Medicaid self-insurance/ASO planning meeting

Friday DSS met with advocates, providers, state agency representatives, and potential bidders to collect input on the RFP for an administrative services organization (ASO) contract for all 600,000 state Medicaid members. In a shift of policy, the Malloy administration announced three weeks ago that the state would be moving to a self-insured ASO model for the Medicaid program by Jan. 1, 2012 and eventually offering every member a patient-centered medical home (PCMH) through the PCCM program. The current capitated HUSKY HMO model this new contract will replace has struggled to save money and provide care to over 400,000 children and parents over its entire fifteen year history. There was a lively debate with the department over advocates’ recommendation that ASO and care management functions be contracted from separate organizations. Until PCMHs are available statewide, DSS intends to provide care management services from a centralized source. Advocates argued that some ASO functions, such as utilization management, may at times be in conflict with care management. As the administrative and care management functions are separate capacities and often do not overlap in single organizations, it would be wise to contract with a different entity than the ASO for interim care management services, ensuring that the state is able to get the best value for each set of functions. Advocates are also concerned that an ASO will have no economic incentive to support development of PCMHs as that would result in a loss of revenue. A separate contract could be written with the expectation that the care management contract would eventually cease and incentives to help develop local PCMHs could be included. It was noted that in behavioral health, administrative and care management functions have reportedly been delivered by a single company with success, however over 15 years and across at least that many HMOs, the record of co-locating administrative and care management functions for HUSKY families has been disappointing. The advocates also argued strongly for a single ASO, to have the ASO responsible for recruiting (not credentialing or paying) providers, and that financial incentives be tied to quality standards over simple savings. The RFP is expected next month.
Ellen Andrews

Insurance exchange planning meeting

CT’s Health Insurance Exchange Planning Group held its first meeting under the new administration. Filed legislation offers two very different views for CT’s health insurance exchange, particularly regarding the role of insurers and providers in developing standards and choosing health plans allowed to participate in the exchange. OPM reported on the RFP for development of CT’s exchange planning grant; six letters of intent have been received. The group discussed the successful regional application, led by Massachusetts, for exchange enrollment planning and how it will benefit CT. The current twenty two members of the planning group include five from the insurance industry, eleven from state agencies, four providers, one small business representative and a former legislator; no consumers or advocates are included. It was noted that membership of the group will be changing. OPM is developing an outreach strategy to collect input from stakeholder groups and the public. OPM will be accepting comment on the plan from committee members until March 4th.
Ellen Andrews

Free dental care resource

The CT State Dental Society website includes a new charitable outreach dental calendar outlining free dental care events across the state. The site lists what is covered, where, when, who is sponsoring, and how to get more information.

State Health Insurance Exchange Webinar

Join the Council of State Governments for a webinar for our Eastern region states with Joel Ario, DHHS Director of the Office of Health Insurance Exchanges, to answer all our questions about federal funding and supports for states creating health insurance exchanges. The webinar is tomorrow, Feb. 23rd at 11:30 am. This promises to be a very productive discussion and well worth your time. To register, go to https://www2.gotomeeting.com/register/138484027. For more info on the webinar, click here.

CT Health Foundation fellows program

The CT Health Foundation is currently seeking nominations for their Health Leadership Fellows Program. Training includes understanding and implementing health systems change solutions; developing strategic messaging and communications; and organizing and working in multidisciplinary teams. The Foundation is seeking people who will work to eliminate racial and ethnic health disparities. Applications are due by May 1st.

Medicaid Council update

Today's meeting started with an entertaining LOB intruder alert drill by the Capitol Police. DSS described shift to ASO for Charter Oak, HUSKY A and B, low income adults and all other Medicaid clients. The goal is to create dynamic, innovative local systems of care and support that are rewarded for providing better value over time. Most decisions have not been made. They do not believe they need any legislative changes to implement the program and expect to release an RFP next month and have the program operational Jan. 1, 2012. ASO functions will include a call center, utilization management, assignment of members to primary care providers or patient-centered medical homes, routine and intensive care management/coordination, coordination with other medical programs, risk modeling, member handbooks, and cost and quality data aggregation. DSS will remain responsible for provider contracting, credentialing and claims payments. By January they expect to have every member assigned to a primary care provider, but sufficient expect patient centered medical homes capacity to take longer. They will make 5% of the ASO’s payments contingent on reaching quality and savings standards. Eventually DSS wants to have similar incentives for providers and move to a shared savings model. Advocates suggested that the state contract with only one ASO to reduce fragmentation and competitive distractions in the program, to attract the widest possible range of bidders that there be no advantage to the current HMOs should they choose to apply in scoring the RFPs, bonuses based on quality over savings to avoid any incentive to deny care, and to have the ASO responsible for recruiting and supporting providers. Advocates are also concerned that as DSS acknowledged, local systems of care are more effective; the closer care is to the patient, the more effective it is likely to be. However, leaving care management functions with the ASO until patient centered medical home capacity is built, requires the ASO to foster a system that eventually will reduce their functions and bottom line. It would be better, in the interim, to have a different entity provide care management to members who don’t have a patient centered medical home. The other advantage is that care management requires different skills and staff than more administrative ASO functions and separating the two could widen the pool of available bidders – giving consumers better service and a better price for the state.
The Council then heard about value-based purchasing and developed questions/priorities for the state as we move forward with payment and delivery reform.
Ellen Andrews

Governor’s budget proposal out

Governor Malloy’s first budget proposal, released today, includes tough choices for health care consumers but also some very good news. New copays for Medicaid services will likely reduce both appropriate and inappropriate utilization, but all Medicaid members will be able to access important tobacco cessation treatment. Reductions in benefits for low income adults are concerning but moving HUSKY families out of HMOs and into non-risk Administrative Services Organizations and creating PCCM/patient-centered medical homes for every Medicaid member is an important innovation that will save $41 million in FY 2012 (only effective for half the year) and $86 million in FY 2013. We expected consumers to share some of the sacrifice necessary to fill a $3.2 billion budget deficit, and they will. But a previous administration, with a much less deep budget hole, cut 20,000 HUSKY parents from coverage completely. Even in good times the day each year that the Governor releases his/her budget has never been a good day for consumer advocates, but today wasn’t as bad as I feared. For our analysis, click here.
Ellen Andrews

SustiNet and health insurance exchange bills heard

The Public Health, Human Services and Insurance Committees had a public hearing on the SustiNet bill and competing visions for CT’s health insurance exchange yesterday. Public support was overwhelming for SustiNet; most legislators were supportive. Some asked for concrete assurances of how much the plan will reduce costs and improve access to care. But as several speakers pointed out, there are no guarantees in health care. SustiNet is an option – if it doesn’t save money, people won’t join it. And where we were headed is not working for anyone.

The two visions for the state’s new health insurance exchange share many features but differ in some very important ways. Under national health reform, states create health insurance marketplaces that make coverage choices clear for individuals and small businesses. CT’s exchange will help residents eligible for subsides purchase coverage. Exchanges will set standards for insurance companies to participate in the exchange and monitor marketing for deceptive practices. One vision, SB-921, puts insurers and providers on the governing body that will decide which insurers can participate in the exchange – a clear conflict of interest. CA, MA and ME’s exchange boards do not include people with current financial ties to the industries they will regulate or oversee and the conflict of interest may raise legal problems. The other version of exchanges, HB-6323, does not allow those conflicts of interest. HB-6323 also includes more sensible protections and innovations including consumer surveys, focus groups and secret shopper studies to make the exchange user-friendly, rate plans based on customer satisfaction, seamlessly coordinates with enrollment into Medicaid for eligible applicants, creates a standing consumer advisory committee, ensures that no plan’s marketing is designed to discourage high-need patients, strong transparency and quality of care standards, requires coverage of emergency care and adequate provider networks.
Ellen Andrews

Webinar: CT health information exchange up and running

Join us for a webinar with Scott Cleary of eHealthCT, Feb. 22nd at 1pm to hear about CT's successful Medicaid health information exchange. Funded under a Medicaid transformation grant, the exchange is up and running, sharing treatment information securely with consumer-friendly privacy protections, to improve patient safety and reduce duplication. To register for the webinar, go to https://www1.gotomeeting.com/register/395043977

Desig Thinking Conference – Designing for Health

This year’s Donaghue Foundation conference will explore how design thinking is being used to reduce fragmentation in today’s health care system. The conference will be Friday, May 6th from 7:30am to 12:30 pm in Farmington.

State moving to ASO and PCCM for all Medicaid consumers

At a press conference today, Lieutenant Governor Nancy Wyman and OPM Secretary Ben Barnes announced that CT’s Medicaid program will move to a self-insured administrative services organization (ASO) model effective Jan. 1, 2012. An RFP is expected to be released next month. The state will also expand the current PCCM/patient-centered medical home program statewide as soon as possible to serve as an option for every Medicaid member. Under this model, the state will directly pay all medical costs of care for all Medicaid clients including HUSKY Parts A and B, Low Income Adults (formerly the SAGA program), Charter Oak, seniors and people with disabilities. PCCM patient-centered medical homes will provide consumers with all their primary care, personalized care management, help accessing needed specialty care and expanded service hours reducing the need for ER visits. Patients will have help navigating an increasingly hostile health care environment and get tools and support to manage their own health. Beyond savings millions of dollars, the shift will allow the state to track exactly where tax dollars are going and improve accountability. The new system puts CT in a better position to access opportunities under national health reform, including the health home option that will reimburse the state 90% of the care coordination costs for patients with chronic conditions.
Ellen Andrews

Health in the News – long term care insurance, mandates, and Medicaid inpatient admissions up

Interest in the CLASS Act, part of national health reform, has focused attention on long term care insurance. All sides agree that something needs to be done, but is federally sponsored insurance sustainable?

Issues around mandated insurance benefits are heating up again. Federal standards for the essential benefits package are being developed that may or may not be required of all plans sold in the state insurance exchange. Any benefits mandated in state law but not included in the federal standard, must be funded by the state.

From 2001 to last year, Medicaid’s share of hospital admissions rose 48.6%. As unemployment rises, so do the Medicaid roles. Hospitals claim that they are underpaid by Medicaid causing financial stress. However in 2009 CT hospitals profit margins rose; three out of four were making money that year.
Ellen Andrews

Legislators looking at UConn contract for prisoners’ care for savings

An AP article in the New Haven Register reports that policymakers are looking to review and possibly open UConn’s $94 to $100 million health care contract with the Department of Corrections. UConn provides medical, dental and mental health care to 19,000 state inmates at an average of $4,780 each last year. At least one other potential bidder has expressed interest and suggested that they may be able to provide savings. The Governor is open to the idea but concerned about destabilizing UConn’s medical school.
Ellen Andrews

Consumers getting too many heart tests

A new survey by Consumers Union finds that most 40 to 60 year olds with no symptoms or risk factors who see a doctor are routinely getting unnecessary heart tests including EKGs (50%), exercise stress tests (21%), and ultrasounds of the carotid arteries (7%). Few respondents were aware of the risks and complications that can result from over-testing. 87% felt that it was “better to have a scare that turns out to be nothing than to not get tested at all.” Few understood the risks of false positive results including costly and potentially risky further testing, procedures and even unnecessary treatment such as medication for a problem that doesn’t exist. Almost two thirds said that they would have a full battery of tests if it were free.
Ellen Andrews

Aetna begins tiered benefit offerings in CT

In a move to reduce costs, Aetna is now charging members in some plans based on the costs of the hospitals they choose, according to the CT Mirror. For example, in the program women who choose to give birth at Midstate Hospital will pay almost 35% of their bill in coinsurance; those who deliver at Dempsey will pay 10%. More common in other states cost sharing tiers is a tool used by payers to steer patients to less expensive care, although other states’ plans generally emphasize the quality of care as well as cost. Early evidence on tiers from other states is mixed. In Massachusetts, the state employee plan implemented tiered physician payments in 2007. A recent study found that only about half of members are aware of the cost differential, most do not trust managed care companies to rank providers, but most of those who learn the information before their first visit use it to choose a physician. The Maine Health Management Coalition, a group of over 50 employers, has used quality-based purchasing tools to improve health care value for all Mainers since2007, providing a trusted source of both quality and cost information to let consumers drive the market. The Coalition has an impressive history of success in both reducing costs and improving the quality of care for every patient. For more on the potential of value-based purchasing, go to CSG/ERC’s Value over Volume site.
Ellen Andrews

February webquiz – insurance offerings in CT

Test your knowledge of health insurance offerings by CT employers. Take the February CT Health Policy Webquiz.

Families USA conference

Nancy Pelosi, President Obama, dear friends and lots of great information on ACA implementation – and what CT needs to do. Last week’s Families USA conference was inspiring and exhausting. Now back to work.
Ellen Andrews