Thursday, April 30, 2009

Authorities Update

Both the Primary Care and HealthFirst Authorities met yesterday, the later most likely for the last time. The HealthFirst Authority meeting featured Jonathan Gruber, an MIT economist, who is the leading proponent of individual mandates across the US. He championed the mandate in MA and is working with other states and the fed.s on building an individual mandate for all of us. His argument is that, based on economic modeling, there is no other way to get completely universal coverage; in a voluntary system, there will always be some who choose to opt-out if given the option. Dr. Gruber crunched numbers for the Authority’s reform proposal.

The CT Health Policy Project has published a detailed list of challenges in implementing any individual mandate in CT. Despite a legal mandate, 12% of drivers in CT do not carry auto insurance. MA, despite its mandate, exempts 62,000 people due to financial constraints who remain uninsured, in addition to the 86,000 uninsured residents who are paying the mandate tax penalty. Insurance in CT is very expensive – family premiums rose 8.2 times faster than incomes from 2000 to 2007. Also, buying insurance is no guarantee of coverage in CT; thousands of people have found that the policy for which they’ve been faithfully paying premiums, often for years, does not cover them when they become ill.

The mandate is built on a myth – that uninsured people can afford coverage and are choosing not to buy insurance. The truth is that most either do not have an offer of benefits or cannot afford what is available. Only 1.5% of uninsured Americans go without by choice. High deductible plans, that do not cover preventive care, are not protecting the assets of consumers (low-income uninsured patients tend to have few assets), but are protecting institutional interests of hospitals, providers, payers and government. Forcing low-income people to buy coverage of questionable value is just another tax for the common good and we should fund it that way.

SustiNet, the only comprehensive reform package being considered in CT, does not include a mandate, but does include extensive auto-enrollment mechanisms that may work better than a legal mandate. SustiNet was developed by the Universal Health Care Foundation of CT who, together with the CT Health Foundation, paid for Dr. Gruber’s analysis of both the Health First proposal.

Dr. Gruber’s analysis of the Authority’s proposal does not yet include raising provider rates in Medicaid, HUSKY or SAGA; he expects to add that soon and the following numbers will change. He found that by 2012, without a mandate the Authority proposal would reduce the number of uninsured in CT by 35,000 to 55,000 and cost the state (net) between $275m and $425m, depending on whether individuals are allowed to join the state pool. With an individual mandate, costs rise to between $695m and $760m but almost all of the uninsured would be covered. He acknowledged that these numbers do not account for expected savings to the health care system, CT families and employers. An interesting assumption he makes (that doesn’t have a huge effect on the numbers) is that while he predicts some employers to drop coverage due to the reforms (crowd-out), he assumes that those employers would increase wages to compensate for dropping benefits, thereby raising tax revenue to the state. While most economists agree that benefits come out of wages, as a practical matter would they return those costs to workers when they drop benefits or put those resources elsewhere? Tom Swan noted that the much feared crowd-out effect did not happen here in CT when HUSKY Part B was implemented. Dr. Gruber felt that the Authority’s proposals were overly generous; he believes that most Americans are over-insured. He acknowledged that MA’s reforms, including the individual mandate, have not reduced ER visits in that state.

The Primary Care Authority’s meeting was less contentious. That group is reviewing DPH’s provider licensure forms and making recommendations to collect better information on primary care workforce in the state. The group is also considering recommendations to the General Assembly on coverage, workforce development, access to care, medical home, chronic disease management, prevention and payment mechanisms to support quality and access in primary care, and oversight.
Ellen Andrews

Donaghue Foundation conference notes

The Donaghue Foundation held their annual conference titled “Innovation in the quest for better health: Patient driven transformations in research, technology, and treatments.” The conference was well-attended by people from a wide variety of organizations, from hospitals to banks and non-profits.

The first speaker was Alejandro Jadad, MD, Chief Innovator & Founder, Center for Global eHealth Innovation, whose topic was “Will we be able to innovate in time? Meeting the health care expectations of the Obama generation”. He said that some health care professionals are reluctant to use technology in their practices but he always asks his patients if they have found any useful information on the internet. He compiles this information into a list of resources to give to other patients. He used an example of a colleague who has his patients in the operating room call their families in the waiting room to report on their successful surgeries. Another interesting example is taking a digital photo of a post-surgical wound and emailing it to a doctor, who can look at this and let you know how the healing is progressing without your even having to go into the doctor’s office.

The second speaker was Sharon Terry, MA, President & CEO, Genetic Alliance, whose talk was titled “Participants at the center: Accelerating pathway from research to health.” Mrs. Terry and her husband started an advocacy organization when they found out that their two children had a rare genetic disorder. Through the Genetic Alliance, she promotes an environment of openness that focuses on the health of individuals, families and communities and to make sure their perspectives are at the “center of efforts to improve health systems and use of genetic information.”

The final speaker was Ben Heywood, Co-founder & President of PatientsLikeMe who spoke about “The power of sharing with patients like you: Transforming research, treatments and care.” PatientsLikeMe is an online community for people with life-changing illnesses where they can share treatment options and coping mechanisms. The site has “created a platform for collecting and sharing outcome-based patient data and real life experiences amongst patients.” The company is for profit and sells the medical information (in aggregate form and without identifiers) to pharmaceutical, medical device, and insurance companies. Patients are aware of this and some feel that it could help find treatments for their diseases. One of the goals of the site is to help participants answer the question, “Given my status, what is the best outcome I can expect to achieve, and how do I get there?” I think one of the most powerful statements made by Mr. Heywood was when he stated that he has been to many conferences about health care where they talk a lot about patients – but patients are never at the table. As wary as I would be about sharing my medical details online, maybe it provides a way to bring patients into the discussion about the medical treatments that affect them.
Jen Ramirez

Tuesday, April 28, 2009

New consumer tip sheets

The Consumer Health Action Network has published new tip sheets and the new federal poverty levels. The tip sheets, available in English and Spanish, include Finding Health Insurance After You Lose Your Job, Individual Insurance Plans: What to Look Out For, and our Updated COBRA tip sheet. The poverty levels are used to determine eligibility for many public programs including HUSKY. The Consumer Health Action Network is a program of the CT Health Policy Project.

Monday, April 27, 2009

Recent media stories highlighting medical error s in CT

Efraim Gomez-Zapata, Stamford physician, will have a hearing this week before the medical examining board and is facing a civil suit. A family practitioner, Dr. Gomez is not board certified in cosmetic surgery or anesthesia. However, he has been advertising himself as a leader in laser liposuction surgery in the Hispanic community. Apparently this is allowed under CT law. However, two of his patients had to be taken to the emergency room due to problems during surgery. One suffered seizures and another difficulty breathing after Dr. Gomez administered anesthesia. Dr. Gomez is also charged with not obtaining appropriate consent from patients and operating an unlicensed and unsafe surgical facility.

Hartford Hospital will remain on probation with the Dept. of Public Health indefinitely due, in part, to medical errors including a surgeon leaving a 13 inch medical instrument, a malleable ribbon retractor, in a patient after closing this January. The instrument was removed in another surgery two days later after the patient returned to the hospital in pain.

CT hospitals reported 65 instances of “retained objects” between mid-2004 and mid-2008. Nationally, the rate of leaving something behind in surgeries is one in 7,000. Two other hospitals cited in consent orders include Yale-New Haven Hospital for leaving behind a sponge in one patient and a surgical pad in another, and John Dempsey Hospital cited for missing the tip of a needle in a patient. For DPH reports on hospital medical errors, click here.

Several safety initiatives have proven to reduce the incidence of errors during surgery. The World Health Organization has developed a set of checklists, used at three points during surgery, that has reduced deaths and complications by one third. The Agency for Health Care Research and Quality has a great deal of helpful information for consumers to ensure they receive safe, quality health care. To research your doctor, check the CT Physician Profile. To check your hospital’s record, go to Medicare’s Hospital Compare.
Ellen Andrews

Thursday, April 23, 2009

April 30th briefing on proposed elimination of legal immigrant coverage

Next Thursday, April 30th at 10:30am in Room 1E of the LOB, the CT Health Foundation will hold a briefing on budget proposals to eliminate health coverage for legal immigrants and proposals to increase copays and other costs on all HUSKY families. Two policy briefs will be released at the briefing. Speakers include Pat Baker of the CT Health Foundation, Jack Hoadley of Georgetown University, to describe his research, and Evelyn Richardson, a Medicaid consumer from Hartford, to describe the impact on her family. For more information or to RSVP, contact Midge Mongillo at or (860) 224-2200 X33.

PCCM subcommittee to meet

At the last Medicaid Managed Care Council meeting, a subcommittee was formed to follow and advise DSS on implementation of the HUSKY PCCM program. The first meeting of that subcommittee will be May 20th at 10am in Room 3800 of the Legislative Office Building (LOB) in Hartford. For directions to the LOB, click here. The meeting is open to the public; anyone interested in PCCM and HUSKY is urged to come.

Wednesday, April 22, 2009

Obesity and overweight in Connecticut forum

May 14th the CT Public Health Institute will release their study of the problem of overweight and obesity in CT including background, costs and consequences, and possible interventions. The forum was originally scheduled for May 5th. The study was funded by the Universal Health Care Foundation of CT. The forum will be at the Wilde Auditorium, University of Hartford from 8:30 to 11:30 am on that Thursday. For more information, contact Katherine Kranz Lewis at or (860) 768-5464.

Tuesday, April 21, 2009

eHealth consumer privacy forum begins an important discussion

The Connecticut Health Policy Project and AARP- CT hosted a forum yesterday on electronic medical records at the State Capitol in Hartford – eHealth: Why Consumers Should Care. The purpose of the forum was to provide information about electronic medical records and to get input from advocates and consumers on privacy and security issues. The forum was well-attended and the audience had the opportunity to participate by asking questions and making comments. Speakers included Kevin Carr, MD, from Trusted Medical, Brenda Kelley of AARP-CT, and Ellen Andrews from the CT Health Policy Project.

The problems with the health care system in CT were discussed including quality lapses, rising costs, and increasing rates of chronic disease. 17% of Americans report that test results or medical records were not available at a medical appointment in the last two years; that rate is twice as high for low income as for higher income patients. The potential benefits of electronic health information include preventing medical errors, coordinating care, improving public health surveillance, reducing paperwork, improving efficiency, saving money, and making health care more affordable for everyone.

All speakers emphasized that consumers and their advocates have an opportunity to build CT’s health information system with security and privacy built in from the beginning. This forum is the beginning of a conversation, not an end. There is a great deal of both federal money and coordination coming to ensure that health information technology grows. All stakeholders, in CT and in Washington, are welcoming, even seeking, consumer input into the design of systems.

Dr. Carr described electronic medical records and showed a few examples so the audience could see what they look like. He showed a fictional electronic medical chart for a patient with allergies and a list of what medications the patient is taking. Dr. Carr emphasized that electronic health records put patients at the center of health care. The purpose of sharing health information through electronic medical records is to improve medical care.

The audience was very involved in the discussion by asking questions and sharing their concerns. Vicki Veltri, General Counsel for the Office of the Health Care Advocate, was very concerned about medical records being sold to insurance companies and thought this should not be allowed to happen. Dr. Carr said that they would follow the rules established for the governing body of the Health Information Exchange.

Shawn Lang, from the CT AIDS Resource Coalition, asked about how patients with HIV could control the sharing of information. Dr. Carr responded that this needs to be addressed in CT. In other states, the information might only be released to a primary care doctor. If the patient doesn’t want to share it with other doctors he or she can opt out of showing that information.

Jill Zorn, from the Universal Health Care Foundation, asked who owns the medical record because most doctors’ offices think that they do, but ideally the patient would. Dr. Carr answered that the data in the system is seen as belonging to the providers. When the information is being exchanged (between doctors) it becomes the patient’s and it is under the patient’s control.

The CT Health Policy Project has developed a resource page on our website for advocates to follow and join the discussion. It includes a glossary of terms.
Jen Ramirez and Ellen Andrews

Friday, April 17, 2009

Medicaid Managed Care Council update

At today’s meeting, ACS reported that there are 337,533 CT residents covered by HUSKY Part A as of April 1st, up more than 6,000 from March. HUSKY Part B now covers 15,063, moving back toward its pre-July 08 levels. There are also 7,068 people covered by the Charter Oak Plan, however 3,319 Charter Oak applications were denied in March. (Probably a high number due to elimination of backlogs; 1,210 were denied in February). ACS will be reporting on the reasons for denials, including how many are ineligible because they have not been uninsured for six months.

DSS described the PCCM amendment to the HUSKY waiver that was passed by the Human Services and Appropriations Committees March 31st. The department is planning provider and consumer mailings to open participation in the program. A brochure is in development. Objections were raised to DSS’s intention to hire Mercer for the evaluation of the program; the Council will explore other sources of funding to commission an independent auditor. The Council created a PCCM subcommittee to be Co-Chaired by Rep. Toni Walker, Co-Chair of Human Services, and myself.

DSS reported on significant expansions of the dental provider network under the dental carve-out. There are now 835 participating providers. At a previous meeting, it was reported that before the carve out there were 174 dental providers participating in HUSKY. A mystery shopper survey of the provider panel conducted in February and March found that between 77 and 93% of callers were able to secure an appointment with the contracted 8 weeks. The carve out also has a new name, the CT Dental Health Partnership, and a logo. The need to dispel old perceptions of the program was emphasized including that there are few participating providers, that it is hard to get dental care in HUSKY, and they myth that oral health is less important than the rest of the body.
Ellen Andrews

Tuesday, April 14, 2009

What is public health?

The US is the most powerful country in the world, right? So why aren’t we the healthiest? Last week was Public Health Week. (I didn’t miss it, I was just busy celebrating.) Click here for a great video explanation of what public health is, and how we can become the healthiest nation in one generation.
Ellen Andrews

Monday, April 13, 2009

2009 CT Health Disparities report

The Department of Public Health in cooperation with the CT Health Foundation recently released their 2009 Connecticut Health Disparities Report. The report defines health disparities as “avoidable differences in health that result from cumulative social disadvantage.” Connecticut is becoming more racially and ethnically diverse; from 2000-2007, there were significant increases in the populations of Asians, Latinos, and Native Hawaiians/Other Pacific Islanders.

Some key findings:
From 2000-2004, Black Connecticut residents had a death rate from all causes that was 1.2 times higher than White residents. This is the highest death rate of any CT residents.
The leading cause of death in CT from 2000-2004 was heart disease. Black residents had the highest death rate from heart disease, roughly 1.2 times higher than White residents.
Black residents also have higher rates of cancer, cerebrovascular disease or stroke, diabetes, death from diabetes, hospitalizations for diabetes, and lower-extremity amputations from diabetes.
Lower income adults are less likely to get recommended screening tests for certain cancers and are more likely to be obese.
Adult cigarette smokers are more likely to be lower income, younger, and have less education.
From 2001-2005, Black and Latino residents were diagnosed with HIV/AIDS at rates 7.4 and 6.6 times higher than Whites, respectively.
The highest rates of pregnant women with late or no prenatal care in the first trimester were among Latina and Black women.
Latino children had the highest percentage of “tooth decay experience” (49.3%); for Black children the percentage was 42.8% and for Asian children 42%.
Latino residents are about 5.4 times more likely to be uninsured than White residents.

No solutions are suggested to improve any of these serious health disparities. However, the report does recommend collecting more data. Some of the areas in which they would like to see more research are:
Subgroups within the Latino and Black populations
Access to quality health care and issues concerning language barriers for Latinos
Influences on health of poverty, environments, and discrimination for Black residents
Health experiences of American Indians, Alaska natives, Asians, Native Hawaiians and Other Pacific Islanders
Jen Ramirez

Thursday, April 9, 2009

Forum for consumers and advocates: eHealth Privacy and Security

The CT Health Policy Project and AARP-CT are hosting a forum on electronic medical records and how to ensure patient’s privacy and security are protected. Electronic medical records and sharing them is an important part of improving the quality of care, reducing costs, and reforming our health care system. Planning is beginning at the state and federal levels. Come hear about the issue, share your concerns and become part of the discussion. The forum will be Monday, April 20th at 1:00pm in Room 310 of the Capitol. For more information contact us at 1-888-873-4585 or

Wednesday, April 8, 2009

Forum on overweight and obesity

May 5th the Universal Health Care Foundation of CT and the CT Public Health Policy Institute will hold a forum to present a new analysis of the overweight and obesity problem in CT, including background, costs and consequences, and possible future interventions. The forum will be in May at the University of Hartford. For more information contact Kathy Kranz Lewis PhD, MPH, RNExecutive Director, Connecticut Public Health Policy Institute and Assistant Professor, Department of Nursing, University of Hartford at or (860) 768-5464.

Tuesday, April 7, 2009

Hear a brain scientist describe her stroke

Jill Bolte Taylor, a Harvard-trained brain scientist, wrote a book describing her experience of surviving a stroke. For a very entertaining video of the author relating the morning she woke up to find that a blood vessel had burst in her brain click here and scroll down. She describes, with great humor, how she processed the pain, the euphoria, her struggle to summon help through the fog, and her remarkable opportunity as a scientist to observe a stroke from the inside.
For the long version of her talk, including a real human brain, click here.
Ellen Andrews

Monday, April 6, 2009

Half of foreclosures due to sickness and medical bills

In a legislative meeting Friday I heard an amazing statistic from a realtor – that half of foreclosures are due to medical bills. This doesn’t surprise me, many of our clients have health problems that threaten their ability to pay the mortgage. Previous studies have found that half of bankruptcies are due to high medical bills. But still many people in the meeting were surprised to hear the connection. It is not well-reported. This blog featured a March 15th Courant article about a family’s bankruptcy to avoid foreclosure and noted that the precipitating factor, an illness that led to a lost job that led to the financial problems, was buried in the 8th paragraph.
Searching the internet to find the realtor’s source, I found “Get Sick, Get Out: The Medical Causes of Home Foreclosures”, a study by Christopher Robertson, Richard Egelhof, and Michael Hoke at Harvard Law School. In a study of foreclosures in four states, they found that medical illness and high bills caused half (49%) of the cases of families losing their homes and were involved in seen out of ten. Thirty two percent were due to illness or injury, 23% due to unmanageable medical bills, 27% due to lost work resulting from a medical problem, and 14% due to caring for a sick family member. Thirty seven percent of respondents paid more than $2,000 out of pocket for health costs, 30% missed two or more weeks of work due to illness or injury, 8% were disabled and unable to work, and 13% used home equity to pay medical bills. The authors recommend legally suspending foreclosures during a verifiable medical crisis as a policy option to address the housing crisis.
Ellen Andrews

Saturday, April 4, 2009

Approps budget health impact analysis

Our summary of health coverage related items in the Appropriations budget is posted. The legislature restored the large majority of Governor Rell’s proposed cuts including rejecting premiums and copays for Medicaid, cuts in services to SAGA, restored coverage for immigrants and medical interpretation.

Friday, April 3, 2009

Lousy student health insurance – An update

Aetna Student Health finally returned my call about the $500 in medical bills they haven’t paid. Now I’m getting a completely different answer (I think I’ve been given about four different explanations so far). The most recent customer service representative said that I met the maximum benefit level for this medical service. I explained that the last person I talked to said these doctor visits were counted differently, under the three doctor visits per accident or sickness. She said that the case notes were not showing that he said that and if he did, he was wrong. She was a bit curt and not at all sympathetic. Seeing as I’ve been given so many different answers by customer service reps, I’m going to give myself a few days to calm down, review my notes and the policy’s brochure, and call back to see if I get a different answer from the next person I talk to. I might decide to submit a written appeal. Maybe if Aetna has to reject my bills with a written explanation, I’ll get a definitive answer.

As an aside, I was re-reading my Aetna Student Health policy and I read a few things that struck me as odd. The policy lists 50 exclusions that the plan will not cover, including medical bills from committing a felony and medical bills from participating in a riot. But you are allowed to defend yourself in a riot and have your resulting medical bills paid, as long as you’re not defending yourself against “persons who are trying to restore law and order.” I don’t know why they would single out those two types of activities as ones that they won’t cover. What about all of those college students committing misdemeanors or getting hurt at political demonstrations? I guess they’re covered.
Jen Ramirez

Thursday, April 2, 2009

Appropriations passes a budget

The budget approved by the Appropriations Committee restores many of Governor Rell’s proposed cuts to health care programs. The committee did not agree to the Governor’s proposed co-pays and premiums on HUSKY families; imposition of premiums would jeopardize significant federal stimulus funding. Also to ensure CT gets new federal funding, the committee rejected the Governor’s proposal to eliminate self-determination of income for HUSKY applicants. The legislature restored HUSKY eligibility for legal immigrants that the Governor proposed to eliminate; the federal SCHIP reauthorization bill grants the state a 65% match on those costs. The committee did not agree to the Governor’s proposal to eliminate prenatal care for undocumented immigrants, eliminate funding for medical interpreters, or to eliminate vision and transportation services for SAGA clients. The committee provided funding for smoking cessation treatment under Medicaid that was not in the Governor’s budget. The committee provided funds to implement the family planning waiver; those funds would be 90% matched by the federal government. The committee did not agree to the Governor’s proposal to eliminate all but emergency dental care for adults in Medicaid and SAGA, however they did implement utilization review for those services. The committee did agree to weaken the Medicaid and SAGA medical necessity definition. The committee agreed to some of the Governor’s proposed pharmacy cuts, but not others. The legislature took money out of the Governor’s proposal for her Charter Oak Plan to reflect lower than expected enrollment. The budget restores funding for the Office of Health Care Advocate. A more detailed analysis will be coming.
Ellen Andrews

Wednesday, April 1, 2009

HUSKY waiver hearing – good and bad news on PCCM

As expected, yesterday’s Medicaid waiver hearing before the Human Services and Appropriations Committees was contentious and long. DSS brought out the troops – I counted nineteen staff in the room and they flew in two actuaries from Mercer. CMS also came in from Boston. DSS began with a rosy, but incomplete, description of the program and of PCCM. We did learn that the program is up to 200 members now. They left out the part about the working group of advocates, providers and DSS staff which developed a state plan last summer, submitted to and approved by the legislative committees in September without revision. That plan called for statewide, expansive implementation open to any willing provider and any HUSKY families within 20 miles of a PCCM provider. They left out the part about DSS, in November, suddenly deciding to limit the program to two small communities, only providers who applied during a very short time frame, and only to some of their current patients. DSS stated, in error, that those two communities were the only ones with sufficient provider capacity to support PCCM. Advocates pointed out that the Commissioner admitted in a November letter to legislators that New Haven and Hartford also had sufficient capacity. They also left out that they are arbitrarily subjecting PCCM providers to Freedom of Information laws and refused to approve marketing and educational materials developed by the working group for consumers to explain the program. Sensing the likelihood of criticism from legislators, consumer advocates and others who care about health care for HUSKY families, DSS offered a symbolic amendment saying they would expand PCCM statewide sometime in the next two years and it was their “intention” to be statewide by the end of 2009.

In their testimony, advocates and providers universally expressed strong support for PCCM and state wide implementation. Click here for our testimony. Speakers also argued for opening the program to any providers willing to care for HUSKY families, eliminating irrelevant and intimidating Freedom of Information burdens on doctors’ offices, PCCM marketing efforts equivalent to the HUSKY HMOs (funded by taxpayers), and opening the program to all HUSKY families. The advocates described recruiting 350+ providers this summer from across the state to apply to the program, providers who are sick of the HMOs, the hassles, and the lousy rates, and getting ready to leave the program but who were willing to stay and give PCCM a chance. Unfortunately, DSS said no thanks to all but 25 of them who practice in Waterbury and Willimantic. The advocates emphasized that since November, DSS has systematically hobbled the program to the point where it is no longer viable for providers, ensuring it will fail. HUSKY needs PCCM as an alternative to the troubled HMOs. Advocates noted that if the committees allowed DSS to destroy PCCM, they need to get used to 24% HMO rate increases.

Legislators expressed deep frustration with the department for the delays and policy changes to weaken the program. They drafted a different amendment (and then amended that), negotiating the terms in a back room with only DSS and OPM staff. Advocates were told to leave the room. The amendment requires DSS to market the program and open it to any willing providers and families in the pilot areas. That’s the good part. However, the amendment also requires DSS to implement PCCM in Hartford and New Haven only by the end of 2009 and to commission an evaluation (DSS directed) six months later to assess quality, access to care, and cost containment. If that evaluation finds that PCCM is “successful” they may expand it farther. That’s the bad part. Staywell Health Center, Waterbury’s community health center, testified that they have only twenty PCCM patients enrolled because of DSS’ limitations. Staywell will get the massive sum of $1,800 per year to manage the care of those patients. What are the chances that DSS’ evaluator will find improved access, higher quality AND reduced costs with those resources?
Ellen Andrews