Wednesday, October 30, 2013

Massachusetts: America's Next Top Model, Many Years Running...

The double take is probably warranted, but rest assured, you're in the right place. No, you haven't mistakenly ended up in the opinion pages for the CW Television Network's top performing show, nor is there even an inkling of a chance in this blog taking a runway-style turn into discussing the ins and outs of high fashion (sorry to disappoint!). In rounding out the analogy though, let's for a moment imagine the following scenario: What if the Miss America pageant, the competition that pits model-citizens (not to be confused with model citizens) from each state against one another, alternatively focused its sights on identifying the state leading the way in social policy in a given year?

In this fantasy competition, I would wager that historically Massachusetts would have come out on top, donning the winner's sash and tiara, more than any other state since the colonies came into being some 400 years ago.

To see how I came to such a conclusion, let me share a quick list of national social milestones that took place in the beloved Bay State (click on the year to view sources):

1630 - First self-governing colony, with the General Court housed in the colony instead of in London, U.K. This landmark feature set the stage for Massachusetts to catalyze many of the significant movements of that time period (think the original Tea Party!), eventually leading up to the colonies' independence from Britain in 1776. Not only of national significance, the Massachusetts General Court happens to be the oldest continually operating governing body in the world!
1798 - First public hospital was erected in Boston following passage of the Act for the Relief of Sick and Disabled Seamen (our nation's first law to mandate the purchasing of health insurance).
1799 - First public health department is created in Boston and Paul Revere is named its first leader. To find the noteworthy department in its present form, look no further than the Boston Public Health Commission.
1820 - Boston's English High School is founded as the country's first public high school.
1848 - Boston Public Library is established, the first to be publicly funded and open to the public, even allowing patrons to borrow books for free.
2004 - First state to legalize gay marriage.
2013 - First state to attain universal healthcare (> 98% coverage).

In addressing the crowd that gathered for the 71st Citizens' Legislative Seminar at the Massachusetts State House a few weeks ago, Senate Majority Leader Stanley Rosenberg spoke of the state's history as a "bellwether" for innovative policy, a history that is apparently congruent with the present as Massachusetts continues to construct original frameworks for social policies that eventually spread nationwide, not the least of which being the Affordable Care Act (ACA or "Obamacare") of 2010. Now that's what I call a model state!

Inching our way toward the onset of the ACA at the start of 2014, let's take a look back at the Massachusetts' legislative decisions on health care of the past decade to see exactly how the state shaped the national debate that lead to the corresponding landmark law.

Interestingly enough, it all began with then Governor Mitt Romney signing into law Chapter 58 of the Acts of 2006, at the time known as "Romneycare" (and without a bit of irony).

Boston's Faneuil Hall plays host as legislators gather around to witness Governor Romney ink his approval, effectively chiseling this groundbreaking piece of legislation into law. NPR captures the photo op!

Since policy by nature is comprehensive in its form, providing no shortage of words; what follows is an attempt to ease your exhausted eyes with my version of what I'll call legislative "sparknotes", as I highlight the key provisions in Massachusetts' healthcare policy of recent history, starting from the ancestral legislation of 2006 that set the state in motion toward its universal healthcare model and leading up to today. Those well-versed in the proceedings of the ACA (and you all should be considering you've now memorized the entirety of "Walk with Me..."!) should begin to notice the resemblances without breaking a brow sweat.

[Links to full text versions available at].

An Act Providing Access to Affordable, Quality, Accountable Health Care
  • Establishes the Commonwealth Health Insurance Connector, or "the Connector" for short, to be overseen by the newly proposed Commonwealth Health Insurance Connector Authority or simply "the Authority". 
    • The Connector → functions as the health insurance marketplace, enabling people to shop a comprehensive list of approved insurance plans online. The competitive nature of the Connector has resulted in lower insurance premiums on average.
    • The Authority  written into law as an independent public entity that administers the Connector and filters out health insurance plans that do not meet their base requirements.
  • Reformulates insurance plan options to include MassHealth, Commonwealth Care and Commonwealth Choice Health Insurance Programs.
    • MassHealth  the state's combined Medicaid and Child Health Insurance Program (CHIP). Expands Medicaid eligibility to include incomes up to 133% of federal poverty level (FPL).
    • Commonwealth Care  a subsidized insurance program that assists eligible individuals in affording health insurance through use of a sliding fee scale. Eligibility= 133%-300% FPL.
    • Commonwealth Choice  allows people with income exceeding 300% FPL to shop for insurance through the Connector, a generally cheaper option than buying insurance directly from an insurer.
  • Enforces an individual mandate requiring all Massachusetts residents to have health insurance, with exceptions for those who hold opposing religious beliefs or cannot reasonably afford coverage. Violators of the mandate are subject to paying a fee.
    • Similarly, employers who fail to provide sufficient incentives to enroll their employees in health insurance plans will be fined per employee not covered.
  • Prohibits insurance providers from excluding any eligible person from coverage based on pre-existing conditions.
  • Increases commitment to data tracking and reporting on health insurance plans and coverage.

An Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care
  • Establishes incentives to increase primary care work force with the purpose of increasing patients access to primary care.
    • UMass Medical School (UMMS) agrees to offer full tuition and fee remission to medical students pursuing primary care training, requiring four years of service to the Commonwealth in a primary care or public service capacity focused on underserved areas.
      • Non-UMMS MD's can opt into a similar program to receive loan repayment.
    • Qualifies nurse practicioners as certified primary care practicioners. 
  • Institutes regulations on pharmaceutical and medical device manufacturers making them accountable to the Department of Public Health in following the "Marketing Code of Conduct"- the goal of such ventures is to "benefit patients, enhance the practice of medicine and not interfere with the independent judgment of health care practicioners."
  • Sets a goal of equipping all health care facilities with electronic health record (EHR) systems by October 2015.

An Act to Promote Cost Containment, Transparency and Efficiency in the Provision of Quality Health Insurance for Individuals and Small Businesses
  • Requires health care providers to track and report data on care quality in addition to cost to the Department of Public Health.
    • Defines the "Standard Quality Measure Set", a grouping of tested quality measures to be universally adopted as the standard form of reporting by providers. Includes measures such as:
      • Health status adjusted total medical expenses  total cost adjusted by health status tracked on a per member per month basis.
      • Relative prices negotiated amounts paid to providers by private and public payers for health care services.
      • Inpatient and outpatient costs  accounting for both direct and indirect costs of the two care types.
      • Medical loss ratios (MLR "the percentage of insurance premium dollars spent on reimbursement for clinical services and activities to improve health care quality. e.g. Large group insurers must have minimum MLR of 85%. Individual and small group insurers are required at least 80%."
  • Creates what is now known as the Center for Health Information and Analysis (CHIA) tasked with researching cost effective health care services that increase care coordination, efficiency and quality. Special interest paid towards "bundled payment arrangement", as opposed to fee-for-service, which serves as the basis for the major reforms in health care payment structure.
  • Focuses state regulation on reducing payer's unnecessary/excessive administrative costs, particularly to lower the insurance costs for individuals and small businesses.
    • Experiments with means of cost sharing through establishment of small business group purchasing co-ops and requiring qualified payers to offer varying degrees of choice.
*Approved on August 10, 2010. The ACA was enacted into law on March 23rd of that same year.

An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation
  • Establishes the Health Policy Commission (HPC), "an independent state agency responsible for reducing overall cost growth, improving access to quality, accountable care and reforming the way health care is delivered and paid for in Massachusetts", existing within the Executive Office of Administration & Finance, but not under its control.
    • Sets health care cost growth goals for each year based on gross state product (GSP), eventually whittling down growth to be in line with inflation, which was at 3.6% this past year. In years' past, growth has approached 10%!
      • Holds an annual public hearing on health care cost trends, generally falling in October. Given this a public hearing, anyone can attend! Mark your calendars for next October!
    • Enhances transparency of provider organizations through increased data tracking and reporting
    • Monitors development and adoption of accountable care organizations (ACO), patient centered medical homes and any other risk-bearing provider organization with the purpose of containing costs while increasing care quality through increased focus on integrated care with long-term benchmarks.
      • "risk-bearing"  utilizing an alternative payment methodology that adjusts for health status (i.e. quality of care)
    • Serves to protect patient access to necessary health services; increasing primary care services, reducing disparities of care and health across racial and ethnic groups, integrating mental and behavioral health, and substance abuse treatment into primary care.
  • Promotes development of a statewide health information exchange allowing for EHRs to be shared across providers within ACOs.

In summarizing these points, I urge us all to the refer to following figure on healthcare spending.

Projecting health care cost per capita over the next decade shows a trend of near exponential increase.
RadioBoston- WBUR bring on Professor Stuart Altman and Reverend Burns Stanfield to discuss matters further.

The above chart tracks the annual per capita cost of health care expenditures for the state of Massachusetts from 1991 to 2009 and projected forward to 2020. As you can see, health care cost growth is expected to continue and at what seems to be a near exponential rate! Though, Massachusetts regularly lands itself at the top of the nation's chart for health care expenditures per capita, this trend in cost growth is by no means unique to this state. Nationwide, you could expect to see similar curves projecting future state healthcare cost increases, and not to mention that includes states who have nowhere near universal healthcare! I'm looking at you Texas (76% coverage).

With all this brought to light, we should quickly begin to realize that "business as usual" healthcare policy will not do the trick in turning around the cost growth trend. We also should keep in mind that with any changes in healthcare legislation we can expect that there could be a short-term increase in cost growth - which is fine. More people being covered by health insurance and consuming health services will undoubtedly cost more money. It's not rocket surgery. But, what is important to note here, is that healthcare is not in the business of needlessly rationing to keep margins high. No, this is a human service. I repeat, a service. So with the opportunity to do something about this OR not, I say we have no option but to do something - which begs the question: What should we as citizens of this great nation do?

I say there's no point in guessing, since at least one state has been trailblazing in this territory for the better part of the past decade. That's right - I say, if you want answers about what to do in your state (or even what is about to happen nationwide with implementation of the ACA), turn to Massachusetts.

Speaking of Massachusetts, at 3:55PM today, I encourage you to tune in for President Barack Obama's address on healthcare reform as he's chosen Boston's famed Faneuil Hall as his site for making his remarks on issues of national interest pertaining to implementation of the ACA and U.S. healthcare reform. Enjoy!

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