46% of Americans can’t afford a $400 emergency; CT average individual deductible up to $1,547

A new survey by the Federal Reserve finds that almost half (46%) of Americans last year reported that an unexpected expense of $400 would be a challenge and they would have to put off the bill, borrow from family or friends or sell something to pay it. Many who experienced a financial hardship, especially low-income Americans, used credit cards, payday loans, loans against tax refunds, pawn shops or auto title loans to pay bills. The same survey found that 36% of Americans had a health emergency expense in the last year. 2014 data finds that three out of four Connecticut workers with employer coverage had a deductible, averaging $1,547 for individuals and $3,080 for families.

CT insurance exchange premiums high, but growing slower than national and regional averages

A new analysis by the Urban Institute finds that insurance exchange premiums for the lowest-cost Silver plan in CT averaged 0.7% growth annually over the last two years. This is well below growth at the national and regional averages of 5.5% and 4.2% respectively. While they aren’t rising as quickly, CT premiums started out much higher than other states. At $351/month, CT premiums for the lowest-cost Silver plan are higher than all but seven other states and 24% above the national average. Unfortunately a new report by Avalere, based on early proposed filings in nine states, rates may go much higher next year. It is important to note that most consumers are protected from full premium costs with income-based subsidies. 

National ACO survey echoes CT survey results

A national survey by the National Association of ACOs finds leaders are concerned about recovering their investments and pressure to share in losses. ACOs bristled at the assertion that up-side only shared savings arrangements are just bonuses. One survey respondent said, “The investment risk is substantial (in our case $2.5 million per year) with no guarantee of any return. I call that risk.” 43% of respondents said they would definitely or likely leave Medicare if forced to accept downside-risk arrangements. Our survey earlier this year of ACOs in CT found similar themes – concerns about recovering costs, modest savings, and an uncertain future. Both surveys include recommendations for policymakers and payers to promote success.

New to the Book Club: The Ghost Map: The Story of London’s Most Terrifying Epidemic – and How it Changed Science, Cities, and the Modern World

Every first year public health student hears the story of London’s 1854 cholera epidemic, Dr. John Snow, his map, and the Broad Street pump handle -- but there is so much more to that story. The Ghost Map describes in terrifying detail the disgusting details of life in an over-populated Victorian city, the devastating disease that took advantage of the city’s growth, with no known cause or cure, and the superstitions that rose to fill that gap. Read more on this and other Book Club selections.

Medicaid update – HUSKY parents cut implementation, wait times improve

Friday’s Medicaid Council meeting focused on DSS and AccessHealthCT’s plans to alert 17,688 working parents that their HUSKY benefits will end August 1^st. The cut was passed in last year’s state budget and 1,215 parents lost coverage last year, but the large majority qualified for another year of HUSKY under federal law. In good news, of the 1,215 cohort that lost coverage last year, about half qualified to remain on HUSKY through a different eligibility category. In bad news, only 7% are currently enrolled in insurance plans through AccessHealthCT. The remainder are likely uninsured. In more bad news, among the small number who initially enrolled in an AccessHealthCT plan, the number who have cancelled their coverage has more than doubled from November to May – likely because of the considerable expense to working families. In addition to informing people about insurance options, Council members urged DSS and AccessHealthCT to include information helpful to people who don’t qualify to stay on HUSKY and can’t afford expensive insurance plans, even with subsidies, so they can plan to preserve their health. Such information could include getting preventive care appointments and getting refills for maintenance medications before August 1^st, as well as talking to providers about continuing care, setting up payment plans for ongoing health problems after coverage ends.

We also heard about encouraging progress by DSS in reducing phone wait times. About half of callers needs are accommodated through the interactive voice response system. The average caller waits 9 minutes to speak with a live worker; down from 47 minutes in April 2015. Only 18% of callers who need to speak to a live worker are abandoning their call. In response to a question, DSS cannot determine how many of those abandoned callers call back later or how many eventually lose coverage in the program.

Drug forum looks for state options to control costs

Yesterday’s forum on rising drug costs at the Capitol included the expected messages from the expected sources but the real news was in the second panel that offered solutions. The CT State Medical Society and the State Comptroller’s Office sponsored the forum. Dr. Jacobs, President of CSMS, laid out the problem. One medication that supports the immune system against cancer costs $150,000/year and another combination treatment for cancer costs $300,000/year. The cost of tetracycline, an old, very cheap antibiotic, rose over 75-fold in two years. Drug costs are driving half of patients to skip their meds; failure to take medications causes $125,000 deaths/year and up to 10% of hospitalizations. Representatives of Pharma, Pfizer, UConn School of Pharmacy and CVS laid out their perspectives in the first panel, which got a bit testy at points. But the second panel was helpful. Dan Ollendorf of ICER outlined their independent comparative effectiveness assessments and how they define value-based benchmark prices for new drugs. In addition to traditional quality-adjusted life years (QALYs), ICER’s analysis also includes new drugs’ avoided treatments (e.g. fewer transplants), breakthrough potential, population health impact and the tension between long term health benefit and short term budget impact. Many payers are using ICER’s analyses as a starting point for drug pricing. We also heard from Peter Michaud, MD about Maine’s successful academic detailing program providing independent information to prescribers about the effectiveness and the costs of medication options to treat a dozen common health problems. We wanted to hear more about keeping costs under control but then the lights went out (just saying).

Rich/Poor Life Expectancy Gap Depends on Where You Live

The richest 1% of Americans live 14.6 years longer, on average, than those with the lowest 1% of incomes and that gap is growing. While this disparity is well-known, the reasons are not well-understood. The Health Inequality Project is working to change that. Publishing their results in JAMA, researchers from across academia joined forces to map income disparities in life expectancy finding wide variation across the US.  Rich Americans’ life expectancy is growing regardless of where they live, but gains and losses for poor Americans vary considerably by geography. Some large cities are making good progress extending the lives of the poor. New York City leads the nation with the highest life expectancy for low-income 40 year-olds. However in other regions, poor residents have lifespans closer to very poor countries and are losing ground. Connecticut is in the middle of the pack. Improvements correlate with reducing health risks such as smoking and obesity, and with local circumstances such as public health programs and education. The authors argue that health equity efforts need to happen at the local level as well as nationally.

Bottom income quartile life expectancy, CT counties
Rank among 100 largest US counties	County	Life expectancy at age 40
		All	Men	Women
22	Fairfield	80.9	78.7	83.2
50	Hartford	79.8	77.0	82.5
52	New Haven	79.6	77.0	82.3

CT Health Care Cabinet considers WA reform strategies, CT stakeholder input

At last week’s meeting, the Health Care Cabinet heard about lessons from Washington state’s successful reforms. Washington has consolidated health care planning across both the public and private sectors. The structure isn’t the key – what’s surprising is that they can get to a thoughtful consensus through power-sharing. Like many states, they are working on integrating behavioral health and primary care and emphasizing public health initiatives. In a very fortuitous turn, they didn’t reach their ambitious goals for rushing people into accountable care/risk sharing models. Recognizing that local context in health care is powerful, Washington’s planning is locally tailored and organized by regions – one size does not fit all. They also include a locally defined “early warning system” to monitor for problems. Proposed metrics include provider payments, ED use, wait times for care, patients shifting between providers, crisis calls and prescription drug utilization changes.

Washington is the last state on our list. We’ve found some themes among the successful states we’ve studied at the Cabinet that do not reflect Connecticut – local non-profit insurers, strong histories of collaboration -- in and outside government, reliance on smart analytics and evidence, and constructive, supportive leadership that engages and respects all voices. A Washington stakeholder was quoted saying, “We are lucky here because collaboration is in the water.” They are very lucky.

Input consultants received from Connecticut stakeholders demonstrated how “siloed” our state is. Many were not aware of successful initiatives already implemented by others in our state. Now we begin framing recommendations. Given the disagreements over guiding principles, and even the definition of a principle, it may be a long haul.

Palliative care webinar offers opportunities to improve life for seriously ill people -- and save money

Today’s webinar with Dr. Diane Meier from the Center to Advance Palliative Care was moving as well as offering a very promising policy option for CT’s Medicaid program. 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. Click here to watch a video of the webinar click here; and here for the slides. MAPOC’s Complex Care Committee, which sponsored the webinar, will be discussing the possibilities at our next meeting May 27^th at 9:30 at the Legislative Office Building.