New to the Book Club -- How Not to Be Wrong

The title of the latest addition to the CT Health Policy Project Book Club, How Not to Be Wrong: The Power of Mathematical Thinking, sold this book but the content delivered on the promise. It was entertaining and funny – not what you expect from a book about math. The author dives into fascinating questions using math concepts including how long until every American is obese (the dangers of extrapolation), and perspectives on genetic influences on schizophrenia, and rare serious side effects of birth control pills (what statistical significance is and what it isn’t).

CT employer coverage eroded over last decade, well before ACA implementation

A new report by SHADAC finds that 11.3% fewer CT firms offered health benefits to workers in 2012/2013 than eight years before, following national trends. Most of that loss happened in the last four years (8.8%) following the economic downturn, but well before implementation of the Affordable Care Act. Eligibility for coverage (among employers who offer coverage) didn’t change significantly in CT over the eight years, but take-up rates slid by 7.1%. That slide was likely driven by rising premiums which grew by 45% for singles and 48% for families. Workers at small firms were hardest hit – they are less than half as likely to be offered coverage and even that rate dropped 17.1% over the eight years. Also following national trends, part-time CT workers are less than half as likely to be eligible for coverage at work although that percentage didn’t change significantly.  While far more likely to be offered coverage, workers at large firms lost ground over the eight years both in offers and take up rates.

CT exchange members more likely to get financial assistance and slightly older than other states

The latest federal ACA enrollment report finds that AccessHealthCT, CT’s health insurance exchange, received 76,460 total applications between Nov. 15^th and Jan. 16^th. 162,921 state residents were found eligible for Medicaid. Of the 142,287 applicants eligible for exchange coverage, 77% are also eligible for financial assistance – higher than the 70% average across all state-based exchanges. 24% of people who’ve made a plan selection in CT are ages 18 to 34. This is lower than the state-based exchange average (26%) and below our neighboring states (MA 29%, NY 28%, RI 25%).

Budget Update: more interim budget cuts, calls for long term fix, Medicaid deficit due to temporary issues

In response to a growing budget shortfall for this year, last week the Governor ordered $31.5 million in budget rescissions. This is the Governor’s second round of cuts for this fiscal year. Health-related cuts included $8.4 m from DDS, $1.3 m from DMHAS, $602,435 from school-based health clinics, $71,515 from Healthy Start, and $1.3m from UConn Health Center. Republican leaders are concerned that continuing rescissions are keeping the deficit just under the statutory level requiring a deficit mitigation plan be submitted to the legislature.

OPM is reporting that Medicaid spending is $120 m over budget. It is our understanding that the shortfall is due to one-time issues including CMS settlement payments from difficulties categorizing eligibility, and uncertainty over relevant dates (service vs. payment) affecting reimbursement in the first Medicaid expansion year. The state is responsible for half the costs of care for enrollees in pre-ACA coverage categories, in contrast to newly eligible enrollees whose costs are 100% reimbursed by the federal government trough 2016, slipping modestly to 90% eventually. Reports of higher than expected enrollment in pre-ACA HUSKY categories have reversed in recent months. Also adding to the Medicaid shortfall was an optimistic fraud recovery estimate in the original budget passed last Spring. Hospital retroactive settlements are up over last year, but this will also be resolved when the state moves to a DRG-based payment system.

All the issues adding to the shortfall will be resolved soon and should not precipitate calls that Medicaid spending is “out of control”. Because of quality and value improvements in the program, per person spending in the program is stable, saving about $150m in state Medicaid funds compared to per person health cost increases for all Americans

FDA Advisory Committee recommends new orphan anti-infective drug

Yesterday’s FDA Anti-Infective Drug Advisory Committee meeting considered evidence about the safety and effectiveness of ISA, a new drug to treat a rare fungal infection threatening the lives of people with severe illnesses. The condition affects a few thousand Americans each year suffering from weakened immune systems due to conditions such as HIV, stem cell transplants, or cancer. Without treatment virtually all these patients would die. We heard very compelling public testimony from an affected patient, a doctor calling for more treatment options, and the father of a young boy who died from a fungal infection, not from his cancer. There are few other drug options to fight these infections and they are very imperfect. Because these conditions are rare, there is not a lot of clinical data about the effectiveness of the drug but it is promising. The committee voted to recommend that the FDA approve the medication for these uses, but with warnings about use in children, pregnant and nursing mothers. The committee emphasized the need for more studies including more information on an interesting ethnic variation in the drug’s physiology.

Medicaid deficit rises to $120 million, but causes are unclear

The Governor announced yesterday that new cuts to the state budget will be necessary due to the rising state deficit. A large part of that deficit is in the Medicaid program, but the causes are unclear. Per person costs in the program are stable, even declining slightly since the switch away from financial risk-bearing organizations – which has saved the state many millions compared to past trends and other states – and likely will continue to deliver savings sustainably into the future. It is unclear how much of the current deficiency is temporary and administrative. OPM’s monthly letter points to higher than expected enrollment (but most of that is still fully reimbursed with federal funds), resolving enrollment category issues, higher than expected hospital settlements, and medication initiative estimates. The letter does not give details on the deficiency causes. Advocates are concerned that potential cuts to program eligibility or provider rates, meant to address the deficiency, will be counter-productive -- undermining recent success in the program and reversing CT’s progress toward meaningful coverage for every state resident.

Medicaid update – impressive quality dashboard demo

At Friday’s Medicaid Council meeting, DSS demonstrated their upcoming HUSKY Health Data Dashboard. When it goes live the dashboard will give visitors drill-down access to a wealth of quality and access data across the program including outcomes, member and provider experience, provider enrollment, spending and utilization, as well as special projects. All Medicaid services will be included in the dashboard – medical, behavioral health, dental, non-emergency transportation, pharmacy, and long term services and supports. Because the state no longer fragments the program among managed care organizations, we avoid all those apples-to-oranges disclaimers that kept policymakers in the dark for over a decade. The data will be available in pre-set charts as well as downloadable aggregate data. I am particularly interested in the ability to parse spending increases by category of service and price vs. utilization influences. There were objections to a suggestion that providers receive identifiable information on Medicaid members not affiliated with a provider for outreach purposes. While we acknowledge the benefits of encouraging connections to the health system, release of identifiable data raises concerns of adverse selection, especially given DSS’s controversial plan to introduce provider risk into the program a year from now.

Rhode Island’s exchange trusted consumers and it worked

Exchanges across the country had to decide last year whether to require current members to return this year and choose a health plan or automatically re-enroll them in their old plan if they don’t choose to switch. A federal study found that 70% of consumers would save money if they switched. But there was general concern among the experts that many wouldn’t come back and would lose coverage. Both the federal Healthcare.gov and CT’s exchanges decided to default people back into their old plan, sometimes with much higher premiums, if they didn’t affirmatively switch. Rhode Island’s exchange, however, trusted consumers to come back and re-evaluate the best fit for them – 78% did, and many saved a lot. Only 40% of HealthCare.gov consumers returned to shop. There is also evidence that plan switching causes health plans to offer better value plans to keep customers. Rhode Island has a history of successfully trusting consumers to manage their own affairs.  A NY Times article explores the exchange enrollment assumptions that drove the different decisions, and how Rhode Island turned out to be right to trust consumers.

Surgical hospital coming to CT, promises to serve Medicaid

The Hospital for Special Surgery has received approval to open a large outpatient center in Stamford, according to Crain’s New York Business. The New York hospital has a reputation for very high quality and serving wealthy patients. But as a condition of DPH approval, HSS has agreed that 10% of their CT patients will be Medicaid members. Only 2% of NY patients are covered by Medicaid. Access to orthopedic specialty care has been a serious issue for Medicaid members in our state. This announcement is testament to the improvement in CT Medicaid’s attractiveness to providers.

Only half of fully-insured US Medicaid providers available

A new HHS-OIG survey found that only 49% of providers listed as participating by full-risk Medicaid managed care plans were available for routine, non-urgent appointments. When CT had full-risk MCOs running our Medicaid program, a secret shopper survey found that shoppers could only schedule appointments with 25% of listed providers. But things have improved significantly in CT. A recent secret shopper survey in our self-insured program found that 68.3% of providers were taking appointments, a large improvement over CT history and exceeding the national average. 

Medicaid coverage for children linked to higher tax receipts by age 28

A new study finds that in addition to improved health and lower mortality, children who were covered by past Medicaid expansions paid more taxes by age 28. The longer they were eligible for Medicaid, the higher the tax receipts. They also had lower Earned Income Tax payments and were more likely to attend college.  Interestingly, the effect was higher for girls than boys. Advocates often talk of Medicaid as an “investment”, but it’s nice to have studies to back us up.

New to the Book Club: The Health Care Handbook, 2nd edition

The Health Care Handbook is the newest addition to the CT Health Notes Book Club. The new edition of this incredibly helpful primer on the US health system is even better than the 2012 version. Written by two med students who searched for a balanced, useful, and readable source of information for students like themselves explaining the industry and culture they were about to join, the book includes just enough information to be useful, but not enough to be confusing. The new edition includes updates on virtually every page including implementation of the Affordable Care Act, the recent health cost slowdown, and what we’re learning about health care quality. Definitely recommended – both students and wonks can find a lot here.

SIM & CAB update

Today’s SIM steering committee meeting has been cancelled. (BTW- the Medicaid Council meeting scheduled for tomorrow has been postponed to next Friday, the 16^th.)

Tuesday’s SIM Consumer Advisory Board (CAB) meeting was frustrating. They were supposed to vote on an ethics resolution proposed last month, but delayed a vote yet again. (They sent it to a workgroup for more study.) They are questioning whether they are legally subject to the state’s Code of Ethics for public officials. The Code prohibits people with a role in setting policy and budgets (CAB already has done this in a good deal of detail), or their businesses, from financially benefitting from those decisions.

The CAB has already stipulated that they are public officials in a related refusal to comply with FOI. They entered an executive session, a meeting where the public is not allowed, to discuss and vote on applicants for positions on SIM committees. They maintain that the secrecy is allowed because they are public officials and were discussing a personnel matter.

Bottom line: CAB is asserting they are public officials for FOI -- evading transparency -- but aren’t sure they are public officials for ethics -- evading accountability. Several members noted that CAB -- a board meant to represent and protect consumers in health care reform – should exceed the legal minimum and “take a higher road.”

In a hopeful note, SIM staff reported that they will recommend that the steering committee take up the ethics issue for the entire SIM process. Staff expressed a strong intention to abide by all laws and regulations, and to ensure the integrity of SIM policymaking and contracting.

Surgical errors in CT hospitals climbed in 2013

A new analysis by C-HIT found that adverse events (serious medical errors) in CT hospitals were up significantly in 2013, more than double the year before. The greatest increases were for foreign objects left in bodies and perforations during surgery. Deaths, serious falls, serious medication errors, and surgeries on the wrong body part all increased as well. New Milford, Danbury, and Day Kimball Hospitals had the highest error rates adjusted for patient volume. Charlotte Hungerford, Backus, and CCMC had the lowest rates. DPH’s report is careful to note that the increase may be due to better reporting.  Click here for DPH’s full adverse event report including hospitals’ patient safety plans to improve quality and reduce errors.

January CT Health Policy Webquiz: ACO performance in CT

Test your knowledge about the quality and efficiency performance of CT’s Medicare ACOs. Take the January CT Health Policy Webquiz.

Questionable Hartford flu numbers

A fascinating piece from CT by the Numbers digs into why conflicting reports find over 150,000 flu cases in Hartford for one week, in a city with 125,000 residents. Bottom line: Don’t believe everything you read in an ad.

CT health reform progress meter down again slightly to 29.5%

CT’s progress toward health reform is still stuck. The meter moved down again this month slightly to 29.5%. As usual, Medicaid accounted for most of the progress with comprehensive quality reporting, impressive long term services and supports, and transparent, collaborative payment reform planning. We love it when state agencies show all their work – even the stuff that needs improvement -- it builds credibility and you can trust that you are seeing the whole story. Again SIM challenges lowered the progress meter by abandoning workforce, and transparency (FOI) and accountability (ethics) challenges for the SIM consumer advisory board. The CT health reform progress meter is part of the CT Health Reform Dashboard.