Health First/Primary Care Authority updates

Today’s joint meeting of the two Authorities was interesting. Mitch Katz, MD, MPH, San Francisco’s health director presented on their Healthy San Francisco program. The city isn’t waiting for the state or the fed.s to do something -- they created their own program to cover everyone. The crux of the model is a medical home for everyone – your place to get health care, a provider who is responsible to you and to the city for your health. Every adult resident of San Francisco, who doesn’t qualify for another program, is eligible with no pre-existing condition exclusions – including undocumented immigrants. It is built on the safety net, and doesn’t waste money on insurance - every dollar is spent on care and coordination. It is also built on electronic records and eligibility systems; the resulting administrative efficiencies are a critical part of the program. Healthy San Francisco includes coverage for a very comprehensive set of services. Consumers know what their costs of care will be before they sign on – a critical component when half of bankruptcies are due to medical bills. They already have 20,600 enrollees in only ten months, well on the way to their 60,000 person goal. Over 700 businesses have chosen the city option to cover their employees. Financing includes government funds as well as both employer and individual contributions. The San Francisco restaurant association has filed an ERISA challenge in federal court, which is on appeal. Meanwhile, the program continues to provide care. Believing that they could create public resistance to the program, city restaurants added a note to their menus stating that recent price increases were the result of Healthy San Francisco. But that backfired on them, 95% of comments to the notice were positive -- supporting a price increase that goes to provide health coverage. Dr. Katz’ lesson for Connecticut – be brave and be creative; progress isn’t coming from Washington.
Ellen Andrews

HUSKY, Charter Oak and other session updates

The General Assembly acted on very few health proposals this year.
Some things that did pass:
HB 5536 -- Rep. Donovan’s bill to allow municipalities and small business to buy directly into the state employee plan pool – the Courant says “Rell’s signature is iffy”. Even if she does approve it, the plan may not help many cities and towns -- New Haven has determined that it wouldn't save the city any money
SB 681 – creates a Minority Health Advisory Commission to eliminate health disparities. The Commission will be housed within the Office of Health Care Advocate.

Others that didn’t make it:
HB 5617 – the Charter Oak fix bill. For earlier posts on this bill, click here, here, here, here, here and here
HB 5618 – would have delinked Charter Oak from HUSKY and delayed re-contracting for the HUSKY program – for more on this bill click here, here, here and here
Nursing home oversight and staffing standards – Based on recent scandals and strong language about protecting fragile elders from virtually every politician, it is remarkable that nothing happened on this issue – victim of budget impasse
SB 217 -- requiring employers to offer paid sick days – died on House calendar
SB 419 -- to ban smoking in tribal casinos – died on House calendar

And there is no new budget. The state will use the second year of the budget passed in last year’s session. In the words of one state agency worker “We are in uncharted territory.” Problems include the fact that there is no provision for carrying forward money not spent this year or covering deficiencies. Also overheard, “We still have to feed prisoners.” Not clear how this will all work out.

Go to the Hartford Courant’s website to give the legislature a grade. As I am posting this, over three quarters of respondents gave them a D or F.
Ellen Andrews

Book Club: Better

A couple of weeks ago, I wrote about the Annual Meeting of the Donoughue Foundation. The keynote speaker at the event was Atul Gawande, a general surgeon, writer for the New Yorker and author of two books, Complications and Better. Gawande spoke about the small things that can be done to make the healthcare system function significantly better. So, I satisfied my curiosity and picked up Better.

Before I reflect on one of the key ideas Gawande presents, let me tell you: this book is incredibly readable, engaging, and insightful. The essays are discrete, but they build on one another. It is a book that can sustain a straight read-through. Or, you can read it episodically – jumping around from an essay at the beginning to one at the end or putting the book down for other endeavors in between essays. No matter your approach, you will be rewarded for your effort.

In many of the essays, Gawande argues that great strides in healthcare can be made by concentrating on how healthcare is delivered, rather than on a race to new technologies of care. In his essay “Casualties of War,” Gawande looks at the vast reduction in fatalities in the Afghanistan and Iraq wars, compared to previous wars. He attributes this success to the attention to data collection and analysis. By tracking the kinds of injuries, the medical responses, and the outcomes, military medical personnel have been able to recommend preventive measures and improve the medical response system. Simple steps. Things like making sure soldiers wear their bulletproof vests or moving the medical team together with soldiers so that response times are cut substantially. These interventions were possible only because the medical staff tracked patterns of injury and analyzed their results.

In another essay, “The Bell Curve,” Gawande reports on the efforts of an organization called the Institute for Healthcare Improvement to improve medical practice by doing, in Gawande’s words, “two things: measure ourselves and be more open about what we are doing”. One outcome of this openness involves patient participation in improving the delivery of healthcare.

Connecticut could learn from the lessons of these essays. Many of the data that could be helpful for those of us who are trying to make our healthcare system more accessible, effective, and affordable are locked in individual companies (hospitals, doctors’ practices, insurance companies) and in our state agencies (where, even with FOI, the information may or may not be in a useful format). More systematic data collection and greater openness with that information is a necessary – though not sufficient – precondition to improving our healthcare system.
Connie Razza

Charter Oak update

Last night, the House passed a stripped down version of the Charter Oak fix bill, 5617, leaving only mental health parity. The House version removed critical provisions including dental and vision care, removing limits on prescriptions, medical equipment and lifetime limits on care, independent grievance and accountability options, sustainability provisions, prohibition against contracting with unlicensed HMOs, reduction in emergency room copays, limits on HMO administrative costs, separation from the troubled HUSKY program, a prudent delay to collect consumer input, research costs, and benefits to build a better program and, my favorite, removal of the requirement that consumers be uninsured for six months before enrolling. The stripped down version was the result of lobbying by mental health special interests. It is important to note that Charter Oak, in its original design, does include mental health services, but coverage is not unlimited. Not all advocates, including this one, supported passage of this stripped down bill. This highlights the dangers of making broad policy decisions behind closed doors at the harried end of the session without time for reflection or input from the world outside the Capitol lobbies.
Ellen Andrews

DPH launches on-line health personal health assessment tool

DPH has launched a very useful Protective Health Assessment Tool on their website. The site takes you through a variety of questions about health risks, behaviors, medical history, clinical and lifestyle factors and gives you a list of recommendations and resources to improve your health. The assessment takes about 10 or 15 minutes and is anonymous. Taking the assessment is fairly painless, the prescriptions may not be. Highly recommended.

Health First Authority Update

After eight months, the Health First Authority is getting to consider some options to cover CT’s uninsured. Five options to be specific. And while most of the conversation was predictable, it did get interesting near the end. The five options include single payer universal coverage, a bolstered employment based system (employer mandate, state subsidies for low income/high risk people, reinsurance, market reforms, and tax incentives), insurance choice (Donovan’s plan – using the state employee pool to cover everyone), regionally organized networks of care building on Charter Oak, and universal primary care (Sen. Dem.s plan – with insurance for inpatient care only). Issues cutting across all options include benefit package, IT, quality, efficiency, defining affordability, cost control, individual vs. societal responsibility, financing, workforce shortages, evidence based medicine, licensure/scope of practice, and undocumented immigrants.

The comments were predictable with criticism of public programs and praise for the private system from those proponents, concerns about reimbursements from providers, and defense of public programs from the likely suspects. There were many comments opposing an employer mandate, but no one came to the defense of consumers on proposals for an individual mandate. Thankfully statements about adverse selection, risk magnets and “polluting” risk pools drew an impassioned comment from Margaret Flinter, Co-Chair of both Authorities, noting that high risk patients are exactly who needs coverage and who is being left out of the current system – if the plan only addresses the needs of healthy people, it isn’t solving anything. At the end it did get interesting – a discussion of whether single payer is the only moral option or whether trying to implement an option that the commenter believes is not feasible and won’t work is immoral.
Ellen Andrews

May Web Quiz

Test your knowledge of the quality of CT’s health care. Take the May CT Health Policy Project Web Quiz.