Source: Nursing Economics
Massachusetts health care reform: lessons for the nation? An interview with Thomas Smith
Despite a national policy agenda crowded by efforts to deal with the recession, the federal budget, energy policy, auto bailouts, the Iraq and Afghanistan wars, and a flu pandemic, momentum is growing to enact legislation to reform the nation's health care delivery system. While it is unclear whether legislation will be passed and whether reform will be comprehensive or iterative, there is little doubt that policymakers and the media will closely examine the experiences of Massachusetts, the one state that has already enacted comprehensive reform.To learn more about Massachusetts health care reform, I talked with Tom Smith, who is the chief nursing officer at the Cambridge Health Alliance (CHA) in Cambridge, MA. CHA is a public, academic health system affiliated with Harvard Medical School, and includes three acute care hospitals and 20 primary care sites that serve seven communities in metropolitan Boston. Annually, CHA provides more than 700,000 ambulatory care visits and discharges nearly 18,000 inpatients. Prior to joining CHA, Tom served as the CNO for 9 years at The Mount Sinai Hospital in New York City.
Q: When did the Massachusetts health reform begin, and what are its goals?
A: The Health Care Access and Affordability Act was enacted in April 2006 to achieve three goals: enhance the quality of care, increase access, and lower the costs of health care. If you asked people 5 years ago if these goals were achievable, most would have said "You have to be kidding." Yet, we were able to pull it off because, from the outset, key stakeholders came together: elected officials, citizens, providers, the business community, health care organizations, the insurance industry, labor unions, and the health professions. There was a sincere effort to build consensus among stakeholders which sustained the momentum needed to achieve health care reform, and perhaps even set a model for the nation.To increase access to health care, the reform expanded the state's Medicaid program, provided subsidies to low-income individuals, created a new public coverage program called Commonwealth Care, established a "connector" to help individuals sign-up for a private insurance option, implemented an individual mandate that required all residents to purchase insurance or pay a tax penalty to the Commonwealth, and required employers to either provide health insurance or pay a fee to the state on an annual, per-employee basis.These changes resulted in nearly 450,000 newly insured individuals of whom 57% are enrolled in Commonwealth Care and 43% have private insurance. Increasing coverage required a shared commitment of state government, employers, the private insurance industry, and individuals. You may recall that the bipartisan appeal of our reform originated with a Republican governor, Mitt Romney, and has continued with the current governor, Democrat Deval Patrick, who took office in early 2007, 9 months after the health reform legislation was passed.Nursing Input
A: The Health Care Access and Affordability Act was enacted in April 2006 to achieve three goals: enhance the quality of care, increase access, and lower the costs of health care. If you asked people 5 years ago if these goals were achievable, most would have said "You have to be kidding." Yet, we were able to pull it off because, from the outset, key stakeholders came together: elected officials, citizens, providers, the business community, health care organizations, the insurance industry, labor unions, and the health professions. There was a sincere effort to build consensus among stakeholders which sustained the momentum needed to achieve health care reform, and perhaps even set a model for the nation.To increase access to health care, the reform expanded the state's Medicaid program, provided subsidies to low-income individuals, created a new public coverage program called Commonwealth Care, established a "connector" to help individuals sign-up for a private insurance option, implemented an individual mandate that required all residents to purchase insurance or pay a tax penalty to the Commonwealth, and required employers to either provide health insurance or pay a fee to the state on an annual, per-employee basis.These changes resulted in nearly 450,000 newly insured individuals of whom 57% are enrolled in Commonwealth Care and 43% have private insurance. Increasing coverage required a shared commitment of state government, employers, the private insurance industry, and individuals. You may recall that the bipartisan appeal of our reform originated with a Republican governor, Mitt Romney, and has continued with the current governor, Democrat Deval Patrick, who took office in early 2007, 9 months after the health reform legislation was passed.Nursing Input
Q: Was the nursing profession involved when health reform was being proposed and debated?
A: Indeed. Many nurses participated in advocacy groups or through the efforts of their employer. One group was particularly active, Affordable Care Today, which is composed of nurses, physicians, labor unions, hospitals and health systems, the faith-based community, and others. Among labor unions representing nurses, SEIU1199 has been the most active within this coalition. The Massachusetts Nurses Association, which is the largest union representing nurses in the state, chose not to be involved as it favored a single-payer system. The Massachusetts Organization of Nurse Executives partnered with the Massachusetts Hospital Association to emphasize the need for strong outreach efforts aimed at increasing the number of people with health insurance.
A: Indeed. Many nurses participated in advocacy groups or through the efforts of their employer. One group was particularly active, Affordable Care Today, which is composed of nurses, physicians, labor unions, hospitals and health systems, the faith-based community, and others. Among labor unions representing nurses, SEIU1199 has been the most active within this coalition. The Massachusetts Nurses Association, which is the largest union representing nurses in the state, chose not to be involved as it favored a single-payer system. The Massachusetts Organization of Nurse Executives partnered with the Massachusetts Hospital Association to emphasize the need for strong outreach efforts aimed at increasing the number of people with health insurance.
Q: Did nurses' involvement shape the design of the reform legislation or its subsequent implementation?
A: In my judgment, nurses influenced the values that shaped health reform and some of its design principles, particularly the goal of improving the quality of care. Early on nurses emphasized that a reformed delivery system needed to include wellness, prevention, chronic disease management, coordination, and continuity of care. These are the areas where the profession's voice was loudest, most compelling, and had the most influence.I think that many nurses believe that reform has created a significant opportunity to influence ongoing efforts to change the way care is organized and delivered in the state. For example, as nurses we believe that patients and families should be more active in self-management of health or illness, and thus need to have the skills and motivation to engage in their own care. In this regard nursing interventions are essential, including education, guidance, and goal setting. For advanced practice nurses, I am optimistic that a current statewide shortage of primary care physicians will provide an opportunity to meet patients' needs by increasing the number and contributions of nurse practitioners. Nurses have already made a positive impact and their contributions will only become more prominent as reform evolves.
A: In my judgment, nurses influenced the values that shaped health reform and some of its design principles, particularly the goal of improving the quality of care. Early on nurses emphasized that a reformed delivery system needed to include wellness, prevention, chronic disease management, coordination, and continuity of care. These are the areas where the profession's voice was loudest, most compelling, and had the most influence.I think that many nurses believe that reform has created a significant opportunity to influence ongoing efforts to change the way care is organized and delivered in the state. For example, as nurses we believe that patients and families should be more active in self-management of health or illness, and thus need to have the skills and motivation to engage in their own care. In this regard nursing interventions are essential, including education, guidance, and goal setting. For advanced practice nurses, I am optimistic that a current statewide shortage of primary care physicians will provide an opportunity to meet patients' needs by increasing the number and contributions of nurse practitioners. Nurses have already made a positive impact and their contributions will only become more prominent as reform evolves.
Q: How well do you the think the goals of health reform have been accomplished?
A: The state has been very active in education and public outreach aimed at enrolling people into private insurance products or the public insurance system, particularly the disenfranchised and the uninsured, many of whom had not received needed care in years. A recent study showed that about a year and a half into health care reform, the number of low-income residents without health insurance who said they had not received needed care in the prior 12 months decreased by nearly 40%. The objective of providing access to residents has been achieved and, in fact, has probably exceeded expectations. The latest data show that all but about 3% of the state's 6.5 million population is now insured. This outcome has been touted nationally and state officials have connected with policymakers and the new administration in Washington about our success with this goal.However, with respect to improving the quality of care, the picture is not as clear. The Health Care Quality and Cost Council was created under health reform and is chaired by The Secretary of the Executive Office of Health and Human Service. Two nurses were appointed to this council, including an advanced practice nurse. The council, now integrated with another state agency, adopted six goals to lower health care costs while improving quality and reducing ethnic and racial health disparities. Examples include reducing hospital-associated infections and eliminating serious reportable events as defined by the National Quality Forum. Some promising data are beginning to emerge. For example, an Urban Institute study showed that post-reform low-income adults in Massachusetts were more likely to have an identified location of care and a completed encounter with a provider for preventive care (Long, 2008). While not quality indicators per se, obtaining preventive care and using a consistent location to receive care are proxies for continuity, which has been shown to improve health outcomes. But, health reform is a work in progress and we are going to have to wait and see what evaluation studies learn about whether and how quality of care has improved.
A: The state has been very active in education and public outreach aimed at enrolling people into private insurance products or the public insurance system, particularly the disenfranchised and the uninsured, many of whom had not received needed care in years. A recent study showed that about a year and a half into health care reform, the number of low-income residents without health insurance who said they had not received needed care in the prior 12 months decreased by nearly 40%. The objective of providing access to residents has been achieved and, in fact, has probably exceeded expectations. The latest data show that all but about 3% of the state's 6.5 million population is now insured. This outcome has been touted nationally and state officials have connected with policymakers and the new administration in Washington about our success with this goal.However, with respect to improving the quality of care, the picture is not as clear. The Health Care Quality and Cost Council was created under health reform and is chaired by The Secretary of the Executive Office of Health and Human Service. Two nurses were appointed to this council, including an advanced practice nurse. The council, now integrated with another state agency, adopted six goals to lower health care costs while improving quality and reducing ethnic and racial health disparities. Examples include reducing hospital-associated infections and eliminating serious reportable events as defined by the National Quality Forum. Some promising data are beginning to emerge. For example, an Urban Institute study showed that post-reform low-income adults in Massachusetts were more likely to have an identified location of care and a completed encounter with a provider for preventive care (Long, 2008). While not quality indicators per se, obtaining preventive care and using a consistent location to receive care are proxies for continuity, which has been shown to improve health outcomes. But, health reform is a work in progress and we are going to have to wait and see what evaluation studies learn about whether and how quality of care has improved.
Q: Has reform had an impact in controlling the growth of health care costs?
A: Lowering health care costs is one of the biggest challenges. Frankly, the costs of health care have not decreased and, in fact, have exceeded projections. In the first year of implementation spending exceeded projections by $153 million. More recently, the recession has made it even more difficult to lower costs. Ironically, part of the reason costs have increased is that the number of people enrolled surpassed expectations. Even though cost control has not been achieved to the degree people want, public support for health reform does not appear to have weakened. To turn the corner on costs, we need to reform the payment system so that models and systems of coordinated care and primary care are more highly rewarded and promoted.
A: Lowering health care costs is one of the biggest challenges. Frankly, the costs of health care have not decreased and, in fact, have exceeded projections. In the first year of implementation spending exceeded projections by $153 million. More recently, the recession has made it even more difficult to lower costs. Ironically, part of the reason costs have increased is that the number of people enrolled surpassed expectations. Even though cost control has not been achieved to the degree people want, public support for health reform does not appear to have weakened. To turn the corner on costs, we need to reform the payment system so that models and systems of coordinated care and primary care are more highly rewarded and promoted.
Q: How has the Commonwealth financed the cost of health reform? Have taxes increased?
A: Taxes have not increased, at least not yet. Funds have been redistributed from various programs and Medicaid reimbursement rates have decreased. The Commonwealth has also received stimulus monies from Washington. There is also an expectation that reform will lead to greater efficiency, which we are working hard to obtain. Lowering costs is proving to be a daunting goal!
A: Taxes have not increased, at least not yet. Funds have been redistributed from various programs and Medicaid reimbursement rates have decreased. The Commonwealth has also received stimulus monies from Washington. There is also an expectation that reform will lead to greater efficiency, which we are working hard to obtain. Lowering costs is proving to be a daunting goal!
Q: As a chief nurse executive of a highly regarded major safety-net institution, how have you experienced health reform?
A: Like other safety-net hospitals, CHA is experiencing major payment reductions and significant financial shortfalls. Initially, we were concerned that some people, now that they had health insurance, might transfer their care to other organizations. However, our patient volume has actually increased and we are meeting the needs of a large safety-net population. Our patients are diverse--linguistically, racially, and ethnically--and have complex health care needs which we are determined to meet. CHA has a strong reputation for providing high-quality care and a track record of innovation in designing and delivering patient care services that are culturally sensitive and respond to the needs of the communities we serve. Our doors are always open and we never refuse to treat a patient who comes to us as long as we provide the services they need. Our mission and promise to improve the health of our communities is always first and foremost in everything we do.That said, we face a financial reality in which nearly 85% of our total patient service revenue is publicly financed. Unfortunately, payments from Medicaid and other governmental sources do not come anywhere near meeting our costs, and the gap between payment and actual costs is widening. That is a significant concern for all hospitals that care for Medicaid patients, but since we care for such a large proportion of such patients, the impact has been extremely challenging. Although, we support the principles of health care reform, financially we have taken a big hit.To survive, we are consolidating several primary care sites and inpatient services. We are also intending to close our inpatient addictions service later this year because we are paid approximately 20 cents on every dollar it costs us to provide this care. This is unfortunate because this is a needed service, so we are looking at developing new partnerships with community agencies so that our patients receive the care they require and deserve.During the past year, we have had to freeze hiring for nurses and other employees. We have been making numerous changes to reduce expenses and become more efficient so that we can preserve jobs and minimize the devastating impact of layoffs and personnel reductions.I find it helpful to take a long-term point of view when thinking about health care reform. This allows me to be positive and optimistic about our institution's future because we are truly evolving the way health care should be organized. We are providing more care in ambulatory and community-based health settings, and we have a first-rate clinical information system that connects our providers within ambulatory settings to our inpatient units. This is working out so well that we are exploring opportunities with the Commonwealth's Executive Office of Health and Human Services to participate in demonstration projects which will promote many of the principles of health care reform, especially continuity, collaboration, and coordination. If we can weather the financial storm, which has been made worse by the lousy economy and decreasing payments, then I think we will lead the way in demonstrating how to more effectively organize and deliver health care.
A: Like other safety-net hospitals, CHA is experiencing major payment reductions and significant financial shortfalls. Initially, we were concerned that some people, now that they had health insurance, might transfer their care to other organizations. However, our patient volume has actually increased and we are meeting the needs of a large safety-net population. Our patients are diverse--linguistically, racially, and ethnically--and have complex health care needs which we are determined to meet. CHA has a strong reputation for providing high-quality care and a track record of innovation in designing and delivering patient care services that are culturally sensitive and respond to the needs of the communities we serve. Our doors are always open and we never refuse to treat a patient who comes to us as long as we provide the services they need. Our mission and promise to improve the health of our communities is always first and foremost in everything we do.That said, we face a financial reality in which nearly 85% of our total patient service revenue is publicly financed. Unfortunately, payments from Medicaid and other governmental sources do not come anywhere near meeting our costs, and the gap between payment and actual costs is widening. That is a significant concern for all hospitals that care for Medicaid patients, but since we care for such a large proportion of such patients, the impact has been extremely challenging. Although, we support the principles of health care reform, financially we have taken a big hit.To survive, we are consolidating several primary care sites and inpatient services. We are also intending to close our inpatient addictions service later this year because we are paid approximately 20 cents on every dollar it costs us to provide this care. This is unfortunate because this is a needed service, so we are looking at developing new partnerships with community agencies so that our patients receive the care they require and deserve.During the past year, we have had to freeze hiring for nurses and other employees. We have been making numerous changes to reduce expenses and become more efficient so that we can preserve jobs and minimize the devastating impact of layoffs and personnel reductions.I find it helpful to take a long-term point of view when thinking about health care reform. This allows me to be positive and optimistic about our institution's future because we are truly evolving the way health care should be organized. We are providing more care in ambulatory and community-based health settings, and we have a first-rate clinical information system that connects our providers within ambulatory settings to our inpatient units. This is working out so well that we are exploring opportunities with the Commonwealth's Executive Office of Health and Human Services to participate in demonstration projects which will promote many of the principles of health care reform, especially continuity, collaboration, and coordination. If we can weather the financial storm, which has been made worse by the lousy economy and decreasing payments, then I think we will lead the way in demonstrating how to more effectively organize and deliver health care.
Q: As prospects for national health care reform increase, what advice would you offer hospital chief nurse executives?
A: At the end of the day, health care reform is really about improving quality and trying to control costs, and nurses need to step up and contribute in both areas, particularly in improving quality where we have unique insight, experience, and public support. Reform has helped me appreciate the importance of linking nursing practice to quality, measuring quality, and becoming more sophisticated in quality improvement methods. The Institute of Medicine's six aims to improve the quality of health care systems (safe, effective, patient-centered, efficient, equitable, and timely) have become very meaningful to me. With health reform, nursing's role in primary care will expand and nurses are likely to have increased team coordination and integration roles. The nursing profession needs to get much better prepared to take on these challenges.Finally, should my fellow CNOs experience health reform in their state like we have here in Massachusetts, I encourage them to learn all they can about health reform; get involved early on; advocate within their organization, community, and profession; adopt a long-term perspective; stick to the core values of what health reform is all about; and realize that they can exert a powerful influence on improving health care for all people.
A: At the end of the day, health care reform is really about improving quality and trying to control costs, and nurses need to step up and contribute in both areas, particularly in improving quality where we have unique insight, experience, and public support. Reform has helped me appreciate the importance of linking nursing practice to quality, measuring quality, and becoming more sophisticated in quality improvement methods. The Institute of Medicine's six aims to improve the quality of health care systems (safe, effective, patient-centered, efficient, equitable, and timely) have become very meaningful to me. With health reform, nursing's role in primary care will expand and nurses are likely to have increased team coordination and integration roles. The nursing profession needs to get much better prepared to take on these challenges.Finally, should my fellow CNOs experience health reform in their state like we have here in Massachusetts, I encourage them to learn all they can about health reform; get involved early on; advocate within their organization, community, and profession; adopt a long-term perspective; stick to the core values of what health reform is all about; and realize that they can exert a powerful influence on improving health care for all people.
Tom, thank you for your time. I wish you all the best in your efforts to help improve health care delivery, assure the financial well-being of the CHA, and promote the interests of nurses in Massachusetts.
