CT Health Policy Project turns ten

The number of CT residents living without health insurance is up 18% in the last ten years. Ten years ago the CT Health Policy Project began our work to improve access to quality, affordable health care for every CT resident. In the last ten years we’ve published 223 analyses, briefs and studies and mentored 43 students. To mark the occasion we asked nine prominent CT stakeholders to reflect on how health care has changed in our state in the last decade and make predictions for the future. Contributors include Pat Baker of the CT Health Foundation, Congressman Joe Courtney, former Congresswoman Nancy Johnson, Sen. Edith Prague, Rep. Betsy Ritter, Gary Spinner PA, Hillary Waldman of the Hispanic Health Council and former Hartford Courant health reporter, State Comptroller Nancy Wyman and Jill Zorn of the Universal Health Care Foundation of CT.
The CT Health Policy Project wants to thank the many students, volunteers, interns, fellows, Board members, funders, collaborators, donors, staff, clients, bureaucrats, elected officials, very supportive family and friends who have made the last ten years not only possible, but a joy. We all get five minutes to reflect, then back to work.
Ellen Andrews

Teachers lead with germiest work environments

As cold and flu season approaches, the WSJ blog has identified the occupations most likely to encounter germs. As expected, teachers lead the list with twenty times the germs per square inch of attorneys who have the cleanest offices. Teachers’ phones are the main culprit, accountants have the dirtiest desks and you don’t want to touch a banker’s computer mouse or door knob. Women’s offices are dirtier than men’s but are less likely to have MRSA.
Ellen Andrews

Heroin overdoses hit most CT towns, moving to suburbs and to older victims

A new study by researchers at the Yale School of Public Health finds that, on average, more than one CT resident died every other day from heroin overdose deaths in the last eleven years. That rate is rising; it may soon overtake automobile accidents as a cause of death. The problem is spreading out of cities into the suburbs; all but 22 of CT’s 169 cities and towns had a fatal overdose of either heroin or pharmaceutical narcotics between 1997 and 2007. At Blue Hills Substance Abuse Services in Hartford the proportion of young adults in treatment for heroin addiction has risen from 10 to 30 percent in recent years. Overdoses are rising among older victims becoming more common among middle aged residents than young adults because of changing physiology over the lifespan, according to the Yale Daily News. A series of articles in yesterday’s NY Times finds that CT is not alone – heroin use is up across the region. Experts blame heroin’s lower cost compared to other drugs and it is sold in more lethal forms now than in the 1970’s.
Ellen Andrews

Annual comparison of health plans out

The CT Insurance Dept. has released their 2009 Consumer Report Card on Health Insurance Carriers in CT. The report compares insurance plans on the number of participating providers and 14 quality measures including rates of cancer screening, immunization rates and the percent of physicians who are board certified. For example, the percentage of patients who’ve been hospitalized with heart disease who are now managed for their cholesterol levels varies from a low of 55.6% (Oxford) to a high of 74.3% (HealthNet). Eye exams for people with diabetes vary from 56.2% (Oxford) to 75.2% (ConnectiCare). Beta blockers after heart attacks ranged from 38.6% (ConnectiCare) to 100% (Aetna). The report also includes insurers’ customer appeal numbers; rates of denials that were reversed on appeal range from 25.8% (HealthNet) to 57.2% (Anthem). Medical loss ratios varied from 81.5% (Oxford) to 85.8% (ConnectiCare). The report also includes information on member satisfaction, prescriptions, mental health and substance abuse services as well as a very helpful glossary of terms. The comparisons are based on 2008 data. The report also includes insurer’s customer service phone #s and government agencies to call for help.
Ellen Andrews

CT far behind in patient centered medical homes

According to NCQA, the organization that certifies medical homes among other things, CT has no practices that have been certified. Compare that to our neighboring states – MA with 87, ME with 56, NY with 225, NH with 132, RI with 31, and VT with 32.

But we are going to fix this. CT Medicine’s current issue includes several articles featuring the promise of medical homes including one on the patient perspective authored by Sheldon Toubman of New Haven Legal Assistance and myself, and today’s CT State Medical Society’s annual conference features a panel of experts on the subject. CSMS deserves great credit for their leadership on this critical issue.
Many thanks to Rose Stamilio of St. Francis Care for the NCQA numbers.
Ellen Andrews

Danbury and Windham county lead the state in uninsured rates; large variability between CT cities and counties

A new report from the US Census finds that at 14% of residents uninsured, Danbury led CT municipal areas last year. Danbury’s rate was 60% higher than the Hartford area at 8.6%. Both the Hartford and New Haven municipal areas were below the state average of 10.2%. Among counties, Windham led the state at 14.1%, more than twice as high as neighboring Tolland County at 6.2%. The new report highlights the striking variability in uninsured rates within CT and the pressing need for health care reform. For more, see the newest CT Health Policy Project issue brief.
Ellen Andrews

Joanne Iennaco joins CT Health Policy Project Board

CTHPP welcomes Joanne Iennaco to our Board of Directors. Joanne is an Assistant Professor at the Yale School of Nursing in the Psychiatric Mental Health Specialty. She holds a PhD in Chronic Disease Epidemiology; her research focuses on the effect of psychosocial aspects of the workplace on health. To learn more about Joanne, visit her blog Mental Notes. The Board also announces the departure of Sally Cohen. Sally has moved to the University of New Mexico and will be dearly missed.
Ellen Andrews

Individual mandate may be unconstitutional

In a Wall Street Journal Op-Ed, two former Justice Dept. attorneys argue that the individual mandate included in national health reforms could be overturned by federal courts as “profoundly unconstitutional.” The attorneys make different points than the CT Health Policy Project’s paper last year, arguing that the mandate is an unfair cross-generational subsidy, infringes on personal liberties and is politically motivated. We argued that it is an unfair burden on low income people, difficult to administer or enforce, and poor public policy. It requires people who don’t have extra money to buy a product (it now seems likely from only private sources) that, if history serves, may never cover their needs if they become ill. Those consumers will have to rely on government to enforce the value of their mandatory purchase; they can be forgiven for being skeptical. It is also based on the myth that the uninsured are just greedy, selfish people who could buy insurance but prefer to spend their money elsewhere. It is a classic case of blaming the victim.
Ellen Andrews

SustiNet celebration

oin the Universal Health Care Foundation of CT and all the partners who made passage of SustiNet possible for a celebration Thursday, October 1st 6 to 9pm at Union Station in Hartford. Click here to RSVP.

Individual mandate’s drawbacks getting national attention, finally

All the current health reform bills being considered in Washington include an individual mandate, requiring every resident to have health coverage – either through a public program like HUSKY or, if not eligible, people will have to buy it. The only open question is whether they will have a publicly run option to purchase insurance from, or if our only options will all be privately run companies. Until now, the extraordinary dilemma this places working families in, with incomes too high for subsidies but too low to afford any insurance worth what you pay for it, has been ignored. Yesterday’s Wall Street Journal takes a good look at how the mandate will “squeeze those in the middle” – exactly the families that are bearing the brunt of the current economic crisis. WSJ highlights the McDonalds, a family caught in this Catch-22 by MA’s individual mandate. For our analysis of how difficult and unfair an individual mandate would be for CT families, go to our policymaker brief or longer analysis.
Ellen Andrews

SustiNet update

The second SustiNet Board meeting today was uneventful. Stan Dorn of the Urban Institute gave a presentation on the original SustiNet plan; his presentation was made possible with support from the Universal Health Care Foundation of CT and the CT Health Foundation. He congratulated CT on passing a roadmap for comprehensive health care reform in a challenging economic environment. He outlined the original plan including the self-insured pooling concept, transparency, patient centered medical home structures (modeled on planning for PCCM in the HUSKY program), health information technology, evidence based medicine, and public health initiatives. Questions focused on re-aligning incentives to support quality and reduce costs, how the plan fits with national health reform proposals, funding reforms, barriers to adoption of electronic medical records in small practices, how to encourage creation of larger provider networks (something like accountable care organizations), primary care workforce shortages, insurance market reforms, and adverse selection. Co-chairs for the advisory groups were proposed; the Board asked for bios from the candidates before they voted. The next meeting will be September 30th at 12:15 pm.
Ellen Andrews

DSS gets an earful at PCCM subcommittee meeting

Today’s PCCM subcommittee meeting of the Medicaid Managed Care Council was very heated. Again the room was packed, including four legislators in person and one on the phone. DSS reported that they still have 54 providers in the Waterbury and Willimantic areas participating; no increase from the last meeting two months ago. They are beginning to reach out to New Haven and Hartford providers and have some interest, but no firm commitments. DSS was strongly criticized for a lack of marketing, stating that they consider it the providers’ responsibility. However, language in the contracts severely restricts providers’ ability to talk with their patients about PCCM. In response to action steps from the last meeting, DSS reported that the Commissioner refused to consider either removing the Freedom of Information language from the provider contracts, or alternatively to require the same of providers in the HMO program – in the interest of ensuring equal treatment of PCCM and the HMOs. DSS refused to consider including providers from other areas of the state that have expressed interest in the program to at least one legislator. DSS also reported that the Commissioner refused to allow auto default enrollment into PCCM of new enrollees in those areas who do not choose an HMO, which had been suggested by DSS as an option to more fairly apportion enrollment among the HMOs and PCCM. When the two new HMOs entered the program last year, DSS gave them a similar advantage in default enrollment to help them increase enrollment levels and ensure sustainability. DSS stated that they considered it a “test” of the PCCM option whether consumers would choose the option over the HMOs – if the HMOs aren’t performing, people will leave them to enroll in PCCM. However that led into the next issue – the serious inequality of marketing between the HMOs and PCCM. Pages of DSS-approved marketing activities by the HMOs including an airplane banner, radio advertising, free ice cream, school uniforms, school supplies, and haircuts. Providers have had to bring in volunteers from community groups to explain PCCM to their patients, as they are not allowed to discuss the program with them. Providers are also required to copy the brochure themselves; it is not clear that PCCM brochures are even available in the local DSS office. The program has been in place for over seven months. DSS’ response was that PCCM is a work in progress, but a legislator commented that “pilots can take a year to set up, not a decade.” Another suggested that DSS was “throwing PCCM under a bus” and another characterized the provider contracts as “horrific.” Concerns were raised that DSS was not following through on their stated commitment to implementing PCCM and were intentionally undermining its chances of success. Advocates and legislators were urged to contact the Commissioner to urge him to reconsider his decisions.
Ellen Andrews

Challenges and promise of PCCM highlighted in today’s Waterbury Republican-American

An article on the front page of today’s Waterbury Republican-American describes both the potential for PCCM and the challenges in implementing the program, especially with a reluctant state agency responsible for marketing. Volunteers have been left with the job of letting people know about the opportunity and what the program is. Sandi Carbonari, a Waterbury pediatrician, commented “It's a lot of work to take on, but it's the way medicine should be for everybody”.
Ellen Andrews

The Day Editorial – He snores, so why can’t we buy health insurance?

Susan Epstein has so many good points, it is hard to know where to start. “Don't think it can't happen to you. We're ordinary people. My husband snores and I take too much medicine and therefore, we're ineligible for health insurance.”
Ellen Andrews

From the Consumer Helpline

A consumer called our helpline because he has Medicaid and can’t find a primary care provider in New Haven who takes Medicaid and will take a new patient. He tried looking on the DSS Provider Directory Search and called the doctors listed there. They weren’t taking new Medicaid patients. He tried asking his specialist, who didn’t know of any Medicaid PCPs who were taking new patients. The Yale clinic he tried wasn’t taking new patients either. When he went to the Hill Health Center for an alarming medical issue, they told him he should go see his specialist – and not because that was the specialist’s area of expertise.

I gave him a few suggestions: try looking up doctors besides general practitioners (there’s only one listed in New Haven) like internists or family practitioners and try looking them up in the towns near New Haven. He could also try some of the other community health centers in the area. I also suggested that he ask his specialist to help him find a primary care doctor and maybe his specialist could put a little pressure on another doctor to take a new Medicaid patient. He said he hadn’t thought of that but he wasn’t convinced it would work because his specialist doesn’t spend much time with him. The clinic sets aside Thursday afternoons to see Medicaid clients and he said his doctor spends about five minutes with him and gets testy if he asks too many questions. But he said he’d try at his next appointment to ask her for a referral.

This consumer would have been helped by a medical home. Medical homes offer coordinated, comprehensive primary health care that is accessible, continuous, compassionate, culturally appropriate, and patient-centered. If Medicaid patients started out with medical homes, this patient wouldn’t have had this problem. He would have had someone to coordinate his care and find and make appointments with the other doctors he needs.
Jen Ramirez

Medicaid Managed Care Council update

Today’s Medicaid Managed Care Council meeting touched on some new issues and revisited some old ones. There was a strong exchange on the Charter Oak annual $100,000 and lifetime $1 million limits. Sen. Prague talked about a patient who called her office needing treatment for cancer that exceeded the annual cap. He was eventually able to continue his care, but is facing very large bills. She asked if the department is considering allowing people to tap into their lifetime caps when they have reached the annual limit. DSS stated that they are considering several options to address this concern including her idea of accessing the lifetime cap, but most of the options might include an increase in premiums. The conversation then turned to balancing affordable premiums with some relief for people reaching the coverage limits. Options include excluding specialty drugs from the calculation of the cap, links to the state’s high risk pool, reinsurance and placing a lien on the patient’s house. DSS reported that to date, only one person had exceeded the annual cap, but four others had received letters advising them that they had incurred expenses over $50,000. In the letter, DSS urges patients to contact them to see if they are eligible for other programs or resources to pay their bills.
The revenue and expense reports for 2008 generated a great deal of comment. CHN made a profit of $1.6 million; the other HMOs reported losing money. Overall the state paid $207.30 per member per month, including dental and pharmacy costs until they were carved out. DSS defended CHN’s profits at about 2.7% saying that is to be expected. DSS also believes that the program cost more per member during the months the plans were not at risk (the PIHP model) than under capitation, but did not provide numbers to support that assertion. There was a great deal of discussion of the Comptroller’s audit and the $50 million cut from HUSKY HMO rates in the budget that just passed. DSS stated that it is their expectation/goal to recoup that savings from the plans’ rates in the upcoming negotiations, although they do not agree with the Comptroller’s report. However after further discussion, Rep. Villano stated his concern that DSS did not plan to re-bid the contracts and about their “reluctance” to aggressively pursue those savings. DSS noted that they are no longer hiring outside auditors for rate-setting, but are performing those functions in-house and are restructuring their encounter data management system and should have better information on which to base the rates in the future.
DSS also described the prior authorization process for medications, but never got to the update on PCCM.
The PCCM subcommittee meets next week on Wednesday the 16th at 10am in the LOB.
Ellen Andrews

Uninsured up 17,000 in CT last year

The new Census figures on health insurance released today show that CT’s uninsured rate was up to 10% last year. 343,000 state residents were without insurance, including 44,000 children. The really stunning finding is that private employer-based coverage was down by 107,000. Thankfully government coverage picked up more people, about evenly split between Medicaid and Medicare. This continues a trend in CT and the nation of shifting coverage from private employer-sponsored plans to public programs. And without health reform, things are not likely to get better soon – family premiums in CT grew over 7 times faster than median earnings from 2000 to 2008. Click here for our latest policymaker issue brief on the new numbers.
Ellen Andrews

Middlesex Hospital has an online ER clock

If you need an emergency room in the Middletown area, you can now go online to see what the waiting time is at Middlesex Hospital’s three ERs. As the volume of ER patients rises across the state, wait times have grown to average four hours according to the Courant. Patients in Middletown can now reduce their wait by checking the clock. As always, in an emergency you should call 911.
Ellen Andrews

More on the challenges and promise of primary care

Today’s NY Times features an article on a summer immersion program linking University of Washington medical students back into rural and underserved communities. The video is the best part. Students experience the frustrations of caring for people without adequate coverage, without the resources they need to be well, all in a few minutes for each visit. I love the moment eager, energetic, and idealistic students touch the real world – the best part of my job here at the Project.
Ellen Andrews

The best argument for primary care I’ve heard in a long time

From the WSJ blog -- http://blogs.wsj.com/health/2009/09/08/how-one-doc-discovered-the-connection-between-heart-disease-and-depression
Read down to the third paragraph for the story that makes the point.
Ellen Andrews

CT papers feature health reform

The Day has a well-considered editorial today on health reform, centering on the Cleveland Clinic. The President has publicly cited the Cleveland Clinic as an example of exceptional care at lower cost. The editorial points out that what we need is a revolution -- we need to reform our health care system, not just insurance markets. We have to change incentives, putting providers on salary as the Cleveland Clinic does. The article also urges bundling services into one payment to discourage over-utilization, consolidating providers into seamless systems of care to promote accountability, provide incentives for people to manage their own health, and improving transparency and competition – on costs AND quality. “If we insure everyone without reforming the delivery process, the costs will be ruinous.” Well said.

Today’s Hartford Courant features just the physician perspective on health care reform. Issues raised include lack of support for primary care, paperwork and an entire section devoted to medical malpractice. While the article notes evidence that defensive medicine is a very small part of rising health costs, that fact is buried. What’s interesting in the article is that CT hospitals claim that they lost more money on Medicaid patients than the uninsured in 2007.
Ellen Andrews

Foundation for Community Health Open House

The Foundation for Community Health has moved to a new home with available meeting rooms. They are holding an Open House October 7th from 4 to 6pm at 155 Sharon Valley Road in Sharon, 06069. Hear about their expanded services and give them ideas for enrichment programs they can host for nonprofits. RSVP by September 30th at (860) 364-5157 or info@fchealth.org.

SustiNet Board meeting

Yesterday’s first SustiNet Board meeting was well attended by the members. Most of the discussion was introductory remarks and process. They talked about the committees, collecting input from the Board members, developing a work plan, etc. The next meeting will be Sept. 16th at noon.
Ellen Andrews

GAO report finds reduced competition in insurance markets is associated with higher premiums and profits

After pages of disclaimers and cautions that there is not enough good research on the issue, a recent GAO report finds evidence that there has been increasing concentration in health insurance markets in the US. Market share of the top five insurers rose from 43.2% in 1994 to 49.9% in 1997. The impact varied by region with some experiencing no effect and some with increases that are “significant enough to raise antitrust concerns.” Studies generally found that more competitive markets were associated with lower premiums, and lower insurance company profits, but the impact on provider rates was mixed. Greater competition was associated with lower utilization of inpatient services; the impact on outpatient services was unclear. There is no consensus on the effect of competition on quality of care. It appears that conservative economists were right – competition is good.
Ellen Andrews

Congressional health care reform town hall

Congressman John Larson will be holding a Health Care Reform Town Hall Forum tomorrow, Sept. 2nd at 5:30 at West Hartford Town Hall, 50 South Main Street. There is very little street parking near the town hall; click here for options. Paid parking is available. Similar events are planned in other Congressional districts – we will let you know.

Test your knowledge of CT health policy premiums

Take the September CT Health Policy Webquiz to test your knowledge about the costs of health insurance premiums in CT.