June web quiz

Test your knowledge of substance use in CT. Take the June CT Health Policy Web Quiz.

HealthFirst Authority update

Today the Authority tried to narrow down the options they will consider for study through the rest of the process. The Chairs began with their list of issues that everybody agrees on. It is long:
Strong prevention and health promotion component
Medical home
Electronic medical record and health information technology
Enrolling everyone who is eligible for public programs
Management of chronic illness
Incentives for healthy lifestyles and wellness
Transparency – most emphasis on data for state policymakers to make decisions (if they will) but expanded to include information for consumers in response to a question
Evidence based practices
Improving Medicaid reimbursements – recent increases were not enough
Patient safety
Employer and individual contributions
Addressing workforce shortages
Members also suggested adding Medicare cuts, universality, military health care cuts, consumer education, sustainability, adaptability, increasing federal reimbursements, and access to specialty care.
They then moved onto components that may not be unanimous. They noted that the legislation requires the Authority to consider single payer universal health care and universal primary care options. They also agreed to model the CT Health Insurance Policy Council’s proposal. Other ideas included:
· Maintaining employer and Medicare coverage
· Expanding Medicaid
· Moving SAGA into Medicaid
· Insurance pooling – including what subsidies would be needed
· Shared responsibility (employers, government and individuals) as in Healthy San Francisco, this model includes undocumented immigrants
· Incentives for quality and wellness and support for Medical Home Services
After the list was read, there was silence as most in room waited for the debate to begin. We weren’t disappointed. Perspectives and concerns were predictable. Insurers want a cost benefit study of insurance mandates and lauded Florida’s new barebones policies. There was a great deal of support for studying how a Healthy San Francisco-style model would work in CT. A suggestion to pilot it in an urban area led to concerns about two tiered care. There was no real consensus on which options to move forward. Important decisions were put off until the next meeting. At the next meeting, the members will also each get a copy of the latest Health Affairs – we’ll see if it helps. They will also discuss financing vehicles and an individual mandate – I can’t wait.
Ellen Andrews

New Kaiser Blog Watch

Every Tuesday and Friday, the Kaiser Daily Health Policy Report will feature “Blog Watch”. Recognizing that blogs have become an integral part of health policy coverage, kaisernetwork.org will now summarize the best of the blogosphere. To sign up for Kaiser’s Daily Updates, click here.

Pooling bill update

First, the good news. The Attorney General has issued an opinion on HB-5536, House Majority Leader Donovan’s bill to allow municipalities, small businesses and nonprofits to buy into the state employee plan. His formal legal opinion is that the bill will not increase costs to the state, a concern that reportedly has the Governor considering vetoing the bill. The bad news is that the reason it won’t raise costs is because municipalities, small businesses and nonprofits can’t join the state employee pool, but must form completely separate pool. The separate pool must include the same rich benefit package as the state employee plan, which as the Courant points out, could price many municipalities, small businesses and nonprofits out of the new pool or discourage any insurers from offering the new plan. It is also unclear how this separate pool is different from the Comptroller’s MEHIP program which has been providing coverage to small businesses and nonprofits since 1996. The Comptroller’s office operates the state employee plan covering 200,000 state employees, retirees and dependents using that buying power to leverage lower rates for MEHIP members.
Ellen Andrews

Summer reading

To get ready for this weekend and the unofficial start of summer with its long days of reading, we have added to our Book Club. In between your Beach Reads, try these.

Made to Stick: Why Some Ideas Survive and Others Die – interesting, engaging stories that help all of us make sure that what we are trying to say gets heard
Sick: The Untold Stories of America’s Health Care Crisis – and the People Who Pay the Price – an inspiring book that combines policy wonkery with the stories that make it matter
Redefining Health Care: Creating Value-Based Competition on Results – I expected to hate this book. I disagree most of the time with everyone who recommended it to me, but it changed the way I look at the health care system. The business lobby and consumer advocates have a lot more in common that we know.
Listening is an Act of Love: A Celebration of American Life from the StoryCorps Project – An amazing project collecting history that would otherwise be lost and an exceptional demonstration of the power of storytelling
Maxed Out – a documentary that explains the tragedy of consumer credit and bankruptcy – especially when you consider that half of bankruptcies are due to medical bills
Better – a collection of essays that describe what medicine can become if we are smarter
The Secret History of the War on Cancer – outlines in meticulous detail how the powers-that-be have focused massive attention on treating cancer, but very little on addressing the causes, even covering up conflicts of interest and preventing important protections of our health

These are the newest Book Club recommendations. Check out the whole list.
Have a great weekend.

Pooling Bill rhetoric heats up

Rep. Chris Donovan’s proposal to allow municipalities and small businesses to buy into the state employee plan passed the House and Senate easily. But proponents are concerned that the Governor will not sign the bill. The concept is that bringing thousands of municipal, small business and non-profit employees together with into the same health purchasing pool as the 200,000 state employees, retirees and dependents will achieve significant savings. Cities and towns could use that money to fill budget holes and reduce property taxes. Rep. Donovan has been visiting with city officials across the state to generate interest in the plan.

However, this year the state was very fortunate to negotiate no increase in rates with the three participating health plans that cover state employees when premiums are rising 6 % nationally. That $54 million in state budget savings would be threatened if this bill is signed into law, according to the insurers. Anthem says adding municipalities and small businesses would add “adversity in mix and utilization” and new administrative costs. Anthem will have to recalculate rates and expect an increase of $24 million under the proposal for the state employees they cover. OPM Secretary Genuario says that there is no time to re-bid the contracts as the old ones end June 30th and that with a projected $53 million deficit this year the state cannot afford to lose any savings. Upon researching the proposal, New Haven city officials didn’t find the promised $8.6 million savings, but rather that they would pay slightly more to cover city workers in the state employee pool than they are paying now.
Proponents have been holding several press conferences, featuring small businesses that would save money under the plan, calling on the Governor to sign the bill. The proponents argue that enlarging the state employee pool should reduce prices. Comptroller Nancy Wyman has called in top officials of the three state employee insurers, Anthem, HealthNet and United Health Care, to explain their claim that rates will increase. Today’s lead Hartford Courant editorial urges the Governor to veto the bill, noting that in addition to New Haven, Danbury also found that joining the state employee pool would cost the city $5 million rather than the promised $2.8 million savings. The legislature’s calculation did not include retirees, according to the city. When Massachusetts opened their state employee pool to municipalities few took advantage, finding it more costly. The Courant recommends that the state hire independent actuaries to determine the costs to the state and to cities and towns. The bill has not yet reached the Governor’s desk.
Ellen Andrews

Archive of web quizzes

Many people have asked if our web quizzes from previous months are available on the website. They are now, click here for quizzes back to 2001.

CT free clinics meeting

About two weeks ago, a group of clinics that offer free care to anyone who needs it met to discuss common challenges and share resources. I was amazed and deeply grateful that we have so many generous spirits in our state. Representatives from First Hispanic Baptist Church (New London), Samaritan Health Center (Danbury), Kevin’s Community Center (Newtown), the Community Health Van (New Haven), UCONN Health Center/Bergdorf Community Health Center (Hartford/CT River Valley), and AmeriCares Free Clinics (Norwalk, Danbury, Bridgeport) attended. Haven Free Clinic (New Haven), Hanahoe Children’s Clinic (Danbury), Malta House of Caring (Hartford), Christian Medical Fellowship Health (Farmington), and the New London Community Meal Center (New London) couldn’t make it to this meeting. The CT Health Policy Project talked about CT’s uninsured and the market forces that created the problem. Mark Thompson from the Fairfield Medical Society shared that they were successful in gaining passage of a bill reducing licensing fees for physicians who volunteer at least 100 hours/year providing free care. They discussed ways to work together including developing standards of care, quality improvement, getting medications, malpractice liability coverage, and possible advocacy at the Capitol next year. They learned from each other’s experiences, shared tips and ideas, and found alot of common ground. I can’t wait for the next meeting.
Ellen Andrews

HUSKY/PCCM/Charter Oak update

At Friday’s Medicaid Managed Care Council meeting, DSS described plans to transition 337,181 HUSKY members from the current non-capitated, fee-for-service structure back into potentially three capitated HMOs starting July 1st, to begin Charter Oak enrollment also on July 1st, the planned dental carve out also set to begin July 1st, and their plan to provide HUSKY members with the new PCCM option beginning October 1st.

In the fall, HUSKY families will be able to choose Primary Care Case Management (PCCM) rather than one of the new HMOs. In PCCM, members will choose a primary care provider (PCP) to serve as their medical home. Their PCP will be responsible for providing all their primary care needs, as well as coordinating their care – making arrangements for needed specialty care, collecting results from tests and other visits, providing follow up care and encouraging healthy behaviors. PCPs will receive a monthly fee per member for care coordination in addition to fee-for-service reimbursement for medical services. A working group of advocates, including this one, and DSS staff has been meeting regularly. A concept paper describing the plan’s details is awaiting the Commissioner’s approval. The RFQ and provider agreement are almost complete and DSS expects to release the RFQ next month. A provider advisory group will be convened in August.

The transition for HUSKY families from the current managed care organizations – CHN and Anthem – and fee-for-service to the three new managed care organizations, assuming they are all approved by DSS – CHN, Aetna Better Health and AmeriChoice (United Health Group) – will be gradual from July thru December. Counties will transition as the new plans build enough provider panel capacity to meet the needs of HUSKY members in that region. Members who do not choose among the new plans will be defaulted, based on network capacity. The dept. will provide both separate Charter Oak applications and one combined with HUSKY. ACS, the current enrollment broker, will collect premiums and monitor out-of-pocket costs for Charter Oak members. DSS is now choosing a company to run the dental carve out among the four applicants – Benecare, HealthPlex, Doral and Liberty. There is also $4.5 million for safety net grants to expand dental capacity and DSS is working to recruit providers to the new program.
Ellen Andrews

HUSKY dental lawsuit is settled

Finally, some good news about HUSKY. After eight years, the state and legal aid attorneys have reached a settlement to improve access to dental care in the program. Finding a dentist has been nearly impossible in the program for many years; only 4% of CT dentists participate in HUSKY. The problem pre-dates managed care. Dentists blame low reimbursement rates. The settlement will significantly raise rates to dentists using $20 million passed in last year’s budget. Also, as of July 1st dental care will be carved out of the rest of HUSKY to be run by a non-capitated administrator hired by the state rather than through the HUSKY managed care organizations; dentists will bill the state directly for the care they provide. The HUSKY HMOs were capitated – they got paid whether or not children got any care. The HUSKY HMOs compounded the burden on dentists and have been a significant barrier to expanding access to dental care. The credit goes to Jamey Bell, the lead attorney at Greater Hartford Legal Assistance – her determination, legal expertise and people skills are considerable. Jamey has a way of getting people to do the right thing while thinking it was their idea. We are very lucky to have her and all her legal aid colleagues on our side.
Ellen Andrews

Health First/Primary Care Authority updates

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

HUSKY, Charter Oak and other session updates

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

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

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

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

Book Club: Better

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

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

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

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

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

Charter Oak update

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

DPH launches on-line health personal health assessment tool

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

Health First Authority Update

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

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

May Web Quiz

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