CMS approves forcing HUSKY families into HMOs

In a reversal of their position in a Dec. 5th letter, CMS is now allowing DSS to force 138,000 HUSKY members, 40% of the total HUSKY membership, to join capitated HMOs that advocates maintain do not have enough providers to provide care. The decision also disregards a letter from CT’s Congressional delegation urging CMS to wait until the networks are adequate. HUSKY families in the Anthem network will lose access to thousands of participating providers on February 1st. DSS is forcing the issue because they want to end their contract with Anthem and they believe the HMO networks are adequate.
Ellen Andrews

HUSKY (waiting for news) and PCCM (more bad news) update

DSS has now changed the date of PCCM’s start from next Thursday to February 1st even in the two small areas they approved, Waterbury and Willimantic. DSS’ plan, approved without revision by the Appropriations and Human Services Committees this summer, called for statewide implementation January 1st. In another sudden change of policy, further limiting the program’s reach, PCCM will only be open to current patients of participating providers in those two areas. In a meeting with providers and legislators last week, DSS stated that they expect to begin offering PCCM in other communities within three or four months. Consumer advocates were dis-invited by DSS from the meeting.

The state still intends to end HUSKY families’ access to Anthem’s more generous list of providers February 1st. Over 130,000 HUSKY members will be forced to find a provider participating in one of the three participating capitated HMOs -- Community Health Network, AmeriChoice (United Health Group) or Aetna Better Health. The state is awaiting word from the Centers for Medicare and Medicaid Services (CMS, the federal agency that oversees HUSKY) about whether the HMOs’ provider panels are sufficient to accept members. A December 5th letter from CMS required DSS to halt enrollment into the two new HMOs – AmeriChoice and Aetna – until they have sufficient network capacity. DSS now believes they have that capacity. But a survey of HUSKY HMO providers in New Haven and Hartford by New Haven Legal Assistance found that only one third are accepting new patients. This could make it very difficult for current Anthem members to find a new provider if forced into the HMOs.
Ellen Andrews

HealthFirst Authority draft report

The Authority’s much anticipated draft report was unveiled earlier this month. Thankfully, it does not include a recommendation for an individual mandate that all consumers must purchase health insurance. The report does recommend auto-enrollment in public programs of anyone who is uninsured with an income under 300% of the federal poverty level. A report on the inadvisability of an individual mandate in CT will be coming soon from the CT Health Policy Project.

Otherwise, the draft contains some good ideas that have been widely discussed – value based purchasing, evidence based medicine, raising Medicaid provider rates, maximizing federal funding, chronic disease care coordination, accelerate adoption of health information technology, better data collection and analysis, cost containment, and health care workforce planning. The authors intend to expand coverage options for CT residents by building on employer-sponsored health care, creating a pool based on the state employee health plan to offer coverage to those with an employer offer, with affordability standards and premium subsidies, and expansions of public programs including Charter Oak. The reforms could be coordinated by current agencies or a new entity. The authors recommend implementation and evaluation of Primary Care Case Management. Cost estimates for the recommendations will be available next month when the Authority will take a final vote on the report.
Ellen Andrews

Health First Authority update

The Authority is winding down, but there is still no draft of the plan. At Monday’s meeting, members got a list of bullet points that caused serious contention. There were many complaints about disorganization and not having a draft to review. Part of the problem is that they are not on the same page about the meaning of some of the bullets. But there are also substantive differences. Creation of a new agency, the CT Health Trust, to coordinate all state health care purchasing, implement national health reforms, monitor progress, ensure transparency, advance change, work to eliminate disparities and ensure everyone has access to quality affordable health care by 2012 caused the most disagreement. Members worried that creating a new “mega-agency” will not solve anything and asked why current agencies are not performing these functions. Plans to build on last year’s state-employee purchasing pool bill also created conflict. They decided to table discussion of the really difficult recommendations – whether to have an individual and/or employer mandate. Overall, the meeting was very contentious with interested stakeholders raising predictable objections and concerns. The facilitator kept trying to take the conversation to a higher level, without much success. There will be another Authority meeting on the 17th; a draft for review has been promised by Friday. I am so sorry I will miss it.
Ellen Andrews

Helpful DSS staff

It’s important to recognize people when they are helpful and good at their jobs, especially at DSS. Over the last couple of weeks four people at DSS have been exceptional and we wanted to thank them. One analyst I called for information ran an independent data analysis for me, and when he learned more about what we needed, he realized that I should have included another category and he re-ran the report. He asked questions, listened to my answers, and offered more help than I asked for. Jen got help from three DSS staffers – two with questions about DSS programs and one to help with a case. All four had to do some investigation to answer our questions and got back to us quickly. Most of them were people we contacted randomly from a website or a report, not personal contacts, but were friendly and helpful.
We want to thank these four and all the wonderful staff at DSS who share our mission to improve health care for everyone in CT. (Names are kept private to protect the innocent.)
Ellen Andrews

CT hospitals more profitable in 2007

The financial status of CT’s acute care hospitals continued to improve last year, according to OHCA’s latest report. Average margins (profits) were 3.62% of revenues in 2007, up from 2.51% in 2006. The biggest winner was Saint Vincent’s with a margin of 14.49%; Johnson lost 18.73% last year. The number of hospitals that lost money dropped from six in 2006 to five last year. Hospitals payments to cost ratios dropped from 2005 to 2007 for private pay, Medicare and Medicaid by 2, 6 and 7%, respectively. The average case mix (measure of patients’ medical complexity) continued to rise, but average length of stay is stable. The percent of discharges for patients in government programs (Medicare and Medicaid) held relatively steady at 58% in 2007. Uninsured discharges were up 14% from 2005 to 2007 while total discharges grew by only 2%. Uncompensated care rose to 3.1% of total expenses in 2007 from 2.8% in 2005, however CT’s average is still well below the national hospital average of 5.7% (2006).
Ellen Andrews

Good news for CT doctors, United to offer “insurance” that you can buy insurance in the future

CT physicians are getting some relief in their medical malpractice rates, according to today’s Hartford Courant. Most will see no increase next year and some will save money. Unfortunately, those savings are not expected to pass onto consumers. Employers and workers face six to seven percent increases in premiums next year.

Other news about doctors -- the most viewed article from yesterday’s NY Times is “Arrogant, Abusive and Disruptive – and a Doctor.” While the majority of physicians are well-mannered and respectful, a small minority who intimidate staff and refuse to do their jobs are reported to be responsible for low morale, workplace stress, and medical errors. Thankfully, the problem appears to be improving.

Today’s NY Times includes a report that United Health Care plans to offer people the option to pay now for the right to purchase individual insurance in the future, even if you become sick. You have to be well now and pass a medical review. The new product, called UnitedHealth Continuity, is not insurance but just the right to buy insurance in the future and will cost 20% of the current cost of individual coverage. There is no price guarantee for the eventual coverage. United expects UnitedHealth Continuity to appeal to people who have insurance now but are worried they may lose it in the future. The author points out that it may not be a good value for consumers and that national health reform may make the product obsolete. United is applying to sell this product in CT.
Ellen Andrews

More from the Consumer Helpline

I received a phone call on Tuesday from a Communications Officer in the Commissioners Office of the Department of Social Services. She was concerned about my blog posted on Monday, which mentions the difficulty I had with the general phone number at one of the DSS regional offices. She explained that there is a toll free number on the DSS website to which I should have referred this consumer, rather than the general phone number for that office. I explained that I had worked for DSS as an eligibility worker for seven years and had never heard of this number. She replied that it is right on the website (with a bit of a tone, I might add). To which I replied that I didn’t have internet access while I worked there (or rather it was limited and we were instructed not to use it). The phone number we always gave to clients when they had called the wrong office was the general number for that office. I even asked a few current DSS employees, who didn’t know about this 1-800 number and said they also refer clients to the general number for the office nearest them. (As an aside, the general number in the Hartford office was so busy sometimes that desperate clients would dial a random extension just to be connected to a person. We even received an email instructing us to look up phone numbers for the clients’ workers and not transfer them back to the general number).

The Communications Officer proceeded to instruct me in all of the toll free numbers for DSS, including those for HUSKY and Charter Oak. First she told me that the client should have a worker she could call. Again I relied on my experience from DSS and said that I know there are times that an application isn’t entered right into the system, so the client wouldn’t know who that worker is. What I was really looking for when I originally called the general DSS number was an intake supervisor for the client to talk to, to see if the application had been received and assigned to a worker.

After all of this information sharing, the Communications Officer asked, “So you’re going to take it down, right?” “The blog? No,” I answered, I’m not going to take it down because that was the experience I had trying to find information from DSS and that was the experience the client had as well.”

I tried the 1-800-842-1508 number and was not able to speak to a person. I could push buttons for various program areas and was provided with some general information about programs but there no way to speak to an actual human being. I could, however, leave a message for someone to get back to me. Interestingly enough, the phone line did tell me that, “In order to serve you better we encourage you to contact the [regional] office by telephone or mail whenever possible.”

I have to say, I was a little angry that I was asked to remove the blog. I was also a little angry at the Communications Officer’s condescending tone, which suggested that everything she was telling me was common knowledge and apparently I just didn’t know where to look for the proper information. My closing thoughts are that, in this Thanksgiving season, I am grateful for many things, one of which is my freedom of speech.
Jen Ramirez

PCCM advocates forced to walk out of meeting

Yesterday’s PCCM working group meeting at DSS did not go well. DSS had no agenda for the meeting which started twenty minutes late. Advocates asked for an explanation of the department’s sudden decision to reverse course from the months-long policy of starting the program statewide to a far weaker program limited to two smaller communities. We were told they had no explanation. When we asked staff to call and see if the Commissioner could come down to the meeting to deliver an explanation, staff refused to make that call. DSS had no response to advocates’ assertions that the illegal reversal contradicted the statewide plan required under law submitted by DSS and approved by the Human Services and Appropriations Committees without revision. They also had no response to the assertion that this sudden reversal violated the good faith efforts of advocates working for months collaboratively and diligently to recruit providers and build support for HUSKY. Asked to confirm a promise made at a morning meeting with policymakers that PCCM would be statewide in three to six months, DSS answered that there is no timeframe for any potential statewide expansion. One petulant comment made was “I never wanted to have this meeting.” Asked why advocates should continue to meet with DSS and labor to make the program a success, we were given no answer. And the meeting ended.
Ellen Andrews

From the consumer helpline

I started working with the CT Health Policy Project a few weeks ago and I’ve been familiarizing myself with the types of calls that come into our consumer helpline. So far, what I’ve observed is that for people without health insurance, their options are usually limited. The system of care available to them is fragmented and uncertain as well as full of hoops to jump through. There are lengthy applications to fill out and numerous verifications to provide.
For one consumer who called, I tried contacting the Department of Social Services to find a direct number for her to call with her question about an application. I called DSS’s general number several times over a period of a few hours and was hung up on, the number was busy, or it rang indefinitely. When I finally got through to a person and asked for the phone number for a consumer to call about a new application, I was told that it was the number I had just been calling. I asked if there was someone else this consumer could call and was told the consumer has to call the general DSS information number. Now this consumer will have to deal with the same frustrations I faced, just to ask a simple question. Yet another barrier for an uninsured person to deal with before they can access health care.
Jen Ramirez

Charter Oak “pettiness”

To root out the sources of “negativity” about the Governor’s troubled Charter Oak program, on Friday DSS Commissioner Starkowski made very broad requests, under Freedom of Information laws, for any documents pertaining to Charter Oak from a long list of public officials including Sen. Jonathan Harris, Rep. Peter Villano, Sen. Toni Harp, Health Care Advocate Kevin Lembo, Child Advocate Jeanne Milstein, and Attorney General Richard Blumenthal. The letter specifically asks for all communications with Anthem and with consumer advocate Sheldon Toubman. (DSS has a history of trying, and failing, to silence advocates who disagree with them). It is highly unusual for government officials to use FOI to obtain documents from other officials. The request is extremely broad; if advocates (who have to use FOI to get information) submitted such an extensive request, we would receive a testy phone call from DSS’ FOI officers.
Today’s Editorial in the New London Day characterizes the administration’s move as “petty”.
Yesterday afternoon the Governor reportedly sent a letter asking all parties to work together to support Charter Oak and calling a meeting to discuss the issue next Tuesday. We’ll see if the drama is over.
Ellen Andrews

AG, Health Care and Child Advocates call on Governor to separately re-bid HUSKY and Charter Oak contracts

In a press conference today, Attorney General Richard Blumenthal, State Health Care Advocate Kevin Lembo, and State Child Advocate Jeanne Milstein commended the Governor for her decision Friday to de-link the HUSKY program of health coverage for families from her Charter Oak Health Plan for uninsured adults. The officials also called on the Governor to re-bid the programs as the delinking substantially changes the structure of both programs. In Friday’s Medicaid Managed Care Council meeting, a representative from Anthem, with a large provider network serving most HUSKY families, stated that their health plan might have chosen to bid on HUSKY if it were not linked to Charter Oak. ConnectiCare previously stated in a letter to DSS that they would have bid on Charter Oak if it weren’t linked to HUSKY. Re-bidding could significantly increase health plan and provider options for both HUSKY and Charter Oak consumers. The two new current health plans, AmeriChoice and Aetna Better Health, have been unable to develop an adequate provider network after months of recruitment. Without re-bidding, the Attorney General warned that plans such as Anthem could sue the state for changing the terms of the contract after it was awarded.
Ellen Andrews

Governor delinks HUSKY from Charter Oak, guts PCCM

Friday afternoon Governor Rell announced that she will reverse two long standing policies that jeopardized health care for over 340,000 CT residents in the HUSKY and Charter Oak programs. Providers will now be able to contract with the new HUSKY HMOs to provide services only to HUSKY families and not Charter Oak members. The state will also continue to contract with Anthem, allowing access to a far larger network of providers than any of the three HUSKY HMOs has been able to develop. Her announcement came just hours after DSS received strong criticism at the Medicaid Managed Care Council meeting from legislators, advocates and providers that both policies were creating widespread confusion and barriers to care that threatened both programs. A letter from five members of CT’s Congressional delegation was also released at the meeting asking CMS to halt enrollment into the two new HUSKY HMOs because of inadequate provider networks.

Also at the meeting, in direct contrast to the on-going good faith efforts of advocates and DSS staff on the PCCM working group, DSS announced their plan to only implement PCCM in two communities – Waterbury and Willimantic – rather than statewide as had been promised to advocates working diligently recruiting providers and families to make this program a success. This decision also violates the terms of DSS’ plan submitted to and approved by the Appropriations and Human Services Committees. Advocates voiced deep concerns about this sudden decision, delivered with only five minutes left in the meeting, given that 300 CT providers across the state applied to participate in PCCM, and that this program is the first evidence of energy and interest on the part of providers to participate in the program and provide care to HUSKY families in many years. Advocates are left to wonder how important policy decisions are made at DSS and whether good faith participation in DSS working groups is productive.
Ellen Andrews

CT health plan comparisons

US News and World Reports has published their annual national comparison of HMOs. CT has two commercial HMOs listed in the top 20 “Honor Roll” – Health New England (#6) and Anthem Blue Cross Blue Shield (#7). Health New England is not listed as a managed care organization on the CT Insurance Dept.’s website. A call to their offices found that their network is limited mainly to Western Massachusetts, and the only CT members they cover are in employer self-funded plans. No CT Medicaid or Medicare plans made either the “Honor Roll” or the top 10 for our region. There are several helpful articles with the rankings including “How safe is your health care?” and “When your insurer won’t pay up”.

Last month, CT’s Insurance Dept. published their annual comparison of managed care plans in the state. Lots of interesting information, for example – a patient survey found that in the last year between 41% (Aetna) and 61% (HealthNet) felt that they always got the non-urgent care they needed when they needed it. On most measures, Anthem performed at about the CT HMO average, with the exception of beta blockers prescribed after a heart attack – Anthem’s performance was lowest at 44%; the CT average was 64% and Aetna reached 100%.
Ellen Andrews

New law allows children to stay on their parents’ policies until age 26, but there’s a catch

A new law takes effect January 1, 2009 that allows children to stay on their parent’s health policies to age 26. As young adults are at highest risk of being uninsured, this will be an important option to reduce CT’s uninsured. Previously, children were only covered on their parent’s policies until age 19 or 23 for full-time students. Under the law, unmarried children living in CT (not necessarily living with their parents) or out of state as full time students, without group coverage through employment can stay on their parents’ health insurance until the policy anniversary date after they turn 26.

However, there are few caveats families need to be aware of. The law only applies to the 49.5% of CT residents covered by state-regulated, fully-insured health plans. Consumers should check with their employers to see if their plan is covered by the law. It does include the state employee plan including medical and prescription coverage but not dental. The other big catch is that parents may be taxed, for both federal and state taxes, on the value of their child’s coverage. For state employees that value varies between $4,533.60 and $7,199.76/year for one child. There are five tests to determine if a child’s benefits will be taxable. While this is an important new option for young adults to remain insured, families need to consult with their employer, their tax advisor, and to research other coverage options to be sure they are getting the best deal.
Ellen Andrews

PCCM applications rolling in

They are still counting provider applications at DSS for participation in PCCM, but early returns are encouraging. Dozens of providers have applied, including physicians, nurse practitioners and physician assistants, from across the state. All but one community health center has applied. We’ll let you know when we have a definitive list for the opening of the program January 1st. It is important to know that providers can still apply, they just may not be in the network as of Jan. 1 – DSS has promised to get people into the program as quickly as possible. Participating providers can join the PCCM Provider Advisory Group and guide the program’s design including operations, provider feedback and program evaluation. For an application, click here.
Ellen Andrews

New faces at the CT Health Policy Project

We are pleased to announce two additions to the CT Health Policy Project community. Jen Ramirez, MSW has joined us as Director of Programs. Jen will be in charge of the Consumer Health Action Network, including newsletters, surveys and advocacy, as well as several policy areas. Jen has worked at the Latino Policy Institute of the Hispanic Health Council, the Partnership for Strong Communities, CCAG and as an eligibility worker at DSS. We are excited to have her policy experience and sensitivity to consumers’ needs here at the Project. (And to students and former staff, we've already taken Jen's picture for the wall.)
Hillary Waldman has also joined our Board of Directors. Now at the Hispanic Health Council, until recently Hillary was the health care reporter at the Hartford Courant for twenty years.
Please join us in welcoming Jen and Hillary.

PCCM could save HUSKY more than $100 million over HMOs

An analysis by the CT Health Policy Project estimates that it will cost the state $113 million more annually to moving HUSKY families to HMOs than to Primary Care Case Management (PCCM). PCCM is a way of running HUSKY without HMOs, by creating “medical homes” to coordinate care. PCCM has been successful in thirty other states providing better health outcomes, and higher consumer and provider satisfaction and saving money. The estimates are based on total HUSKY program costs reported by DSS for November 2007 (before the capitated HMOs left the program) and May 2008 (during the fee-for-service transition) adjusted for HMO and PCCM administrative fees and the 24% rate increase granted to HMOs this year. Policymakers facing difficult program decisions due to this year’s significant budget deficit are taking note.
Ellen Andrews

Second PCCM provider forum also successful

Last night, DSS held their second forum for providers on PCCM at DSS’ offices in Hartford. Again the event was very well attended and most providers were enthusiastic about the program. As in Tuesday’s forum, concerns about adequate adult medicine resources were raised, but in at least one case community adult and pediatric providers linked up at the meeting to collaborate in providing care in their area. Concerns were also raised about marketing guidelines and how families will be informed about this new option.
Ellen Andrews

Governor agrees to delay HUSKY defaults until February

Yesterday legislators and the Attorney General held a press conference urging Governor Rell to delay forcing 250,000 HUSKY families into HMOs with inadequate provider networks. Families were scheduled to be defaulted into three HUSKY HMOs December 1st including two new health plans, Aetna Better Health and AmeriChoice, which have had difficulty enrolling providers. Just after the press conference, the Governor announced she would delay the default until February 1st. It has been reported that CMS also urged the state to delay defaulting families. Advocates have urged the state to focus on the PCCM pilot project scheduled to begin January 1st as a less costly alternative, more attractive option to the HMOs for HUSKY families.
Ellen Andrews

Possible legal action to stop HUSKY families default into HMOs

Kevin Lembo, CT’s Health Care Advocate, plans to sue the state to stop the planned December 1st mandatory transition of over 200,000 HUSKY consumers into managed care plans that do not have adequate provider networks. Lembo and a growing group of advocates and officials have been concerned that the planned transition will lead to many consumers unable to access necessary services and worries about the impact on HUSKY families’ health. DSS has been under pressure at Medicaid Managed Care Council meetings for months to delay the transition and reportedly CMS has also urged DSS to reconsider. DSS has asked CMS for an additional four months for the transition if needed.
Ellen Andrews

Successful PCCM provider forum last night

Over 30 providers attended the PCCM forum held with DSS at our offices in New Haven last night. We had to get more chairs and make extra copies of the materials. There was a great deal of enthusiasm for the program and most providers suggested that they will be filling out an application. Most providers attending were pediatric; there are concerns about getting enough adult providers to participate in HUSKY – either PCCM or the HMOs. However DSS noted that they have received inquiries from adult providers about PCCM and community health centers are enthusiastic about participating. Aetna’s medical director attended and was offered an opportunity to speak by DSS.
Ellen Andrews

Photography exhibit highlighting racial and ethnic disparities

Friday afternoon 2pm at New Haven City Hall there will be a reception to feature an exhibit of photographs taken by ten African American women highlighting issues that make it difficult to live healthy lifestyles to eliminate racial and ethnic disparities. Senator Toni Harp, our Board President, joined the project as a photographer-for-a-day. The exhibit includes 48 photographs, commentary and statistics. The project was led by Yale-Griffin Prevention Research Center with funding from the CT Health Foundation.

Governor’s deficit mitigation plan includes cuts to medical interpreters

Today the Governor announced her plan to address CT’s looming $268 million state budget deficit. Her plan cuts $1.175 million in previously approved funding for medical interpretation services in the Medicaid program. The CT Health Foundation reports that 22,000 people with limited English proficiency were enrolled in CT’s Medicaid program in 2003 and that communication is critical to effective health care service delivery. Her plan also diverts $14.5 million in anticipated savings from the state employee health plan from addressing the state’s unfunded liability to her deficit reduction plan. Her plan includes an expectation of $2 million in increased Medicaid Disproportionate Share (DSH) federal funding for hospitals and $157 million from a settlement with the federal government of rates paid to Dept. of Developmental Services intermediate care facilities and group homes. The Governor does not recommend new taxes, layoffs, or accessing the Rainy Day Fund but does include a Tax Amnesty to increase revenues. These cuts follow cutbacks directed by the Governor earlier this year including a hiring freeze. The Governor plans to call the General Assembly into session on November 24th to consider her plan to address the deficit.
Ellen Andrews

Windham PCCM forum cancelled

The provider forum on PCCM planned for October 22nd at Windham Hospital has been cancelled.
To learn more about the program, come to either the October 21st forum in New Haven (at our offices at 703 Whitney Avenue in New Haven) or the October 23rd forum in Hartford (at DSS' offices, 25 Sigourney Street in Hartford). Both are at 6:30pm.

HUSKY/Charter Oak update

At today’s Medicaid Managed Care Council, the HUSKY HMOs’ provider panel reports showed that progress continues to be very slow. Sen. Harris pointed out that at this pace, the two new HMOs will take over a year to reach capacity similar to CHN’s panels. In the counties already transitioning to the HMOs, 94% of HUSKY members have not been able to choose an HMO. DSS still plans to default everyone in the state into an HMO as of December 1st. Letters to that effect will be going out to families in two weeks giving them 30 days to choose a plan or be assigned to one.
Plans for PCCM continue with an anticipated start date of Jan. 1st. Legislators strongly urged DSS to wait to default members into plans until PCCM is operational giving consumers the best array of options and giving PCCM a fair chance to succeed. DSS announced three PCCM provider forums.
DSS also released numbers suggesting that the state saved money under the old HMO-based system compared to the interim fee-for-service based system we have now. They stated that total HUSKY costs in Oct. 2007 (before the HMOs left the program) were $61.4 million and in April 2008 (during the fee-for-service period) costs were $73.3 million. However those numbers do not account for the increase in enrollment of 11,483 people between those dates or the (very high) $18.18 per member per month fee paid to the HMOs in April for administrative processing. However, even if we allow DSS those numbers, adding the 24% increase in rates to the former HMO spending (Oct. 2007 numbers) brings the monthly spending $3 million higher per month than fee-for-service (April 2008 number). The bottom line is that, even using DSS’ numbers, we will likely be spending significantly more under the new HMOs than we did under fee-for-service.
Thankfully, there is good news on the dental carve out. The number of participating dental providers has almost doubled; there are now 342 “Doors Open for Access” or sites to access dental care for HUSKY families across CT with 674 participating providers. We lost a very small number due to lower payments but picked up far more in the new system independent of HMOs. This is very encouraging news for PCCM which is also independent of HMOs.
Ellen Andrews

PCCM provider forums scheduled

DSS has scheduled three forums for providers to learn more about PCCM. They are all at 6:30 pm.
October 21 CT Health Policy Project offices in the Red Cross Building, 703 Whitney Avenue, New Haven
*CANCELLED* October 22 Windham Hospital, 112 Mansfield Avenue, Willimantic
October 23 DSS offices, 25 Sigourney Street, Hartford

Applications and the PCCM concept paper are available on-line.
To RSVP contact Marcea Wolf at Marcea.Wolf@ct.gov or (860) 424-5354.

Report: CT family premiums rising 8.2X faster than earnings

A new report by Families USA finds that from 2000 to 2007, family health insurance premiums in CT rose from $7,292 to $13,173 (80.7%) while CT family median earnings rose only 9.9%. Employees’ share of premiums rose even more – 10.5 times faster than earnings. Individual coverage grew by 52.8% during those years, and employees’ share grew by 73.1%. CT had the third worst disparity between health insurance premiums and earnings. The report doesn’t address the increasing burden on families of rising co-payments, coinsurance and the costs of benefits no longer covered by employer sponsored insurance. Wall Street’s problems will fall hard on CT, and with unemployment already at 6.5 % (above the US average of 6.1%) it is likely that the gap between premiums and earnings will only grow this year.
Ellen Andrews

DSS asks CMS for a HUSKY delay

The administration has asked the federal government for a four month delay for moving HUSKY families into the new HMOs. DSS and the two new HMOs, AmeriChoice (United Health Care) and Aetna Better Health, have been criticized for having inadequate provider networks and for not devoting enough time to building those networks. The third HMO participating in HUSKY, Community Health Network, is based on CT’s community health centers and has served HUSKY clients for over a decade. DSS still expects to be able to meet the deadline of defaulting families into the HMOs on December 1st, but asked for the extension to March 31st just in case. DSS is still fully committed to moving all families into managed care but has promised not to force anyone into an inadequate network. Previously, Anthem, who left the program last fall, agreed to continue serving HUSKY families indefinitely with their larger provider network. HUSKY covers approximately 340,000 CT residents, including one out of five children and one in four births in the state.
Ellen Andrews

Drug company Cephalon will pay CT $6 million fine

CT’s Attorney General announced yesterday that Cephalon, Inc. will pay $425 million nationally and $6.13 million to CT for illegally marketing three drugs causing serious complications in some patients including seizures, respiratory depression, addiction and death. The off-label marketing of the drugs for uses not approved by the FDA caused sales of the drugs to increase by as much as 1,000 percent. The agreement resulted from a four year investigation finding that Cephalon engaged a strategy of buying overlooked drugs with narrow approved uses and aggressively marketing them for non-approved uses to boost profits. The settlement subjects Cephalon to broad corporate integrity and financial transparency standards.
Ellen Andrews

Critical Condition documentary showing tomorrow night

PBS’ POV series tomorrow night at 9pm will be, Critical Condition, describeing the barriers to accessing care for America’s uninsured. A streaming version of the film will be online until Nov. 11th. Directly following at 10:30 pm will be RX for Change, a MacNeil/Lehrer Special, a discussion of Americans’ top health insurance concerns. June 5th CPTV aired a CT version, Critical Condition: Focus on CT.

Legislature and Comptroller announce audit of DSS

Legislative leaders and Comptroller Nancy Wyman announced today that the Comptroller’s office will conduct an audit of DSS to eliminate waste and over-budgeting. Specific concerns include difficulties tracking expenses, over $100 million in DSS carry-forward requests, turmoil in the HUSKY program, start up costs of the Charter Oak Health Plan, and funds appropriated for programs that are not implemented or partially implemented such as delays in securing disease management, PCCM and medical interpreting services. The Appropriations and Finance Committees will hold a joint fiscal accountability meeting on November 18th.
Ellen Andrews

PCCM public hearing and RFA out

The Appropriations and Human Services Committees held a public hearing today on DSS’ proposal for a PCCM pilot for HUSKY. Over thirty legislators came to hear Commissioner Mike Starkowski and Director of Medical Administration David Parrella outline their plans for the program. Legislators universally expressed enthusiasm for the plan and commended DSS for faithfully implementing the program. DSS is planning to hold forums around the state to introduce the program to providers and to collect feedback. They intend to hire a contractor to evaluate the program and a nurse advice line for patients. Legislators expressed concern that the implementation of PCCM be timed to fairly compete for members with the current plans to default HUSKY families into HMOs December 1st. PCCM isn’t slated to start until January 1st. The committees then heard from provider representatives, an IPA, advocates and consumers all in favor of the plan and urged the committees to approve it. Advocates commended DSS for an inclusive process to design the program, including advocates at every step and incorporating most of our input. Improving access to care for families and reducing burdens on providers were the highest priority and every design decision was tested against that standard. The collaboration created not only a strong proposal, but also deepened trust and respect between the agency and stakeholder groups which will continue into the future. While the vote was left open, voting at the meeting was unanimously to approve the plan.
The application and draft agreement for providers interested in PCCM is posted on DSS’ website.
Ellen Andrews

CTHPP is seeking a Program Director

The CT Health Policy Project is hiring a Director of Programs. The position involves coordinating consumer assistance and educational programming for the Project. There are opportunities for policy analysis and advocacy as well. Qualifications include organizational and interpersonal skills, resourcefulness, ability to work independently and take initiative, and most important – enthusiasm and commitment to our mission to improve access to quality, affordable health care for every CT resident. Knowledge of CT’s health care system is not necessary. Bilingual English/Spanish is preferred. Hours and salary are negotiable and based on experience. For more information, click here.

DSS answers Medicaid Managed Care Council on HUSKY and Charter Oak costs

Yesterday’s Medicaid Managed Care Council was standing room only for what is generally a dry actuarial discussion about rate setting. Questions from legislators and advocates were pointed but answers were fuzzy.
First, representatives from Shramm and Raleigh, DSS’ no-bid financial contractors, described how Charter Oak’s costs and benefit package were arrived at. The original bids for the original package promised by the administration from the only three HMOs to apply -- Community Health Network, Aetna Better Health, and AmeriChoice – was $335 per member per month, higher than the $250 premiums the Governor had promised. So they asked the HMOs how they could tweak the package to save 24% and keep the Governor’s promise. They arrived at the $100,000 annual limit on benefits. The auditors acknowledged that this provision will cause a number of very ill patients every year to incur significant medical debt as a planful part of the program’s design – they didn’t know how many, but they will get back to us. They also revealed that the actual premiums for members at lower income levels are higher than the $256 paid by un-subsidized members. While this doesn’t matter to those members, their maximum contributions are set in statute, DSS acknowledged that this increases the state’s financial risk, especially given that so far the large majority of enrolling members are in those subsidized income ranges. Many concerns were raised about the state’s financial risk and the sustainability of Charter Oak. There was no answer to the question posed by Kevin Lembo, the State Health Care Advocate, about when we will know if the costs are in a death spiral and what will be done about it.
Council members also had serious concerns about Mercer’s presentation on how the 24% increases in the HUSKY HMO rates were arrived at. Questions focused on the 8.2% increase to bring provider rates under the HMOs up to the fee-for-service floor. Sen. Harp, Co-Chair of Appropriations, stated that the legislature’s understanding was the HMOs were using the 4 to 4.5% increases they have received every year for over a decade to raise provider rates and last year’s fee-for-service increases were just to catch up. She was very concerned to learn that we were paying the HMOs yet again to raise rates. Members also questioned why price increases were included in the 8.2% item as well as in the 5.6% trend adjustment raising concerns that price increases were being counted twice. Significant concerns were raised about the 5.3% increase (over $30 million) allotted for “Change in MCO financial position.” This appears to be money to cover HMO profits and for “negotiations.” We can only imagine those negotiation sessions, when DSS needed three HMOs to run the program and only got three bids.
When asked about the Governor’s dismissive response to the Council’s unanimous resolution advising DSS to slow implementation of the HUSKY transition and until the HMOs have adequate provider panels (as required under federal law), the Commissioner stated that a handful of members are receiving care now.
The meeting then turned to those inadequate provider networks which continue to grow very slowly. Despite that DSS intends to begin enrollment in New Haven, Tolland and Litchfield counties October 1st and the rest of the state November 1st. Middlesex County began enrollment the first of this month, but thankfully less than 7% of consumers have switched into the skeletal plans. The large majority of those have chosen CHN, the already existing HMO based on the state’s community health centers. All HUSKY families will have to choose one of the three HMOs by November 25th or they will be randomly defaulted into a plan on December 1st.
The next Council meeting will be October 10th at 9:30am and will discuss revenues and expenses for HUSKY during the last year and progress on the dental carve out. Can’t wait.
Ellen Andrews

Behavioral Health Partnership/HUSKY update

At Wednesday’s BHP Oversight Council meeting, DSS reported HUSKY MCO enrollment numbers in Middlesex County, the first to go “on-line” back to managed care plans. Voluntary enrollment in the MCOs started Sept. 1st; at the end of November it will be mandatory. Of Blue Care members, 170 (41%) chose Aetna Better Health, 28 chose AmeriChoice (7%) and 218 (52%) chose CHN. Of traditional Medicaid members, 18 (25%) chose Aetna, 1 (1%) chose AmeriChoice and 54 (74%) chose CHN. It is important to remember these are very early numbers and provider networks are still skeletal.

DSS and DCF also reported on BHP finances ($109 million in FY 08), and access numbers. Access was broken out by children vs. adults, and by outpatient services, intermediate care, home-based services (which have increased significantly) and emergency mobile psychiatric services. We also received detailed information on inpatient care – the numbers of admissions is up but length of stay is down. While we have far to go, inpatient days in discharge delay for children (children ready to leave the hospital, waiting for an appropriate treatment setting) is down from 37% in the last quarter of 2007 to 26% in the second quarter of 08, coming closer to national averages. The Council is reviewing DSS’ plans for using targeted new funding to reduce length of stays in psychiatric residential treatment facilities, with more focused treatment and reducing delay days.

Significant concerns were raised about DSS’ plans for mental health and substance abuse services under Charter Oak. Services are limited and costs to consumers could be substantial. The effect of medical debt on patients’ financial health, serving as a disincentive to needed follow up care, and that Charter Oak could be ineligible for free bed assistance because they have insurance, in some cases, they may be worse off with Charter Oak than uninsured.
Ellen Andrews

PCCM hearing date set

The mandated public hearing on DSS’ Primary Care Case Management proposal has been set. The hearing of the Human Services and Appropriations Committees will be September 25th at 11am at the Legislative Office Building. If you cannot come and would like to submit comments, the Chairs of the Committees are Representative Peter Villano, Senator Jonathan Harris, Senator Toni Harp and Representative Denise Merrill. Mail to any legislator can be addressed simply to the Legislative Office Building, Hartford CT 06106; email addresses can be found at www.cga.ct.gov.

Authorities holding public hearings

The Health First and Primary Care Authorities will hold public hearings on their mandates to develop options for health coverage of all CT residents and to assess the capacity of CT’s primary care system. All are 6:30 to 8:30 pm.
9/17 Putnam Middle School
9/18 Norwalk City Hall
9/23 Torrington City Hall Auditorium
9/24 CHA building, Wallingford
9/25 Norwich Town Hall Chambers
9/29 Danbury Town Hall Chambers
10/1 Waterbury Arts Magnet School
10/2 Legislative Office Building, Hartford
TBA Manchester

The Project turns nine !!!

Yesterday marked the ninth anniversary of the CT Health Policy Project. We took the day off.

To celebrate, we are moving our offices (actually just Ellen’s office). Our address will be not change. As of next week all the staff will be in the same part of the building. Our phones and internet won’t be working on Friday, but hopefully everything will be back up and running again on Saturday. Many thanks to Brian Roccapriore, former Director of Programs, who will be sharing his weekend with us, fixing the inevitable computer glitches.

PCCM concept paper out

The concept paper for the state’s planned PCCM pilot has finally been delivered to the legislature. The Appropriations and Human Services Committees now have 30 days to hold a public hearing and approve, deny or make changes to the plan. PCCM is a way of running HUSKY without HMOs and will serve as another option for consumers and the state to run the program. Under PCCM, consumers will choose a primary care provider (PCP) – a physician, APRN, nurse midwife, or Physician Assistant – who serves as their first contact for health care. Their PCP is responsible for providing routine checkups and health care, arranging for tests, specialists and other needed care and coordinating everything. Consumers will need referrals from their PCP for specialty and other care; PCPs will only need prior authorization from DSS for some hospital services. The state will provide access to an off-hours nurse advice line. PCPs will need to have or get an electronic medical record or electronic disease management data registry within a year. PCPs will be held accountable for the care and coordination they provide.

The goals of the program include improving outcomes, expanding access to primary and preventive care, improving doctor-patient relationships, lowering expenses, and empowering providers and consumers in guiding the HUSKY program. An advisory committee of providers will be convened and charged with developing a proposal for accountability and all other aspects of the program.

DSS plans to implement the program on Jan. 1st and to pay PCPs $7.50 per member per month for care management costs in addition to the usual fee-for-service payments for visits and procedures. Plans for outreach include regional forums for providers and consumers. We will let you know when those and the legislature’s public hearing have been scheduled.
Any providers who are interested in participating can call the CT Health Policy Project at (203) 562-1636.
Ellen Andrews

Sad news

From Gary Spinner, COO of the Hill Health Center:

“It is with great sadness that I let you know of the passing away of Cornell Scott, Hill Health Corporation's Chief Executive Officer. Scotty passed away at noon today in Yale New Haven Hospital. He had been ill for a great deal of time, and the past year has been one of frequent hospitalizations. Scotty has been the CEO of Hill Health Corporation since its founding in 1968. HHC was his love, his life, and his passion, and even until the end, he took great pleasure and joy in hearing about the work and mission of the Center.”

Scotty will be dearly missed here in New Haven, in Connecticut and across the US as one of the first and most prominent leaders in the movement to bring health care to those who need it the most.
Ellen Andrews

New Census numbers find uninsured largely unchanged in CT; many more buying insurance directly

In 2007, there were 326,000 uninsured CT residents, or one in eleven of us had no coverage – not significantly different from the 2006 numbers according to Census numbers released today. We had a good decrease in uninsured from 2005 to 2006 which has been stable. CT has the eighth best (lowest) uninsured rate in the US. HUSKY enrollment grew by 2% from 2006 to 2007. While this is all good news, there are still far too many CT residents living without coverage, risking both their physical and financial health. Click here for the CT Health Policy brief on the numbers.
Amongst all the stability is an interesting trend – the rising number of CT residents who directly purchase health insurance. That number rose significantly in 2007 to now equal the number of people without any insurance coverage. Anyone who has shopped lately for insurance, especially here in CT, knows how expensive it is. The state could do more for those direct purchasers to improve affordability and availability. Purchasers in CT’s small group market have several protections under state law including modified community rating (spreading costs over a larger group), guaranteed issue and renewability and the Insurance Dept. has to approve rate increases in the small group market. None of these protections apply in the individual market but they could. As part of their health care reforms, Massachusetts is merging their individual and small group markets, a reform that is expected to save individual purchasers 15 % (and only costing the small group market 1 to 1.5% more). MA also requires employers to allow workers to buy insurance with pre-tax dollars, saving direct purchasers even more. CT should look at these reforms at a minimum as more residents are relying on our largely unregulated individual insurance market.
Ellen Andrews

COHI seeking Executive Director

The CT Oral Health Initiative needs to hire a new Executive Director. For five years COHI has been advocating for better oral health for everyone. They have focused on access to dental care for CT’s underserved and education about the importance of oral health. COHI is seeking an experienced nonprofit leader who shares the organization’s mission and values. Speaking personally, I enjoyed my term working with COHI, learned a lot about the importance of oral health, and have rarely met a group of advocates as dedicated and nice to work with. For more info, go to www.ctoralhealth.org.
Ellen Andrews

eHealthCT designated as a Chartered Value Exchange

Connecticut is entering the e-health big leagues! Yesterday, our own eHealthCT was designated as a Chartered Value Exchange by the Agency for Healthcare Research and Quality. eHealthConnecticut is a not for profit entity incorporated in January 2006 and represents a collaborative approach to meeting the challenges of health information technology adoption and interoperability for the entire State. It is Connecticut’s single organization focused on statewide HIE, with the combined governance and resources of the public and private sectors and the flexibility of a private corporation. A Board of Directors representing physicians, providers, consumers (including the CT Health Policy Project), purchasers, payers, academia, and quality organizations governs eHealthConnecticut, with State agency officials providing direction on an ex-officio basis. Chartered Value Exchange status allows eHealthCT to bring critical resources back to our state, allowing CT health care consumers and payers to benefit from the benefits of health information technology sharing. Congratulations to eHealthCT for their hard work so far and good luck with the hard work yet to come.
Ellen Andrews

Drama at the Medicaid Managed Care Council

Yesterday, the Council passed a resolution to recommend a delay in transitioning HUSKY families into the new HMOs and to freeze enrollment in Charter Oak until July 1st, 2009. The council was concerned that only a handful of providers have signed up with the two new plans, AmeriChoice and Aetna Better Health, and that patients won’t be able to access care. The motion was offered by Rep. Peter Villano and passed unanimously.
Unfortunately, DSS wasn’t there to hear Council members’ concerns. The Commissioner was not able to attend due to a family illness, but other staff were prepared to present and were in the room distributing handouts when they were abruptly called back to 25 Sigourney Street just before the meeting started.
The Council and visitors, including seven legislators, had a lively discussion with the three HMOs, the CT State Medical Society and the CT Hospital Association. Concerns beyond the inadequate provider networks about the program included provider rates and whether they will be made public under Freedom of Information law, inclusion of retail clinics, higher rates paid to some providers, whether the plans were contracting with providers for all three programs (HUSKY Parts A and B with Charter Oak), linkage of HUSKY with Charter Oak and the impact on families, the state’s liability for behavioral health and prescription costs, and why providers are being offered lower rates when the MCOs received a 24% increase in their rates from the state? (We were promised an answer to that question at the next meeting – Sept. 19th at 9:30am).
According to news reports, the Governor has dismissed the Council’s concerns suggesting that the legislators favor universal health care. There was no discussion of universal health care at the meeting. She says the HUSKY transition and launch of Charter Oak will go ahead unchanged.
It’s August; aren’t we supposed to be taking it easy?
Ellen Andrews

Retail Medical Clinics and Primary Care panels

Today’s panels at the CSG/ERC annual meeting explored retail clinics – opportunities and concerns – and primary care shortages. The clinic panel included Kim Rhodes from Take Care Clinics (owned by Walgreens) and Ken Ferrucci from the CT medical society. There are about 1000 retail clinics in the US, providing affordable access, including evenings and weekends, to basic services for conditions such as immunizations, colds, and ear infections. Ninety percent of patients who have used clinics are satisfied with the quality of care they received. Take Care Clinics have strong quality standards and work to connect patients to appropriate community services. Demand for clinic services is strong and growing, especially for people who cannot reach their doctor’s office during business hours and don’t need an emergency room. Ken emphasized that the medical society is not advocating to prohibit the clinics, but to ensure that they are regulated to protect patient safety. Other concerns include providing health care in stores that sell tobacco, offering lower copays to patients for visiting a clinic over a physician’s office, and the effect of clinics on the rest of the health care market.
The second panel focused on the shortage of primary care services and included Sen. Lisa Marrache (ME), Dr. Mario Motta, President-Elect of the MA Medical Society, and Dr David Stevens, of the National Association of Community Health Centers. Sen. Marrache, who is also a practicing primary care physician, created a legislative Commission to Study Primary Care Medical Practice. The Commission found that primary care physicians are leaving practice in record numbers primarily due to low reimbursement rates. The Commission recommended increasing and equalizing Medicaid rates, streamlining prescribing processes, investments in health information technology, and creating a medical home pilot project. Dr. Motta described the medical society’s recent study that found serious and growing physician workforce shortages, particularly in primary care fields. Half of MA physicians reported that they would not choose to practice medicine again as their profession. Waiting times for primary care appointments are increasing in MA which has serious implications for the success of MA’s health care reforms to cover all state residents. Insurance coverage is only part of the answer, being able to find a provider is just as important. Dr. Stevens focused on the critical role of community health centers in filling primary care gaps for underserved patients. He also highlighted the “medical home” model of care as a potential solution. In a medical home, patients have one place to access and coordinate comprehensive care in a culturally competent, compassionate setting. The medical home uses a team of providers including physicians, nurse practitioners, nurses and others to deliver appropriate, patient-centered care.
CT’s Governor Rell and Senator Harp attended both panels and actively participated in the discussions.
Ellen Andrews

State reform updates

I’ve been staffing the annual meeting of the Council of State Governments/Eastern Regional Conference health policy track meetings in Atlantic City, NJ. Today we heard updates from states at varying stages of reforming their health care systems – Maine, Massachusetts, Vermont and New Jersey.
Sen. Joseph Vitale described New Jersey’s comprehensive plan to cover all 1.2 million uninsured residents. Phase I was just signed into law expanding SCHIP for parents. They are starting an insurance mandate for children, but there are no penalties attached to it yet. Policymakers decided against any employer contribution. They allow families with higher income children to buy into the program at full cost – similar to HUSKY Band 3 – at a cost of about $137 per child per month (twice that for two children and three times that for three or more children in a family). The law increased the minimum allowed medical loss ratio for managed care companies from 75% to 80% -- CT has no standards for medical loss ratios. Phase II will include coverage for everyone not eligible for existing programs, will be self-funded, provide a benefit package similar to the most popular small group market product, and will reimburse providers at commercial rates.
Sen. Richard Moore updated the conference on Massachusetts’ reforms. The rate of uninsurance has dropped from 13% two years ago when Chapter 58 passed to at least 7% and possibly as low as 4% now – over 355,000 people have found health insurance. Not only has Massachusetts found no evidence of crowd out (employers dropping coverage assuming workers can join the new public programs), in fact employer sponsored insurance rates have increased since Chapter 58 passed two years ago. Uncompensated care spending is down 34%. Fewer state residents report not being able to access care due to cost, and medical debt is down. Public support for the reforms is strong and growing. Reforms of the non-group market have made insurance far more affordable and enrollment is up 50%. Despite this rosy picture, challenges remain. Residents who have chosen to remain uninsured may be difficult to convince, covering the underinsured, workforce shortages, and containing health care costs. To contain costs, a new law just signed by the Governor addresses price transparency, health information technology adoption, regulation of drug company gifts to providers, prohibits billing for “never events”, CON reforms, and a medical home demonstration project.
Jim Hester, Director of Vermont’s legislative Health Care Reform Commission, described Catamount Health which also passed in 2006. The Commission is a legislative oversight body that follows the implementation of reforms closely and is critical to the state’s success. 5,800 Vermonters have joined Catamount Health and 4,300 have newly enrolled in state programs. Vermont is having difficulty getting the federal government to honor its commitment to their global Medicaid waiver at promised funding levels. This year Vermont enhanced their reforms by expanding coverage for children on their parents’ policies to age 23 and a large increased investment in health information technology paid for with a 0.2% fee on paid claims across all payers. Vermont is also expanding their successful Blueprint for Health plan to reduce the prevalence and provide chronic care management for diabetes. ER use is down by 40% for patients in the self-management program.
Phil Saucier, from Maine’s Governor’s Office of Health Policy & Finance, talked about progress covering the uninsured. Their Dirigo health plan passed in 2003 and now covers about 18,000 Mainers. The state has taken the federal government to court arguing that they are owed financial support for the program. The state repealed the contentious savings offset payment mechanism to fund the program in favor of a flat fee on all payers, including self-funded plans, of 1.8% of claims as well as taxes on alcohol, tobacco and soda. The soft drink industry has mounted a referendum on the November ballot to repeal the tax on soda – a “people’s veto”. The state also increased the age children can stay on their parents’ policies to 25, prohibited billing for “never events”, created medical home pilots, and are addressing overtreatment inefficiencies.
Ellen Andrews

Charter Oak/HUSKY troubles in the news

The current problems getting providers to participate in the new Charter Oak/HUSKY plans have been hot news lately. A sampling:
The Day
ctnewsjunkie.com
Hartford Courant
Journal Inquirer
New Haven Register
Waterbury Republican American
Kaiser Daily Health Reports
Medical News Today
CT Post
WTIC News Talk 1080
Fox News 61
News Channel 3
Norwich Bulletin

According to DSS, as of Friday there were only 314 total primary care providers enrolled statewide in Aetna’s plan (only 2 in Windham county) and 225 in Americhoice’s panel (5 in Middlesex County). On Friday, there was still only one hospital signed up with Aetna and none had signed on with Americhoice.
Ellen Andrews

Charter Oak/HUSKY/PCCM update

DSS Comm. Mike Starkowski met with the Appropriations and Human Service Committees yesterday delivering a 72 page program update. The big news (from our perspective) is that the PCCM concept paper, drafted by a working group of DSS staff and advocates (including the CT Health Policy Project), will be submitted to the legislature next week. The committees will then hold a public hearing on the draft plan, and approve, reject or modify it. In response to a question from Rep. Villano, the Commissioner also announced that the per-member-per-month payment to Primary Care Providers in PCCM will be $7.50, not $5 as was previously reported. The working group had recommended $7.50 after animated negotiations. The bad news is that PCCM may not start until Jan. 1st. Legislators urged DSS to do everything possible to have it ready as another option at the same time that consumers have to choose between HMOs.

There was a great deal of discussion about the 24% increase in rates to the HUSKY/Charter Oak HMOs that seemed “awfully high” to Sen. Harp, with the committees asking DSS to get back to them with more detail. Sen. Harris and others asked about the lack of providers in the new HMOs’ panels. DSS says the HMOs are actively recruiting providers and the plans will pay the out-of-network costs for care to members through November. Legislators expressed concerns that if out-of-network services are not paid at reasonable levels, consumers may still have difficulty accessing care. The Commissioner emphasized that no consumers will be defaulted into any plan until November 25th and the current ASO arrangement, that by all accounts is working well and possibly saving money, will continue until at least the end of the year.

Overall, the committee members expressed a lot of frustration with DSS – in delays to implementing programs, selectively cutting legislative priorities, and numbers that “change every time we meet”. Rep. Merrill said, “We will keep having hearings until we get answers.”
Ellen Andrews

Troubling Charter Oak call

We’ve received calls from many consumers about Charter Oak – and it is a good option for some. However yesterday we got a troubling call on our Consumer Helpline (888) 873-4585. Leslie Dmowski called the Charter Oak application number to find out how to apply. She was injured in a car accident and can no longer work. She has applied for disability and is now paying for COBRA – a considerable burden on her family when she is without an income. When she called Charter Oak, she was told she was not eligible because she has insurance coverage. She was told nothing about the financial hardship exception. DSS has stated that if someone is now paying 10% or more of their income for health coverage, they do not have to drop coverage for six months to qualify for Charter Oak. Leslie is paying over 20% of her family’s income for coverage. Thankfully she called us, told her about the financial hardship exception, and sent her an application.

She also waited a long time on the phone after calling Charter Oak and got lost in the phone tree before she spoke to an actual person who was rushed and not helpful. She wanted to make sure that callers know not to press any numbers at the phone prompts to get a real person.

Leslie’s troubles point out a common problem with translating policies to the real world. We at the CT Health Policy Project have been very concerned about the six month uninsured requirement for Charter Oak – we feel it is unfair to people like Leslie who are sacrificing to pay for coverage now and it is bad public policy – excluding those who need health care is an odd way to build a health care program. We advocated with DSS and the legislature to remove the six month exclusion. Policymakers decided not to change it, but assured us that there would be generous exceptions. However it really doesn’t matter how fair the policies are on paper when they don’t get translated to the real world Leslie and her family live in. Advocates have to be especially vigilant – our job is only starting when we get policies passed in Hartford. And policymakers should be realistic when designing programs.
Ellen Andrews

What would you tell her?

I just returned from a wonderful trip visiting family. While I was there, I ended up in a conversation that put me in an awkward situation, given my job. I was talking with one of my sisters and some of her friends, about half of whom are uninsured. One friend, who is a self-employed 39 year old, asserted, “I don’t believe in health insurance.”

“How’s that?” I asked, preparing myself to tout the importance of health insurance and primary health care.

The friend said that certainly the cost of health insurance is prohibitive, but her main concern was that you can’t be sure of what you’re getting when you pay your premiums. If you have pre-existing conditions, insurers will likely not cover costs associated with those. If you are diagnosed with some unrelated but expensive condition, insurers will likely fight having to cover those costs. She continued. The small print may exclude a number of common events or conditions. And, you may still have an absurdly high deductible or burdensome co-pays.

I was deflated. She’s right…particularly for people who would be finding their insurance as individuals and especially for those who are unable to afford a Cadillac insurance plan on their own.

Insurance is important, but only when it really protects its clients. Too often, we get calls at the Consumer Health Action Network (toll-free in Connecticut at 888-873-4585) from people who have upheld their side of the insurance contract only to find that the insurance companies have built in loopholes that exclude their conditions or key parts of their treatments, or that their “insurance” is not insurance but simply a Medical Savings Account, which offers little in the way of negotiating power to reduce the cost and nothing in terms of offsetting the cost itself.

As I listened to my sister’s friend, I thought about the calls I’ve taken from people here in Connecticut who have seen significantly higher costs than benefits to having health coverage. In order to convince these people (and my sister’s friend) that health insurance is an important and worthy expense, there must be more meaningful standards for what’s covered, clearer explanations of coverage, and better cost controls. Short of either this kind of regulation or of a system that provides truly universal health coverage, we will always have people who forego preventive care, rely too heavily on safety-net providers, and take their chances that they’ll stay healthy enough. That approach is not good for them and it’s not good for our society.
Connie Razza

HUSKY/Charter Oak health plan rates up 24% from last year

After accounting for the impact of dental and prescription drug carve outs, the capitated rates paid to the three HUSKY HMOs – Aetna, AmeriChoice (United) and CHN – are 24% higher than the capitated rates paid to the plans last year before November. This is according to an analysis done July 17th for DSS by Mercer obtained by the CT Health Policy Project through a Freedom of Information request. The 24% rate increase includes a 13.1% increase due to programmatic changes (coverage for HPV vaccines, routine dental exams by PCPs, eligibility expansions, etc.) that some advocates and analysts take issue with. Along with medical trend and case mix adjustments, the rate hike also includes a 5.3% or $36.7 million increase for “negotiations” with the plans. $36.7 million is significantly more than the increase in physician fee-for-service payment rates last January – the first in twenty years. It is important to note that the budget, agreed to by both the legislature and the administration, allowed for a 2% rate increase to the plans.
Ellen Andrews

Mr. Lembo goes to Washington

Yesterday State Health Care Advocate Kevin Lembo testified at a Congressional hearing on health insurance company abuses -- post claims underwriting and policy rescissions. That’s when an insurance company cancels a policy after consumer has been paying premiums faithfully, sometimes for years, and they get sick. The company, when faced with mounting claims, looks back into the patient’s history for reasons to cancel. A consumer who joined Kevin on the panel was cancelled after sustaining back injuries from a mountain bike accident because her husband had previous back problems. It is amazing that this was legal in CT until Kevin’s office advocated to change the law. Unfortunately it is still legal in other states, but hopefully Congress will help change that. We are very fortunate to have our State Health Care Advocate, and now Congress knows how lucky we are as well. Read Kevin’s blog on his odyssey into the Beltway.
Ellen Andrews

Concerns about new Charter Oak $100,000 annual cap

On Monday, Time magazine posted a story called “Low Health Insurance Caps Leave Patients Stranded.” The article exposes the real impact of caps as low as $1 million on individuals and families who face very serious illnesses. This issue is particularly important as the new state Charter Oak Health Plan rolls out. On the day it was launched we learned that the plan now includes a $100,000 annual cap on services, in addition to the $1 million lifetime cap.

According to the article, “Only 1% of employer-offered group plans – the largest health insurance segment – had caps as low as $1 million last year, according to a survey by the Henry J. Kaiser Family Foundation. But 22% had caps of less than $2 million, and some want to see all these relatively low maximums eliminated.”

The article outlines several cases – a leukemia patient, a child with a virus attacking her heart, another child in need of a heart transplant. In two of these cases, the families surpassed the caps within a year of diagnosis.

People with long-term conditions may not exhaust their benefits in one year, but can clearly see the cap approaching. The National Hemophilia Foundation told the reporter, “People with hemophilia can spend more than $200,000 a year just on drugs that prevent internal bleeding.” If they have any other medical needs, they could reach their cap even more quickly.

Sometimes people call the Consumer Health Action Network (888.873.4585) to get help with choosing an insurer. We always encourage people to weigh their options carefully and to check with the Office of the Healthcare Advocate (866.466.4446) to make sure that the plans they are considering are reputable. We are adding to our list: consider the lifetime coverage cap and any annual caps. Consumers should weigh the advantages and limitations of Charter Oak before signing up.
Connie Razza and Ellen Andrews

Health First Authority update

Today’s Health First Authority meeting was uneventful. Sharon Langer from CT Voices for Children gave a primer on Medicaid and SCHIP. David Parrella from DSS gave an update on Charter Oak and the HUSKY transition (the same slides he used for Friday’s Medicaid Managed Care Council meeting). DSS has developed a concept paper for an 1115 Affordable Choices waiver to cover Charter Oak, HUSKY, and SAGA and submitted the paper to CMS. DSS refused to share the concept paper with the Authority. Discussion topics included client churning (no answers about why), rate increases (too little, too late), the spending cap (how it restricts the state from accessing federal money), and affordability standards (CT is less generous to uninsured consumers than Massachusetts). There was a presentation by Paul Lombardo of the Dept. of Insurance on MA’s health reforms and by Paul Grady of Mercer on value-based purchasing. Materials from the meeting are online. The next meeting is Sept. 11th at 9am.
Ellen Andrews

Medicaid Managed Care Council update

We got a first look at the HUSKY HMOs’ provider networks at Friday’s Medicaid Managed Care Council meeting and it wasn’t good. CHN, which has been a part of HUSKY from the beginning, has robust panels of providers across the state. However, the two new HMOs – Americhoice (United) and Aetna – have a long way to go. As of July 11th CHN had 2,109 primary care providers available to serve HUSKY consumers, while Aetna Better Health had 367 (190 of those are in New Haven County), and Americhoice had only 140 primary care providers statewide. Both Aetna and Americhoice each have a county with only two primary care providers taking HUSKY and Charter Oak patients. And the HMOs are still in negotiations with hospitals for contracts.
We also learned that undocumented immigrants are not eligible for Charter Oak, even the unsubsidized portion of the program. We learned more about how cost sharing the in the program works – the out-of-pocket maximums are on top of the deductibles and copays. Many on the Council were concerned that the state is still at financial risk for behavioral health and drug costs under Charter Oak. Sen. Harp noted that during budget negotiations this spring, HUSKY expenditures were down significantly – suggesting that the state was saving considerable sums without capitation. CMS has asked for that analysis – how much the state spent before and after the state removed capitation in November. DSS also stated that they have no intention to respond to the state’s budget deficit by proposing cuts to HUSKY or Charter Oak.
Ellen Andrews

CT’s Health Partnership bill featured in NY Times article

Today’s NY Times includes an article outlining proposals to make health coverage more affordable for small businesses. Small companies pay 18% more than large businesses for the same coverage. The recent CT Healthcare Partnership bill proposing to open the state employee pool to small businesses was vetoed by the Governor; however she indicated that she wants to work with legislators next year to craft a bill she can sign. The article also applauds CT for earlier legislation that added some fairness and stability to rate setting for small businesses. CT Comptroller Nancy Wyman is quoted, “This is not an easy problem to solve. We know it.”
Ellen Andrews

Sinking or Swimming in the High-Risk Pool?

On the front page of the New York Times this morning, I saw an article that highlights a problem with proposals to model a new component of national healthcare coverage on states’ high-risk pools. Earlier this year, I had been looking at the Connecticut High-Risk Pool (created by the Connecticut Health Care Act of 1975).

What it is? Connecticut High Risk Pool is managed by the Health Reinsurance Association (composed of all private insurance companies and HMOs that offer health insurance in CT) and offers a comprehensive healthcare plan to eligible Connecticut residents who cannot get other coverage because of pre-existing conditions. State law caps HRA rates at 125% -150% of standard insurance rates.

Who it “serves”? Connecticut residents between 19 & 65 and their dependents can be eligible for the high-risk pool. The Health Reinsurance Association offers several plans, but the range of cost is largely covered by two closely related examples:
· The special Low-Income Portability TAA Plan costs a 45 year-old male $317.63 per month; a 45 year-old female would pay $395.40 a month.
· The same plan for a non-low-income individual costs $972.53 per month for a 45 year-old male and $1210.65 for a 45 year-old female.

In my opinion, the high-risk pool is dangerous because it appears to offer safety-net coverage, while actually being priced out of reach of the very people who most need it. While the new Charter Oak Health Insurance program may help cover many Connecticut residents who would earlier have had no option but the high-risk pool or no coverage, the program’s co-pays and deductibles may still bar our state’s sickest residents from participating.
Connie Razza

Book Club -- Sway

I just finished Sway: The Irresistible Pull of Irrational Behavior by Ori and Rom Brafman. A fascinating book that details the psychological forces that keep us from making good decisions. There are dozens of great examples, but my favorite is the “twenty dollar auction”. One the first day of class, a Harvard business school professor plays a game with his students auctioning off a twenty dollar bill. The highest bidder gets the bill, but the second highest bidder also has to pay his bid and receives nothing. Bargain hunting students quickly move the bidding up to $12 or $16, when the contest slows down and only the two highest bidders continue. At $17 for instance, the second highest bidder can spend another $2 and go to $18 hoping to win the bill or risk losing his entire $16. The students “roar with laughter when the bidding passes $20”; the record is $204. The professor has never lost money in the game; all proceeds go to charity. Students are caught “chasing the loss” – the deeper the hole, the more they dig. This illustrates loss aversion, one of several psychological forces that drive our irrational behavior. Thankfully, the authors do not just describe these traps, but provide guidance to avoid them – critically important in policymaking. For more book reccomendations, go to the CT Health Policy Project Book Club.
Ellen Andrews

Family Values - a small but significant gap in Connecticut’s health care system

There are a number of people who cannot get healthcare coverage in Connecticut no matter where they turn: Documented immigrants over 65 years of age who have had green cards for less than 5 years. The people affected by this gap are often parents who have come to be with their children and help raise their grandchildren.

This morning, the Consumer Health Action Network hotline (toll-free 888-873-4585) answered a call from a daughter who had brought her 70-year-old parents to Connecticut. They both have had their green cards for 3 years. She has tried many avenues to get healthcare coverage for them.
· Most private insurers will not look twice at the application when they learn that her parents are over 65 years old. One company that did consider the couple came back with a monthly premium of $1400 for one parent, for coverage that would not address any pre-existing conditions.
· Medicare requires that immigrants hold their green cards for 5 years before they are eligible for coverage.
· Medicaid does not cover anyone over 64 who isn’t eligible for Supplemental Security Income, doesn’t receive Medicare, or hasn’t spent a significant amount on medical expenses already.
· The new Charter Oak Health Plan is designed for 19 to 64 year olds and does not make exceptions to those parameters.

It’s a small gap, frankly, but an important one to fill. Models exist for how to fill this gap (for instance, our neighbor to the South, New York). Let’s get to it and make sure that we make sure that as many of the currently uninsured will be able to get healthcare coverage.
Connie Razza

COBRA calls to Consumer Network Helpline

In the past three weeks, the Consumer Health Action Network (888-873-4585) has received a number of calls about COBRA. COBRA (which stands for the Consolidated Omnibus Budget Reconciliation Act) is the federal law that allows workers and their dependents to continue group health coverage at their own expense after employer coverage ends because of termination, reduced hours, and other reasons. This trend is disturbing because it indicates at least one if not more of several problems:
· More Connecticut residents are losing their jobs;
· Employers don’t know their obligations under COBRA; and/or
· Employers are counting on their employees not knowing their rights under COBRA.

The program is complicated, but here are some basics:
· In Connecticut, all employers are covered by COBRA law.
· Employees are eligible for COBRA insurance when they retire, quit, are laid off or fired for anything other than gross misconduct, or have reduced hours.
o Employees are covered up to 18 months under the federal COBRA law. If the employee is between 62 and 65 and eligible for COBRA, Connecticut law requires the employer to offer COBRA coverage until the person reaches 65 (when Medicare starts), regardless of the number of months involved.
· COBRA insurance will also cover surviving, divorced, or separated spouses; dependent children; or dependent children who lose their dependent status under their parent’s plan.
o Depending on the reason for loss of coverage under an employer plan, spouses and dependent children may be eligible for COBRA benefits up to 36 months.
· Retirees can qualify for COBRA if their former employer files for bankruptcy.

COBRA coverage can be expensive, especially for people who have just become unemployed, but it is an important option for people to keep coverage through transitions. It is critical that everyone know their rights.
If you have questions about COBRA, go to http://www.cthealthpolicy.org/action/tips/200612_cobra.pdf or call the Consumer Health Action Network Helpline toll-free in CT at 1-888-873-4585.
Connie Razza

State taking applications for Charter Oak

This morning at the Town Line Diner in Rocky Hill, the state began signing up consumers for the Charter Oak Plan. The Governor held a press conference at the diner announcing the opening of the plan and two consumers filled out applications. New information includes premiums which vary between $75 and $279/month and an annual cap on services of $100,000 in addition to the lifetime $1 million cap. Annual deductibles still range from $150 to $900 – above that amount consumers will have to pay 10% of inpatient hospital bills and 20% of outpatient surgery. The three participating health plans are Community Health Network, Aetna Better Health and AmeriChoice (United Health Plan).

Charter Oak covers hospital care, doctor or clinic visits, X rays and lab tests, prescriptions, and some mental health and substance abuse treatment. There is no pre-existing condition exclusion and subsidies in premiums and deductibles based on income.

While Charter Oak is an important new option for CT’s uninsured, it is not right for everyone. As with all insurance, consumers need to do their homework. Charter Oak may not be right for consumers who:
Have insurance now – there are exceptions, but you may not be eligible if you’ve had insurance in the last six months
Don't have money in the bank available for health costs -- $900 deductibles plus 10% of hospitals stays can get very expensive
Have high prescription needs – prescriptions are limited to $7,500/year
Need to see a specific doctor – the provider panel is likely to be very limited
Need dental or vision care – they are not covered
Need mental health or substance abuse treatment – coverage is limited

Consumers who want more information or to sign up can go to http://www.charteroakhealthplan.com/ or call 1-877-77CTOAK (1-877-772-8625).
Ellen Andrews

New uninsured numbers – CT residents more likely to be uninsured than other New Englanders

Between 2004 and 2006, 8.9% of New England residents were uninsured, but 10.7% of CT residents lacked insurance, according to point in time surveys by the National Health Interview Survey. Not surprisingly, low income CT residents (below 200% of the federal poverty level) were 2.4 times less likely to have coverage. 12.2% of CT residents, including one in four children were covered by Medicaid. This is lower than our neighbors in Maine (23.3%), Massachusetts (14.6%) or New York (18.7%). 13.2% of all Americans rely on Medicaid or SCHIP for their health coverage.
Ellen Andrews

CT assessing the strength of our public health system

Yesterday over one hundred CT public health leaders gathered in Farmington for the first of a two day project developing a detailed assessment of our state’s system to protect the public’s health. The project is being led by DPH using CDC’s National Public Health Performance Standards. Five generous souls from New Jersey are serving as independent, disinterested facilitators and two advisors from the CDC set the context for the assessment. The standards measure the CT system’s strengths and weaknesses against ten essential services. I was assigned to the policy breakout session; our group included a very diverse set of backgrounds with many members who had never met. Many felt that just taking a day to reflect on the system and hearing about it from others’ perspectives was instructive. Voting on the questions was entertaining with a lot of lobbying and peer pressure. I can’t wait for next week.
Ellen Andrews

Health First and Primary Care Authority Updates

Last Thursday both Authorities met in separate meetings.
The Health First Authority is collecting information on CT’s spending on health care and Medicaid rates. Urban Institute researchers shared info from a 2003 Health Affairs article showing that CT’s Medicaid rates averaged 83% of Medicare, compared to 69% nationally. MA pays 80%, NY 45% and RI 42%. These rates do not include increases implemented this winter. The Authority then discussed the options they will consider for their report, due in December. Options include a single payer system (required by the statute, they will be taking only written comment on this one), universal primary care only public coverage (the Primary Care Authority is working this one out),and a building block/gap filling approach. The building block approach could include improving Medicaid, new alternatives for the currently insured, an Insurance Partnership plan based on Rep. Donovan’s pooling bill, a Healthy San Francisco-type model, a MA-type Connector plan, and a public gap-filling model run like a self-insured employer plan. Most discussion centered on the building block idea. There was little enthusiasm for any of the options.
The Statewide Primary Care Access Authority met later on Thursday. They had a presentation by OHCA on their preventable hospitalization report. Later they moved on to outlining the structure of their report and the universal primary care system proposal. Suggestions included coverage of prescription drugs, wellness services like Weight Watchers and smoking cessation, specialty care, mental health, and oral health care. They will explore guidelines for FQHCs, pediatrics and adult medicine coverage and build on the list. They discussed loan repayment and removing regulatory barriers to expand the health care workforce. They also discussed creating a standardized process for defining where to place future safety net provider expansions.
Ellen Andrews

Health care jobs carry CT’s employment outlook

The current issue of The CT Economic Digest, from the CT Dept. of Labor, reports that between December and April both CT and the US have had four consecutive months of contracting employment. (Apparently this isn’t bad enough for economists to label it a recession yet.) Historically CT’s employment downturns average 24 months while US cycles only average 13.8 months. However the good news for CT is health care. CT created 6,233 new health care jobs in the first quarter of 2008, compared to last year. Most of the gains were at hospitals, nursing and residential care facilities and in ambulatory care. Just behind health care in job creation, government added 4,367 jobs. Job losses were worst in the manufacturing sector. Predictions are that overall CT job losses will continue into next year, but that health care will create 7,970 new jobs between the fourth quarters of 2007 to 2009.
Ellen Andrews

Governor vetoes pooling bill

Today Governor Rell vetoed HB-5536, An Act Establishing the Connecticut Healthcare Partnership. While she applauded the intent of the bill, to reduce health care costs for municipalities, nonprofits and small businesses by pooling them with state employees, she is concerned about potential costs to the state. She also cited legal problems with the bill, doubts about estimated savings for municipalities, and concerns that the bill does not address the problem of Connecticut’s uninsured. She called on legislators to work with her office to refine the concept next year.
Ellen Andrews