Yesterday’s
Health Care Cabinet meeting started with a statement by the Lieutenant
Governor stating that the commitment made last year not to implement downside
risk in Medicaid was time-limited to end with the state’s SIM grant in 2019.
However that was never conveyed to advocates and, in fact, the state made a
clear commitment, without any conditions, not to implement downside risk in
Medicaid here,
here
in their plan to CMS and to potential PCMH+ (formerly MQISSP) applicants in
the RFP. The commitment was originally made in negotiations to get partners,
including advocates and providers, to participate in designing PCMH+, Medicaid’s
plan for upside-only shared savings.
The rest of the meeting focused on proposals to cap health
expense growth across the state, setting a target for payment reform contracts
in the state, merging state agencies that touch health, HIT, ad comparative
effectiveness research, and creating a new Office of Health Reform to set
spending caps and payment reform targets among other duties. We then moved onto
alternatives plans from many sources, including
the CT Heath Policy Project. Other commenters also concerned about the
expansive shared/downside risk proposal included AARP, Christian Community
Action, and a collaborative alternative signed by twenty independent consumer
advocates. Alternatives to the ACO provider coordination/consolidation plan
included coordinating care with community-based organizations and building on Medicaid’s
successes. Alternatives to the very controversial
shared/downside risk proposal included focusing reform on primary care,
moving back to global capitation across the state, and continuing to tie more
provider/health system compensation to quality and away from volume.
Alternatives to the cost growth cap proposal include regulating mergers, direct
rate setting and consumer affordability. There were calls not to put the tool
before the goals and wait before considering the 1115/DSRIP proposal. A new
goal was raised in alternative plans to limit the growth of prescription drug
costs – the Cabinet decided to take these up separately.
Unfortunately big areas were ignored (or danced around but
not addressed) including the biggest – a pervasive lack of trust – and its
corollary – very poor communications. The proposal is entirely silent on the
critical issue of underservice*, which is a problem far beyond Medicaid. There
was no mention of regulating ACOs as they assume huge control over health care
spending and treatment decisions, the need to address high-cost, high-need
patients, ensuring we have the workforce to do any of this, integrating
behavioral health into medical care, social determinants of health or addressing the sorry state of health care
quality in Connecticut.
We will deliberate and vote on Nov. 1 at 4pm and there will
(finally) be an opportunity for public input at the Cabinet’s Nov. 15th
meeting at 9am.
