SIM update: PCMH standards affirmed but rushing into a radical Medicaid payment change

The good news: At yesterday’s meeting the SIM steering committee voted to accept their workgroup’s recommendation to use NCQA national standards, with some CT-specific additions, as the patient-centered medical home (PCMH) standard for the SIM glide path program. SIM will work with NCQA to develop the additional standards, possibly to include oral and behavioral health integration and cultural/linguistic standards. New practices, without any PCMH certification, will be offered support to achieve the new NCQA Plus standards. Existing PCMHs will not be affected by the decision.

The troubling news: To get the federal grant, SIM leaders believe they need to be more aggressive in Medicaid payment reform and have proposed a shared savings model to cover over 200,000 members starting Jan. 1, 2016. There are very few details on the proposal and committee members had a lot of questions. Consumer advocates raised significant concerns both in public comments and during the meeting. Concerns focused on an 1115 waiver with a global cap on federal reimbursements, HSAs for Medicaid members, reductions in current fees to providers but potential future savings payments, the lack of time and vetting through councils and committees for the proposal, and undertreatment/incentives to deny necessary care. Doubts have also been raised about SIM’s assertion that they must include radical Medicaid payment reforms to secure a successful SIM grant. Advocates noted that earlier successful SIM states’ Medicaid reforms followed a natural progression of ongoing reforms in those more mature states. And we’ve known about their plans for over a year. CT has a poor history with similar Medicaid incentives. Since CT Medicaid moved away from capitation in HUSKY to one focused on PCMHs, health outcomes are better, provider participation is up, and per person health costs are down.

Good news on SIM and PCMH national standards

The new SIM Practice Transformation Workgroup met last night for the first time and support for patient-centered medical home national standards was strong. Advocates have been strong supporters of national standards for PCMHs over a CT-specific program. There is growing evidence that PCMHs that meet national standards perform better on quality, enhance access to care and control costs. Advocates developed a Q&A to answer questions and address misinformation about PCMH national standards. The group agreed to tie the SIM medical home program to NCQA standards. The vote was overwhelmingly in favor of NCQA, with no votes recorded against.  NCQA is the leader in PCMH recognition – certifying 80% of PCMHs nationally. Practices would have to commit to an NCQA PMCH application and recognition to participate in SIM’s glide path program. Only new, non-PCMH practices will receive PCMH assistance from SIM, so practices that currently have certification, NCQA or another standard, will not be affected. There was strong interest in adding other, CT-specific standards to the standard – the NCQA Plus option. The committee will pursue those options with NCQA. The decision now goes to the SIM Steering Committee in their Thursday meeting – where there has been strong opposition to national PMCH standards.

Advocates’ comment urging DSS not to erode successful PCMH standards in Medicaid regulations

Eighteen consumer organizations signed onto a letter of comment sent yesterday making the case that DSS should continue using successful national standards for patient-centered medical homes (PCMHs) in new Medicaid regulations. Original versions of draft language included the current practice of adopting NCQA national standards for PCMH recognition and incentives. However, without notice, national standard language was dropped from the latest draft and replaced with CT-specific standards. Advocates have been very concerned about a similar move by SIM to replace proven, successful, well-established national PCMH standards that are working in CT with a yet-to-be developed home grown standard. Since CT’s Medicaid program shifted to a NCQA-based national standard PCMH focused program, quality outcomes are up, non-urgent ER visits are down, per person costs are down, and the program has attracted 32% more participating providers, just as program enrollment grows under the ACA. Based on consumer advocacy, a SIM committee will meet tonight to re-consider the SIM decision to reject NCQA in favor of CT-specific standards.

SIM committee to discuss PCMH national home standards

The first meeting of the SIM Practice Management Taskforce will re-visit SIM’s earlier decision to reject national standards for patient-centered medical homes. National standards, such as NCQA, have been very successful nationally and in CT in improving health outcomes while controlling costs. Advocates have serious concerns about eroding standards that promote quality care and ensure we are paying for value. The meeting will be Tuesday June 24th from 6 to 8pm at the CT State Medical Society’s offices, 127 Washington Ave, East Building, Third Floor, North Haven CT.

Comparative effectiveness opportunity guide for New England OB-Gyn services

The Institute for Clinical and Economic Review (ICER) has produced a comprehensive analysis of opportunities to reduce overtreatment from the Choosing Wisely list of five overused treatments identified by the American College of Obstetricians and Gynecologists. ICER’s report focuses on New England including analysis of current regional utilization patterns, the feasibility of practice change, resources for implementation, and opportunities for cost savings. The report identified reducing routine annual Pap tests in women ages 30 to 65 years of age as the greatest opportunity for impact across New England among the Choosing Wisely ACOG list with substantial current levels of overuse and variation, large potential savings, and expected innovations making it easier to identify inappropriate care.

SIM update – good news but new concerns

Last week’s SIM steering committee included some good news but new concerns. Based on public comment from independent advocates supporting national standards for patient-centered medical homes and urging SIM to reconsider their decision to create a CT-specific standard, wasting time and resources to fix something that is not broken and working well. In response, the committee agreed to send the issue to the new Practice Management Transformation Committee to re-consider. That’s the good news.

Later in the meeting we heard from multiple groups at UConn, which appears to be given most or all of the SIM functions. It was unclear how and under what authority the proposals for these very important functions was sole-sourced to UConn. One presentation was from the UConn School of Pharmacy on how they intend to design and implement the new CT-specific medical home standard. Unfortunately there were not many details on the plan and none of the independent advocates’ concerns have been addressed or acknowledged. The plan seems to be designed to track with requirements to get the federal funding rather than CT experience and what is working well in our state. Consumer advocates have emphasized that getting federal funds to state agencies and consultants is not a high priority for consumers. Transparent, inclusive, thoughtful processes leading to better access to quality care and cost control are priorities for consumers. There is substantial and growing evidence that national PCMH standards are working and delivering on that triple aim, both nationally and in CT’s Medicaid program.

Medicaid Council update

The agenda for last week’s Medicaid Council meeting was very full. We reviewed DSS’s latest ConneCT Dashboard. More clients are using the online system, but more are also walking into a DSS office. The backlog of documents to be scanned is gone and last month the online system was never down. However, the call abandonment rate, still unacceptably high at 59% in May, and minutes waiting on hold until hanging up (13 minutes) are not moving. DSS is working on a call-back option.

We also heard about encouraging improvements in access to dental care in HUSKY. The number of participating dentists is up from 349 in October 2008, before the carve out, to 1,855 last year. Two out of three CT dentists now participates in Medicaid. The 2013 dental care utilization rate of HUSKY children (67%) and adults (48%) is higher than the national average and rising every year. Per member costs are declining and more of the total funding is being spent on preventive care over time.

AccessHealthCT gave an update and responded to questions about privacy and security given the breach a week earlier of names, social security numbers and dates of birth for about 400 applicants. It is not known how many of those 400 are Medicaid members. Maximus is moving to a paperless system to avoid the problem that happened last week. Concerns were raised about security and a policy decision not to allow people to opt-out of the AccessHealth Analytics APCD.

Cabinet update – DSS/exchange IT and SIM updates

The SIM update included a description of the recent funding application release. All drafts for the grant will only go through the Steering Committee. It was clarified that the “owners” of the SIM process are the related state agencies. SIM intends to “align” CT’s health priorities with the federal grant. Concerns were raised that the state was making important decisions about the health of millions of state residents, sometimes contrary to the priorities developed here in CT, just to get a federal grant and to benefit state agencies.

At this week’s Health Care Cabinet meeting we heard about ambitious plans to extend the IT plan integrating DSS’s ConnectCT with the insurance exchange. If the expansion works as planned, it will solve a lot of the ongoing problems. Members offered support but warned about unintended consequences. It was suggested that planners include people from the real world – consumers, advocates and assisters – now, in the design process – not just in testing – to ensure that the system is workable from the beginning and to avoid future problems.

The exchange update was the usual stuff until they described the recent security breach. While the exchange was open in reporting the breach, there were no details about how it happened. The exchange was urged to take measures to ensure this never happens again. It is very difficult to re-build trust and, as the exchange takes on the APCD and even more sensitive information – consumer privacy and security must be the top priority.

The Cabinet decided not to meet again until the Fall.

New Brief: Patient-centered medical homes are working in CT, but standards are at risk

Patient-centered medical homes (PCMHs) are working well in CT. There is growing national and state evidence that certified PCMHs improve health care access and outcomes while controlling costs. PCMHs are a new way of delivering health care that uses a team of providers to coordinate care and help people keep themselves healthy. CT’s Medicaid program has significantly benefitted by adopting certified PCMHs attracting more providers to the program just as the program expands. Growing every month in CT, PCMHs are the foundation of thoughtful payment reform – paying for value rather than volume. But it is critical to maintain standards and accountability, ensuring that PCMHs are doing what they are paid to do. National PCMH certification standards like NCQA, the gold standard, work – ensuring we get value for our spending. Unfortunately nationally recognized PCMH standards are at risk in CT. The SIM process, and now DSS Medicaid regulation language, have proposed eroding those important standards, that are working so well for consumer and payers. A new brief by the CT Health Policy Project outlines the value of PCMHs and what is at risk for CT.

Data breach at Access Health CT, troubling for APCD future

Friday afternoon a backpack was found on a Hartford street with sensitive information on about 400 Access Health CT customers. The backpack included four notepads with handwritten names, social security numbers and dates of birth, as well as internal Access Health CT papers. People whose information was breached have been contacted and offered credit monitoring and resolution services. Access Health CT says they will find out how this happened and make changes to see that it isn’t repeated. Access Health CT testified against a bill this session requiring enhanced background checks for people handling sensitive information. The bill did not pass.

Unfortunately this is the same organization is being given responsibility for even more sensitive information in our medical records. Access Health Analytics, a unit of Access Health CT, will soon be collecting our medical records, across all insurers and government programs in an all-payer claims database (APCD). The plan is to use the information for health planning and, hopefully, to give consumers the information they need to make better health care choices. It could be a very effective tool to improve our health system. However, unlike Rhode Island’s APCD, Access Health Analytics has decided not to include an opt-out provision giving people control over their most sensitive information. Reportedly a very small number of people have chosen that option in Rhode Island, but just having it builds trust. Connecticut should re-visit this poor decision that undermines trust in a system that is not perfect.