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