Hartford Business Journal 2016 economic outlook including health care

The Hartford Business Journal is looking ahead to next year for trends, predictions and stories to watch in CT’s economy. Health care contributors included Matt Katz of the CT State Medical Society, Elliot Joseph of Hartford Healthcare, John O’Connell of the CM Smith Agency and Ellen Andrews of the CT Health Policy Project. Trends included the impact of market consolidation, protecting Medicaid’s progress, insider advantages in policymaking, HIT, medical liability, the feasibility of independent practice, new care coordination models, the Cadillac tax, price and quality variation, health care’s role in CT’s economy, a shift to consumer-focused care, and that coverage doesn’t necessarily equal access. Interesting reading -- lots of overlap despite different perspectives.

Advocates urge SIM not to disrupt successful Medicaid PCMH program

In a letter to SIM steering committee members, the Medicaid Study Group urged support for DSS’s decision to build Medicaid reforms on the successful person-centered medical home program. Specifically the Group applauded DSS’s decision to only include members served by certified PCMHs in the new, untested shared savings model being planned for Medicaid. The Medicaid Study Group includes over twenty independent consumer advocates who’ve taken a deep dive into research surrounding Medicaid reforms. Under the PCMH program, quality of care in CT’s Medicaid program has enjoyed sustained improvement, rivaling private coverage in many cases, while at the same time controlling the total cost of care. There is ample evidence of the benefits of PCMHs across states, payers and programs. Advocates are concerned that practices that do not reach PCMH standards may not be equipped to serve Medicaid members’ needs adequately in the new program. The advocates urged SIM to respect the hard work of all Medicaid stakeholders to improve the program in their recommendations to DSS.

British medical humor for the holidays

Formerly known as the British Medical Journal, the BMJ Christmas issue is out with critical additions to the scientific literature such as a study of doctors’ coffee purchasing at work (surgeons drink the most, hierarchical position is positively correlated with high consumption and generosity in paying for others’ coffee) and the growing frequency of quotes from Bob Dylan songs in the scientific literature (the study was inspired by a long-running bet among scientists at a Swedish institute over how many they could sneak in, apparently “The Times They are a-Changin” is most frequently cited overall).  For the last 35 years, BMJ’s last issue of the year has included novel, sometimes irreverent, often Christmas-themed articles. Unlike April Fool’s, the articles must meet the same rigorous scientific standards as the rest of the year. Prior issues have included a scientific explanation of why Rudolph’s nose is red (more blood vessels), debunking a Danish myth that people can get drunk by soaking their feet in alcohol, and a survey of sword swallowers’ medical issues. My favorite this year is Rejection of Rejection – Overcoming Barriers to Publication. The bane of academic life, leading scientific journals reject 80% of submissions. The piece includes a form letter response to a returned article thanking the journal for the rejection, but adding “Unfortunately we are unable to accept it at this time.” It goes on to explain that the author, as you might imagine, receives many rejections every year and is unfortunately unable to accept them all. I think advocates should expand the concept. We could refuse to accept state budget cuts, the death of an important bill, or the loss of HUSKY eligibility for parents. This has potential.

Advocates offer comment on MQISSP design proposals to date

As requested, the Medicaid Study Group has drafted comments to DSS on current design proposals for MQISSP, CT’s Medicaid reform plan. The Medicaid Study Group, with over twenty independent consumer advocates, has taken a deep dive into the health reform literature and the experience of Medicaid reforms in other states, and providing feedback and recommendations to DSS as they design MQISSP. Our latest comments address concerns about networks that include non-person-centered medical home (PCMH) practices. We are especially concerned about the danger of internal cherry-picking which could result in moving patients who need it most out of PCMHs, and overspending in the program by segmenting risk and generating false “savings”. We offer suggestions to mitigate that risk. The comments also address communications, governance, entity oversight, Community Care Team inclusion, the role of SIM’s CCIP program, procurement, and shared savings methodology and distribution.

Briefing focuses on CT nurses’ role in improving population health

The CT Nursing Collaborative-Action Coalition held a briefing today on Building a Culture of Health in Hartford with the CT League for Nursing and the Robert Wood Johnson Foundation. Sue Hassmiller from RWJ briefed the audience on the critical role of prevention and population-based services in improving health and the central role of nurses in that effort. One RWJ program pairing visiting nurses with high-risk families returned $5.70 for every dollar spent supporting pregnancy and early childhood. She emphasized that much of health outcomes are outside the traditional medical system, commenting that “the choices we make are based on the choices we have.” The CT Nursing Collaborative-Action Coalition is working to build healthier communities in our state through a strong, diverse nursing workforce. Efforts include engaging nurses to serve on Boards,  developing models to help nurses progress up the career ladder, and creating an online tutorial for population health concepts. A new survey of RN and LPN programs in CT found that most students are ages 22 to 25 (RNs) and 26 to 30 (LPNs), most faculty teach part time, and the vast majority are white.

December web quiz: CT Medicaid quality

Test your knowledge about the improvements in quality of care in Connecticut’s Medicaid program. Take the December CT Health Policy Webquiz.

Medicaid update: New data on high-cost, high-need members

Friday’s Medicaid Council meeting focused on CT’s participation in a national technical assistance program to identify and meet the needs of high-cost, high-need patients. This population has received a great deal of attention from policymakers as the best opportunity to both improve access and quality of care as well as control costs. The concept offers exceptional opportunities for CT’s Medicaid program, that cares for some of the state’s most fragile and costly residents. An initial look at the top 10% of children and adult CT Medicaid utilizers, measured by total spending, ED use and inpatient care, finds 4,385 adult and 3,913 child high cost members. Fortunately, there is little evidence of racial or ethnic disparities among high-need Medicaid members in CT – likely due to DSS and CHNCT’s substantial outreach efforts. However both inpatient admissions and total costs among high-need adults are more than twice the rate for high-need children. More study is needed to determine the reason(s). The program offers exciting potential for data-driven solutions targeted to specific problems and great potential to save money in the program.

CT tied for fifth among states in health system performance

CT’s health system performs better than 45 other states according to the 2015 Commonwealth Fund State Scorecard on State Health System Performance. We improved on eight metrics, but lost ground on four. States are ranked on 42 indicators such as avoidable hospitalizations, health risk behaviors, childhood vaccinations, and hospital patients discharged with information to help recover at home. CT did well on all but one distinct dimension of health system performance. CT was tied for fifth in Access and Affordability of Care, ninth in Prevention and Treatment, tied for second for Healthy Lives, and third in Health Equity. However CT ranked far lower at 28^th among states on Avoidable Hospital Use and Cost. The rankings offer Connecticut guidance to improve health system performance especially around avoidable hospitalizations.

Report details dangers of hospital consolidation, especially YNHH and L&M

A new report by a coalition of labor and consumer advocacy groups including the CT Health Policy Project, calls for caution and more study before the state approves pending hospital consolidations. Concentration in CT’s health care system is being driven by new, untested shared savings payment reform models being adopted in Medicare, Medicaid and private insurance plans. CT already suffers from a highly concentrated hospital market, with the fourth highest health care costs in the US but lagging quality. Twenty years ago all CT hospitals were independent, but if pending mergers across the state are approved, 80% of inpatients will be cared for in large, multi-hospital systems. The report highlights Yale-New Haven’s proposed acquisition of L&M’s hospital system and “slow motion” takeover of Milford Hospital facilities and functions. This consolidation, if approved, would further consolidate the market in CT’s currently most concentrated market. Studies find that consolidations in already concentrated markets can raise prices by 20%. The authors urge policymakers to study the impact of current mergers, determine the impact on prices, access and quality of care, and develop protections to ensure value and protect consumers.

CT health reform progress meter ticks up slightly

December’s CT health reform progress meter ticked up very slightly this month. Medicaid redesign planning is still on track, working collaboratively with all voices at the table. New Medicaid quality data confirms the program’s improvements and the number of person-centered medical homes in the program passed 100. However that good news was balanced by troubling news on the fate of the first HUSKY parents cut from coverage, SIM ethics problems continue and SIM’s push to make their new, but not promising CCIP program a mandatory burden on new Medicaid networks. In other good news however, an RFP went out to hire health planners for the study of CT reform options from SB-811 last session. The CT health reform progress meter is part of the CT Health Reform Dashboard.

Op-Ed -- CT Medicaid: Don’t Mess With What’s Working

In an unusual twist, two prominent legal aide attorneys highlight Medicaid’s exceptional performance in improving quality, expanding access to care and controlling costs in a New Haven Register op-ed yesterday. CT’s Medicaid program is remarkable in actually lowering the cost of care for members, while improving the care they receive.  Legal aid’s role is not usually to compliment the state, but these two attorneys felt compelled to applaud the accomplishments. Other states should take notice. Read more

22,166 CT residents sharing $1.8 million in ACA premium rebates

Over $469 million in 2014 insurance premium rebates will soon be going back to US consumers including 22,166 CT residents, according to CMS. CT rebates will average $177 per family. Since 2011, under the Affordable Care Act, insurers are required to spend at least 80% of individual and small group insurance premiums on medical care or activities that improve health. Large group insurers must spend at least 85% of premiums on health care and activities.  Under the law, insurers that do not meet this standard must rebate excess administrative costs to consumers. Over $2.4 billion has been returned to US consumers since 2011. Rebates come either directly to consumers or to their employers to benefit employees.  Since 2011 the percent of compliant, fairly priced coverage has increased every year, necessitating fewer rebates.

Fate of terminated HUSKY parents troubling, implications for families staying together

At Friday’s Medicaid Council meeting we learned that 167 of the 1,215 HUSKY parents that lost coverage last year were able to buy insurance from the health insurance exchange. Unfortunately 32 former HUSKY parents initially signed up for insurance through AccessHealthCT, but later lost coverage because they didn’t pay their premiums. It is not clear if they found other coverage or weren’t able to afford coverage at all and are now uninsured. It is unclear how many have been able to stay on HUSKY because they remain eligible in another category. At least three HUSKY parents cut off the program left their original households and now are eligible as single households. Council members expressed concern about the potential implications of the cuts for keeping families together. Another 18,389 HUSKY parents are scheduled to lose coverage on July 31, 2016 unless the state reverses the cuts.

We also heard that the backlog of pdf applications is now gone, so application delays should be far lower. Total Medicaid eligibility has fluctuated over the last year because of the pdf problem, the shift to MAGI income eligibility and HUSKY parents’ cuts. As of last month, 716,833 state residents were enrolled in Medicaid.

RFP open for state health planning grant

At today’s Health Care Cabinet, we heard about the RFP for health care planning made possible by passage of SB-811 this year. Section 17 of the law directs the Cabinet to compare mechanisms to improve health care value in Connecticut looking to other states and assessing what would work best here. The plan for the grant is thoughtful, focuses on engaging all stakeholders to collect the best ideas, and improving communications across CT’s health care landscape. The plan holds great promise to address the shortfalls of past and current reform efforts. Advocates sent a letter in July supporting the project and offering our help.

We also heard from SIM about a CMS-led summit meeting and strong federal pressure toward narrowly defined, strong payment models. It was pointed out that evidence of effectiveness to date for these new payment models is very sparse and mixed. While CT should learn from federal and other states’ experience, we have to chart a course that makes sense for our state. Our Medicaid program has reversed our history of poor performance and is now saving money, improving quality, increasing access to care, and improving consumer experience of care. No one wants to jeopardize that progress. SIM leaders disagreed saying that CT can chart its own course, but that course will align with federal directives.

After moving public testimony, FDA committee advises stronger warnings on fluroquninolons

Last Thursday two FDA Advisory Committees heard hours of moving public testimony on Fluoroquinolon—Associated Disability (FQAD). We also heard doubts about the effectiveness of this class of antibiotics that is prescribed over 30 million times in the US each year. FQs were first approved by the FDA many decades ago, before better effectiveness tests. New studies question the effectiveness of FQs in treating infections compared to placebo. At the hearing, FQAD sufferers and family members described serious, but somewhat rare, neuromuscular, psychiatric and cardiac effects and deaths from taking just a few pills, generally in previously very healthy, active people. Many were given the drug as a precaution, and never had an underlying infection. We also learned that previous changes to strengthen warnings on the drug label have been ineffective; prescribers and consumers were unaware of the risks. Drugs companies that developed FQs minimized the risks and questioned the integrity of disability reporting, because most reports come directly from consumers rather than professionals. The committees recommended even stronger label language, including the risks of disability, but also asked the FDA to consider a public/prescriber education campaign about the risks, measures to ensure FQs are used only as second line therapy, and to promote informed consent by consumers using the medication.

Funds available to pay medical bills for Hartford area residents

There are funds available to cover Hartford area residents’ medical bills that aren’t being spent. Responding to requests, Nelson and Elsie Brainard started the fund in 1957 to help people “of modest means” facing unemployment and bankruptcy because of high medical bills. The Fund now spends hundreds of thousands each year covering bills, but as the end of this year approaches, there is still money available. Of course there are qualifications – the Fund pays bills for medical care of adults that aren’t eligible for public programs facing financial hardship due to a serious or chronic medical condition. The bills must be at least $3,000 and patients must pay some part of the bill. The Fund works with 12 area agencies to assist people applying for funds. For more, go to the Brainard Fund brochure or call 211 and ask.

November web quiz: CT health coverage

Test your knowledge of health care coverage in Connecticut. Take the November CT Health Policy Webquiz.

CT health reform progress up slightly this month

CT’s progress toward health reform inched up this month to 25.7%, ending a four month decline. New Medicaid numbers confirmed that per person costs continue to decline, long after the initial savings from switching away from capitated insurers. The continued progress suggests that structural changes like patient-centered medical homes, quality incentives and intensive care management are working. In other good news, we got an additional, badly-needed six months to allow thoughtful Medicaid redesign, allowing CT to avoid costly past mistakes and preserve progress. Officials continue to consult with stakeholders in the design. Unfortunately the good news was balanced by Medicaid provider cuts, SIM’s efforts to force a poorly designed CCIP plan on Medicaid, the inability to find funding for the collaborative Health Neighborhood shared savings plan, and disappointing new Census numbers about CT’s uninsured rate. The CT health reform progress meter is part of the CT Health Reform Dashboard.

25 CT hospitals decline to respond to Leapfrog quality survey

Only five CT hospitals reported quality and patient safety data to the Leapfrog Group this year – Bristol, Backus, Dempsey, Stamford and Windham hospitals. The hospitals that did report performed very well in general. Released this morning, the 2015 Leapfrog survey covers nineteen areas including maternity care, high risk surgeries, hospital acquired conditions and resource use. CT hospitals have not performed well in national quality rankings, including Medicare hospital readmission rates.

Community Care Teams addressing high-cost Medicaid member needs

Friday’s MAPOC Complex Care Committee meeting focused on Community Care Teams (CCTs) that collaborate across social service to help people with complex health problems. So far, seven CT communities are developing or already operating CCTs that focus on frequent ED visitors. The CCT teams include hospitals, behavioral health and primary care providers with community resources such as food and housing programs. CCTs include regular meetings of all partners, to review cases and align treatment resources, as well as dedicated staff to connect with patients and help them navigate the resources. At the committee meeting we heard from Middlesex County’s CCT, which started three years ago and has already achieved impressive reductions in ED usage and costs. The Middlesex CCT has saved an estimated $1.7 million in ED costs to date. Each ER visit avoided by a Medicaid member saves the program an average of $915.66. On behalf of DSS, CHNCT and the CT Behavioral Health Program both support and participate in CCTs across the state. Funds this year to support and expand CCTs across the state were cut from the state budget but there is optimism that funding in next year’s budget will be protected.

CTNJ Op-Ed on CT’s ACA progress covering the uninsured

Yesterday’s op-ed in CT News Junkie focused on CT’s mixed results in covering the uninsured under the Affordable Care Act. Read more

ACA and covering the uninsured: How did CT do?

An analysis of new Census data finds that 88,000 more CT residents had coverage last year than the year before, largely due to expansions under the Affordable Care Act. CT’s uninsured rate dropped from 9.4% in 2013 to 6.9% last year. However that drop was less than the US average and far less than other states like CT that expanded Medicaid. The drop in the uninsured was accompanied by a large increase in Medicaid enrollment, and a smaller increase in people directly purchasing coverage. About half the remaining uninsured are eligible for either Medicaid or subsidized coverage through AccessHealthCT, the state health insurance exchange. As in the past, CT’s remaining uninsured are more likely to be poor or near poor, less educated, non-citizens, work part time and live in Fairfield County. Employer-sponsored coverage dipped slightly last year, but it has been slowly declining for over a decade. In fact, the drop last year was less than the average annual drop since 1999. The ACA did not adversely impacted employer-sponsored coverage in CT.

Anthem, Aetna and CIGNA have 82.5% of CT health insurance enrollment

As always, this year’s managed care report card from CT’s Insurance Dept. is fascinating.  Anthem has 44% of total enrollment. Anthem is seeking to buy CIGNA for $54 billion; together they have 64% of CT enrollment. Aetna has 18.5% of enrollment, ConnectiCare has 9.2%, and Oxford/United Health Care has 6.8%. Enrollment is very low in CT’s two nonprofit insurers -- Healthy CT has only 0.3% of enrollment, and Harvard Pilgrim’s enrollment is less than a thousand people so far. The report includes 2014 medical loss ratios (MLRs) for each plan, including federal calculations and the more rigorous state MLR. The MLR is the percent of premiums that go to pay for medical care (and quality improvement in the federal calculation). Anthem’s HMO plans and all Oxford/United Health Care plans are below 80% on the state’s MLR calculation.

The report also has a wealth of useful information for consumers including customer service info, NCQA accreditation level, and number of providers by county and type. The report includes several quality measures including performance on cancer screenings, controlling high blood pressure and cholesterol levels, prenatal and postpartum care, drug utilization with costs, behavioral health, and member satisfaction.

Half of CT’s remaining uninsured eligible for subsidies or Medicaid

A new analysis by Kaiser finds that 47% of CT’s remaining uninsured are eligible for subsidized coverage. The latest Census report found that CT’s uninsured rate dropped by 2.5% from 2013 to 2014., but 6.9% of state residents are still without coverage. While 87,000 more residents gained coverage in the first year of the ACA expansion, CT’s progress lagged behind the US average (2.8%) and especially behind the average for states like CT that expanded Medicaid (3.2%). The new Kaiser analysis drills deeper into those numbers finding that half of the remaining 247,000 uninsured CT residents are eligible for either Medicaid (69,000) or subsides to purchase coverage on the exchange (62,000). Unfortunately 116,000 uninsured state residents do not qualify for subsidized coverage either because of income, an employer offer or immigration status. We have a lot of room to improve, to take advantage of the opportunities under the ACA and get affordable coverage to every state resident.

NJ conference on Medicaid ACOs – deep commitment to applying lessons learned

A CT contingent ventured to NJ last week for their 4thAnnual MedicaidPayment Reform Summit. The conference was sponsored by the QI Collaborative which is working with the state and private foundations to support accountable care in NJ’s Medicaid program. We heard from Jeff Brenner of the Camden Coalition about their impressive results in serving high-need, high-cost consumers through intensive and culturally appropriate outreach, robust provider collaboration, and strong links to social services. We heard about other effective high-cost, high-need programs from Baltimore, Boston, and New York. We heard from three ACOs that were certified for NJ’s Medicaid program and one that wasn’t but is still working toward accountable care. We heard from Jurgen Unutzer from the Univ. of Washington about what works, and what doesn’t, to effectively integrate behavioral health into primary care. Click here for slides. A panel talked about technology innovations that can support effective payment and delivery reforms. Fascinating information from people really doing the work.  NJ is well ahead of CT in designing thoughtful Medicaid reforms. We learned a lot.