SIM update

The SIM steering committee reviewed final recommendations from their work groups yesterday. The SIM project is developing payment and care delivery models for at least 80% of state residents – 3 million people or more and $30 billion in CT health spending. The recommendations are very detailed and specific, but they maintain that there is still an opportunity for revision. Advocates are concerned that the decision-making groups lacked consumer input, and that the process was largely conducted out of public view over a short few months in the summer. The state intends to apply for up to $60m in federal funding to implement the plan.  Most troubling, the plan includes moving 80% of state residents into a total-cost-of-care payment model within 5 years. Total-cost-of-care gives providers “responsibility for the value of patient care by tying a portion of payment to achievement of total cost and quality metrics.” It could include “gain sharing, full risk sharing, and/or capitation.” Proponents acknowledge that CT does not now have the monitoring infrastructure to ensure that savings are not achieved by denying appropriate care. Advocates are urging the state for a plan modification that requires a meaningful quality monitoring system be in place before any provider risk dollars attach. It is also critical that any incentive payments (or capitation withholds) be contingent on meeting meaningful, not minimal, quality standards. CT is well behind other states in capacity to measure quality and in performance.  SIM leaders do intend to create a metrics workgroup to develop quality standards. Hopefully this is a more diverse, transparent committee with all stakeholders represented.

Access Health CT rates up sharply, CID review and competition helped

Today’s CT Health Insurance Exchange/Access Health CT board meeting included a report from Wakely actuaries hired by the exchange to review rate proposals from health plans applying to offer coverage in the exchange. According to Wakely, plans have filed numerous revisions lowering their rate proposals, largely in response to each other and questions from the CT Insurance Dept. in their review. Despite that, in contrast to many other state exchanges, unsubsidized rates will be rising sharply from this year’s level. In examples comparing 2013 premiums with 2014 for five consumer examples, impact varied considerably. For example, single males age 21 not eligible for subsidies (over $45,900 annual income) can expect premiums to more than double for a bronze plan. Half the examples of people eligible for modest subsidies will also see their premiums rise, also more than doubling for that single young man now at 350% of the Federal Poverty Level. However some consumers eligible for the most generous subsidies, may see no premiums. While assumptions the rates are based on vary widely between plans, the final rates are remarkably similar with fairly little price difference between plans. Most plans that will be offered on the exchange are bronze level (covering 60% of medical costs on average). Of the individual coverage examples given by Wakely, the lowest premium cost was from Aetna in 14 of 15 examples.

In other news, the exchange announced they have hired a director for the All Payer Claims Database, Tamim Ahmed, PhD Economics. He has experience in data analysis and risk adjusting rates.

ConnectiCare withdraws SHOP exchange proposal

ConnectiCare has notified Access Health CT, our state’s health insurance exchange, that they are withdrawing their proposal to participate in the SHOP exchange. This leaves only three insurers in the small business portion of the exchange – Anthem, United and HealthyCT. ConnectiCare still intends to participate in Access Health CT’s individual exchange along with Anthem, HealthyCT, and Aetna. The SHOP exchange is expected to enroll approximately 40,000 people, far less than the 200,000 or more people expected to enroll in individual exchange coverage. 

An ACA primer for CT

Arielle Levin Becker of the CT Mirror has drafted a sensible, brief FAQ on health reform, what is coming in January and what it means for people who don’t read Health Affairs for a living. She has done an expert job of distilling the confusion into an accessible resource. Thank you Arielle.

HealthyCT lowers rates in insurance exchange

Healthy CT, the new co-op insurer created with federal support under the ACA, has revised their proposed premiums for the CT Health Insurance Exchange, Access Health CT. The new rates, much lower than their competitors, will average $271 per month for individuals and $408 for small businesses. Those individual rates will vary between $111 and $1,080 based on age, geography and which plan they choose. Competing plan premiums will average $364 to $424 monthly. HealthyCT’s lower individual premiums, down 36% from their original proposal, resulted from new data about the likely health of enrollees in the exchange. 

Entertaining new video explains Obamacare implementation

Medicaid Council update

Last Friday’s Medicaid Council meeting focused on ACA primary care rate increases for 2,277 CT providers including MDs practicing pediatrics, internal medicine, family medicine and some specialties and APRNs for preventive care services. Effective January 1^st but implemented July 1^st, the ACA increased these rates to Medicare levels, with 100% federal funding through 2014. On average, rates are almost doubling,;for example rates for code 99203 - new patient visit will rise from $66.40 to $123.53. The rate increases are significant, impressive and universally welcomed by Council members. However hesitations about fully realizing the impact in increased CT provider Medicaid participation were raised concerning the delay in implementing the increase, and lingering administrative challenges. CT ranks fourth lowest among states in physicians taking new Medicaid patients. Council members urged the state to track increases in provider participation before and after the rate increases. 

CT community health centers awarded $1.6 million for outreach and enrollment

Thirteen CT community health centers will share almost $1.6 million in federal grants to hire 28 workers across the state to help an estimated 23,167 uninsured state residents enroll in affordable health coverage. Awards varied from $68,284 to the CT Institute for Communities in Danbury to $ 238,366 to Community Health Center Inc. in Middletown. The clinics, spread over 185 sites in CT, saw 139,000 people last year; 23% were uninsured. 

State health care pooling plan growing slowly

The Comptroller’s Office announced this week that the CT Partnership Plan, allowing municipalities and other non-state governments to buy into the state employee plan, has 2,415 members from eight municipal entities at the end of a year saving between 1 and 36% on health benefits. While enrollment has lagged behind expectations, it is growing. Comptroller Lembo noted that the impact of the Plan has been greater than the enrolled membership. Several municipalities used quotes from the Partnership Plan to negotiate savings from current insurers. There are no plans to open the plan to nonprofit organizations, as originally intended in the SustiNet plan for comprehensive health reform in CT.

Governor vetoes bill allowing for-profits into medical foundations

Yesterday the Governor vetoed SB-992, a bill that would have allowed for-profit entities to join medical foundations to provide health services. The bill language was added to a different bill in the last hours of the legislative session. The bill resulted from lobbying by Waterbury Hospital and the for-profit Vanguard Health Systems from Tennessee that is seeking to buy the hospital. Since the bill passed, Vanguard announced that they are being acquired by Tenet Healthcare, adding to concerns from labor and consumer groups. The Governor noted the uncertainty about the bill’s impact in his veto message. 

Cabinet meeting centers on SIM project

An update on the SIM project was the main agenda item at yesterday’s Health Care Cabinet meeting. At last month’s meeting, members were asked to collect feedback on SIM proposals for payment and delivery reform to cover 80% of CT residents.  The SIM committee is planning to set payment and delivery models for the state by Sept. 1^st and apply to the federal government for a $40 to 60 million grant to the state to implement the models they are deciding on now. The proposal centers on provider risk-sharing, including total cost of care models (capitation) which elicited grave concerns among advocates. Capitation has a very troubled history in CT. When capitation in the HUSKY program was eliminated, savings were significant, provider recruitment, utilization, access to care and care coordination improved and patient-centered medical homes were launched. CT is also behind other states in being able to measure quality or access to care – if the payment reform is harmful to people as advocates fear, we won’t know it and we won’t be able to do much about it. The SIM committees include no consumer advocates among the 75 members but state agencies, insurance industry and provider groups are very well-represented. Concerns were also related from advocates who are troubled that a very small group of people, no matter how well-intentioned, are making very large decisions for our state very quickly, largely out of public view. This is in contrast to the very successful health neighborhood project by DSS for people eligible for both Medicare and Medicaid that was developed in an open, deliberative process and resulted in overcoming all stakeholder reservations to earn universal support. Advocates asked that the process be opened and that we take more time to be sure we build a reform plan that engages the wisdom among all stakeholders, especially consumers, and has every chance to be successful. Advocates will be sharing their concerns formally in a letter to the SIM leaders. 

Youth Health Ambassadors program applications open

The summer Youth Health Ambassadors program is now taking applications. The five week training program for Hartford youth ages 16 to 18 is designed to increase understanding of health disparities, health literary, and civic engagement, and to build development and leadership skills through video blogging, social media, volunteer service and community development. The Ambassadors program is sponsored by Health Justice CT, the CT Office of Health Care Advocate and Central AHEC.

ACA employer mandate delayed; tiny number of CT employers affected

Only 3% of CT employers with over 50 workers don’t offer health benefits; nationally 4.3% don’t. Despite this on Tuesday, out of concern for the economy and paperwork burdens, the IRS announced they will delay for a year implementation of the health reform requirement that employers with over 50 workers offer health coverage to workers. This means that the 616 affected businesses in CT that don’t offer coverage will be exempt from the standard that the other 19,920 affected CT businesses already meet. Reform was supposed to be a delicate balance of “shared responsibility”. But while employers get another year to comply, and our state insurance exchange wants 3 to 5 years to fully implement their project, consumers will still be subject to the individual mandate this January 1^st. We are awaiting details about how this will affect consumers and eligibility for subsidies in the exchange and, later, to see how the delay affects the ongoing erosion of employer-sponsored health benefits that the mandate was meant to address. 

July CT Health Policy Webquiz: CT’s hospital executive pay

Test your knowledge of hospital pay for executives in Connecticut. Take the July CT Health Policy Webquiz

CT health reform progress first time drop to 21.8%

For the first time, Connecticut moved backward in progress toward health reform from 22.5% of tasks completed last month to 21.8% this month in the CT Health Reform Dashboard. Most reform tasks are due on Jan.1^st of next year. Medicaid showed positive movement, as it has over the last year. However the state moved backward with the SIM project’s plans for ambitious payment reform without quality standards, and concerns about affordability in the insurance exchange, especially given the death of SB-596 directing the exchange to negotiate premiums with insurers.

CEPAC meeting focused on effectiveness of Community Health Workers

Friday’s CEPAC meeting centered on the clinical and cost-effectiveness of community health workers. The meeting was very well-attended with dozens of stakeholders represented both in the audience, the policymaker panel and in public comment. Community health workers (CHWs) are trusted members of a community who assist patients in accessing appropriate care and in keeping themselves healthy. Known by many names, CHWs are usually non-clinical professionals working in public health settings. The committee recognized that CHWs can provide value in improving health status, reducing inappropriate care and those costs, and promoting health equity. There was general agreement that there is not enough high-quality research to define best policies and standards for training, certification, types of patient interaction, specialization, patient matching, and evaluation. But there was general agreement that CHWs offer a promising opportunity to further the goals of improving health and controlling costs.