This month’s Health Reform Dashboard update reflects more attempts to unravel progress in CT. Medicaid leads the concerns with broken promises on downside risk and attempts to weaken critical consumer notices about shifting provider incentives, potential underservice, and how to protect yourself. OHCA’s approval of YNHH’s acquisition of L&M health system will require a lot of unusual regulatory oversight and political will. The Health Care Cabinet continues to consider troubling reform recommendations for CT and SIM ethics concerns continue, especially in efforts to weaken Medicaid shared savings consumer notices.
Monday, October 31, 2016
Friday, October 28, 2016
A broad coalition of consumer advocates, including the CT Health Policy Project, community leaders, caregivers, labor representatives, and providers has called on OHCA to engage the public and consider the community when implementing the unusual deal allowing Yale to purchase L+M hospital and physician group. In a letter to DPH, the coalition praised price caps but voiced concerns about other aspects of the deal including community investment and retention of vital services in Southeastern CT. Much of the deal’s success depends on the hiring of a genuinely independent monitor to ensure the price caps and other promises are meaningful. As Yale will be choosing and hiring the monitor, subject to DPH/OHCA approval, the coalition’s letter calls for public input into the choice of the monitor.
Saturday, October 22, 2016
According to new numbers for 2014 from the Centers for Disease Control and Prevention (CDC), tobacco use is the leading cause of preventable disease and death in the US. Tobacco use is blamed for 480,000 premature deaths and over $300 billion in direct healthcare costs each year. Unfortunately CT is not immune; 15.4% of adults in our state smoked cigarettes in 2014. That rate has remained relatively steady over the last five years. Like every other state, men in CT more likely to smoke than women (17.5% vs. 13.5%). Also as in the rest of the US, blacks and Hispanics are more likely to smoke in CT than whites (17.9%, 19.0% and 14.34% respectively).
Thursday, October 20, 2016
Last weekend NESCSO, the Millbank Fund and the New Hampshire Department of Health and Human Services convened a group of twenty-two state executive and legislative branch health policymakers in Portsmouth, NH to consider the future of hospitals in the region. All six New England states were represented. Hospital roles are evolving quickly with national and state health reforms, implementation of the Affordable Care Act, community health needs assessments, and value-based purchasing. The group discussed hospital and payer consolidation, payment reforms, quality improvement, and the states’ role in protecting capacity while controlling costs. The group also emphasized the need for simple communication tools to help legislators and the public understand complex shifts in the region’s health care system. Congratulations to CT’s Medicaid Director, Kate McEvoy, who now chairs the NESCSO Board of Directors.
Wednesday, October 19, 2016
Last week’s Medicaid Council meeting focused on the controversial Strawman proposal for reforming CT’s health care system and the implications for Medicaid. We reviewed continuing progress in the program improving quality and access while controlling costs. State spending on the program is down, despite strong enrollment growth, and per person costs are stable saving the state many millions. The program is also very efficient with only 5.2% of costs spent on administration. However, despite this progress, consultants to the Health Care Cabinet have proposed implementing downside risk for CT’s Medicaid and state employee programs. Several Council members spoke strongly against the proposal and in favor of building on current success. Sen. Gerratana described her husband’s experience as a physician under downside risk in Medicaid in the 90’s as a “nightmare.” Rep. Abercrombie expressed frustration that policymakers concerned about rising health care costs elsewhere, too often turn to CT Medicaid, where we don’t have a problem, with “extremely concerning” policies because it is one of the only programs the state controls. The Council agreed to send a letter to the Cabinet outlining our concerns and opposition to the proposal.
Medicaid advocates and providers have been talking a lot about the administration’s policy reversal with a troubling decision to consider downside risk as a payment model for Medicaid. A main source of concern is that stakeholders had clear and repeated promises from the administration not to implement downside risk in Medicaid. Click here to thrash through those weeds, lay the question to rest, and move on.
Wednesday, October 12, 2016
Yesterday’s Health Care Cabinet meeting started with a statement by the Lieutenant Governor stating that the commitment made last year not to implement downside risk in Medicaid was time-limited to end with the state’s SIM grant in 2019. However that was never conveyed to advocates and, in fact, the state made a clear commitment, without any conditions, not to implement downside risk in Medicaid here, here in their plan to CMS and to potential PCMH+ (formerly MQISSP) applicants in the RFP. The commitment was originally made in negotiations to get partners, including advocates and providers, to participate in designing PCMH+, Medicaid’s plan for upside-only shared savings.
The rest of the meeting focused on proposals to cap health expense growth across the state, setting a target for payment reform contracts in the state, merging state agencies that touch health, HIT, ad comparative effectiveness research, and creating a new Office of Health Reform to set spending caps and payment reform targets among other duties. We then moved onto alternatives plans from many sources, including the CT Heath Policy Project. Other commenters also concerned about the expansive shared/downside risk proposal included AARP, Christian Community Action, and a collaborative alternative signed by twenty independent consumer advocates. Alternatives to the ACO provider coordination/consolidation plan included coordinating care with community-based organizations and building on Medicaid’s successes. Alternatives to the very controversial shared/downside risk proposal included focusing reform on primary care, moving back to global capitation across the state, and continuing to tie more provider/health system compensation to quality and away from volume. Alternatives to the cost growth cap proposal include regulating mergers, direct rate setting and consumer affordability. There were calls not to put the tool before the goals and wait before considering the 1115/DSRIP proposal. A new goal was raised in alternative plans to limit the growth of prescription drug costs – the Cabinet decided to take these up separately.
Unfortunately big areas were ignored (or danced around but not addressed) including the biggest – a pervasive lack of trust – and its corollary – very poor communications. The proposal is entirely silent on the critical issue of underservice*, which is a problem far beyond Medicaid. There was no mention of regulating ACOs as they assume huge control over health care spending and treatment decisions, the need to address high-cost, high-need patients, ensuring we have the workforce to do any of this, integrating behavioral health into medical care, social determinants of health or addressing the sorry state of health care quality in Connecticut.
We will deliberate and vote on Nov. 1 at 4pm and there will (finally) be an opportunity for public input at the Cabinet’s Nov. 15th meeting at 9am.
Wednesday, October 5, 2016
Provider networks authorized to negotiate for participation in PCMH+ (formerly MQISSP), CT Medicaid’s new shared savings program, have been announced.
The winners are:
Northeast Medical Group, St. Vincent's Medical Group, Community Health Center, Inc., Cornell Scott-Hill Health Corporation, Fair Haven Community Health Clinic, Inc., Southwest Community Health Center, Generations Family Health Center, Inc., OPTIMUS Health Care, Inc., and Charter Oak Health Center, Inc.
DSS welcomed all stakeholders into the PCMH+ design process, including independent advocates. The plan has pros and cons.
In response to questions, we’ve published two new documents about the most controversial part of the Health Care Cabinet’s Strawman proposal for health reform in Connecticut. To help in understanding how downside risk might work, and whether it works, in the context of other options, we’ve developed a fairly short Downside Risk Explainer. To address points offered by downside risk proponents, we’ve also drafted a somewhat longer response to the proposal. The response answers the proponents’ arguments with Connecticut-specific context, and outlines concerns of advocates and others including the administration’s promise not to impose downside risk on Medicaid, that downside risk is experimental and very new, it is very unpopular among providers, potentially reducing our hard-won increases in Medicaid participation rates, the proponents’ economic theory suggests that downside risk will reduce investment in innovation, and the model creates very strong incentives to deny necessary, appropriate care but includes no monitoring system or policies to prevent it. In many respects, downside risk combines the worst features of shared savings with capitation, which was a “spectacular failure” in Connecticut. The response also includes better alternatives to achieve the goals of improving quality and controlling costs without the risks of downside risk.
Monday, October 3, 2016
October’s CT Health Reform Dashboard update reflects the controversy surrounding the Health Care Cabinet’s controversial proposal for state health reform. The current proposal would move CT back into failed payment models and would break the administration’s promise to Medicaid members. Other concerns include a vague hospital consolidation deal that leaves a lot of accountability to administrative decisions, and a troubling shift in HIT leadership in the state.