Healthcare Cabinet gets an earful on reform proposals

At today’s public hearing, the Cabinet got a lot of thanks for the hard work, but not a lot of support for the proposals. Unfortunately the meeting was poorly attended, especially by some of the strongest proponents of downside risk. Speakers included providers, advocates, a SIM official, a foundation, and business representatives. Many spoke against downside risk, noting that it could jeopardize hard-won progress, that it is untested and we should wait and see how current reforms perform, concerns about changes at the federal level, and that the looming state budget deficit make any investments unwise. Prospect Medical Holdings, the for-profit company based in Los Angeles that bought Waterbury Hospital and ECHN, offered that if the state would give them a capitated fee for Medicaid and they would save the state millions. They must not be aware of the “spectacular failure” of capitation in our Medicaid program. Since we shifted away from capitation, quality and access to care are up, fewer people are visiting the ER for non-urgent care, and per person costs are down.

Poor choice of monitor in YNHH-L+M deal undermines accountability

Yale-New Haven Health has chosen Deloitte & Touche to monitor compliance with conditions of their acquisition of Lawrence + Memorial Healthcare. The conditions on the unusual acquisition were set in place by the state to protect prices in the new monopoly market, protect health services for southeastern CT, oversee promised investments in the region, and to enforce ACA community benefit requirements. The monitor’s independence, including perceptions, is crucial to effectiveness. However, YNHH has paid Deloitte over $30 million over the last ten years in other capacities and Deloitte paid a million dollar fine to settle charges of violating auditor independence rules in 2015.  DPH has already approved the choice but a diverse coalition of consumers, labor, elected officials, and community representatives has called on the state to rescind that approval and support an independent choice in a transparent process. DPH also refused to meet with the coalition.

Advocates’ webinar on better alternatives to Health Care Cabinet proposal online

CT’s Health Care Cabinet has voted on a controversial set of recommendations for reforming our state’s health system. The Cabinet will take public comment on their plan at a public hearing on Nov. 15^th at 9 am in the LOB. In a webinar yesterday, advocates and others heard about the plan, better alternatives to downside risk, and the many many issues that are missing from the Cabinet’s plans. Slides and a video of the webinar have been posted online.

DSS plans for high-cost, high-need members focuses on behavioral health

At yesterday’s online MAPOC Complex Care Committee meeting, DSS described their innovation plan to address the needs of high-cost, high-need Medicaid members. (meeting video and slides) The project was made possible by a technical assistance grant from the National Governor’s Association. Five agencies and the Medicaid Administrative Service Organizations, CHNCT and Beacon Health, have worked with the committee to identify the top 10% of members – adults and children -- in cost, ED and inpatient use, each separately. Interestingly we found that there is not a lot of overlap between those groups. The top 10 conditions for each of the six categories are listed on the slides. The team then turned to identifying interventions that could have an impact. Consequently the group decided to focus on members with behavioral health needs; many have co-morbid medical conditions. The project will focus on enhanced care management by Beacon Health. 1,236 high-need adults identified from the data will receive intensive care management in the community including intensive outreach from peer counselors to help them develop a personalized care plan and connect them to that care. Yale-New Haven is the highest volume hospital by far with almost four times the number of ED visits and in patient stays as the next highest. Beacon will conduct the evaluation using a matched set of members who do not receive those services due to geography. Questions from the committee included how the state will ensure that the new PCMH+ ACOs do not collect shared savings based on this care coordination funded by the state, measuring connections to primary care, needs of people with intellectual disabiliites, how to address members served by home or nursing home care, and why Yale-New Haven has so many high-utilizing members.

FDA panel barely approves new antibiotic for pneumonia

Friday, the FDA’s Antimicrobial Drug Advisory Committee split 7 to 6, to approve Solithromycin, a new drug for community-acquired pneumonia. Pneumonia is responsible for 4.5 million ambulatory visits. About half of bacteria causing pneumonia in the US are now resistant to the best current treatment option. The committee agreed that the drug was proven effective, but serious concerns were raised about liver toxicity.  The concerns centered on small sample sizes of clinical trials, troubling liver enzyme levels in patients, and a scandal from a decade ago when a similar drug was approved, but was later linked to deaths from liver failure. The problem is identifying somewhat rare but deadly adverse events in clinical trials which cannot include enough patients to detect the problem directly. In the end, most members felt that as bacterial resistance to antibiotics is rising quickly, we don’t have time to wait for perfect data.

Troubling Cabinet vote for downside risk on Medicaid and state employees, but there will be a public hearing

In a 13 to 4 vote Tuesday, the Health Care Cabinet voted to impose the controversial downside risk payment model on CT’s Medicaid and state employee plans. DSS, OPM, DPH and the only consumer advocate at the meeting all voted against the option (votes are listed below). Deep concerns have been raised about downside risk including underservice incentives to deny necessary treatments, incentives to avoid costly patients, and disincentives to even tell people about treatments that may be costly. The Cabinet’s proposal includes no mention of even monitoring for underservice. Other downside risk concerns include a broken promise, disincentives to invest in quality, it is very new and experimental, it is based on extrapolating economic theory from very different subjects, and providers are widely rejecting it in other states. In many ways downside risk is worse than capitation, which “failed spectacularly” in CT.

Other troubling options endorsed by the Cabinet include creation of a costly Office of Health Strategy, giving the Attorney General subpoena power to monitor health market trends, to study applying for a costly Medicaid 1115 waiver with a risky DSRIP option to implement downside risk, and to create a new comparative effectiveness committee to make recommendations about which treatments should be approved in CT. In good news, the Cabinet did endorse creation of community health teams to connect medical care with public health and social services. The concept is modeled on Vermont’s successful Blueprint for Health program.

A troubling plan to create a state agency-only Health Planning Council was scrapped when concerns about open meeting/Freedom of Information laws reached social media during the meeting.

The Cabinet will take public comment on their plan at a public hearing on Nov. 15^th at 9 am in the LOB. Advocates are invited to hear more in a webinar November 9^th at 2 pm about the plan, better alternatives to downside risk, and the many many issues that are missing from the Cabinet’s plans. Click here to register for the webinar.

Cabinet members’ organizations and votes on downside risk are listed below. For links to the vote tally click here and the voting guide click here. * indicates funders of the Cabinet consultants who developed the plan. The votes are provisional; they may be changed after the public hearing Nov. 15^th.

Voted against downside risk

Office of Policy and Management

Dept. of Social Services

Dept. of Public Health

CT Health Policy Project

Voted for downside risk

Office of State Comptroller

Acting State Healthcare Advocate

AccessHealthCT

CT Pharmacists Association

Bristol Hospital

TR Paul, Inc.

CT Coalition of Taft-Hartley Health Funds

Universal Healthcare Fndn of CT*

CT Health Fndn*

Bill Handleman, MD

Gary Letts, MD

Masonicare

Hussam Saada

Nominations open for New England comparative effectiveness council

The Institute for Clinical and Economic Review is seeking new members for the New England Comparative Effectiveness Public Advisory Council, in addition to two other councils in California and the Midwest. Many health policy experts blame new technologies for drugs, devices and other innovations with driving health costs up without necessarily improving the quality of care. The Councils include leading clinician, patient and public representatives, researchers, and health economists who meet a few times a year to consider, and vote on, the effectiveness and value of new health treatments. Previous topics include treatments for liver disease, multiple myeloma, and lung cancer, as well as system-level interventions such as palliative care and diabetes prevention programs. Members must meet conflict of interest guidelines and will be reimbursed for travel to meetings and for their time. To apply, send a CV/resume and letter of interest to info@icer-review.org by December 15^th. Learn more about ICER here, here and here.