Monday, July 20, 2015

SIM underservice protections get a cool reception, weak ethics policy adopted

Thursday the Equity and Access Council delivered to the SIM Steering Committee a draft report with recommendations to avoid underservice in SIM’s planned payment reforms. Advocates were successful in getting a provision in the SIM final plan that prohibited payment of shared savings to provider networks that systematically denied needed care to generate those savings. The Council’s job was to draft recommendations to implement that provision. Members were thankful for the hard work and complimented the Council on a thoughtful report. However members raised concerns with the recommendations, especially with a provision that would divert payments denied due to underservice toward quality improvement and fixing the underservice problem, rather than back to the insurer. It is important to note that, under the Council’s recommendations, provider networks would not know what metrics are being monitored for underservice. But the insurers do know what is being measured, and as we learned in Council discussions, insurers have tools that could result in underservice, as were used during managed care in the 1990’s. (My students don’t know what is going to be on the test, but I don’t get paid double for students who get F’s.) The main concern was that this would limit the ability to cut costs, and that the money belongs to employers and should be returned to them. It was noted that the ultimate payers of health care are actually consumers – through our taxes, our premiums/out-of-pocket costs and our lost wages. Employer health benefits are part of earned compensation. Concerns were also raised with a recommendation to prohibit directing shared savings payments to the pockets of providers with the lowest costs, as this would be an exceptionally strong incentive to underserve. It was noted also that, if reform is done right to improve the value of care and improve health status, reductions in costs will be a team effort including the provider, but also potentially a nurse, nutritionist, pharmacist, community health worker, aide, and/or behavioral health specialist. Concerns were raised about rewarding networks that improve health quality (and hence value), even if they did not achieve savings, with sharing the cost of necessary investments with providers, and a recommendation to exempt very high cost patients from the shared savings methodology as these would undermine cost savings. It was suggested that fraud detection systems would be adequate to deter underservice; there is a great deal of underservice that is not fraudulent. The report will be submitted for public comment soon.

Unfortunately at the same meeting the committee was presented with the final version of their very weak conflict of interest policy that does not meet the standards of the State Code of Ethics. A declaratory ruling of the State Ethics Board found that SIM committees have substantial authority over setting state health standards and over state and federal funding but are exempt due to a loophole in the law. The ethics law does not specify appointees of the Lieutenant Governor, as all SIM committee members are. Two Steering Committee members have been awarded SIM grants from federal funds. The Hartford Courant Editorial Board has called on SIM to adopt the State Code of Ethics.