Contrasting gubernatorial candidates on health care

Health policy has emerged as the latest disagreement among CT’s candidates for Governor. Dan Malloy’s and Tom Foley’s positions on health care are significantly different.
Ellen Andrews

HUSKY HMOs made $19 million profits last year; families paid $323.16 to HMO profits

At the very end of yesterday’s Medicaid Care Management Oversight Council meeting, DSS reported that the HUSKY HMOs made $18.8 million in profits on the program during 2009. This profit is on top of their administrative costs. Aetna made most of that profit -- $14 million – despite having only one fourth of total enrollment. While the medical care ratio (better term than medical loss ratio) for the program overall was a respectable 90.7%, it varied considerably by program. Worst was 62% for AmeriChoice’s HUSKY Part B plan; none of the HUSKY Part B ratios would comply with federal Accountable Care Act standards.

As bad as the state’s loss of millions to HMO profits, worse is overcharging HUSKY families. There are currently 1,260 children in HUSKY Part B Band 3; these families are paying an extra $323.16 in premiums annually to HMO profits. Families in this band have incomes over 300% of the federal poverty level ($54,930 for a family of three) and pay the full cost of HUSKY coverage for their children. Even worse, 1,279 children lost HUSKY Part B Band 3 coverage in the last year because they couldn’t pay premiums. It is unknown how many of those children may have kept coverage if premiums were $323.16 lower and reflected only the HMOs’ costs.

The HMOs defense to criticisms about large profit taking was that the profits served to partially offset losses on the Charter Oak program. Council members pointed out that the state and CMS do not allow cost shifting between programs, especially from one that is federally matched to one that is supposed to be fully state and consumer funded. Advocates have been concerned for years that HUSKY rates are set at overly generous levels to subsidize the politically favored Charter Oak program.
Ellen Andrews

More state health policy in New Orleans

Yesterday, I finished up at the NASHP conference hearing the latest from VT’s Blueprint for Health and a panel on how FQHCs are stepping up to provide coordinated care and patient-centered medical homes (PCMHs). VT is planning to expand their Blueprint PCMH program to the entire state in three years. Primary care practices certified as PCMHs by NCQA are paid a flat per member per month fee based on their level of certification; the Blueprint does not include a quality or performance based payment provision. The pmpm rates vary from just $1.39 to just over $2, far below CT’s $7.50 pmpm in our PCCM program. Preliminary results are very promising both for savings and improving health status. The program also includes community health teams with a team of clinicians for each community; the team offers more intensive care coordination services to any patient in the community regardless of payer or insurance status. The clinicians on the team and services offered are locally based, no remote disease management, and are based on an assessment of local population needs. Each team serving about 20,000 people costs $350,000/year. All four private insurers in the state contribute to the community health teams. Because of the health teams two insurers have been able to cancel their expensive disease management contracts with outside companies. It is not clear yet if premiums to consumers will be reduced to reflect the savings.

The panel on FQHCs and PCMHs highlighted the natural fit between the two models of care and the cost advantages of linking the two. Iowa had a bare bones coverage program with limited provider participation, similar in many respects to Charter Oak. Also like Charter Oak, IowaCare quickly began sinking under its own weight from adverse selection and administrative issues soon after it was implemented in 2005. Iowa wisely decided to transition the program to a PCMH model based on their FQHCs. IowaCare Medical Homes are paid a monthly care management fee as well as performance payments.

Building on their successful PCCM program, Montana also created a flexible, locally controlled PCMH program through their FQHCs. Patients are referred to the program by a prospective payment risk assessment system or by referral from primary care providers; many PCPs state that they can tell which of their patients are at risk of incurring high medical costs before they would be picked up by a claims based system. Primary care providers hire the care managers, who meet patients where they are – in their homes, in their cars, at the grocery store, at a laundromat, etc. Care managers must become certified within three months of hire. They engage in a conversation with patients and their families to see “what the problem is and find a way to fix it.” That may mean arranging reliable transportation to appointments, pulling out carpet, cleaning drapes, or finding a vacuum cleaner for someone with asthma whose cleaner broke a year ago and hasn’t been able to replace it. Since care managers are local residents connected to their communities, they can identify informal resources and donations. The switch from using outside disease management companies to local community programming has expanded benefits and reduced costs for patients in the program. The total number of care management FTEs has increased from 4 to 25 now and soon will be 45 at a lower cost to the state.
Ellen Andrews

More health policy from New Orleans

A long day at the NASHP conference today. We heard about challenges facing states; the common theme was planning deep reforms on very short timelines with limited staff capacity and growing budget deficits. William Hazel, recently hired Virginia Secretary of Health and Human Services, pulled together the heads of departments to look for savings. When they all told him they had been cut to the bone, he commented that it was pretty funny that they sent them an orthopedic surgeon as the new Secretary. Another speaker compared giving insurance cards to people without making sure they can access care and get appointments, is like giving a parking permit to a college kid – it’s just a license to hunt.
We learned about the parameters of building state insurance exchanges, updates on states building patient centered medical homes, and the challenges of measuring and paying for quality. Rosemary Gibson, author of the Treatment Trap, described the dangers and costs of overtreatment. A fascinating panel focused on undocumented immigrants, completely left out of public coverage programs, and the likely impact on the safety net. New data from SHADAC estimates that there are 10.4 million undocumented immigrants in the US and 3.7 million of them live in low-income households (138% or less of the federal poverty level) that would have qualified for Medicaid but for their immigration status. SHADAC researchers estimate that there are between 50,000 and 100,000 undocumented immigrants in CT and between 10 and 19% of CT low income adults are undocumented immigrants, one of the highest proportions among states.
Ellen Andrews

New Orleans health care – five years after Katrina

Yesterday, the NASHP conference in New Orleans started with a plenary session on the state of health care in the city. Things were not great before Katrina – the city was at the bottom of national list for health care access and outcomes. 80% of the housing stock was lost; health care institutions were devastated. Progress in rebuilding has been slow and the BP oil spill has cut into available resources. One speaker compared it to trying to pursue national health reform when two thirds of the nation is under water. EMRs became critical as most medical records were destroyed and patients scattered across the nation. Patient-centered medical homes became a necessity as the lack of providers required teams; coordinating care and engaging patients in their own care was critical. Approximately 90 clinics have grown around the city sponsored by a wide diversity of groups including payers – government, religious, civic groups, foundations – serving different populations – musicians, pregnant women, specific communities. Speakers noted that this diversity is an important strength – if one payer drops support, such as the state – the system can adjust. However, thoughtful planning has hit roadblocks. The state offered to pay all the costs to build desperately needed mental health care capacity, but hospitals refused, instead building transplant services to attract patients from outside the area.
In other news, the big story in New Orleans this morning is that Blue Cross Blue Shield of LA and East Jefferson General Hospital have not been able to reach an agreement. Thousands of patients will no longer be able to get care there. Sound familiar?
Ellen Andrews

CT uninsured rates vary significantly by geography, income, race/ethnicity and citizenship

New numbers from the Census find that last year minorities in CT were more likely to be uninsured, but not being a citizen raised your risk by more than four fold. CT residents with household incomes between $25,000 and $50,000 were most likely to be without coverage. Fairfield County led the state with 11% uninsured; Tolland was lowest at 5%. The survey found that uninsured rates in all CT counties dropped from 2008 to 2009. Almost one in five Stamford and Bridgeport city residents lacked insurance. For more, check the CT Health Policy Project issue brief.
Ellen Andrews

CT gets federal grant for health care workforce planning

The CT Employment & Training Commission and the CT Office for Workforce Competitiveness were successful in their application to HHS for $150,000 to support the CT Workforce Investment Strategies in Health Care (WISH) Planning Grant. The funds will be used to produce a statewide health care workforce plan, coordinate disparate planning efforts, strengthen regional workforce planning efforts, and improve data collection and data sharing capacity about licensed health care professionals across the state. The planning grant puts CT in a position to apply for subsequent federal grants to expand the state’s workforce over the next decade. State partnership members have committed over $100,000 in matching funds for the project.
Ellen Andrews