Thoughtleaders give CT a C+ on health reform this year

In the latest survey, CT health care thought leaders give our state a C+ grade on health reform, down from last year’s survey. CT’s grade for effort also dropped to a B-/C+ in this survey. Higher marks go to the health insurance exchange, Medicaid, and patient-centered medical homes, as for last year. Payment reform/quality improvement scored lowest followed by HIT, workforce and health insurance market reform. Suggestions to improve progress are to engage consumers (a perennial leader), learn from what works (also a familiar theme), opening the process to all voices/transparency in planning (also not new), and support Health Information Technology and data tools. Recommendations were more diverse and specific than in previous surveys; all responses are included in the brief.

Governor orders delay, time to study CON approvals for massive hospital mergers

Yesterday Governor Malloy issued an Executive Order halting state Certificate of Need approvals for hospital mergers that would cover more than 20% of total CT hospital spending until Jan. 15, 2017. The delay will allow for a “fair and through” review of the CON process by a new taskforce. Concerns about the current CON process have been raised most recently because of reductions in services at Windham Hospital when they merged with Hartford Healthcare and creating a tipping point of market concentration that could escalate prices. The Executive Order came a day after the Public Health Committee held a public hearing on bills to revise the CON process and restrict hospital administrator pay.

SIM’s CCIP proposal for Medicaid reform – poor process drives weak plan

Public comments from the CT Health Policy Project raise deep concerns about SIM’s proposal for Medicaid reform requirements could undermine hard-won successes in the program and may not achieve the goals. The Community and Clinical Integration Plan (CCIP) is SIM’s plan for community-based resources to support Medicaid advanced networks that will be sharing in savings under the evolving reform plan. While CCIP’s goals, to promote health equity among others, are important, independent advocates and other stakeholders have expressed concerns about the plan. The CCIP proposal imposes substantial costs on Medicaid provider networks without any source of funding. CCIP’s 66 pages of standards are too prescriptive in some places and too vague in others, creating a very large burden for already busy providers and undermining innovation and flexibility to serve local conditions. Consumers could get conflicting advice on how to manage their conditions from different sources. No evidence is given to support the effectiveness of CCIP’s standards. Unlike successful states, SIM is proposing that CCIP standards be required of Medicaid networks. However networks that don’t serve Medicaid members will not be affected. The proposal to have SIM and their vendor oversee the standards is also a concern. Because of a loophole in the law, SIM is not subject to the State Code of Ethics; concerns have been raised about SIM grants being awarded to SIM committee insiders in the past. Advocates and other stakeholders are urging delay allowing Medicaid stakeholders to consider the evidence, ensure CCIP is feasible, and ease the burden on providers.

Medicaid update – plans to “transition” 17,688 HUSKY parents off the program, serious SIM/CCIP problems jeopardize Medicaid redesign

Friday’s Medicaid Council meeting focused on implementation of last year’s budget provision that will end coverage for 17,688 HUSKY parents on July 31^st of this year. DSS reported on efforts to assure that people still eligible for Medicaid in other categories do not lose coverage. Of the 1,215 parents who lost coverage last year due to the cuts, almost half (47%) were able to continue coverage in Medicaid. Only one in seven (14%) was able to afford and purchased coverage through AccessHealthCT, CT’s health insurance exchange. 52 parents selected an AccessHealthCT plan but cancelled or disenrolled, likely due to cost. Council members voiced deep concerns about ineffective notices, and children losing coverage when their parents do. Many children lost coverage in 2003 when the state last cut coverage for HUSKY parents even though children’s eligibility levels did not change. Council members offered to help get out the message that even if parents lose coverage, children should stay on the program. The Council asked DSS and AccessHealthCT to come back with a plan for outreach and assistance for members losing coverage.

Members of the Care Management Committee reported on MQISSP progress -- the “mighty undertaking” to redesign Medicaid to incorporate integrated care networks and the potential for shared savings back to those networks. The committee has been working very hard and very collaboratively to ensure the program is feasible, but also protects both members and taxpayers. To have an RFP released this summer, we must finish our work in just a few weeks. However, two weeks ago a SIM committee dropped a 66-page set of standards for Community and Clinical Integration Standards for the Medicaid provider networks, with little opportunity for input. Beyond process concerns and questions about the evidence-base for the standards and priorities, concerns were raised that the standards are both extremely prescriptive and extremely vague in different places. The standards duplicate many successful programs and collaborations already in place, would place a large burden on overwhelmed primary care providers, places a large and ill-defined liability on networks, and would be controlled by SIM which is not subject to the State Code of Ethics nor does the agency focus on the unique features of the Medicaid program. In our hastily-scheduled Care Management Committee meetings to address the issue, members did not have time to fully outline all our concerns.  There is no funding source for networks even willing to take on this massive mandate. Advocates have urged policymakers to either delay implementation of CCIP standards until they can succeed, until other SIM payers require them in their network contracts, delay the RFP entirely, or make the CCIP standards optional for networks, as is the case for successful programs in other states.

CT Medicare members have saved over $285 million on prescription drugs under the ACA; almost half a million received free preventive care last year

Thanks to the Affordable Care Act (ACA) thousands of elderly and disabled Medicare beneficiaries in CT have saved millions of dollars on prescription drugs and free preventive care, according to new numbers from the Centers for Medicare and Medicaid Services.  The ACA includes discounts for Medicare Part D beneficiaries on their prescription drugs that increase every year until 2020 when the Part D “donut hole” in coverage will close completely. Last year 66,843 CT residents covered by Medicare Part D saved more than $78 million on prescription costs, with discounts averaging $1,174 each. The ACA also eliminated copays and deductibles for Medicare preventive care such as annual wellness visits and many cancer screenings, improving access and preventing more serious and costly health problems. Last year 470,712 state residents paid nothing for preventive care within Medicare including 147,135 wellness visits.

Fascinating Health Care Cabinet meeting on hospital markets, concentration, costs and the magic of VT

This week’s Health Care Cabinet meeting was fascinating. We first heard about the impact of hospital consolidations in CT. We heard a moving story about a Spanish-speaking woman suffering a mild stroke who had to be airlifted from Windham to Hartford because since Hartford Hospital’s acquisition of Windham Hospital, there is no longer a neurologist available. This is despite hospital assurances during OHCA’s merger approval process that there would be no change in service availability. There was no interpreter for the patient, no one to talk to, on the 30-minute helicopter ride, as she was experiencing the effects of the stroke. We also heard from the authors of a critical report outlining the likely cost impact of Yale-New Haven’s proposed acquisition of L&M Hospital, and from a nurse from L&M concerned that what happened in Windham will happen in New London if the merger goes through.

We then heard a fascinating presentation by Zack Cooper from Yale’s School of Public Health and the Health Care Pricing Project on the first of several articles he is working on about health care prices. There were many themes including that hospital prices average 15.3% higher in monopoly markets where there is no competing hospital within 15 miles, that Medicare price and utilization dynamics are not correlated with private coverage, and that private plan prices are not linked to better quality of care – a big problem as we try to move CT’s health system toward paying for value over volume. My favorite finding is that there is no evidence of a cost shift from Medicare to private coverage prices. While it is true that Medicare pays providers less than private prices (Medicare rates cover the costs of care plus a small profit), there is no support for the widely-held assumption/complaint/excuse that this drives up private hospital rates.

Not surprisingly, all of CT is among the highest Medicare per person spending areas in the US. And while the Bridgeport and New Haven areas are also among the highest spending for private coverage, Hartford is a little below the US average. He also showed substantial price variation within markets. Patients searching for a lower limb MRI in CT can save $1,000 by shopping around. This is increasingly important with the growth of high-deductible health plans.

We also heard from the consultants working on the Cabinet’s cost-containment study. This month they focused on the magical state of VT which is miles ahead of CT in cost control. There was a lot of information on VT’s cost control success with Patient-Centered Medical Homes and the Blueprint for Health that supports those PCMHs, and their plans for a single, multi-payer ACO. The consultants’ attribute VT’s success to committed leadership, regulatory power and a culture that expects trust and collaboration. VT stakeholders put aside their narrow interests and work together in good faith toward a system that works for everyone. Cabinet members generally agreed that CT especially needs to work on the trust part.

It was a fascinating morning. I can’t wait for next month’s meeting.

New to the Book Club: Fighting for Life, by S. Josephine Baker, 1939

In the 1890s New York’s Lower East Side was the most densely populated square mile on the planet, with largely immigrant residents. A third of children born there died before their fifth birthday often due to epidemics of diarrhea, smallpox, typhus, child labor, poor sanitation, and other preventable conditions. But by 1911 the child death rate had fallen sharply and the community was among the most healthy in the country. By her retirement in 1923, Dr. Josephine Baker, director of the city’s Bureau of Child Hygiene, was credited with saving the lives of 90,000 children. In her very entertaining autobiography Dr. Baker describes how she did it. Read more on this book and others in the CT Health Policy Book Club

Governor’s budget proposal – it could be way worse

Today the Governor announced his proposed budget for the coming fiscal year that starts July 1^st. The very, very good news is that Medicaid is largely untouched – no new cuts to providers, no more people losing coverage, and minimal service limits (orthodontia). This is smart because current reforms in the program are working to control costs significantly, while improving access and quality of care. The Governor proposes continuing hospital cuts from December and a 5% cut to the CT Children’s Medicaid Center’s subsidy. A lot of programs would shuffle between agencies to maximize federal reimbursements and fringe benefits would move into agency budgets. Like most other agencies, DSS would have to cut 5.75% from their operating budget ($18.6 million, not from Medicaid) if the Governor’s budget is adopted. It is hard to imagine how DSS staff will manage their difficult and increasingly complex job with fewer resources.

Unfortunately other services were not as fortunate as Medicaid. At DPH, the Governor has proposed reducing funding to local health departments, eliminating grants to community health centers, reducing grants to school-based health centers (because there are fewer uninsured due to the ACA), and $700,000 earmarked for asthma programs will be diverted from the Tobacco and Health Trust Fund to the General Fund. Fall prevention and respite care funding at the Dept. on Aging would be cut and mental health and substance abuse grants would be cut at the Department of Mental Health and Addiction Services. All those agencies will also have to cut 5.75% of operating costs if the Governor’s cuts are passed. Many observers are not only concerned about the cuts but also the lack of specificity; agency leadership will decide where to make cuts without legislative approval.

While the list of proposed cuts is long, it could be far worse. And please remember that because of cuts passed last year, about 18,000 working parents will lose HUSKY coverage this summer if nothing is done.

Two in three CT physicians had an electronic health record in 2014; well below US average

In 2014, only 67.5% of CT office-based physicians had a certified electronic health record (EHR) system according to a new CDC brief. Nationally 74.1% of office-based physicians had certified EHRs in 2014, up from 67.5% the year before. Only five other states had lower EHR participation levels. On the bright side, CT physicians who did have an HER were slightly more likely to share patient information with external providers or unaffiliated hospitals (33.7% CT vs. 32.5% US). Nationally only about one in ten physicians with an EHR shared patient information with home health, long term care or behavioral health providers. Electronic health records are key to improving patient care decisions and safety, consumer engagement and participation, care coordination, evaluation, research and better health planning.

February web quiz: costs on CT’s health insurance exchange

Test your knowledge about costs of plans and MLRs on CT’s health insurance exchange. Take the February CT Health Policy Webquiz.