Wednesday, October 1, 2014

Fascinating discussion -- US Senate panel considering regulatory barriers to ACOs

The first meeting of a panel convened by Sen. Angus King (ME) to consider federal regulatory barriers to provider risk payment models was held in Dirksen Senate Office Building this morning. The panel was moderated by Michael Chernew of the Health Care Markets and Regulation Lab at Harvard Medical School, which is guiding the process with Sen. King’s policy staff. I was joined on the panel by Carrie Arsenault of Beacon Health in Brewer ME, one of the brave remaining 19 Pioneer ACOs of the original 32, Eric Bieber of University Hospitals in Cleveland OH, and Janet Niles of Ochsner Health System in New Orleans. The discussion was thought-provoking and a little provocative at times. After hearing all the challenges, I left wondering why any group would consider becoming an ACO. Only one in four Medicare ACOs earned savings payments last year, despite spending $2 million each on average to support the model. It was clear that all the panelists are primarily motivated by improving the quality of care they provide; financial interests are far less important. Concerns included regulatory paperwork burdens, even if you get a commonsense waiver, the difficulty of reaching the savings threshold, attribution, and the need for a glide path for organizations wishing to develop ACO models responsibly. Downside risk is a very heavy lift for these organizations; reportedly many Medicare ACOs will leave the program if they are required to accept downside risk, as the Pioneer ACOs are this year. We heard a lot about the importance of engaging consumers in improving their health. In my remarks, I focused on consumers’ perspectives and concerns – that shifting risk onto providers holds great promise to build value and reduce overtreatment, but great risk in that it significantly changes incentives in the patient-provider relationship. Every regulation was a good idea and served a purpose at the time it was proposed. Undoing those standards should be done carefully. I talked about the importance of monitoring for underservice and how CT’s health neighborhood pilots for dual eligibles is building such a monitoring system. There was no argument that incentives in Medicaid are different than other programs – when providers are underpaid, the incentives to overtreat are less, but undertreatment is more of a concern. I talked about anti-competitive concerns of consolidating providers, overlap and conflict with state regulatory roles, and the importance of paying for quality, independent of and in addition to shared savings. Relying only on shared savings to improve quality is not realistic – if we want it, we have to pay for it.


It was a fascinating conversation. I can’t wait for the next meeting.

Tuesday, September 30, 2014

Investigators highlight problems in Medicaid managed care nationally – but through collaborative effort CT is a success story

Getting a lot of national attention, a new report by federal investigators highlights significant problems in accessing Medicaid care, largely through private managed care plans, as millions of Americans enter the program. However, through collaborative effort, Connecticut serves as an exception to that trend. The report outlines a lack of access or quality standards across states, and even worse monitoring or enforcement of the few standards that exist. Connecticut used to have this problem. But two years ago the administration shifted to a self-administered, care coordination-based system and we have largely reversed the problem. Since the shift quality of care is up, 32% more providers participate, and per person costs are down. In a survey of providers, advocates also outlined the system’s challenges, and identified best practices from other states and systems. Over the last two years DSS has addressed the report’s issues, one by one -- improving operations, transparency and stability. Connecticut Medicaid is a success story – both in outcomes and demonstrating the power of collaboration; other states should take notice.

Monday, September 29, 2014

HHS finds ACA is lowering hospital uncompensated care costs

CT News Junkie is reporting on a new analysis by HHS finding that hospital uncompensated care costs are down significantly, particularly in Medicaid expansion states like Connecticut. However the CT Hospital Association says they have not experienced a decrease in the first nine months of 2014. The state’s OPM budget office expects to see a decrease over time.

Thursday, September 25, 2014

CEPAC diabetes comparative effectiveness meeting Oct. 29th


The next CEPAC meeting will review the latest research on effectiveness of treatments for diabetes. CEPAC is a New England group of researchers, consumers, physicians and payers that evaluates and translates the best information on treatment effectiveness into useable tools and policies to improve the quality and value of health care in the region. Past CEPAC topics have included evaluations of treatments for opiod addiction, breast cancer screening, and community health worker services. The meeting will be October 29th in Providence, RI. Registration is free.

Tuesday, September 23, 2014

Webinar -- Provider Payment Reform Options: Aspiration Meets Reality

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.

Monday, September 22, 2014

SIM update

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.

Medicaid Council meeting

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.