CSG/ERC annual meeting highlights

This year’s CSG/ERC annual meeting in Puerto Rico this month included several health panels and meetings. The first was an initial report on Value over Volume 2.0, an update on our first report from 2009 on payment reform for state/provincial/territorial policymakers with tools to both improve quality and control costs. An ACA Roundtable generated a lively discussion among policymakers sharing resources, challenges and solutions. The update from Puerto Rico policymakers was fascinating. Because of the way the ACA was written, residents of Puerto Rico and the other territories are not bound by the individual mandate to have coverage but insurers are bound by all the ACA reforms – which will create an interesting but imperfect test of the mandate’s effectiveness or necessity. Territories are treated differently under both Medicaid and the Affordable Care Act. Puerto Rico was given a capped $925 million allocation, which they will be using to expand their Medicaid program. However the funding expires in 2019. In addition, the Commonwealth will create an affordable state-supplemented health plan for the remaining uninsured.

Sessions were very well attended despite strong competition for attendees attention from the beautiful venue.

CEPAC meeting on dense breast tissue screening

This month’s CEPAC meeting focused on that status of comparative effectiveness research on supplemental cancer screening for women with dense breast tissue. 40% of women have dense tissue, both raising the risk of cancer and the chances that a lump will be masked on a routine mammogram. CT is the only state that both requires notification of women with dense tissue and requires insurers to cover supplemental screens. The evidence was conflicting and confusing (they never give us easy ones.) While supplemental screens pick up more cancers, they also find more false positives with attendant risks. We heard compelling testimony from women whose cancers were missed on mammograms, possibly for years, because they didn’t know. We also considered the risks of false positives (including anxiety and unnecessary biopsies), as well as the costs and availability of various supplemental screens (and what else that funding could be spent on). In the end, we voted to recommend supplemental screens for women at risk of breast cancer.

SIM update

SIM leaders released their financial analysis, response to public comments, and revised vision statement at the last meeting. We will be providing a longer analysis when the final plan is available, but a few points bear highlighting. Despite strong public comments voicing concern about under-treatment incentives in shared savings, SIM leaders recommended not to include a commitment to monitor for under-treatment and deny savings payments generated by under-service. They argued that all seven insurers have not agreed to it, and they can’t make them do anything. Members of the steering committee argued that the entire document is aspirational and unenforceable, and that it was a clear message from public commenters. In response, the group agreed to add language to the vision statement. They also included language about engaging stakeholders, another common complaint in public comments.

They intend to pursue plans to develop a CT-specific patient-centered medical home certification, bypassing the current, widely accepted national NCQA standards. (There are currently 891 NCQA PCMHs in CT; that number grows every month.)

They have carved out long term care, DMHAS clients and (to some extent, see below) Medicaid consumers from the SIM for a variety of reasons.

They will not be reinstating the payment reform workgroup. They will continue to set policy with payers in private, non-public meetings.

The financial analysis expects that Medicaid providers will receive only 30% of the savings they generate (including care management payments), compared to 45% for providers caring for commercially insured consumers. This is on top of lower Medicaid fee-for-service rates. At a subsequent Cabinet meeting, SIM leaders stated that these numbers were only for illustration and promised to get back to us with the source of the inequity. They have based return on investment calculations on the questionable assertion that 40 to 60% of CT primary care providers are now in shared savings contracts. Several members expressed doubt about this assumption.

New language reportedly negotiated since the meetings includes some limits on shared savings models in Medicaid and a commitment to delay shared savings until under-service monitoring is in place — but only for Medicaid.

The final plan will be submitted to the Center for Medicare and Medicaid Innovation on Dec. 30^th.

SIM public comments: diverse and mostly critical

Last month Connecticut’s State Innovation Model (SIM) planning group, working for most of the year, solicited public comment for the first time. SIM is the administration’s plan, based on federal grant provisions, to radically transform Connecticut’s health system – payment and care delivery. The federal grant requires the plan to cover at least 80% of state residents within five years – Medicare, Medicaid, employer-sponsored, and private coverage. SIM received 84 comments from a broad range of stakeholders; the majority were critical of the plan. Top themes in the comments were concerns about excluding key stakeholders, incentives to deny necessary care, excluding consumers and advocates, a lack of transparency and downside risk that could jeopardize recent progress improving Medicaid.

Safety net hospitals expect to see more uninsured undocumented immigrants

CT hospitals are expecting a growing burden of uncompensated care for undocumented immigrants next year, according to C-HIT. Undocumented immigrants cannot benefit from expansions of coverage under the ACA. They are not eligible for Medicaid regardless of income level and cannot purchase coverage on the insurance exchange, even without a subsidy.  The ACA also decreases federal funding (DSH) for uncompensated care next year, under the assumption that the number of uninsured state residents will drop with coverage expansions. Last year, CT hospitals provided $233.6 million in total uncompensated care; Yale-New Haven highest at $31.8 million, Sharon Hospital lowest at $1.4 million. Hospitals hope to counter the myth that the ACA covers everyone.

CT Health Reform Progress Meter moves up to 28.3%

CT policymakers have completed 28.3% of the tasks necessary for health reform, up slightly from November. Most tasks on the Progress Meter list are due in just a month. Medicaid accounted for the forward progress in again this month, largely due to strong quality and care management performance reports. Once again, deep concerns about payment reform in the SIM process and the insurance exchange’s premium increases are holding Connecticut back. The Progress Meter is part of the CT Health Reform Dashboard.

December CT Health Policy Webquiz – CT health insurers’ performance

Test your knowledge of CT health insurer performance. Take the December CT Health Policy Webquiz.

CT Mirror Obamacare Maitre d’ – everything you wanted to know

CT Mirror has created a set of tools to guide the confused through Obamacare’s maze. Obamacare Maitre d’ steps you through the basics, simple questions about CT’s health insurance exchange, and the Medicaid/HUSKY program. Helpful articles include Obama and you – an explainer, What you need to know (overview) – and resources, and 6 things to know when buying health insurance.