Join Bob Berenson, MD of the Urban Institute for a CTHPP webinar November 8th at 1pm as he explains health care payment reform options. Dr. Berenson has long health policy experience, both inside and outside government. He served as Director of Medicare Payment Policy at CMS. His work focuses on quality measurement/improvement and Medicare shared savings. In the webinar Dr. Berenson will focus particularly on shared savings models as CT is considering for both the Medicaid/Medicare health neighborhood pilots and the much more ambitious SIM plan. Click here to register for the Nov. 8th webinar.
Tuesday, September 23, 2014
Monday, September 22, 2014
Across various meetings this month we’ve received a few updates on CT’s SIM planning. CT is competing with 17 other states for 12 test grants. SIM staff has acknowledged receipt of the independent advocates’ letter to CMMI and an FOI regarding Consumer Advisory Board voting and SIM budget development, but we’ve had no response to either. They are still fully committed to the controversial rushed timeframe for the Medicaid shift to shared savings.
SIM also committed to using Medicare quality measures for everyone in the state, which admittedly does not fit the needs of Medicaid and other populations and many are self-reported, simply to improve the states’ prospects of winning the grant to hire more state employees and consultants. There may be opportunities to add to the Medicare measures to ensure quality of care for other populations but it is unclear what group will have a possible opportunity to do that for over 800,000 Medicaid members.
There is also a huge effort to “align” quality standards across all payers. This is unfortunate for several reasons. Variation often leads to better learning and reduces gaps in measurement. Metrics need to make sense for each population and alignment risks including useless measures, wasting time and effort, and missing critical information – both on what is working well (serving as clues to innovation) and what needs improvement. There is ample evidence that people shift their efforts when they know their performance standards ahead of time, focusing effort on the areas on which they will be evaluated, at the expense of other areas. In the new world of bigger and better data that is collected automatically, reducing human error and tendencies, there is no additional burden on providers and minimal cost in collecting and analyzing more metrics. Quality improvement efforts may need to be focused to be effective – quality monitoring shouldn’t be.
The workforce and HIT workgroups are forming and outside consultants should be in place to help guide the SIM process soon.
This month’s MAPOC meeting was loaded with updates on the program. The highlight was results from the newest mystery shopper survey. Callers were able to get appointments within appropriate timeframes with 63.8% of participating providers this year, compared to 33.6% last year. Even that is better than the only survey conducted while HUSKY was run by managed care companies; mystery shoppers were only able to get appointments with 20 to 25% of providers listed on those HMO panels. This reflects the state’s progress in recruiting new providers -- for example the number of participating PCPs is up 21% over 2012 levels. In more good news, only 14.6% of mystery shoppers were told that their insurance status (Medicaid coverage) affected the availability of appointments and only 7% felt unwelcome or discouraged from making an appointment. Unfortunately much work remains in enrollment, especially reducing the 78-minute average wait time for the call center. There was also discussion of implementation of new MAGI eligibility standards, total eligibility growth, network adequacy, and access to dental care.
Monday, September 15, 2014
Twenty-two independent consumer advocates signed a letter sent Friday to CMMI voicing concerns about CT’s SIM application. While advocates have many concerns, the letter focuses on the sudden planned shift to shared savings payments in Medicaid. Concerns include the prospect that shared savings incentives could drive inappropriate underservice and that state’s quality and financial monitoring resources will not be able to detect harm to people or financial gaming of the system. Shared savings is a very new payment model that other, more mature, health systems in other states are struggling to implement. CT’s recent failed HUSKY managed care program was driven by similar financial incentives; since we moved away from those incentives quality of care is up, costs are down and more providers have joined the program.
The independent advocates’ letter asks CMMI in negotiations over the grant application to require the state to return to the more reasoned, progressive Medicaid plan in the December SIM “final plan” – to first pilot shared savings through the thoughtful, consensus-led Medicaid health neighborhood program for dual eligibles very close to implementation. This would allow the state to identify challenges, learn from them, test solutions and evaluate results -- improving the chances of sustainable success and limiting harm to people.
Thursday, September 11, 2014
The Care Coordination committee of MAPOC has been given responsibility for oversight and advice on SIM’s controversial new plans for Medicaid, especially the shared savings payment model. The committee’s original mission remains as well – to track Medicaid’s successful patient-centered medical home program.
In yesterday’s meeting we heard more about continuing PCMH success. The number of participating practices is accelerating every quarter. Even as enrollment climbs with the ACA expansion, the percent of members served by a PCMH remains at 32%, matching growing capacity with growing demand. Unfortunately since the last report, a large hospital-affiliated practice decided not to renew PCMH certification citing financial reasons. It was reported that some payers increasingly prefer to reward large practices with advanced analytic and other capacities that support shared savings (as well as quality in some cases) at the expense of PCMH supports (which focus on quality and access to care, but do save as well).
The SIM update reiterated the intent, over advocates’ objections, to have the underservice and quality measures developed by SIM’s Equity & Access and Quality Committees apply to Medicaid. To improve chances of getting the federal SIM grant, the Quality Committee adopted Medicare ACO quality measures as the basis for the entire state population. Advocates have argued that Medicaid serves a very different population with different needs than Medicare or commercially insured populations. Advocates are concerned that the SIM committees are dominated by commercial insurers, who no longer have a role in the state’s Medicaid program, and little Medicaid consumer representation. We were told that the PCMH SIM committee, that includes Medicaid expertise, can review the SIM committees’ decisions, but cannot use a more appropriate set of standards.
Monday, September 8, 2014
An Op-Ed published in today’s CT News Junkie debunks the persistent, old (pre-ACA) myth that state spending on Medicaid is “out of control”. Unfortunately that myth is driving SIM policymakers into a risky shared savings payment model that is unproven, ill conceived and wouldn’t make much difference in the state budget even if it worked.
Friday, September 5, 2014
Because CT dropped insurers from our Medicaid plan three years ago, we are not subject to the ACA tax on insurers saving state taxpayers more than a billion dollars over the next decade. The ACA tax on fully-insured plans is due for the first time September 30 and will cost fully-insured states $700 million just this year. Twelve other states without Medicaid insurers are also spared this tax. Medicaid programs in NY, RI and NJ will pay over $2,000 per member over the next decade in ACA taxes. In a satisfying twist, several states that did not expand Medicaid under the ACA are paying the tax to fund our expansion.