At Home May, 2010 With Mass Home Care Vol 23 #5 Al Norman, Editor

Governor Releases

Elderly Funds After more than 3 ½ years of wait-ing, a key piece of the Equal Choice law of 2006 has fi nally been partially funded. In a short note to contractors, Secretary of Elder Affairs Ann Hartstein, and Mass Rehabili

House Ways & Means Chairman Charles Murphytation Commissioner Charles Carr announced the release of $2.5 million that had been impounded since last fall, hindering the expansion of a pro-gram called the “Long Term Care Options” Program. “We are pleased to announce the implementa-tion of the expansion of the Long Term Care Options Counseling Program, to all Aging and Disability Re-source Consortia (ADRCs) across the state,” the EOEA/MRC letter stated. “As you know, this is an initiative supported by the passage of the Equal Choice bill, en-acted through Chapter 211 of the Acts of 2006. Over the past year, the Options Counseling program has helped to advance the state’s Community First agenda in three

At Home May, 2010 2geographic areas by ensuring that individuals in need of long term support services have the information and decision support that they need to make an informed choice about where and how they receive services. This expansion across the Commonwealth will help to ensure access to consumers seeking relevant infor-mation about long term support options and decision support at a variety of points in the planning process.” With less than 80 days left in the fi scal year, legislative leaders in the House and the Senate began pushing the Patrick Administration to spend $2.5 mil-lion meant for counseling elderly and disabled individ-uals about their options to avoid costly nursing home care---or to explain why the money has not been spent. The genesis of this story goes back to Au-gust of 2006, when then-Governor Mitt Rom-ney signed the Equal Choice law, known as Chapter 211 of the Acts of 2006. That law con-tained in it the following statutory requirement:

“A person seeking admission to a long-term care facility paid for by MassHealth shall receive pre-admission counseling for long-term care ser-vices, which shall include an assessment of com-munity-based service options. A person seeking care in a long-term care facility on a private pay basis shall be offered pre-admission counseling.” This language applies not only to the elderly, but to younger individuals with disabilities as well. This so-called Long Term Care Options pro-gram was initially implemented with only $270,000 in state funding. Three pilot programs for pre-admission counseling were established, and the program was ad-ministered at the local level by Aging and Disability Resource Consortia (ADRCs), comprised of Aging Ser-vices Access Points and Independent Living Centers. In FY 2010, the General Court increased the funding base for the Options program, by insert-ing the following language into the state budget: “provided further, that not less than $2,500,000 shall be expended from this item to implement the provi-sions of section 2 of chapter 211 of the acts of 2006, the pre-admission counseling and assessment pro-gram, which shall be implemented on a statewide ba-sis through aging and disability resource consortia;” It appeared initially that the Patrick Administra-

tion would implement this language. In August of 2009, the Executive Offi ce of Elder Affairs issued a draft memo allocating $2.5 million across the state to the Aging and Disability Resource Consortiums, as directed by the legislature. EOEA required each ADRC to “hire a mini-mum of 2 full-time equivalents who will be primarily responsible for the provision of long term care options counseling services. A total of 11 grants were ready for implementation, along with a budget estimate for FY 2011 as well. That draft plan was never implemented.

Elder Affairs Secretary Ann Hartstein Instead, on November 13, 2009, A&F Sec-retary Jay Gonzalez wrote to the House and Senate Ways and Means Chairs asking for "additional fi s-cal stability legislation concerning....additional leg-islation to resolve MassHealth's defi ciency." Sec-retary Gonzalez said that MassHealth was facing a $307 million defi ciency, and he listed out some savings categories in MassHealth including: "a) pre admission counseling: eliminates an ear-mark to educate elders and disabled individu-als about alternatives to facility living. The fed-

At Home May, 2010 3eral Medicare plan already requires hospitals to include this information in their discharge planning." The Administration was asking lawmakers to strike out the language providing not less than $2.5 M for pre admission counseling, but keeping the actual funds in the budget. In this way, the Administration could use the funds for other programs within the MassHealth line item. But the General Court never acted on Secretary Gonzalez’s memo, and never gave the Governor authori-zation to move the Options funding into other programs. Months passed and none of the $2.5 million was released. When the General Court began processing a sup-plemental budget for FY 2010, the issue of funding for the Chapter 211 counseling mandate rose to the surface again. State Representative Alice Wolf, House Chair of the Elder Affairs committee, drafted an amendment to the supplemental budget which required the $2.5 million for Options to be spent, or for the Governor to explain why he was unable to spend the funds. The House ad-opted Wolf’s amendment and sent it over to the Senate. On the Senate fl oor, Elder Affairs Committee Chairwoman Pat Jehlen introduced similar language to that of her co-chair, Rep. Wolf. “This amendment would require the administration to explain what hap-pened to the $2.5 million they were required to spend on preadmission counseling,” Jehlen said. “That pro-gram is still limited to only three pilot programs. The goal is to keep people safely at home rather than in nursing homes. This simply asks them to report why they didn’t spend this money on preadmission coun-seling and what they spent it for. I think we deserve an explanation…I want to make a special remark about home care services because the waiting list in home care is over 3,000 now. We have a longer waiting list in home care than we have had in 35 years. Some of those people are going to be OK. Some of those peo-ple will lead more stressful lives. Some of those peo-ple will face dilemmas, accidents that will cause them to spend the rest of their lives in rehab. Home care is one of the best investments we can make. Preadmis-sion counseling catches people before they go home from a hospital. I ask that we approve this amendment, which just requires reporting on why counseling hasn’t

been required.” Jehlen’s amendment was adopted 37-0. On April 8, 2010, House Ways & Mean Chairman Charles Murphy sent a note to Health & HumanServic-es Secretary JudyAnn Bigby urging the administration to put the $2.5 million out to the network. “I would sug-gest to you,” Murphy wrote, “that the [budget] language is unambiguous in its intent and clear as to your obliga-tion….The language in the budget relative to pre-admis-sion counseling does not leave much to interpretation. The legislature passed, and the Governor signed, a bud-get requiring the money to be spent to assist our seniors in staying in their homes rather than moving to a nursing home. As the administration acknowledged….the pro-gram saves a signifi cant amount of money each year.”

House Elder Affairs Chair Rep. Alice WolfMurphy ended his letter by asking EOHHS:

“Please provide me specifi c information on how the administration intends to fund the pre-admission coun-seling program before the end of this fi scal year.” Six days later, Elder Affairs and Mass Rehab announced that the Options funding would be released.

“This is a win-win for the Governor as well as for elders and persons with disabilities,” said Mass Home Care President Paul Lanzikos. “It helps direct seniors back into their community, where they want to be, and it saves taxpayers the cost of a nursing facility bed.” Lanzikos said implementing Equal Choice has been a top priority of Mass Home Care. “We don’t want any-one to go into a nursing facility who doesn’t need to be there,” Lanzikos added. “Nursing facilities should only be used by people who really need that kind of service.

House Budget: On the Level

On April 14, 2010, the House Ways and Means Committee released its FY 2011 state budget. For elderly services, the House bud-get closely mirrored the Governor’s House 2 budget released at the end of January. Most line items for the elderly were level-fund-ed at the same level recommended by the Governor---which leaves a number of key line items signifi cantly below FY 2009 levels. Many of the elderly line items took a hit in FY 2010, either because of legislative cuts, or due to Gubernatorial 9c cuts. For example:• Home Care was cut by $10 million in FY 2010 (home care and care management) and that $10 mil-lion cut remains in place for FY 2011. There are cur-rently 2,500 people waiting to get into home care, and the House Ways & Means budget ensures that there

will be waiting lists with us until the end of June, 2011.• The enhanced home care program (ECOP) is also level-funded, which means that the $2.3 mil-lion cut to ECOP will remain in place and wait lists in this program will likely occur in FY 2011.• The protective services program is level-funded, which means that the $1 million cut the elder abuse pro-gram took at the hands of the Governor in FY 2010 will remain in place for FY 2011. This account is already under-funded by roughly $3 million, so continued tri-aging of investigations and other program reductions will take place unless more funding is made available.• LTC Options: In the large Medicaid account, 4000-0600, House Ways & Means continues funding for ‘not less than $2.5 million” for the LTC Options counsel-ing program, part of the Equal Choice law. The Pat-rick Administration announced that it will release the $2.5 million for Options that had been impounded (see lead story). For FY 2010, only two months of fund-ing is being released, or $702,000 in Options funding. • Spouse as caregiver: The HWMs language in the 4000-0600 account allows spouses to be paid as caregivers for the fi rst time---but only in the “Caring Homes” project, which is the Level II tier of the Adult Foster Care program. This same provision was includ-ed in the House budget for FY 2010, but was elimi-nated in the fi nal conference committee budget when the House and Senate went to reconcile their versions. According to House Ways & Means Committee Chairman Charles Murphy, this budget makes $1.4 billion in cuts from expected maintenance funding to various line items, agencies, and programs. None of those cuts come from these elderly line items. In ef-fect, FY 2011 would be a mirror image of FY 2010---but this locks in signifi cant cutbacks that were made in FY 2010. Level-funding means further cutbacks, because the cost of doing business, the cost of la-bor, health care insurance, and other operating costs---all will be increasing. The home care, enhanced home care and protective services programs will be most affected by the lack of any increased funding. In response to these funding levels, three amendments were fi led to support elderly needs: 1. Protective Services: Representative Alice

Wolf (D-Cambridge), who chairs the House Elder Affairs committee, along with Representative David Sullivan (D-Fall River) fi led an amendment that re-stores the elder abuse/protective services line item to the level recommended by the House in its FY 2010 budget: $16.246 million and then adds $1 million to the line item, bringing it to $17.246 million. This line item is used to investigate reports of elder abuse and for the case work necessary to resolve the abuse. In FY 2010, the Governor used his 9c power to cut the protective account back to $15.246 million, so the fi rst million added to this account is to wipe out the ongo-ing impact of the Governor’s 9c cut. Nearly 80% of the cuts made to the protective services program were made to staffi ng for protective services investigators.

State Representative Kate Hogan 2. Enhanced Home Care: Chairwoman Wolf also fi led an amendment that would add $1 million to the Enhanced Community Options Program. This would partially restore the $2.41 million that was cut from this program in FY 2010. This program is especially critical because it is targeted exclusively to people who are nursing facility eligible but who can stay in the community. They are also elders who are not yet on MassHealth. If they are in the ECOP program, they can avoid “spending down” their income to become

MassHealth enrollees. This budget request is slightly higher than the $46.21 million expected spending level for ECOP in FY 2010---a year in which a waiting list was in place for roughly half the year. There may still be some waiting lists in this program in FY 2011 at this re-quested funding level, but $1 million will allow an ad-ditional 96 elders per month into this critical alternative to a nursing facility. Roughly 5.5 elders can be placed in the ECOP program for the cost of 1 elder placed in a nursing facility. The annual cost of the ECOP program is roughly 18% of the cost of a nursing facility bed.3.Home Care Wait List: Representative Kate Hoganof Stow fi led an amendment to the home care purchased services line item that would partially address the wait-ing list in this program. There are approximately 2,500 people waiting to get into the home care program to-day. Based on level-funding in the House budget, there is little prospect that the waiting lists will be substan-tially reduced. This means that elders being placed on a waiting list will face waits of 6 months or longer to get home care. Many will need care before that, and will either have to pay out of pocket for their care, or go without. Some will require nursing home care—which is almost 18 times more expensive than maintaining a home care placement. This budget amendment would allow an additional 625 elders to get into home care—which would reduce the current waiting list by 25%. “While we recognize that this is a diffi cult budget year,” said Paul Lanzikos, the President of Mass Home Care, “we wouldn’t be doing our job if we did not support amendments like these. House Ways & Means Chairman Charles Murphy has been much attuned to the needs of elders, and has been a good friend to home care programs. Mass Home Care will push for seniors every opportunity we get. It’s the only way we can inch the line forward.” House budget debate begins the week of April 26th.

Elderly Dental Care: “Overwhelming Needs”

The dental health needs of the elderly are markedly different from the rest of the population.

That’s one of the conclusions of a state re-port released last fall on the “Great Unmet Need” of dental care in the Commonwealth. Here are some of the highlights regarding the elderly and dental care:• By 2030, people over the age of 65 will comprise 21% of the state’s population.• Seniors make up an increasing portion of the population who are at greater risk for oral disease.• Edentulism, or complete tooth loss, is the principle oral health indicator to deter-mine dental health for adults aged 65 or older.• 14% of Massachusetts elders are edentulous---but this is less than the 22% average nationally.• The elderly not only have increased risk of oral disease, but also lack access to oral health care. Financial barriers stem from individuals that are homebound, on fi xed in-comes, have Medicare coverage, or lack dental coverage.• 27% of MassHealth members over the age of 60 and 45% of eligible residents in LTC facili-ties, and those who participate in state subsidized meal sites show overwhelming oral health needs.• 65% of residents in nursing homes have some natural teeth• 59% of seniors with teeth in nursing homes have untreated decay, with 7% having urgent dental needs. • 18% of edentulous seniors in long term care facilities have no dentures’• 34% of seniors at meal sites have untreat-ed decay, with 4% having urgent dental needs• About one in 5 (19.8%) seniors at meal sites have not visited a dentist in at least 5 years On April 12th, a group of advocates released a new plan for improving the oral health of Massachu-setts residents at a State House press conference. For the elderly, this is a serious concern, given the limited dental coverage offered by MassHealth and Medicare. In 2000, a Special Legislative Commission on Oral Health released a report titled The Oral Health Crisis in Massachusetts, outlining fi ve major recommendations for legislators, policy-makers, com-munity advocates and residents to improve the oral health of the Commonwealth. In the same year, the federal government released Oral Health in Ameri-ca: A Report of the U.S. Surgeon General, alerting Americans to the importance of optimal oral health in their daily lives. While much progress has been

made in oral health in Massachusetts over the last decade – for example, covering many more low-in-come people for dental care through MassHealth and more than doubling the number of community health center dental providers, much remains to be done. Created in 2008, the Better Oral Health for Massachusetts Coalition is working to improve the oral health of all Massachusetts residents. The Coalition is a broad-based statewide collaborative of programs, providers (dentists, dental hygienists, physicians and other health providers), lawmakers, state oral health offi cials, insurers, health advocates, policy leaders and consumers in communities from Cape Cod to the Berkshires. Mass Home Care mem-ber Highland Valley Elder Services is represented on the Coalition by Executive Director Robert Gallant.

The Coalition has one full-time staff and a facilitator sponsored by the DentaQuest Foundation. With a focus on improving access to care for all, reducing disparities and promoting equity in Mas-sachusetts’ oral health, the Coalition has fi ve goals: � Increase access to oral health services and pre-vention. � Promote positive policy, advocacy and public awareness concerning oral health. � Strengthen, diversify and expand Massachusetts’ oral health workforce. � Promote and support ongoing statewide assess-ment and surveillance systems.

� Form a clear oral health action plan that incor-porates at least all of these elements. The Coalition held its fi rst meeting in June 2008. Over 200 individuals involved in oral health in Massachusetts, including community programs and organizers, dentists, dental hygien-ists, physicians, professional organizations, legisla-tors and policy makers from Massachusetts and other New England states attended this leader-ship summit to discuss opportunities and concerns. The Oral Health Plan for Massachusetts was developed by four working groups with more than 100 individuals. In the coming months, Coalition members will focus on achieving the plan’s goals and objectives. This will require developing the organizational capacity to choose priorities, direct resources, and implement action steps outlined in the plan. Coalition members have agreed to con-tinue working together and to engage additional partners in making the transition from an ad hoc working coalition to a more permanent organization. According to the Coalition, the state has “made great strides” in improving oral health in the Commonwealth over the past 10 years. “But there is much more to be done, especially to protect the oral health of our most vulnerable residents. There re-main signifi cant regional, racial and ethnic dispari-ties in access to dental care and dental outcomes.” The Coalition says the ‘good news’ is that preven-tion works: “We all learned that brushing and fl ossing is im-portant for a healthy mouth, as are regular dental checkups.” “As much as I am impressed with the work of the Coalition, it is depressing to record the need and the oral health challenges elders face” says Robert Gallant of Highland Valley Elder Services. “As we marvel at the condition of the 1.5 million year old Sediba Fos-sil’s teeth, we have to hope that the Coalition’s recom-mendations can be implemented so we can give peo-ple 100 year’s worth of teeth and good oral health!” For the elderly, dental care needs are very dif-ferent from the school-age population. It has cultur-ally been acceptable that older people will lose their teeth and need dentures, which is a negative health outcome that has been defi ned as acceptable—even inevitable. Many seniors believe that needing den-

tures is an acceptable outcome, and lack of den-tal care earlier in their lives has led to that outcome. A 2009 report from the Massachusetts Depart-ment of Public Health found that 14% of Massachu-setts elderly residents have complete tooth loss, which is below the national average of 22%. Some seniors are especially vulnerable. Among seniors living in nurs-ing homes, 59% were found to have untreated decay. A study of lower income seniors at state-subsidized meal sites found that 35% of seniors had untreated decay. Diabetes contributes to lost teeth also: 74% of residents with diabetes have lost teeth to oral disease or decay, compared to 42% of those without diabetes. The Oral Health Plan focuses on improving data collection on oral health needs, advocating for improved access, eliminating disparities across the lifespan, inte-grating oral health into all aspects of health education and care, improving access to preventive, restorative and rehabilitative oral health services for vulnerable and diverse populations, and educating the public about the connection between oral health and general health. One of the goals of the Plan is to improve access to dental care for “older residents living independently, in nursing homes and in assisted living residences.” The Plan seeks to increase access also for “people with special health care need, including people with disabili-ties and people living with HIV/AIDS.” The Plan also seeks to increase the number of people on MassHealth who receive preventive, restorative and rehabilitative dental care. Part of that goal is to increase from 34% currently to 65%, the number of licensed dentists who accept MassHealth patients. That will require increas-ing the reimbursement for dental services provided under MassHealth to the 75th percentile of the Ameri-can Dental Association Survey of General Dentists. Dental care for the elderly today re-mains a “great unmet need” that will cost mon-ey to improve. But the cost of letting a deplor-able situation decay further, is far more costly

Senate President: The End Of Fee-For-Service

On April 14th, the same day that the House Ways & Means budget was released, State Senate President Ther-

ese Murray gave a speech to the Boston Chamber of Com-merce about health care reform. The speech was billed as a major policy pronouncement by the Senate President.Here are excerpts from President Murray’s remarks: “We all know we have to get our economy back on track. The effects of the global fi nancial crisis have been apparent, but Massachusetts is better off than most states. That’s because of our foresight and prior efforts to boost our capital program, make the tough budget decisions, and maintain a healthy stabilization account which has preserved our strong double-A bond rating.

Senate President Therese Murray We have continued to build on our stable eco-nomic foundation cemented by world-renowned higher education and medical institutions. We have cultivat-ed a vigorous biotech and life sciences sector that is expanding, even in this recession; we have commit-ted to new industries in biofuels and renewable en-ergy; and our commitment to reforms in education and transportation are also producing positive results. We’ve stopped the economic freefall, but recovery will be gradual and come at a very slow pace. Our biggest challenge now is creating jobs. Just last week, the Senate passed signifi cant legislation to restructure and streamline the state’s

network of agencies charged with helping business-es grow and getting new businesses off the ground. We have also taken steps to reduce our corporate tax rate from 9.5 percent to 8 percent over the next three years. And to further help businesses along, we have frozen the rate schedule for unemployment insurance. In addition, I recently proposed a package of new tax initiatives to create a more favorable and stable business tax climate in Massachusetts that pri-oritizes new and small businesses. Small businesses are the job producers in our state. So, we must fi nd a way to help them. Health care costs are the biggest roadblock. Costs are squeezing small businesses to the point of layoffs and in many cases outright extinction. Stabilizing and controlling health care insurance costs for small businesses is essential to improving our economy and growing jobs. The Department of Insur-ance recently imposed a cap on insurance premiums, which has resulted in a stand-off that threatens to leave businesses and individuals in limbo. It was a shot across the bow and a warning that something must be done, but we’ve come too far to be stymied by prolonged litigation. Just as we did with Health Care Reform in 2006, we need to bring all stakeholders – lawmak-ers, insurers, providers, doctors, businesses and consumers – together to address the cost crisis. It’s an issue my staff and I work on every day. It’s chal-lenging and complicated, but critically important for our short-term and long-term economic growth. Between 2006 and 2008, health care costs in Massachusetts grew by 15.5 percent, or 7.5 percent each year. But many small businesses have seen in-creases far in excess of 7.5 percent and continue to see increases, making it impossible to retain health care coverage for employees while also making new invest-ments or hiring new employees. This has to change. But as we tackle this issue, we must also keep in mind that our health care industry accounts for a sig-nifi cant portion of our gross state product. In fact, hos-pitals make up nine of our state’s 25 largest employers, and 50 of our largest 250 employers. Our health care industry draws in hundreds-of-millions of dollars from out of state and the federal government; and it attracts the most skilled nurses, doctors, surgeons, specialists and researchers in the world. It’s an obvious strength

that we must protect as we make necessary changes. In the federal health care debate, Massachusetts health care reform has been used as a political symbol for out-of-control government spending. The facts, howev-er, tell a different story. While health care costs have risen substantially throughout the Commonwealth and the na-tion, these costs are not attributable to health care reform. Senator (Steven) Panagiotakos and our Sen-ate Ways and Means committee recently worked with the Mass Taxpayers Foundation to update analysis of Massachusetts health care reform through the current fi scal year. They confi rmed that costs attributable to health care reform have had only a marginal impact on state spending. The average yearly incremental in-crease in the state share of health care reform fund-ing has been only $108 million. These increases are relatively modest and consistent with projections de-veloped at the time Health Care Reform was passed. Since we passed health care reform, we have been pursuing a number of initiatives to control the growth in health care costs. The comprehensive cost-containment bill I passed in 2008 has laid the foundation for this effort by encouraging statewide use of electron-ic medical records and uniform billing, creating greater transparency, reducing administrative overhead, and promoting primary care. Two initiatives in that bill: a Special Commission on Payment Reform and the Hear-ings on Health Care Cost Drivers, which were conduct-ed earlier this month, have provided the data and dis-cussion necessary to move forward in a thoughtful way. Informed by these efforts, and recognizing the need for immediate relief, I am recommending a two-phase approach. Before the Senate takes up the state bud-get next month, we will consider two pieces of legislation:• The fi rst is a comprehensive plan to provide imme-diate relief to small business health insurance costs.• The second is a long-term strategy to begin our transition from a fee-for-service payment sys-tem to a patient-centered, integrated health de-livery system with sustainable cost growth. For the fi rst phase, I have been working with Senator Richard Moore on a proposal that establish-es effi ciency requirements, addresses the current in-stability in the market, reduces year-to-year premium fl uctuations, and ensures that health insurance carriers

offer affordable products to small businesses. While some cost-drivers are beyond direct control of health insurance companies, carriers must be held to a higher standard and a more transparent regulatory structure if we want to provide premium relief to small busi-nesses and eliminate cost-shifting among different-sized businesses. This proposal introduces new re-quirements for health insurance companies that make sure premium dollars are being spent on actual care, not administrative costs such as marketing, salaries or profi t margins. By targeting costs that insurers can control – their own administrative costs – this proposal provides short-term relief to small businesses with-out jeopardizing the long-term solvency, competitive-ness and fi scal stability of the insurance companies. Under this proposal, insurance carriers must fi le premium rates with the Division of Insurance prior to their effective date for review and will have the option of fi ling rates under an Effi ciency Guar-antee. Under the Effi ciency Guarantee option, car-riers must agree that under the rates fi led, not less than 90 percent of the premium dollars will be spent on medical services. This effectively restricts the amount of premium dollars the carriers allocate to their own operations. We will hold them to this promise.If, at the end of the year, the carrier does not meet this standard, then it must submit rebates to small businesses to make up the difference. If, however, carriers choose not to fi le rates with an Effi ciency Guarantee, then they would be subject to a rigorous review by the Divi-sion of Insurance, and premium increases that exceed medical infl ation would be presumptively disapproved. We also need to address underlying drivers of market instability by closing existing loopholes and making technical changes to the oversight of the merged market. For example, there is mounting evidence that people who game the system by purchasing coverage for only expensive treatments and then dropping cover-age are driving up premiums for everyone, including small businesses. This proposal ensures that individuals are purchasing insurance in appropriate, on-going ar-rangements through an annual open enrollment and ac-cessing employer-sponsored coverage where available. We must also address the excessive volatility in the market that leads to 30-to-40 percent increases in

health care premiums for some small businesses. On top of the base annual health care cost increases, current market provisions allow for annual rate adjustments for specifi c groups based on factors such as age, industry and geography. Year-to-year changes in group demo-graphics can contribute to signifi cant premium rate volatility. During economic downturns, as small busi-nesses are more likely to lay-off younger workers, these adjustments can result in dramatic increases for small businesses. This proposal will smooth out these sharp spikes in premium increases and hold down very large increases. This will allow small businesses to plan for the future with more certainty and make hiring and fi r-ing decisions without undue effects on premium costs. Finally, we need to provide more affordable health care products to small business employers. Most health insurance carriers in Massachusetts offer prod-ucts with comprehensive networks that include almost all providers. This contributes to the underlying cost of health insurance products because there is wide varia-tion in provider costs. This proposal requires carriers in the small group market to offer at least one reduced network plan with premiums that are at least 10 per-cent lower than the premiums for the full network product. By requiring carriers to offer and market more affordable products this year, small business employ-ers can immediately reduce costs while maintaining a high-quality health insurance product for employees. By implementing each piece of this proposal, we estimate immediate premium relief of 10-to-15 percent with the possibility of more for small businesses to save and reinvest in themselves and their workforce. Howev-er, these short-term solutions do not address some of the main drivers of health care cost growth over the long-term for all businesses, families and individual consumers. To do that, health care providers need to be part of the conversation and part of the shared sac-rifi ce. Recent reports by the Attorney General and Division of Health Care Finance and Policy iden-tify rising provider prices as the main driver of health care costs. That’s why the second phase of this effort will take on health care payment reform. Together with EOHHS Secretary JudyAnn Bigby and Senator Richard Moore, I am working on legislation that sets the path for Massachusetts to

transform its health care system into an effi cient, ef-fective, integrated, patient-centered delivery system. To drive this change, this legislation will set the goal of ending the fee-for-service payment system for most providers within fi ve years. The current fee-for-ser-vice reimbursement system pays for care regardless of whether services are appropriate or of high qual-ity, and it supports wide variations in health care use and spending. Instead of rewarding providers who try to reduce unnecessary services or shift patients into low-cost settings, the current system actually car-ries the dis-incentive of reduced revenues and profi ts, creating a sizable barrier to delivery reform. Patient care also suffers in the fee-for-service environment.

Under the fee-for-service model, patients can ex-perience gaps in care that often result in avoidable com-plications, or they receive more services often without any benefi t to health outcomes. It encourages overuse of many costly services while short-changing important but less lucrative areas such as primary care and telemedicine. While some providers are anxious about any change that disrupts the status-quo, the truth is that a full range of payment approaches can be designed to support the varying profi les of providers currently op-erating in the Commonwealth. We should examine a range of payment approaches, including global pay-ments. But, as the Attorney General’s recent report

concluded, this effort may not be enough to complete-ly control long-term cost growth and encourage mar-ket competition. This payment reform effort must be matched by a new, independent review of provider/in-surer contracts to make sure they meet our long-term goals and provide value to businesses and health care consumers statewide. There must be greater transpar-ency and accountability of these contracts and the anti-competitive provisions they may contain. This review must ensure reductions in current market disparities, promote standardization in payment methods and qual-ity measures, and make sure overall cost-growth is reasonable as we transition away from fee-for-service. But, this review cannot be done in a “one-size-fi ts-all” approach. Rate caps, rate freezes or statewide bench-marks tied to Medicare cannot recognize the breadth and variety of unique provider institutions that exist in Mas-sachusetts and their different fi scal situations. To do it right will take time. It must include independent experts and individuals with real-life experience in the health care market. And it must be done with the constructive engagement of the entire provider community. Right now, however, we are in a crisis, and small businesses especially cannot wait any longer. … Providers can be a part of the immediate solution for small businesses. One of those providers, Partners Healthcare, has stepped up and offered to make a one-time contri-bution of $40 million to be used exclusively for small business relief. Now I’m calling on other hospitals and provider networks to follow that example and make a contribution to relieve small business health insur-ance costs. The bill I fi le will provide a mechanism to guarantee that any amount put back in the system will be targeted directly at small businesses and used solely to reduce small business health insurance rates. I recognize that some providers are not in a po-sition to contribute. But some can – and their shared sacrifi ce can help restore order to the health care mar-ket. One-hundred-million dollars from the provider community for this voluntary effort would result in additional premium relief of 2.5 percent for all small businesses and individuals for the next year. Com-bined with the other measures I have announced to-day for small businesses, we can create the neces-sary relief to jump start economic growth and move

us into the diffi cult challenge of long-term reform. In closing, I want to recognize that health care is hard. There are no easy answers and no easy solutions. As I’ve said many times, “It is rocket sci-ence.” I do not expect the proposals I introduced to-day to be the end of the conversation on health care cost control, but hopefully it will be the beginning of the end. It is time to get to work and time for real action. – Our economic survival depends on it. For all of the health care executives here to-day – I want you to know that my door is always open, and I will work with you to tackle these chal-lenges. If you have other solutions, we want to hear them. To be successful, we must rebuild the coalition that made health care reform in Massachusetts pos-sible. That coalition of consumers, businesses, provid-ers, insurers, politicians, and Massachusetts citizens set our state – and now our country – on a historic path. When you look at the national health care reform law, it is clear that Massachusetts is the model. On controlling health care costs, Massa-chusetts can be the national model once again.”

Congress Asked To Reverse “Years of Stagnant Funding”

While most attention this month is fo-cused on the state budget for elderly services, a similar battle is being waged in Congress over the federal commitment to help elders live at home. The National Association of Area Agencies on Aging (n4a), which represents 629 area agencies on aging (AAAs) and 246 Title VI Native Ameri-can aging programs in the U.S., has been urging the members of the House and Senate Appropriations Subcommittee to “make the programs that help older Americans get the support they need to age success-fully at home and in their community a top priority.” In a letter sent to the Appropriations com-mittees, n4a lobbied for the following issues: • Invest in Older Americans Act (OAA) programs. The Administration’s signifi cant budget request for the OAA’s National Family Caregiver Support Program, Title III B Supportive Services and the Title VI Native American

aging programs—all part of the Caregiver Initiative—should be the fi rst step. In order to respond to years of stagnant funding for OAA, as the population, demand for services and infl ation continue to grow, however, an increase of at least 12 percent overall will be needed.• Provide adequate resources for Medicare Part D en-rollment assistance and counseling by providing $10 million in FY 2011 funding to AAAs and Title VI Native American aging programs, $7.5 million to Aging and Disability Resource Centers (ADRCs), and $55 million to State Health Insurance Assistance Programs (SHIPs).• Older Americans Act: Historically, AAAs and Title VI Native American aging programs, along with others in the Aging Services Network, coordinate and/or pro-vide these critical home and community-based services to older adults and their caregivers. This system refl ects how people want to age—at home and in the community. It also helps individuals avoid the unnecessary and more expensive institutional care that results in their need tospend down to Medicaid. Given that home and com-munity-based services are estimated to cost one-thirdof the expense of institutional care, these services save money for federal and state governments. As the older adult population continues to grow, it is critical that Congress place greater emphasis on fed-eral policies and programs that strengthen home and community-based services. The OAA is the corner-stone of the nation’s long-term services and supports system, providing older adults with much-needed ser-vices that include home care, congregate and home-delivered meals, adult day care, case management, legal services, transportation and caregiver support. N4a says that the current economic crisis is making it increasingly diffi cult for the Aging ServicesNetwork to even maintain existing services. “The poor economy is creating increased demand forservices, as families struggle to support and care for older relatives and as more older adults struggle tomake ends meet,” said Sandy Markwood, the CEO of n4a. “Yet, state budget crises are forcing severe cuts to the very programs that are in place to help this population. State-funded programs for older adults and caregivers—created to wrap around or fi ll the gaps in federal funds—are facing drastic reductions or even eliminations. Waiting lists are long and grow-

ing. This dire situation only intensifi es the need for federal investment, both in the short and long terms. To support older Americans and their caregiv-ers, n4a is urging Congress to adopt the following fourrecommendations:1. Sustain the capacity of Older Americans Act (OAA) programs by increasing total funding forthese programs by at least 12% above FY 2010 to allow them to keep pace with projectedpopulation growth, price increas-es and escalating demand in FY 2011.

N4a commended the Administration’s signifi cant budget request for the OAA’s National Family Caregiver Support Program, and the Title III B Supportive Servic-es program. N4a encourages appropriators to give spe-cial attention to the Title III B Supportive Services, and Title III-E National Family Caregiver Support Program. OAA Title III B Supportive Services provides fl exible funding to states and local agencies to provide a wide range of needed supportive services to older Americans. Title III B dollars, for example, support senior transportation programs, information and referral/as-sistance services, case management services, home modifi cation and other housing help, chore services, in-home services for frail elderly and emergency/disaster response efforts targeted to older adults. The fl exibil-ity of this funding stream gives agencies greater abil-ity to meet the needs of older adults, as identifi ed at the community level, and often is the bridge between private pay and Medicaid. According to n4a, FY 2011 funding needs to refl ect this vital role with an increase for Title III B of at least 13% over the FY 2010 level.

The National Family Caregiver Support Pro-gram (NFCSP), added to the OAA as Title III-E in 2000,funds programs offered at the community level through the Aging Services Network and their partners,which assist family members caring for their older loved ones who are ill or who have disabilities. TheNFCSP offers a range of services to support fam-ily caregivers, including information about services;assistance in gaining access to services; individu-al counseling, organization of support groups, andcaregiver training; respite care; and supplemental ser-vices as the limited funding allows. These servicesare in high demand in every community yet have limited federal resources. N4a supports the Presi-dent’s request for a 31% increase over last year, for a total funding level of $202,220,000 in FY 2011. N4a has also asked for increases in the Medi-care Part D Prescription Drug Benefi t Program. Con-gress should provide discretionary funding under the Centers for Medicare and Medicaid Services to AAAs and Title VI Native American aging programs in the amount of $10 million and to Aging and Disability Re-source Consortiums in the amount of $7.5 million in FY 2011 to meet the ever-growing need to provide one-on-one assistance and counseling on Medicare Part D. n4a requests that SHIPs receive funding of $55 million in FY 2011, a $10 million increase above FY 2010, in order to effectively continue their Medicare enrollment assistance and one-on-one counseling efforts. Stabiliz-ing these resources under the annual appropriations pro-cess will be especially critical as Medicare benefi ciaries seek assistance in understanding their prescription drug plan options, especially if any changes to the Part D and Low-Income Subsidy (LIS) programs go into effect. N4a says it understands “the diffi cult fi scal con-straints” under which Congress is operating, but adds: “We hope you will make every effort to reverse the ero-sion of—and invest in the future of—the innovative and cost-effective Older Americans Act programs in FY 2011. In a related matter, U.S. Senator Blanche Lin-coln (D-AR) and Senator Debbie Stabenow (D-MI) have circulated a letter to fellow Senators asking the Senate Appropriations Subcommittee on Labor, Health and Human Services to increase funding for the Old-er Americans Act (OAA) by “at least 12% overall.”

According to Lincoln and Stabenow, “The OAA is the cornerstone of the nation’s long term care sys-tem, providing older adults with critical services that include information and referral, home care, home-de-livered meals, adult day care, legal services, transpor-tation and caregiver support. Without these programs, more than 8 million older adults each year would need more expensive institutional care or suffer from hunger, isolation, poor health, neglect, abuse, unem-ployment or other challenges to their quality of life.”

C Congresswoman Blanche Lincoln

The letter notes that OAA funding has not kept up with the OAA mission. “For years, the OAA appropria-tions have failed to keep pace with growth in infl a-tion and the aging population, leading to signifi cant shortfalls even as demand increases.” Only a fraction of the eligible seniors receive benefi ts from the OAA. “The need for OAA programs among older adults and caregivers cannot be greater during these diffi cult economic times,” the Senators write. “There are now nearly 39 million Americans over the age of 65, making up approximately 13% of the total U.S. population. As increasing numbers of older Americans and caregivers face fi nancial trouble, more will come

to need the bedrock programs created by the OAA.” The letter commends the White House’s re-quest for increased funding for the National Fam-ily Caregiver Support Program, and Title IIIB support services as “an important fi rst step,” but says demand for services and infl ation require at least a 12% in-crease in overall funding for the Older Americans Act.

Congress: Long Term Care Has “Gotten Far Worse”

Buried in the 900+ pages of the federal Pa-tient Protection and Affordable Care and Act, is an ad-mission by the U.S. Senate that it has thus far failed to address the major issue of long term care reform. Here is the Section 2406 of the health care reform law, entitled “Sense of the Senate Regarding Long Term Care:” “The Senate makes the following fi ndings: (1) Nearly 2 decades have passed since Congress serious-ly considered long-term care reform. The United States Bipartisan Commission on Comprehensive Health Care, also known as the ‘‘Pepper Commission’’, released its ‘‘Call for Action’’ blueprint for health reform in Sep-tember 1990. In the 20 years since those recommenda-tions were made, Congress has never acted on the report.(2) In 1999, under the United States Supreme Court’s decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals with disabilities have the right to choose to receive their long term services and supports in the community, rather than in an institutional setting.

(3) Despite the Pepper Commission and Olm-stead decision, the long-term care provided to our Nation’s elderly and disabled has not im-proved. In fact, for many, it has gotten far worse.(4) In 2007, 69 percent of Medicaid long-term care spending for elderly individuals and adults with physi-cal disabilities paid for institutional services. Only 6 states spent 50 percent or more of their Medicaid long-term care dollars on home and community-based ser-vices for elderly individuals and adults with physical disabilities while 1⁄2 of the States spent less than 25 percent. This disparity continues even though, on aver-age, it is estimated that Medicaid dollars can support nearly 3 elderly individuals and adults with physical disabilities in home and community-based services for every individual in a nursing home. Although ev-ery State has chosen to provide certain services un-der home and community-based waivers, these ser-vices are unevenly available within and across States, and reach a small percentage of eligible individuals. It is the sense of the Senate that—(1) during the 111th session of Congress, Con-gress should address long-term services and sup-ports in a comprehensive way that guarantees elder-ly and disabled individuals the care they need; and(2) long term services and supports should be made available in the community in addition to in institutions.”

After Health Care Reform The passage of national health care re-form represents just the start of efforts to make the new law actually work for people.A new national group, called the Campaign for Better Care, has been launched. The group says its goal is “a multi-year initiative focused on making health reform work for older adults with multiple chronic conditions.” Funded by the Atlantic Philanthropies, the campaign will focus on improving health care quality, coordination, and communication for older patients with multiple health problems and their family caregivers. One key goal is to build a consumer move-ment of and for older adults and individuals who have multiple chronic conditions and are count-

ing on health reform to provide the patient-cen-tered, comprehensive, coordinated care they need. One of the groups supporting the new or-ganization is the National Council on Aging. In March, NCOA helped to sponsor a national survey of Americans aged 50+. According to that survey:• 74% of people 50+ wish that their doctors talk-ed and shared information with each other; • 33% said their doctors don’t talk to them about po-tential interactions with other drugs or over-the-counter medications when prescribing new medications; and • 20% said they’ve received confl ict-ing information from different doctors. Through the Center for Healthy Aging, the NCOA says it is working to promote evidence-based community programs that teach older adults how to manage their chronic conditions and make healthy lifestyle choices. NCOA also sponsors sev-eral Consumer Health Education programs de-signed to give older adults the tools and information they need to better communicate with their doctors.

The Campaign for Better Care — led by the National Partnership, Community Catalyst, and the National Health Law Program, begins the criti-cal work of convincing policymakers to implement reform in ways that give people the comprehensive, coordinated health care they need--especially older adults and individuals with multiple chronic condi-tions, and those who are sickest and most vulnerable. In communities across the country, patients cope with extraordinary pressures from a health care

system that doesn’t coordinate their care. And family caregivers — including wives, daughters, husbands, sisters, grandchildren, other relatives and friends — struggle to help, often with little or no support. The Campaign says that “doctors should work together as a team, medical records should be at our fi ngertips, and patients and families should not be left to fend for themselves. We get it. There is a better way. And it’s what the Campaign for Better Care is all about.” The group has created a website, www.Cam-paignforBetterCare.org where consumers can be-come part of the “face” of the campaign, by add-ing their photo to the slide show, fi lled with photos and stories shared by real consumers. In April, the Campaign produced an advertising blitz on Capi-tol Hill to welcome Congress back from recess and to remind them that now the hard work begins!

Social Security Rights For Same-Sex Couples

On April 11, 2010, state and local offi cials joined hundreds of people outside the Los Ange-les Gay and Lesbian Center in Hollywood to kick off a national grass-roots campaign demanding equal Social Security benefi ts for same-sex couples, ac-cording to an article in the Los Angeles Times. The rally was called the “Rock for Equal-ity” and was organized by the center and the Na-tional Gay and Lesbian Task Force, with help from the Aids Community Action Founda-tion. An estimated 700 people attended the event. Congresswoman Linda T. Sanchez (D-Lake-wood), who is a member of the House Subcommit-tee on Social Security, attended the Los Angeles rally, and said that she plans to fi le a bill that would give equal Social Security benefi ts to same-sex couples as those extended to heterosexual couples. "I don't think it's right that Americans should be treated differently by the country they love because of who they love," Representative Sanchez told the crowd. "Right now, same-sex marriage couples pay equally into a system that they don't receive equal benefi ts from in return.

Shame on this country for allowing that to happen." Under current Social Security law, the sur-viving partner in a same sex couple receives no ben-efi ts from their deceased partner, because the federal government does not recognize same-sex marriages or domestic partnerships as valid relationships, un-der the federal Defense of Marriage Act (DOMA). Sanchez's bill would require Social Security Adminis-tration to treat civil unions and domestic partnerships as valid relationships on the same footing as other spou-sal relationships, for the purpose of disbursing survi-vor benefi ts that married heterosexual couples receive.

Photo: L.A. Times"I'm saying to the Social Security Ad-

ministration, this must stop," Sanchez said.Another Congresswoman from California, Judy Chu (D-El Monte), offered to cosponsor the bill with Sanchez. "In 1935, President Franklin D. Roosevelt signed the Social Security Act as a law to protect the elderly from poverty. It was a great moment, but the act wasn't perfect," Chu told the crowd. “In 1966, members of the armed services were added. In 1983, federal employees were added. And, in the year 2010, that will be the year people from the LGBT community will be added,” Chu said.

Obama: Allow Hospital Visitation Rights to LGBTs

On April 15th, President Barack Obama sent a memo to the Secretary of Health and Human Services, Katherine Sebelius, directing her offi ce to draft rules

for hospitals that accept federal funds that will lead to the right for lesbian, gay, bisexual and transgender families to visit their loved ones in civilian hospitals. The President’s memo says that “hospi-tals may not deny visitation privileges on the ba-sis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability.”Once the rules go into effect, they are in effect un-til Congress acts on legislation that is signed by the Executive Branch, or until the President issues another memorandum requesting a rule change.

Here is the text of the White House memorandum: “SUBJECT: Respecting the Rights of Hospi-tal Patients to Receive Visitors and to Designate Sur-rogate Decision Makers for Medical Emergencies There are few moments in our lives that call for greater compassion and companionship than when a loved one is admitted to the hospital. In these hours of need and moments of pain and anxiety, all of us would hope to have a hand to hold, a shoulder on which to lean -- a loved one to be there for us, as we would be there for them. Yet every day, all across America, patients are denied the kindnesses and caring of a loved one at their sides -- whether in a sudden medical emergency or a prolonged hospital stay. Often, a widow or wid-ower with no children is denied the support and com-fort of a good friend. Members of religious orders are sometimes unable to choose someone other than an immediate family member to visit them and make medical decisions on their behalf. Also uniquely af-fected are gay and lesbian Americans who are often barred from the bedsides of the partners with whom they may have spent decades of their lives -- unable to be there for the person they love, and unable to act as a legal surrogate if their partner is incapacitated. For all of these Americans, the failure to have their wishes respected concerning who may visit them or make medical decisions on their behalf has real con-sequences. It means that doctors and nurses do not al-ways have the best information about patients' medica-tions and medical histories and that friends and certain family members are unable to serve as intermediaries to help communicate patients' needs. It means that a stressful and at times terrifying experience for patients is senselessly compounded by indignity and unfair-

ness. And it means that all too often, people are made to suffer or even to pass away alone, denied the com-fort of companionship in their fi nal moments while a loved one is left worrying and pacing down the hall. Many States have taken steps to try to put an end to these problems. North Carolina recently amended its Patients' Bill of Rights to give each pa-tient "the right to designate visitors who shall receive the same visitation privileges as the patient's imme-diate family members, regardless of whether the vis-itors are legally related to the patient" -- a right that applies in every hospital in the State. Delaware, Ne-braska, and Minnesota have adopted similar laws. My Administration can expand on these important steps to ensure that patients can receive compassionate care and equal treatment during their hospital stays. By this memorandum, I request that you take the following steps:

1. Initiate appropriate rulemaking, pursuant to your authority under 42 U.S.C. 1395x and other relevant provisions of law, to ensure that hospitals that par-ticipate in Medicare or Medicaid respect the rights of patients to designate visitors. It should be made clear that designated visitors, including individuals des-ignated by legally valid advance directives (such as durable powers of attorney and health care proxies), should enjoy visitation privileges that are no more re-strictive than those that immediate family members enjoy. You should also provide that participating hos-pitals may not deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual ori-entation, gender identity, or disability. The rulemak-ing should take into account the need for hospitals to restrict visitation in medically appropriate circum-

stances as well as the clinical decisions that medical professionals make about a patient's care or treatment.2. Ensure that all hospitals participating in Medicare or Medicaid are in full compliance with regulations, codi-fi ed at 42 CFR 482.13 and 42 CFR 489.102(a), promul-gated to guarantee that all patients' advance directives, such as durable powers of attorney and health care proxies, are respected, and that patients' representatives otherwise have the right to make informed decisions regarding patients' care. Additionally, I request that you issue new guidelines, pursuant to your authority under 42 U.S.C. 1395cc and other relevant provisions of law, and provide technical assistance on how hos-pitals participating in Medicare or Medicaid can best comply with the regulations and take any additional appropriate measures to fully enforce the regulations.3. Provide additional recommendations to me, within 180 days of the date of this memorandum, on actions the Department of Health and Human Services can take to address hospital visitation, medical decision making, or other health care is-sues that affect LGBT patients and their families. This memorandum is not intended to, and does not, create any right or benefi t, substantive or procedur-al, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its offi cers, employees, or agents, or any other person.

BARACK OBAMA”

Michael J. WidmerMass Home Care’s

27th Annual MeetingMonday, June 21st. 11:30 AM

for invitations, email: info@masshomecare.org