Congressional staff not worried about defunding health reform

Health staff for CT’s delegation are not concerned about prospects of defunding national health reform – a great relief for policymakers across the states worrying about their responsibilities under the law. A lot of the funding is mandatory. In general, everyone has a great attitude about the constant stream of votes by the new majority in the House to repeal everything accomplished in the last two years. I tend to be worried when I come down for these trips, but I leave very comforted – everything will be OK. They all emphasized that their members are eager to help us secure every opportunity for CT to build our health system and support innovations. They will be sorry they offered.
Ellen Andrews

Health care reform – CT and national

While Republicans in Washington work to repeal national health reform, Connecticut’s Public Health Committee has raised the SustiNet bill – our state’s version of reform.

Painless way to save $40 million in HUSKY

Our new policymaker issue brief outlines how moving HUSKY to self-insurance should save the state at least $40 million, without any changes in access to care. In 2008, under the PHIP/ASO model medical costs were actually lower than under HMO capitation the next year. Because the shift to self-insurance was sudden DSS was in a poor negotiating position . The administrative fees paid to the HMOs were $5 per member per month higher than the HMOs spent the next year – when they were spending their own money. As the state is now in more deliberative negotiations with the HMOs, it is possible to secure more reasonable administrative rates. Together, the lower medical costs and more reasonable administrative fees could result in significant savings to the state. Both SustiNet and the current state budget require self-insurance for HUSKY. If DSS chooses to re-bid the program rather than limiting negotiations to the current HMOs, we could save more and potentially engage partners with larger provider panels – easing the severe shortage of providers willing to see HUSKY patients.
Ellen Andrews

Vermont pursuing single payer reform

Under Act 128 passed last year, Vermont is considering implementing a single-payer health care system for their state. The much-awaited consultants’ report outlining options was released Wednesday. One option is very similar to CT’s SustiNet plan.

The report outlines the cost and quality pressures that led Vermont to consider a single-payer plan including fragmentation of care, cost shifting between payers, skyrocketing costs, economic burdens, and rising consumer debt levels – all common to other states. The report outlines federal barriers and opportunities to support a single-payer option. The options had to provide coverage for every state resident and fund the costs of covering the uninsured and underinsured with savings from the reforms. They propose a timeline with full implementation in 2015.

The first option includes a government-run system covering every state resident with one insurance fund and a standard benefit package funded by employer and worker contributions. The legislative budget process will define the fixed global budget for the system. The option also includes plans to expand primary care provider capacity and encourage wellness programs. This plan is estimated to reduce health spending by 24.3% between 2015 and 2024.

The second option is very similar to our SustiNet plan. This alternative creates a public coverage option within Vermont’s insurance exchange, but all claims payment and administration, across all payers, would be funneled through a single source. The public option plan would be government-administered and would compete with private plans in the market. It is estimated that this option would save 16.1% of health spending.

The last option is similar to the first, but instead of being administered through government, this option would be governed by a public/private board. The hope is that this structure will insulate the system from political pressures around coverage and payment rates that have posed barriers to cost containment in other systems. This option is estimated to save the most at 25.3%.

Savings among the three options result from reductions in administration, fraud and abuse, waste and duplication, implementing integrated delivery systems (Accountable Care Organizations), health information technology and medical malpractice reforms. Options one and three include uniform payment rates for providers across all payers and all options envision a move to risk-adjusted capitated payments for providers.


The 138 page report is very detailed and Vermont-specific. Interesting reading.
For background on payment reform, including Accountable Care Organizations, go to CSG/ERC’s Value over Volume report.
Ellen Andrews

Rep. Courtney on health reform repeal debate

Our CT Health Policy Project Board member and longtime advocate for CT’s health care consumers, Rep. Joe Courtney argued persuasively on the floor of the House against the recent bill to repeal national health care reform. Unfortunately, he was not able to persuade enough of his colleagues to join him in voting no. To watch his remarks, go to http://www.youtube.com/repcourtney. For a webinar with Rep. Courtney on what reform means for CT consumers struggling to access health care, go to http://www.cthealthpolicy.org/webinars/default.htm. The repeal bill now goes to the Senate, where it is not expected to pass.

CHCradio.com – Headlines and interviews with health policy leaders

Every Tuesday at 4:30pm CT’s Community Health Centers Inc. sponsors Conversations on Health Care, a fascinating series of radio shows including headlines and interviews with leaders across the health policy spectrum. Speakers have included Dr. Carolyn Clancy of AHRQ, Maureen Bisognano of the Institute for Healthcare Improvement, and Dr. Howard Koh, Assistant Secretary for Health at HHS. Listen online or on your mobile device.

The final word – HUSKY ASO cost less than HMOs – or it should have

At Friday’s Medicaid Oversight Council meeting Mercer actuaries gave us the final comparison of the costs of the HUSKY program under the ASO/PHIP arrangement compared to the costs under capitated HMOs. We learned that in 2008 during the PHIP period, when the Governor removed any financial risk from the HMOs and the program ran as a self-insured ASO model, medical costs per member per month actually dropped $2.78 pmpm (per member per month) compared to the next year when the program was fully capitated under the HMOs (comparing 2009 adjusted dollars). Unfortunately because the shift to PHIP was sudden and the state was at the mercy of the HMOs, we paid them $5.47 pmpm more to administer the program than they spent the next year – when they were spending their own money (again in 2009 adjusted dollars). The bottom line is that, moving forward, as the state is negotiating new contracts with the HUSKY HMOs, if we return the program to the self-insuring ASO/PHIP model and pay the HMOs the more-than-reasonable administrative rate that they managed with in 2009, again for emphasis when they were spending their own money instead of ours -- the state could save over $41 million (in 2011 dollars). This would involve no disruption in care continuity, no change in quality of care, but would increase access to care immeasurably. No brainer.

If we bid it out, we might bring in new players with more providers and save even more.

At the Council meeting, we also heard AmeriChoice’s extremely disappointing performance improvement report. They measured their performance in four areas – adolescent wellcare, timely prenatal care, comprehensive diabetes care and mammograms. In no area was the plan’s performance above the 50th percentile; in two of the four cases it was at the 10th percentile. The plan acknowledged that these created “key opportunities for improvement.” No meaningful corrective plan was provided; there was no indication of accountability for the plan by DSS.

Consultants Meryl Price and Marcia Stein of Health Affairs Matters presented their report to the Council on the success and potential of varying Medicaid payment models from other states. The consultants emphasized that their study was not an evaluation of CT’s program, but a comparison of other states’ models. PCCM and MCOs provide roughly equal opportunities for improving quality and managing costs. States found having both programs in place provided incentives for each to perform better and a robust PCCM program gives states important negotiating leverage with HMOs. Patient centered medical homes offer more levers, particularly to improve quality and add value. Accountable Care Organizations (ACOs), which are very new and have not been evaluated, in theory offer even more opportunities. However CT is far from prepared to create Medicaid ACOs at this point (see above). The report serves as a starting place for the Council and other policymakers to begin discussions on Medicaid payment reform. An important theme emphasized by many states was that the specific payment structure is far less important than strong oversight, solid evaluation data to act on, and a willingness to follow through.

In response to a question, DSS announced that they have been separately working with provider groups to design payment reform plans for Medicaid consumers in the fee-for-service program moving them into some form of managed care. The Council created a subcommittee to track DSS on their plans and advise the Council.
Ellen Andrews

Advocacy group financial ties to drug companies probed

The Wall Street Journal Blog is reporting on growing interest about drug company financial support for health care advocacy organizations. The latest report on funding from Eli Lilly found that only one in four groups that receive the funding disclose it on their website. The company admits that they fund groups that advocate in areas where they sell a lot of drugs or hope to expand their market. Senator Grassley has highlighted the role of drug company funding to groups that advocate for people with mental illness. Last summer a controversy erupted when the American Academy of Family Physicians accepted funding from Coca Cola for an obesity prevention project.
Ellen Andrews

Cthealthbook.org – new collection of resources

While you are home avoiding getting out to shovel, check out the updated www.cthealthbook.org. The site includes a collection of basics on CT’s health care environment. Health Policy 101 is a basics module created as a training tool for incoming CT Health Policy Project interns, volunteers and staff. Health Policy 201 includes 21 sets of slides from a class given this fall on topics ranging from health care finance, Medicare, Medicaid, private insurance, the uninsured and international comparisons along with some of the class writing assignments. The site also includes a link to our 2010 candidate briefing book with 21 short briefs on CT’s health care environment, background, trends, and policy options. Topics in the briefing book include obesity, tobacco, health information technology, workforce, patient-centered medical homes, and accountable care organizations.

UConn Dempsey Hospital’s high use of controversial scans questioned

Patients at UConn’s Dempsey Hospital in Farmington are nearly ten times more likely to receive “combination CT scans” than at other CT or US hospitals; other CT hospitals’ rates are similar to the national average. In 2008 national rates for the higher intensity scans were 5% for chest scans and 19% for abdominal scans; at Dempsey those scan rates were 48 and 72% respectively. The controversial scans expose patients to much higher levels of radiation – 700 times higher than a standard X ray for combination CT scans of the chest. Radiation from CT scans given nationally in 2007 has been estimated to cause 29,000 cancers. Combination CT scans are also more costly, almost 60% more expensive, than standard scans. Experts at CMS state that combination CT scans are very rarely necessary and are concerned about over-treatment. Dempsey officials were “absolutely staggered” by the results and are changing policies to reduce overuse of the scans.
Ellen Andrews

SustiNet final report off to General Assembly

The SustiNet task force has sent their recommendations to the legislature. Recomendations include payment and delivery system reforms, including patient centered medical homes, and taking advantage of a federal reform opportunity to extend Medicaid eligibility to twice the poverty level for adults – saving money for CT consumers and for the state. The plan includes a stepped implantation schedule for a public insurance option beginning by combining the state employee and Medicaid programs into one large purchasing pool – however each plan will retain its own benefit package, provider panels, and payment rates – most members will not notice any change. The larger pool will be able to use its size to leverage improvements in quality of care and conserve precious resources. Next, SustiNet will be offered to municipalities, nonprofits and small businesses. In 2014, SustiNet will be opened as an option, both inside and outside the new state insurance exchange, to consumers – just as residents of our state and all Americans will be required to secure coverage under national health reform. SustiNet will be voluntary for individuals and one of many options available to consumers. Now the recommendations go over to the sausage factory hopefully for passage into law. Then the even harder work of implementation begins.
Ellen Andrews

January CT Health Policy web quiz – long term care

Test your knowledge of long term care costs in Connecticut. (Hint: they are very high). Take the January CT Health Policy Webquiz.

Geek alert: New report on geographic variation in Medicare spending

Huge variations in health care spending per person between different regions of the US have generated a lot of interest in the last year or two. The variations cannot be explained by the incidence of disease, demographics, or even prices. You won’t be surprised to hear that CT is a very expensive state. There is a large body of literature showing that higher spending does not correlate with quality. While this is controversial, there is even evidence that higher spending is linked to lower quality of care. This research, spearheaded by the Dartmouth Atlas project, has generated great hope (and high expectations) that we can learn what more efficient regions are doing right, take what we learn to other regions, and both save money and improve people’s health. (We were very lucky to hear from Dartmouth’s Elliot Fischer, a leader in this research, at last summer’s CSG/ERC annual meeting.) If we can figure this out, it could save as much as 30% in health care spending. (Now do I have your attention?)

A new report by Medicare actuaries sheds more light on these regional differences. Surprise #1 – they found no difference between patients who died that year and those who didn’t – it’s not end of life spending. Sort of surprising – they found that the variation is greatest in post-acute care spending (nursing homes, home health care, inpatient rehab hospitals, durable medical equipment, long term care hospitals, etc.) not inpatient or ambulatory care. Variation in post-acute care spending can range from $60 to $450 between regions. There’s lots more in the report but I’ve probably lost all but the most wonky readers by now. Read it.
Ellen Andrews

Serious quality of care questions in defibrillator implants

A new study on over 100,000 patients found that over one in five who received heart defibrillator implants shouldn’t have, based on best practice guidelines. The implants require surgery, with a risk of complications, and cost about $25,000 each. Not only was the surgery risky and expensive, but the 22% of patients who should not have received implants were at significantly higher risk for in-hospital death than appropriately treated patients – four more deaths per 1,000 patients when the devices were implanted contrary to guidelines. The chance that a patient would receive an implant contrary to best practice guidelines was significantly different depending on the specialty of their physician. More evidence that we are being overtreated and it is compromising our health.
Ellen Andrews

Online calculator outlines bottom line business case for quality

I’ve been playing with NCQA’s Quality Dividend Calculator – a cool toy that estimates how much improving health care quality can mean to a company’s bottom line. Visitors input some basic information about a company (I made mine up) such as number of employees, ages/gender, total revenues, overhead percentages, area of the US, industry, how often you replace sick workers with a temp, etc. The calculator estimates the number of workers suffering from various chronic diseases, how many sick days they take, productivity losses, what it costs your company and finally shows the difference choosing a higher quality plan can make for your bottom line. I was just trying to procrastinate writing a paper, but I ended up learning a lot.
Ellen Andrews

New report confirms that uninsured are NOT the reason for ER overcrowding, Medicaid is

Six out of seven ER visits to CT hospitals did not require hospital admission between 2006 and 2009, according to a new report by the Office of Health Care Access. Almost half were for non-urgent problems. Uninsured patients accounted for only one in eight ER non-admit visits, virtually the same as their proportion in the population. Medicaid accounted for one third of ER non-admit visits. (Possibly more -- it is not clear from the paper’s methods section if the 400,000 HUSKY members are classified as Medicaid or commercial insurance). The number of non-admit ER visits rose by 10% over those four years. ER visits were 41% more likely to be non-urgent for residents of urban core areas than wealthy community residents. Among urban core residents, Medicaid accounted for more ER non-admit visits than all other payers combined. The authors comment, “Residents of urban core towns with federal or state government sponsored health care coverage may be using EDs for treatment instead of visiting primary health care facilities.” More proof that access to care is exceptionally difficult for Medicaid patients.
Ellen Andrews