April CT Health Policy Web Quiz

Test your knowledge of trends in CT’s uninsured, take the April CT Health Policy Web Quiz. This month’s quiz was written by Karen Nepomuceno, Policy Intern at the CT Health Policy Project.

HUSKY waiver hearing tomorrow; DSS proposal kills PCCM

The Human Services and Appropriations Committees are holding a public hearing tomorrow, March 31st, at 1pm in the LOB Room 2C on DSS’ proposed HUSKY waiver. Sign up begins at 11am in Room 2700; bring 50 copies of testimony. The waiver draft codifies DSS’ reversed course from the legislatively approved PCCM plan and limits the program so severely that it will never be viable. PCCM is a way of running HUSKY without HMOs, and consequently would be strong competition to those HMOs – forcing them to compete on quality and cost. A viable PCCM option would use market forces to improve HUSKY.

We noticed that DSS’ website now has PCCM at the top of the News column. We are grateful that DSS is now beginning to market PCCM, but unfortunately it took this hearing to make it happen. The link takes you to the comprehensive plan developed by a workgroup of advocates, providers and agency staff. DSS submitted that plan to the legislature and it was approved in September without revision. That plan calls for a statewide, open, viable and feasible program that attracted over 350 providers across the state to apply this summer. However, the site also includes DSS’ letter that takes it all back and hobbles the program. Only the 25 providers in Waterbury and Willimantic who applied were approved by DSS, and then only some of their current patients were invited to join. Despite the headline on the site "Primary Care Case Managment: Physicians invited", there is no application. Any provider interested in applying has no where to go – that’s because they aren’t taking applications, even in Waterbury and Willimantic.

The CT Health Policy Project is urging the legislature to return the HUSKY waiver draft to DSS for modifications to create a statewide, viable PCCM option for families, providers and state policymakers.
Ellen Andrews

SustiNet plan approved by Public Health Committee

HB- 6600, An Act Concerning the SustiNet Plan, passed out of the Public Health Committee yesterday on a party line vote. SustiNet is the only comprehensive health care reform plan currently being considered in Connecticut. Concerns raised at the Committee meeting included the costs of the plan, merging state employees with Medicaid, and increasing Medicaid provider rates. The version of the bill that passed was modified after the public hearing to remove the limited medical malpractice relief for providers when they adhere to evidence based medicine, and changed in order that provisions with high costs will only be implemented when funds become available. Sen. Debicella, the most vocal critic of SustiNet, acknowledged at several points that the bill includes a large number of admirable provisions that he supports.
Ellen Andrews

PCCM waiver hearing March 31st

Next Tuesday the Human Services and Appropriations Committees will hold a public hearing on DSS’ proposed waiver application to continue to run the HUSKY program. Click here for our comments. The notable part of DSS’ application is the decision to limit Primary Care Case Management (PCCM) to Waterbury and Willimantic and to only a select group of families and providers within those communities. PCCM is a way of running HUSKY without HMOs. In PCCM, consumers choose a primary care provider (PCP) who is responsible for providing their regular primary health care as well as coordinating any other care they need, for which they receive payment for services at feel-for-service rates and the massive sum of $7.50 per member per month to coordinate care. PCCM is working in 30 other states, improving health outcomes, keeping patients out of emergency rooms, attracting more providers to Medicaid, and saving states money. Often states have both PCCM and HMOs serving families in the same communities, offering options, providing competition that improves both programs, and keeping costs down. Last year, DSS granted our HUSKY HMOs a 24% rate increase. Not surprisingly, the HMOs have lobbied hard against PCCM.

DSS’ waiver application contradicts the PCCM plan submitted by DSS and approved by the two legislative committees in September without revision. That plan committed to providing PCCM statewide from the beginning anywhere providers showed interest in participating. The application also contradicts the department’s stated “intention” to expand PCCM to the entire state eventually. The legislator-approved plan was the product of a working group of advocates, providers and DSS staff that labored to develop the many details of the program. Advocates and provider representatives spent the summer crossing the state to recruit providers for PCCM. Hundreds of providers from across the state applied, despite a very tight time frame. However in January DSS made a sudden, unilateral decision to accept only 25 from Waterbury and Willimantic. Others have expressed interest since and have been denied, even from within Waterbury and Willimantic. Subsequently DSS crippled the program further by limiting enrollment to only a sample of current patients of those 25 providers. Not surprisingly, enrollment is miniscule – far too small to be economically sustainable. Can we expect that in a short time, DSS will announce that they tried PCCM, it didn’t work, and shut the program down forever? Maybe the HMOs didn’t have to try so hard to kill the PCCM bill two years ago.

On the bright side, the waiver application does acknowledge that PCCM will not cost any more than the HMOs. The CT Health Policy Project estimates that the state could reap significant savings with a legitimate PCCM program. At the very least, the HMOs would have trouble justifying 24% increases in a competitive environment. So why not give it a real shot?

The public hearing will be next Tuesday, March 31st at 1pm in Room 2C of the Legislative Office Building. A committee meeting to decide whether to accept or reject DSS’ waiver application will follow.
Ellen Andrews

Inside the LOB -- Everyone wants what they want

This legislative session I have been to several Public Health Committee hearings and the Appropriations Committee hearing at which I testified. I noticed many interest groups and most of them are asking for money. They either want an increase in funding or they don’t want their funding to be cut. The issues being brought to the committees are important ones, including funding for: mental health programs, autism services, domestic violence centers, LifeStar, a diaper bank, after school programs, home care for the elderly, medical interpretation and many more. I don’t envy legislators in this session, having to balance the budget while trying to ensure that the needs of CT residents are met.

I’m not the only one who’s noticed that the interest groups are asking for funding. It was the topic of discussion at the lunch table with some legislative clerks. One person asked, “Why are all of these groups asking for money when they know we don’t have any?” My answer was that maybe each group believes legislators will make an exception for them.

Our Health Advocacy Toolbox has some relevant advice under Tips No Advocate Should Forget:
· Understand that everyone [meaning advocates] wants what they want.
· While your issue is your top priority, you need to understand that policymakers have to balance everyone's priorities.
Jen Ramirez

Doing nothing is not an option

Go to Saturday’s OP-ED in CT News Junkie to see why the President is right and we can’t settle for a lot of little somethings anymore.
Ellen Andrews

Match Day 2009 not good news for primary care

Yesterday was Match Day – the day graduating medical students are matched with residency slots. According to the WSJ blog, only 42% of family practice slots went to students graduating from US medical schools this year. The rest went to foreign school grads, osteopathic medicine graduates, and graduates from prior years. Nine percent of those family practice residency slots were not filled. And the number of residency slots offered in family practice has dropped by 226 in the last four years. Family practice docs average $180,000 per year and work difficult schedules. In contrast, 99% of anesthesia residency slots were filled, 84% by 2009 graduates of US medical schools. Anesthesiologists average $400,000/year and work predictable hours. Medical genetics filled only one out of three residency slots.
Ellen Andrews

Courant article highlights medical causes of bankruptcy and foreclosure, if you read into the article

The headline of an article in Sunday’s Courant reads “In CT and elsewhere, more debtors choose personal bankruptcy,” but they missed an important point. The slant of the article is the growing number of bankruptcies resulting from foreclosures. The article describes Maryann Hagberg, a Waterbury woman, and her husband forced into bankruptcy to remain in their home. Maryann is a nutritionist at Griffin Hospital who put herself through college by waiting tables. She describes the bankruptcy as a “matter of survival”. But reading further into the story, it becomes clear that the precipitating financial crisis for Maryann’s family was her husband’s illness. Last summer he became so ill he had to give up his job cutting their income in half. The couple started to rely on credit cards to pay bills and the slide accelerated from there into a risk of foreclosure. But you have to read to the eighth paragraph to find out that medical costs were behind the crisis. A 2005 study found that half of bankruptcies involved medical debt. The Courant buried the lead.
Ellen Andrews

Great advocacy tool

CT’s League of Women Voters’ 2009-2010 elected officials guide is on-line. It includes how to find your legislators – state and federal – and executive branch elected officials. It includes contact information and guidance to address letters, including titles. (I always have to look that up). Other useful information includes dates of the sessions, legislative leaders, committee chairs, committee contact information, directions to the Capitol, other resources and links. It also includes how to get a tour of the Capitol – highly recommended.
Ellen Andrews

Medicaid Managed Care Council meeting; Dumb idea redux

DSS may take advantage of a legislative error and try to implemented premium assistance for HUSKY, according to the department at Friday’s Medicaid Managed Care Council meeting. Two years ago, the agency’s proposal for premium assistance was rejected by legislators in budget negotiations, as it had been for four years in a row. However due to an error, one section of the bill was not deleted and the option passed into law. Thankfully, leadership at the department realized that implementation of premium assistance would be a nightmare for clients and for DSS. But apparently, the department is again considering this imprudent program.

Premium assistance would require HUSKY families with an employer offer of coverage to sign up and drop HUSKY. The idea is to leverage the money employers are spending on benefits to reduce the state’s burden. It sounds fine if that’s as far as you look, but other states have found it to be very difficult to administer and difficult for consumers to navigate. And those are states with efficient and well-performing Medicaid managed care programs, unlike CT which has had trouble running plain old vanilla HUSKY.

To enroll a family in premium assistance, the state would have to certify in every case that the employer’s coverage is a better value than HUSKY – very unlikely as Medicaid rates are lower than most commercial insurance. And as commercial insurance costs have increased far faster than HUSKY, even cases where it is cost effective for the state this year may not be next year. Families would be left searching for new doctors that take the HUSKY HMOs, which is hopeless. HUSKY families unlucky enough to be forced into premium assistance would have to pay out of pocket for deductibles, premiums, copays and for any services or drugs that their employer’s package doesn’t cover but HUSKY does. They would then apply to DSS for reimbursement. This places an enormous hardship on low-income families to up-front potentially thousands of dollars and wait for government to reimburse them. And given how poorly DSS has administered HUSKY so far, consumers could be forgiven for having some reservations about this arrangement.

This only touches on the problems with premium assistance. The few states that have implemented the program are drawing back. Many realized that the extra administrative costs overwhelmed any small savings. Many are finding it more and more difficult to find qualifying employer coverage cases. Overall, premium assistance would require massive resources at DSS when they should be devoting all their time to fixing the program they have.

If they have time on their hands over at DSS, maybe they could step up their ambivalent attempt at implementing PCCM, a program that most other states have easily implemented, saving money, engaging new providers, and improving health outcomes for their states’ Medicaid families.
Ellen Andrews

New on cthealthpolicy.org

Updated policy paper: The Federal Stimulus Package and Passage of the SCHIP Reauthorization Bill: How Much Health Care Help Can CT Expect?
Significant funding is coming to CT due to federal generosity including $1.3 billion in added Medicaid funds, $3.7 million for community health centers, and matching funds to cover legal immigrants under Medicaid/HUSKY. The bill also provides important COBRA relief for recently laid off workers and big incentives to providers for electronic medical records. Read the paper and study up for the March web quiz (below).

March CT health policy webquiz
Test your knowledge of the federal stimulus package and SCHP reauthorization bill and the impact on CT. Take the March CT health policy quiz.

New Book Club item
Rock, Paper, Scissors: Game Theory in Everyday Life By Len Fischer, 2008
Game theory has a lot to teach us about working out seemingly impossible roadblocks to negotiating solutions. Policymakers and advocates who are often “stuck” in the weeds of health care systems and reform will find the author ten concrete tools very helpful. The author is a wonk who can write; good enough reason alone to give this book a try.

Lousy student health insurance coverage

While I was a student at the University of Connecticut School of Social Work, we were required to have health insurance. If we didn’t have insurance on our own, we had to buy it through the school and the only option was Accident/Sickness Insurance from Aetna Student Health. It was fairly inexpensive - $870 for one person for a year. But the coverage was awful.

I’ve recently been dealing with Aetna concerning $500 in medical bills they won’t pay. I made four calls to customer service and talked to four different people. I was told a couple of different things before learning what was really going on: first I was told that I hadn’t reached the $5000 benefit limit and the customer service representative didn’t know why the bills weren’t being paid. She said she would re-submit them and get back to me. When I called back because I received another bill from my doctor’s office, showing these same bills had not been paid, I was told that I had reached the $1000 benefit limit. I finally found out that Aetna Student health will only pay for three doctor visits per accident or sickness, leaving me to pay the rest. Then I called my doctor’s billing office to let them know this and, out of curiosity, asked how many visits Aetna had paid for. The billing clerk checked her files and told me that only one visit was paid for. So I had to call Aetna again and speak to another person who agreed that Aetna had only paid for one of my doctor visits. He said he would look into it and call me back (I’m still waiting for his response).

I think the health insurance system is designed to force you to be persistent if you want to find out why a claim isn’t paid. Otherwise you just give up and pay the bills that you may not even be liable for. What will probably end up happening is that Aetna will pay for three of the visits and I’ll end up paying for the rest. This is unfortunate because these visits took place between 3/08 and 8/08 and I’m just finding out that I owe money to my doctor. I don’t know if it’s because the doctor’s office billed late or because Aetna took a while to process the claims, but it left me thinking that the doctor visits were covered and all I had to pay was the co-payment. Instead, I’m left with a bill for $500 and a feeling of disgust with the bare bones “coverage” I received from Aetna Student Health.
Jen Ramirez

Democrats outline three scenarios to save $2.8 billion

Emphasizing that they do not endorse the cuts, the Appropriations Committee described the types of cuts necessary to fill the remaining $2.8 billion budget gap without additional revenues. Across the three budget versions reductions include cutting Medicaid provider rates by 10% for nursing homes and 20% for all others, Medicaid co-pays, eliminating adult pharmacy in Medicaid, eliminating DSH grants to hospitals, eliminating SAGA, eliminating Charter Oak, cutting Alzheimer’s respite care, and eliminating state funded home care. These cuts are in addition to, not instead of, the cuts in the Governor’s budget proposal. Leadership praised the committee for giving a “more accurate picture of what the Governor’s budget would have looked like had she balanced the budget” but was clear that the cuts are “unacceptable.”
Ellen Andrews

Health Care Advocate’s Office saved CT patients $5.07 for every $1 spent on the office last year

The annual report of our state Office of Healthcare Advocate (OHA) describes the importance of this office and what CT consumers could lose if the Governor is successful in eliminating it. The number of patients getting help from the office has grown every year reaching 2,143 last year. Those cases returned over $5 million to CT consumers from insurance companies due to OHA’s efforts. The most common problem OHA helps with is consumers being denied treatment or service. Cases highlighted in the report include a nurse needing a heart transplant, coverage of a lifesaving immunization for a child with complex health needs, and ensuring that a high school student with leukemia received the care he needed from the right hospital. Not only does OHA help individual consumers, the office has also been active in correcting public policies that are hostile to consumers such as creating a definition of medical necessity in state law, public program accountability, and prohibiting insurers from revoking coverage just when a consumer becomes ill.

CT’s Dept. of Insurance, with far more staff and resources than OHA, returned $3 million to CT consumers last year across the industry including auto, life, homeowner’s, accident and health insurance.
Ellen Andrews

US Supreme Court rejects federal pre-emption of state law in VT drug case

In a 6 to 3 vote, the Supreme Court Wednesday held that federal law does not pre-empt the right of patients to sue in state court over a federally regulated medication. The case involved a VT musician who lost her arm after Phenergan, an anti-nausea drug, was administered by “IV push” rather than “IV drip”. Both Wyeth, maker of Phenergan, and the FDA were aware of the dangers of administering the drug through IV push, but the FDA did not prohibit the practice and Wyeth never sought prohibition on the label. A VT jury awarded Ms. Levine $6 million. Wyeth argued that because the drug is regulated and was approved by the FDA, that Levine had no right to sue in state court. The Supreme Court disagreed in this case closely watched by the pharmaceutical industry. For more background on the case click here and here.
Ellen Andrews

How to live to 101

Susan Campbell’s column in yesterday’s Courant highlighted Mary Labieniec, age 101 from Kensington. Mary shares her eleven tips to a long and healthy life. Some are expected – stay active, don’t smoke and don’t drink (too much). She is a big fan of well water and she warns about house guests. But she also eats at McDonald’s almost every day, and she’s not ordering salads.
Ellen Andrews

Inside the LOB

As a volunteer with the Public Health Committee for the past couple of weeks I’ve witnessed the hard work done by legislative aides and clerks. Without them, the system would not run as smoothly (or maybe it wouldn’t run at all). They do all the behind the scenes work, from scheduling appointment for legislators to making sure a public hearing runs smoothly. There was a Public Health Committee hearing last week and I saw firsthand the amount of behind the scenes organizing and running around that was done so that the hearing would go well. The clerks signed people up, organized the written copies of testimony, answered questions from legislators and those there to testify, made sure the equipment was working, and kept track of the testimony for the official transcript. This allowed the legislators to concentrate on listening to the people who were testifying. Imagine if there were no clerks or aides and the legislators had to do it all themselves. The legislative process would certainly run slower and have many more hitches. Consider this a friendly reminder to show your gratitude to legislative clerks and aides. They can’t accept gifts but I think a smile and a ‘Thank You’ would be appreciated.
Jen Ramirez

Health care reform hearings

Despite the weather, the Human Services, Public Health and Insurance committees heard several health reform bills yesterday. The two that drew the most attention were HB-6582, creating the Healthcare Partnership, and HB-6600, creating the SustiNet plan.

The Speaker’s Healthcare Partnership bill was heard first. This bill reflects a similar bill passed last year, pooling the state employee health plan with municipalities and eventually small businesses, nonprofits and CT’s uninsured. The bill passed both houses but was vetoed by the Governor. This year nonprofits, small businesses and the uninsured are not included and the bill moves the merged plan to self-insurance. Self insurance means that the state would accept all risk for the health costs of the population, rather than paying a capitated rate to managed care plans as we do now. Self insuring should give the state one-time savings of $60 to 145 million. Most states self insure their state employee plans. Proponents also suggest that cities and towns could save money by pooling with state employees. Participation would be voluntary for municipalities – if they don’t save money, they don’t have to join. Most testimony was favorable.

Going last on the agenda actually worked for the SustiNet bill as the weather had cleared and the hearing was well attended. Dozens of speakers testified in favor of the bill including small business owners, clergy, advocates, consumers and providers. A couple of speakers argued against the provision giving malpractice liability relief to providers in certain circumstances where they appropriately followed evidence-based medical standards. The provision is intended to improve adherence to the best available clinical standards of care, reducing poor health outcomes and improving quality.
Ellen Andrews

People rushing doctor appointments before they lose their job

The Hartford Courant this morning is reporting that people worried about layoffs are hurrying to schedule doctor and dentist appointments before they lose health benefits. Practices have reported an increase in calls from people who aren’t sick but need to get in for routine appointments fast. They are also getting cancellations from people who have just lost jobs. The federal stimulus package offers some relief to the jobless, starting yesterday, with 65% subsidies for COBRA benefits. ProHealth, CT’s largest primary care practice, is offering uninsured patients 20% or higher discounts for physicals, office visits and lab work.
Ellen Andrews