Legislative Dems newest budget rejects most of Governor’s newest cuts

In the latest budget proposal for the next two years, Democrats in legislative leadership have rejected many of the Governor’s most recent cuts. The newest legislative proposal rejects the Governor’s plan to cut another 8,700 working parents off HUSKY. Because of cuts passed last year, 17, 688 working parents will lose coverage as of July 31^st. The latest legislative proposal also reverse 85% of proposed hospital cuts, restores mental health cuts, and rejected proposals to expand the administration’s authority to cut the budget without legislative approval. The legislative proposal does cut payments to Medicaid ASOs that operate the program by 10%, nursing home payments by $5.25 million, home care payments by over $5 million, and rates for children’s dental care by 5%. The proposal increases health care premiums and co-pays for legislative and non-union state workers, expedites transitions under Money Follows the Person, and allows liquor stores to sell smokeless tobacco products. Interestingly the budget also calls for $26 million in unspecified Medicaid savings – we have lots of ideas to achieve that and improve care. The latest proposal builds off the version that passed the Appropriations Committee. That version differed significantly from the Governor’s initial proposal in February. Differing versions are driven both by differing priorities and by declining revenue projections in the last few months. Negotiations will continue; the legislative session is scheduled to end next Wednesday.

Forum on skyrocketing drugs costs and what can be done

May 17^th the CT State Medical Society and the Office of State Comptroller are sponsoring CT Pharmaceutical Forum: Access, Affordability and Better Health. The forum will explore value and outcome-based purchasing programs to improve access to affordable prescription drugs. The forum will be in Room E2 of the Legislative Office Building from 9 am to noon. Click here to register.

Update – Palliative Care Webinar time change

Due to an unavoidable conflict, the time for the webinar: The Potential of Palliative Care for People with Serious Illness by the MAPOC Complex Care Committee will be an hour later than originally scheduled. The webinar will still be on May 9^th but will be at 10:30 am. All registered participants should have received an email about the change. Registrants will receive a link to the slides and video after the webinar, whether or not they can attend. We apologize for any inconvenience. Click here to register.

Palliative care offers great potential to improve and extend the lives of people with serious illness, allowing them to get care at home if they wish, while controlling costs. In addition to her considerable expertise and knowledge, Dr. Diane Meier is an enthusiastic advocate for palliative care. She directs the Center to Advance Palliative Care in addition to her position on the faculty at the Icahn School of Medicine at Mount Sinai in New York City. Among many awards, she won a 2008 MacArthur Fellowship. Join the MAPOC Complex Care Committee webinar May 9^th at 10:30 am to hear from Dr. Meier about the potential of palliative care and how it could benefit seriously ill Connecticut Medicaid members.

Connecticut most costly for nursing home care, above US average for all LTSS costs

A new survey of Long Term Services and Supports (LTSS) costs by Lincoln Financial finds that Connecticut was among the costliest states in the nation last year. Connecticut ranked highest for nursing home care (both private and semi-private rooms) and in the top five for assisted living arrangements. Home health care was slightly less costly, relative to other states, but Connecticut was above the national average in all categories. Neighboring Rhode Island was the least costly for home health care provided by a licensed nurse. Lincoln Financial’s site also has sobering projections for LTSS cost trends, out to 2040, by service, state, and by metropolitan region.

Webinar: The Potential of Palliative Care for People with Serious Illness

Palliative care offers great potential to improve and extend the lives of people with serious illness, allowing them to get care at home if they wish, while controlling costs. In addition to her considerable expertise and knowledge, Dr. Diane Meier is an enthusiastic advocate for palliative care. She directs the Center to Advance Palliative Care in addition to her position on the faculty at the Icahn School of Medicine at Mount Sinai in New York City. Among many awards, she won a 2008 MacArthur Fellowship. Join the MAPOC Complex Care Committee webinar May 9^th at 9:30 am to hear from Dr. Meier about the potential of palliative care and how it could benefit seriously ill Connecticut Medicaid members.

Private employer costs higher in New England, but health costs are less of the total

 According to the US Bureau of Labor Statistics, New England employers paid the highest total compensation per worker in December 2015 averaging $38.14/hour, well above the US average of $31.70. Health insurance and other benefit costs were also high in New England but not as a percent of total compensation. At $2.93/hour health insurance was the most costly benefit for New England employers, compared to $2.40/hour nationally. However health insurance comprised 7.7% of total compensation in New England. In comparison, health insurance comprised 8.5% of total compensation in West South Central states (AR, LA, OK and TX), 8.3% in West North Central states (IA, KS, MN, MO, NE, SD and ND) and 8.2% in East South Central states (AL, KY, MS and TN). Life and disability benefits cost New England employers 19 cents/hour compared to 15 cents/hour nationally.

Connecticut’s Medicaid redesign update-- Pros and Cons

Connecticut’s Medicaid program has earned national recognition for combining improved access to high quality care with an impressive record of cost control. Shifting the program from a financial risk payment model to care coordination through person-centered medical homes (PCMHs) four years ago is widely credited with that success. Last year the administration began developing a new, ambitious reform plan, Medicaid Quality Improvement and Shared Savings Program (MQISSP) committed to build on and support the success of the PCMH program. The goals of MQISSP are to “improve health and satisfaction outcomes for Medicaid beneficiaries”.

Under MQISSP, the state intends to contract with competitively selected networks of providers, both Federally Qualified Health Centers and advanced networks (i.e. Accountable Care Organizations). Networks will coordinate person-centered care among a continuum of providers and community resources. Networks will share in the resulting savings in the total cost of care for their attributed members if they meet quality standards. Over the last year, the Department of Social Services (DSS) has worked with the Care Management Committee of Connecticut’s legislative Medical Assistance Program Oversight Council to develop the program. The Care Management Committee includes legislators, providers, consultants, and consumer advocates. As of April 2016, that process is largely complete and drafting has begun on the MQISSP application for networks.

Among fourteen major issues decided to date, most are very positive (pros) and will support the goals of improved quality and satisfaction. But three are problematic For more information, read the CT Health Policy Project brief.

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Webinar: The Potential of Palliative Care for People with Serious Illness

Palliative care offers great potential to improve and extend the lives of people with serious illness, allowing them to get care at home if they wish, while controlling costs. In addition to her considerable expertise and knowledge, Dr. Diane Meier is an enthusiastic advocate for palliative care. She directs the Center to Advance Palliative Care in addition to her position on the faculty at the Icahn School of Medicine at Mount Sinai in New York City. Among many awards, she won a 2008 MacArthur Fellowship. Join the MAPOC Complex Care Committee webinar May 9^th at 9:30 am and hear from Dr. Meier about the potential of palliative care and how it could benefit seriously ill Connecticut Medicaid members.

Health Care Cabinet considers Oregon and Maryland’s reforms

At this month’s Health Care Cabinet meeting, we heard about health reforms in Oregon and Maryland with a focus on how/if their successful strategies could be applied in Connecticut. Oregon consolidated state health purchasing under one new state agency, implemented an ambitious Medicaid waiver with a total annual cap on cost increases, assistance for PCMH transformation (similar to CT Medicaid’s glide path), and a commission that reviews medical evidence of effectiveness and makes coverage recommendations. Oregon relies heavily on data analysis and evidence-based medicine to address both over- and under-use of care. Several Cabinet members supported expanding this capacity in Connecticut. Oregon Medicaid has created 16 capitated Coordinated Care Organizations (CCOs), similar to ACOs, that have responsibility to care for all Medicaid members in a specific region. CCOs have improved quality and access measures and have exceeded savings targets. Maryland’s reforms have focused on reducing hospital and total costs and expanding PCMHs. Consumer satisfaction rates have improved, racial disparities are down, and achieved savings across measures. Next month we will hear from our last state and begin deliberations on recommendations for Connecticut.  

Governor’s latest budget cuts even more HUSKY parents

Yesterday the Governor released his counter-proposal for the next biennial budget. The proposal cuts the remaining working parents above 138% of the federal poverty level, the eligibility level for all adults, in the HUSKY program. Last year the Governor and legislature agreed to cut parents to 155%. Due to federal law allowing time for transition, 17,688 working parents in Connecticut will lose Medicaid July 31^st of this year. Based on prior experience, most of those parents will not be able to afford coverage in the insurance exchange and will likely become uninsured. Due to federal reimbursements, the state only receives half the savings from these cuts -- $900,000 in Fiscal Year 2017 but rising to $21 million by FY 2018 when all the parents are off the program.

Other cuts included in the Governor’s proposal include cuts to community health centers, hospitals, children’s dental care, and funding to the Medicaid Administrative Services Organizations. State employees will be asked to pay 20% of their health benefit costs. In 2014, Connecticut workers paid 21% of single coverage premiums on average. Discussions will continue. The legislative session is scheduled to end May 4^th.

New to the Book Club -- Hand to Mouth: Living in Bootstrap America

Sometimes raw and even offensive, in Hand to Mouth Linda Tirado describes for middle class readers what it is like to live in working class America. Tirado is an educated white married mother of two who needs two jobs, in addition to her husband’s two jobs, to make ends meet. She describes in vivid detail why she makes decisions that may seem (and often are, she admits) self-defeating, including health risks like smoking and eating junk food. Her take on government assistance is revealing – Catch-22 eligibility rules that make no sense and so many holes “Moby Dick could swim through.” Chapters include “You Can’t Pay a Doctor in Chickens Anymore”, “I’m Not Angry So Much as I’m Really Tired”, “We Do Not Have Babies for Welfare Money” and “I’ve Got Way Bigger Problems Than a Spinach Salad can Solve.” Readers should definitely get to the final chapter “An Open Letter to Rich People” – her description of “rich people” work meetings is funny but embarrassingly true. Her comparison of “rich people’s” jobs with minimum wages jobs and the work ethic will make you think. For more, visit the CT Health Policy Project Book Club

Northeastern physicians lowest paid in US

According to Medscape’s 2016 Physician Compensation Survey, at $266,000 physicians from Northeastern states have the lowest incomes in the US. Medscape reports that uneven distribution between physicians and patients drives compensation levels. Just over half (52%) of US physicians believe that their compensation is fair. Specialists tend to make more than primary care doctors; highest paid are orthopedists while pediatricians make the least. Dermatologists are most satisfied with their career, while nephrologists tend to be least satisfied specialty. In very good news, 77% of self-employed and 84% of employed physicians report that they are taking new and keeping current Medicare and Medicaid patients, up from 64% and 79% respectively last year. Most physicians spend between 13 and 20 minutes with each patient, which has been relatively stable since 2011. Over half of US physicians spend at least ten hours each week on paperwork and administration. Only 30% regularly discuss treatment costs with patients. The survey included 19,200 physicians across 26 specialties.

April web quiz: Medicare disparities in CT

Test your knowledge of Medicare disparities in CT. Take the April CT Health Policy Webquiz.

Approps budget restores many health and human service cuts

The budget approved by the Appropriations Committee yesterday restores many of the health and human services cuts in the Governor’s proposed budget. Long supported by advocates and financial analysts, the Appropriations Committee also proposed de-collapsing the massive Medicaid line item. The Committee’s budget separates out payments to hospitals and community health centers, giving more transparency to significant state spending but also limiting the Governor’s ability to make cuts without legislative approval. Cuts reversed, in part or fully, in the committee’s budget include hospitals, community health centers, school-based health centers, developmental disabilities, the CT Children’s Medicaid Center, Alzheimer’s respite care, and mental health and substance abuse. The bill maintains the Governor’s proposal to privatize 30 DDS group homes, but requires an evaluation of the impact. The bill also restores sorely needed independence to watchdog agencies by de-consolidating functions under the Office of Governmental Accountability. The Governor called the committee’s budget “incomplete” and promised to release a new proposal next week.

CT Health Reform Dashboard update: mixed Medicaid progress, a few good signs elsewhere

Both good and bad news for consumers in planned Medicaid reforms influenced CT Health Reform Dashboard this month. In good news, DSS and SIM agreed to make the well-intentioned but poorly-designed CCIP program optional for Medicaid networks applying to participate in shared savings. A Wall Street Journal article reported on the success of CT’s Medicaid program in improving the Triple Aim. However DSS rejected calls to protect person-centered medical homes in their reform plan, creating incentives for networks to shift the most needy members out of PCMHs. A survey of ACOs in our state found good intentions but mixed views of the future. Members of a taskforce to review CON rules and promote a competitive market were appointed; the first meeting will be next week.

April Health Affairs features CT state employee VBID plan results

An evaluation of CT’s state employee Health Enhancement Program (HEP) published in Health Affairs found improved access to primary care, reductions in ED use, but has not produced savings. HEP is an early adopter of the Value-Based Insurance Design (VBID) model, linking consumer costs to the value of care. Implemented in 2011, HEP encourages preventive care and chronic care disease management with lower premiums and deductibles combined with $35 copays for non-emergency ED visits. Before HEP, per person spending in CT’s program was $7,914, far higher than a matched comparison group from other state employee programs at $4,375, almost three times as many CT state employees had high health costs (over $50,000), and ED use was 56% higher. Over 98% of members enrolled in HEP and utilization of preventive care rose significantly. ED visits dropped by a modest amount while visits in the comparison group rose. Results for members with chronic conditions were mixed and modest. Not unexpectedly, in the first two years costs per person rose – by $730 in the first year and $961 in the second. CT Mirror’s coverage points out that this is due to increases in use of preventive care and reports that the state expects to benefit in the long term from this investment in the health of employees.

CON taskforce members appointed

Governor Malloy has announced the appointments to the Certificate of Need Taskforce. The taskforce was created in a February Executive Order halting mergers and takeovers of large hospital systems for one year to allow a review of CON rules and process. Consolidation in Connecticut’s hospital market has raised significant concerns about the lack of competition, rising prices and reducing consumer choice. A bill to make changes to the CON process is moving through the General Assembly. The taskforce’s first meeting is next Tuesday, April 12^th at 1pm in Room 310 of the State Capitol.

CEPAC meeting affirms the value of outpatient palliative care, but more research is needed

At yesterday’s meeting in Hartford, CEPAC took a deep dive into the clinical and cost effectiveness of palliative care delivered in outpatient settings.

From CEPAC’s report, “Palliative care is a management approach that provides symptom relief and comfort care to patients with serious or life-threatening illnesses, with the goal of improving quality of life for both patients and their families. Unlike hospice care, which is typically restricted to individuals with a prognosis of survival of six months or less, palliative care can begin at diagnosis and is often provided along with treatment aimed at prolonging life, such as chemotherapy or radiation for cancer.  One of the primary objectives of palliative care is to help patients prioritize their goals of care, and may include conversations around advance care planning (e.g., a “living will”) depending the anticipated disease trajectory.”

The group voted unanimously that there is evidence to demonstrate some forms of outpatient palliative care treatment are effective at improving the quality of life and reducing hospitalizations and ED use. The majority also voted that outpatient palliative care is a high value treatment. But members expressed concern that more research is needed to persuade payers to cover it. Other concerns included workforce capacity challenges, time for training busy primary care providers in palliative care, and teasing out which parts of the model are critical to success. Aetna described their successful Compassionate Care program which has an impressive record of improving the quality of life for people and their families facing serious illness, as well as saving money.

Evidence is growing that palliative care can prolong life as well as support patients who choose to remain home. For more on the issue, read CEPAC’s Palliative Care: Barriers, Opportunities and Considerations for Quality Improvement.