Highlights

• Paid Family Leave
• ACS Caregiver Resource Guide
• Boston Shelter Accessibility
• BMC Lifeline for Parents of those with SUDs
• Medicare Ambulance Coverage
• MassHealth and HSN Provisional Eligibility Ending
• MassHealth Ombudsman
• AHA Guidelines on Treating SUDs Patients

Sections

• Program Highlights
• Health Care Coverage
• Policy & Social Issues
• Of Clinical Interest - The Opioid Crisis

Questions, comments about the newsletter? Contact Ellen Forman, 617-726-5807.

The RIDE’s paratransit pilot with Uber and Lyft was scheduled to end at the end of June, but T officials said this month that they plan to continue it indefinitely while they figure out a 2.0 version.

The pilot is continuing to grow at a fairly rapid pace. Ben Schutzman, the T’s director of innovation and the overseer of the RIDE said the number of customers signed up to use the ride-hailing apps is growing 6 percent a month while the number of trips provided by the apps is increasing 7 percent a month.

The price to the user is generally less ($2 per trip plus any charges over $15) and the T’s average cost is far less ($46 with the traditional RIDE versus $9 with the ride-hailing apps).

Schutzman said the ride-hailing apps allow the T to offer much better service at lower cost. But he said the popularity of the apps has prompted users to use them to take a lot more trips, which has erased any potential savings.

Schutzman and his colleagues have been more focused recently on transitioning the overall paratransit service to a new vendor. The T concluded last year that the old vendor, Global Contract Services, was not up to the job of consolidating three control and call centers into one, so the transit agency hired a company called TransDev in April to take over. The transition to TransDev was completed this month, and Schutzman said the process went smoothly, with next to no service disruptions.

-See the full Commonwealth Magazine article.

The wide-ranging “grand bargain’’ bill signed by Governor Baker this month makes Massachusetts just the third state in the country to approve both a $15 minimum wage and mandatory paid family and medical leave.

The law will also impose a small payroll tax on workers and employers to pay for the leaves.

The Legislature passed the comprehensive bill to block three ballot questions from going before voters in the fall. The legislation will raise the minimum wage to $15 from $11 over five years, increase tipped wages to $6.75 an hour from $3.75 over five years, and create a paid family and medical leave program.

Workers will be eligible to take up to 12 weeks of paid family leave to care for a new child or 20 weeks of paid medical leave to deal with a serious injury or illness for themselves or family members.

The program would be paid through a 0.63 percent payroll tax that would, on average, cost $4 to $4.50 a week per employee, split roughly 50-50 between worker and employer. Employees would see a deduction in their paychecks starting next summer, with the leave benefits available beginning in 2021.

An employee’s compensation under the program would be a percentage of salary, capped at $850 a week.

As part of the compromise that worker advocates reached with business groups, the bill would also gradually eliminate time-and-a-half pay for retail workers on Sundays and holidays and create an annual sales tax holiday weekend.

New York and California are the only other states that have approved a $15 minimum wage and paid leave.

The pay hike would raise wages for roughly 1 million workers in Massachusetts, including those who currently make more than $15 an hour, who would get a bump once those below them got a raise, according to the left-leaning Economic Policy Institute. This is about a third of the state’s workforce, the majority of whom are adults with full-time jobs.

Paid Family Leave FAQs

Who benefits from this?

Virtually every employee who qualifies for unemployment insurance is eligible for paid leave. Municipalities are exempt, but they can opt in.

My company already offers paid leave. Does the law apply to us?

Employers that already provide paid leave can opt out, as long as the benefit they offer meets or exceeds the state plan.

How much time can I take off from work?

Workers receive up to 12 weeks of paid family leave to care for a new child, and up to 20 weeks of medical leave if they or a family member has a serious illness or injury. The maximum aggregate amount allowed in a year is 26 weeks.

How much pay can I receive?

The amount is based on a sliding scale of your income, capped at no more than 64 percent of the state average weekly wage. Currently, that limit is $850 a week.

How is this going to be funded?

Companies will be charged a 0.63 percent payroll tax, split roughly 50-50 between employees and employers, which goes into a state fund. Employers with fewer than 25 workers don’t have to pay into it, but employees will still have to contribute their portion of the tax.

So how much is this going to cost me?

On average, each employee will have between $2 and $2.50 a week taken out of his or her paycheck. This amount could go down as the program is implemented.

When does it go into effect?

The tax will kick in next summer, and paid leave benefits will become available in 2021.

How do I qualify?

Workers file a claim with their employer, 30 days in advance of the requested leave, if possible, including the date, reason, anticipated duration, and medical documentation. The first seven days are not covered but can be paid for by sick or vacation time.

-See the full The Boston Globe coverage:

• Original article
• Paid Family Leave- What you should know (FAQs)

The US Department of Veterans Affairs (VA) has tracked detailed quality statistics on its nursing homes for years but has kept them from public view, depriving veterans of potentially crucial health care information. Nearly half of VA nursing homes nationwide — 60 — received the agency’s lowest ranking of one out of five stars as of Dec. 31, 2017, according to documents obtained by USA Today and The Boston Globe.

The VA finally made some of its ratings public this month after receiving questions from the Globe and USA Today about all the secrecy. VA officials claimed that President Trump wanted to release the ratings all along and blamed the Obama administration for not making them public earlier.

Statistics the VA has not released paint a picture of government nursing homes that scored worse on average than their private sector counterparts on nine of 11 key indicators last year, including rates of antipsychotic drug prescription and residents’ deterioration. In some cases, the internal documents show, the VA ratings were only slightly worse. In others, such as the number of residents who are in pain, the VA nursing homes scored dramatically worse.

The VA facility in Bedford and another in Brockton were the only one-star nursing homes out of six in New England.

But VA officials argued that the nursing home system overall “compares closely” with private nursing homes despite caring for typically sicker residents. VA spokesman Curtis Cashour called it “highly misleading” to compare pain levels at the VA to private nursing homes because VA residents have more challenging medical conditions. The VA quality tracking found that its nursing home residents were five times more likely to report being in pain than private nursing home residents. “We are committed to continuous improvement efforts in all of the [VA nursing homes] and demonstrating performance that is as good [as] or better than private sector facilities,” Cashour said.

The VA’s hospitals have drawn intense criticism for repeated scandals with veterans’ health care in recent years, including preventable deaths, but the agency has largely operated its nursing homes with scant public scrutiny. VA nursing homes serve 46,000 veterans annually in 46 states, the District of Columbia, and Puerto Rico.

Internally, the agency has long monitored care at its nursing facilities through quality indicators and unannounced inspections, and, since 2016, through star rankings based on the indicators. But until now, it has kept all of these quality measures from the public.

Under federal regulations, private nursing homes are required to disclose voluminous data on the care they provide. The federal government uses the data to calculate quality measures and posts them on a federal website, along with inspection results and staffing information. But the regulations do not apply to the VA.

USA TODAY and The Boston Globe are now publishing the full data, outlined in internal documents, for every VA nursing facility as of Dec. 31, 2017. Search the data.

-See the original full Boston Globe article and the follow-up story including the data search.

The Massachusetts state individual mandate remains in place, even though the federal government will be ending penalties for people without health insurance starting in 2019. This means that Massachusetts residents continue to need to have coverage that meets state standards in 2018 and beyond, or they could face penalties at tax time.

Since 2007, Massachusetts has had a state mandate that preceded the federal ACA mandate and will continue to be in effect even as federal penalties go away. Under the mandate here in Massachusetts, if a resident has access to affordable coverage that meets state standards but does not get covered, they could face the potential of paying a penalty on their taxes in the next year. Penalties range from $22 to $119 per month without health insurance, or $264 to $1,428 for a full year.

The individual mandate includes a requirement that residents buy health insurance plans that meet state standards called Minimum Creditable Coverage. If a plan does not meet those standards, which outline required benefits (such as hospitalization, prescription drugs, and mental health services) and set limits on some out-of-pocket costs, a resident covered by that plan could still pay a penalty.

Most people in Massachusetts get their health insurance through their work, and the majority of employers make sure they are providing plans that meet the state requirements. Some people get insurance on their own, either through a carrier or from the Health Connector or MassHealth. All of the plans offered by the Health Connector and MassHealth meet the state’s requirements, and all plans offered by Massachusetts-based insurance carriers meet these requirements, too. You can make sure your plan meets Minimum Creditable Coverage requirements by contacting your carrier directly.

For more information on the state’s individual mandate, Minimum Creditable Coverage, and penalties for not having coverage, visit the Health Connector’s website and check out its “Stay Covered” initiative at www.MAhealthconnector.org/stay-covered.

The Massachusetts Health Connector has launched a "Stay Covered" campaign to make clear the continuing state-level individual mandate and related market standards.

What is the "Stay Covered" campaign?

The Stay Covered campaign is designed to renew clear messaging to Massachusetts residents, employers, and brokers about our state's continued individual mandate and the continuing standards for coverage here in the Commonwealth. The goal is to reduce confusion resulting from national news about Affordable Care Act individual mandate penalties being eliminated starting in 2019. It is also a precaution regarding insurance products for individuals and small businesses that may not meet state standards.

What resources are available to help educate Massachusetts residents?

The Health Connector has launched a  "Stay Covered" webpage. This webpage houses educational/awareness-raising resources for consumers, employers (including resources for small businesses) and brokers.

Mixtures of cocaine and a powerful synthetic opioid are increasingly tied to fatal overdoses, prompting concerns among health officials who are warning about the deadly concoction.

Newly released data show that cocaine and fentanyl were present in nearly half of the 351 fatal overdoses reported in Massachusetts in the last three months of 2017, according to the state Department of Public Health.

More than 2,000 people died of opioid overdoses last year.

Health officials are warning first-responders and clinicians about the presence of fentanyl in cocaine, which can create a fatal mix. Because cocaine is more widely used than heroin, many users may be unaware of the risks of using a small amount of the drug laced with fentanyl, health officials say.

A public health advisory said the overdoses likely include cases of people who knowingly used the mixed drugs as well as some who were “unknowingly exposed to fentanyl that was present in cocaine.”

The agency warned that using fentanyl-laced cocaine or crystal meth puts users at higher risk from overdose death than heroin addicts.

"People who use cocaine, who do not have tolerance to opioids and are not familiar with the risks of opioid overdose, are at exceptionally high risk of an opioid overdose when using cocaine with fentanyl present," health officials wrote. "Similar risks could emerge among people who use methamphetamine."

Health officials encourage first-responders to continue to use the overdose-reversing drug naloxone to revive patients if there's a likelihood that fentanyl was involved.

"Even though naloxone is not effective in treatment of drug overdoses caused by non-opioids, such as cocaine and methamphetamine, the administration of naloxone may be helpful in drug overdoses caused by a combination of stimulants and opioids like fentanyl," the health department said.

Lowell officials are circulating outreach and prevention materials that recommend safe cocaine use. The "WARNING" fliers -- created by the Substance Abuse and Prevention Division out of the Lowell Health Department in collaboration with the city's Mayor's Opioid Epidemic Task Force -- advise cocaine users to not use the drug alone in isolated areas. In addition, they recommend having Naloxone, also known as Narcan, present when using cocaine.

"Cocaine users think they're immune to a fentanyl overdose, but that's simply not the case," said former City Councilor Corey Belanger, who chairs the Opioid Epidemic Task Force. He added. "The game has changed. This is dangerous."

The other recommended actions on the fliers include: Immediately stop using cocaine and calling 911 if you experience unusual side effects, and immediately calling 911 and then administering Narcan if you witness an overdose.

-See the full The Salem News article.
-See the full Lowell Sun article.

Despite Boston’s massive housing crunch and rents that are some of the nation’s highest, hundreds of new affordable housing units may be sitting empty as city officials work to find tenants. That’s according to City Councilor Annissa Essaibi-George, who said as many as 839 apartments for low- and middle-income residents may be vacant. On Wednesday, she called for a hearing on the issue.

She and some developers said the sometimes months long vacancies result from a complex process for screening tenants and awarding the prized units — and from a city bureaucracy that is understaffed for the current building boom.

The Walsh administration quickly pushed back, saying that most of the 839 apartments the councilor cited are under construction. But City Hall agreed the process for awarding apartments has become bogged down in paperwork and pledged to beef up staffing to handle the backlog.

“Yes, it has at times taken months for units to get filled,” said Sheila Dillon, Walsh’s housing chief. “We want to make sure that they are occupied as soon as they’re ready.”

The debate highlights the complex mechanics of creating affordable housing in Boston. The city requires 13 percent of the units in most new buildings — and more in some neighborhoods — to be rented or sold at prices deemed affordable to lower- and middle-income residents. The program has created about 1,400 units of housing since 2014, with nearly 800 more under construction.

Those units are typically marketed and leased by the buildings’ developers and property managers, but the process is overseen by the city’s Office of Fair Housing and Equity, which reviews marketing plans and supervises lotteries for the units that sometimes draw hundreds of applications.

And despite a surge in the number of both apartments and applications, Fair Housing, Dillon said, has the equivalent of just 1½ full-time staffers assigned to the task. So starting next week, Dillon said, the Department of Neighborhood Development, which she heads and which runs most of the city’s affordable housing programs, will take over and add several staffers. “We’re going to work our way through the backlog,” she said. “And we’re going to set up systems so this doesn’t happen again.”

-See the full The Boston Globe article.

Immigration officials in Massachusetts may once again arrest undocumented immigrants who show up for appointments at government offices, marking the reversal of a February directive that had halted the practice, according to a filing Friday in US District Court in Boston.

The policy change was revealed in an affidavit filed by Rebecca Adducci, who took over June 7 as interim director of US Immigration and Customs Enforcement’s Boston field office.

Adducci said that while the Boston office will “continue to prioritize enforcement efforts toward the apprehension and removal of criminal aliens and those who pose a danger to the community or to the national security of the United States, no classes or categories of removable aliens are exempt from enforcement, including detention.”

Her affidavit was part of a filing in a civil case brought by five couples suing the Trump administration and the Department of Homeland Security over the arrests of immigrants who showed up for hearings at government offices.

The couples are represented by the ACLU and the Boston law firm WilmerHale, which filed the suit earlier this year.

Adriana Lafaille, a staff attorney for the ACLU of Massachusetts, said that in light of Adducci’s policy change, immigrant families might be afraid to show up to appointments or interviews with US Citizenship and Immigration Services.

“This goes to the heart of what we’re fighting for,” Lafaille said. “These are American families trying to seek stability, trying to come out of the shadows, and bring themselves under the law through a process that the government has itself set out. We will be continuing to fight for that process to be protected and for it to be available to those families.”

The case brought by the five couples is rooted in a process created by the government in 2016 for non-citizens living in the US to seek lawful status through spouses who are US citizens, Lafaille said.

She said that since last year, “the administration is no longer respecting those regulations and has basically been pulling a bait and switch on the families that are trying to avail themselves of this process.”

One woman in the suit, Lilian Calderon, was arrested in January at a government office in Rhode Island after officials told her she could begin the application process for legal status as they believed her marriage was legitimate, the Globe previously reported. She remained in jail for almost a month.

In May, the former acting director of the ICE Boston field office, Thomas Brophy, told Judge Mark Wolf, who is presiding over the case, that he ended the practice of in-office arrests in February.

-See the full The Boston Globe article.

The new ACS Caregiver Resource Guide is an interactive, online guide that provides information on cancer, caregiver self-care, patient nutrition, coping, support groups, and much more, including an 18-question quiz to gauge a caregiver's stress level. Topics include information of interest to patients as well such as information on employment rights, health insurance, caring for your children and understanding cancer and treatment.

-From Lindsay Nicholson, ACS, June 27, 2018.

MGH Physical Therapy’s exercise physiology intern, Samantha Wilson, from UMass Boston, has surveyed Boston area homeless shelters about accessibility for people with disabilities. Physical Therapy has generously shared this new list. Social Service staff can find the list under Adult/Individual shelters on our Shelter page or see the direct link.

-Many thanks to Karon Konnor and Alison Squadrito, PT, DPT for sharing this resource.

Boston Medical Center’s Grayken Center for Addiction is teaming up with the national nonprofit Partnership for Drug-Free Kids to provide free resources and advice to parents whose adolescent or adult children are struggling with addiction.
The new arrangement will link parents to the Partnership’s resources, including “parent coaches” — and enhance those resources for Massachusetts residents. “Parents either are getting no advice or bad advice, or often are left to their own devices,” said Michael Botticelli, Grayken Center executive director.

To help them, the two organizations established a new joint website: graykenaddictionsupport.org from which parents can immediately connect with a master’s-level specialist by phone, text, e-mail, or live online chat. They can also reach specialists through a dedicated phone and text help line for Massachusetts families (844-319-5999 or text HOPEMA to 55753).

The specialists will, when appropriate, connect the parents with the Partnership’s “parent coaches” — parents who either lost a child to addiction or have a child who is in recovery, and who are trained in guiding other parents in the most effective approaches to dealing with a child’s substance use disorder.

The Partnership currently has more than 200 trained parent coaches, according to Fred Muench, president and CEO of the Partnership for Drug-Free Kids. Twenty-one of the coaches live in New England, including 12 in Massachusetts.

Massachusetts callers will be referred to a parent coach based in New England, and as demand grows, additional Massachusetts coaches will be trained and brought online. Parent coaches undergo a three-day in-person training program and continue with supervision over the phone for six months.

The Partnership provides help in Spanish and English. With the Grayken Center collaboration, Massachusetts residents will be able to take advantage of Boston Medical Center’s translation services for dozens of languages.

-See the full Boston Globe article.

Mayor Joseph Curtatone recently announced the hiring of Ellen Shachter as the City's first Director of the Office of Housing Stability, which will operate as a division of the Mayor's Office of Strategic Planning and Community Development. The Office of Housing Stability aims to serve as the central point of contact for individuals seeking housing opportunities or advice.

Shachter most recently worked as a senior attorney at Cambridge and Somerville Legal Services and brings with her more than 25 years of experience representing low-income families and individuals on housing and public benefits matters with an emphasis on homelessness prevention. She has represented numerous tenant associations in negotiations with public and subsidized housing providers regarding resource allocations, admissions policies, rent policies, relocation policies and eviction practices. Her range of experience also includes both local and state advocacy campaigns to increase inclusionary zoning requirements, authoring materials about tenants' rights, and current roles as a member of the Cambridge Community Preservation Act Committee, the Housing Task Force of Envision Cambridge, and the Affordable Housing Organizing Committee in Somerville.

"I am excited to be working with the City of Somerville to create its new Office of Housing Stability," said Shachter. "Rapidly escalating rents and home prices have led to significant housing instability for Somerville residents, especially those of low and moderate incomes. The Office of Housing Stability will be a central location working to enact policies to preserve and expand affordable housing and ensure that tenants know their rights and are able to access the myriad of housing and homelessness prevention resources in Somerville. The Office will also work to identify and fill gaps in those services, and I look forward to close collaboration with the Somerville non-profit agencies already working so hard to prevent homelessness in the city."

-See the full Somerville Patch article.

The Autism Insurance Resource Center is pleased to announce its new website. This improved site includes comprehensive resources related to medical insurance for autism treatment. 

Content includes:

• Resources  including FAQs about the ARICA, insurance denials and appeals, and information about self-funded (ERISA) plans.
• Fact sheets regarding insurance coverage for autism treatment. Some available in Spanish and Vietnamese.
• Information about upcoming trainings and events This list includes upcoming webinars and presentations by AIRC staff.
• Request individual technical assistance need help finding answers or have problems accessing coverage or treatment? You can contact us here.
• ABA provider directory Here you will find a list of ABA Providers in Massachusetts
• Recordings of past webinars

- From MNIP News, DisabilityInfo.org, June 21, 2018.

Hampden County Sheriff Nick Cocchi this month announced plans to launch the area's only treatment facility for opioid addicts seeking recovery.

In a ceremony before 100 local, county and state officials, Cocchi said his department will soon have a total of 86 beds available in Springfield and Ludlow available for treatment.

The services will be available for addicts who are voluntarily committed under Section 35 of the state law, and not those who have been arrested and sentenced for a criminal offense. At present, the only such treatment facility for the entire state is a 250-bed facility in Plymouth. 

The new treatment facility, called the Stonybrook Stabilization and Treatment Centers of Ludlow and Springfield, will be housed at the Hampden County Correctional Center in Ludlow and the wellness center on Mill Street.

There will be 54 beds available at the county jail for people in the initial stages of treatment, and another 32 beds at Mill Street for those who graduate to more advanced treatment. The facilities are to be in operation within 60 days.

Cocchi said his plan is to expand the number of beds to meet the need for treatment.

For now, the treatment is for men, not women. Cocchi said this is due to a wording in the state law that forbids female patients under Section 35 from being treated at a correctional facility.

The Ludlow jail is obviously a correctional facility, but the Mill Street location is also considered one, he said. Cocchi said that designation makes little sense, especially since the Mill Street site is a minimal security operation to the point of not having locks on doors to residents' rooms.

He said he is lobbying for the legislature to change the wording of the law.

-See the full Mass Live coverage- original article and update.

Medicare Part B covers emergency ambulance services and, in limited cases, non-emergency ambulance services. Medicare considers an emergency to be any situation when your health is in serious danger and you cannot be transported safely by other means. If your trip is scheduled when your health is not in immediate danger, it is not considered an emergency.
 
Eligibility
 
Part B covers emergency ambulance services if: 

• An ambulance is medically necessary, meaning it is the only safe way to transport you
• The reason for your trip is to receive a Medicare-covered service or to return from receiving care
• You are transported to and from certain locations, following Medicare’s coverage guidelines
• And, the transportation supplier meets Medicare ambulance requirements

 To be eligible for coverage of non-emergency ambulance services, you must: 

• Be confined to your bed (unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair)
• Or, need vital medical services during your trip that are only available in an ambulance, such as administration of medications or monitoring of vital functions

Medicare may cover unscheduled or irregular non-emergency trips, but if you live in a skilled nursing facility (SNF), a doctor’s written order may be required within 48 hours after the transport. Medicare may also cover scheduled, regular trips if the ambulance supplier receives a written order from your doctor ahead of time stating that transport is medically necessary.
 
Medicare never covers ambulette services. An ambulette is a wheelchair-accessible van that provides non-emergency transportation. Medicare also does not cover ambulance transportation just because you lack access to alternative transportation.
Note: If you are receiving SNF care under Part A, most ambulance transportation should be paid for by the SNF. The SNF should not bill Medicare for this service.
 
Costs
 
Part B covers medically necessary emergency and non-emergency ambulance services at 80% of the Medicare-approved amount. In most cases, you pay a 20% coinsurance after you meet your Part B deductible ($183 in 2018). All ambulance companies that contract with Medicare must be participating providers.
 
Visit Medicare Interactive to learn more about Medicare’ coverage of ambulance services.

- From As Federal Deficits Increase, so Do Threats to Medicare, Medicare Watch, The Medicare Rights Center, June 28, 2018.

Last October, Centers for Medicare & Medicaid Services (CMS) announced a yearlong extension of time-limited equitable relief, through September 30, 2018, a critical exception for certain Marketplace enrollees who delayed or declined Medicare enrollment. Time-limited equitable relief lifts the burden of lifetime late enrollment penalties and gaps in health coverage for people with Marketplace plans who mistakenly missed signing up for Medicare.

CMS has now expanded this time-limited equitable relief opportunity to include people who are enrolled in Marketplace plans and could have enrolled in Medicare Part B during their Special Enrollment Period (SEP), which was available to them after they lost their or a spouse’s job-based insurance.

What is the assistance/equitable relief?

CMS is offering assistance to certain individuals enrolled in both Medicare Part A (and/or Part C)and the Exchange for individuals and families to drop their Exchange coverage and enroll in Part B without penalty. Further, CMS is offering assistance to certain individuals who dropped or lost their coverage from the Exchange and are paying a Part B late enrollment penalty from their subsequent enrollment into Part B. These eligible individuals can have their penalty educed. Individuals can apply for the special enrollment and reduction in late enrollment penalties during a limited time – it is available now and ends September 30, 2018.

Individuals must request the assistance and provide documentation showing enrollment in the Exchange for individuals and families.

What should people do to take advantage of this offer for assistance?

Individuals who were notified or believe they are eligible for the assistance should contact Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778) or visit their local Social Security office and request to take advantage of the offer of assistance. They can ask for “equitable relief” when they make their request for Medicare Part B enrollment or penalty removal. Individuals should mention that they were dually enrolled in Medicare free Part A and the Exchange and provide the information listed above.

Individuals requesting to enroll in Part B should complete a Part B enrollment form

(Form CMS-40B) available online on Medicare.gov, CMS.gov and SSA.gov. They can complete this form and take it to Social Security with them when they request the assistance.

Individuals who didn’t enroll in Part B during their SEP working aged or disabled also need to show evidence of group health plan (GHP) coverage based on current employment via Form CMS-L564 (Request for Employment Information).

Individuals requesting penalty reduction should mention this assistance (equitable relief) when they visit Social Security.

ALL individuals must bring their documentation of Exchange enrollment and provide it to Social Security when making their request.

To request this assistance, individuals can:

• Call SSA at 1-800-772-1213 (TTY users should call 1-800-325-0778); or
• Visit SSA.gov to find a local Social Security office

More information for advocates: Assistance for Individuals with Medicare Part A and Exchange Coverage Information for SHIPs and Exchange Assisters.

-Adapted in part fromCMS Expands the Extension of Needed Relief for Marketplace Enrollees Who Missed Medicare Enrollment, Medicare Watch, May 31, 2018 | Volume 9, Issue 22.

As reported previously (MassHealth Ending Provisional Income Eligibility, MGH Community News, December 2017), MassHealth has will stop offering Provisional Income eligibility for adults. The implementation of this change originally scheduled February 1, 2018 was delayed. The change will affect adults newly applying or reporting income changes after July 1 (with some exceptions) whose income can't be verified via SSN & data matches.

Currently applicants and members reporting a change in income who are under 65 are enrolled in MassHealth or Health Safety Net based on their self-declared income and if proof of income is needed, they have 90 days to supply it. Starting July 1, this will no longer be true for most adults (there are exceptions for pregnant women, and people eligible based on HIV+ or Breast/Cervical Cancer). Nothing is changing for children or adults whose self-declared income makes them eligible for ConnectorCare. This means to avoid delays in situations where current income cannot be verified electronically via SSN and match with past federal tax returns or Dept. of Revenue data, people should send proof of income along with their application or when they report a change in income. MassHealth still has no easy way to submit proof; they accept documents via fax, mail, or in person. It also will mean more calls to expedite processing in medically urgent situations. And it creates some new gaps in coverage in movement between ConnectorCare and MassHealth.

For more information see MassHealth Ending Provisional Income Eligibility, MGH Community News, December 2017.

Here are some updates related to the approximately 1 million MassHealth members enrolled in mandatory managed care as of March 1, 2018.
Continuity of Care

The continuity of care period during which new plans were required to honor authorizations from the former plan and to pay for ongoing services from former providers no longer in the new plan’s network ended May 31. Some plans may have agreed to longer continuity of care for individual members or for certain services. Be on the lookout for access problems –if a new plan denies or reduces a previously authorized service, the member should be able to get aid pending appeal if time limits are met. Remember decisions of an MCO or ACO Partnership Plan must go through the MCO’s internal appeals process.

Fixed Enrollment

As of Sunday, July 1, MassHealth members who were enrolled in ACOs and MCOs on March 1 will be in their Fixed Enrollment Period.  This means that unless they qualify for an exception, they are locked into their existing plan until March 1, 2019 when the next Plan Selection period begins.   As of June 1 about 20% of those assigned to a new plan March 1 had changed to a different plan during the plan selection period. Fixed enrollment means members who want to change plans can do so only with approval from MassHealth. The rules describing the grounds for changing plans during fixed enrollment and the process for obtaining approval are at 130 CMR 508.003(C)(3)-(5). MassHealth can take up to 30 days to approve or deny, but in practice will expedite decision-making if there is a compelling medical need. Denials are appealable.

Community Partners

MassHealth has notified the ACOs/MCOs about 33,000 members with complex care needs to be assigned Community Partners (Long Term Services and Supports or LTSS providers) after July 1. During the start-up of this new resource MassHealth will largely be controlling CP assignments. Members will receive a letter identifying the Community Partner organization and it will reach out to the member who is free to participate or decline. Right now Community Partners are not available by referral. However, care coordination/ case management is  available directly from the MCOs, ACO Partnership Plans, and for those in the PCC Plan or one of the Primary Care ACOs, the Behavioral Health Partnership.

-Adapted from MassHealth -June Update, Health-announce, on behalf of Vicky Pulos, MLRI, June 22, 2018.

Partners Resources:Staff are encouraged to use the Partners Plan Participation grid for the most recent contracting information for MassHealth and all other payers across Partners entities. The grid can be found on the Partners Payer Information SharePoint.

Starting July 1, 2018, the Disability Policy Consortium which has been operating the One Care Ombudsman program will continue in that role but also take on assistance for members with disabilities or other complex care needs enrolled in other managed care plans including the MCOs, ACOs, and SCO.

Call: 855-781-9898

email: info@myombudsman.org
Or see https://myombudsman.org/ for more information.

-Adapted from MassHealth -June Update, Health-announce, on behalf of Vicky Pulos, MLRI, June 22, 2018.

This month, House Republicans unveiled a 2019 budget proposal that would balance the federal budget in nine years—largely by significantly cutting and fundamentally restructuring Medicare and Medicaid.

This approach is not unexpected. Lawmakers were clear that after passing a costly tax bill that drives up deficits, they would use these higher deficits to justify cuts to programs like Medicare.

In the House budget resolution, they are keeping that promise: the budget would end Medicare and Medicaid as we know them.

In addition to cutting $537 billion from the Medicare program over 10 years, the House plan would transform Medicare into a ‘premium support system,’ in which Medicare’s guaranteed, earned benefit package would be replaced with a fixed-dollar amount (or voucher) that beneficiaries would use to purchase health insurance. This shift would put the 59 million older adults and people with disabilities who rely on Medicare’s promise of affordable, comprehensive health care at risk of higher costs, fewer coverage options, and greater uncertainty.

The House plan would also jeopardize eligibility and benefits for the 74 million Americans with Medicaid—including nearly 12 million low-income Medicare beneficiaries who also rely on Medicaid for critical health care services. The budget would end their guaranteed coverage by transforming Medicaid’s open-ended financing system into a per-capita cap or block grant, severing the federal-state partnership on which the program was built, shifting costs and risks to states and, ultimately, to people who need and provide services. The budget’s changes would cut Medicaid and other health programs by $1.5 trillion over the next decade.

The budget also lays the groundwork for lawmakers to try once again to repeal the Affordable Care Act through the fast-tracked, filibuster-proof reconciliation process, and recommends changes to Medicare Part D that would increase out-of-pocket costs for some beneficiaries. It also proposes adding work requirements in Medicaid and SNAP, and would cut Social Security by $4 billion.

Since this is an election year, the plan is not expected to get much traction. The Senate is unlikely to advance a budget resolution or take up the House version prior to the November elections. However, the budget process could be used by lame-duck lawmakers to push through priority, party-line items later this year.

Despite its uncertain fate, this budget resolution nevertheless serves an important role by outlining Republican House leaders’ fiscal priorities and goals for future legislative action.

-See the full Medicare Rights Center blog post.

The SNAP program is funded and regulated through the Farm Bill. This month the House passed a Farm Bill that, as reported last month (SNAP Cuts Would Harm 2 Million People and Not Save Money, MGH Community News, May 2018) would tighten and expand work requirements.
According to The Food Research & Action Center (FRAC)

• Under this bill, large numbers of working families with children would no longer receive SNAP, there would be a much harsher “cliff effect” in the program, and, in turn, children would be denied access to other essential anti-hunger programs, such as school breakfast and lunch, putting their health and learning at risk.
• Many low-income households, including those that receive SNAP, are often forced to choose between paying heating bills or buying food. The bill slashes the amount of benefits for SNAP households struggling to pay for both utilities and food — to “heat and eat.”
• The bill also seeks to expand dramatically the number of people subject to harsh SNAP eligibility cutoffs by adding unemployed and underemployed parents with older children and adults up to age 60. Currently, time limits apply to able-bodied adults age 18–50 without dependents, many of whom are between jobs or do not have steady enough work to meet the 20-hour per week minimum, often for reasons outside of their control. Others face significant barriers to work, such as lack of job opportunities and lack of transportation to get to the few available jobs.

Conference Committee to Reconcile Versions of Bill

The Senate this week easily passed its farm bill by a vote of 86-11, clearing the way for a conference committee to reconcile differences with the House's version. Key differences between the House and Senate bills set up potentially contentious negotiations between the lawmakers who will be tasked with melding the two versions into one.

Not a single Democrat backed the House bill. Senate Agriculture ranking member Debbie Stabenow (D-Mich.) and Senate Agriculture Chairman Pat Roberts (R-Kan.) charted a much different course on SNAP in the Senate bill, mindful of the fact that a simple majority can’t get a bill across the Senate floor, as well as SNAP's importance to preserving the rural and urban coalition that historically has been essential to passing the big-ticket legislation.

The Senate farm bill avoids the hot-button subject of work restrictions, with Roberts and Stabenow saying repeatedly in recent months that the House’s SNAP proposals would never clear the 60-vote threshold in the upper chamber. Roberts and Stabenow chose instead to make a series of administrative changes to the $70-billion-a-year SNAP program that are designed to tinker with how it works and combat fraud.

Roberts said after the final vote that it was too soon to “get down that road” of predicting how conference negotiations will play out over the differing Senate and House proposals for SNAP, but suggested the Senate hasn’t gotten enough credit for what it would achieve in making changes to root out fraud in the program.

-See the full Politico article.
-See the full FRAC House Bill analysis.

On June 1, 2018, the Trump administration published a series of proposed changes to the regulations governing the Title X family planning program. For nearly 50 years, Title X has been the sole federal grant program dedicated to advancing people’s access to comprehensive contraceptive and related family planning services in the United States. The program ensures patient-centered, voluntary, confidential, and affordable care for the approximately four million people who rely on Title X-supported providers for care annually. Consistent with the program’s emphasis on meeting the needs of those who often experience barriers to care, Title X patients are disproportionately low-income and young; about one-third identify as people of color, and about one in 10 have limited English proficiency. 

The proposed rule revives a series of changes first advanced (but never fully implemented) under President Ronald Reagan, collectively known as the “domestic gag rule.” These changes prohibit abortion referral; undermine patients’ right to unbiased, comprehensive counseling about pregnancy options; and exclude agencies that provide abortion using nonfederal dollars from receiving any Title X funds. Additionally, the proposed rule seeks to fundamentally reshape both the scope of services and the network of entities supported by Title X funds.

Prohibiting Abortion Referral

The proposed rule would bar clinicians from referring pregnant patients to appropriate providers for abortion services. Professional medical associations, including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, state that providers must offer appropriate referrals for needed follow-up care to all pregnant patients, even if a patient requests information on services to which an individual provider personally objects, such as abortion. Indeed, denying or delaying Title X patients’ ability to obtain abortions jeopardizes the health and well-being of those who have decided to terminate their pregnancies. 

The proposed rule also would mandate that all pregnant patients at Title X sites be referred for prenatal and social services (such as infant or foster care, or adoption)—regardless of their wishes.

If a patient explicitly asks to be referred to an abortion provider, the proposed rule gives sites the option to refuse. If a site chooses to comply with the patient’s request, staff would be sharply limited in what information they could offer and how: A physician could provide the patient with a list of providers, all of whom must offer “comprehensive” prenatal care, but only some of whom also provide abortion. Moreover, staff would be barred from distinguishing sites that offer abortion from those that do not, leaving patients to figure that out on their own.     

The proposed rule’s publication triggered a 60-day public comment period, which will surely garner many thousands of responses. The administration must then consider and respond to those comments, after which time the regulation can be finalized. This will all happen under the leadership of the newly appointed head of the Office of Population Affairs, Diane Foley, who was named to the post just days before the proposed rule’s formal publication. Notably, Foley used to head Life Network, an agency that operates antiabortion counseling centers and abstinence-only-until-marriage programs. Foley’s author profile on a Focus on the Family-affiliated website notes that her “passion is to communicate God’s truth in the secular arena … particularly as it relates to sexual integrity and the sanctity of life.” 

-See the full Health Affairs article.

The Social Security Administration (SSA) has released a new study examining why participation rates in disability programs like Social Security Disability Insurance (SSDI) and Supplemental Security Insurance (SSI) vary based on where people live. The study finds that different rates of SSDI and SSI participation can be explained by differences in how prevalent disabilities are in a particular area, as well as by socioeconomic factors. Importantly, the study explicitly refutes the idea that inconsistent administration of these programs (such as differences in allowance and denial rates, or among disability examiners) is the cause of the variation. Arguments about inconsistent administration have been used to incorrectly imply that certain areas of the country are unjustly receiving a disproportionate level of benefits, or the people in those areas are not actually deserving of benefits.

These findings also support previous research by the Center on Budget and Policy Priorities and other experts showing the correlation between health and socioeconomic factors such as wealth and education. People with higher socioeconomic status have better health and longevity outcomes. And places where people are less educated, older, and do more blue-collar type jobs have higher rates of disability. This new study by SSA confirms that the level of health in a particular geographic area is a strong predictor of SSDI participation. For SSI, socioeconomic factors are also important, and help explain participation rates for that program. The study found that participation in SSI by people with disabilities is higher in economically disadvantaged places. This makes sense because in order to qualify for SSI a person must, in addition to having significant disabilities, also have a very low income and minimal assets. 

-From Study Explains Regional Differences in Disability Benefit, Justice in Aging, June 05, 2018.

As leaders of organizations dealing with two of the most difficult chronic conditions to treat – hemophilia and HIV/AIDS – we consistently hear stories about how patients living with these diseases are given the run around by insurers to obtain affordable access to the medications they need to manage their diseases.

It’s an uphill battle; patients are either getting straight out denials, or their insurance company is charging them far more than they bargained for when signing up for coverage. These are some of the same issues legislators currently face as they try to bring new reforms to a bulging health care system in Massachusetts.

We knew the anecdotes, but we wanted to know more – to hear directly from Massachusetts residents about the issues they face each day at the pharmacy counter. So, we went straight to the source and conduced a poll of nearly 400 of our neighbors.

Here’s what we found:

• 1 in 5 have seen themselves or a family member denied a prescription;
• 20 percent have been required to try a medication their insurer dictates, before the medication the doctor ordered will be covered;
• 62 percent have seen a jump in the cost of co-pays. Only 25 percent of that group had advance notice that their costs would go up;
• Nearly 63 percent have been surprised by the cost of a hospital bill, despite having insurance.

We know that a patient’s adherence to their medication goes down as insurers put new barriers up. The insurers know it, too. So, it often feels like they do all they can to stop you from picking up that prescription, from casting doubt that what your doctor prescribes is what you really need, if maybe you can skip a dose, so that you can pay that other bill – that’s how they win the game, the game that they are playing with people’s health.

But despite that shared experience, it seems that many of us don’t know about what’s driving that sticker shock. The answer in many cases? Pharmacy benefit managers, or PBMs. PBMs are middlemen hired by insurance companies to negotiate what drugs will be covered by your insurer and how much you should pay for them.

Seemingly innocuous paper pushers, right? Well, not now. In recent years, these businesses have started to turn huge profits, as they find ways to manipulate the system, and patients to hike their bottom line.

We’re calling on lawmakers to add common sense protections as they try to tackle health care reform this summer. Put a safety net in place to keep patients from being forced to try and fail on medications. Protect the sanctity of the doctor-patient relationship. Put patients first and make these Pharmacy Benefit Managers be upfront about how and why we pay what we pay at the pharmacy.

Rich Pezzillo is executive director of the New England Hemophilia Association. Carl M. Sciortino is executive director of the AIDS Action Committee of Massachusetts.

-See the full opinion piece in Commonwealth Magazine.

With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerangs back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients' care.

In recent years, the government has begun to tackle the problem. In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.

Starting this October, the government will address the other side of the equation, giving nursing homes bonuses or assessing penalties based on their Medicare rehospitalization rates. The goal is to accelerate early signs of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress' Medicare Payment Advisory Commission.

The revolving door is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a typical patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days.

But nursing homes have their own incentives to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes.

Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a "bed-hold" fee when a patient is hospitalized.

None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs at the American Health Care Association, a nursing home trade group.

But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments. "We're always worried the bad nursing homes are going to get the message 'Don't send anyone to the hospital,' " said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

-See the full WBUR story.

Federal officials have rejected proposals from Governor Charlie Baker’s administration to slash costs in the Massachusetts Medicaid program by limiting coverage for some prescription drugs and moving thousands of people off the program.

The Washington-based Centers for Medicare & Medicaid Services, or CMS, said Wednesday that Massachusetts’ request did not meet the agency’s requirements for such changes.

The decision dealt a setback to Baker as he seeks to curb the rising costs of health care in the state budget.

Baker administration officials had sought to exclude certain specialty medications from Medicaid coverage, noting that just 30 high-cost drugs account for more than $600 million in annual spending.

In another cost-cutting move, the governor also proposed changing eligibility rules to shift 140,000 adults off the state Medicaid program and onto other subsidized health plans. The proposal required approval from state lawmakers as well as federal officials; it now has been rejected by both.

Baker proposed the changes last year as part of a package to save millions of dollars in the state Medicaid program, or MassHealth. The taxpayer-funded program provides health coverage for about 1.85 million poor and low-income residents.
But the proposals have met with resistance from lawmakers and advocates who said they worried the state was trying to diminish coverage for families in need.

Administration officials are pursing other initiatives to cut drug costs that need state legislators’ approval but not federal approval, they said. They want to negotiate prices directly with drug makers, for example, and require drug makers to publicly justify prices for expensive drugs.

The costs of the MassHealth program, which exceed $16 billion a year, are split between the state and federal governments.

State officials said MassHealth spending on prescription drugs doubled from $1.1 billion to $2.2 billion in the last five years — making drug costs a prime target for cuts.

Baker administration officials wanted to create an approved list of drugs for MassHealth, similar to the lists used by private health insurers. But CMS said it couldn’t consider that request unless the state dropped out of a federal program that provides drugs discounts.

Not all of the Baker administration’s ideas were rejected by the federal government. CMS approved a requested change to help disabled veterans and their families maintain access to MassHealth coverage- it would exclude state-funded veteran's annuities from countable income for certain applicants.

-See the full The Boston Globe article.

The June 5 release of the Medicare Trustees Report has triggered alarm bell-style media headlines. Dozens of news reports about Medicare’s worsening financial outlook have painted a bleak picture—some bleaker than others, with one boldface headline announcing, “Medicare will go broke three years earlier than expected.”
The “go broke” headline was referring to the report’s projection that the trust fund that pays for hospital services, called the Hospital Insurance (or Part A) trust fund, will be depleted in 2026, three years earlier than projected in 2017.
Let’s set the record straight: First, Medicare is not going broke. Second, the Trustees Report is not even saying that Medicare won’t be able to pay for hospital services.

Even if the Hospital Insurance trust fund were to be depleted, Medicare would still be able to meet 91 percent of its obligations for hospital services. And, as it has done in the past, it could make adjustments to address the remaining shortfall without resorting to draconian changes to the program or imposing large costs on people with Medicare. According to a recent study, “…the [Medicare] trust fund has been projected to reach insolvency within 12 years or less in 22 of the annual reports issued since 1970, six of which predicted that the trust fund would be ‘broke’ within five years or less.” (Emphasis added.)

Some recent innovations in payment and delivery system reforms have shown promise in decreasing costs. Other strategies include ensuring that Medicare does not pay more for services based on the setting in which those services are delivered, and reducing use of services that are not necessary. Medicare should also stop overpaying for prescription drugs. A recent government report shows that brand-name drug prices in Part D increased six times faster than the rate of inflation between 2011 and 2015.

Finally, the latest report’s projection of the trust fund depletion date reflects Medicare’s position as part of a broader, interdependent whole. Medicare functions interdependently within a larger health care and economic system, and changes outside Medicare can affect Medicare’s finances. The Trustees Report projects higher hospital spending in the future and one of the reasons is rising numbers of uninsured persons and rising uncompensated hospital care due to the repeal of the Affordable Care Act’s health coverage requirement. The Report also projects lower revenues going into the Hospital Insurance trust fund because of lower projected Medicare payroll tax revenue—the result of both lower wages as well as lower revenues from taxes on Social Security benefits due to the recent tax cut legislation.

We should not overreact to the recent Trustees Report. Instead, we should use it as a signal to advance what’s working from current innovations and tackle unnecessary spending in Medicare and the broader health care system.

-See the full AARP blog post. 

Social Security Trustees Report

This month the 2018 Social Security Trustees Report was released, confirming that Social Security, which provides critical income to retirees, people with disabilities, spouses, and survivors, is a solid program that can continue to pay benefits into the future. 
With no action from Congress, Social Security can continue to provide 100% of the benefit people are owed until 2034. After that, even if absolutely no changes were made, beneficiaries would still receive 79% of their benefits. But 79% isn’t good enough. With over 21 million people lifted out of poverty thanks to Social Security, Congress needs to ensure that people receive at least what they’d be entitled to under today’s rules. Additionally, we need to work towards expanding benefits to ensure that low-income older adults receiving Social Security are not living in poverty despite working for most of their lives.

There are some simple, and affordable, fixes that can both ensure the long-term solvency of the Social Security Trust Fund and also expand Social Security benefits. Proposals such as the Social Security 2100 Act would, among other things, raise the wage cap so that people with high earnings pay fully into the Social Security system. Currently, high earners only pay into Social Security up to a point, after which they are entirely off the hook. The maximum amount of individual wages taxed in 2018 is $128,000. This means that the CEO of Apple, who had a $3 million salary last year (not including $9 million in bonuses or $89 million in stock), would have paid the same dollar amount in Social Security taxes as two experienced teachers making $65,000 each. 

Much of what the Trustees Report discussed were things we already know, however it also reminded us that we should act now, and encourage Congress to take up the task of ensuring that we are providing sufficient support to the older adults, survivors, spouses, and people with disabilities in our communities who depend on Social Security now and into the future.

-From 2018 Social Security Trustees Report No Cause for Alarm, Justice in Aging, June 13, 2018.

More health care organizations are making that connection between housing and health. Hospitals subsidize apartments for the homeless in Chicago, Orlando and Portland. Insurer United Healthcare has invested millions of dollars in affordable housing projects in Michigan and Wisconsin. And last month Kaiser Permanente, the health care and insurance giant, announced a $200 million investment in affordable housing.

“The real significance is you've got a major corporation saying it's within our business interests to recognize this relationship,” said Kevin Lindamood, CEO of Health Care for the Homeless in Maryland. “We are confident that that kind of thinking will catch on.”

Several studies have shown the economic benefit of supportive housing, for example a program in Los Angeles saved the county 20 percent on medical and social services for those who got housing, after factoring in the cost of the program.

Kaiser plans to focus not only on providing supportive housing for the homeless, but also on preventing the displacement of lower- and middle-income households. Rising rents have forced families to spend a larger share of their incomes on housing, said Nan Roman, president of the National Alliance to End Homelessness.

“Over half of poor households pay more than half their income for rent,” she said. “That leaves very little for everything else. People can't get healthy food, they can't access health care as readily, they're stressed, and all those result in poor health.”

Just building more affordable units isn’t enough, said Nathan Thomas, a peer recovery specialist at Health Care for the Homeless. “The majority of the work, I believe, is keeping someone housed,” he said. Many homeless people have mental health issues or disabilities that make it hard to live independently, he explained. Thomas helps clients like Sidney Bond navigate those challenges.

Local Initiatives

Closer to home, thanks to an $800,000 investment from Boston Medical Center, the Codman Square Neighborhood Development Corp says it wants to turn a row of downtrodden buildings called near Fields Corner into a paragon of well-being.

"Only about 10 to 20 percent of health is actually determined by what type of health care you get," says Dr. Megan Sandel, one of the leaders of BMC’s housing initiative. "Much more [significant are] the social determinants of health -- where you live, what your environment is like. And so more and more we're starting to screen for people's social determinants."

The Waldeck buildings represent one of nine investments for BMC -- a total of $6.5 million the hospital has designated for housing in some of Boston’s poorest areas. Advocates say BMC’s investment is part of a burgeoning shift among health care leaders to view housing as a key “social determinant of health."

Now, a handful of area hospitals are starting to put their money into housing.

BMC’s housing investment is tied to a renovation of its campus in the South End. The state requires that 5 percent of the cost of a hospital expansion be reinvested in community health. BMC chose to spend the money on housing.

The initiative also includes $1 million to help families fight evictions, $1 million to create a housing stabilization program for people with complex medical issues, and $1 million to support a grocery store at a development in Roxbury.

Sandel says there was little resistance among BMC officials to investing in housing, but it’s an experiment that still needs to be proven.

“I think where people need to be convinced is in the business model. Can we actually show that this is something that's going to reduce costs and improve health outcomes?” Sandel says, adding that it has to make sense for BMC's bottom line.

BMC is not the only hospital in Massachusetts looking to improve health by improving housing. Boston Children’s Hospital recently set aside $5 million, while Baystate Medical Center in Springfield is also dedicating funds to housing.

In a statement, a spokesperson for Massachusetts General Hospital said MGH, Partners HealthCare and Brigham Health are looking at possible investments to benefit local underserved communities.

Overwhelming' Housing Challenges

John Erwin is executive director of the Conference of Boston Teaching Hospitals, which is heading up a community needs assessment of Boston’s health care institutions that will conclude in 2019. Erwin says housing could be identified as a major social determinant of health that requires collective action from the city’s hospitals, health centers and nonprofits.

And Erwin says it’s not just about housing the poor: “We’re seeing it from the patient perspective but also as large employers in the city. It’s increasingly difficult for our own employees to find affordable housing in the city -- and when you’re trying to attract workers from other parts of the country, housing becomes a factor.”

Beyond the finances, it’s still unclear what kind of role hospitals could have in housing. At Waldeck, advocates are still working out important questions: Will there be a clinician onsite? Will fair housing law permit patients from certain hospitals to get to the front of the housing wait list? And what kind of assistance will be available to the residents, many of whom struggle with substances and mental health issues?

Codman NDC's executive director, Gail Latimore says “I want the residents to feel like they have an ownership stake in the property. ... I want the residents to actually be healthier as a result.”

-See the full Marketplace national story.
-See the full WBUR CommonHealth local story.

Stockton California hopes to make itself an exhibition ground for elevated fortunes through a simple yet unorthodox experiment. It is readying plans to deliver $500 a month in donated cash to perhaps 100 local families, no strings attached. The trial could start as soon as the fall and continue for about two years.

As the first American city to test so-called universal basic income, Stockton will watch what happens next. So will governments and social scientists around the world as they explore how to share the bounty of capitalism more broadly at a time of rising economic inequality.

Will single mothers use their cash to pay for child care so they can attend college? Will people confronting choices between buying school supplies or paying their electric bills gain a measure of security? Will families add healthier food to their diets?

Basic income is a term that gets thrown around loosely, but the gist is that the government distributes cash universally. As the logic runs, if everyone gets money — rich and poor, the employed and the jobless — it removes the stigma of traditional welfare schemes while ensuring sustenance for all.

The concept of basic income has been gaining adherents from Europe to Africa to North America as a potential stabilizer in the face of a populist insurrection tearing at the post-World War II liberal economic order. It is being embraced by social thinkers seeking to reimagine capitalism to more justly distribute its gains, and by technologists concerned about the job-destroying power of their creations.

-See the full The New York Times article.

Nurses tell stories of patients who overdose on illegal drugs in their hospital beds. Doctors fret over patients who come out of surgery, go into withdrawal, and flee the hospital. Security guards stand watch while hospital staff search a patient for pills or bags of heroin.

"Every hospital in the state is dealing with this problem," said Dr. Deeb Salem, co-interim CEO at Tufts Medical Center. "It's more than difficult."

Hospitals say there's been little guidance for them about how to screen patients for an opioid addiction, how to manage a patient in detox while treating injuries from a car accident, for example, and where to make naloxone available. (The recommendation on that last one is everywhere, including hospital hallways, bathrooms and cafeterias.)

To remedy this gap, the Massachusetts Health and Hospital Association (MHA) is out with what it says is the first statewide "guide for patient management with regards to opioid misuse." It's a compilation of protocols collected from 13 hospitals in and outside of Massachusetts.

"Everyone seems to be doing it differently," said Salem, one of the guide's authors. "We wanted to produce a guideline that would help hospitals with understanding and using medications and procedures that would make it safer for the patient and safer for the clinicians taking care of these patients."

In addition to recommendations about screening and managing pain for patients addicted to opioids, the guidelines walk hospital staff who may not have worked with patients in withdrawal though the steps, using medications like methadone or buprenorphine to ease that process.

Patients addicted to opioids arrive at hospitals with many health problems that aren't directly related to drug use. MHA's vice president for clinical integration, Steven Defossez, another co-author of the guide, mentions a heart attack or a gallbladder infection.

"When someone comes into the hospital, if they are addicted to opioids, we know they will go into uncomfortable withdrawal symptoms within a matter of 12 hours or so," Defossez said. "What we wanted to do is develop a very compassionate program of medication-assisted therapy to keep people from going into withdrawal ... and this gives us the first step toward recovery for patients who chose to continue recovery on their discharge."

The guidelines include treatment resources, tips about how to deescalate encounters with agitated patients and a recommendation to "closely monitor patients who are at high risk for misuse and harm with 24/7 supervision."

-See the full WBUR story or download the guidelines.

As a recent The Boston Globe story highlighted, there is lingering resistance to treating addiction with drugs. Here are five common myths contributing to the stigma.

Myth #1: People who take buprenorphine or methadone to treat addiction are merely substituting one addiction for another and aren’t truly sober.

Such statements reflect a misunderstanding of addiction. By definition, addiction involves more than taking drugs regularly — it includes a compulsion to pursue drugs despite life-destroying consequences.

Methadone and buprenorphine (known by a brand name, Suboxone) are opioids and they do create physical dependence. But dependence is not the same as addiction; it doesn’t involve behavioral impairments. Patients who want to stop taking buprenorphine or methadone need to taper down their dose very slowly to avoid withdrawal symptoms.

Doctors say that people taking these medications are in fact sober, if they are taking an appropriate dose.

Myth#2. Buprenorphine is sold illegally on the street and smuggled into prison, so it can’t be a legitimate medication.

Addiction specialists say that buprenorphine has street value primarily because it eases the symptoms of withdrawal, which are terrible. Addicted people want to have it when they can’t get heroin or want a break from heroin. If people had easier access to buprenorphine in doctor’s offices and prison infirmaries, advocates say, they wouldn’t need to turn to the black market.

You can’t get high on buprenorphine alone, unless you haven’t taken any opioids in a long time, and even then it’s not much of a high.

Myth #3: Drug companies, which have been blamed for starting the opioid epidemic, are now making billions pushing a different set of opioids as a solution.

Buprenorphine and methadone are not blockbuster drugs for their manufacturers. Methadone is a decades-old generic that is very inexpensive. Buprenorphine comes in many different formulations, including generic versions, so that no single manufacturer is pushing it. The main proponents of these medications are physicians who have seen them improve patients’ lives, including many physicians with no ties to pharmaceutical companies.

Myth #4: Vivitrol is a better choice for everyone because it’s not an opioid and doesn’t cause dependence.

Vivitrol, or injectable naltrexone, is a newer medication that works well for some people. It’s a shot into the buttock that blocks the effects of opioids for three or four weeks. But it doesn’t have as long a track record as buprenorphine and methadone, and some specialists worry that it merely delays overdoses instead of preventing them, because people have no tolerance for opioids after being on Vivitrol.

Still, plenty of people find Vivitrol a lifesaver.

Bottom line: Each of the three medications for addiction works for some people, and none works for everyone.

Myth #5: Many people taking medications for addiction continue to take other drugs to get high, showing that the medications don’t work or make things worse.

No, it shows that addiction is complex and recovery is a process, sometimes a long one.

Some people find that medication is enough to get back on track. For others it’s more complicated. Even with medications blocking the effects of heroin and fentanyl, some still want to get high, so they’ll mix in other drugs. They may be homeless, jobless, or suffering from mental illness, and see no path to sobriety despite the medications.

But as long as they’re taking medication, addicted people are much less likely to die of an overdose. As addiction specialists like to say, a dead person can’t recover.

-See the full The Boston Globe article.

Lofexidine (Lucemyra, US Worldmeds), which has been in use in the United Kingdom for more than 20 years, is now available in the United States. The drug is used in the management of symptoms of severe opioid withdrawal.

In a double-blind, placebo-controlled, multicenter trial in opioid-dependent patients, lofexidine significantly improved opioid withdrawal symptoms and significantly increased completion of a 7-day opioid discontinuation treatment program compared with placebo.

"We desperately need something to address the opioid crisis, where we are losing about 100 Americans every day, with some 16 million on opioids," Danesh Alam, MD, Northwestern Medicine Central Dupage Hospital, Winfield, Illinois, told Medscape Medical News.

"Now we have a drug that actually enables us to achieve a rapid withdrawal from opioids. When we use lofexidine, we can literally bring in someone using opioids, give them this drug, and they can immediately stop using opioids," said Alam.

The study was presented at the American Society for Clinical Psychopharmacology (ASCP) 2018.

Lofexidine, a selective alpha-2-adrenergic agonist, acts on the central nervous system. Through its effect on the brain stem, it reduces the symptoms of withdrawal to a point at which they become very tolerable.
"We found in our study that you could basically give patients the lofexidine and stop the opiate. In the majority of cases, the withdrawal symptoms at that point were mild," Alam said.

Lofexidine was recently granted approval by the US Food and Drug Administration (FDA), as reported by Medscape Medical News.
This approval came after 17 years of hard work on the part of the National Institute on Drug Abuse (NIDA).

"Lofexidine has been used for about 25 years in the UK, and it's widely used, especially for people who are trying to get detoxified, and the experience has been quite positive," Ivan Montoya, MD, deputy director of NIDA, told Medscape Medical News.

"We tried to use that experience from the UK to bring the compound to the US, but the FDA needed data collected in the US, so we went through the whole submission and review process with a new drug application, and it took us about 17 years to complete the development. It was a very long process," Montoya said.

-See the full Medscape Summary article: New Nonopioid Med Blunts Drug Withdrawal Symptoms - Medscape - Jun 01, 2018.