But for now we want to focus on the most glaring problem with the budget – no funds for dental fillings for some 800,00 low-income adults on MassHealth, including 120,000 seniors and 180,000 people with disabilities.

Now, dentists can identify cavities during an examination, but with the exception of a small number of billing codes, fillings are not covered.  Left untreated, a simple cavity can lead to serious medical problems.

The House budget included funds to cover fillings, starting on January 1, 2014. But the Senate did not follow their lead.

Senator Harriette Chandler is filing an amendment to add funds to cover the $18 million cost of adding fillings to the MassHealth dental benefit. The deadline for other Senators to cosponsor her amendment is tomorrow (Friday) at noon.

That’s where you come in.  We need as many Senators as possible to co-sponsor her amendment. Here’s an action alert from our Oral Health Advocacy Task Force:

Materials from the meeting are here and our full report is a click away:

Jean Yang started the meeting with her Executive Director’s report:

• Program Enrollment: As of May 1^st, Commonwealth Care enrollment is 206, 911, the program’s highest enrollment to date.  Commonwealth Choice enrollment remains relatively steady at 41,234.
• ACA Legislation: Governor Patrick filed a bill to reconcile state law with the ACA, another step forward in national health reform implementation.  The legislation is a result of active collaboration between several state agencies.
• Seal of Approval: The deadline for insurance carriers to submit Seal of Approval (SoA) responses was May 1^st.  Health Connector staff are actively reviewing the responses and will recommend plans to be granted conditional SoA in June.
• Navigators: The Health Connector is also reviewing applications for the Navigator grant program, which were due April 30^th.
• HIX-IES: Earlier this week, the state completed its federal design review of its new eligibility and enrollment IT system (HIX-IES) and received favorable feedback.  The Health Connector’s focus is shifting from policy development to operational readiness.

National Health Care Reform Implementation Update

Implementing the ACA has been a major focus of the Commonwealth for the past two and a half years.  As Health Connector staff put it, the remainder of 2013 is the “home stretch” before the October 1^st “Connector 2.0” go-live date.

Major Policy Milestones

In collaboration with other state agencies, the Health connector has made a series of important decisions to move ACA implementation forward:

• Subsidized coverage: Expanding Medicaid and offering premium tax credits and cost-sharing reductions, with a wrap for enrollees below 300% FPL.
• Exchange: Authorizing the Health Connector as the state’s ACA-compliant Exchange.
• Technology: Building a new integrated eligibility and enrollment system, to serve both the Health Connector and MassHealth.
• Market Reform: Maintaining the merged individual and small group market.
• MCC & Individual Mandate: Maintaining the state individual mandate and many of the state’s minimum creditable coverage (MCC) standards.
• Risk Adjustment: Administering a state-based risk adjustment program to help stabilize premiums.

Operational Readiness

The Health Connector is shifting much of its focus to operationalizing their policy and programmatic decisions.

• HIX-IES: Developing a new eligibility and enrollment system, referred to as “HIX-IES,” is a custom-built IT system that allows the Commonwealth itself to own the system.  It will be implemented in two phases, with the hardware, connectivity and infrastructure setup substantially complete.  Coding requirements, design and testing is pending until program requirements are finalized.
• Customer Service: Working with vendor Dell to provide customer service and business operations functions; the company has begun building its call center and designing key systems (e.g. premium billing).
• Plan Management: Administering the SoA process and developing a web interface to transition insurance carrier information from the federal rate filing data system (SERFF) to the Health Connector.
• Marketing, Communications & Outreach: Developing a multi-faceted and coordinated outreach, education and marketing strategy, of which the Navigator program is a part.
• Member Transition: Developing an integrated member transition strategy for subsidized and unsubsidized Health Connector enrollees and coordinating outreach and communication activities with vendors.
• Appeals & Risk Adjustment: Coordinating with MassHealth to develop an eligibility appeals system; obtained federal approval for Massachusetts-specific approach to risk adjustment.

Several Connector Board members commented on the need for the Health Connector to develop understandable information to share with stakeholders and consumers alike to make it clear who will be eligible for what program in 2014, and who specifically will not be eligible.  Jean Yang responded that development of these types of materials will be part of the Health Connector’s outreach, education and marketing work, which Kaitlyn Kenney is overseeing and will talk about at next month’s Board meeting.

Exchange Project Management Contract Extension

The Connector Board unanimously voted to extend the Health Connector’s contract with Deloitte through June 30, 2014 to provide ACA-related project management services.  In addition to project management, Deloitte provides support on customer service and business operations, Qualified Health Plan (QHP) and Qualified Dental Plan (QDP) certification, carrier integration, member transition, and product implementation. This contract has been funded through federal Exchange planning and establishment grants.

Final Chapter 224 Omnibus Regulations Transfer

Chapter 224 transferred responsibility from the Division of Health Care Finance and Policy (now CHIA) to the Health Connector.  The Connector Board voted to approve the transfer of these regulations to the Health Connector section of Massachusetts regulations:

Student Health Insurance Program: 956 CMR 8.00
Employer Free Rider Surcharge: 956 CMR 9.00
Health Insurance Responsibility Disclosure (HIRD): 956 CMR 10.00
Employer Fair Share Contribution: 956 CMR 16.00

The Health Connector had released these changes for comment on February 28^th, and only received one comment.  The Alliance for Health Care Sharing Ministries requested adding language to the student health insurance regulations (SHP) to allow students to waive SHP if they are part of a health care sharing ministry.  Nancy Turnbull recommended that health care ministries are growing rapidly and the Health Connector should do due diligence to understand these arrangements and their broader implications before making any changes to regulations in the future.

The next Connector Board meeting is scheduled for Thursday, June 13^th at 9:00am at 1 Ashburton Place, 21^st floor.

Help influence health care in Massachusetts.

The Health and Disability Program, part of Office of Health Equity at the MA Department of Public Health (DPH) is conducting a health needs survey for people with disabilities in Massachusetts. The Office of Health Equity promotes the health and well being of minority populations, including people with disabilities throughout the Commonwealth. Results from the survey will be used to determine how best to address the current public health needs of the disability community.

To that end, first, please take a few moments to complete the health needs survey at http://www.surveygizmo.com/s3/1219419/Health-Needs-Assessment-2013B.  Then, as we would like to get a broad range of respondents representing all the facets of the disability community, please forward the link to your friends and colleagues in the disability community and ask them to complete it.

Who should complete this survey?

• Residents of Massachusetts, over the age of 18 who have disabilities
• Caregivers or guardians of adults or children with disabilities
• Disability advocates
• Staff at community based organizations or state or local government offices that serve people with disabilities
• Academic researchers
• Healthcare providers
• Public health officials or professionals
• Health and wellness promotion specialists
• Health administrators
• Health policy experts

This is a voluntary and anonymous survey. The responses are compiled and we do not have knowledge of individual respondents.

The meeting began with reports from the subcommittees of the commission. First, David Cutler spoke on the progress of the Cost Trends and Market Performance Committee (p. 11 of this presentation), primarily addressing preliminary drafts of two later agenda items: research topics for the cost trends report and a process for review of notices of material change. Marylou Sudders then gave a brief report on the activities of the Quality Improvement and Patient Protection Committee (p. 12), providing a brief summary of discussions about new regulations released by DOI and DMA, as well as mentioning a later agenda item discussing draft guidelines on mandatory nurse overtime.

Carole Allen from the Care Delivery and Payment System Reform Committee (p. 6) then spoke, detailing their work to register provider organizations. The committee has also been at work at listening sessions with the DOI, regarding risk-bearing and delivery systems. The committee also has worked to establish principles regulating Patient Center Medical Homes. Finally, staffer Nikhil Sahni provided an update on the recently released Report on Consumer-Driven Health Plans, (p. 7 – 10) summarizing the report’s findings for the commission. He also spoke on the committee’s work on establishing a one-time assessment of surcharge payors and acute hospitals, as well as the distressed hospital trust fund.

Next, representatives from the Attorney General’s office reported on the recently released Health Care Cost Trends and Cost Drivers report. This annual report, now in its third year, examines ways in which purchasers, health plans, and providers influence costs of health care. As CHIA and other agencies now report some of the routine quantitative data, the report now shifts its focus onto the shape of the health care market as a whole, as well as cost containment efforts put in place by each of these groups.

The commission then moved to the Cost Trends and Market Performance Committee’s proposed research topics for their upcoming research report on cost trends. (p. 16 – 19) This report, mandated by Chapter 224, requires that HPC consider data from hearings, registration data, and CHIA to compile information on important spending trends and underlying factors, recommendations for strategies to increase efficiency, and legislative language required to implement these recommendations. The ambitious research outline includes a model for setting a growth baseline, using descriptive statistics, analysis of total health expenditures, access and quality data, and market evolution, as well as a model for discovering the driving mechanisms of the cost growth. Reports will be released in December 2013, early Summer 2014, and December 2014. The commission voted to accept these guidelines for the report.

Mandatory nurse overtime guidelines (p. 29 – 35) came up next, as the commission commented on draft language regarding crisis-based exceptions to the prohibition on nurse overtime. Although there was some concern regarding the draft language, the approval of the actual regulations must wait until a hearing is held on the language – after which the HPC will take the issue up again. The commission voted to approve the draft language.

Representatives from CHIA then spoke about their work and its relation to the HPC (CHIA presentation). CHIA is in charge of releasing its own report on cost trends – this year marks the first time CHIA is conducting their survey on health care expenditures. CHIA’s first report is scheduled for release in August 2013, with a report encompassing data from 2012-2013 schedules to appear in August 2014.

The last item of business addressed the process for review of notices for material change. (p. 22 – 26, and see the adopted policy, here) Karen Tseng, the newly appointed HPC Policy Director for Market Performance, gave an overview of the proposed model for this process, which occurs when a material change is likely to affect the commonwealth’s ability to meet the health cost benchmark, or when the change will substantially affect the competitive market. Starting in 2016, these reviews may also be initiated when CHIA identifies a provider as having excessive growth. The commission expressed significant concern on the proposed model’s ability to work with the commission’s schedule, as well as concern that the commission would not be able to devote the time to given all concerning issues proper consideration.
-Devon Branin

While ACA implementation remains contentious in many states, in Massachusetts the building blocks are being set in place in a routine and orderly way.

On Wednesday, MassHealth released its revised ACA implementation plan, called the “Roadmap to 2014.” Also released was the state’s proposal to the federal CMS for an extension of our Medicaid waiver, along with supporting documents (the materials can be found on the MassHealth waiver documents webpage).

And this afternoon, Governor Patrick filed legislation needed to implement the ACA in Massachusetts (here’s the bill, H. 3452, the state’s section by section summary; and here’s their summary by topic).

The Governor’s cover letter sets out why he is looking for passage of the law:

The legislation will allow Massachusetts to realize the full benefits of the Affordable Care Act, including expanded federal funding to support coverage for low and middle-income families and federal insurance reforms that will secure additional protections for Massachusetts residents.

The bill proposes a number of technical changes to state insurance laws to conform with the ACA. Many of these changes will improve access to coverage. For example, current law prohibits individuals from buying individual coverage if they have access to employer-based insurance. The ACA does not allow these restrictions, so the bill eliminates the provision. Another section of the bill extends the ability of adult children up to age 26 to remain on their parent’s coverage, because the federal law is more expansive than our provision, enacted as part of Chapter 58. The bill also eliminates obsolete references in current law to pre-existing conditions and waiting periods, and permits the phase-out of rating factors not allowed by the ACA (explanation).

Other sections of the bill revamp the MassHealth and Connector statues to reflect the new subsidized insurance program starting in 2014. Statutory provisions for Commonwealth Care, Masshealth Essential, the Insurance Partnership program, and other programs are eliminated, replaced by expanded MassHealth eligibility.

The legislation will need to be enacted within the next few months in order to get state laws in place for implementation by insurers and others. The legislature should move quickly on the bill, which will be tough given the difficult budget and revenue issues still to be resolved.

At the same time, the state is asking the federal government to renew the “1115 Waiver” agreement with the federal government (background, and more, from BCBS Foundation). The waiver would permit Massachusetts to receive federal Medicaid funds for some of the cost of health reform programs, including funding for the “QHP Wrap” which is the state’s supplement to federal premium and cost sharing subsidies. The goal of the wrap would be to prevent increases in costs for low-income people in the Commonwealth Care program.

These and other changes are all explained in detail in the “Roadmap” transition plan. The state will be accepting comments on all the proposals, and will be holding an open meeting on Friday, May 17, at 3 pm at the DPH Public Health Council room (250 Washington St, 2d floor) to discuss ACA implementation.

In our quick preliminary read, we don’t see anything particularly new or controversial in these plans. State officials have been very open with advocates and other stakeholders about the plans for ACA implementation. For the public however, the drumbeat of national opposition cannot but raise anxiety. Even though we’ve gone through this before, a targeted public education campaign will be required. For example, the 200,000 some people transferring from Commonwealth Care will need to be guided through the steps required to switch their coverage. All together, around 560,000 people will see some change in their coverage. The reassurances necessary require the availability of one-on-one assistance to affected people.
-Brian Rosman

Oral health is a crucial part of overall health. Left untreated, dental decay can spread throughout the body, causing serious and permanent health issues. Over 800,000 Massachusetts residents are impacted by the 2010 cuts to the MassHealth adult dental program. Some of the most vulnerable residents of our Commonwealth have faced daunting challenges in attempting to access oral health care in the wake of the cuts to MassHealth adult dental benefits.

The current program provides very limited services such as cleanings, screenings, extractions, and very limited fillings, for front teeth only. Access to complete fillings means that infections can be stopped before they become a systemic health issue, before teeth have to be pulled, and before individuals are forced to show up in the emergency room because of significant mouth pain.

The full restoration of MassHealth adult dental benefits is among HCFA’s top priorities. We applaud House Ways & Means Chairman Brian Dempsey and House Legislative Oral Health Caucus Chair Representative John Scibak for their leadership.

The House did not include additional funds requested for administrative support for the MassHealth program. Without these funds, delays in MassHealth enrollment and member processing will continue to worsen.

Our friends at Mass Budget and Policy Center have a full report on the House final budget. For MassHealth, there are still major cuts coming if the House version prevails:

… [F]unding for MassHealth in the final House budget remains about $208.0 million below the amount proposed by the Governor. A portion of that overall gap can be explained by the following differences between the two budgets:

• The House does not fully restore dental coverage ….
• The House eliminates $11.7 million in funding, proposed in the Governor’s H1 budget, that would allow MassHealth to maintain coverage for about 3,400 legal immigrants who will not be eligible for coverage under the ACA, and to extend MassHealth coverage to about 900 disabled adults by extending new ACA rules for calculating income eligibility to cover people with disabilities.
• It appears that the House does not follow the Governor in allocating $10.0 million for primary care provider rate increases.
• The House budget proposes to tap an off-budget trust fund (the Healthcare Payment Reform Trust Fund) to pay for some costs that were included in H1 line items. …

After taking these differences into account, there is still a sizable gap—more than $100 million— between the funding levels proposed by the Governor and the House. While some of this difference may result from different assumptions about enrollment growth, the state’s ability to control health cost growth, and the state’s ability to employ cash management strategies that shift costs into subsequent years, administration budget writers indicate that it will be difficult — if not impossible — for MassHealth to implement this lower level of spending without affecting either rates for providers or services for low-income patients.

We have already begun working with the Senate to restore the full range of MassHealth adult dental benefits, along with other priorities, when they take up their budget proposal in May.
-Cortney Chelo and Brian Rosman

Yet the measure may not have been as effective as predicted. A New York Times article surveys emerging literature relating to these changes, and the results may cast doubt on the ultimate effects of hour restrictions. Since the changes, interns have not been getting more sleep, nor are they happier. Evidence suggests the regulations may even be stunting the educational progress of these doctors: interns have actually been spending less time in educational activities, as the time needed for these conferences and lectures contributes to the 16 hour limit on their time.

Patients haven’t been receiving better care, either – no significant improvements in patient care have been reported since the hour limits. One study reveals an increased concern among interns about making medical errors after the change.

The problem with the regulations? Demand for care stays steady, no matter how many hours doctors work, and hospitals haven’t matched this demand by hiring more interns. This means that interns find themselves spread thinner and thinner, as they struggle to complete all their responsibilities with less time to do them. “It’s as if you told airline pilots that they could only work a certain number of hours, but they had to fly 50 percent more flights,” said Dr. Lara Goitein, lead author of a recently published editorial in JAMA Internal Medicine.

Physician fatigue is a very real problem, but efforts to address it should not stop at blanket-level restrictions. Instead, hospitals need to devote money to hiring more doctors in order to ensure that each patient can receive quality care from an engaged and focused professional. There’s no denying that such an effort would result in short-term losses, but the payoffs in better patient care – and, perhaps, outcomes – would likely be well worth it.
-Devon Branin

These findings highlight warnings issued by those in agricultural public health for years, who have long suggested that the overuse of antibiotics on livestock could pose huge risks for humans. Managers of factory farms have been known to use antibiotics on all animals to encourage growth, a practice which may encourage the development of drug-resistant pathogens. This study demonstrates that these new hard-to-treat germs could easily make people very sick.

The FDA has moved for voluntary action from farms to curb the spread of drug-resistant pathogens, asking those in the food industry to phase out blanket application of antibiotics. Previously, the FDA has pushed for stronger restrictions on antibiotics, partnering with the CDC in a statement condemning the current state of their use in agriculture. However, in 2011, the FDA veered away from efforts to regulate antibiotics, choosing the voluntary path instead.

HCFA has worked extensively with MRSA prevention in hospitals, and this new research poses an additional challenge to those efforts. Farm workers, for instance, who are unaware that they have been infected, may be hospitalized and introduce MRSA to the hospital, risking the health of other patients, especially those with weakened immune systems. With so much at stake, responsible use of antibiotics in animals is essential.
-Devon Branin

Health Care For All is getting the word out that our free HelpLine is available to assist Massachusetts residents with insurance issues following the Marathon attacks. The HelpLine counselors are unparalleled in their understanding of our health care system and the programs available and stand ready to answer questions in English, Spanish, Portuguese and Italian.

Yesterday morning HCFA Executive Director Amy Whitcomb Slemmer appeared on NECN (click to watch) to talk about these important issues.

People are encouraged to contact the HelpLine and Health Law Advocates through our toll free number 1-800-272-4232 if they need assistance.

Health Care For All wants Boston Marathon runners, spectators, family members or anyone affected by last week’s violence to know they have a partner and free resource available if they are struggling with health care coverage issues. We want people to be able to concentrate on healing rather than worrying about their health care coverage, and we stand ready to help anyone who needs assistance to navigate the complexities of any insurance issues.

In addition, if patients or consumers find that they need legal assistance, our partners at Health Law Advocates provides free assistance with payment plans, coverage denial appeals or respite from crushing medical debt.

Coverage following the attacks raises a number of important policy issues. The Georgetown Center on Health Insurance Reforms posted a comprehensive post looking at these concerns (thanks to Community Catalyst’s Health Policy Hub for cross-posting). The discussion looks closely at issues like coverage limits, benefit exclusions, and cost-sharing challenges. Already we are hearing about variations in coverage of prosthetics by different insurers.

This work is at the core of our mission, and it is our privilege to assist people affected by last week’s events to alleviate concerns that might distract them from healing and reclaiming the health they enjoyed before the Marathon.

We at HCFA are excited that this will be a focus of the group and we look forward to continuing to actively participate in conversations about quality measures and quality improvement activities.
-Deb Wachenheim