look at premium costs but all costs consumers pay and ask “What are the costs being transferred to consumers?”

Lou Malzone remarked that the Connector should not make buying insurance more complicated than it already is.  He said, “[The Connector’s offerings] should not be equal to the entire insurance market that has thousands of products that no one understands.  If we don’t do something about this complexity soon, we will be on a path to unsustainable health care costs.”

The Connector will notify existing carriers of their intent to extent the contract within the next week.  Then, they will issue an RFR, hold a bidders conference, and review proposals, with the intent to present recommendations to the Board in August or September.

National Health Care Reform Transition Planning: Continuation of Project Management Assistance

Roni Mansur and Ed DeAngelo (General Counsel) presented the Board with the Connector’s recommendation to extend the Connector’s contract with Deloitte for project management support around ACA planning and transition.

In addition to day-to-day support, analysis, and strategy, Deloitte will help the Connector with a new focus of coordinate robust engagement of external stakeholders on major policy and operational decisions.  The Board voted to extend Deloitte’s contract through June 30, 2013.
-Suzanne Curry

Statement from Health Care For All’s Executive Director Amy Whitcomb Slemmer regarding the Senate bill S. 2260, an Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation:

“We are pleased that the Senate has proposed an approach to improving health care quality and patient care while reducing the cost of the care we receive. We appreciate the hard work of Senate President Therese Murray to ensure that these provisions are meaningful for consumers.

This legislation makes great strides towards improving the coordination of care and access to preventive and primary care services. We are particularly encouraged by the bill’s approach to incorporating behavioral health services with those that are traditionally provided for physical health. We know that the two are inextricably linked, and believe that this era of health reform provides the much needed opportunity to remove barriers to behavioral health treatment and care.

Health Care For All applauds the Senate’s commitment to increased transparency, as we believe this is an important building block for patient empowerment. We also are pleased by the description of enhanced consumer protections in the event of medical errors.

We are grateful that the Senate included the creation of and robust funding for the Prevention and Wellness Trust Fund. We know this investment in wellness and preventable chronic diseases such as obesity, diabetes and asthma, when done from the community level, can simultaneously keep patients healthy while lowering overall health care costs.

We support the integration of behavioral health into the overall health system through the establishment of behavioral health medical homes and the vigorous implementation of the federal Mental Health Parity and Addiction Equity Act. Together these laws will make a significant difference to people who need these services.

HCFA will look closely at the details of this comprehensive bill and looks forward to working with the Senate to make sure that the needs of consumers are represented in both the spirit of the legislation and the implementation of the resulting law.”

Senate Bill Promotes Patient Safety and Quality

The Senate’s payment reform bill released yesterday has some important provisions that seek to improve health care quality and patient safety. The bill requires the Department of Public Health to develop model checklists of care that may be used by hospitals to prevent medical errors and infections. Hospitals are required to report to DPH and the Betsy Lehman Center on their use or non-use of checklists. The one thing we would like to see changed is the section requiring that individual hospital reports be kept confidential and that DPH issue a public report on aggregate rates of checklist use. Publicly reporting aggregate rates, while giving us a sense of the direction the state is moving in as a whole, is pretty meaningless to consumers who want to find out if a particular hospital is focused on patient safety. Checklists are proven tools and should be used by every hospital. We would like to see the public report look at each individual hospital.

The bill also requires Beacon ACO’s to promote patient-centered care by, among other things, demonstrating that they engage patients in shared decision making, they effectively involve patients in care transitions across settings of care, and they activate patients at home to improve care self-management, and by establishing ways to evaluate patient satisfaction with access and quality of care. Beacon ACO’s are also required to show excellence in the area of care coordination and show a commitment to reducing avoidable hospitalizations and adverse events. These are all HCFA priorities and we are pleased to see them addressed in the bill.

The Senate bill also creates a task force to look at the practice of defensive medicine and overuse of medical care, including the overuse of imaging and screening technologies. At least one member of the task force must be a health care consumer representative. Along with checklists, HCFA and the Consumer Council have been advocating for legislation to look at overuse of technologies and we appreciate its inclusion in the bill.

Finally, the bill also creates a Massachusetts Diagnostic Accuracy Task Force, which will include consumer representatives, to make recommendations on how to reduce or eliminate the impact, both financially and in terms of patients’ health and well-being, of inaccurate diagnoses.

This afternoon the House unveiled their cost control bill, the Health Care Quality Improvement and Cost Reduction Act of 2012 (read the full bill text; and the Committee summary (pdf)). Weighing in at 178 pages (3758 lines!), the bill takes a comprehensive approach to improving health care quality and lowering costs.

The bill was endorsed by 11 health economists, represented by Harvard economist David Cutler. Cutler praised the bill as bold and thoughtful, saying that it rightly “put patients in the driver’s seat.”

There’s a good brief summary of highlights on WBUR’s CommonHealth blog, and we’ll try to post the more detailed Committee summary later (UPDATE: Here’s their summary). Posters from the press conference are above and below.

Slides courtesy of Committee on Health Care Financing

“We applaud House Speaker Robert DeLeo (D-Winthrop) and House Chair of the Joint Committee on Health Care Financing Steven Walsh (D- Lynn) for advancing legislation to tackle comprehensive health care payment and delivery system reform.

We are excited about the proposed changes to the current way doctors, hospitals, and other providers are paid so that incentives can be aligned to promote patient-centered care that focuses on health and disease prevention, lowering health care costs.

Addressing the cost and quality of the care will allow us to transform the Massachusetts system from a sick care system to a true health care system.

Health Care For All celebrates progress toward creating an integrated health care system that includes medical and behavioral health. We also share the commitment to promote transparency, cultural competence, patient empowerment, and affordability.

We are pleased that incentives were included to promote the creation of new primary care positions in the state and the opportunity for patients to develop a new relationship with their primary care providers.

We are glad that the legislation focuses on improving the quality of care by encouraging the active participation of patients and their families in making health care decisions. HCFA also applauds the decision to strengthen the tools to protect consumers, as well as the opportunity for providers to offer an apology to a patient in case of a medical error.

The implementation of this second wave of health care reform will not only make a significant difference for consumers but also maintain Massachusetts’ national leadership in health care.

This proposal will open a new chapter for health care in Massachusetts, and follows on our historic progress made in Chapter 58. HCFA will be looking closely at the details of the bill and looks forward to working with the legislature to ensure that the consumer voice is central.

There’s lots to digest, and we will be doing a full analysis later next week. From a quick look-through, we saw strong provisions on many of our priorities, including mental health parity, shared decision making, consumer representation in decision-making, free second opinions, risk adjustment and many more. We were pleased that the bill includes a The Wellness and Prevention Trust Fund, though we joined with Mass Public Health Association and other groups (statement, pdf) to call for sufficient dedicated funding for the trust – something lacking in the bill.

The Senate expects to release their version next Wednesday, May 9, with Senate floor debate early the following week. The House debate will follow, perhaps the last week of May. We will continue to press for our Principles for Better Care -see the last 9 blogs – and look forward to real progress.
-Brian Rosman

As the House and Senate get close [Note: the House is releasing their bill at 2:30 pm this afternoon, in Nurses Hall in the State House] to releasing their versions of comprehensive payment and delivery reform legislation, the Campaign For Better Care, with the help of students from the Harvard School of Public Health, will be doing a series of blog posts this week highlighting our 10 Principles for Better Care.

9.  Transparency: Measures of care and incentives built into the payment system must be transparent, accessible, and understandable by patients. All legislation should provide for an open process that provides full disclosure and explanation of all payment methods.

Key policies:

• The public must have access to comparable, timely, meaningful and accessible information about their care, utilizing multiple forms of technology. Patients must fully understand their care plans, and how their care is being paid for. New technologies can facilitate communication among patients, families, and providers.
• The oversight board should be subject to the open meeting law. The open meeting law would allow the public to participate in the public discussions that impact their health care. The Connector’s open and transparent process has greatly increased public confidence in the policy process. This model should be followed for the oversight entity that will make payment reform policy.
• All consumer materials should be understandable to the average person and provided in languages used by a significant number of consumers. Health literacy requires communications that people can understand. Dense medicalese or insurer obfuscation needs to be rooted out and replaced with clear language that all patients can understand.

The world we live in is changing. In most industries, information is available at our fingertips and at the press of a button. It is time to make these changes in health care. Patients deserve all the information they need to make educated decisions in their care.

Better care means transparency in measures of care, incentives, and payment.
-Martyna Skowron

As the House and Senate get close to releasing their versions of comprehensive payment and delivery reform legislation, the Campaign For Better Care, with the help of students from the Harvard School of Public Health, will be doing a series of blog posts this week highlighting our 10 Principles for Better Care.

8. Consumer Protections: Current protections provided by the Office of Patient Protection and other managed care regulations must be maintained and extended to encompass ACOs, patient-centered primary care homes, and other payment reform entities.

Over a decade ago, abuses in the managed care industry led to the enactment of a strong managed care patient bill of rights in Massachusetts. Under the law, individuals who receive health coverage from a Massachusetts insurer are entitled to new protections covering internal grievances, medical necessity guidelines, continuity of care and external appeals. The law established the Office of Patient Protection (OPP) within the Department of Public Health. They have successfully helped hundreds of patients get benefits they were entitled to, and made sure our insurers were acting in accordance with the rules. As payment systems evolve and shifting incentives apply to providers, and not just insurers, our consumer protection laws must be updated. Massachusetts must ensure that consumer protections are maintained as we enter this new era of payment reform.

Key Policy:

• Patient rights to independent external review, similar to rights now provided to members of HMOs, should extend to members of ACOs and other provider risk arrangements. The OPP process, administered by the Department of Public Health, has been an important check on Massachusetts HMOs. Currently, OPP is suffering from drastic funding cuts, which have strained its ability to oversee independent reviews of denials of care. This is a very serious concern as ACOs are entering onto the health care scene and more resources will be needed for oversight. More funds must be provided to OPP in connection with their expanded duties under payment reform.

Although cost savings will be a major goal of payment reform in Massachusetts, cost reductions must come through better care, not by stinting on quality care to patients. If patients are denied access to care as a result of payment reform, we fail to keep the most basic promise of health care.

Better health care means protecting patients’ rights.
-Akash A. Desai

7. Patient Choice and Accessibility: The payment system should preserve patients’ provider choice. Patients must have access to caregivers with linguistic and cultural capacity to provide effective care within geographic area. Payment systems should promote patients’ continuity of care with their providers. Patients should have access to clinical trials and medically necessary out-or network care, including out-of-state providers.

Key policies:

• Patients must have the ability to get care from any provider covered under their insurer’s plan. The Massachusetts market already has limited and tiered insurance plans, where insurers limit choices of providers. Moving to ACOs should not bring yet another layer of restrictions on patients. A good ACO should demonstrate the value to patients of staying in the family, though the benefits of care coordination, shared communications and practice styles. As the saying goes, the best fence is a good pasture. No patient should be limited in their choice of providers by their providers.
• Patients must be allowed to seek specialized care services that may not exist within an ACO. Specialty care in particular must not be limited by ACOs and global payments. Highly specialized services might be available from only one provider, and patients who need those services must not be shut out of those providers.
• Patients should actively be able to choose to participate in an ACO and be given full information about their care plan, and how their care is being paid for. Despite the proliferation of global payment systems in Massachusetts, many patients are not informed about how their care is paid for. Providers and insurers must provide full transparency to patients on all the details of the reimbursement system that affects their care. Patients should ultimately be the decision-makers about the care model they want to participate in.

Transparency and choice are the linchpins of patient-centered care. Our health care system must be structured to put us in the driver’s seat.

Better care means the promotion of patient choice and accessibility.
-Martyna Skowron

As the House and Senate get close to releasing their versions of comprehensive payment and delivery reform legislation, the Campaign For Better Care, with the help of students from the Harvard School of Public Health, will be doing a series of blog posts this week highlighting our 10 Principles for Better Care.

6. Shared Savings: As cost growth is contained, premium payers must share in the savings. The legislation should provide explicit methods to assure that savings created by payment reform get passed on to consumers and other payers.

Providers and insurers are preparing for, and in some cases have implemented global payment systems and ACOs designed to increase efficiency and improve quality. We are optimistic that shifts of incentives for providers will result in real health care savings, but it is unclear if consumers will share in them. If the savings that are achieved accrue only to insurers and providers, than the payment reform law will not have met its goals, and will not have broad support.

Key Policy:

• Payment reform must include a mechanism to share savings from reduced medical costs with premium payers, including consumers. Strong public oversight of insurer and provider rates and charges can ensure that costs are reasonable and that savings get passed on to payers. This can include extending the state’s tough Minimum Loss Ratio standards, which are expiring this year. These standards require insurers to spend at least 89% of their premium revenue for medical benefits, and limit what the insurers can retain for administrative costs, profit, and surplus. 

Consumers lose big when premiums and deductibles spiral out of control. Not only does it hurt our wallets, but it also becomes more difficult to access quality care. Strong public oversight of insurer and provider rates may be necessary to protect consumers in a health care market with such little transparency.

Better care means lowering the cost of health care for everyone.
-Akash A. Desai

5. Promotion of Public and Community Health: Payment reform must be accompanied by a renewed commitment to funding public and community health. DPH, local health boards, community groups, and community health workers play an integral role in supporting a global payment system oriented toward wellness and prevention.

Out current system is focused around the treatment of disease rather than the promotion of health and wellness. As costs continue to sky to rise, we must begin to think about health care differently and focus on keeping our population healthy by creating a payment system that rewards providers for promoting health rather than the utilization of health services.

Key policies:

• We strongly support dedicated public health, community prevention funding such as Prevention and Cost Control Trust Legislation: The ACA has created a National Prevention Fund and National Prevention Strategy, it is time for Massachusetts to develop similar efforts and lead prevention efforts and wellness on a state level.
• Payment systems must strengthen community health resources, such as Community Health Workers and peer and professional community supports: Research has proven that prevention efforts are most successful when they are created for and by the community and providers that are most engaged with the community; however, our current payment system does not promote comprehensive interventions at a community level.  

Community prevention and public health would allow us to better control costs and promote a healthier population for the Commonwealth. We have seen key individuals including Mayor Menino, Boston Public Health Commission board chair Dr. Paula Johnson, Governor Deval Patrick, as well as key legislators in the Massachusetts State House champion the necessity and urgency of incorporating prevention into payment reform.  The federal government has already taken a leading role through the creation of a National Prevention Strategy and the inclusion of a Prevention Fund through the Affordable Care Act, it is now time for Massachusetts to be a leader yet again and pursue a state prevention strategy through payment reform.

Better care means the inclusion of public and community health prevention.

- Martyna Skowron