APCD Roundtable – lessons for CT

Yesterday’s CT Health Policy Roundtable on All-Payer Claims Databases yielded many lessons for CT from other states and organizations. Lessons included the need for strong privacy and security protections, avoiding commercial uses, licensing to universities and organizations rather than individuals, and developing a transparent, fair process for access to the data based on the needs of all stakeholders. Common challenges included governance, funding, and integrating clinical and claims data. Speakers included Jo Porter of the APCD Council, David Newman of the Health Care Cost Institute, Cynthia Millane of FairHealth.org, State Comptroller Kevin Lembo, and Tamim Ahmed of Access Health Analytics, CT’s developing APCD. Pat Baker of the CT Health Foundation moderated. The Roundtable was sponsored by the CT Health Policy Project, the CT Center for Patient Safety and Access Health Analytics with funding from the CT Health Foundation. Slides and background materials are online.

CT Health Policy Roundtable: CT’s APCD tomorrow

Join national and state experts tomorrow for a Roundtable to learn more about the potential for Connecticut's new All-Payer Claims Database in health care planning, improving health care quality, capacity and promoting health equity. The Roundtable is sponsored by the CT Health Policy Project, the CT Center for Patient Safety and Access Health Analytics and made possible with support from the CT Health Foundation. The Roundtable will be tomorrow -- Thursday, October 24^th from 1 to 3pm in Room 1E of the LOB. Registration is encouraged. Presentations are online.

Moderator: Pat Baker, CT Health Foundation

Speakers:

Josephine Porter, APCD Council

David Newman, Health Care Cost Institute

Cynthia Millane, FairHealth

Tamim Ahmed, Access Health Analytics

Kevin Lembo, CT State Comptroller

SIM update – moving in a better direction

Yesterday’s SIM meeting showed some positive movement toward a system that respects and protects consumers. Recognizing the potential harm to consumers, SIM leaders now intend to monitor for under-treatment and inappropriate treatment, and the payment model no longer includes capitation, both serious concerns raised by advocates. However advocates remain troubled that there is no commitment to withhold savings payments from providers who, through monitoring and a fair resolution process, are found to have reduced appropriate care. The current plan does commit to withhold incentive payments from providers who do not score well in either patient experience of care or in reducing health disparities. Advocates also remain concerned about the possibility of downside financial risk for providers – recouping funds from providers whose patients’ care costs exceed expectations. The steering committee, which includes no consumers or advocates, debated whether to include “patient-centered” in the term for their proposed new CT-specific medical home standards developed by a working group of providers. SIM leaders expect to release a draft plan next week for public comment and to meet with stakeholder groups in November for feedback. 

Medicaid performance dashboard unveiled; marked improvement with switch from HUSKY HMOs

At Friday’s Medicaid Council meeting, DSS described their new ASO accountability dashboard with performance measures for the program. From January 2012, when the HMOs left the program, to this June the number of providers participating in CT’s program has grown 32%, hospital admissions are down 3.2%, the average length of stay is down 5%, and cost per admission is down $200 (2.7%). Emergency dept. visits are down but costs per visit are up. Non-urgent care visits to the ER are down an impressive 11.7%, suggesting better access to preventive and maintenance care. Unfortunately 13 members used the ER over 100 times last year. CHN is focusing member outreach to link those patients with a primary care providers, the 24/7 nurse advice line, intensive care management, and to behavioral health services when appropriate. 61% of members are now linked to a primary care provider allowing better tracking of performance, access to care, and quality. 10,882 members accessed cultural and linguistic Medicaid services in the second quarter of this year; that number has grown every quarter. 16,836 members received intensive care management for a range of problems. It’s exciting to see that since the switch from capitated HUSKY HMOs to the ASO model costs are down slightly, the number of participating providers is up and unnecessary ER visits are down.

Book Club: David and Goliath, by Malcolm Gladwell

I read this latest addition to the CT Health Policy Project Book Club on a long flight and couldn’t put it down. It should be required reading for every advocate. Malcolm Gladwell’s latest book describes why the underdog often wins against what initially seems like long odds. After he drills down on the story of David and Goliath, the reader comes to see that Goliath didn’t stand a chance. Often being under-resourced, disadvantaged and/or overwhelmed is a large advantage. With examples like the myth of smaller class size, difficult childhood experiences as an advantage, how under-resourced rebels were so effective in Northern Ireland, and perception matters for little fish in big ponds he makes the case that at a point, increasing resources backfire. I will be using a lot of the lessons and drawing inspiration from this book, as a health care advocate up against large and imposing opponents. There is power here at the bottom of the food chain.

Connecticut breaks through to a B-/C+ on health reform

Connecticut health care thought leaders give our state a B-/C+ (GPA 2.48) on health reform this fall; the highest marks the state has gotten in over a year. Among issue areas the health insurance exchange and public education improved since the last survey. Areas that lost ground include Medicaid, patient-centered medical homes, health information technology, payment reform/quality improvement, engaging consumers in policymaking, and data-based policymaking. Thought leaders’ suggestions to improve progress are for smarter policymaking and leadership, engage consumers/advocates/public in policymaking, and to fix payment reform. Performance on payment and quality reform has dropped to a D in this survey earning five F grades.

October CT Health Policy Webquiz: Premiums in CT’s health insurance exchange

Test your knowledge of the premiums in CT’s health insurance exchange. Take the October CT Health Policy Webquiz.

CT Health Reform Progress Meter moves up to 23.7%

Despite the frenzy surrounding the opening of the insurance exchanges, health reform has many other moving parts. CT policymakers have completed 26.2% of the tasks necessary for health reform, making progress from last month. Again, Medicaid accounted for the forward progress in October’s Health Reform Dashboard. As last month, deep concerns about payment reform in the SIM process and the insurance exchange’s premium increases are holding Connecticut back. 

SIM update -- questions about numbers driving policy

Significant questions have been raised about the methodology and sources for the Sept. 17^th SIM presentation (slide 30) asserting that 62% of primary care providers in CT currently have provider risk/shared savings/total cost of care arrangements with providers. Questions relate to whether the populations included are representative of the state, provider types included, whether the number relies on one payer disproportionately, and the possibility of double counting among other issues.

Unfortunately this questionable number is being used as the foundation of a proposal that may undermine even the minimal quality standards in the current SIM proposal. Last week, in a private email, SIM steering committee members were asked for input on whether, given the perceived prevalence of provider risk, SIM should propose allowing provider incentives even in the absence of medical home status. Presumably this is to avoid jeopardizing the primary SIM goal of moving at least 80% of state residents into provider risk arrangements, regardless of quality protections. Advocates have called on SIM leaders to build a robust quality monitoring system before any provider incentives are implemented. Advocates are hoping to both improve the quality of care in CT and prevent the harm to people that occurred in managed care risk arrangements in the past.

The current SIM medical home plan is to create a CT-specific, lower standard than the commonly-used, well-vetted national accrediting bodies. (They have taken “person/patient-centered” out of the label for their lower standard.) There are currently 821 NCQA certified PCMHs in CT and the list grows every month. One third of Medicaid consumers are now cared for in a PCMH. It is important to note that a large proportion of Medicaid providers, with lower payment levels, have earned PCMH designation.

CT exchange premiums 4th highest in US

A new analysis from the White House finds that CT’s insurance exchange premiums are among the highest in the nation – behind only Alaska, Mississippi, and Wyoming. CT residents and small businesses buying unsubsidized coverage through the exchange will pay 28 to 37% more than most Americans depending on which plan they choose. We will pay about 24% more than New Yorkers. Passage of SB-596 this session would have directed the insurance exchange to negotiate prices on behalf of consumers, which would have lowered premiums. The bill passed the Senate but died in the House; even a provision allowing the exchange to negotiate (which they can do without legislative authority) died in the last hours of the session. New York negotiated rates with the plans. 

HUSKY is growing outreach tool for community organizations

Connecticut’s Medicaid/HUSKY program is significantly expanding effective January 1st. 700,000 state residents are already benefitting from the program and up to another 130,000 may qualify under new eligibility rules. Many people denied Medicaid or HUSKY in the past will now qualify. Medicaid and HUSKY provide comprehensive health care coverage without cost.

To ensure that every eligible state resident is enrolled as soon as possible, CTHPP summer intern Tanusha Satavalli developed a “HUSKY is growing” toolkit for community organizations to help people know about the expansion. The tools can be customized for your organization.

CT Health Policy Roundtable: CT’s APCD

Join national and state experts for a Roundtable to learn more about the potential for Connecticut's new All-Payer Claims Database in health care planning, improving health care quality, capacity and promoting health equity. The Roundtable is sponsored by the CT Health Policy Project, the CT Center for Patient Safety and Access Health Analytics and made possible with support from the CT Health Foundation. The Roundtable will be Thursday, October 24^th from 1 to 3pm in Room 1E of the LOB. Registration is encouraged.

Moderator: Pat Baker, CT Health Foundation

Speakers:

Josephine Porter, APCD Council

David Newman, Health Care Cost Institute

Cynthia Millane, FairHealth

Tamim Ahmed, Access Health Analytics

Kevin Lembo, CT State Comptroller

Medicaid Council updates: Medicaid enrollment changes

The majority of September’s Medicaid Council meeting focused on massive changes to how people will apply for Medicaid coverage over the next few months. DSS reported that the new ConneCT system is close to caught up on scanning client documents, but work on the indexing system (assigning documents to the right client’s file) continues. Call wait times have increased to average 20 minutes since the new phone system was instituted. There was no information on the rate of dropped calls. DSS is working on technical improvements of the online system to reduce the need for clients and providers to call in. DSS intends to develop a public, online dashboard on how ConneCT is progressing and will update the Council monthly; they are open to ideas on what measures should be included. AccessHealthCT reported on their integrated portal for both exchange and Medicaid applications. After January 1^st all online Medicaid applications (except aged, blind and disabled) must go through the integrated portal. Leadership acknowledged that the system won’t be perfect and there will be mistakes and complaints. They will take paper applications but strongly urge people to apply online. Unfortunately that online application will take about an hour to complete. Data on income levels the system uses will be two years old; they are trying to develop a relationship to use only 6 month old income data. Acknowledging that this is not reliable to accurately determine eligibility, DSS will accept self-reported income and give applicants 90 days to send in supporting documentation. DSS will continue to have to manually enter information in the eligibility system from a pdf generated by the online application for the foreseeable future. There was also a very rich presentation on CHN’s ASO programs and services, but unfortunately there wasn’t sufficient time to explore the information.

Comments on CT’s APCD policies and procedures

In support of the enormous potential to promote and guide sensible health planning in CT, consumer advocates, the CT Health Policy Project and the CT Center for Patient Safety, submitted constructive comments on draft policies and procedures for CT’s All-Payer Claims Database, Access Health CT (APCD). We urge APCD leadership to commit to full public transparency and equitable access to the data for all stakeholders, including CT’s insurance exchange, and strong provisions to avoid even the appearance of conflicts of interest. We also urge policymakers to prohibit commercial uses of the data and to develop very robust privacy and security protections. The advocates’ comments follow from our report for the CT Health Foundation of consumer input into development of CT’s APCD.

September CT Health Policy Webquiz: CT health risks

Test your knowledge of the rates of health risks among CT adults. Take the September CT Health Policy Webquiz.

CT Health Reform Progress Meter moves up to 23.7%

CT policymakers have completed 23.7% of the tasks necessary for health reform, making up for last month’s drop. Most tasks on the Progress Meter list are due on Jan.1^st of next year. Medicaid accounted for the forward progress in September’s Health Reform Dashboard. As last month, deep concerns about payment reform in the SIM process and the insurance exchange’s premium increases are holding Connecticut back. 

Consumer advocates provide constructive input to SIM

Today a letter was sent to state SIM planners from 24 CT consumer advocates representing 21 organizations proposing an alternative to the state’s proposed SIM plan. The SIM project, funded with a $3m federal grant, is developing payment and care delivery models for at least 80% of state residents – 3 million people or more and $30 billion in CT health spending. Advocates are concerned that the decision-making groups lacked consumer input, and that the process was largely conducted out of public view over a short few months in the summer. The plan includes a controversial plan to shift financial risk onto providers. The state now intends to apply for up to $60m in federal funding to implement the model. In the letter, advocates affirmed our support for the concept – to improve quality and access to care, while controlling costs. But advocates also urged policymakers to build a meaningful, feasible quality monitoring system for CT, in an inclusive process engaging all stakeholders, including consumers and advocates. It is critical that this quality system be working and in place, before any provider risk incentives attach. Advocates are optimistic that this alternative will serve the goals of the SIM project but will also protect consumers from savings generated by withholding appropriate care as opposed to the intended reductions in unnecessary care and duplication of services.

Book Club: Naked Statistics

A new addition to the CT Health Policy Project Book Club – Naked Statistics: Stripping the Dread from the Data – makes statistics relevant, accessible and entertaining. “Statistics is like a high-caliber weapon: helpful when used correctly and potentially disastrous in the wrong hands.” If you want to understand health policy, you need to get comfortable with statistics. And this is the book to help you.

Exchange premiums up from this year, lots of variation

Our analysis of the recently announced 2014 Access Health CT standard plan premiums finds that for five typical CT households covered by the two health insurers with premium history – Anthem and ConnectiCare – in all but one case, families will experience significant premium increases from this year.  Premiums will rise between 30 and 163%. The one premium decrease is $8.02/month for a family of three and that family could save even more by switching insurers. The examples were chosen by the exchange’s actuaries to model for their last Board meeting. Monthly premiums on the exchange will vary significantly – from $125.35 for a child living in Hartford County in a bronze ConnectiCare plan to $1,144.80 for a Fairfield County 64-year-old in a gold Anthem plan. The largest premium variation is by age, and to a lesser degree by generosity of plan (bronze, silver, gold). Variation between insurers and counties is much lower. However Fairfield County is the most expensive for each insurers’ plans. Unfortunately Fairfield County has the highest number and rate of uninsurance in the state.

August CT Health Policy Webquiz: CT health insurance base premiums

Test your knowledge of base health insurance premiums in Connecticut for this year. Take the August CT Health Policy Webquiz.