Commonwealth of Massachusetts
Executive Office of Health and Human Services
Gender Issues in Health Reform
State Level Experiences
JudyAnn Bigby
Bigby, MD
Secretary, Executive Office of Health and
Human Services
June 27, 2010
Academy Health Annual research Meeting
EOHHS
Overview
Gaps in access for women prior to reform
Massachusetts Health Care Reform: Focus on Access
Impact of reform on women
Massachusetts going forward
• Payment reform and system redesign
• Opportunities under the Patient Protection and Affordable Care
Act
EOHHS
Gaps in Access for Women
Categorical Eligibility
• Pregnant,
Pregnant uninsured
uninsured, and low
low-income
income
• MassHealth
• Healthy Start
• Non-pregnant, uninsured, low-income
• Family
F il planning
l
i services
i
– 80 diff
differentt sites
it
•
•
•
•
Mass residents with incomes < 200% FPL
Estimated need = 283,000
283 000
Served 100,00
No regular source of funding
• Women’s Health Network
• Screening for breast and cervical cancer
• Heart
H t disease
di
and
d osteoporosis
t
i education
d
ti
EOHHS
Gaps in Access for Women
Free Care Pool
• Massachusetts resident
resident, uninsured or underinsured
• Hospital based services; community health centers
• Full coverage if <200% FPL
• Partial coverage 201%-400% FPL
EOHHS
Percent of Massachusetts Adults Reporting
No
o Insurance,
su a ce, 2005
005
40
35
35
30
Perc
cent
25
Men
Women
20
14
15
11
10
10
7
7
12
6
5
0
MA
White
Massachusetts BRFSS, Health Survey Program
Black
Hispanic
EOHHS
Percent of Massachusetts Adults Who Did
Not
ot See a Doctor
octo Due
ue to Costs, 2005
005
25
21
19
20
Perc
cent
15
15
10
10
Men
Women
11
8
8
6
5
0
MA
White
Source: Massachusetts BRFSS, Health Survey Program
Black
Hispanic
Percent of Women Age 18-44 Who Reported
EOHHS Birth
t Control
Co t o Use, 2002-2005
00 005
100
95
90
perc
cent
85
86
84
85
81
81
80
75
70
65
60
MA
White
Black
Source: Massachusetts BRFSS, Health Survey Program
Hispanic
Asian
Percent of Women Age 18-44 with Who had an
p
Pregnancy
g
y in Past 5 yyears,, 2005
EOHHS Unplanned
50
46
45
40
33
perc
cent
35
30
29
25
25
20
15
10
5
0
MA
White
Source: Massachusetts BRFSS, Health Survey Program
Black
Hispanic
Percent of Women with Adequate Prenatal
EOHHS Ca
Care
e#, 2005
005
100
90
83
86
80
73
75
Black
Hispanic
81
83
Asian
Amer
Indian
perrcent
70
60
50
40
30
20
10
0
MA
#
White
Kotelchuck Index
Source: Massachusetts Registry of Vital Records, Center for Health Information,
Statistics, Research, and Evaluation
Elements of Massachusetts Health Reform
EOHHS
Government supports for low-income individuals
• Medicaid expansion
• Subsidized insurance for non-Medicaid eligible with
incomes up to 300% of FPL
Insurance reform
• Merger of individual and small group market
p
options
p
for yyoung
g adults
• Expanded
Fair employer contributions
Individual
Indi
id al mandate to purchase
p rchase ins
insurance
rance for those
who can afford it
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Elements of Reform
Connector Authority
• Sets floor for coverage
• Defines Minimum Creditable Coverage (MCC) for
individual mandate
• Seal of Approval for health plans
• Sets standard for affordability
non subsidized products
• Insurance exchange for non-subsidized
Other Reforms
• Wellness
W ll
program iin M
MassHealth
H lth
Uninsured Adults in Massachusetts
EOHHS
8
7
7.4
6.7
6.4
5.7
6
Perrcent
5
4
3
2.6
2.7
2008
2009
2
1
0
2002
2004
2006
2007
Health Care Reform 10/06
Source: Massachusetts Household Insurance Survey
Massachusetts Division of Health Care Finance and Policy
EOHHS
Type of Health Insurance
Coverage, 2009
Public or
Other
Coverage
17%
EmployerSponsored
Insurance
68%
Source: Urban Institute tabulations on the 2009 Massachusetts HIS
Massachusetts Division of Health Care Finance and Policy
Medicare
15%
Health Reform Impact on Access to Care
EOHHS Among
o g Women
o e In Massachusetts
assac usetts
Uninsured Women
100
97.1
Has a Usual Source of Care
*
94.5
95
*
9
95.5
100
*
95
89.6
90
Percent
P
Percent
P
91.4
85.1
85
92.8
90.3
90
*
91.8
85.6 86.2
86.6
85
80
80
75
MA Women
75
MA Women
Low Income Women
Minority Women
30
35.8
26.9
21.2 *
26.4
*
31.6
22.8
*
20
10
0
MA Women
Low Income
Women
Minority women
Took Any Prescription Drug
Did Not Get Needed Care
40
Low Income
Women
Minority Women
80
70
60
50
40
30
20
10
0
61.8 64.1
63.4
*
69.5
61.7
49.9
MA Women
Low Income
Women
Minority Women
*p<0.05
Source: Long SK. et.al. The Impacts of Health Reform On Health Insurance Coverage and Health Care Access, Use, and
Affordability for Women in Massachusetts.
Health Reform Impact on Costs of Care
EOHHS Among
o g Women
o e In Massachusetts
assac usetts
Had Problems Paying Medical Bills
Did Not Get Care Due to Costs
40
40
35
31 5
31.5
30
26 26.9
20.9
30
22.2
20
15
20 7
20.7
20
15
10
10
5
5
0
0
MA Women
27.4
25
P ercentt
P e rc e n t
25
35
29.6
Low Income Women
Minority Women
17.2
13.6*
16.2*
*
11.6
MA Women
Low Income
Women
Minority women
*p<0.05
Source: Long SK. et.al. The Impacts of Health Reform On Health Insurance Coverage and Health Care Access, Use, and
Affordability for Women in Massachusetts.
Health Care Utilization Among Massachusetts
EOHHS Women Before and After Reform
Indicator
2005-06
2007-08
No health care insurance (%)*
68
6.8
22
2.2
Have a personal health care provider (%)*
90.9
92.2
Could
C
ld nott visit
i it a h
health
lth care provider
id iin th
the pastt
year due to cost (%)*
Had a routine check up
p in the p
past yyear ((%))
95
9.5
69
6.9
79.9
80.9
Had flu shot in past year, ages 50-64 (%)*
36.7
47.2
Had a Pap smear in past 3 years
years, ages 18-64
18 64 (%)
88 2
88.2
88 7
88.7
Had a mammogram in past 2 years, ages 40+ (%)
84.1
84.7
Had an unplanned pregnancy
pregnancy, ages 18
18-44
44 (%)
21 6
21.6
23 6
23.6
Use any form of birth control, ages 18-64 (%)
80.1
75.9
Did not fill a prescription because of cost (%)*
11.1
5.3
* Difference between 2006-2006 and 2007-2008 statistically significant, p<0.05
EOHHS
Trends in Adequacy of Prenatal Care 20052008,
008, Massachusetts
assac usetts
MA
White
Black
Hispanic
Asian
90
Percent wiith Adequate PNC
88
86
84
82
80
78
76
74
72
70
2005
2006
2007
2008
Source: Massachusetts Births 2005- 2008. Massachusetts Department of Public Health, Bureau of Health
Information, Statistics, Research, and Evaluation, Division of Research and Epidemiology
EOHHS
Summary of Outcomes of Health Reform in
Massachusetts
assac usetts
Decreased number of uninsured
• Low-income women and minorities have seen substantial declines
Mixed results in terms of improving access to care
• More women report having a regular source of care
• Fewer women report that they did not get necessary care
• More women report getting prescription medications
Mixed results in terms of costs
• Women continue to report they have trouble paying medical bills
• Fewer women report they do not get care because of costs
• Fewer low-income and minority women report not getting care
because of costs
Disappointing results in terms of improved outcomes
• No improvement in adequacy of prenatal care, use of birth control,
cancer screening for example
EOHHS
Five Characteristics of a High Performance
y
Health System
1. Extend affordable health insurance to all
2. Align financial incentives to enhance value and
achieve savings
3. Organize the health care system around the
patient to ensure that care is accessible and
p
coordinated
4 Meet and raise benchmarks for high
4.
high-quality,
quality
efficient care
5. Ensure accountable leadership and
public/private collaboration
Source: Commission on a High Performance Health System, A High Performance Health System for the United
States: An Ambitious Agenda for the Next President, The Commonwealth Fund, November 2007
Comprehensive
Health
Care
System
Reform
EOHHS
Access
All insured
Uninsured
Financial and structural barriers to
access removed
Financial barriers to care
Costs/Payments
High and growing costs
Value/Quality driven
Volume and price driven to generate
revenue
Fee-for-service
HIT
Spotty implementation
Lack of interoperability
Potential not met
Payment Reform
Health Care Workforce Planning
Health Resources Planning
Insurance Product Redesign
Malpractice Reform
Wide adoption
Interoperable
Informs and transforms clinical
practice
Systems
Inconsistent Quality
Errors and adverse events
Misuse, overuse, and duplication
Inequities in care
Disorganized, poorly coordinated
N always
Not
l
evidenced
id
db
based
d
Emphasis on specialty care
Predictable outcomes
Patient safety
Appropriate use
Disparities eliminated
Coordinated, integrated care
Evidenced based
Patient centered primary care
EOHHS
Goals of Payment Reform
Offer strong incentives for Integrated, efficient delivery of care
• Eliminate incentives to increase volume
• Eliminate incentives to provide higher-cost services over lower-cost
services that are equally effective
C ea e incentives
ce
es for
o be
better
e ca
care
e coo
coordination
d a o
• Create
• Create incentives for low-cost interventions that reduce future patient
risk/cost and eliminate duplication
• Payments for teaching,
teaching disproportionate share status
status, sole community
provider status, stand-by services and other factors are permissible
• Certain classes of services may be exempt from global payment
Reinforce goals of a patient-centered medical home
Reinforce performance-based incentives, which serve to protect consumer access and
encourage high-quality
high quality, evidence
evidence-based
based care
Foster provider accountability for quality and per capita costs for patients in ACO
S lf f d d plans
Self-funded
l
may iimplement
l
t global
l b l payments
t
EOHHS
Integrated Care Organizations
ICOs are composed of hospitals, physicians and/or
other
th clinician
li i i and
d non-clinician
li i i providers
id
working
ki
as a team to manage provision and coordination of
f ll range off services
full
i
• Incorporated organizations or contracted networks of providers
• Must include primary care as patient centered medical homes
• Must have at least one p
physician
y
on g
governing
g board
• Must possess or procure population management functions; care
management; financial management; contract management;
quality
lit management;
t and
d patient
ti t and
d provider
id communication
i ti
capabilities
EOHHS
Consumer Chooses
ACO by Selecting
PCP
or
Patients (their costs) are assigned
to an ACO based on the majority
of their outpatient
p
E&M visits
Specialists
Mental Health
Full range of
reproductive
health services
Hospitals
Home care
Primary Care
Rehab Services
Will Integrated Care Organizations meet the needs of women?
Comprehensive
Health
Care
System
Reform
EOHHS
Access
All insured
Uninsured
Financial and structural barriers to
access removed
Financial barriers to care
Costs/Payments
High and growing costs
Value/Quality driven
Volume and price driven to generate
revenue
Fee-for-service
HIT
Spotty implementation
Lack of interoperability
Potential not met
Payment Reform
Health Care Workforce Planning
Health Resources Planning
Insurance Product Redesign
Malpractice Reform
Wide adoption
Interoperable
Informs and transforms clinical
practice
Systems
Inconsistent Quality
Errors and adverse events
Misuse, overuse, and duplication
Inequities in care
Disorganized, poorly coordinated
N always
Not
l
evidenced
id
db
based
d
Emphasis on specialty care
Predictable outcomes
Patient safety
Appropriate use
Disparities eliminated
Coordinated, integrated care
Evidenced based
Patient centered primary care
Women
Specific
Measures
Patient
Protection
and
Affordable
Care
Act
EOHHS
•
PPACA has many similarities to
Massachusetts’ reform
Massachusetts
•
•
•
•
Government subsidies for low-income (working)
i di id l
individuals
Expansion of Medicaid eligibility
Insurance Exchange modeled on the Connector
Builds on p
privately
y available options
p
• Individual mandate
• Employer
p y responsibility
p
y
EOHHS
•
•
•
•
Payment Reform and System Redesign
Opportunities in PPACA
Center for Medicare and Medicaid Innovation to test
innovative payment and service delivery models to reduce
health care costs and improve quality
Enhanced payment for primary care services and
encourage physicians to join together to form ACO’s to gain
efficiencies and improve quality
Established a national pilot program on payment bundling
to encourage hospitals, doctors, and post-acute care
providers to work together to achieve savings for Medicare;
encourages increased collaboration and improved
coordination of care
Medicaid medical home and global payment
demonstrations
EOHHS
Conclusions
1. Providing insurance alone will not result in improved health
for women, however making insurance available to all
women is a fundamental first step in improving care for all
women.
2 It is
2.
i necessary to
t re-examine
i th
the hi
historic
t i practice
ti off
allocating funds for categorical programs that in large part
were designed to fill in gaps left by the lack of insurance
3. As payment models are designed to support integrated
systems
y
of care women’s unique
q needs must be considered
and
d measures tto assure high
hi h quality
lit comprehensive
h
i care
for women included as performance measures.
4. Improved access, better integration and coordination of care
and improved quality must lead to improvements in long
standing
g measures of p
poor q
quality
y of care for women