Legislative update: SIM funding may draw lawsuit, nursing home profit sunlight bill passes House

The proposed state budget includes $3.5 million in funds for the new SIM state agency. CT Mirror reports that the funding is planned to come from a tax on insurers. The inclusion of self-insured plans in the new tax may draw a federal lawsuit. The state hopes it won’t and points to a vaccine program that is funded by self-insured plans and others. Industry analysts point out that vaccines are clearly beneficial to everyone, but SIM’s benefits are unclear. Consumer advocates have raised many concerns about the SIM proposal.

Yesterday the House passed legislation to open the books on for-profit nursing homes. CT News Junkie reports that the legislation has been championed by workers in response to concerns about nursing homes claiming losses and seeking state Medicaid increases but potentially hiding profits in affiliated businesses. The bill now moves to the Senate.

Independent advocates publish comments on first 4 SIM position papers

CT independent consumer advocates have published comments on SIM’s first 4 policy papers.

  Regarding Issue Brief #1 (provider surveys), advocates urge that the results of consumer experience of care surveys should be made public to use as tools for choosing care and as a lever to improve care quality, SIM must ensure that results of surveys are used constructively within practices to address gaps, and SIM should provide practices with low scores assistance to improve patient experience of care.

Regarding Issue Brief #2 (payment), advocates are very concerned with proposed options #b and c which would seriously undermine the quality goals of SIM by assuring no payment to providers for care coordination and other important care management services beyond 18 months, despite strong evidence that these value-added services significantly improve the quality and efficiency of care, regardless of whether shared savings are produced. Advocates believe that services that promise to improve value, whether traditional treatments such as drugs or new, innovative services such as care management, should be treated equally.

Regarding Issue Brief # 3 (glade path administration), advocates are very concerned both with the consolidation of administration and standard-setting under one very new state agency, and with the assumption underlying that proposal: that the successful patient-centered medical homes model based on NCQA accreditation, performing very well in CT’s Medicaid program and generally accepted throughout the US health care delivery system as the appropriate certification standard, should be abandoned in favor of some new, CT-specific, yet-to-be developed standard. There is a large body of evidence that NCQA accredited PCMHs are associated with improved health outcomes and there is a growing list of almost 1000 certified PCMHs in CT currently. If advanced standards are necessary, although there is no evidence they are, CT should follow the lead of a few other states by requiring those standards in addition to NCQA certification. CT should build on what is working, not dismantle it.

Regarding Issue Brief # 4 (community integration), while advocates generally agree with the proposal, we are take issue with the assumption that a move to much greater consolidation among providers is both inevitable and should be facilitated, when such consolidation may in fact be harmful to the goals of improvin

Webinar posted: Measuring quality and value at Crystal Run ACO

Video and slides from yesterday’s webinar with Crystal Run ACO have been posted. There are important lessons for CT policymakers implementing shared savings payment models. Crystal Run was one of the first Medicare shared saving ACOs and is one of seven NCQA certified ACOs. Hear the physician leaders explain how they monitor the quality of care against best practices, comparing providers to their peers, and use the analysis to reduce costs. Through this quality improvement process, Crystal Run has been able to reduce spending per patient up to 26% for some conditions. The reductions in unnecessary visits has reduced wait times to see specialists and increased the number of patients they can serve with the same workforce.

SHOP exchange facing challenges, low enrollment

A CT Mirror article examines the reasons behind very low enrollment in CT’s insurance exchange for small businesses (SHOP). This shouldn’t come as news – low enrollment was predicted by analysts hired by the exchange. The reason was also predicted – it’s expensive. The article explores other problems including poor marketing, no online tool linking to ACA small business subsidies, and a website design that doesn’t make comparing plans easy. Next year AccessHealthCT plans to switch from the current vendor to run the SHOP exchange in-house and to revise plan offerings.

208,301 in CT enrolled in health care under ACA

 AccessHealthCT has worked through the queue of applications pending when enrollment into the insurance exchange closed March 31^st. Between Jan 1^st and March 31^st, 208,301 state residents were enrolled in coverage. Most qualified for Medicaid – 129,588 – approximately the number of new eligibles originally estimated for the state. (For the nitpickers out there – it is likely that some of that number come from the “woodwork” effect – people who would have qualified before 2014 anyway). But it is an impressive accomplishment – CT did nowhere near as well in HUSKY outreach when eligibility expanded under CHIP. The navigators and assisters deserve congratulations. And it is very important for readers to note that Medicaid eligibility did not close on March 31^st. Eligible state residents can and should continue to apply for Medicaid coverage through AccessHealthCT.

We hope to know more soon about the other 78,713 people who enrolled into insurance through the exchange, especially how many were previously uninsured. Unfortunately this is only a fraction of the 250,000 to 300,000 CT uninsured who are estimated to be eligible for exchange coverage.

Join us: Measuring quality and value at CrystalRun Healthcare ACO

Please join us for a webinar Apr 22, 2014 11:30 am with CrystalRun Healthcare, one of seven NCQA accredited ACOs in the nation. NCQA requires robust quality improvement systems for accreditation, including under-service monitoring. Learn how CrystalRun Healthcare uses physician variation as a clue to reduce costs and improve access. They have reduced per patient costs by 7.6% without compromising outcomes. 
Over 2 years by decreasing the number of visits per patient, without impacting outcomes or quality, they were able to serve more patients – in essence increasing their workforce by 2.5 doctor/equivalents. Panelists include Co-Chief Clinical Transformation Officers Jonathan Nasser, MD Division Leader, Pediatrics, and Scott Hines, MD Medical Specialties Medical Director. 

Click here to register.

CT free dental clinic April 25 and 26 in Hartford

This year’s CT mission of Mercy free dental clinic will be held later this month Friday and Saturday, April 25^th and 26^th at the XL Center in Hartford. Previous clinics around the state have provided free dental care worth over $1.3 million to 1,782 people from 140 municipalities. Care is provided on a first come, first served basis. Patients can park for free in the city owned Morgan Street Garage. Recognizing the importance of good oral health during pregnancy, this year’s clinic will include a separate, shorter line for pregnant women needing dental care. The clinic is supported by the CT Foundation for Dental Outreach and the CT State Dental Association. Click here for more information on who can get care, how it works, free parking, and other details.

Settlement reached in Medicaid enrollment lawsuit

DSS and legal aid attorneys have reached a settlement in a class action case, filed in January 2012, over Medicaid application delays. Delays of six months are common for people with high medical costs or needing home care. Under terms of the settlement, by next April DSS must process 92% of applications within the federal standard, usually 45 days. DSS also agrees to hire 35 more enrollment workers, costing $2.5 million, and agrees to pay legal aid’s attorney fees and costs. The settlement still needs to be approved by the Court and the state legislature.

“free” preventive care that isn’t free

News reports are highlighting the nuances of implementing the ACA’s provision eliminating consumer cost sharing for preventive care. An article in the Washington Post includes an example of a practices adding a facility fee of $1,935 for a CT woman’s colonoscopy that should have been free. According to a WSJ article ‘"Patients are scheduling 'physicals' because physicals are free," says Randy Wexler, a family-medicine physician in Columbus, Ohio. "But they come in and say, 'I've been having headaches. My back has been bothering me and I'm depressed.' That's not part of a physical. That will trigger a copay."’ Some practices are scheduling separate visits to separate preventive care from treatment. Consumer advocates are seeking guidance from CMS.

Medicaid update

Yesterday’s Medicaid Council focused on improving enrollment and quality performance in the program. From the new ConneCT Dashboard we learned that there is no longer a backlog of enrollment documents waiting to be scanned into the system, that waiting times for the call center are down from 75 to 39 minutes, but that the hours of interruption on the website were up in March from February. However the system has not been down at all in the last two weeks. Council members congratulated DSS on sharing important information but questions remain about the call abandonment rate and wait times to abandonment. DSS outlined the continuing work to reduce wait times and service interruptions.

DSS also reported on new quality measures in the program across eligibility categories and practice settings. While CT generally compares about equally with national Medicaid measures, care delivered at hospital clinics and/or to members not attributed to a primary care provider was significantly lower on 18 of 23 measures. Apparently only two hospitals are reporting quality data, which may be impacting those results. Questions remain about definitions of measures and ordered vs. received care, which may be a clue to underservice and gaps in care. While there is a great deal of work to do on many measures, Council members thanked DSS for comprehensive information we never had in the past.

Health Care Cabinet meeting -- SIM, exchange updates

Yesterday’s Cabinet meeting was lively -- not sure it was productive. The insurance exchange reported on a flurry of last minute activity that significantly boosted enrollment. Final numbers will be available in a few weeks when it becomes clear how many people follow through and pay premiums, and the backlog of people in the queue are able to complete the process. The exchange is looking ahead to the next enrollment period starting in November. Unfortunately they do not expect to keep on the vast majority of navigators and assisters who did such a great job with Medicaid enrollment. It is important to note that the March 31^st deadline for exchange enrollment had no impact on Medicaid – people eligible for that program can and should still sign up. The exchange plans to work on better reporting capability, consumer engagement, and connect with state agencies and brokers. Unfortunately there are no meaningful plans to address the very expensive premiums.

SIM staff asked for comment on their most recent policy papers, especially about financing new services. Concerns were raised that there be no disincentives to providing innovative new services likely to improve health and save money including care coordination and medication management. SIM was urged to finance these promising new services in the same way as promising traditional treatments. Providers are not asked to pay up front for new drugs that keep people out of the hospital, nor are the costs of those drugs subtracted from their shared savings payments. The SIM new services are also expected to improve value and should not be treated differently than other care. The SIM steering committee is creating a finance subcommittee to discuss these issues and more. The group agreed to hear reports on Medicaid’s health neighborhood pilot development at future meetings.

Note: Independent consumer advocates also submitted comments to SIM opposing any state of mind test to enforcement of under service standards.