SIM update -- questions about numbers driving policy

Significant questions have been raised about the methodology and sources for the Sept. 17^th SIM presentation (slide 30) asserting that 62% of primary care providers in CT currently have provider risk/shared savings/total cost of care arrangements with providers. Questions relate to whether the populations included are representative of the state, provider types included, whether the number relies on one payer disproportionately, and the possibility of double counting among other issues.

Unfortunately this questionable number is being used as the foundation of a proposal that may undermine even the minimal quality standards in the current SIM proposal. Last week, in a private email, SIM steering committee members were asked for input on whether, given the perceived prevalence of provider risk, SIM should propose allowing provider incentives even in the absence of medical home status. Presumably this is to avoid jeopardizing the primary SIM goal of moving at least 80% of state residents into provider risk arrangements, regardless of quality protections. Advocates have called on SIM leaders to build a robust quality monitoring system before any provider incentives are implemented. Advocates are hoping to both improve the quality of care in CT and prevent the harm to people that occurred in managed care risk arrangements in the past.

The current SIM medical home plan is to create a CT-specific, lower standard than the commonly-used, well-vetted national accrediting bodies. (They have taken “person/patient-centered” out of the label for their lower standard.) There are currently 821 NCQA certified PCMHs in CT and the list grows every month. One third of Medicaid consumers are now cared for in a PCMH. It is important to note that a large proportion of Medicaid providers, with lower payment levels, have earned PCMH designation.

CT exchange premiums 4th highest in US

A new analysis from the White House finds that CT’s insurance exchange premiums are among the highest in the nation – behind only Alaska, Mississippi, and Wyoming. CT residents and small businesses buying unsubsidized coverage through the exchange will pay 28 to 37% more than most Americans depending on which plan they choose. We will pay about 24% more than New Yorkers. Passage of SB-596 this session would have directed the insurance exchange to negotiate prices on behalf of consumers, which would have lowered premiums. The bill passed the Senate but died in the House; even a provision allowing the exchange to negotiate (which they can do without legislative authority) died in the last hours of the session. New York negotiated rates with the plans. 

HUSKY is growing outreach tool for community organizations

Connecticut’s Medicaid/HUSKY program is significantly expanding effective January 1st. 700,000 state residents are already benefitting from the program and up to another 130,000 may qualify under new eligibility rules. Many people denied Medicaid or HUSKY in the past will now qualify. Medicaid and HUSKY provide comprehensive health care coverage without cost.

To ensure that every eligible state resident is enrolled as soon as possible, CTHPP summer intern Tanusha Satavalli developed a “HUSKY is growing” toolkit for community organizations to help people know about the expansion. The tools can be customized for your organization.

CT Health Policy Roundtable: CT’s APCD

Join national and state experts for a Roundtable to learn more about the potential for Connecticut's new All-Payer Claims Database in health care planning, improving health care quality, capacity and promoting health equity. The Roundtable is sponsored by the CT Health Policy Project, the CT Center for Patient Safety and Access Health Analytics and made possible with support from the CT Health Foundation. The Roundtable will be Thursday, October 24^th from 1 to 3pm in Room 1E of the LOB. Registration is encouraged.

Moderator: Pat Baker, CT Health Foundation

Speakers:

Josephine Porter, APCD Council

David Newman, Health Care Cost Institute

Cynthia Millane, FairHealth

Tamim Ahmed, Access Health Analytics

Kevin Lembo, CT State Comptroller

SIM update

The September meeting of the SIM steering committee changed little to the plan except the name of the payment model. The planners reported to the committee what will happen in the next phase of the process. They changed the name of their provider risk-based payment model from Total Cost of Care to Shared Savings, apparently because people associated TCC with capitation. But it became clear that members’ assumptions that Shared Savings had the generally accepted, Medicare-based meaning, that in fact Shared Savings also includes capitation. They are looking for a term that includes capitation but doesn’t evoke strong negative reactions from stakeholders. (The problem isn’t the term.) They also intend to re-create the committee structure, possibly including consumers and/or advocates in some of the new committees. In response to advocates’ concerns, they are including an Equity Access and Appropriateness Council to monitor for denials of inappropriate care under their provider risk models. However, there is no assurance that a meaningful quality monitoring system will be in place before people are placed in the potentially harmful payment model the committee is designed to prevent. They are continuing their individual, private meetings with insurers and others to test the model. 

CID seeking comments on mental health parity enforcement

The CT Insurance Department is seeking public comments on methods to monitor and ensure compliance with state and federal mental health parity laws. CID has chosen to move ahead with enforcement of the law, despite delays in getting federal regulations. Insurers have urged CID to wait for final federal rules. CID encourages anyone with expertise or experience in the area to comment. They will be accepting comments through October 15^th. 

Medicaid Council updates: Medicaid enrollment changes

The majority of September’s Medicaid Council meeting focused on massive changes to how people will apply for Medicaid coverage over the next few months. DSS reported that the new ConneCT system is close to caught up on scanning client documents, but work on the indexing system (assigning documents to the right client’s file) continues. Call wait times have increased to average 20 minutes since the new phone system was instituted. There was no information on the rate of dropped calls. DSS is working on technical improvements of the online system to reduce the need for clients and providers to call in. DSS intends to develop a public, online dashboard on how ConneCT is progressing and will update the Council monthly; they are open to ideas on what measures should be included. AccessHealthCT reported on their integrated portal for both exchange and Medicaid applications. After January 1^st all online Medicaid applications (except aged, blind and disabled) must go through the integrated portal. Leadership acknowledged that the system won’t be perfect and there will be mistakes and complaints. They will take paper applications but strongly urge people to apply online. Unfortunately that online application will take about an hour to complete. Data on income levels the system uses will be two years old; they are trying to develop a relationship to use only 6 month old income data. Acknowledging that this is not reliable to accurately determine eligibility, DSS will accept self-reported income and give applicants 90 days to send in supporting documentation. DSS will continue to have to manually enter information in the eligibility system from a pdf generated by the online application for the foreseeable future. There was also a very rich presentation on CHN’s ASO programs and services, but unfortunately there wasn’t sufficient time to explore the information.

Comments on CT’s APCD policies and procedures

In support of the enormous potential to promote and guide sensible health planning in CT, consumer advocates, the CT Health Policy Project and the CT Center for Patient Safety, submitted constructive comments on draft policies and procedures for CT’s All-Payer Claims Database, Access Health CT (APCD). We urge APCD leadership to commit to full public transparency and equitable access to the data for all stakeholders, including CT’s insurance exchange, and strong provisions to avoid even the appearance of conflicts of interest. We also urge policymakers to prohibit commercial uses of the data and to develop very robust privacy and security protections. The advocates’ comments follow from our report for the CT Health Foundation of consumer input into development of CT’s APCD.

Very encouraging Medicaid PCMH update

Far exceeding expectations, 34% of Medicaid members are now being cared for in person-centered medical homes according to DSS and CHNCT’s presentations at today’s meeting of the Medicaid Council’s Care Management PCMH Committee. There are almost 1000 primary care providers (between approved, accreditation eligible, and glide path status) receiving higher Medicaid payment rates to compensate for coordinating care, extended practice hours, and assisting consumers with managing and improving their own health. Five new practices joined the program just since the last meeting two months ago. The department also reported on new quality PCMH payments made to three practices that out-performed their peers on nine pediatric and/or adult medicine measures. Total quality payments ranged from $464 to $68,036 per practice. Advocates, providers and policymakers universally congratulated DSS and CHN for their hard work and exceptional success in implementing the PCMH program.

At the meeting DSS and CHNCT also reported on their new Rewards to Quit program – providing cash incentives to Medicaid consumers to quit smoking. The program, funded by a federal grant, will test the effectiveness of both cash incentives and peer coaching in encouraging consumers to quit. Participants can receive up to $600 in a year under the program for attending counseling sessions and for negative CO breathalyzer tests.  All Medicaid recipients are now eligible for smoking cessation services and products; the study will test if there is added effectiveness with peer counseling and cash incentives. 

Cabinet meeting update

This month’s Cabinet meeting included updates on SIM, the insurance exchange and CT’s APCD. SIM leaders reported that with the delay offered by HHS the new deadline for the state health plan model is the end of this year. They expect to have a first draft for public release sometime in October. The testing grant application, for the $50 million, is expected to go out next year. They are working on revising the governance structure – no details on that – and will continue to visit with consumers and community groups for input. Cabinet members urged them in those visits to explain and seek input from consumers and advocates on the entire plan, including the proposed payment model that has raised concerns. They are also considering creating new standards for patient-centered medical homes, with possibly lower standards than NCQA certification, also raising concerns about quality. Most of the new changes and negotiations are happening in private meetings. The insurance exchange is finalizing preparations for Oct. 1^st when people can begin to sign up for coverage. Tamim Ahmed, the new Director of CT’s All Payer Claims Database, Access Health Analytics, laid out his short and long term goals. Members raised concerns about privacy and security, not selling data or analytics for commercial purposes, creating transparent processes for data access, and not prioritizing insurance exchange data needs over others such as population health and health equity. Draft APCD policies and procedures are open for public comment until Thursday.

Public hearing on ER use and Medicaid

The Legislative Program Review and Investigations Committee will be holding a public hearing for their study of whether Medicaid consumers are over-using emergency dept. visits inappropriately and, if true, the impact on the state budget. If true, they will search for reasons including who is inappropriately using the ER, for what problems, and make recommendations. The hearing will be Sept. 26^th at 2:30 pm in Room 2D of the LOB.

New policy brief on “No wrong door” enrollment

A new brief by the CT Health Foundation describes “No Wrong Door” (NWD), the Affordable Care Act’s seamless plan for consumers to enroll in health coverage. NWD allows consumers seeking coverage to enter through an array of state agencies, be seamlessly routed to a common portal that will assess eligibility and needs, and connect them to the appropriate programs and resources for their circumstances. NWD is designed to simplify the dizzying array of programs and applications that consumers now have to navigate to participate in public coverage programs. Authors of the brief estimate that full implementation of NWD will result in about 20,000 more CT adults and 6,000 children with coverage, and will prevent another 36,000 state residents from losing coverage due to churning. It is expected that NWD will help close CT’s health equity gap by reaching people who might have remained uninsured.

Help design Connecticut’s health improvement plan

A broad coalition of stakeholders led by DPH is developing a plan for A Healthier CT by 2020 and we need your input. DPH is holding forums this fall in each CT county to get your input into the plan.

Tolland County: Sept. 10, Rockville High School Auditorium, 70 Loveland Mill Rd., Vernon

Windham County: Sept. 12, EASTCONN Capitol Theater, Magnet High School, 896 Main St., Willimantic

Hartford County: Sept. 24, Legislative Office Building, Room 2C, 300 Capitol Ave., Hartford

Litchfield County: Sept. 26, Torrington City Hall, Council Chambers, Rm. 218, 140 Main St., Torrington

Fairfield County: Oct. 8, Discovery Magnet School Cafeteria, 4510 Park Ave., Bridgeport

New Haven County: Oct. 10, Hill Regional Career High School, Auditorium, 140 Legion Ave., New Haven

New London County: Oct. 17, Three Rivers Community College, Multipurpose Rm F117, 574 New London Tpke, Norwich

Middlesex County: Oct. 21, CT Valley Hospital, Paige Hall Solarium, 1000 Silver St., Middletown

All forums are from 6 to 7pm; registration begins at 5:30pm. Registrations requested but walk-ins are welcome. To register go to http://ct.train.org (use ID# 1045492) or call 860-509-8070. 

New action guide on Community Health Workers

ICER has published an action guide, Community Health Workers: Applying the Evidence to Policy and Practice, to effectively incorporating Community Health Workers into the health system for the CHW workforce, insurers, and providers and organizations that employ CHWs. The guide, based on CPAC’s CHW effectiveness report, gives evidence-based action steps tailored to the needs of stakeholders to apply the best available evidence to policy and practice. ICER, the Institute for Clinical and Economic Review, provides independent evaluation of the clinical effectiveness and comparative value of new and emerging technologies.

 CEPAC, a project of ICER, is a New England stakeholder council that advises policymakers using comparative effectiveness research to improve the quality and value of health care in our region. CEPAC’s next meeting, December in Boston, will focus on supplemental screening in women with dense breast tissue.

September CT Health Policy Webquiz: CT health risks

Test your knowledge of the rates of health risks among CT adults. Take the September CT Health Policy Webquiz.

CT Mirror reports on SIM proposal – administration agenda and advocate concerns

An article yesterday in the CT Mirror describes the administration’s plans to apply for millions in federal dollars to radically redesign CT’s health care system – not just Medicaid and the state employee plan, but for all state residents. The article points out that the administration is working with providers and insurers to design the plan; consumers and advocates have not been included in the process. The plan includes important care delivery innovations, many building on inclusive past processes. However the plan also includes giving providers financial incentives to control costs. Advocates are concerned that there are not sufficient controls or data to ensure that savings are generated by reducing duplication, improving quality and eliminating overtreatment rather than withholding appropriate care. To protect consumers, a group of 24 advocates sent a letter asking the SIM proponents to build a robust monitoring system and quality improvement tools for providers, and ensure that that system is working before any provider savings incentives or capitation is implemented. There has been no response to the letter. 

CT Health Reform Progress Meter moves up to 23.7%

CT policymakers have completed 23.7% of the tasks necessary for health reform, making up for last month’s drop. Most tasks on the Progress Meter list are due on Jan.1^st of next year. Medicaid accounted for the forward progress in September’s Health Reform Dashboard. As last month, deep concerns about payment reform in the SIM process and the insurance exchange’s premium increases are holding Connecticut back.