From the Book Club: An American Sickness: How Healthcare Became Big Business and How You Can Take It Back

This latest addition to the CT Health Policy Project Book Club should be required reading for everyone. I’ve been a health policy analyst for over twenty years and I learned something new on every page. I couldn’t read it in one shot – I kept throwing it down in disgust. The author is a former ER physician, former NY Times reporter, and now editor of Kaiser Health News. She lays out the problems with our broken health care system -- sector by sector. But she doesn’t leave us there. The second half of the book is full of very specific actions for consumers to protect themselves, with resources, and realistic, meaningful policy changes that can start healing our broken health system. For more reading, visit the CT Health Policy Project Book Club.

CMS finalizes important patient-friendly informed consent payment proposal

CMS has finalized their proposed Medicare rule (regulation) for how hospitals are paid that includes a new measure assessing the quality of hospital informed consent documents given to patients before elective procedures. (The relevant section, Potential Inclusion of the Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures Measure starts here on p. 373 of the pdf file – p. 38362 of the Federal Register Rules and Regulations 82:155, 8/14/17). The rule will make an important difference in supporting patient-centered care in hospitals across the US. The current state of hospital informed consent documents is embarrassingly poor. Under this rule, the 4,700 US hospitals that treat Medicaid members will be paid, in part, based on the quality of their informed consent documents. The measure may also be included in public quality comparisons such as Hospital Compare, allowing patients to use this measure in choosing between hospitals for their care. Many thanks to all who submitted supportive public comments to the proposed rule.

Survey of state legislators’ values for health reform finds strong differences by party but some encouraging overlap

Both Democratic and Republican state legislators from across the US agree on the need to control health care costs, according to a new survey published in the American Journal of Public Health. However, other top priorities between the parties differ strongly. Republicans prioritized smaller government along with reducing costs while Democrats prioritize improving health equity with cost control. Republicans were split among themselves between prioritizing improving overall health and reducing government involvement in health care. The authors suggest that this reflects a split in the party between moderates and conservatives. There was no difference between legislators based on geography or legislative chamber. The results suggest opportunities for bipartisan progress on health reform, especially on controlling costs, and messaging for advocates. The survey was supported by the Commonwealth and Milbank Memorial Funds.

DPH launches website comparing CT quality and cost of hospital and nursing home care

Last week, CT’s Department of Public Health unveiled MONAHRQ, a web tool allowing consumers and other health care decision-makers to compare the quality, outcomes, utilization and costs of health care in our state. For example, Only three of CT’s 24 general hospitals are above average in patient ratings – Greenwich, Middlesex and Milford. Sadly, most (17) rank below average and seven are average. Another report from the web tool finds that New Haven county has the dubious distinction of the highest per capita rate of avoidable hospitalizations in the state.  We have a lot of room for improvement.

State policymakers hear how bioscience is generating jobs with health innovation

The growing Bioscience industry holds great potential to improve the region’s economy and health , according to speakers at “Bioscience Initiatives: Improving Health and Growing the Economy” at this week’s CSG-ERC Annual Meeting in CT. Panelists included Mostafa Analoui, PhD, Executive Director, UConn Venture Development, Mike Hyde, Vice President, External Affairs, The Jackson Laboratory, and Jon Soderstrom, Ph.D., Managing Director of the Office of Cooperative Research, Yale University. The Northeast has a unique bio-medical ecosystem with considerable capacity to spawn innovative new bioscience companies and to meet those companies’ need for talented workers. Bioscience has attracted hundreds of millions of dollars in private equity and venture capital funding to CT alone. New companies are driving research, developing new drugs and treatments, and leading cutting edge fields such as genomic medicine. UConn has created a Technology Incubation Program supporting dozens of new bioscience ventures across industries. The 88-year old nonprofit scientific research institute, Jackson Labs, has brought 320 well-paying jobs and hundreds of millions of dollars to their new CT site. Yale has created 40 new biotech companies in the Greater New Haven area and more are forming.

State health policymakers get the latest from DC and options to respond

At this week’s CSG-ERC Annual Meeting in CT, state policymakers from across the Northeast got updates from experts on the federal health care landscape, state options to adapt. CT’s Lieutenant Governor Nancy Wyman pulled it all together describing CT’s progress toward health reform. Mitchell Stein gave a detailed summary of federal activity including CHIP reauthorization (ends Sept. 30 without action), tax bills and raising the debt limit which all could impact Medicaid and/or the Affordable Care Act. He re-capped ACA repeal efforts and the status of insurance exchanges including cost-sharing reduction payments, underserved counties, premium levels and degradation of the risk pool. It’s estimated that about half of premium rates for next year are due to uncertainty about ACA implementation. He outlined what is likely to happen this fall and potential state responses including reinsurance waivers and creating a Medicaid buy-in option.

Policymakers then heard from Chris Koller, President of the Milbank Memorial Fund, on the big picture and states’ capacity to address the quickly changing environment. He reminded policymakers about the importance of social services in health outcomes and America’s poor performing health system that costs more and delivers less than other countries. He outlined concerns about slow economic growth’s impact on the health of poorer populations and government’s ability to address that stress, rising health disparities, and political changes. Probably his most popular slide described the results of a Milbank survey of state legislators finding that Democrats and Republicans have very different goals and values for health reform. Republicans are most interested in reducing costs while Democrats prioritize improving health and equity. The federal government is delegating more health policymaking to states, while Medicaid costs rise, crowding out other priorities. In good news, he highlighted Georgia’s progress in reducing infant mortality, and Delaware’s success in addressing chronic illnesses, with lessons learned. He emphasized that states need to get creative in building state health policy capacity and shared a roadmap to get there.

Lieutenant Governor Nancy Wyman ended the meeting by recapping what we heard and describing CT’s long history of success in reforming health care and expanding access. She outlined work creating AccessHealthCT, outreach efforts that cut CT’s uninsured rate in half, Medicaid reforms, and support for primary care and prevention with the state employee plan’s Health Enhancement Program.

This was followed by a lively question and answer discussion touching on the relationship between health care industries and jobs, state options to create a reinsurance program and/or require all individual coverage be sold on the insurance exchange, the role of 1332 waivers, the role of family caregivers, end of life care costs, and comparisons with the Canadian system.

More information on state reinsurance programs and Medicaid buy-in options will be coming.

The Future of Medicine in the Human Genome Genomics -- Making a difference in patients’ lives / By Mary Branham

From CSG-ERC’s Annual Meeting in Connecticut

Mapping the first human genome in 2000 cost about $4 billion; today, it costs about $1,000.

The cost has come down because of investment, and because of the important role genomics is playing in medicine today, according to Dr. Murat Gunel, a professor of neurosurgery, genetics and neuroscience at Yale University, who spoke during Sunday’s luncheon plenary, “Genomics and Precision Medicine: Investing in the Future of Health Care.”

“We have all recognized the power of genomics,” Gunel said. “This is clinical. This is making a difference in our patients’ lives everyday.”

Plus, he said, “this is the new Internet race.” Various nations are investing in the research, recognizing the main race now is learning how to decode the genomic makeup of people to understand their diseases. It is one of four areas in which China is making multi-billion dollar investments. The U.S. also has made significant investments in the area, starting with the 2000 investment in mapping the first genome.

“You can imagine the impact it will have on our health care system if you can predict a disease before it starts,” he said.

Now, for the most part, while the ability to diagnose disease is evolving, treatments are often a best guess based on effectiveness over a general population. Genomic testing will allow for precision—also referred to as individualized—medicine to treat patients based on many factors.

But, Gunel cautioned, “genomics in isolation does not mean much.”

He said that information must be combined with what is known about the quality of the air or water in a person’s environment or about how much they exercise, for example.

Having that information for individuals can help them tailor their lifestyles to improve their health. Even so, Gunel said a bigger purpose would be to use that information in population health. Precision medicine has already seen some success, such as addressing newborn diseases, prenatal diagnosis, pharmacogenomics and individualized treatment for cancer, he said.

That’s because genomic testing has increased the number of genes that can be tested. Gunel said cancer patients are looked at with regard to their genomic makeup. That ability has helped bring a 30 percent cure rate for metastatic melanoma, he said.

It’s changing the way diseases are treated. For instance, now everyone diagnosed with lung cancer is given the same treatment, according to Gunel. With genomic testing, physicians are able to understand the baseline risks individuals have and make specific lifestyle recommendations to help prevent the diseases. Then, if the disease occurs, “we could diagnose it faster and give more effective and more individualized treatments.”

While precision medicine will have major impacts on health care, Gunel said it could also bring $1 trillion in economic growth. That could impact the development of things like new medicines and the creation of new fields to fill such roles as genetic counseling and computational biology—the people who can run the artificial intelligence (AI) in the data center.

“We think the number of people we are going to need in that field is going to ramp up tremendously,” said Rich Lisitano, vice president at Yale-New Haven Hospital.

Early look at exchange premiums finds Hartford premium trends modest compared to other US cities

A Kaiser Foundation very early look at 2018 health insurance exchange monthly premium proposals, subject to change, across 21 US cities predicts that Hartford consumers will do well next year. The report compares early rate filings for a 40 year old non-smoker making $30,000/year choosing the second-lowest silver plan. Silver plans are the most popular. Among the 21 cities, Wilmington DE consumers face both the highest premium ($631) and the biggest increase over this year (up 49%). Detroit consumers will have the best bargain next year at $244/month and Providence consumers will see a decrease of 5% in their premiums. Hartford premiums are at about the middle of the pack at $417/month next year without subsidies, up 9% from this year, but $201/month with the premium tax credit, down 3% from this year. Most exchange consumers qualify for subsidies. Overall, Hartford’s average annual trend from 2014 to 2018 without the tax credit is up 6%, better than 13 of the 21 cities, but down 1% annually with the credit, similar to most cities.

It is very important to note that these numbers, for all cities, are based on early rate filings; final rates will not be set until the fall. Insurers are facing far greater uncertainty this year about federal policies and resources that impact premiums.

One in ten CT adults has high medical needs

Understanding high-need adults with complex conditions and their barriers to care are key to developing solutions that improve health and control costs. High-need adults have at least two chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks. A new report from the Commonwealth Fund outlines in depth the number of high-need adults and their challenges across states. Ten percent of adults in CT have high medical needs, just below the US average of 12%. High-need adults tend to be older and over one in three in CT has income below 200% of the Federal Poverty Level. In good news, only 7% are uninsured, compared to 9% of all CT adults, and 94% have a usual source of care. Unfortunately high need adults in CT are more to have gone without or delayed needed care due to cost. Almost one in three (31%) went without a provider visit because of cost and 15% went without a prescription due to cost.  Ot those who delayed care for reasons other than cost, 40% were due to transportation problems and 24% could not get a timely appointment for care.

CT Medical Society standing up an HIE for the state

Miscommunication is blamed for thousands of deaths and billions of dollars in costs. One part of miscommunication involves providers not being able to access records for patients they are treating. Numerous state groups working to reform CT’s broken health care system over the last decade have urged policymakers to develop a Health Information Exchange (HIE) to help with that problem. But despite several attempts costing millions of dollars, the state has failed for a variety of reasons. The CT State Medicaid Society has decided not to wait for the state and is building their own HIE – CT Health Link. CSMS is investing hundreds of thousands of dollars to have Kansas customize their successful HIE for our state’s needs. Kansas’s HIE launched in 2012 and now includes all hospitals and three out of four physician practices in the network. CT Health Link gives providers tools to share information, making care coordination far more effective, but the tool goes much further as well. Patients will be able to see all their information with opportunities to opt-out or in, correct errors and better understand their care. CT Health Link will enable public health reporting for providers, a significant administrative burden. The tool also includes an analytics dashboard that focuses on high-risk patients, disease registry, preventive care, readmissions, and population health that will be invaluable in improving quality and effectiveness of care. It is disappointing that CT Health Link has decided to, by default, include all patients’ information without first getting permission. They do make it easy to opt-out and have committed to a robust patient education process.

August CT Health Reform Dashboard – Medicaid concerns grow but continuing hope for drug costs

CT’s August Health Reform Dashboard remains mixed. Medicaid policy development and implementation remains mired in mistrust, rushing ahead without data, quality problems, and a lack of transparency while state officials refuse to answer questions. The new state HIT plan is travelling the same troubled path from the past but thankfully physicians and others are just getting it done, despite state government. The state budget remains dreary but ACA repeal and replace efforts were dealt a setback when the latest bill died in the Senate. In other good news, the Health Care Cabinet is digging into our work to control drug costs in CT with new workgroups to develop options. Growing mistrust remains at the core of problems in CT.