A Haven in the City

An article in the Yale Journal of Public Health describes HAVEN, a Saturday morning free primary care clinic providing care to residents of the Fairhaven neighborhood in New Haven. HAVEN was conceived by and is staffed by students from Yale’s medical, public health, physician assistant and nursing schools and is held at the Fair Haven Community Health Center. The clinic provides an array of primary care services, including prescriptions, patient education, medical intepretation and social services, to uninsured adult Fairhaven residents free of charge. Patients get help accessing any care or services that can’t be provided on-site, as well as application assistance for public programs and hospital free care. HAVEN started in 2004 as a response to the growing need for services for uninsured community residents. As of May 2007, the average medical debt of HAVEN patients was $10,498, while the average annual income was $10, 274. The clinic is supported through donations and grants; no government funds are used.
Ellen Andrews

CT family premiums grew by 21% from 2001 to 2005; median income grew by 2.4%

A new report explains why CT families are feeling like they are moving backward. “Squeezed: How Costs for Insuring Families are Outpacing Income” by the Robert Wood Johnson Foundation found while the percent of premium that CT families pay dropped slightly from 2001 to 2005, total average family premium payments increased 6.4%. In more bad news, the number of CT employees that work at firms offering health insurance dropped by 91,512, CT residents with private coverage dropped by 5.4% and uninsured residents rose by 2.9%. The study only looked at premiums and did not consider rising copayments, deductibles, co-insurance and the erosion in covered benefits – so the real burden of health costs on CT families is likely much worse.
Ellen Andrews

Highlights from CT Health Notes

Thursday’s issue of CT Health Notes, our biweekly list serv, includes
Aging baby boomers intensify looming health care workforce shortage -- a new report from the Institute of Medicine finds that the growing number of older patients with more complex health care needs will overwhelm an already stressed health care workforce.
Health care becoming “employer of last resort” -- Tuesday the Wall Street Journal reported on the increase in health care jobs, especially where manufacturing jobs are disappearing. The interactive map is fascinating – see the increases in health care employment in CT, particularly in New Haven, and the decreases in manufacturing.
Something is not always better than nothing in health insurance -- A recent report in Health Affairs compares the assets of uninsured households with cost sharing requirements under high deductible health plans. Among families with at least one uninsured member, only about 15% had net assets sufficient to cover single-person cost-sharing levels for an HSA.
Survey finds 76% of CT cardiologists cite a great need for health care reform -- A survey of CT Chapter of the American College of Cardiology members published in this month’s CT Medicine, found that while a large majority believe health care reform is needed, only 9% are familiar with the presidential candidates’ proposals.

For more on CT Health Notes, including how to search the archives, click here. To subscribe, click here.

Donaghue Foundation Annual Meeting & Conference

Wednesday, I went to the Donaghue Foundation Annual Meeting and Conference. The Donaghue Foundation was established to “promote medical knowledge which will be of practical benefit to the preservation, maintenance and improvement of human life.” Three very different projects were highlighted.

The first panelist, Harlan Krumholz, MD (Yale School of Medicine) presented on a project he undertook to reduce the time to intervention for patients presenting with a particular kind of heart attack. The good news is that this goal can be reached with a relatively modest financial investment from hospitals. The bad news: it requires a cultural shift in most healthcare organizations, empowering various team members – EMS staff, ER docs, cath lab staff – to make decisions they are trained to make, rather than waiting on a primary care physician to come in and make the call.

The second presentation was by Elizabeth Pivonka, PhD, RD, from the Produce for Better Health Foundation. They are the “5 a day” people. She talked about the investment that the Produce for Better Health Foundation made in social marketing that would reach its target audience of Gen X moms. Because of the research, focus groups, and surveys they’ve undertaken, “5 a day” is becoming “fruits & veggies: more matters.” The foundation has strong relationships with both public & private partners. Whereas the “5 a day” campaign really looked to healthcare workers to disseminate the message, the “fruits & veggies: more matters” campaign is looking to moms themselves to spread the word to each other.

Finally, Veronica Nieva, PhD, discussed a new toolbox that the Agency for Healthcare Research & Quality (AHRQ) is pulling together, called AHRQ Health Care Innovations Exchange. This website is designed for health care professionals of all stripes to share with each other innovations that improve quality and care of patients.

The three projects on which the conference focused present a well-rounded picture of necessary action to improve our healthcare systems:
1. We need to improve the efficiency and efficacy of our systems of care.
2. We need to address the broader environmental factors that impact our health status.
3. We need to make sure that practitioners, policy makers, and other stakeholders are communicating best practices and thinking collaboratively & strategically about how to implement those practices in different settings.

I would have liked to hear more about the policy implications arising out of each of these projects. In each case, I believe that policy action bolsters significantly the impact of the work described. I guess that part’s what we do here!
Connie Razza

New report details questions and answers on implementing medical interpretation for CT Medicaid consumers

A new report, Medicaid Payments for Medical Interpreters: Implementation Questions and Recommended Action, commissioned by the CT Health Foundation lays out details the state needs to consider in implementing legislation passed last year providing medical interpretation services to Medicaid consumers. Questions addressed include how much should DSS pay and to whom, in what situations will the services be available, and will payment be an administrative expense or a covered service. The report explores the experiences of 12 states and the District of Columbia and makes recommendations to ensure that every CT Medicaid recipient receives high-quality health care.

Life expectancy drops for women in 183 US counties

From 1983 to 1999 life expectancy in many US counties decreased, especially for women (183 counties) while life expectancy for all Americans grew by 7 years for men and 6 years for women from 1960 to 2000. The last time US life expectancy experienced any decline was in the 1918 Spanish flu epidemic. The authors of a study published today in the peer-reviewed, open access journal PLoS, blame a slowdown in preventing deaths from heart disease together with a modest rise in diabetes, lung cancer and other lung diseases. The researchers found disparities in life expectancy between US counties growing since 1983 after declining for decades. Four percent of American men and 19% of US women experienced either a decline or stagnation of life expectancy between 1983 and 2000. The 183 counties with declining life expectancy for women had lower average incomes, fewer residents who complete high school and a higher proportion of black residents than counties with increasing life expectancy. Counties with declines were clustered in the Deep South, Appalachia, the lower Midwest and one county in Maine.
Ellen Andrews

Retail medical clinic issue brief

Connecticut now has at least fifteen retail medical clinics, mainly Minute Clinics in CVS stores, but more are coming. Go to our Policymaker Issue Brief No. 44 for more on what these clinics are, their potential as an affordable source of care, concerns about safety and impact on the rest of the health care system, and what other states are doing to regulate these clinics.

CA to review thousands of insurance policy cancellations after consumers get sick, New CT law prohibits this practice

The LA Times reports that the CA Dept. of Managed Health Care will be reviewing thousands of cancelled individual policies looking for cases where coverage was cancelled after patients have become ill, despite paying premiums for years. The insurers cancel policies citing errors by consumers on insurance applications, often completed years earlier and often honest mistakes answering confusing questions. Policies found to be wrongly terminated will be reinstated and insurers will be responsible for patients’ medical bills. In February, a CA court awarded $9 million to a woman whose coverage was terminated during chemotherapy for breast cancer.

Thanks to the Office of Health Care Advocate, that practice is no longer legal in CT. PA 07-113, effective Oct. 1, 2007, prohibits health insurers from rescinding, limiting or cancelling policies without the Insurance Commissioner's prior approval, and must be based on a knowing misrepresentation or omission of health facts by the consumer in their application. An insurer's failure to thoroughly review the application and medical records is not a basis for rescinding, limiting or cancelling the policy. Beyond that, the law prohibits insurers from rescinding, limiting or cancelling any policies after two years. For more on the law, click here.
Ellen Andrews

Desperate Measures

Yesterday, I was catching up with a friend of mine who lives in Memphis when she told me about the beginning of her week:

On Sunday, my friend, Meredith, went to introduce her newborn daughter to some friends who run a gym. She ran in for five minutes and, by the time she returned to her car, someone had smashed in her window and stolen her purse. The next day, Meredith got a call from a postal worker who told her that her wallet had been placed in one of their mailboxes. Meredith went down to the post office, picked up her wallet, and found that all her cards were still in the wallet – her credit cards, her ATM card, her driver’s license, and even two $50 gift cards to Target and Walgreens. (She hadn’t had any cash.)

The only things missing were her insurance cards – her medical, dental, and prescription drug insurance cards were all gone.

At this point in the telling, Meredith laughed and said, “And, when I think about it, those really are the most valuable things in my wallet.”

The unsustainable imbalances of our healthcare system are laid bare by this series of events: a person was desperate enough for access to healthcare to break into Meredith’s car (without knowing if they would find insurance cards or not) and forego the currency in her wallet.
Connie Razza

Yale School of Nursing Bellos Lecture -- A fresh view of racial and ethnic disparities

This year’s Sybil Bellos Lecture at the Yale School of Nursing, given today by Harvard’s David Williams, PhD, MPH, focused on racial and ethnic disparities as a social construct. His talk titled “Social Sources of Disparities: Patterns, Causes and Interventions” compiled a wealth of research from disparate sources providing a different interpretation of the issue. First, he noted that most Americans are not even aware that health disparities exist – this is our most important barrier to resolving the problem. While the US has enjoyed significant improvements in mortality over the last century, the gaps between blacks and whites has not improved. He outlined the evidence that race is not a genetic or biological construct -- that variation in health parameters within races far outweighs variation between races. But racial and ethnic disparities exist and race is a clear and compelling social category. He noted that recent immigrants are in better health than their native-born counterparts across races. He demonstrated that socio economic status is the strongest predictor of health status, stronger than race, smoking and other commonly appreciated variables. Income, and more importantly wealth, explains a large part of racial and ethnic disparities, but not all of it. He made a startling statement that the US is just slightly less segregated than South Africa under apartheid and that segregation is the most important driver of health disparities. The bottom line of his talk was the idea that the solutions for health disparities may not at first seem to have anything to do with health – poverty, education, environment, housing and other issues having more to do with social context than access to health care. It echoes what I hear from other states much farther along in reforming health care systems than CT – it’s not all about coverage.
For more reading, go to RWJ’s Commission to Build a Healthier America.
Ellen Andrews

“Sick Around the World” airs tonight

Tonight’s episode of Frontline, Sick Around the World, compares the universal health care systems of five capitalist countries – Germany, Japan, Taiwan, Switzerland and the UK – looking for ideas that could work in the US. Japanese consumers go to the doctor 3 times as often as we do, get more than twice as many MRIs, use more drugs and spend more time in the hospital, and still spend half what Americans do per capita for health care. Many countries include private insurance with public oversight in their programs. Frontline airs on PBS stations at 9 pm tonight.

Community Catalyst at the HealthFirst Authority

Friday, Michael Miller of Massachusetts-based Community Catalyst presented to the Cost, Cost Containment & Finance Working Group of the HealthFirst Authority. His presentation focused on “cost containment strategies in other states.”

He opened with, “Cost containment is not a useful framework.” He went on to say that if we were spending more than other countries and were getting better care, that would be a good trade off, right. But, though it is true that we are paying more, we are actually getting worse care, by many measures. The frame, then, should be, “Are we getting our money’s worth?” or “How do we get our money’s worth?”

Miller described the current state of the US healthcare system: health purchasing in the US is less coordinated than in the rest of the industrial world; we devote more of our healthcare dollars to high-tech and specialized care; our healthcare resources are distributed unequally; and our administrative costs are very high.

He offered numerous possible solutions, with the caveat that they must be done well.
Pay for Performance, should be Pay for Improvement
Regulation of healthcare at the level of insurers, capital expenditure and (less so) providers
Improving care coordination for the chronically ill
Increasing administrative efficiency
Addressing the primary care crisis
Enacting medical technology review at the federal level (or through interstate cooperation)
Value-Based Benefit Design
Smarter prescription drug purchasing
Public health initiatives to reduce the occurrence of certain conditions

In the coming year, Community Catalyst will be studying each of these areas to see what it takes to make these suggestions successful – in terms of both policy and politics. I, for one, am looking forward to their reports.
Connie Razza

Three Charter Oak/HUSKY bids are in, Congressional investigation of United

Today DSS released the names of the managed care organizations (MCOs) that submitted bids for the HUSKY and Charter Oak plans to begin July 1st. They are Community Health Network, which currently participates in HUSKY, and two new MCOs – Aetna Better Health, a subsidiary of Schaller Anderson and Aetna, and AmeriChoice, a subsidiary of United Health Group. The death in February 2007 of 12-year-old Deamonte Driver, a United Health Plan Medicaid member in Maryland who died of a brain infection caused by untreated tooth decay, prompted a hearing and investigation by the Congressional Domestic Policy Subcommittee of the Oversight and Government Reform Committee. The Subcommittee found that Deamonte was not alone; 10,780 children enrolled with United in Maryland’s Medicaid program had not seen a dentist in four or more consecutive years. The Subcommittee’s investigation also “raises serious questions about the quality of United’s network of providers and the reliability of the lists the company publishes for use by its enrollees.”
Ellen Andrews

Health care figures prominently in US middle class worries

The Pew Research Center’s annual survey of America’s middle class finds that one in five says that it’s likely their health benefits will be reduced or eliminated in the next year. 12% expect a cut in wages. One in four say that they have not moved forward in the last four years and 31% say they have moved backward -- the worst assessment in almost fifty years of polling. Over half (53%) of Americans identify themselves as middle class. The survey was conducted in January and February of this year. Interestingly, 71% agree with the statement that government should guarantee health care to every citizen. Not surprisingly, that number was higher (79%) among poorer Americans and lower but still 66% of upper class Americans. So why don’t we have health care for everyone yet?
Ellen Andrews

The high cost of prescription drugs

In the last month, we’ve fielded a number of calls to the Consumer Helpline (1.888.873.4585) about the high cost of prescriptions. A quick Google search demonstrates why. Prescription drug prices are out of control.

An April 3rd USA Today article reported that the Patient Advocate Foundation found that over 30% of people they serve “cited drug co-payments as their top medical-debt problem.”

On March 5, AARP released a report on the rising cost of prescription drugs. The study found that the manufacturers’ price of brand-name drugs has increased at more than 2 ½ times the inflation rate between 2002 and 2007. Ninety-eight percent (98%) of the drugs studied had manufacturer price increases and 99% of those increases exceeded the inflation rate. AARP concludes that these price increases “result in higher out-of-pocket costs for those [Medicare Part D] beneficiaries who pay a percent of drug costs rather than a fixed co-payment.” Of course, they also result in higher out-of-pocket costs to consumers with no insurance or with any insurance that requires them to pay a percent of drug costs.

According to a March 5th Los Angeles Times article, “US drug prices are as much as 50% higher than in Canada, Western Europe and Japan, where limits are placed on how much drug companies can charge patients.”

The Patient Advocate Foundation has a Co-Pay Relief Program to provide “direct financial support to insured patients, including Medicare Part D beneficiaries, who must financially and medically qualify to access pharmaceutical co-payment assistance.”

But we need a systemic solution, and one that addresses the price, not simply the cost to individuals. I’d hate to see drug companies gouge other public health insurance programs like they have Medicare Part D.
Connie Razza

CT Health Notes highlights

Some highlights from the latest CT Health Notes -- the CT Health Policy Project’s e-newsletter:

• UConn hospital study recommends partnering with area competitors, Hospital needs another $22 million this year
• AHRQ annual quality and health disparity reports find mixed results
• Consumer directed health plans continue to attract healthier, wealthier members

Click here for more on CT Health Notes
Click here to subscribe

Legislative Health Care Study Group

For the last few months, a small group of Connecticut legislators and other officials has been meeting to explore health care issues in some depth. Legislators choose the issues and ask questions; CT Health Policy Project staff research the topics and find answers. To access the discussion guides for the last two meetings, go to the Study Group webpage.

Comptroller announces cost-saving health program for municipalities

Today Comptroller Nancy Wyman is announcing a new venture from her office that could save CT cities and towns tens of millions of dollars on health insurance costs. The Comptroller was joined in the announcement by Bart Russell, head of the CT Council of Small Towns, Sal Luciano, from AFSCME Council 4, and John Yrchik, of the CT Education Association. The self-funded Enhanced Municipal Employees Health Insurance Plan leverages the state’s buying power and pools municipal workers across the state to reduce costs. As an example, a town with 1,000 employees could save as much as $720,000 each year. The program will cost the state nothing – all costs will be paid through premiums. Coverage is scheduled to begin July 1st. The Comptroller’s Office purchases health coverage for over 200,000 state employees, retirees and dependents.
Ellen Andrews