Posts filed under 'Healthcare'
Today marks the 6th extension granted to the Commonwealth for the Medicaid waiver that serves as the foundation for our 2006 reform. I have written about this before here and here.
As a review, the Massachusetts MassHealth 1115 waiver from the federal government allowed the 2006 health reform to become a reality financially. The waiver was last negotiated by the Patrick Administration in 2008, and was extended until June 30, 2011.
From SHNS this morning ($):
HIGH-STAKES MEDICAID TALKS DRAG ON: Secretive negotiations between the Patrick administration and the Obama administration over the distribution of billions of dollars in Medicaid funding have failed to produce an agreement and will continue into December. The outcome of the talks, which are occurring as Washington looks to ratchet back spending and address bulging deficits, will have major ramifications for the state’s health care reform efforts….The Patrick administration is believed to be seeking a three-year agreement with the federal Centers for Medicare and Medicaid Services that includes billions of dollars in funding for hospitals that care for low-income and uninsured residents. U.S. Sens. John Kerry and Scott Brown, along with the entire Massachusetts Congressional delegation, pleaded with CMS chief Donald Berwick last month to preserve $4.6 billion to care for those uninsured or underinsured residents, as well as special payments to the hospitals that care for them….
Three layers to add to the discussion this month:
1. How will the resignation of Don Berwick impact this discussion?
From my understanding, he was very interested in this waiver issue. Which leads me to Q2…
2. When does this become a political issue in the Presidential race?
CMS sees this as an opportunity to save some money, and knows that the Federal law is funded, in part, by similar cuts in Medicare Disproportionate Share Hospital (DSH) payments in the future. The National Association of Urban Hospitals estimates that private, non-profit urban safety-net hospitals will bear 45% of the cuts in 2014, but only account for 7.5% of the hospitals in the country. (Paging all urban members of Congress.)
If the Federal government can’t figure it out with one state run by a personal friend of the President who is ideologically similar, how will they conduct the process with hundreds of billions on the line?
Governor Patrick is slated to campaign for President Obama’s reelection and the ACA health care plan, but if the waiver is still unresolved, will reporters start to ask about it?
3. When will local political leaders on Beacon Hill start to engage on this issue?
One of the most confusing aspects about this process has been how few people know about or are asking about the waiver renewal. This is the foundation of the Massachusetts reform, and all Beacon Hill can talk about is layering price controls and regulations on top of our health care system without even checking the health of what is underneath. Perhaps a step back is needed.
Follow on twitter: @josharchambault
December 1st, 2011
My now monthly blog post wondering if there will be agreement soon between the Obama Administration and the Patrick Administration on a multi-year extension of the Massachusetts health care waiver.
As a review, the Massachusetts MassHealth 1115 waiver from the federal government allowed the 2006 health reform to become a reality. The waiver was last negotiated by the Patrick Administration in 2008, and was extended until June 30, 2011 at that tome. Quietly this summer, the new deadline was pushed back three times, and is set to expire again tomorrow.
The Boston Globe’s Liz Kowalczyk and Chelsea Conaboy were kind enough to ask CMS Administrator Dr. Don Berwick about it in a recent interview:
Berwick would not comment on negotiations with Massachusetts over renewal of its federal health care financing package, known as the Medicaid waiver, which is crucial to the state’s mandatory health insurance law.
“We’re working through it as fast as we can,’’ he said. Part of what he’s looking for from Massachusetts and other states is a plan to improve care and cut costs for patients who have both Medicare and Medicaid coverage. They are a relatively small but very sick population that eats up 40 percent of state Medicaid budgets.
Dr. Berwick added another layer of complexity to the discussion, as state officials plan to file a waiver for so-called “duals” (those on both Medicare and Medicaid) in October. So, the question this month– are the two waivers connected, or separate?
Follow Josh on twitter: @josharchambault
September 30th, 2011
This post was co-written by Michael Morisy.
During this year’s budget debate, Pioneer asked many questions about the reality behind optimistic health care cost predictions which, if flawed, could leave the state facing a $900 million budget hole next year alone. The passage of the Patient Protection and Affordable Care Act (PPACA) could make things even worse down the line – if it survives judicial challenges. But as much as we’d like to share the state’s optimism, we have had an incredibly hard time getting answers to some basic questions about the underlying assumptions that the state may have about future health care costs.
Back on April 9, we requested documents from the Massachusetts Health Connector that discuss the financial implications of the Affordable Care Act on Massachusetts, including estimates of the impact on those currently enrolled in an insurance plan offered through the Connector. Early Pioneer research on the impact of PPACA on Massachusetts, estimates that 95,000 individuals will be moved out of the Connector and into the Medicaid program. The Connector will lose almost 60% of its current operating revenue under this scenario, which will have a direct impact on the state budget. Under PPACA, the state can transfer many of these people onto Medicaid any time before 2014, so it should impact state budget estimates and discussions.
We received an e-mail on March 18 stating that all responsive materials were posted on the Connector’s website. While there is certainly some useful information there, nowhere to be found are the critical, underlying calculations and estimates we requested.
We re-sent the request to the MassHealth (Medicaid) Privacy Office on June 7, hoping for a more useful response, and while the request was confirmed the same day, to date we have received none of the requested materials.
We’ve found this sort of bureaucratic opacity nearly every direction we’ve turned when requesting materials related to Massachusetts’s health care planning. In late April, we filed a request for a list of participants in meetings analyzing the impact of federal health reform on Massachusetts, as well as the names of any committees or sub-committees they sit on. The latter part of the request was particularly important: Agency after agency passed the buck when we asked for materials, so by naming the members and sub-committees involved in the analysis, we could more specifically ask for materials.
A single hand-written attendance sheet was produced, as well as an explicit confirmation that this document was the only response material that the Executive Office of Health and Human Services of Massachusetts possessed. The agency later provided the agenda for the April 13, 2010 “Federal Health Reform Implementation Working Group Kick-Off Meeting.”
By that point, we were frustrated and confused as the exchange planning grant quarterly progress reports listed on the Connector website outlined a number of efforts that had been ongoing for months, and some of which were supposed to be complete at the time of our requests.
After being given very little information from the FOIA process, you can imagine our grievance when, in multiple public forums this summer Connector, Medicaid and HHS staff talked about the work of numerous committees that had been meeting roughly twice monthly for a year or longer.
The groups had: identified outstanding policy questions, identified potential options/approaches, solicited feedback on the policy options and evaluation components from leadership and Health Connector Board, and established an advisory council.
A recent Blue Cross Blue Shield Foundation report documented the five interagency committees: Insurance Reform, Long Term Care/Behavioral Health, Employer, Health Care Workforce, and Subsidized Insurance/Medicaid.
And the Connector’s quarterly exchange planning reports listed other subgroups: Policy and Legal, Product Assessment and Development, Subsidized Insurance/Medicaid, Small Business, Information Technology (IT) and Business Development, and Financial/Accounting.
The Executive Office of Health and Human Services (EOHHS) has done its best to appear transparent. They send roughly weekly “Affordable Care Act Massachusetts Implementation Updates,” set up a website, and hold occasional stakeholder meetings. Yet these outlets have lacked policy substance, and mostly have served to copy and paste basic information on federal regulations and grants. State officials have referenced a major report to be released in September, and Pioneer looks forward to that analysis as officials have stressed the importance of “a comprehensive assessment of each option” including federal and state finances. Yet Pioneer has received only the limited information mentioned above.
If trust is going to exist in the public sector, transparency is necessary. Pioneer has been frustrated and disappointed in the lack of compliance and engagement with the FOIA process that is intended to protect public access to information. In this case, there seems to be a clear disconnect between the reported activities of government and the FOIA documents returned to us.
If these committees are working so hard and for so long, why won’t they provide even the most basic information required by the open records law?
September 14th, 2011
This op-ed ran in the Boston Business Journal Friday September 2, 2011.
Boston’s Children’s Hospital was recently recognized as the nation’s top hospital for children by U.S. News and World Report. But what will Obamacare and Gov. Patrick’s “Phase II” state health reform, which move the health industry toward so-called accountable care organizations (ACOs) and alternative payment methods, have on world-class medical facilities like Children’s?
An ACO is a network of doctors and hospitals that share responsibility for patient care. In theory, it’s like purchasing a car from a dealership; instead of buying each part yourself, an ACO brings together the different parts of patient care and ensures that the pieces work well together.
Yet the reality isn’t so simple. While ACOs may help improve health care delivery, their complexity should give policymakers pause.
The federal government is pushing our health care delivery system toward ACOs by setting up a program for patients over 65 who are covered under Medicare. Over time, many experts believe, these rules will come to define the broader health care delivery system. But are ACOs designed to care for grandparents also good for their grandkids?
Ninety percent of Children’s business is pediatrics, and Children’s serves the third most patients on public insurance in Massachusetts. For years, reimbursements at hospitals with a sizable number of publicly covered patients have been as little as 60 percent of what private insurers pay.
Acute pediatric care often requires more nurses and different levels of medicine, and it cannot be measured by the same cost and quality standards as adult care. However, current ACO regulations don’t account for these differences. At Children’s, 0.5 percent of patients account for 20 percent of spending. Coordinated care is especially important for this population, but current Medicare proposals do not account for the uniqueness of pediatric care.
There are two ways to “bend the cost curve.” The first is to regulate the market into compliance, but setting reimbursement rates makes it less likely that officials will be able to account for subtle or regional differences in care. The second approach is to create incentives for integrated, innovative service delivery and rewards consumer engagement. This causes fewer economic issues and is much more likely to yield long-term savings.
The goal of health care reform should not be to force all patients in ACOs, but to promote innovation and coordination. Policymakers must not lose sight of that if they want local institutions like Children’s to continue providing the kind of care that has made it a national pacesetter.
Josh Archambault is the director of health care policy at Pioneer Institute. Dan Winslow represents the 9th Norfolk District in the Massachusetts House of Representatives.
September 9th, 2011
A local group (run by a former classmate of mine) is accepting entries for an annual contest that highlights stories of medical costs gone wild.
The group Costs of Care’s mission is that:
All doctors should understand how the decisions they make impact what patients pay.
The prompts for the contest stress the importance of all stakeholders being more aware of the impact of decisions that we make in receiving our health care.
Do you have a story about a medical bill that was higher than you expected it to be? Or a time when you wanted to know how much a medical test or treatment might cost? How about a time you figured out a way to save money while still receiving high-value care?
Unlike any other purchase, we rarely act as consumers of health care. When was the last time you called to ask for a price or switched providers based on the cost of the care?
Here are the rest of the details for the contest:
As part of our second annual essay contest, Costs of Care, a nonprofit group based in Boston, is offering $4000 in prizes for anecdotes like these that illustrate the importance of cost-awareness in medicine. Judges will include former White House Budget Director Peter Orzsag, former United States Surgeon General C. Everett Koop, Governor Jennifer Granholm, women’s health and cancer research advocate Dr. Susan Love, and Harvard University Provost Dr. Alan Garber.
The mission of Costs of Care is to expand the national discourse on the role of care providers in controlling healthcare costs. The stories we receive as part of our second annual essay contest will provide everyday examples from across the nation that illustrate the power patients and healthcare workers have to curb costs at a grassroots level.
Submissions should be no longer than 750 words and are due by November 15th. More details are available at www.CostsOfCare.org/essay.
You can also read about our winning essays from last year here.
September 6th, 2011
The summer has led to little news from the Legislature and Governor Patrick on the health policy front. Which, on the first day of September, left me to wonder whatever happened to the temporarily extended Massachusetts MassHealth 1115 waiver?
Simply put, this waiver from the federal government allowed the 2006 health reform to become a reality. The waiver was last renegotiated by the Patrick Administration in 2008, and was extended until June 30, 2011. Quietly this summer, that deadline was pushed back twice, and was set to expire yesterday.
I have just learned that the waiver was extended for another 30 days. So I am left to ask–what is the issue(s) holding up a longer term renewal?
In a summer of earthquakes and tropical storms in Boston, is there another storm brewing behind closed doors over the waiver?
Follow me on twitter: @josharchambault
September 1st, 2011
The state senate is trying to decide whether to override the governor’s veto of provisions that were included in the state budget that
…narrow the amount of time the insurance commissioner has to review [health insurance] rate-hike proposals to 30 days from 45 days. In addition, if the commissioner fails to make a judgment within 30 days, the proposed rate hikes would automatically take effect.
These provisions were included in the budget in response to the Division of Insurance’s denial of 235 of 274 increases proposed by insurers for plans covering individuals and small businesses, last April.
However, the madness of this debate from the Administration comes in the next paragraph of the State House News Services ($) story:
Under the proposal [in the budget], insurance regulators would also be required to prioritize the “actuarial soundness” of rate hikes, a metric that insurer advocates say simply requires that premiums be sufficient to cover costs.
Wait for it:
But critics [the Patrick Administration] of that proposal say it would prioritize that measurement over others that are currently equal under the law, such as “excessiveness” and “reasonableness.”
Really? Is this the key to health care cost containment? A vague ill defined standard left open to bureaucrats? If so, we are in real trouble.
August 18th, 2011
Over at the left-of-center blog The Incidental Economist, Austin Frakt has picked up the misplaced logic of those on the left to compare the experience of Massachusetts and extrapolate it to the national level, especially for employer behavior. Perhaps some wishful thinking.
By pointing to recent state data on employer offer rates for insurance, it seems to prove that employers under a mandate system at least still offer insurance. But I am not sure offer rates are a good indicator of much, especially in a down economy. Weaker companies go under and push up the rate. Plus if you look at historical data, offer rates have always been higher in Massachusetts compared to most of the rest of the nation.
I don’t think the behavior and commitment to health insurance shown by a bio tech company in Boston will be a good predictor of behavior for a manufacturing company in New Mexico or Texas that has not offered insurance to its employees in the past. Culture matters, and insurance is no different in this regard.
I think a more important stat is take up rates. In Massachusetts we have seen an almost 10 percent decrease in eligible employees accepting insurance from their employers. This deserves much more attention and digging to find out why.
Finally, the incentives and penalties on employers in Obamacare and Romneycare are not the same. I will not go into detail here, but there is one HUGE difference that matters for employer behavior. There is a very high employer firewall in Massachusetts, keeping employees eligible for ESI out of the exchange and off subsidies.
In contrast, Obamacare has a 9.5 percent of income affordability threshold or actuarial value of below 60 threshold. This difference between the two laws, will impact employer behavior dramatically and the bottom line for ACA as well. I have written a much longer piece on this topic, which I hope will be published soon.
Follow me on Twitter @josharchambault
August 16th, 2011
However, this gold medal is one we wish we could return. Kaiser Family Foundation released a report this week that documents the wide ranging differences in health insurance premiums across the country. Massachusetts led the pack with an average individual insurance premium topping $437 per person per month. This is almost double the national average.
It should be noted that this report does acknowledge the many factors that lead to high insurance costs, such as cost of living, patient cost-sharing, generosity of benefits, the base cost of care, age-based demographics, and cost control efforts. As a result, most of the Northeast is considered expensive.
From a long term health policy perspective, the report will provide a baseline to measure changes in premiums after Obamacare is fully implemented.
I have written numerous times about the concern of “insurance reforms” being forced down on other states and resulting rise of prices in those states. In the Commonwealth, there is a real lack of understanding by policy makers in regards to how market regulations, such as guarantee issue, coverage mandates, and community rating can increase the cost of insurance. Other states are about to find out in 2014.
The Democratic Congress included in the ACA these “market reforms” and a recent report out of the Office of the Actuary in the Centers for Medicare and Medicaid Services, highlighted in their annual projections the continued upward trend in national health care spending. The report projected that Obamacare will dramatically increase the growth rate of health care spending in the near-term.
The growth rate by 2014 will approach 14 percent, compared to 3.5 percent, if Obamacare had never been implemented. This graph appeared in the July issue of Health Affairs and illustrates the point.
Blue is without Obamacare, Red is with.
This certainly will call into question the President’s 2008 claim that “Under [our] plan, if you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year.”
August 10th, 2011
The World Health Organization released a report recently that led with the headline that you are more likely to die from a medical error than from flying in an airplane.
Reuters take on the report:
While being treated at a hospital, there is a one in 10 chance a patient will experience a medical error and a one in 300 chance that a patient will die because of the error. Meanwhile, the risk of dying in an airplane crash is about one in 10 million…
Each year in the United States, 1.7 million infections are acquired in hospital, leading to 100,000 deaths, a far higher rate than in Europe where 4.5 million infections cause 37,000 deaths, according to WHO.
More than 50 percent of acquired infections can be prevented if health care workers clean their hands with soap and water or an alcohol-based handrub before treating patients.
Simply put, data on medical errors in the US should be a national scandal, and is yet another reason why health care spending is so high. The most troubling fact is that we have known about the issue for years, see IOM’s To Err is Human.
July 25th, 2011
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