Health Care Reform in Massachusetts: The Role of Public Health John Auerbach, Commissioner
States Are the Laboratories for Health Care Reform Three states are implementing plans to achieve near universal coverage: Maine, Vermont and Massachusetts Fourteen other states are already moving towards comprehensive reform by expanding insurance options, especially for children and for low income populations 2
The Massachusetts Law: Why So Much Attention? Reaching the ambitious goal: Near universal coverage immediately 3
The Results: After 18 months 4
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What does this have to do with improving health? 7
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While the attention is on the cost and mechanism of insurance coverage and the treatment of illness Public Health is important
Designing the Health Care Reform Package Attention was/is needed to what is covered in the insurance packages and what else is funded
Public Health Given Central Role Public health expansion was part of the core of health care reform Increases in funding for vaccinations, chronic disease prevention, tobacco control and core services 12
Why did Massachusetts increase these? Some efforts are better coordinated statewide (example: childhood immunizations) Population-wide public health campaigns increase the likelihood of success in clinical settings (example: the importance of giving up smoking) Public health programs can reach the populations that are not linked to reform (in Massachusetts, at least 125,000 adults) Some services are better provided in specialized settings (TB, STD) 13
Decisions Are Needed on Preventive Services for Insurance Packages Will screening for diseases be offered? Will nicotine replacement therapy and cessation counseling be offered? Will counseling for behavioral change be covered for certain diagnoses, such as diabetes? Will substance abuse and mental health treatment be covered? What services will be offered with first dollar coverage? No copays, deductibles. 14
Prevention is a Priority Reduce the cost of reform by actively promoting good health using proven approaches
Example: With New HCR-related Funding for Tobacco Control Expanded monitoring to prevent sales of tobacco to minors Free nicotine replacement therapy and counseling Expanded public information campaigns with targeted populations Enforcement of ban on workplace smoking The result 16
10% 8% Data Source: Massachusetts Behavioral Risk Factor Surveillance System Percent Drop in Smoking Prevalence Massachusetts, 1998-2007 7.9% 6% 4% 4.3% 3.1% 3.1% 2% 1.5% 2.0% 2.2% 1.7% 0% -2% -4% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007-1.1% -2.4% 17
Example: To address overweight epidemic and resulting chronic disease risk With over 60% of adults and 30% of children overweight a statewide comprehensive effort needed Percent 7 6 5 4 3 2 1 0 4.1 3.8 Prevalence of Diabetes in Massachusetts, 1994-2005 4.7 4.3 3.8 4.9 5.8 5.6 5.8 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year 6.2 5.6 6.4 Overall Source: Massachusetts Behavioral Risk Factor Surveillance System (BRFSS); 18 1994-2005. Note: Estimates have been age-adjusted to 2000 US standard population
Mass in Motion Campaign Includes Statewide regulations: Menu labeling of fast foods Schools: mandated BMI testing of all students Worksites: Employee wellness programs Cities and towns: Community-wide mobilization grants 19
Multi-faceted Education and Support Interactive web site with resources Public information campaign and Support for primary care-based counseling (but doctors are the first to say they can t do it alone) 20
Monitoring the Progress on Improving Health..with an emphasis on expanded insurance coverage for preventive and screening services
Evidence that reform is improving health Changes in the first year of implementation Flu vaccinations rose 3% for 19-64 year olds at primary care sites as new patients see primary care doctors in a year DPH cut adult public health vaccine doses Colonoscopy rates increased 6% in one year among the recommended age group as newly insured 50+ year olds get referrals for screening And smoking rates sharply decreased at a rate not seen in many years (11% of Medicaid adults used the cessation service) 22
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Reducing costs and improving quality Public Health also key in avoiding medical errors and unnecessary costs
After first year In July, 2008, the Legislative passed a sweeping new bill: Health Care Reform Part 2 with focus on cost containment, transparency and efficiency Public Health is assigned the largest number of new tasks in this bill 25
In order to prevent hospital associated infections and serious medical mistakes
Promotes Health Care Quality in Hospitals *Requires hospitals to report hospital associated infections and serious reportable events to the public health department (with transparent web site) *Prohibits health care facilities from charging for services provided as the result of the occurrence of serious reportable event/medical error decisions based on public health dept. 27
In order to insure that physicians and hospitals have the tools to assist in the provision of high quality care
Promotes Health Care Quality in Hospitals and Community Health Centers Requires hospitals and community health centers to implement computerized physician order entry systems and interoperable electronic health record systems - standards to be overseen and monitored by public health departments (with population-wide disease components built in) 29
In order to prevent unnecessary costs related to the construction of unneeded or duplicative services
Changes to the Determination of Need Program Mandates the licensure and subsequent Determination of Need review for ambulatory surgery, for outpatient capital projects exceeding $25 million and for new beds added to hospital satellites with approval required by the public health department before new and expensive construction can occur 31
In Order to Prevent Inappropriate and Costly Influences on Clinical Decision- Making
The Department of Public Health Required to Monitor Pharm. Influence Bans certain meals, recreational events, sponsorship, travel, lodging, grants Requires submission of report of any benefit above $50 to anyone in health care publicly released Requires pharmaceutical/medical device manufacturing companies to submit training program, investigation policies, compliance contact and proof of compliance with marketing code. 33
Among the Risks Associated to Failure to Attend to Prevention in HCR Costs of Reform may be unnecessarily high (example: little attention to prevention) Faulty assumptions may be made about what is covered by insurance (example: NRT) Current programs that are effective may be cut due to a false assumption about what insurance covers (example: immunization) Populations who fall through the cracks may suffer (example: family planning services) Copays and deductibles may create obstacles to care that don t currently exist for some services (example: breast and cervical cancer screenings, SA) 34
Among the Key Lessons Prevention primary and secondary - needs to be addressed as an integral part of health care reform Public Health efforts cannot be cut as a result of health care reform. If involved they can help to insure the success of Health Care Reform 35