Courant editorial critical of CT physician oversight

Authorities in CT are too lax in approving physicians to practice here, according to the Hartford Courant’s editorial page. The editorial was based on an article by the CT Health I-Team. The authors highlight numerous cases of disciplined doctors who’ve lost their license in neighboring states who are later approved to practice in CT. Hospital error reporting has improved in our state, but physician oversight lags. The authors blame a stubborn cultural bias of excusing bad practitioners over patient safety. Physicians in CT are regulated by a volunteer board including mainly other physicians. A recent report by Public Citizen ranks CT 47th among states in regulating doctors; we’ve been in the bottom ten states for each of the last three year reporting cycles. The report lays out qualities of top states with the best records of protecting patients including adequate staffing, independence of the board, and reasonable legal standards. Both Norma Gyle, Deputy Commissioner of Public Health, and the CT State Medical Society have proposed changes to improve patient safety.
Ellen Andrews

Waterbury uninsured have a place to get care

Yesterday’s CT Mirror highlights Waterbury Project Access, a free health clinic program providing care to uninsured patients in the area. Because of the program Dennis Hayes, a truck driver with no coverage and $50,000 in medical bills from a heart attack, doesn’t have to ration his medications or doctor visits – keeping him working and out of the hospital. The program, led by Leslie Swiderski since 2003, brings together volunteer providers, donated labs, medications, and hospital care with uninsured patients who aren’t eligible for any public programs. In the last four years, the program has helped over 1,200 patients and provided $4.6 million in donated care. A Project Access program opened this summer in New Haven.
Ellen Andrews

Factoid: Even wealthier Americans more likely to face barriers to health care than lower income consumers in most countries

It’s no surprise that low income Americans are almost twice as likely to encounter at least one barrier to accessing health care than the wealthy. But an analysis of an international comparison study finds that higher income Americans are more likely than even low income residents of seven out of ten industrialized countries to face barriers to health care. The only country with no income disparity, the UK, also had the lowest level of barriers overall. So much for the US having the best health care system in the world – rich or poor.
Ellen Andrews

Reading for the holiday break

The Wall Street Journal Blog has health care book recommendations for the end of the year promising ideas on how to fix a flawed system. Let us know what you think of them. Send us your suggestions for the Book Club. From the reading obsessed at CT Health Notes.

It’s official – 2010’s biggest lie of the year . . . .

PolitiFact, the Pulitzer-prize winning antidote to deliberate misinformation, has named the assertion that national health reform is a “government takeover” of health care as the biggest lie of the year. If only it were true -- no public option, consumers required by law to purchase a costly product from private companies, reliance on weak state regulators to enforce value in the product – it’s laughable. And 2009’s Lie of the Year? Death panels. Why does health care attract lies? How did we get so lucky?
Ellen Andrews

New estimates of savings needed for medical care in retirement

Too many people assume that Medicare will cover their medical costs after age 65 and fail to save. While Medicare does pay almost two thirds of seniors’ health costs, a new analysis by EBRI finds that an average American 65 year old man retiring this year without employer-sponsored premium assistance needs $109,000 in savings just to be 50% sure of covering his future medical bills. Women need to save even more at $146,000. To be 90% sure, they would need $211,000 and $242,000 respectively. That man, if he retires in 2020, needs $183,000. Retirees lucky enough to have employer subsidies are not off the hook – men retiring in 2010 need $66,000 and women need $88,000 in savings to meet just median likely health costs. Not surprisingly, CT is the most expensive state for Medigap coverage and we should be saving even more.
Ellen Andrews

Vote for the most influential health policy articles of 2010

For all the wonky types, RWJ is taking votes online for this year’s most influential research articles. You may have missed one or two (I did) so it’s also a chance to catch up.

A constituent who made a difference

Eva Bunnell was a mother whose husband was about to lose his job because he was spending time with their daughter with complex medical problems when she spoke to Sen. Christopher Dodd. Out of that conversation came the Family and Medical Leave Act. Eva told that story to advocates assembled to honor Sen. Dodd’s service to Connecticut. Sen. Dodd persisted for decades to make that law a reality in 1993. The law protects the employment of people who need to take time off for their health or that of a family member. Because of the law, Eva’s family was able to be with her daughter at the end of her life earlier this year. Defying the experts, Jacinta lived to the age of 27.
Full Disclaimer: In addition to being an inspiring advocate, Eva Bunnell is a former CTHPP Board member and a dear friend.
Ellen Andrews

Cost cutting commission final proposals

The state Commission on Enhancing Agency Outcomes issued its final recommendations to save money in the state budget including over $145 million from health care spending. Proposals include more efficient Medicaid drug purchasing, drug recycling, preventing falls, and reducing the number of nursing home beds in the state and re-balancing long term care to emphasize care delivered in the community.
Ellen Andrews

Almost half of CT physicians are using electronic medical records

A new survey from the CDC finds that 48% of office-based physicians in CT are using some form of an electronic medical record/health record (EMR, EHR) this year, just under the national average (50.7%). State rates varied from 38% (KY) to 80% (MN). But only 10% of US physicians have fully functional EMRs; most are using basic systems. The national rate has been increasing since 2003 when it was 17%. Interoperable electronic health information is a critical driver of health care system reform in our state, will improve patient safety and is one of the few ways to save money in the system that improves efficiency and does not involve shifting costs between stakeholders, most often onto consumers.
Ellen Andrews

Medicaid Council update

Financial numbers released at Friday’s Medicaid Care Management Oversight Council meeting highlighted the need for more sophisticated accountability or, even better, moving the program to a self-insured ASO model and removing any HMO incentives to game the system. The Council first heard about Aetna’s underwhelming and vague performance improvement programs; Aetna’s quality performance for members varied between the 25th and 90th percentiles among states. No numbers were given to quantify any efforts by Aetna to improve members’ health. In several areas, it was not clear that Aetna’s programs were making any difference at all given considerable efforts by public health programs such as Healthy Start and community health centers.

Interestingly, Aetna was the only plan among the three HUSKY HMOs to make a profit on every program – HUSKY A, B and Charter Oak – in both 2009 and 2010. Aetna was paid more per person than either of their competitors for each program in each year, in one case 31% higher, and spent less on medical care than any other HMO or program in both years. The three Mercer actuaries at the meeting (yes, three actuaries at the meeting) stated that they build in a 1% profit margin into their rate estimates – that would be about $8 million/year for all three HMOs. Aetna alone made $14.7 million in profits on HUSKY and Charter Oak in 2009. In fairness, their profits were down to only $5.3 million on HUSKY A in FY 2010, but both AmeriChoice and CHN reported losing money last year. Aetna’s unique profit experience in the program raises concerns about adverse selection, especially given that the plans were given essentially unlimited authorization for marketing during the time frame. From the poor performance measures described at the beginning of the meeting, Aetna’s profits are unlikely to be due to keeping members healthier than the other plans.

DSS was then questioned about their decision in August, retroactive to July, to allow the HMOs to reduce provider payments below Medicaid-fee-for-service levels. The Council only learned of the policy change at last month’s meeting. DSS claims they don’t believe the policy change will impact access to care and that they are monitoring it. Concerns were raised that it is not reasonable to assert that reductions in rates will not reduce access in a program that has struggled with poor provider participation over most of its history. Advocates also questioned relying on DSS’ inadequate monitoring, which even if it can pick up a reduction in access, would not find it until months or years have passed, and serious damage has been done.

In response to the rate reduction policy change, each of the HMOs reported that they have no intention and have not reduced provider rates below the Medicaid fee-for-service floor. However, this advocate reported that I have seen a letter to a provider citing the new policy and reducing rates to 70% of Medicaid fee-for-service levels.

All these concerns would be erased if the program moved to an ASO-model as was included in the latest budget passed by the General Assembly and signed by the Governor projected to save the state $79 million this year. Advocates, policymakers and the plans could get back to working on improving care in the program.
Ellen Andrews

New journalism focusing on CT health

The CT Health I Team, led by veteran CT journalists Lisa Chedekel and Lynn DeLucia, will publish original investigative reports on health and safety in Connecticut and surrounding states. Top stories include Disciplined Docs Practice Freely in State and PTSD Cases in State Up. C-HIT is sponsored by the Online Journalism Project.

CT fourth healthiest state

America’s Health Ranking has placed CT as the fourth healthiest state in the nation, behind only VT, MA and NH. Since 1993 CT has been in the top ten healthiest states. However performance on specific indicators varied widely. CT was the top state in recent dental visits, but 27th in air pollution and 31st in public health funding. Measures of the nation’s health used in the rankings improved by one percent from last year, however from 1990 to 2000 health measures improved by 1.5% annually.
Ellen Andrews

Rally for SustiNet December 14th

The Interfaith Fellowship for Universal Health Care is holding a rally for SustiNet December 14th from 5:30 to 6:30 pm at the Emmanuel Lutheran Church, 311 Capitol Avenue, Hartford. Governor-elect Malloy will join the Rally. For more information, go to http://www.ctneweconomy.org/

OLR reports on major issues for 2011

The Office of Legislative Research’s annual list of issues likely to be addressed in the coming session includes:
· Considering alternatives to HMOs for the troubled HUSKY, including statewide PCCM
· Reconsidering last year’s budget requirement that HUSKY move from the current capitated HMO-based model to a self-insured ASO model, as is common to most large insurance groups
· Cuts to eligibility and/or benefits in DSS programs, but higher caseloads due to the economy will require more funding
· Creation of a state health insurance exchange
· Health insurance premium rate review – directing the use of federal funds to the insurance dept. to improve capacity for reviews and requiring public hearings on excessive rate increase requests
· Requirements that employers provide workers with paid sick leave
· Possible implementation of the SustiNet plan and the recommendations of its taskforces and committees

What the report does not include is any mention of re-balancing long term care spending (LTC). At 53% of all Medicaid spending, CT is second in the nation in the proportion of Medicaid spending that goes to LTC. CT’s is 12th highest among states in the share of our LTC that is spent on nursing homes. Advocates have long called for re-balancing our LTC spending, making community-based care options more available – letting seniors stay in their homes and saving the state money.

For 15 other ways to save money in CT’s health care budget without harm, and in most cases improving quality and access to care, visit our brief and paper. There are many alternatives for thoughtful, sensible and responsible budget reforms in CT. Let’s hope the new administration is open to new ideas and new voices.
Ellen Andrews

CT insurance premiums up more than 30% from 2003 to 2009

An analysis by the Commonwealth Fund finds that single health insurance premiums in CT grew 34% and family coverage by 39% from 2003 through 2009. Interestingly, the rise in premiums was greater for employees of large firms than for workers in small firms, both in CT and nationally. CT family premiums were the 7th highest among states last year, but one of the lowest as a percentage of median income. Nationally premiums rose 41% and deductibles by 77% between 2003 and 2009. Without health reform, premiums would be expected to grow another 79% by 2020. If health reform slows the growth in health care spending by 1.5% (hopefully we can do much better), the average CT single policy will be $1,283 lower annually and $3,674 less for family coverage by 2020.
Ellen Andrews

SustiNet Board update

The SustiNet task force met yesterday to refine their final recommendations for proposed legislative language to the General Assembly. In an earlier survey of task force and ex-officio members there was agreement that the plan should merge state employees, Medicaid members and municipal employees. However, there was disagreement about including small businesses, nonprofits and the uninsured. Sal Luciano noted that the original intent of SustiNet was universal coverage and it is critical to provide access to an affordable, transparent public option to CT’s uninsured. The group also decided to “encourage” patient-centered medical homes, although Norma Gyle noted how important delivery reform is to the success of SustiNet and the larger health system and suggested substituting the stronger language of providing incentives for medical homes. There was also lengthy discussion about whether to raise HUSKY and Medicaid provider rates to private pay rates or leave them at the current lower rate. It was proposed that rates be raised only after compensating savings can be demonstrated in the program. Cristine Vogel argued that the group needs to make a “bold statement” about raising provider rates. Rates for care provided to poor children should be equal to those for state employees’ children. The group will deliberate further before their recommendations for proposed legislation are finalized. Special thanks should go to Sal Luciano, Norma Gyle (CTHPP Board members) and Cristine Vogel for their thoughtful, principled and consumer-centered comments.
Ellen Andrews

Courant Live Chat today on why insurance rates keep skyrocketing

Join Matt Katz of the CT State Medical Society and Jackie Aube of CIGNA today at noon for a live chat to discuss why health insurance rates continue to climb. If you can’t join at noon, you can email questions ahead.

SustiNet public briefings scheduled

Two SustiNet public briefings have been scheduled.

Monday Dec. 6 6pm to 9pm Hill Regional Career High School, 140 Legion Avenue, New Haven
Tuesday Dec. 7 9am to noon Legislative Office Building Room 1D, Hartford

A legislative briefing has been scheduled for Dec. 16th from 9am to noon at the LOB Room 2C.

State panel recommends $140 million in health care budget savings

Over half the recommended budget proposals for state budget savings from the Commission on Enhancing Agency Outcomes focus on health care spending. The savings center on prescription spending in Medicaid and moving nursing home residents to assisted living. The Commission is Co-Chaired by Sen. Gayle Slossberg and Rep. James Spallone.
Ellen Andrews

Most CT doctors will reduce Medicare participation if rates are cuts

An online survey by the CT State Medical Society found that 78% of the 360 state physicians who responded would restrict access to care for Medicare and TRICARE patients if rates are cut. Nineteen percent of respondents would stop taking any Medicare or TRICARE patients at all, 31% would limit the number of new patients and 28% would only continue seeing current patients. However it is unclear whether many physicians will be able to restrict their participation in the programs that cover more than 600,000 state residents, particularly in specialties that disproportionately treat elderly health issues. Since the survey was conducted, the scheduled rate cuts were postponed from Dec. 1st to Jan. 1.
Ellen Andrews

New Book Club post -- The Treatment Trap

A study found that one third of people who were told they needed heart bypass surgery did not need it. Tens of thousands of Americans have back surgery for pain when there is no evidence to support it; studies have found that pain management and therapy are more effective. The 70 million CT scans performed in 2007 will cause 29,000 cancers in Americans and 15,000 deaths. One third of Americans believe they have received medical care they did not need. There are powerful interests heavily invested in providing too much care, whether we need it or not. The Treatment Trap, by Rosemary Gibson and Janardan Prasad Singh, collects mountains of evidence that we are being overtreated and it is killing us. Moreover, we can't afford it. The authors include heartbreaking real life stories and recommendations that are commonsense and practical. Before people get worked up about "rationing", they need to read this book.

For more additions to your gift giving list for the health policy wonk in your life, check out our CT Health Policy Project Book Club.

Advocates ask CMS to intervene in HUSKY rate reductions

Two years ago, the state increased payment rates to providers in the Medicaid fee-for-service program and required that the HUSKY HMOs pay providers at least fee-for-service rates within the managed care program. The change in HMO contracts to require higher rates was included in the program’s federal waiver and capitation rates paid to plans were raised to pay for the change. (At the time, advocates found the HMO rate increase interesting as plans maintained that they routinely paid providers above fee-for-service rates.)

At the last Medicaid Care Management Oversight Council meeting DSS reported that they have reversed that policy and exempted the plans from the requirement to pay at least fee-for-service rates, retroactive to July 1st. However there has been no reduction in capitation rates to plans allowing the HMOs to reduce their medical costs and divert more state funds to administration and profit. At the October Council meeting we learned that the HUSKY HMOs made $19 million in profit on the program last year while they were still required to pay fee-for- service rates.

A group of advocate and provider organizations have sent a letter to CMS alerting them to the violation of the terms of the federal waiver that “threatens substantial harm” to more than 400,000 HUSKY members struggling now to access care in the program. Advocates are concerned that payment rate reductions will cause more providers to leave the program that already suffers from low provider participation rates. The advocates are asking CMS to intervene and reverse DSS’ policy decision to reduce provider rates.
Ellen Andrews

From the consumer helpline: Medicaid consumers being charged

Two calls just this morning came from consumers covered by Medicaid being charged by hospitals. One was a mother on HUSKY Part A charged $281 by a hospital for services she already received. But the first call was from a man on Medicaid who was told by the hospital that they would not schedule the second surgery he needs to heal an injury and get back to work until he pays $2,000 up front. They were both sent to the appropriate authorities and strongly urged to call their Senator and Representative as well.
Ellen Andrews

Estimated costs of SustiNet options described

Stan Dorn of the Urban Institute outlined the estimated costs of six SustiNet coverage options at yesterday’s Board meeting. Under any of the options Connecticut’s uninsured rate drops by more than half, the state budget deficit is improved, small businesses save (mainly by reducing the number of workers they cover), SustiNet grows into a significant, but not dominating, market presence (which can be leveraged to drive important reforms) and there is little impact on household incomes.

The estimates are based on economic modeling by Jonathan Gruber from MIT, and are estimated for 2017 when implementation should be complete. The committee was given two scenarios -- one extremely conservative that assumes no savings due to delivery system reforms already occurring in CT such as patient-centered medical homes, and another, more likely, scenario that still conservatively estimates those savings to only reduce skyrocketing cost increases by 1%. (Other researchers estimate that delivery system reforms could save twice that much. Below are the more modest 1% savings estimates.)

· Just including state employees and Medicaid in SustiNet saves the state $371 million, saves employers $485 million and covers 620,000 people in SustiNet by 2017.
· Adding the Basic Health Plan option to the model, taking advantage of a federal option to cover people under SustiNet to higher income levels with better coverage, lower costs to families and saves federal dollars, covers 650,000 state residents, saves the state $418 million, and saves employers $459 million.
· Also allowing small employers, nonprofits and municipalities to buy into SustiNet brings coverage in SustiNet up to 815,000 people, saves the state $425 million and employers $466 million.
· Opening SustiNet to everyone covers 1 million people, saves the state $427 million and employers $498 million.
· Raising provider payment rates to private pay levels covers the same 1 million people and saves employers the same $498 million but reduces the state’s savings to a still respectable $244 million. (Note: this option does not include any potentially significant savings from reductions in private pay rates as there will be no need to cost shift to cover Medicaid underpayments and that increasing rates will attract more participating providers, keeping HUSKY families out of expensive emergency rooms.)
· The last option expands HUSKY to higher income adults before national health reform’s schedule which would cover 600,000 people in the program, save employers $217 million but costs the state $103 million. (This is the only option under which the state doesn’t save money).

The Board will consider the options next month and make recommendations to the General Assembly in January.
Ellen Andrews

Consumers protest Anthem rate hike request

Consumer advocates demonstrated their concerns at a CT Insurance Dept. public hearing about Anthem’s request to raise premiums 20% or more. The consumers outlined the enormous economic burden this places on state residents and businesses while unemployment remains high and Anthem’s parent company made millions in profits last quarter. Policymakers questioned Anthem’s documentation to justify the increases. This is the latest in a string of double digit rate increase requests by Anthem that have been approved by the department.
Ellen Andrews

CT's Medicare patient centered medical home application -- bad and good news

Unfortunately, CMS did not approve CT’s application to include Medicare in our patient-centered medical home plans for state employees and Medicaid. If it helps, we are in good company – Massachusetts and Maryland, states with sophisticated reform efforts – also did not get approved.
But the good news is that the partners are all interested in moving forward with the project anyway. And our Congressional delegation is working on finding support at CMS for our project. We should consider this Round 1.
Thank you to everyone who gave their support to this effort. We will be calling on you again soon.
Ellen Andrews

eHealthCT’s Medicaid health information exchange up and running for real patients

CT’s pilot Medicaid health information exchange (HIE) project is up and securely sharing patient information successfully. Affirmative consent is collected from patients and registered with the HIE. The system can accommodate, among other things, secure email, eReferrals, lab data exchange, radiology image viewing and should conform with meaningful use criteria. The project has taken years to develop; as an advocate I have been amazed at the enormous amount of work involved in what looks effortless to most of us. Successful, secure exchange of accurate health information is crucial to reforming, and even sustaining, our health care system – to collect data driving intelligent reform, to improve patient safety, to align incentives and reward value, and to “bend the cost curve”. Congratulations to all the collaborators – you get five minutes to rest on your laurels, then the rest of the state needs this system.
Ellen Andrews

NY Times budget deficit graphic illustrates the scope of the problem

Yesterday’s NY Times Week in Review included a compelling graphic comparison of the federal budget deficit and options to fill it. The page long piece uses blocks to illustrate the size of the hole and how much or how little each option contributes to the solution. The options include spending cuts and revenue enhancements (taxes); many are health-related. It is interesting to see how much difference each option makes. For example, eliminating farm subsidies (often linked to rising obesity levels) saves a pittance. But capping Medicare growth at GDP rates + 1% starting in 2013 makes the most difference among all the options, spending cuts or tax hikes, saving $560 billion by 2030 and filling 41% of the budget hole. That is more than allowing all the Bush tax cuts to expire on everyone or reducing the tax break for employer-sponsored health insurance.
Someone should do this for CT’s budget hole.
Ellen Andrews

State Strategies for Health Reform Implementation conference

I’ve been in DC for a fascinating conference for state-based advocates on how we can influence and support health reform at home. First, it is an incredible opportunity to connect (and reconnect) with advocates from across the states, get ideas, share stories and learn what is really happening. For example, Utah’s much publicized insurance exchange is not working and they have problems getting accurate information from their state agencies as well. We’ve heard from leaders at CMS and the new Office of Consumer Information and Insurance Oversight. We’ve heard from strategists, think tanks, state officials, advocates, and communications experts. We’ve heard from states with great success reducing Medicaid spending, without disturbing services. We’ve heard a lot about how to build insurance exchanges, market reforms inside and outside the exchange, preventing adverse selection, linking Medicaid to the exchanges, benefit design, , setting up selective contracting processes with integrity, transparency and to get the best price for consumers in the exchange. We’ve also heard about hospital community benefit requirements. The Obama administration is eager to hear from advocates – we heard over and over that they know the rubber is hitting the road in states and they want to support us in making this work (including giving us personal email addresses).

Families USA, Community Catalyst, the Georgetown Center for Children and Families, and the Center on Budget and Policy Priorities put together an exceptional conference. I usually only learn one or two new things on most trips – I am walking away from this one with a full notebook of ideas.

Wednesday I also visited with health staff in some of CT’s Congressional offices. People were generally reassuring. While there will be attempts to repeal the Accountable Care Act, they won’t succeed. There will also be attempts to defund and repeal parts of the Act, staff also felt that they would largely fail as well. I felt much better.
Ellen Andrews

Candidate briefing book online

The 2010 CT Health Policy Project Candidate Briefing Book is now available online. Password protected access was sent before the primaries to every candidate registered with the Secretary of the State’s Office for all statewide offices, Congress, State Senate and House. The book has been updated periodically and is now available without a password at www.cthealthbook.org. Many thanks to all the students who worked on the book.

Health Care Advocate position posted

The state is seeking to fill the position of Health Care Advocate. The agency assists consumers struggling to access care in an increasingly hostile environment and makes recommendations to policymakers. For more information, click here.

NY hospital takes artwork in exchange for care

28% of NY artists are uninsured. To meet the needs of their community – both artists and patients -- Woodhull Medical Center in Brooklyn gives 40 credits toward health care services for every hour artists share with the hospital. Artists in Woodhull’s Artist Access Program take professional first photos of newborns and moms, provide storytelling in the pediatric ward, perform music in the lobby, and act as surrogate patients teaching residents how to break bad news. Credits can be used for appointments, lab tests and medical procedures.
Why can’t we do something like this in CT?
Ellen Andrews

Fifteen ways to save money in CT’s health care budget

The next administration faces an unprecedented budget deficit. The good news is that CT has barely scratched the surface of policy opportunities that save money, many of which also improve health care. Taking guidance from other states and other payers, we have assembled 15 ideas potentially reaching hundreds of millions in savings. We include PCCM, patient-centered medical homes, fiscal accountability in HUSKY, wellness programs, payment reform, and engaging the power of consumers and markets to reward value. Click here for the policymaker issue brief; click here if you want the long version.
Ellen Andrews

Courant photoblog on health care salaries

One of the Hartford Courant’s online featured photo galleries compares average salaries for health care workers in Connecticut. The highest are obstetricians and gynecologists at $209,160; lowest are home health aides averaging $29,020.
Ellen Andrews

YNHH surgeries under scrutiny after wrong site operation

The New Haven Independent is reporting that on June 9th a car crash victim had a skeletal traction pin surgically inserted into the wrong leg at Yale-New Haven Hospital. The error was the result of poor communication between surgeons during a “handoff” of the patient and had to be corrected in another surgery. The mistake was quickly caught and reported to DPH. DPH found that the staff should have taken a “time out” to review the records and double check the planned surgery. Handoff and time out procedures at YNHH have been updated. YNHH’s spokesman says the patient was not “seriously or permanently harmed.” All surgeries at the hospital will be monitored by DPH staff for three months through Dec. 1st.
Ellen Andrews

November web quiz

Test your knowledge of CT managed care plan performance. Take the November CT Health Policy Web Quiz.

State Supreme Court to decide if widows are responsible for nursing home bills

The New Haven Advocate reports that the CT State Supreme Court is considering a case that could have a devastating impact on CT’s 28,000 nursing home patients and their families. The case involves who should pay the $60,795.32 nursing home bill of a man who died two years ago. The nursing home, Wilton Meadows, is suing the patient’s widow citing a law that requires a spouse to pay bills from dentists, doctors, hospitals or items bought to benefit the family; nursing homes are not listed in the law. The lawyers argue that nursing home care is an “item” that benefited the whole family but a lower court disagreed. Nursing homes claim they have no other choice than to bill families because of low Medicaid rates. Too often families bringing patients to nursing homes sign papers taking responsibility for applying for Medicaid and agreeing to pay the bills that Medicaid doesn’t cover. Medicaid applications are difficult and it can take years to qualify.
Ellen Andrews

CT managed care report card out and medical loss ratios

The CT Insurance Dept. has published this year’s comparison of health insurers with interesting comparisons across managed care plans. (Study up for next month’s webquiz). Near the end, on p. 48, medical loss ratios are reported across insurers. It is important to note that the MLR definition used for the report is stricter than the proposed federal reform standards. Even so, all CT HMOs are well above the 85% level that will be required January 1st. Among CT indemnity insurers below 80% (the standard for individual coverage), Golden Rule is the only company with over 350 members.
Ellen Andrews

Health information privacy complaint filed against Hartford Hospital

State employee unions have filed a complaint with HHS’ Office of Civil Rights about Hartford Hospital sending letters to union members and patients about tense rate negotiations with Anthem. The union contends that the hospital is trying to scare patients to create leverage in their negotiations with CT’s largest insurer. The state uses Anthem’s network to provide health care to most of the plan’s 200,000 employees, retirees and dependents. The complaint alledges that the hospital improperly used protected patient information to influence payment negotiations.

"Hartford Hospital is manipulating our members, many of whom are deeply worried about the future of their medical care," said Jean Morningstar, president of University Health Professionals, Local 3837 in AFT Connecticut. "The hospital is simply trying to achieve a better financial outcome in their negotiations with Anthem. This is a shameful and dangerous tactic to engage simply for profit."

Ellen Andrews

CT Health Foundation seeks a communications Officer

The CT Health Foundation is hiring a Communications Officer to manage their Web, social media and e-mail efforts and contribute to overall Web vision and strategy. The Foundation is looking for at least five years experience in journalism or communications, strong writing and editing skills, extensive experience with Web sites and hands-on knowledge of social media tools. Knowledge of health policy and the world of philanthropy are a plus.

CID will hold rare public hearing on Anthem’s 2011 increase request

The CT Insurance Dept. has decided to hold a public hearing on Anthem’s requests for 2011 premium increases. The Commissioner was strongly criticized for approving Anthem increases of 47% for the end of this year with little review and no modification. Anthem has not yet submitted their proposal for 2011 rate increases, and the hearing date has not been set. As part of a $1 million federal grant, CID will now publish all insurer rate requests online. Politico is reporting that Commissioner Sullivan, who has been critical of national health reform, was “aggravated” by a strongly worded letter from HHS about the Anthem rate approval given the federal grant. Reportedly, he would have preferred a private phone call over a public letter.
Ellen Andrews

Countering campaign spin and negative ads

Yesterday’s NY Times top editorial is a list of fact checks on campaign distortions about national health reform, the Accountable Care Act. For the record, the law does not require patients to go through a bureaucrat to reach a doctor, reform is not a “government takeover” of health care – the law relies heavily on the current, very private, fragmented, inefficient, purely American health care system, some lousy insurance plans that don’t meet minimal standards for value won’t count as coverage (but the administration is being very generous with waivers, so maybe they will), health care costs are going up but it has little to do with the law, under reform Medicare is stronger and most recipients will be far better off with preventive care and lower drug costs, the vast majority of Medicaid costs are covered not by states but by the feds (states are big winners under national reform), and the law is already helping people with changes that became effective last month.
Ellen Andrews

New campaign describes benefits of Connecticut reforms

The Universal Health Care Foundation of CT has launched a new public education campaign about the benefits of SustiNet and national health reform to our state. A new brochure describes SustiNet, outlines the savings it will bring to businesses and individuals, and why we need Connecticut needs health reform now.
Ellen Andrews

CT teen pregnancy rates down

The rate of pregnancies among CT teens dropped to 22.9 per 1,000 girls in 2008, down from 23.1 the year before and 35.8 ten years before. CT’s rate has consistently been below the national average; our 2008 rate was the fourth lowest in the nation behind only MA, NH, and VT. The bad news is that racial and ethnic disparities among CT’s teens are very large. Non-Hispanic black teen girls in CT are 4.5 times more likely to be pregnant than whites and among Hispanics the rate is 8 times higher. Babies born to teen mothers are more likely to be preterm and low birthweight than babies born to mothers in their twenties.
Ellen Andrews

Large employers urge Hartford Hospital to be reasonable in Anthem negotiations

Rate negotiations between Anthem and Hartford Hospital have become tense as the October 31st contract end date nears, according to a CT Mirror article. On Monday a coalition of self-funded health plans, including the Office of State Comptroller on behalf of CT’s state employees, sent a strongly-worded joint letter to Hartford Hospital questioning the hospital’s case for double digit rate increases and critical of efforts to frighten patients. The large plans are not part of the negotiations but will have to pay large rate increases and out-of-network costs if reasonable rates cannot be agreed on. Next year’s state budget is expected to be $3.4 billion in deficit. The letter urges Hartford Hospital to agree to performance-based payment reform, to improve the quality and efficiency of care, ensuring that any increases are linked to increased value.
Ellen Andrews

Feds urge CT Insurance Dept. to reverse Anthem 47% rate hike approval

HHS has sent a letter to CT Insurance Department (CID) Commissioner Sullivan asking him to reconsider the department’s approval of Anthem 47% health insurance rate hikes for next year. "The consumers of Connecticut expect and deserve transparency and a fact-based rationale as to why their rates are increasing," according to the letter. The insurance department recently received a $1 million federal grant to build capacity for better rate reviews.

"HHS is therefore surprised that, after being awarded this grant, the CID has
approved a substantial increase by Anthem Insurance Company without holding a
public hearing, without having tested or validated the proposed rates and the
assumptions underlying those rates, and without publicly disclosing any data
filed by Anthem, analysis done by the CID, or correspondence between the CID and
Anthem."
Letter from Jay Angoff, HHS

Anthem and the Commissioner blame the new national health reform act for the increases, but actuaries allot increases of only 2 percent to the new act. Other CT insurers have asked for far more modest increases. No hearings were held before the department approved the rate hikes without any modification.
Ellen Andrews

Celebrate 30 years with the Hispanic Health Council

Join the Hispanic Health Council in celebrating their 30th anniversary. The party is next Thursday, October 21st from 5 to 8pm at the HHC offices, 175 Main Street in Hartford. For over three decades, HHC has been a pillar of Hartford’s large Latino community -- working to improve health, fighting for social justice, and building a healthier community. Click here to RSVP.

Office of Health Care Advocate saved CT consumers over a million dollars this quarter

CT’s Office of Health Care Advocate (OHA) returned $1.36 million in savings to health care consumers in our state between July and September of this year. OHA assists consumers struggling with insurance companies to access the care they need. So far this year, OHA has saved consumers $3.3 million in health costs. The savings include the costs of services denied by health insurers; without OHA’s help those costs would have been shifted onto consumers or providers. With rising unemployment OHA’s caseload is up 24% over the same period last year. Anyone needing help accessing care from an insurer can call OHA toll free at 1-866-HMO-4446 or email healthcare.advocate@ct.gov.
Ellen Andrews

SustiNet Board considers governance and structure recommendations

At today’s meeting the SustiNet Board considered three different structural options for the new SustiNet Plan. Options varied in whether the new SustiNet governing body will oversee or directly administer the plan, whether the SustiNet option will be a licensed state insurance product offered in the new state health insurance exchange, the relative roles of SustiNet and existing state agencies, liability and responsibility for complying with federal Medicaid laws, and layers of administration. Pros and cons of offering SustiNet inside and/or outside the new exchange were discussed – federal premium subsidies are only available inside the exchange, but undocumented immigrants may not purchase coverage in the exchange. Concerns were raised about levels of authority, raising capital reserves necessary for state licensure under current state law, and ensuring SustiNet is compatible with efforts to coordinate delivery system and payment reform across all payers. Next month we get the cost and financing numbers.
Ellen Andrews

Contrasting gubernatorial candidates on health care

Health policy has emerged as the latest disagreement among CT’s candidates for Governor. Dan Malloy’s and Tom Foley’s positions on health care are significantly different.
Ellen Andrews

HUSKY HMOs made $19 million profits last year; families paid $323.16 to HMO profits

At the very end of yesterday’s Medicaid Care Management Oversight Council meeting, DSS reported that the HUSKY HMOs made $18.8 million in profits on the program during 2009. This profit is on top of their administrative costs. Aetna made most of that profit -- $14 million – despite having only one fourth of total enrollment. While the medical care ratio (better term than medical loss ratio) for the program overall was a respectable 90.7%, it varied considerably by program. Worst was 62% for AmeriChoice’s HUSKY Part B plan; none of the HUSKY Part B ratios would comply with federal Accountable Care Act standards.

As bad as the state’s loss of millions to HMO profits, worse is overcharging HUSKY families. There are currently 1,260 children in HUSKY Part B Band 3; these families are paying an extra $323.16 in premiums annually to HMO profits. Families in this band have incomes over 300% of the federal poverty level ($54,930 for a family of three) and pay the full cost of HUSKY coverage for their children. Even worse, 1,279 children lost HUSKY Part B Band 3 coverage in the last year because they couldn’t pay premiums. It is unknown how many of those children may have kept coverage if premiums were $323.16 lower and reflected only the HMOs’ costs.

The HMOs defense to criticisms about large profit taking was that the profits served to partially offset losses on the Charter Oak program. Council members pointed out that the state and CMS do not allow cost shifting between programs, especially from one that is federally matched to one that is supposed to be fully state and consumer funded. Advocates have been concerned for years that HUSKY rates are set at overly generous levels to subsidize the politically favored Charter Oak program.
Ellen Andrews

More state health policy in New Orleans

Yesterday, I finished up at the NASHP conference hearing the latest from VT’s Blueprint for Health and a panel on how FQHCs are stepping up to provide coordinated care and patient-centered medical homes (PCMHs). VT is planning to expand their Blueprint PCMH program to the entire state in three years. Primary care practices certified as PCMHs by NCQA are paid a flat per member per month fee based on their level of certification; the Blueprint does not include a quality or performance based payment provision. The pmpm rates vary from just $1.39 to just over $2, far below CT’s $7.50 pmpm in our PCCM program. Preliminary results are very promising both for savings and improving health status. The program also includes community health teams with a team of clinicians for each community; the team offers more intensive care coordination services to any patient in the community regardless of payer or insurance status. The clinicians on the team and services offered are locally based, no remote disease management, and are based on an assessment of local population needs. Each team serving about 20,000 people costs $350,000/year. All four private insurers in the state contribute to the community health teams. Because of the health teams two insurers have been able to cancel their expensive disease management contracts with outside companies. It is not clear yet if premiums to consumers will be reduced to reflect the savings.

The panel on FQHCs and PCMHs highlighted the natural fit between the two models of care and the cost advantages of linking the two. Iowa had a bare bones coverage program with limited provider participation, similar in many respects to Charter Oak. Also like Charter Oak, IowaCare quickly began sinking under its own weight from adverse selection and administrative issues soon after it was implemented in 2005. Iowa wisely decided to transition the program to a PCMH model based on their FQHCs. IowaCare Medical Homes are paid a monthly care management fee as well as performance payments.

Building on their successful PCCM program, Montana also created a flexible, locally controlled PCMH program through their FQHCs. Patients are referred to the program by a prospective payment risk assessment system or by referral from primary care providers; many PCPs state that they can tell which of their patients are at risk of incurring high medical costs before they would be picked up by a claims based system. Primary care providers hire the care managers, who meet patients where they are – in their homes, in their cars, at the grocery store, at a laundromat, etc. Care managers must become certified within three months of hire. They engage in a conversation with patients and their families to see “what the problem is and find a way to fix it.” That may mean arranging reliable transportation to appointments, pulling out carpet, cleaning drapes, or finding a vacuum cleaner for someone with asthma whose cleaner broke a year ago and hasn’t been able to replace it. Since care managers are local residents connected to their communities, they can identify informal resources and donations. The switch from using outside disease management companies to local community programming has expanded benefits and reduced costs for patients in the program. The total number of care management FTEs has increased from 4 to 25 now and soon will be 45 at a lower cost to the state.
Ellen Andrews

More health policy from New Orleans

A long day at the NASHP conference today. We heard about challenges facing states; the common theme was planning deep reforms on very short timelines with limited staff capacity and growing budget deficits. William Hazel, recently hired Virginia Secretary of Health and Human Services, pulled together the heads of departments to look for savings. When they all told him they had been cut to the bone, he commented that it was pretty funny that they sent them an orthopedic surgeon as the new Secretary. Another speaker compared giving insurance cards to people without making sure they can access care and get appointments, is like giving a parking permit to a college kid – it’s just a license to hunt.
We learned about the parameters of building state insurance exchanges, updates on states building patient centered medical homes, and the challenges of measuring and paying for quality. Rosemary Gibson, author of the Treatment Trap, described the dangers and costs of overtreatment. A fascinating panel focused on undocumented immigrants, completely left out of public coverage programs, and the likely impact on the safety net. New data from SHADAC estimates that there are 10.4 million undocumented immigrants in the US and 3.7 million of them live in low-income households (138% or less of the federal poverty level) that would have qualified for Medicaid but for their immigration status. SHADAC researchers estimate that there are between 50,000 and 100,000 undocumented immigrants in CT and between 10 and 19% of CT low income adults are undocumented immigrants, one of the highest proportions among states.
Ellen Andrews

New Orleans health care – five years after Katrina

Yesterday, the NASHP conference in New Orleans started with a plenary session on the state of health care in the city. Things were not great before Katrina – the city was at the bottom of national list for health care access and outcomes. 80% of the housing stock was lost; health care institutions were devastated. Progress in rebuilding has been slow and the BP oil spill has cut into available resources. One speaker compared it to trying to pursue national health reform when two thirds of the nation is under water. EMRs became critical as most medical records were destroyed and patients scattered across the nation. Patient-centered medical homes became a necessity as the lack of providers required teams; coordinating care and engaging patients in their own care was critical. Approximately 90 clinics have grown around the city sponsored by a wide diversity of groups including payers – government, religious, civic groups, foundations – serving different populations – musicians, pregnant women, specific communities. Speakers noted that this diversity is an important strength – if one payer drops support, such as the state – the system can adjust. However, thoughtful planning has hit roadblocks. The state offered to pay all the costs to build desperately needed mental health care capacity, but hospitals refused, instead building transplant services to attract patients from outside the area.
In other news, the big story in New Orleans this morning is that Blue Cross Blue Shield of LA and East Jefferson General Hospital have not been able to reach an agreement. Thousands of patients will no longer be able to get care there. Sound familiar?
Ellen Andrews

CT uninsured rates vary significantly by geography, income, race/ethnicity and citizenship

New numbers from the Census find that last year minorities in CT were more likely to be uninsured, but not being a citizen raised your risk by more than four fold. CT residents with household incomes between $25,000 and $50,000 were most likely to be without coverage. Fairfield County led the state with 11% uninsured; Tolland was lowest at 5%. The survey found that uninsured rates in all CT counties dropped from 2008 to 2009. Almost one in five Stamford and Bridgeport city residents lacked insurance. For more, check the CT Health Policy Project issue brief.
Ellen Andrews

CT gets federal grant for health care workforce planning

The CT Employment & Training Commission and the CT Office for Workforce Competitiveness were successful in their application to HHS for $150,000 to support the CT Workforce Investment Strategies in Health Care (WISH) Planning Grant. The funds will be used to produce a statewide health care workforce plan, coordinate disparate planning efforts, strengthen regional workforce planning efforts, and improve data collection and data sharing capacity about licensed health care professionals across the state. The planning grant puts CT in a position to apply for subsequent federal grants to expand the state’s workforce over the next decade. State partnership members have committed over $100,000 in matching funds for the project.
Ellen Andrews

National health reform standards may not cover college health plans

The Wall Street Journal raises the question of whether the notoriously inadequate health plans offered to college students will be covered under national health reform regulations. While these plans are generally inexpensive they typically include caps on coverage and would not meet new standards on how much of premiums must be spent on health care. A study from Massachusetts found that profits were five times higher on student health plans than other insurance. About 80% of US college students are covered by public or private health plans. The article highlights the cases of students who fell through the cracks of questionable insurance often leaving them with massive medical debt. It is important to note that as national reform also includes an option for young adults to stay on their parents’ policies through age 26.
Ellen Andrews

Survey predicts employee share of health insurance to rise 12.4% next year

Hewitt’s annual survey of large US employers estimates health costs to be $9,821 per worker in 2011, up from $9,028 this year. While total costs are expected to rise 8.8%, workers’ share of that bill will rise 12.4%, continuing a trend of shifting more costs onto consumers. From 2001 to 2011, while total premiums will have doubled, consumers’ share of costs will have tripled. Hewitt blames higher medical costs – both increasing prices and higher utilization by a slightly older workforce due to layoffs – and national health reforms. Hewitt estimates that immediate reforms, such as removing annual and lifetime caps on claims and allowing children to stay on their parents’ polices until age 26, contributed 1 to 2% to the increase. The report acknowledges that national reform also provides new opportunities to reduce long term cost trends, but that the impact of those measures won’t be realized next year. To keep down their costs employers plan to raise employee cost sharing (increasing co-insurance and deductibles), changing how they subsidize dependent coverage and monitoring eligibility, holding venders accountable, and expand disease management and wellness programs. A growing number of employers plan to use penalties such as higher premiums and cost sharing to encourage workers to enroll in health improvement programs.
Ellen Andrews

Webinar cancelled

Unfortunately, the Malloy campaign has cancelled tomorrow’s webinar. We apologize for any inconvenience.

Gubernatorial candidates on health care

Connecticut’s next Governor will face significant challenges in health care as well as exciting new tools and opportunities under national and state health reform efforts. The candidates have both now released their plans. Click here for Dan Malloy’s plan and here for Tom Foley’s plan.
Join us for a webinar with Dan Malloy and Nancy Wyman next Tuesday at noon. The candidates will answer your questions. The Foley and Boughton campaigns received a similar invitation.

236,400 CT residents eligible for health care tax credits in 2014

A new report by Families USA estimates that $830 million in tax credits will be coming to 236,400 middle income CT residents to help pay for health coverage. The credits are structured on a sliding scale, targeted toward those who need assistance the most. The majority of people who will benefit have incomes just over twice the poverty level (currently $44,100/year for a family of four). 92% of people eligible for the credit are in working families. About half the likely beneficiaries will have been previously uninsured; they only receive the credit if they enroll in coverage. The other 57% will go to help pay skyrocketing health insurance bills for currently insured low income families. The credits are refundable (taxpayers don’t have to have large tax bills to get the full credit), and available as consumers pay their premiums; they will not have to wait until they file taxes to get the relief.
Ellen Andrews

CT medical home Medicare application in

The Office of State Comptroller has taken the lead in filing an application for CT to participate in a new Medicare option. The project would join the state employee plan, Medicaid, Medicare and private insurers in an exciting plan to build patient-centered medical homes for over a million state residents eventually. The Governor, DSS, the SustiNet PCMH Advisory Committee and dozens of consumer and provider groups have all signed on to support the application. The plan is to start with ProHealth, a large primary care practice with 74 sites across CT, but to reach out to other accredited PCMH providers soon after. Beyond the core PCMH functions, the project includes special focus on discharge transitions, expanding primary care for nursing home residents, extended hour facilities, and care coordination for patients with multiple chronic conditions. CT has also agreed to collaborate with a new multi-state PCMH collaborative sharing data, evaluations, technical assistance, and best practices. There is so much here to be excited about, but the best part may be the cooperation across agencies and provider groups. This project can serve as a foundation for thoughtful reform in Connecticut.
Ellen Andrews

Webinar: Dan Malloy and Nancy Wyman on health care issues

The next administration faces both great challenges and great opportunities to improve health care in Connecticut. Join us for a webinar September 28th at noon to hear from Dan Malloy and Nancy Wyman, Democratic candidates for Governor and Lieutenant Governor, on health care issues. There will be time for your questions at the end and, as always, a video of the webinar will be posted online. To register for the webinar and to be notified when the video is posted, go to https://www1.gotomeeting.com/register/260958984 After registering you will receive a confirmation email containing information about joining the Webinar.

CT uninsured rate up to 12%

The Census is reporting that CT’s uninsured rate rose from 10% in 2008 to 12% in 2009, an increase of 43,000 residents without coverage. Employer sponsored coverage levels held steady despite rising unemployment, possibly because of generous federal COBRA subsidies. While Medicaid numbers dropped during the study period, HUSKY enrollment grew and has grown faster since. Click here for the CT Health Policy Project’s brief.
Ellen Andrews

CT insurers propose double digit rate hikes

Once again CT health insurance companies are asking the CT Insurance Department for permission to charge very large premium increases, more than 20% in many cases, according to the Hartford Courant. Predictably, insurers are blaming rising medical costs and national health reform. Members of CT’s Congressional delegation and the Attorney General are objecting. The largest increases would fall on new businesses and individuals. CID has not yet ruled on the increases. In their applications, the insurers outline how much they believe various provisions in national reform will raise premiums above the effect of rising medical costs. Anthem estimates that requiring coverage for children with pre-existing conditions will raise premiums 4.8% and removing annual caps will cost 22.9% more. The federal government and independent analysts estimate the impact of national reform on premiums for next year at 1 to 2%. I hope that someone at CID remembers these estimates and looks back next year to see if they were realistic. Especially as they consider next year’s proposed increases.
Ellen Andrews

CT lags in health IT adoption

If you’ve been avoiding the health information technology debate (it can get a bit technical), yesterday’s CT Mirror has a great analysis. While electronic medical record adoption is slow across the US, it is glacial here in CT. There are several reasons nicely outlined in the story; we need to address them all. Health IT is critical to improving quality, reducing waste, avoiding errors, coordinating care (patient-centered medical homes), accountability, and so much more. How often have you heard that we don’t have the data we need in CT to do any meaningful system planning or even to know where the problems are? We don’t know what is really working and what is just hype. Health IT is critical to all this and more. The feds have devoted billions to the effort, but it is still a slow slog in CT. The problem is that busy providers, especially primary care practices, don’t have the time or resources to invest in health IT. It will help them, but it will help the rest of us far more. We need to support them – with money, resources, and political chits to make this happen. Hopefully, the next administration is listening.
Ellen Andrews

HealthJusticeCT launches website

Health Justice CT, a new social networking project to address racial and ethnic health disparities in CT, has launched a website, www.healthjusticect.org. It is interactive, gathering news, research, events, and online conversations. The resources section is particularly helpful. Health Justice CT is funded by the CT Health Foundation. Check back often to learn more.

CT residents need to eat more fruits and veggies, but we are doing better than most states

The good news is that CT residents eat more fruits and vegetables than most Americans, according to today’s MMWR. The bad news is that our consumption of fruits dropped each year from 2000 to 2009; vegetable consumption was somewhat steady. Last year, 37.6% of us ate fruit two or more times a day and 28.5% ate three or more vegetables each day. We all should be, but the US averages were 32.5% and 26.3%, respectively. Compared to other states, we do better in fruit consumption (5th) than veggies (11th). Eating fruits and vegetables is important for maintaining healthy weight and reducing the risk of many illnesses.


Between 1987 and 2007, the percentage of obese adult Americans more than doubled. A new analysis by CBO estimates that we could reduce health spending increases 3% by 2020 if we could level off rising obesity rates; we would save 4% if we could return to 1987 levels.
Ellen Andrews

Two job openings

The health policy sector of the economy is doing its part to reduce unemployment. The Bridgeport Child Advocacy Coalition is seeking a Director of Public Policy and eHealthConnecticut is seeking a CEO.

The new CEO of eHealthCT will lead the nonprofit organization dedicated to creating a sustainable, secure, private health information exchange in our state. eHealthCT is looking for a senior health care executive with an entrepreneurial approach. For more information, click here.

BCAC’s new Director of Public Policy will help the community coalition develop effective advocacy campaigns in areas such as early childhood, K-12 education, after-school programs, economic self-sufficiency and health care. Applicants should have experience in community organizing, policy and legislative advocacy, and coalition building. For more information, email information at cthealthpolicy.org.

The jobs are important, but so is the context. While the organizations seem very different, they have common goals. Connecticut needs to find more ways to bridge the gaps between policy cultures.
Ellen Andrews

Conversion to risk corridors in HUSKY seems less likely

As reported by Christine Stuart at CT News Junkie, in a meeting yesterday the Executive Committee of the Medicaid Managed Care Council considered HUSKY financing options outlined by DSS at the last Council meeting. The budget passed earlier this year includes $76 million in savings to move HUSKY from the current capitated system to a non-risk model where the state pays all medical bills and pays a fee to an outside company to administer the program. DSS favors a model that retains the current system with some, potential limits on profits and losses. Representatives from CMS on the phone emphasized that they do not favor any option and are not pushing CT into managed care. DSS also wants to extend whatever financing/managed care model is adopted for HUSKY to all Medicaid populations including the elderly and people with disabilities. All agreed that the current system is “broken” but without more information, they could not recommend any option. Most felt strongly that any new payment system should reward quality and value.
Ellen Andrews

Will Charter Oak survive?

An interesting story by Arielle Levin Becker at the CT Mirror asks whether Charter Oak will survive after Governor Rell leaves office. The best thing about Charter Oak is that people with pre-existing conditions are not excluded from coverage; under national health reform, that exclusion will be prohibited in all health insurance in 2014. It is also unclear whether some of Charter Oak’s limits in coverage that consumer advocates have criticized will be allowed in any coverage plan. There is also a question about the sustainability of funding. Currently, there are concerns that Charter Oak’s monthly $307 premiums are sufficient to sustain the costs of care for patients attracted to a safety net plan. As Charter Oak is now linked to HUSKY, insurers can spread the costs over a much larger pool. (An audit by the Comptroller’s Office found that the plans are overpaid in their HUSKY rates). If HUSKY converts to a non-risk model as is called for in the budget, in which plans are paid only an administrative fee and the state pays all medical bills, Charter Oak’s premiums will have to reflect just the higher risk of those consumers alone. Given the looming $3 billion deficit next year, it is unlikely that the state will subsidize the program. In the article, all the candidates for Governor expressed doubt about Charter Oak’s future.
Ellen Andrews

Win Win -- state cigarette tax increased revenue and reduced smoking

The $1/pack tax increase in cigarette taxes implemented last October brought in over $100 million while seven million fewer packs of cigarettes were sold, according to the Hartford Courant. It was expected that increasing taxes would both increase revenue and reduce cigarettes sold, but this increase brought in $5 million more than projected. The increase brought total taxes to $3/pack in CT, fourth highest in the nation but behind neighboring NY and RI. Over the last five years, the number of state residents who smoke and the number of packs sold has declined; about 17% of CT adults smoke.
Ellen Andrews

Almost half of Americans use a prescription medication each month

Forty eight percent of Americans reported that they had taken a prescription medication in the last month, according to new numbers from the CDC for 2007-2008. That number is up from 44% in the last ten years. Not only are more of us taking medications, but we are taking more drugs. The percentage of Americans taking five or more drugs grew from 6% to 11%; seniors are three times more likely to be taking five or more drugs than just one. Children and seniors are more likely to be taking medications; people without insurance or without prescription coverage are less likely. Americans without a regular place to access care are almost three times less likely to be taking prescription medications. The most commonly used medications were bronchodilators for children (for asthma), CNS stimulants for adolescents (attention deficit disorder), antidepressants for adults, and cholesterol lowering drugs for seniors. Prescription drug spending grew 3.2% from 2007 to 2008; that growth is expected to accelerate reaching 7.7% by 2019.
Ellen Andrews

Forty seven CT employers qualify for early retiree reinsurance program

Nationally less than one in three large firms offer health benefits to retirees. Premiums and deductibles for early retirees can be four times as much as for younger workers. National health reform included $5 billion for a temporary reinsurance program to help subsidize employer-sponsored retiree coverage for early retirees over age 55 but not yet eligible for Medicare. The program covers 80% of the costs of care for individuals between $15,000 and $90,000 in claims. HHS just approved the applications of forty seven CT employers for the program including the state employee plan. The plan is intended to continue until 2014 when state insurance exchanges will offer everyone affordable options. However, analysts estimate that the $5 billion appropriation is not enough and may run out as soon as 2012.
Ellen Andrews

September webquiz -- CT teens and risky behavior

Test your knowledge of CT teens and risky behavior. Take the September CT Health Policy Webquiz.

Candidates’ health care positions forming

Paul Bass of the New Haven Independent interviewed both candidates for Governor about their plans and a lot of the questions related to health care. Foley wants to emphasize community-based alternatives over increasing reimbursements to nursing homes; Malloy believes that both are needed as CT’s population gets older and health care needs increase. Malloy supports SustiNet as a means for CT to implement health reform; Foley believes SustiNet is too expensive and the uninsured is not a big problem in CT. In HUSKY, Malloy wants to enroll every eligible child; Foley emphasized rooting out fraud by individuals. Foley wants to privatize Riverview Hospital and Southbury Training School; Malloy does not and wants to address unmet needs for mental health care.
Ellen Andrews

On the passing of Brandon Levan

We have some very sad news to share. Brandon Levan passed away last week after a three month bout with cancer. According to his brother, “Due to his strong will and character, he never gave in and he fought the cancer to his last breath and passed away with dignity and bravery.” Brandon was a very committed volunteer with the CT Health Policy Project for the last two years and recently joined our Board of Directors. He graduated from Yale in 2008 and became a systems analyst/developer. Earlier this year, he quit his job to apply to medical school and become a healer. Brandon had a strong sense of how the health care system was failing consumers and he worked hard to change policies. He worked with the Project and New Haven Legal Assistance on PCCM outreach across the New Haven and Hartford communities, he attended meetings and testified at the Capitol, and was a main author of our candidate briefing book this year. Throughout his illness, he was still submitting chapters to the book. His last message to us was upbeat; he talked about how the experience of his illness made even more clear to him the unfairness in the health care system and how badly it needs fixing. Brandon was an inspiration to students, volunteers and staff here at the Project and will be dearly missed.
Ellen Andrews

PCCM/HUSKY Primary Care now on Facebook

The effort to move PCCM forward in Connecticut is taking a new turn - yes, we are joining Facebook! Type in “HUSKY Primary Care” on Facebook. The goal of this new group is to get people on or interested in HUSKY to talk about the exciting new option of PCCM/HUSKY Primary Care, with each other and with their “friends.”

Come join us and help get the word out!

CSG/ERC meeting slides online

Health panel slides from last week’s CSG/ERC annual meeting in Maine are online. They include Sen. Richard Moore (MA) and Trish Riley/Karynlee Harrington (ME, Dirigo) on payment reform, Lisa Letourneau (ME Quality Counts) on patient-centered medical homes, and Alan Weil (NASHP) on state roles in national health reform.

Admitting mistakes and making an offer reduces malpractice suits

A new study has found that responding to medical errors with full disclosure, an apology and an offer of compensation significantly reduces lawsuits, costs and the time it takes to resolve claims. Since the policy was instituted in 2001, malpractice lawsuits filed against the University of Michigan Health System monthly dropped from 2.13 to 0.75 per 100,000 patient encounters. Liability costs dropped by more than half. The health system reviews each claim to determine if there was an error – if not, they defend vigorously, if so they apologize and make an offer to compensate the victim. It would be interesting to see what the impact on total health costs (medical malpractice is often offered as a driver of skyrocketing costs, Michigan implemented med mal reform in 1994) and on the quality of patient care. There is evidence that linking the apology to resulting improvements in patient safety reduces lawsuits; many patients are not seeking money but want to make sure the same mistake doesn’t happen again.
Ellen Andrews

Updated health policy basics

Just in time for Back to School, the CT Health Policy Project has updated our health policy basics module for student, intern and volunteer training.

More health policy at CSG/ERC meeting

Last week’s CSG/ERC annual meeting in Portland ME included talks by some health policy rock stars.
Sen. Richard Moore, Senate Chair of MA’s Joint Committee on Health Care Financing, spoke in the Value to Volume panel. He described MA’s progress toward rewarding higher quality providers in the state employee health plan, using public reporting, and tiering provider payments as tools. As much of health spending is focused in specialty care, they began there. Challenges included accurately attributing the right patients to the right providers, problems with consumer choice (if there are too few providers available consumers can’t use the economic incentives), and the reliability of provider quality assessments (ratings of providers with very few state employees may not be meaningful). He updated the committee on progress toward statewide cost control. Challenges include workforce shortages (if consumers do not have a choice of providers, cost sharing incentives can’t be effective), creating an all-payer database, public and provider resistance to tiering, adoption by self-insured plans, and creating improvement incentives and tools for low-performing providers. Future plans include statewide health information technology adoption by 2014, requiring meaningful HIT use for licensure, expanding the number of primary care providers, standardizing claims processing, and creating patient and family advisory councils to engage consumers.

Karynlee Harrington, Director of the Dirigo Health Agency, talked about Maine’s progress toward quality-based purchasing. Maine has 39 hospitals for 1.3 million people, ED use is 30% higher than the US average, and has $400 million in avoidable hospitalizations annually, all driven by the fee-for-service environment. In response the legislature created a payment reform workgroup that developed a set of six guiding principles. She outlined the Maine Health Management Coalition that includes the state’s major employers in quality-based payment reform, and the patient-centered medical home initiative with 26 sites currently and plans to grow.

Alan Weil, Executive Director of the National Academy for State Health Policy, described the opportunities and challenges for state policymakers in national health reform. He described choices involved in development of state insurance exchanges, changes to regulation of health insurance, the need to simplify and integrate eligibility systems, address workforce shortages and system capacity, benefit design challenges, challenges for dual eligibles, data needs, population health goals, and engaging the public.

Elliott Fisher, from the Dartmouth Atlas program, described his pioneering work outlining the disconnected goals of our current utilization-based health care system that fosters high health care spending but low quality outcomes. He described how the health care market is different from other markets in that supply can drive its own demand (who says no to a doctor that says you need another test), preference driven care, and too few incentives for effective care. He outlined the need for accountable systems of care (accountable care organizations), thoughtful workforce policies, and end-of-life care.
Ellen Andrews

Patient centered medical homes at CSG/ERC

At today’s Council of State Governments/Eastern Region Annual Meeting in Portland ME, we heard a fascinating panel on patient centered medical homes. We heard from Lisa Letourneau of Maine Quality Counts about their multi-payer PCMH pilot, including Medicaid – they have included community health centers, private practices and hospital-owned practices serving adults and children across the state. They are requiring NCQA accreditation plus ten other “core expectations” including population risk stratification and management, connection to community health and wellness programs, and a commitment to waste reduction. The pilot includes a learning collaborative, quality improvement practice coaches, technical assistance experts, including how to work with consumers effectively, and ongoing feedback, both clinical and claims-based, from an all-payer state database. PCMH providers are paid their regular fee-for-service rates, plus a per-member-per-month care management payment (about $3 pmpm) and the P4P bonuses they are getting now from the payers. Ten percent of all primary care practices in the state applied to participate in the program, reflecting broad support from providers across Maine. The 3 year pilot started operating in January. Lisa outlined the challenges encountered so far and lessons learned – change starts with effective leadership (physician leadership skills need ongoing support), change happens through effective teams, NCQA credentialing is not sufficient, the value of outside coaching and “it’s all about relationships” – with patients and within teams.

Then Ron Preston, from the University of New Hampshire, former CMS Boston office director, spoke about the current Medicare PCMH demonstration applications due tomorrow. This demonstration is different for Medicare in that only states can apply, they expect other payers to be engaged, they expect the project to be scalable – there needs to be an indication that other providers are interested in joining the effort in the future, they expect standards for PCMHs (such as NCQA), the pilot must engage the rest of the health care system, and must, of course, be cost neutral. CT is expected to submit an application along with other states for this competitive opportunity; Ron worked with the Comptroller’s Office and DSS to develop CT’s application. Ron also talked about the new cooperative arrangement forming among the New England states to support PCMHs including learning collaborative and evaluation activities.
Ellen Andrews

DSS outlines options to move HUSKY away from capitation – or not

At yesterday’s Medicaid Care Management Oversight Council (formerly known as the Medicaid Managed Care Council), DSS outlined three policy options to restructure HUSKY’s financing. The options were a response to direction in the latest budget to move HUSKY from a fully insured, capitated system to a self-insured, ASO model; the budget included approximately $75 million this year in savings from the switch. The options include a non-risk ASO model using the current Medicaid provider network – similar to the successful Behavioral Health Partnership, a non-risk ASO model using the current HMO provider networks, or continuing the current capitated managed care arrangement with the tweak of risk corridors -- essentially limiting potential profits and losses by the HMOs. The last, most regressive option, appears to be DSS’ favorite.

Advocates pointed out that, while the current Medicaid provider network is admittedly inadequate, when dental care and behavioral health services were carved out to non-risk arrangements, the number of participating providers increased significantly. Advocates pointed out that the HMOs in this program have never really been at financial risk -- they have consistently received whatever they ask for in negotiations, largely because of a lack of oversight and extreme aversion to re-bidding. Advocates also noted that while DSS considers leveling the playing field and paying all providers equal rates in an ASO arrangement as a disadvantage (rates for a few providers might decrease slightly), it is probable that providers would welcome a system that is more fair. When you are being underpaid, it is some comfort to know that at least everyone else is in the same situation. Other advantages to the non-risk ASO models include improved transparency, accountability, and a better ability to provide incentives for quality care directly to the providers who are most directly connected to care. Advocates also pointed out that DSS neglected to consider potential savings from re-bidding the contracts to bring in plans with larger provider panels and lower costs through competition. All of DSS’ options include negotiating with the same three companies that now participate in HUSKY and Charter Oak. Expanding the potential number of competitors could significantly improve the state’s position in those negotiations, save tax dollars, support accountability, and expand access to care for families. The reason for not re-bidding has always been administrative burden on DSS and timing – they don’t have time to capture the savings. Neither of those reasons applies now.

DSS also strongly recommended using the same payment structure for all Medicaid programs – for HUSKY, ABD (aged, blind and disabled) and LIA (low-income adults). This decision will cover at least $4.5 billion/year in health coverage for over half a million state residents. Council members were clear that this is a very large, very important decision that should not be rushed into, despite DSS’ concerns that they will not meet the savings targets in the budget negotiated by the Governor and legislature. A committee of Council members will meet with DSS to explore the options and report back next month.

At the meeting, we neglected to thank DSS for outlining options to the Council and soliciting our input before a decision has been made. This is a welcome change for the department and they should have been recognized for it. I regret missing that.
Ellen Andrews

More evidence that doctors and patients are not communicating

A new study by Yale and Waterbury Hospital researchers finds that despite the fact that physicians believe that they are completely explaining hospital discharge plans, many patients do not understand very basic information. 90% of patients report that they were never advised about side effects when prescribed new medications; in fact, only 25% report being informed by their doctor that they were prescribed new medications they hadn’t been taking before admission. Physicians and patients differed significantly in assessments of whether the patient wanted to become more involved in their care. In good news, it seems that physicians understand that they are not always being clear and there are no significant differences in communication based on patient age, sex, race or payment source (Medicaid vs. other sources). This study builds on others finding that too many patients do not know their doctor’s name, their diagnosis or understand their medications. This work highlights both the challenges and the importance of patient-centeredness in healthcare.
Ellen Andrews

New to the Book Club – national health reform

The newest addition to the CT Health Policy Project Book Club, Landmark: The Inside Story of America’s New Health-Care Law and What It Means for Us All by the Staff of the Washington Post, details the ups and downs of how national health reform passed this year, highlighting the players. Our Sen. Lieberman got his own chapter. The the book takes the reader through the law in understandable chapters outlining the impact on each stakeholder group. It’s on the reading list for my classes this fall.

Don’t forget to vote, compare candidates on health care

It’d be hard to miss, but today is Primary Day in dozens of races around the state. Today Democrats and Republicans will choose their candidates for Governor. If you are still confused about the candidates’ positions on health care, check out our Candidate Compare. The polls are now and stay open until 8pm.

21% of CT adults are obese

Over one in five adults in our state were obese in 2009, up from 12.5% in 1995. While that is bad, we are below the even worse US average of 26.7%. As in the rest of the US, CT adults between the ages of 45 and 54, men, and blacks are at greatest risk. College graduates are less likely to be obese but the benefit seems to require graduating – there was little difference between high school graduates, less than high school or some post-high school education. Maybe it has something to do with the fact that only 28.3% of us in CT are getting five servings of fruits or vegetables in a day, and 68% of us aren’t even physically active for 20 minutes three days/week.
Ellen Andrews

Eastern region state/provincial updates

The latest health policy updates from the CSG/ERC states and provinces has been posted. The region includes states from New England south through Maryland and west to Pennsylvania; we also cover the Canadian provinces from Newfoundland west to Ontario. CSG/ERC’s health committee includes over 50 executive and legislative branch state and provincial policymakers.

Enhanced Medicaid match funding moving through Senate

The Senate has reached a deal on an extension of the enhanced Medicaid matching funds that most states had already counted on in budgets. CT’s current year budget included $266 million in expected funding which was scaled back to $199 as part of the deal. However, states were concerned that none of the funding would be approved. Many groups, including CSG/ERC, have been lobbying Congress intensively to restore the funding through next June. The funding to states was originally included as part of last year’s stimulus package but was scheduled to end in December.
Ellen Andrews

CT gets $695,000 for electronic health records in Medicaid

CMS has awarded CT $695,000 in federal matching funds under the federal stimulus program for state planning activities to implement electronic health records in the Medicaid program. This funding will match state spending at the 90% rate – the state needs to contribute only $77,222 to access the full federal amount. The funding will help CT analyze the current status of EHR use in the state, identify barriers to adoption, assess provider eligibility for EHR subsidies, and create a statewide Medicaid health information technology plan.
Ellen Andrews

Candidate compare for next Tuesday’s primary

Connecticut’s next administration will face significant health care challenges but also benefit from unique and historic opportunities to improve our state’s health. For health care voters in next Tuesday’s primary, we’ve collected health care policies from the major candidates running for Governor.

August webquiz – Have you read the SustiNet reports?

The SustiNet task forces and advisory committees have completed their final reports. The committees explored and made recommendations on CT’s health care workforce, obesity, tobacco, prevention, disparities, information technology, quality/providers, and patient-centered medical homes. Since we’re sure you’ve all added the reports to your beach reading for the summer, take a pop quiz. The August CT Health Policy Project Webquiz focuses on the reports and their findings.

CT hospitals cutting costs and jobs

St. Francis hospital will be laying off 200 workers and other CT hospitals are also cutting payroll, according to the Hartford Courant. Like other CT businesses, the cuts are due to the recession, in part, increasing the number of patients who can’t pay their bills, the number on public coverage such as HUSKY which pays less than private coverage, and patients delaying elective procedures. Also contributing are other structural shifts such as expanded home health care and competition from non-hospital based providers. Complicating the picture, however, for the last three years CT hospitals improved their operating margins (profits) significantly, totaling almost $250 million last year. Information on individual hospitals’ finances is expected later this month.
Ellen Andrews

Wellness programs not living up to the hype

A new study finds that building effective corporate wellness programs is not as easy as it seems. Employers have blamed workers’ poor health habits for rising benefit costs and are embracing programs intended to get us to “take responsibility’ for our health, lose weight and stop smoking. However new research finds that many of these programs are a waste of money. Effective programs include personalized follow up, such as health coaching, clear commitment to the program from company leadership with a clear linkage to company goals, reasonable expectations, and careful use of incentives. Purchasing off-the-shelf, cookie-cutter programs with no employer involvement is the option most likely to fail. Unfortunately wellness, like everything else in healthcare, is labor-intensive and takes years to show financial results. WSJ blog authors offer that as they tend to lose weight on vacation, management should consider extending vacations.
Ellen Andrews

DPH public hearings on health information technology plan, privacy policy

Next month, DPH will be holding public hearings and accepting public comment online on their proposed plan for health information exchange for Connecticut. The plan includes a controversial privacy policy recommendation to default all patients into the system, unless they affirmative opt-out. Under the opt-out plan, providers would be responsible for removing any sensitive information (HIV, behavioral health, reproductive health issues, etc.) from shared records. Providers accessing information from the system will not know if the patient records are complete or whether any medications or treatments have been removed. Advocates have raised concerns about this policy. Health information technology holds great promise to improve the quality of care, patient safety and reduce costs; it is critical that privacy be a high priority to ensure public trust and the integrity of the system, especially in the case of any breach of information. Consumers must fully understand the system and their rights, both benefits and risks. Last year eHealthCT, a nonprofit dedicated to expanding health information exchange in CT , convened a privacy and security committee of CT stakeholders including providers, consumer advocates, state agency staff, legal and technology experts for a Medicaid pilot health information exchange. After an extensive public process, that group recommended an opt-in policy including patient information only after they have affirmatively agreed to participate. Massachusetts conducted an well designed, extensive, effective public education campaign that included significant consumer input for their opt-in policy and over 90% of patients choose to participate. Vermont’s exchange began with an opt-out policy, similar to DPH’s recommendation, but after operating the exchange has changed policy to opt-in. DPH intends to send their recommendations to the federal Office of National Coordinator for Health Information Technology (ONC) to access millions in federal grants to create CT’s health information exchange. DPH’s health information technology committee includes no consumer representatives.
The hearings will be August 19th from 5 to 7pm in Room 2E of the Legislative Office Building and August 26th from 9 to 11am at the Holliday Inn, 201 Washington Ave, North Haven. Online comment will be accepted August 16 thru 27 at www.ct.gov/dph. DPH reportedly expects to submit the recommendations to ONC Sept 7th.
Ellen Andrews