Independent advocates call for more study on Medicaid payment shift

A letter signed by twenty one independent consumer advocates calls on the state to halt the SIM-driven Medicaid’s rush into a return to shared savings, a risky payment model. Dozens of issues remain to be addressed to protect the 770,000 people who rely on the program before the deadline of October 5^th. The rush is being driven by the needs of CT’s small SIM grant, which pales in comparison to state spending on Medicaid. Advocates are concerned that the return to financial risk, this time placed on provider networks, could jeopardize quality improvements, gains in provider participation and effective cost control. Based on Medicare’s experience with the shared savings, Medicaid costs for the state would increase rather than save. Current state budget shortfalls have already prompted $64 million in provider cuts and dropping 20,000 working parents from the program.

C-HIT forum on the benefits of preventive care

Join C-HIT for a community health forum, Get Health Wise: The Benefits of Preventive Care, Oct. 7^th from 5:30 to 7:30pm at the Artists Collective in Hartford. Hear from clinicians about how to manage diabetes, heart disease, cancer, mental health and primary care’s central role.

Shared savings math doesn’t add up, CCIP plans could undermine Medicaid

A new brief outlines the risk to taxpayers from Medicaid shared savings increasing health costs, as SIM is pressing. About half of Medicare ACOs spent more money on health care for members under shared savings last year. If Connecticut’s ACOs perform in Medicaid shared savings as they did for Medicare, CT taxpayers could lose as much as $100 million in higher health care costs.

Concerns have been raised by MAPOC Care Management Committee members about SIM’s plans for their Community and Clinical Integration Program (CCIP). Just some of the concerns include undermining patient-centered primary care teams, duplicating services and no budget or identified funding source. Advocates have urged DSS not to fund CCIP from Medicaid funds, which are already stretched by provider rate cuts and cutting 20,000 HUSKY parents from eligibility. Advocates have urged Medicaid to make CCIP participation optional for ACOs in the first wave of enrollment, allowing time for evaluation and finding a sustainable funding source.

Advocates have raised concerns about SIM’s rush to move Medicaid into shared savings and have called for a delay to allow thoughtful consideration, and to avoid costly past mistakes.

CTNJ Op-Ed: Let’s Halt the Rush to Risky Medicaid Experiment

Today’s CT News Junkie includes an opinion piece urging caution and more time for thoughtful deliberation in moving 200,000 HUSKY members into a very new, untested payment model that is costing more for Medicare. CT’s Medicaid program is a success story – improving quality, increasing providers, and lowering costs – but that success is fragile. We can’t afford the risk of rushing into this. Read more

Advocates’ Medicaid Study Group offers recommendations for Medicaid shared savings reform

Over a dozen Connecticut independent consumer advocates representing diverse populations and issue areas spent the last several months diving deep into Medicaid shared savings and today released recommendations for our state’s program. The Medicaid Study Group formed early in 2015 in response to a request from the Co-Chairs of the Medicaid Council’s Care Management Committee to the committee consult with colleagues to give guidance to the Department of Social Services in redesigning our state’s Medicaid program to incorporate a shared savings payment model. The Group researched the available literature, other state Medicaid programs, and the experience of other shared savings programs, among other sources. The Group’s 76 recommendations are designed to protect consumers and taxpayers from unintended harm, avoid higher spending as in other shared savings programs, improve the quality of care, and ensure integrity and accountability. The recommendations cover administration & governance, payment & financing, network requirements, and quality. Final details for the RFP are due October 5^th; advocates are concerned about the rushed timeline and the risk of imprudent decisions.

$103 million in new budget cuts Medicaid, mental health services

On Friday, the administration announced $103 million new budget cuts in response to lagging revenues. The biggest cut is $63.5 million in Medicaid, reportedly focused on hospitals. Community providers raised concerns about the impact of the cuts, including $7.4 million in behavioral health funding and $5 million from services for people with developmental disabilities, which follow cuts in the budget passed in June.

Ten SIM committee members sign alternative stronger ethics policy

Ten brave SIM committee members signed a stronger ethics policy in place of SIM’s weaker policy. Advocates were given until this Wednesday to sign SIM’s policy or they would “not be able to participate as members in future meetings of the advisory groups.” The alternative policy agrees to also abide by the State Code of Ethics for Public Officials and notes that we signed in order to continue to serve on the committees. Because of a loophole in the law, our state Code of Ethics only applies to appointees of the Governor and General Assembly. SIM committee members are all appointed by the Lieutenant Governor or her appointees. Nine SIM committee members sent a letter earlier this month, rejecting SIM’s weak ethics policy that does little to limit conflicts of interest, such as those that tainted the awards of SIM’s first grants. At yesterday’s SIM Steering Committee meeting, it was announced that SIM will accept the stronger, alternative policy and allow us to continue to serve on SIM committees.

ACOs not saving for Medicare, model could cost CT Medicaid almost $100m/year

CMS’s vast shared savings experiment for Medicare has disappointed again in its second year. The plan was to encourage providers to assemble into health care systems, called Accountable Care Organizations (ACOs), to coordinate care and keep people well. The incentive was that the systems share half (or more) of the resulting savings. The only problem is that the savings aren’t there. An analysis by Kasier Health News found that last year, the second year of the program, the costs of care for patients in 45% of those groups nationally cost more than they would otherwise have. After paying bonuses, the entire program lost almost $3 million while it was expected to save  $10 – 320 million in 2014. Pundits are spinning hypotheses for the disappointing results and Medicare officials say it will eventually work.

Unfortunately CT’s ACOs performed even worse than the national average. Among the ten ACOs serving CT Medicare beneficiaries, only WESTMED Medical Group in Purchase NY earned a savings bonus from Medicare last year. Collectively those ten ACOs spent $12.5 million over what care would have cost without the program. Among the four ACOs that serve only CT residents (Hartford Healthcare, MPS, ProHealth and St. Francis together covering 82,027 people) none earned a bonus and they collectively spent $14 million over targets.

CT’s administration, through their SIM plan, has encountered serious challenges with plans to put every state resident into this same shared savings payment model. Advocates are especially concerned about a rush to put 200,000 Medicaid members into the untested model by July 1, 2016. Details of Medicaid’s ACO program must be set in two weeks to meet that deadline and dozens of critical decisions haven’t been explored. CT’s budget could be hit hard if this program doesn’t perform. If CT’s Medicaid ACOs perform as they have for the Medicare program, the program would cost an extra $93.7 million/year.

CT median insurance premiums often higher on exchange than off

According to an analysis by the US Government Accountability Office of health insurance premiums, CT consumers paid more on our exchange than off, for many plan choices both last year and this year. This is unusual among states; nationally the best deals are usually found on health insurance exchanges. Median monthly silver-level premiums for a 30-year old CT resident rose modestly from $305 last year to $307 this year. The report finds more choices for consumers nationally this year than last. Most US consumers had six or more plans to choose from across three metal tiers – bronze, silver and gold. Premiums for the same level plan vary considerably between states, but also within states by as much as 270%. The report includes CT maximum, minimum and median monthly premiums for various purchasers for gold, silver and bronze plans, both on and off the exchange, both 2014 and 2015, as well as the number of plan/county combinations available on and off the exchange.

Advocates support SIM underservice, cherry picking protections

Connecticut’s SIM plan acknowledges that risks of inappropriate under-treatment and cherry-picking are higher in new shared savings payment models. Advocates were successful in getting a provision included in the SIM final plan that prohibits payment of shared savings to provider networks that systematically deny needed care or cherry pick patients to generate those savings. The task of implementing that provision fell to SIM’s Equity and Access Council, which has released its draft report for public comment, due today. In June the Council issued 28 recommendations to prevent, identify and fix underservice and cherry picking in new payment arrangements. All but one of those recommendations were adopted by consensus. The one controversial provision directs payments denied due to underservice or cherry picking to be invested in improving quality and access to care, reversing the problem and building value across the system. That recommendation was opposed only by insurers on the Council who, in its absence, would keep the inappropriately-derived profits. In public comments, a group of fourteen advocates have voiced our support for all twenty eight of SIM’s Equity and Access Council recommendations, including the provision to ensure all resources promote value over profit-taking across Connecticut’s $30 billion in health care spending.

Issue Brief: Attribution and Why It Matters

A new brief describes attribution, a key component of payment reform. Attribution done wrong in a shared savings payment model can create incentive to cherry pick out less lucrative or difficult patients and disrupt existing provider-patient relationships. Attribution is the process of defining the population that a provider network is responsible for managing under a shared savings contract. Effective attribution helps both consumers and providers. Consumers know who is responsible for their care and who to call with a problem. Providers know who they are responsible for, giving them every incentive to invest in care management and other appropriate services to keep people well. Provider networks share in the savings that consumers and providers generate together through better health. The brief outlines how prospective attribution models that connect providers and patients at the beginning of the payment timeline protect consumers from cherry picking and payers from the associated costs.

Nine SIM committee members reject weak ethics policy

In a letter sent yesterday, nine members of various SIM committees rejected the weak ethics policy promoted by SIM leaders. The weak policy does little to limit conflicts of interest, such as those that tainted the awards of SIM’s first grants. Instead they urged SIM to limit conflicts of interest and adopt the State Code of Ethics. SIM’s weak policy asserts that SIM programs in other states have similar conflict of interest policies, and cites Vermont’s SIM program specifically. However, officials on Vermont’s SIM governance committees routinely recuse themselves from the room during decision-making on grants and other policies that may potentially apply to them, parallel to CT’s state Code of Ethics. (See minutes here and here.) Because of a loophole in the law, our state Code only applies to appointees of the Governor and General Assembly. SIM committee members are all appointed by the Lieutenant Governor or her appointees.

September web quiz on Medicare hospital readmissions in Connecticut

Test your knowledge of Medicare hospital readmissions in Connecticut. Take the September CT Health Policy Webquiz.

CT health reform progress down again

Unfortunately CT’s progress toward health reform dropped again this month to 26.2% this month, adding to last month’s dip. Growing ethics and transparency problems at SIM led the concerns. CT hospital’s continuing poor performance on Medicare readmissions, consolidation and loss of services across hospitals added to the drop. In good news, if adopted SIM’s underservice recommendations will help protect consumers in new payment models. While rushed, Medicaid redesign continues to listen to stakeholders but provider concerns about rate cuts are troubling. The CT health reform progress meter is part of the CT Health Reform Dashboard.