Posts filed under 'Healthcare'
This afternoon the Patrick Administration announced a new deal with Federal HHS on the Medicaid waiver that serves as the backbone of our reform law. The last waiver expired in June of 2011.
It is a 3-yr $26.75 billion deal.
I need some more details before I can figured out how exactly this waiver will mesh with the Governor’s payment reform bill. But until then, some early thoughts:
- The Patrick administration looks like they withdrew a number of requests to get this deal done.
- The Massachusetts waiver deal raises some interesting questions for the future of the national health reform law. [Even if I think the lessons to be learned from Massachusetts are somewhat limited to the national plan.]
- A foundational assumption of the Massachusetts reform was that as patients obtained insurance, the cost of care for individuals without insurance would go down. The record has been mixed on this front.
- If safety net hospitals in Massachusetts cannot transition to a new care model that allows them to be more self-sustaining with 98% coverage, how much will the PPACA ultimately cost when similar hospitals in 49 other states try to adjust? This waiver includes an additional $120 million a year to try to push a transition that was supposed to take place organically 3-5 years ago.
- The new PPACA entitlement is in part funded with reductions in payments to similar hospitals across the nation, but the precedent set here by the federal government should call into question that basic “savings” assumption.
- I am glad to see that CMS has included some benchmarks for the state to hit in order to receive funding.
- Massachusetts officials will be happy with more federal funding for the reform, as it means less of a future hit to the state budget, but taxpayers are smart enough to know they pay for both state and federal spending.
Find me on twitter: @josharchambault
December 20th, 2011
I was recently asked by a reporter for some trends that I expect to see in 2012. I thought I would share my bullet points on the Pioneer blog:
In no particular order.
- Continued provider consolidation, both locally and nationally.
- Greater cost-shifting from Medicare and Medicaid, as both federal and state government continue to cut reimbursement levels. On a related side note, I think over the next few years you will see cash-based pre-paid practices opening in Boston.
- Gains in the use of high-deductible and health savings account plans nationally. The question for 2012 is whether Massachusetts will break out of its status quo and catch up.
- The story I will be watching for in 2012: The interaction between cost saving reforms (global budgets, ACOs, limited networks, etc) and individuals that have put off care because of the economic downturn. When will these folks reenter the medical system in a meaningful way? And how will we pull apart and separate the impact of the economy from the reforms being implemented? In my mind, the true test for the sustainability of any reform will be revealed when the economy turns around and these patients start to return to receive the care they have been putting off. (Perhaps, I am a year off, and this will not be a full blown story until 2013, or even 2014, which if the ACA remains on the books, we could have a prefect storm brewing for 2014 as coverage is widely expanded and latent demand returns to the system)
You can find me on twitter: @josharchambault
December 20th, 2011
The Connector held its annual retreat this past weekend, and since the omnipresent Health Care for All (HCFA) representatives were not in attendance to write up a summary, I thought I would provide an overview of what was discussed at the meeting, and outline some of the future challenges for the Connector. The agenda can be found here.
Basic Health Plan
The Connector is seriously thinking about offering a basic health plan, an option in the ACA, and is one of the few states in the nation to be doing so. (When the Connector posts the slides from Saturday, I will link to them for more detail on the different circumstances being modeled.)
With a BHP the federal government would pay a state 95% of the cost of tax credits and subsidies that they would have spent without a BHP. This may result in the feds covering 100% of the cost of running a BHP depending on how a state set up a program, and is a very different funding structure when compared to the current 50% FMAP reimbursement for CommCare or Medicaid.
There are lots of policy tradeoffs with a BHP. (I will write on this more in the future if the state decides to move forward with a BHP.) But just as an example, the BHP can be contracted out or run by the state. If state run, one can imagine Medicaid II, but without take-one take all rules. In other words, under current law, if a provider accepts one Medicaid patient, they can’t turn down any other because they are on Medicaid. This is the government’s “solution” to the historical practice of under reimbursing for the care of these patients. As a result of being underpaid, some doctors just decide to not accept any Medicaid patients.
The Massachusetts Medical Society has documented the challenge these folks are facing finding internists (only 53% accepting new patients) and family physicians (62%). I don’t believe the government imposed access rules hold for the BHP. In a future downturn, the state would cut BHP payments (they are doing it with Medicaid now), and these low-income patients would be caught between a rock and a hard place, as no provider will take them. They are functionally uninsured.
Finally, in a recent NEJM piece John Graves, Rick Curtis, and Jonathan Gruber (who sits on the Connector Board) predicts significant churning and increased instability of coverage for those on the edge of eligibility between a BHP and the exchange.
This blog post is part 4 of 4 from the Connector meeting.
Twitter @josharchambault
UPDATED: The Connector just posted the slides from Saturday.
December 8th, 2011
The Connector held its annual retreat this past weekend, and since the omnipresent Health Care for All (HCFA) representatives were not in attendance to write up a summary, I thought I would provide an overview of what was discussed at the meeting, and outline some of the future challenges for the Connector. The agenda can be found here.
State Budget Considerations
The Commonwealth will have to finance state mandates that are over and above the federally set essential health benefits (EHB). The Connector has identified at least 7 current mandates that are unlikely to be in EHB. The Legislature will need to reopen the discussion over mandates.
40,000 legal immigrants will be enrolled back into Commonwealth Care due to a lawsuit. The current Bridge program only has 15,000 legal immigrants, so the Connector will have to welcome back the Bridge enrollees and 25,000 additional immigrants picking up the additional cost in the process, till at least 2014.
One of the biggest changes will be enrollment in the subsidized CommCare program. The ACA, transfers a significant number of enrollees into Medicaid or a Basic Health Plan(BHP) (more on this in the 4th blog post) out of CommCare. This would leave the Connector with just over 60,000 enrollees, a huge drop in revenues, and a floundering unsubsidized CommChoice program. What became clear from Board members was that the Connector should be scared about future power and market share. Numerous board members wanted to discuss how the Connector could best position itself to keep the reins of power in the health care market.
A few other observations.
The small business and broker representatives were silent on Saturday. Not a single question or comment. They are some of the newer appointed officials, but this leaves the conversation to be dominated by government and union officials.
Is the tension escalating on the left? There was a lengthy conversation about the role of liberal advocacy groups going forward in Connector policy decision making. Some Board members expressed frustration with these groups and advocated for “education about the reality of the situation,” while others wanted to protect the access and input these groups have had since the Patrick Administration has been in office.
State officials are concerned about future cuts in federal funding. Given that the federal government finances a considerable portion of the Massachusetts reform, and is being debated in secret waiver negotiations, this issue could mean big changes in program design.
To the credit of the Connector staff, they presented ACA implementation as a chance to design Connector 2.0. I hope they mean that. But the sympathy shown by staff to Board concerns about the evils of– the private sector, competition, and greater choice for consumers—I have little confidence of real reform.
Shouldn’t the opposite question be asked– what reforms would be best for taxpayers and for possible consumers of Connector products?
This blog post is part 3 of 4 from the Connector meeting.
Twitter @josharchambault
December 7th, 2011
The Connector held its annual retreat this past weekend, and since the omnipresent Health Care for All (HCFA) representatives were not in attendance to write up a summary, I thought I would provide an overview of what was discussed at the meeting, and outline some of the future challenges for the Connector. The agenda can be found here.
The main theme of the retreat was the Affordable Care Act’s (ACA) impact on the Massachusetts reform. Connector staff, confirmed what Pioneer’s research has shown, that the Connector we know today will look very different by 2014. Here are a few of the examples of the policy discussions ahead:
- The Connector will need to figure out changes to the individual mandate (MEC in the federal law) vs our current minimum creditable coverage.
- Adjustments to the penalty and affordability schedules.
- Changes to employer responsibilities.
- Matching essential health benefits (EHB)– in the federal law vs. our mandated benefits.
- Changes to the seal of approval process, by which insurance plans are approved to be sold in the Connector.
- The return of an employee choice model. (Pioneer has written on the design failures and manipulation of the CP program by staff the first time around, hopefully the Connector can learn from past mistakes.)
- Big changes to the Young Adult Plans. The state may have to offer a catastrophic insurance plan for the first time, which a few Connector Board members are ideologically opposed to, but Governor Romney envisioned as the basic level of coverage in the 2006 law.
- There will be some shifting in the metallic tier levels within the exchange.
- The introduction of navigators into the Massachusetts market.
- The incorporation of risk adjustment mechanisms, risk corridors, and reinsurance programs.
While these provisions are not exhaustive, they do outline some major policy discussions ahead, and many have financial consequences for the state budget. I will cover some of the budget fall out in the next post.
This blog post is part 2 of 4 from the Connector meeting.
Twitter @josharchambault
December 7th, 2011
The Connector held its annual retreat this past weekend, and since the omnipresent Health Care for All (HCFA) representatives were not in attendance to write up a summary, I thought I would provide an overview of what was discussed at the meeting, and outline some of the future challenges for the Connector. The agenda can be found here.
I must mention a moment that I found especially troubling.
Politics at the Connector.
Secretary Gonzalez made a statement during a conversation about protecting the reputation of the Connector and media coverage that struck me as odd. He said that the Connector needs to be seen positively as it means a great deal to the political future of the Governor and the President. He encouraged board members to use the Connector staff as a resource so they are “well armed with information” to present a positive story about the Connector.
Appropriate political positioning for a quasi-public agency? I will let you decide.
This blog post is part 1 of 4 from the Connector meeting.
Twitter @josharchambault
December 7th, 2011
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
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