SIM proposal draft – no commitment to deny payment to providers who deny care

During yesterday’s meeting, SIM leaders posted their first draft online of the administration’s plan to reform health care in CT. SIM is designed to radically transform how health care is delivered and paid for in our state across all payers – Medicare, Medicaid, private insurance, self-insured employers, individuals and small businesses. Despite earlier encouraging conversations, the draft does not include a provision crucial to advocates to deny payments to providers who achieved savings by inappropriately under-treating consumers. Consumer advocates have been very concerned that shifting provider incentives from volume to financial risk could result in inappropriate under-treatment causing harm. In contrast, the draft does commit to limiting payment for poor consumer experience of care and poor performance in addressing health equity. Steering committee members raised concerns about weak health equity provisions, placing Medicaid providers at strong financial risk, inadequate consumer empowerment in system change, and whether goals for cost savings are ambitious enough. One member asked that the next draft list the considerable risks that the plan will fail. There are no independent consumers or advocates on the SIM steering committee, but insurers, state agencies and other payers are well-represented. Steering committee members received the draft well before the meeting, but a public version was not available until half way through the meeting. Steering committee meetings do not include opportunities for public input.

CT among ten highest states in Medicare drug spending

A new analysis by C-HIT finds that CT seniors on Medicare are spending more than consumers in most other states on prescriptions. CT elderly Medicare beneficiaries are more likely to use brand name drugs than generics, especially in high income towns in Fairfield county. Within the state, Meriden has the highest per beneficiary prescription spending and Winsted the lowest. In good news, more than 81% of CT seniors are still taking recommended beta-blockers seven to ten months after a heart attack, compared to only 78.5% of all Americans. The study found wide variation in per capita drug spending but no evidence that higher spending was associated with better care.

Early insurance exchange enrollment older and half to Medicaid

Between the beginning of the month and Tuesday 3,847 people had enrolled in coverage through Access Health CT, our state’s health insurance exchange, according to a presentation to the exchange Board this morning. 1,857 (48%) are eligible for Medicaid, 1,125 (29%) for subsidized insurance, 772 (20%) for insurance without a subsidy, and 93 (2%) for HUSKY Part B. Enrollees into both Medicaid and insurance plans are more likely to be older – ages 55 to 64. This isn’t unexpected for early applicants who may have higher health needs and will likely even out as enrollment picks up. Most enrolling in insurance are choosing Anthem (67%), 31% are choosing ConnectiCare, and only 2% choosing the new HealthyCT plan. Half are choosing silver level plans. Only 11 small businesses covering 47 workers had enrolled by Tuesday.

SIM forum with advocates

This morning, SIM leadership held a forum to explain their plan to advocates. Unfortunately few independent consumer advocates were given an opportunity to ask questions, including this one. Most of the time was taken by SIM committee members expressing their positions, describing their programs and experiences. Many of the questions came from providers and others urging SIM leaders to include their programs in the SIM plan and fund their services. The committee did not respond to questions raised in the advocates’ letter. There were no assurances that a robust quality monitoring system will be in place before potentially harmful provider risk incentives are implemented and plans to lower medical home standards are still in place. Governance plans for continuing SIM are not settled and it is unclear who will decide, but the leaders are considering adding consumer advocates to committees. Advocates have posted Frequently Asked Questions About SIM and Guiding Principles for a Successful SIM. No further discussions are planned. 

CT insurance exchange switch flips on -- lots of interest, some glitches

Yesterday’s opening of CT’s insurance exchange, Access Health CT, went about as well as expected. Despite the administration and exchange staff’s repeated lowering of expectations, there was a lot of interest – 123,000 visits to the website by 28,000 unique visitors by 4pm. 167 people got signed up for coverage, including 84 into the Medicaid expansion set to begin January 1st. (Click here for the HUSKY is growing Medicaid outreach toolkit.) The site was down for over an hour and users reported difficulty creating accounts, but patience was rewarded. 

SIM update

The September meeting of the SIM steering committee changed little to the plan except the name of the payment model. The planners reported to the committee what will happen in the next phase of the process. They changed the name of their provider risk-based payment model from Total Cost of Care to Shared Savings, apparently because people associated TCC with capitation. But it became clear that members’ assumptions that Shared Savings had the generally accepted, Medicare-based meaning, that in fact Shared Savings also includes capitation. They are looking for a term that includes capitation but doesn’t evoke strong negative reactions from stakeholders. (The problem isn’t the term.) They also intend to re-create the committee structure, possibly including consumers and/or advocates in some of the new committees. In response to advocates’ concerns, they are including an Equity Access and Appropriateness Council to monitor for denials of inappropriate care under their provider risk models. However, there is no assurance that a meaningful quality monitoring system will be in place before people are placed in the potentially harmful payment model the committee is designed to prevent. They are continuing their individual, private meetings with insurers and others to test the model. 

CID seeking comments on mental health parity enforcement

The CT Insurance Department is seeking public comments on methods to monitor and ensure compliance with state and federal mental health parity laws. CID has chosen to move ahead with enforcement of the law, despite delays in getting federal regulations. Insurers have urged CID to wait for final federal rules. CID encourages anyone with expertise or experience in the area to comment. They will be accepting comments through October 15^th. 

Very encouraging Medicaid PCMH update

Far exceeding expectations, 34% of Medicaid members are now being cared for in person-centered medical homes according to DSS and CHNCT’s presentations at today’s meeting of the Medicaid Council’s Care Management PCMH Committee. There are almost 1000 primary care providers (between approved, accreditation eligible, and glide path status) receiving higher Medicaid payment rates to compensate for coordinating care, extended practice hours, and assisting consumers with managing and improving their own health. Five new practices joined the program just since the last meeting two months ago. The department also reported on new quality PCMH payments made to three practices that out-performed their peers on nine pediatric and/or adult medicine measures. Total quality payments ranged from $464 to $68,036 per practice. Advocates, providers and policymakers universally congratulated DSS and CHN for their hard work and exceptional success in implementing the PCMH program.

At the meeting DSS and CHNCT also reported on their new Rewards to Quit program – providing cash incentives to Medicaid consumers to quit smoking. The program, funded by a federal grant, will test the effectiveness of both cash incentives and peer coaching in encouraging consumers to quit. Participants can receive up to $600 in a year under the program for attending counseling sessions and for negative CO breathalyzer tests.  All Medicaid recipients are now eligible for smoking cessation services and products; the study will test if there is added effectiveness with peer counseling and cash incentives. 

Cabinet meeting update

This month’s Cabinet meeting included updates on SIM, the insurance exchange and CT’s APCD. SIM leaders reported that with the delay offered by HHS the new deadline for the state health plan model is the end of this year. They expect to have a first draft for public release sometime in October. The testing grant application, for the $50 million, is expected to go out next year. They are working on revising the governance structure – no details on that – and will continue to visit with consumers and community groups for input. Cabinet members urged them in those visits to explain and seek input from consumers and advocates on the entire plan, including the proposed payment model that has raised concerns. They are also considering creating new standards for patient-centered medical homes, with possibly lower standards than NCQA certification, also raising concerns about quality. Most of the new changes and negotiations are happening in private meetings. The insurance exchange is finalizing preparations for Oct. 1^st when people can begin to sign up for coverage. Tamim Ahmed, the new Director of CT’s All Payer Claims Database, Access Health Analytics, laid out his short and long term goals. Members raised concerns about privacy and security, not selling data or analytics for commercial purposes, creating transparent processes for data access, and not prioritizing insurance exchange data needs over others such as population health and health equity. Draft APCD policies and procedures are open for public comment until Thursday.

Public hearing on ER use and Medicaid

The Legislative Program Review and Investigations Committee will be holding a public hearing for their study of whether Medicaid consumers are over-using emergency dept. visits inappropriately and, if true, the impact on the state budget. If true, they will search for reasons including who is inappropriately using the ER, for what problems, and make recommendations. The hearing will be Sept. 26^th at 2:30 pm in Room 2D of the LOB.

New policy brief on “No wrong door” enrollment

A new brief by the CT Health Foundation describes “No Wrong Door” (NWD), the Affordable Care Act’s seamless plan for consumers to enroll in health coverage. NWD allows consumers seeking coverage to enter through an array of state agencies, be seamlessly routed to a common portal that will assess eligibility and needs, and connect them to the appropriate programs and resources for their circumstances. NWD is designed to simplify the dizzying array of programs and applications that consumers now have to navigate to participate in public coverage programs. Authors of the brief estimate that full implementation of NWD will result in about 20,000 more CT adults and 6,000 children with coverage, and will prevent another 36,000 state residents from losing coverage due to churning. It is expected that NWD will help close CT’s health equity gap by reaching people who might have remained uninsured.

Help design Connecticut’s health improvement plan

A broad coalition of stakeholders led by DPH is developing a plan for A Healthier CT by 2020 and we need your input. DPH is holding forums this fall in each CT county to get your input into the plan.

Tolland County: Sept. 10, Rockville High School Auditorium, 70 Loveland Mill Rd., Vernon

Windham County: Sept. 12, EASTCONN Capitol Theater, Magnet High School, 896 Main St., Willimantic

Hartford County: Sept. 24, Legislative Office Building, Room 2C, 300 Capitol Ave., Hartford

Litchfield County: Sept. 26, Torrington City Hall, Council Chambers, Rm. 218, 140 Main St., Torrington

Fairfield County: Oct. 8, Discovery Magnet School Cafeteria, 4510 Park Ave., Bridgeport

New Haven County: Oct. 10, Hill Regional Career High School, Auditorium, 140 Legion Ave., New Haven

New London County: Oct. 17, Three Rivers Community College, Multipurpose Rm F117, 574 New London Tpke, Norwich

Middlesex County: Oct. 21, CT Valley Hospital, Paige Hall Solarium, 1000 Silver St., Middletown

All forums are from 6 to 7pm; registration begins at 5:30pm. Registrations requested but walk-ins are welcome. To register go to http://ct.train.org (use ID# 1045492) or call 860-509-8070. 

New action guide on Community Health Workers

ICER has published an action guide, Community Health Workers: Applying the Evidence to Policy and Practice, to effectively incorporating Community Health Workers into the health system for the CHW workforce, insurers, and providers and organizations that employ CHWs. The guide, based on CPAC’s CHW effectiveness report, gives evidence-based action steps tailored to the needs of stakeholders to apply the best available evidence to policy and practice. ICER, the Institute for Clinical and Economic Review, provides independent evaluation of the clinical effectiveness and comparative value of new and emerging technologies.

 CEPAC, a project of ICER, is a New England stakeholder council that advises policymakers using comparative effectiveness research to improve the quality and value of health care in our region. CEPAC’s next meeting, December in Boston, will focus on supplemental screening in women with dense breast tissue.

CT Mirror reports on SIM proposal – administration agenda and advocate concerns

An article yesterday in the CT Mirror describes the administration’s plans to apply for millions in federal dollars to radically redesign CT’s health care system – not just Medicaid and the state employee plan, but for all state residents. The article points out that the administration is working with providers and insurers to design the plan; consumers and advocates have not been included in the process. The plan includes important care delivery innovations, many building on inclusive past processes. However the plan also includes giving providers financial incentives to control costs. Advocates are concerned that there are not sufficient controls or data to ensure that savings are generated by reducing duplication, improving quality and eliminating overtreatment rather than withholding appropriate care. To protect consumers, a group of 24 advocates sent a letter asking the SIM proponents to build a robust monitoring system and quality improvement tools for providers, and ensure that that system is working before any provider savings incentives or capitation is implemented. There has been no response to the letter. 

Quinnipiac med students start classes today

The first class of students at the new Quinnipiac University medical school started classes today. Training for the sixty students will emphasize team-based care with the goal of encouraging them to practice primary care.

Waterbury Hospital for-profit takeover community forum tonight

A community forum on Vanguard/Tenet’s planned takeover of Waterbury Hospital will be tonight at 7pm at St. John’s Episcopal Church, 16 Church St. in Waterbury. Community and labor organizations are concerned about the for-profit, out of state company buying the nonprofit hospital.

SIM and Cabinet meeting update

Yesterday’s Health Care Cabinet meeting wasn’t very enlightening. The SIM report on consumer outreach was pretty much as expected. Consultants reported on focus groups with HUSKY and uninsured consumers and described plans for an online survey. Not surprisingly, they found lots of complaints about challenges accessing health care, stigma and poor treatment. They did not report talking about payment models or systems change with consumer groups and it is not mentioned in their online survey. They are planning five new taskforces and the current payment group will continue meeting. There was no discussion of adding consumers or advocates to the groups.  They intend to have a draft SIM plan ready by Labor Day.

In other news, we have heard from advocates in other states about their SIM processes. Most have large, public, diverse stakeholder meetings that include consumers and advocates. Maryland’s SIM planning is amazing. They started Local Health Improvement Coalitions in 2011 with diverse membership – consumers, advocates, community organizations, schools, public health, legislators, plus all the CT SIM stakeholder groups – and are using their APCD, advanced analytics and performance monitoring to identify hot spots and other problems, uniting the entire health system to create local solutions. They intend to use the SIM grant to build on the local quality coalition capacity. Payment reform is a much smaller part of their plan; quality is clearly the priority.

Colorado also has an exciting SIM process. They have a strong APCD and are also using the data to target quality and access interventions.  They have a large, diverse, public stakeholder group, including advocates and consumers, that meets monthly. They have a strong stakeholder and public input process, including inviting written public comment on the final plan. They even hired a consumer organization to write the patient-centered care part of the plan.

For-profit Vanguard and Yale-New Haven set to takeover ECHN

Eastern CT Health Network, including Rockville and Manchester Hospitals and their networks, has entered an agreement with for-profit Tennessee-based Vanguard Health Systems and Yale-New Haven Health Systems. Under the agreement Vanguard will takeover outpatient facilities at both hospitals and Yale will provide clinical support. Vanguard is also seeking to acquire Waterbury Hospital and more recently announced they will be purchased by Tenet Healthcare Corp. Advocates have raised concerns about Tenet’s history of federal actions and penalties.

CT moves up to 13th worst in hospital Medicare readmission penalties

Twenty four CT hospitals will face Medicare penalties because of readmission rates averaging 0.43% of Medicare revenues. In an important move to link payment to quality of care, Medicare began last year providing individual hospitals with penalties and rewards based on the number of discharged patients who are readmitted within a month. While CT is 13^th worst among states both in the percent of hospitals penalized and in the average penalty, that is up from the very bottom last year. 

Aetna leaves CT insurance exchange

Aetna has withdrawn their application to participate in Access Health CT, our state’s health insurance exchange. Aetna’s proposal was the least costly individual premium option for 14 of the 15 examples given at the last Board meeting. Unfortunately this reduces the affordability of options in the exchange and leaves only three plans each in CT’s individual and small business exchanges. Aetna intends to continue to offer individual coverage in CT outside the exchange. Last week ConnectiCare withdrew from CT’s small business exchange but maintained their proposal in the individual exchange.