Advocates offer help with payment reform study for CT

Among the many important provisions in SB-811, is Section 17 directing the state Health Care Cabinet to conduct a study of successful payment reform models from other states. The Cabinet is to report back to the General Assembly with recommendations for policy changes that will provide a framework to control health care costs, reward value-based care and improve health outcomes for Connecticut residents. No one is more committed to meaningful reforms than consumers and advocates. As the ultimate payers for all health care – through our premiums, out of pocket costs, lost wages and taxes – consumers take the full burden of inefficient spending.  As veterans of current and past reform attempts, in a sign on letter, nineteen independent consumer advocates have offered the Cabinet their full support and assistance in developing a feasible, effective plan to control health care costs and build value. Based on CT’s history with reform, the advocates urge the Cabinet to ensure transparency, robust public input, build on what is working in our state, recognize unique populations, and to adhere to ethical standards that guard integrity. The next meeting of the Health Care Cabinet is scheduled for September 8th.

Happy Birthday, Medicaid -- Connecticut has a lot to be thankful for

Fifty years ago today President Johnson signed the Medicaid program into law. The program now covers one in five Connecticut residents with efficient, quality care. Since switching from a capitated, insurer-based program to a self-determined, care-focused program in January 2012, costs are stable (down slightly) per person, quality is up (fewer people are going to the ER for non-urgent problems), and 32% more providers are participating. It took the efforts of many advocates over more than a decade, and it was difficult, but we finally made that switch happen. And good health is a powerful thing. Children covered by Medicaid are more likely to finish school and have higher earnings as adults. In one study, economists estimated that just the taxes on the higher earnings of those adults make up the cost of Medicaid coverage for children now on the program. So Happy Birthday to Medicaid – especially to the many professionals that provide that healing care. Many many thanks to Connecticut’s Medicaid providers.

New to the Book Club: The Myths of Modern Medicine: The Alarming Truth about American Health Care

The Myths of Modern Medicine: The Alarming Truth about American Health Care by John Leifer is very readable. The book organizes the problems in modern American health care into ten myths, that are accessible to any reader, but not dumbed down. The myths are simple and straightforward, without all the usual waffling. The descriptions not only outline the problem, but also include the causes – why our “system” is the way it is – and why it is hard to change. The author, a reformed hospital executive, is not sparing in blaming hospitals, but also points at insurers, physicians, employers, politicians, bureaucrats, and consumers. Myths debunked include – the US has the best health care system in the world, the concept of shopping for health care services, and that treatments are based on science and best practices. A great read for consumers, but important perspectives for all stakeholders. Click here for more books

Where We Live: Medicaid is 50 and Looking Good

Fifty years ago this week, Lyndon Johnson signed Medicaid into law. On today’s show, WNPR’s Where We Live celebrated the program that covers one in five CT residents with comprehensive care and brought $3.3 billion in federal funds to our state. More efficient than private insurance, leading the state in quality improvement as it cares for CT’s most fragile residents, Medicaid is modeling thoughtful reforms that save money by improving care. DSS Commissioner Rod Bremby, Christian Community Action’s Rev. Bonita Grubbs, Health Affairs Editor-in-Chief Allan Weil, and Ellen Andrews of the CT Health Policy Project joined host John Dankowsky to explore how the prgram is living up to the original vision. Hear the conversation online.

Growing percent of AccessHealth CT members are not using their coverage

A new survey by AccessHealth CT found that 36% of their customers had not used their health coverage, compared to 26% last year. One in four (28%) don’t have a primary care provider. Enrollment in qualified health plans is now 96, 966, down 13,129 from the open enrollment period earlier this year. The biggest reason people left the exchange was cost – the coverage was too expensive/unaffordable. 7% dropped it because they didn’t use it. The survey found that 51% of enrollees this year were previously uninsured.

Care delivered by CT family members worth $5.9 billion, but capacity is uncertain

In 2013 almost half a million CT residents provided 427 million hours of unpaid critical health care services to family members according to an updated report by AARP. The value of that care was $5.9 billion, about what CT spends on Medicaid in total. Family care is expanding and becoming a vital piece of our health care system, as the job becomes more complex, costly, stressful and demanding. Most caregivers are employed, making this a business concern as much as a health system issue. The report outlines key challenges facing caregivers and policy recommendations that could help.  

SIM underservice protections get a cool reception, weak ethics policy adopted

Thursday the Equity and Access Council delivered to the SIM Steering Committee a draft report with recommendations to avoid underservice in SIM’s planned payment reforms. Advocates were successful in getting a provision in the SIM final plan that prohibited payment of shared savings to provider networks that systematically denied needed care to generate those savings. The Council’s job was to draft recommendations to implement that provision. Members were thankful for the hard work and complimented the Council on a thoughtful report. However members raised concerns with the recommendations, especially with a provision that would divert payments denied due to underservice toward quality improvement and fixing the underservice problem, rather than back to the insurer. It is important to note that, under the Council’s recommendations, provider networks would not know what metrics are being monitored for underservice. But the insurers do know what is being measured, and as we learned in Council discussions, insurers have tools that could result in underservice, as were used during managed care in the 1990’s. (My students don’t know what is going to be on the test, but I don’t get paid double for students who get F’s.) The main concern was that this would limit the ability to cut costs, and that the money belongs to employers and should be returned to them. It was noted that the ultimate payers of health care are actually consumers – through our taxes, our premiums/out-of-pocket costs and our lost wages. Employer health benefits are part of earned compensation. Concerns were also raised with a recommendation to prohibit directing shared savings payments to the pockets of providers with the lowest costs, as this would be an exceptionally strong incentive to underserve. It was noted also that, if reform is done right to improve the value of care and improve health status, reductions in costs will be a team effort including the provider, but also potentially a nurse, nutritionist, pharmacist, community health worker, aide, and/or behavioral health specialist. Concerns were raised about rewarding networks that improve health quality (and hence value), even if they did not achieve savings, with sharing the cost of necessary investments with providers, and a recommendation to exempt very high cost patients from the shared savings methodology as these would undermine cost savings. It was suggested that fraud detection systems would be adequate to deter underservice; there is a great deal of underservice that is not fraudulent. The report will be submitted for public comment soon.

Unfortunately at the same meeting the committee was presented with the final version of their very weak conflict of interest policy that does not meet the standards of the State Code of Ethics. A declaratory ruling of the State Ethics Board found that SIM committees have substantial authority over setting state health standards and over state and federal funding but are exempt due to a loophole in the law. The ethics law does not specify appointees of the Lieutenant Governor, as all SIM committee members are. Two Steering Committee members have been awarded SIM grants from federal funds. The Hartford Courant Editorial Board has called on SIM to adopt the State Code of Ethics.

Study finds CT early Medicaid expansion reduced hospital uncompensated care

A new study published in this month’s Health Affairs finds that CT hospital Medicaid revenue grew by 7 to 8% after CT took advantage of the ACA’s early Medicaid expansion option in 2010. The study also finds that uncompensated care costs to CT hospitals were one third lower than they would have been without the expansion. Researchers from the University of Michigan used CT hospitals’ Medicare cost reports compared with other Northeastern states to reach their conclusions.

New tool allows comparison of local surgeons’ safety record

Patients considering surgery often check their hospitals’ quality rating, but the your surgeon’s safety rating can be even more important. Half of US hospitals have surgeons with both high and low complication rates. ProPublica’s new Surgeon Scorecard allows patients to compare the safety record of surgeons by hospital. ProPublica used Medicare data to calculate surgeon’s death and complication rates, adjusted for patient health, age, and hospital quality, across eight elective procedures. Visitors can search by state, by address, by hospital or for a surgeon near them. For example, of 28 CT hospitals that perform knee replacements, 12 have at least one surgeon with a high complication rate, but five have at least one surgeon with a low rate. Other procedures included in the Scorecard include hip replacement, cervical (neck) spinal fusion, lumbar spinal fusion – posterior and anterior techniques, laparoscopic gallbladder removal, prostate removal and prostate resection. The site also offers important information on medical errors and what policymakers can do to improve the quality of care.

Medicaid phone wait times drop significantly

At last week’s Medicaid Council meeting we heard about strong progress toward reducing phone wait times. Average wait times dropped 52% from April to May while abandoned calls fell 42%. By the last week of June, average wait times were down to 11 minutes from 57 minutes in March. The improvements resulted in 6,466 more calls answered in May over April. The improvements came from an internal review of business processes and included enhancements in training, maximizing DSS office staff time use, standardizing information that managers use to direct work, eliminating duplicate imaging, and improving information for consumers to help them navigate the system more easily. The shifts to processing staff is being carefully monitored to ensure it does not impact other important work. Interestingly, phone wait time improvement preceded implementation of the reforms. DSS is not resting on its laurels and has plans to continue improvements and monitor to sustain the progress to date.

CT earns an F on heath price transparency laws, again

CT joined all but five states nationally earning an F grade for public reporting of health prices according to Catalyst for Health Care Reform’s 2015 Report Card on State Price Transparency Laws. The report assesses state laws, regulations and public websites to make health care prices public, allowing consumers to base purchasing decisions on the value of care. CT should move up in the ranks next year with passage of SB-811 this session which includes several provisions to promote health care price and quality transparency. Three of the five states that earned better grades are neighbors -- Maine, New Hampshire, and Vermont. New Hampshire moved from an F in 2014 to earn the only A this year by publishing NH Health Cost, a consumer-friendly price transparency website. The authors suggest that other states, like CT, use NH Health Cost as a best practice model.

SIM ethics concerns intensify with first grants choice

Monday the Lieutenant Governor’s office announced the award of SIM’s first grants from federal funds; two of the four recipients are represented on the SIM Steering Committee. The members represent Northeast Medical Group (Yale-New Haven affiliate) and St. Vincent’s Health Partners. This would have been prohibited under the state’s Code of Ethics but for a loophole in the law.

Totaling $650,000, the grants are to large provider networks to develop patient-centered medical homes. The standards for the grant were set by a SIM committee and initially rejected by the Steering Committee. With others, both conflicted Steering Committee members then met with the subcommittee arguing to reduce one specific standard to allow at least one to apply for the grant. The committee agreed and the Steering Committee subsequently approved the new, lower standards. 

In May, CT’s state ethics board released an opinion that the SIM Steering Committee (and Consumer Advisory Board) both have substantial roles in setting state policies and funding, but there is a loophole. SIM committee members are not subject to the state’s Code of Ethics for Public Officials because members are appointed by the Lieutenant Governor. The law defining Public Officials subject to the Code only identifies appointees of the Governor and General Assembly; it does not address the very new practice of very significant policy and funding decision-making by appointees of the Lieutenant Governor. Two amendments were offered in the last days of the session to include SIM in the Code of Ethics.

This problem allows situations, as happened at the AccessHealthCT Board, where a member argued and voted for weak standards for insurers to join the exchange and opposed active purchasing. He then resigned from the Board, and subsequently went to work for an insurer that intends to participate in the exchange under the weak standards and without facing negotiation with the state to keep rates affordable.

This issue was first raised with SIM’s Consumer Advisory Board in November, with no action taken, and in a February sign on letter from advocates to the Lieutenant Governor, with no response.

July web quiz on CT hospital quality

Test your knowledge of Connecticut hospital quality. Take the July CT Health Policy Webquiz.

CT health reform progress dips again

Unfortunately CT’s progress toward health reform dropped again to 27.5% this month, undermining last month’s gain. News that the state’s uninsured rate may not have dropped much, sharp increases in insurance premiums, SIM’s ethics, transparency and underservice council issues and budget cuts, especially HUSKY parents, all contributed to the decline. Bright spots include restoration of most Medicaid provider cuts, passage of SB-811, and Medicaid’s strong stakeholder engagement in reform planning. The CT health reform progress meter is part of the CT Health Reform Dashboard.