Maryland’s SIM proposal emphasizes quality improvement, community resources and engagement

Maryland’s newly released SIM proposal includes many attractive features CT advocates have been championing for our state. Quality improvement and sophisticated analytical tools to support quality are MD’s priority and constitute most of their proposal’s content. The foundation of their plan is to “integrate patient-centered care with community-based resources while enhancing the capacity of local health entities to monitor and improve the health of individuals and their communities as a whole.” Payment reform is less important than improving quality and resulting cost control. The proposal emphasizes local quality improvement collaboratives, including many consumers and independent consumer advocates, data analytics to identify high utilizers by geography, health condition and other metrics to effectively target resources and evaluate for effective solutions. The community utilities they will build to support providers and consumers in health improvement and self-care are impressive. In contrast to CT’s simple, incentive-based model, MD’s payment model includes provider practice performance bonuses and imposes no provider incentives to deny care. Only the community resource utilities are capitated.  MD intends to begin with Medicare and Medicaid, which make up 24% of covered lives in their state, and work toward engaging private insurers in the future. This is in contrast to CT’s process that has been driven by private payers. MD does not intend to include any downside risk in the near future and are very careful and conservative in discussions of transferring any financial risk to providers. Unlike CT, consumers and advocates have been involved at SIM decision-making tables in MD.

SIM proposal draft – no commitment to deny payment to providers who deny care

During yesterday’s meeting, SIM leaders posted their first draft online of the administration’s plan to reform health care in CT. SIM is designed to radically transform how health care is delivered and paid for in our state across all payers – Medicare, Medicaid, private insurance, self-insured employers, individuals and small businesses. Despite earlier encouraging conversations, the draft does not include a provision crucial to advocates to deny payments to providers who achieved savings by inappropriately under-treating consumers. Consumer advocates have been very concerned that shifting provider incentives from volume to financial risk could result in inappropriate under-treatment causing harm. In contrast, the draft does commit to limiting payment for poor consumer experience of care and poor performance in addressing health equity. Steering committee members raised concerns about weak health equity provisions, placing Medicaid providers at strong financial risk, inadequate consumer empowerment in system change, and whether goals for cost savings are ambitious enough. One member asked that the next draft list the considerable risks that the plan will fail. There are no independent consumers or advocates on the SIM steering committee, but insurers, state agencies and other payers are well-represented. Steering committee members received the draft well before the meeting, but a public version was not available until half way through the meeting. Steering committee meetings do not include opportunities for public input.

APCD Roundtable – lessons for CT

Yesterday’s CT Health Policy Roundtable on All-Payer Claims Databases yielded many lessons for CT from other states and organizations. Lessons included the need for strong privacy and security protections, avoiding commercial uses, licensing to universities and organizations rather than individuals, and developing a transparent, fair process for access to the data based on the needs of all stakeholders. Common challenges included governance, funding, and integrating clinical and claims data. Speakers included Jo Porter of the APCD Council, David Newman of the Health Care Cost Institute, Cynthia Millane of FairHealth.org, State Comptroller Kevin Lembo, and Tamim Ahmed of Access Health Analytics, CT’s developing APCD. Pat Baker of the CT Health Foundation moderated. The Roundtable was sponsored by the CT Health Policy Project, the CT Center for Patient Safety and Access Health Analytics with funding from the CT Health Foundation. Slides and background materials are online.

CT Health Policy Roundtable: CT’s APCD tomorrow

Join national and state experts tomorrow 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 tomorrow -- Thursday, October 24^th from 1 to 3pm in Room 1E of the LOB. Registration is encouraged. Presentations are online.

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 – moving in a better direction

Yesterday’s SIM meeting showed some positive movement toward a system that respects and protects consumers. Recognizing the potential harm to consumers, SIM leaders now intend to monitor for under-treatment and inappropriate treatment, and the payment model no longer includes capitation, both serious concerns raised by advocates. However advocates remain troubled that there is no commitment to withhold savings payments from providers who, through monitoring and a fair resolution process, are found to have reduced appropriate care. The current plan does commit to withhold incentive payments from providers who do not score well in either patient experience of care or in reducing health disparities. Advocates also remain concerned about the possibility of downside financial risk for providers – recouping funds from providers whose patients’ care costs exceed expectations. The steering committee, which includes no consumers or advocates, debated whether to include “patient-centered” in the term for their proposed new CT-specific medical home standards developed by a working group of providers. SIM leaders expect to release a draft plan next week for public comment and to meet with stakeholder groups in November for feedback. 

CT among ten highest states in Medicare drug spending

A new analysis by C-HIT finds that CT seniors on Medicare are spending more than consumers in most other states on prescriptions. CT elderly Medicare beneficiaries are more likely to use brand name drugs than generics, especially in high income towns in Fairfield county. Within the state, Meriden has the highest per beneficiary prescription spending and Winsted the lowest. In good news, more than 81% of CT seniors are still taking recommended beta-blockers seven to ten months after a heart attack, compared to only 78.5% of all Americans. The study found wide variation in per capita drug spending but no evidence that higher spending was associated with better care.

Early insurance exchange enrollment older and half to Medicaid

Between the beginning of the month and Tuesday 3,847 people had enrolled in coverage through Access Health CT, our state’s health insurance exchange, according to a presentation to the exchange Board this morning. 1,857 (48%) are eligible for Medicaid, 1,125 (29%) for subsidized insurance, 772 (20%) for insurance without a subsidy, and 93 (2%) for HUSKY Part B. Enrollees into both Medicaid and insurance plans are more likely to be older – ages 55 to 64. This isn’t unexpected for early applicants who may have higher health needs and will likely even out as enrollment picks up. Most enrolling in insurance are choosing Anthem (67%), 31% are choosing ConnectiCare, and only 2% choosing the new HealthyCT plan. Half are choosing silver level plans. Only 11 small businesses covering 47 workers had enrolled by Tuesday.

Medicaid performance dashboard unveiled; marked improvement with switch from HUSKY HMOs

At Friday’s Medicaid Council meeting, DSS described their new ASO accountability dashboard with performance measures for the program. From January 2012, when the HMOs left the program, to this June the number of providers participating in CT’s program has grown 32%, hospital admissions are down 3.2%, the average length of stay is down 5%, and cost per admission is down $200 (2.7%). Emergency dept. visits are down but costs per visit are up. Non-urgent care visits to the ER are down an impressive 11.7%, suggesting better access to preventive and maintenance care. Unfortunately 13 members used the ER over 100 times last year. CHN is focusing member outreach to link those patients with a primary care providers, the 24/7 nurse advice line, intensive care management, and to behavioral health services when appropriate. 61% of members are now linked to a primary care provider allowing better tracking of performance, access to care, and quality. 10,882 members accessed cultural and linguistic Medicaid services in the second quarter of this year; that number has grown every quarter. 16,836 members received intensive care management for a range of problems. It’s exciting to see that since the switch from capitated HUSKY HMOs to the ASO model costs are down slightly, the number of participating providers is up and unnecessary ER visits are down.

Book Club: David and Goliath, by Malcolm Gladwell

I read this latest addition to the CT Health Policy Project Book Club on a long flight and couldn’t put it down. It should be required reading for every advocate. Malcolm Gladwell’s latest book describes why the underdog often wins against what initially seems like long odds. After he drills down on the story of David and Goliath, the reader comes to see that Goliath didn’t stand a chance. Often being under-resourced, disadvantaged and/or overwhelmed is a large advantage. With examples like the myth of smaller class size, difficult childhood experiences as an advantage, how under-resourced rebels were so effective in Northern Ireland, and perception matters for little fish in big ponds he makes the case that at a point, increasing resources backfire. I will be using a lot of the lessons and drawing inspiration from this book, as a health care advocate up against large and imposing opponents. There is power here at the bottom of the food chain.

SIM forum with advocates

This morning, SIM leadership held a forum to explain their plan to advocates. Unfortunately few independent consumer advocates were given an opportunity to ask questions, including this one. Most of the time was taken by SIM committee members expressing their positions, describing their programs and experiences. Many of the questions came from providers and others urging SIM leaders to include their programs in the SIM plan and fund their services. The committee did not respond to questions raised in the advocates’ letter. There were no assurances that a robust quality monitoring system will be in place before potentially harmful provider risk incentives are implemented and plans to lower medical home standards are still in place. Governance plans for continuing SIM are not settled and it is unclear who will decide, but the leaders are considering adding consumer advocates to committees. Advocates have posted Frequently Asked Questions About SIM and Guiding Principles for a Successful SIM. No further discussions are planned. 

Connecticut breaks through to a B-/C+ on health reform

Connecticut health care thought leaders give our state a B-/C+ (GPA 2.48) on health reform this fall; the highest marks the state has gotten in over a year. Among issue areas the health insurance exchange and public education improved since the last survey. Areas that lost ground include Medicaid, patient-centered medical homes, health information technology, payment reform/quality improvement, engaging consumers in policymaking, and data-based policymaking. Thought leaders’ suggestions to improve progress are for smarter policymaking and leadership, engage consumers/advocates/public in policymaking, and to fix payment reform. Performance on payment and quality reform has dropped to a D in this survey earning five F grades.

October CT Health Policy Webquiz: Premiums in CT’s health insurance exchange

Test your knowledge of the premiums in CT’s health insurance exchange. Take the October CT Health Policy Webquiz.

CT Health Reform Progress Meter moves up to 23.7%

Despite the frenzy surrounding the opening of the insurance exchanges, health reform has many other moving parts. CT policymakers have completed 26.2% of the tasks necessary for health reform, making progress from last month. Again, Medicaid accounted for the forward progress in October’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. 

CT insurance exchange switch flips on -- lots of interest, some glitches

Yesterday’s opening of CT’s insurance exchange, Access Health CT, went about as well as expected. Despite the administration and exchange staff’s repeated lowering of expectations, there was a lot of interest – 123,000 visits to the website by 28,000 unique visitors by 4pm. 167 people got signed up for coverage, including 84 into the Medicaid expansion set to begin January 1st. (Click here for the HUSKY is growing Medicaid outreach toolkit.) The site was down for over an hour and users reported difficulty creating accounts, but patience was rewarded.