Wednesday, July 19, 2017

Quality challenges remain in CT Medicaid PCMHs

Also at Friday’s meeting, DSS reported on a selection of quality results from 2015, highlighting concerns. The results compared quality measures for patients receiving care from private practice and community health center Patient-Centered Medical Homes. In other programs, PCMHs have improved quality performance over non-PCMH practices. There remains a lot of room for improvement. Only 23.9% of children ages 1 to 17 are getting behavioral health screenings in private PCMHs (they all should be), but it’s even worse at community health centers (10.2%). Emergency department visits are still too high but are 35% higher for community health center PCMH patients. Less than half of patients in both private (47.3%) and community health center (38.6%) PCMHs are getting follow up within seven days of discharge from the hospital. The trend isn’t encouraging -- between 2014 and 2015, almost as many measures worsened as improved. Following past trends, quality at community health centers is lower than at private practice PCMHs for all but one of twelve measures listed. CT Medicaid has a great deal of work to do, but unfortunately PCMH+ and its administrative burdens, lack of evaluation, and unhelpful financial incentives to stint on care will make it much harder.

Monday, July 17, 2017

Déjà vu at Medicaid Council meeting

Friday’s Medicaid Council meeting focused on the controversial PCMH+ shared savings program reminding many observers of years of rosy DSS presentations about the very similar, failed HUSKY MCO program. PCMH+ started six months ago with 137,000 members. The concept is to give Accountable Care Organizations (large health systems) a reason to lower the total cost of care for members by sharing half the savings with them. We heard inspiring stories of consumers who have been helped by the care managers hired with PCMH+ upfront funding. (Note that many of the anecdotes could/should have been covered under the current successful PCMH (no plus) program.) To avoid the stunning failure of the HUSKY MCOs, there was to be robust tracking of quality and underservice metrics, higher spending (despite the program’s name), and enforcement of policies to ensure that ACOs do not cherry pick members to drive up false “savings” payments, as has happened in other states. Unfortunately, DSS has not lived up to their promises in implementation intending to expand the risky program to another 200,000 people in six months without an evaluation of harm or overspending. Advocates have expressed deep concerns about this among other problems, but at the meeting Friday, DSS refused to answer the question or explain their decision. Reportedly, the capacity to evaluate and report on PCMH+ performance exists at UConn and they are eager to help. We have not received an answer to that question either. Concerns about sustainability of funding for the care managers were also ignored. As questions were cut off, advocates are sending our questions to DSS and to the ACOs individually. We’ll let you know if we get any answers.

Thursday, July 13, 2017

Sen. Blumenthal holding fifth hearing on ACA replacement bills

Friday at 2pm Senator Blumenthal will convene an emergency field hearing to collect input from Connecticut residents on current proposals to repeal and replace the Affordable Care Act. This is the Senator’s fifth hearing on the issue. The latest Senate version of the bill from Republican leaders was published today. The hearing will be held Friday, July 14th from 2 to 4pm in the Weller Center (2nd floor of Clark Building), Mitchell College in New London. Parking is available in the Montauk Avenue lot.

Wednesday, July 12, 2017

ACA repeal, Medicaid, personalized medicine, and bioscience highlight at ERC Annual Meeting in Connecticut next month

Join CSG-ERC for our 2017 Annual Meeting and Policy Forum August 13 to 16 in Uncasville, CT. Health programming includes a lunch talk on the promise of genomics, the potential of bioscience to improve health and grow state economies, and the potential state impact of federal proposals to replace the Affordable Care Act, significantly change Medicaid funding, and budget cuts. Registration is now open.

Tuesday, July 11, 2017

Lowest wage workers least likely to be offered health benefits at work

Only 22% of Americas earning the lowest ten percent of wages are offered medical benefits by their employer, according to a new report by the Bureau of Labor Statistics. This compares with 93% of the top ten percent of earners who are offered medical benefits at work. Unfortunately, the lowest wage workers also pay more for their benefits and employers pay less. Workers with wages in the lowest ten percent pay almost $125 more per month for family coverage than workers with wages in the top ten percent. Not surprisingly, even the lower wage workers who are offered benefits are less likely to accept them. Only 11% of workers with wages in lowest ten percent of Americans participate in employer-sponsored coverage, compared to 72% of those in the highest ten percent of wages. Employer offers of dental and vision benefits are lower than medical benefits among all workers, but the disparity between high and low wage earners is also reflected there. Low wage workers are also less likely to be offered retirement, paid leave, paid vacation, and paid holiday benefits, according to the BLS.

Friday, June 30, 2017

Pervasive uncertainty affects CT Health Reform Dashboard

July’s CT Health Reform Dashboard reflects growing uncertainty at the state and federal levels. If passed, Congressional proposals to replace the ACA will shift massive costs onto CT and result in a sharp drop in coverage. State budget cuts threaten current services and coverage. Nevertheless, DSS is doggedly forging ahead with a questionable payment experiment without waiting for data; we’ve seen this before and it doesn’t end well. Insurers seek double digit rate increases and physicians are building a health information exchange, because the state can’t seem to get it done.

Thursday, June 29, 2017

Sen. Blumenthal holds third hearing on Senate ACA repeal bill

In response to public concerns, Sen. Richard Blumenthal will hold a third emergency field hearing on the Senate’s Better Care Reconciliation Act tomorrow, June 30th 10:00 to 11:30 am at the Hartford Public Library, 500 Main St. Earlier this week, CBO reported that the bill would make 22 million more Americans uninsured and cost state Medicaid programs $772 billion by 2026. A new analysis from Governor Malloy predicts that the Senate’s bill would raise insurance premiums in CT by 10 to 15% and cost CT’s state budget up to $2.9 billion annually when fully implemented.

Tuesday, June 27, 2017

Advocates document concerns with PCMH+ implementation

The Medicaid Study Group, a coalition of independent consumer advocates, have published an update on CT Medicaid’s new payment reform experiment, PCMH+,  fact sheet and report. The program started January 1st with 137,037 members. Under the new shared saving payment model, large health systems (called ACOs in other states and programs), get half the health care savings they are able to generate on their assigned patients. Advocates are concerned that DSS intends to rush forward with a massive expansion of the experiment to another 200,000 people without data on outcomes, possible harm to people, and overspending. UConn reportedly has the ability to give policymakers timely performance information, but cannot get access to DSS's data. In response to concerns, DSS did survey members who opted out of the program, but only spoke to 7 of the 1,808 people who refused the program. There is no mechanism to detect ACOs shifting patients between practices to generate false “savings” payments, as happened in other states. Advocates are concerned that, despite the label “shared savings”, PCMH+ could end up costing the state more as has happened in other states and programs, which CT cannot afford. The biggest problem is that trust has been eroded by broken promises and a lack of transparency. Mistrust makes it very hard to move forward.

One hopeful note from the Governor’s otherwise dismal executive order budget proposal is to save $700,000 by delaying the expansion of PCMH+ planned for next year.

Monday, June 26, 2017

CBO estimates that 22 million more Americans will become uninsured by 2026 under the Senate’s ACA replacement proposal

Thursday morning Senate leaders published their plan to replace the Affordable Care Act and modified it earlier today. The Senate proposal closely follows the bill that passed the House in May. According to today’s Congressional Budget Office’s report, the Senate bill would increase the number of uninsured Americans by 15 million next year and 22 million by 2026, including 15 million losing Medicaid. Increases in the uninsured rate would cross income and age categories, but would fall hardest on low-income and older Americans. The Senate bill would reduce Medicaid funding to states more than the House bill but spreads those cuts out over three years. Under the Senate bill, Medicaid funding to states would drop by $772 billion by 2026. According to the CBO, “With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes, or (to the extent feasible) arriving at more efficient methods for delivering services.” CBO also estimates that the Senate bill would increase private insurance premiums by 20% on average next year but lower them beginning in 2020 when plans could be less generous. By 2026 premiums would be 20% lower than under current law, but because of less generous plans, consumer out-of-pocket costs would be higher. CBO predicts that some people will “experience substantial increases in what they would spend on health care” depending, in part, on whether states choose to waive Essential Health Benefit standards in current law.
(Update added 6/30/17) A subsequent extended CBO analysis finds that under the Senate bill federal Medicaid spending would decrease even farther in the future. Analysts estimate that under the Senate’s bill, federal spending on Medicaid would decrease by 26% by 2026 and 35% by 2036.
The Kaiser Family Foundation has published a side-by-side comparison of ACA repeal and replacement proposals.

New to the Book Club -- Economic Ideas You Should Forget

The title alone pulls you in – Economic Ideas You Should Forget. Ideas and theories that everyone believes but aren’t true. 71 eminent economists and social scientists from around the world each contributed an economic theory that should be forgotten. Myths debunked include more choice is better, that economic growth increases well-being, and that CEO pay reflects talent and hard work. This book, and the underlying message, should be required reading for all healthcare payment reformers. For more summer reading books, visit the CT Health Policy Project Book Club.

Wednesday, June 21, 2017

Blumenthal holding second emergency field hearing on ACA repeal proposals

Senator Blumenthal has scheduled an emergency field hearing in New Haven Friday to hear the public’s thoughts on federal proposals to repeal and replace the Affordable Care Act. Monday’s hearing in Hartford drew over 200 people with standing room only who wanted to share their concerns. Senate leaders will not allow any official public hearings or committee review of their bill. Senator Blumenthal is scheduling these hearings to give CT residents a voice in this important legislation that will touch every American’s life and one fifth of our economy. A draft of Senate leadership’s bill is expected tomorrow morning.
Sen. Blumenthal’s hearing will be this Friday, June 23rd at 1:30pm in the Aldermanic Chambers, New Haven City Hall, 165 Church St. Street parking is limited. Click here for a map of local parking.

Tuesday, June 20, 2017

Report estimates AHCA would cut $5.9 billion in Medicaid funds to CT

Connecticut would lose $5.9 billion in Medicaid funding from 2019 to 2028 under the American Health Care Act passed by the House last month, according to a new report from the Urban Institute and the Robert Wood Johnson Foundation. Connecticut would likely not be in a position to fill that funding gap with state funds. The authors note that provider rate and benefit cuts are unlikely to generate much in savings. If the AHCA passes, Connecticut would have to decide whether to fill some or all of the gap with state funds and/or cut eligibility to ease state funding. If Connecticut chooses to cut only the 168,300 people estimated to have gained coverage under the Affordable Care Act by 2022, the state funding gap drops to $900 million over those ten years. If Connecticut chooses to cut eligibility enough to keep state Medicaid spending level, 179,600 more people would be uninsured by 2022. The report’s authors point out that their estimates are very sensitive to changes in Medicaid spending growth and per capita cap growth rates.

Sunday, June 18, 2017

New data finds CT leads nation in lowering Medicaid costs

New data from CMS actuaries finds that Medicaid per capita health care spending dropped 5.7% from 2010 to 2014, better than any other state. Of note, in 2012 CT Medicaid shifted away from capitated managed care organizations to run Medicaid. Unfortunately, the rest of the CT’s market is not performing as well as Medicaid – Medicare per person costs rose 1.6% and private insurance by 2.5% over those same years. Despite the progress, at $8,058 per person in 2014, CT was still twelfth among states in per capita Medicaid spending. But for total per capita spending across all populations, CT ranked fifth among states at $9,859 in 2014. Our average annual rate of increase from 1991 to 2014 was 4.9% for total per person spending, equal to the US average. It appears the rest of CT’s market and other US states should be copying CT Medicaid’s success.

Monday, June 12, 2017

Medicaid update – administrative conversion drives up call wait times

Friday’s Medicaid oversight council meeting focused on DSS’s conversion to ImpactCT, a new IT system to handle eligibility and enrollment. The hope is that moving more administrative functions online will streamline the process and reduce errors. Unfortunately, implementing the system is pulling staff away from their desks for 9 days of training, causing a sharp increase in average call wait times up to 54 minutes last month. Also disturbing is the very large volume of calls – 134,903 monthly on average -- which has been pretty steady over the last two years. If those were unique callers (which they probably aren’t) that would mean that one in five members was calling for help every month. The phone tree is only serving half of the callers -- 76,021 average ask to be connected to a real person, and 30% of those callers give up – not surprising as they will lively wait an hour to talk to that real person. In good news, by all reports, when callers do reach a person they are getting what they need and have a very good experience with the call. But in more bad news, shifting members to apply and manage their eligibility online is not working. DSS receives an average of 355,118 separate paper envelopes of applications, renewals and changes each month while only a few thousand are using the online system. An average 33,761 members (4% of the population, if unique) trek to a walk-in service center monthly but that rate is going down. DSS acknowledged the problems, said they’ve learned from past administrative shifts, are working to improve service, and promised to remain transparent, sharing public updates regularly. Committee members noted the large reductions in staff over the years and expressed concern that tight state finances not make the problem worse. DSS asked all of us to help them guide people to the online system, but they never addressed whether the system is user-friendly and working. In good news, DSS noted that timelines for SNAP applications and error rates have improved with the administrative updates so far. The shift to ImpactCT should be completed by this Fall.

Monday, June 5, 2017

CT insurers’ 2018 rate requests as much as 52% increase -- public hearing, comment

As part of the health insurance rate review process, CT’s Insurance Department will hold a public hearing June 14th in Hartford on insurers’ double-digit rate requests for next year. In the morning, the hearing will address Anthem’s requests averaging 33.8% increases and affecting 35,000 policyholders. In the afternoon, the hearing will consider ConnectiCare’s average 17.5% increase request affecting 50,907 policyholders. The hearing will be at 153 Market St. in Hartford in the 7th floor hearing room. Info on the hearings, including parking validation and public comment, and the full rate filings are online. Residents can also submit written comment online by July 1st by clicking “Select” next to the filing you want to address. Commenters can also mail comments to CT Insurance Department, P.O. Box 816, Hartford CT 06142.

Thursday, June 1, 2017

June CT Health Reform Dashboard – concerns remain but some hope for drug costs

CT’s June Health Reform Dashboard remains unsettled. Mistrust remains at the core of problems in CT. The new state HIT environmental scan mentions the need for trust a dozen times.  Medicaid policy development and implementation remains mired in mistrust, rushing ahead without data, and a lack of transparency. The state budget remains dreary and signals around Medicaid from the US Senate are mixed. In good news, CT’s Senate unanimously passed a bill to remove gag clauses so pharmacists can tell us the full truth about our medications, their costs and effectiveness. The Health Care Cabinet is continuing our work to control drug costs in CT with new workgroups to develop options.

Tuesday, May 30, 2017

MD drug anti-gouging bill passes into law, CT Senate passes drug benefits fairness bill

On Friday, a Maryland bill to control generic drug prices passed into law without the Governor’s signature. Maryland’s Attorney General Frosh championed this first-in-the-nation anti-gouging bill. The issue was raised in response to extreme price increases in older drugs such as EpiPen, naloxone, and Daraprim. The bill requires Maryland’s Medicaid program to notify the Attorney General when an “essential” generic drug’s price rises by 50% or more over two years. The Attorney General may then require records and documents related to the price increase, seek penalties in court, or ask the court to compel the company to offer the drug to the state at the original price.   In his letter, Governor Hogan applauded the bill’s “laudable goal, to combat price-gouging of consumers for life-saving drugs” but raised legal and constitutional concerns. He also noted that the law only applies to generic and off-patent medications, missing important and costly treatments. He urged the legislature to return to the issue next session. States across the US are considering legislation to control drug costs.

Last Wednesday, Connecticut’s Senate unanimously passed SB-445, An Act Concerning Fairness in Pharmacy and Pharmacy Benefits Manager Contracts on the Consent Calendar. The bill prohibits “gag clauses” in contracts with pharmacists and allows them to disclose prescription costs, the reimbursement to the pharmacy, the prescription’s efficacy, and any alternative, less expensive medications. The bill also prohibits charging consumers more than the drug costs. Right after the bill passed, Governor Malloy sent a letter to Senate leaders criticizing the bill and an “antagonistic approach” to the insurance industry. Senate leaders are confident the bill will pass the House and, if necessary, override a veto by the Governor.

Thursday, May 25, 2017

CBO estimates that AHCA would cause 23 million more uninsured in ten years

In more federal health news, the nonpartisan Congressional Budget Office released their analysis of the impact of the House’s American Health Care Act yesterday. CBO predicts that 23 million more Americans would lose health coverage in the next decade, 14 million just next year, if the AHCA becomes law. The law would reduce the federal deficit, largely by cutting $834 billion from Medicaid over the next ten years. CBO also predicts that insurance markets would become very unstable for about one in six Americans who live in states that elect the AHCA option to remove community rating and Essential Health Benefit standards now required by the Affordable Care Act. Young, healthy residents of those states would benefit with lower premiums but residents with higher-than-average health costs would see a large increase in premiums if they could even find coverage. According to the CBO, benefits that would likely be cut in those states include maternity, mental health and substance abuse, rehabilitation and habilitation, and pediatric dental care. Residents of those states that need the services removed from Essential Health Benefit standards would face very large increases in out-of-pocket costs or would have to forgo care.  Plans in those states may re-institute annual and/or lifetime caps on coverage which would also significantly raise costs for residents with high-cost health needs such as expensive prescriptions, according to the CBO. The AHCA has not been taken up by the Senate; leaders there have stated they intend to start over with a new health reform bill.

Wednesday, May 24, 2017

President’s budget proposal includes large cuts to state Medicaid funding, among other health programs

President Trump’s FY 2018 budget proposal includes $610 billion in mandatory savings over the next decade by instituting state Medicaid block grants or per capita caps starting in FY 2020. This goes beyond cuts included in the American Health Care Act passed by the House of Representatives three weeks ago, that is estimated to cost Connecticut $1 billion/year when fully implemented.  According to the proposal, “The Budget ensures that Medicaid and other programs focus on the most vulnerable Americans that they were intended to serve—the elderly, people with disabilities, children, and pregnant women.” The proposal also includes $250 billion net deficit savings over ten years from repealing and replacing the Affordable Care Act. Other ten-year cuts include a $5.8 billion reduction in CHIP funding and approximately 20% cuts to both the NIH and the CDC. The budget proposes shifting more of the FDA’s budget to industry fees and away from taxpayer funding. The President’s budget estimates $55 billion in federal savings over the decade, including $339 million in Medicaid savings, from nine specific medical liability proposals including caps on damages, safe harbors for providers based on clinical standards, and a three-year statute of limitations. The budget proposes expanding Direct Primary Care in Medicaid, a relatively new capitation model for primary care providers. The proposal includes some expanded funding for emergency preparedness and continues funding to address the opioid epidemic but cuts almost $400 million from the Substance Abuse and Mental Health budget. It’s important to remember that the President’s proposal has to be approved by Congress and likely will be changed significantly.