Questions for SIM about radical new Medicaid proposal

Questions sent yesterday for today’s meeting about SIM’s risky, new Medicaid proposal have been posted. One asks why a dangerous 1115 waiver is necessary? Did SIM planners explore other, less dangerous options? 1115 waivers necessarily include a cap on federal reimbursement (to meet the federal budget neutrality requirement) endangering the state budget and potential future Medicaid cuts if health costs continue to rise. The two stated reasons for a waiver – covering community health worker preventive services, and providing air conditioners for people with asthma – are not compelling. As of Jan. 1^st federal rules changed to allow Medicaid payment for CHW services and the extra state cost of air conditioners for 75% of Medicaid adults with asthma is minimal. Advocates have many concerns about the skeletal proposal rushed out to win a federal grant. The MAPOC will hear from SIM proponents about their plan this morning at 9:30 in Room 2C of the LOB.

Special Medicaid Council meeting on new SIM Medicaid plan

The very new SIM plan for Medicaid will be the subject of a special MAPOC meeting tomorrow July 8^th at 9:30 in Room 2C of the LOB. Concerns have been raised about both the content and the process for this radical departure from the original SIM plan for CT’s largest health plan. We expect more details on the plan soon, but what we’ve heard is here and here.

CT Health reform dashboard down – change in SIM/Medicaid plan largely responsible

CT’s Health Reform Progress Meter is down this month to 28.5%, mainly because of a new, rushed reversal on the original SIM plan to put Medicaid members’ care under financial risk, pursue a waiver that caps federal reimbursements putting the state budget and benefits in the state’s largest health plan at substantial risk, and a silly health savings account proposal for low-income Medicaid members. There are few details on the new plan being readied for the SIM grant application due in a few weeks. The new SIM proposal outweighed progress protecting national standards for patient-centered medical homes, also at risk in the original SIM proposal. SIM is being driven by an effort by the administration to secure a federal grant to fund state agencies. Positive progress in CT includes movement toward underservice protections and a final agreement in developing a constructive Medicaid/Medicare health neighborhoods plan. The progress meter is part of the CT Health Reform Dashboard.

CT News Junkie Op-Ed: SIM shouldn’t just chase a federal grant

A new Op-Ed in CT News Junkie outlines consumer advocate concerns that SIM planners are putting their pursuit of a federal grant ahead of what’s best for CT. Contrary to the original plan, SIM leaders are now planning to move Medicaid back to an incentive scheme similar to the failed HUSKY HMOs. Since we moved away from that system two years ago, health outcomes are up, more providers are participating in Medicaid, and the cost of care per person is down. That hard won progress would be at risk in SIM’s new proposal. The plan also includes pursuing a Medicaid waiver that would cap federal reimbursements to the state, putting taxpayers at significant financial risk if health costs in our state increase or the economy doesn’t rebound. The sole motivation for this reversal is to get a $50 million federal SIM grant to benefit state agencies. Consumers don’t care if state agencies get more funding – we only care about making our health care system work better.

SIM update: PCMH standards affirmed but rushing into a radical Medicaid payment change

The good news: At yesterday’s meeting the SIM steering committee voted to accept their workgroup’s recommendation to use NCQA national standards, with some CT-specific additions, as the patient-centered medical home (PCMH) standard for the SIM glide path program. SIM will work with NCQA to develop the additional standards, possibly to include oral and behavioral health integration and cultural/linguistic standards. New practices, without any PCMH certification, will be offered support to achieve the new NCQA Plus standards. Existing PCMHs will not be affected by the decision.

The troubling news: To get the federal grant, SIM leaders believe they need to be more aggressive in Medicaid payment reform and have proposed a shared savings model to cover over 200,000 members starting Jan. 1, 2016. There are very few details on the proposal and committee members had a lot of questions. Consumer advocates raised significant concerns both in public comments and during the meeting. Concerns focused on an 1115 waiver with a global cap on federal reimbursements, HSAs for Medicaid members, reductions in current fees to providers but potential future savings payments, the lack of time and vetting through councils and committees for the proposal, and undertreatment/incentives to deny necessary care. Doubts have also been raised about SIM’s assertion that they must include radical Medicaid payment reforms to secure a successful SIM grant. Advocates noted that earlier successful SIM states’ Medicaid reforms followed a natural progression of ongoing reforms in those more mature states. And we’ve known about their plans for over a year. CT has a poor history with similar Medicaid incentives. Since CT Medicaid moved away from capitation in HUSKY to one focused on PCMHs, health outcomes are better, provider participation is up, and per person health costs are down.

Good news on SIM and PCMH national standards

The new SIM Practice Transformation Workgroup met last night for the first time and support for patient-centered medical home national standards was strong. Advocates have been strong supporters of national standards for PCMHs over a CT-specific program. There is growing evidence that PCMHs that meet national standards perform better on quality, enhance access to care and control costs. Advocates developed a Q&A to answer questions and address misinformation about PCMH national standards. The group agreed to tie the SIM medical home program to NCQA standards. The vote was overwhelmingly in favor of NCQA, with no votes recorded against.  NCQA is the leader in PCMH recognition – certifying 80% of PCMHs nationally. Practices would have to commit to an NCQA PMCH application and recognition to participate in SIM’s glide path program. Only new, non-PCMH practices will receive PCMH assistance from SIM, so practices that currently have certification, NCQA or another standard, will not be affected. There was strong interest in adding other, CT-specific standards to the standard – the NCQA Plus option. The committee will pursue those options with NCQA. The decision now goes to the SIM Steering Committee in their Thursday meeting – where there has been strong opposition to national PMCH standards.

Advocates’ comment urging DSS not to erode successful PCMH standards in Medicaid regulations

Eighteen consumer organizations signed onto a letter of comment sent yesterday making the case that DSS should continue using successful national standards for patient-centered medical homes (PCMHs) in new Medicaid regulations. Original versions of draft language included the current practice of adopting NCQA national standards for PCMH recognition and incentives. However, without notice, national standard language was dropped from the latest draft and replaced with CT-specific standards. Advocates have been very concerned about a similar move by SIM to replace proven, successful, well-established national PCMH standards that are working in CT with a yet-to-be developed home grown standard. Since CT’s Medicaid program shifted to a NCQA-based national standard PCMH focused program, quality outcomes are up, non-urgent ER visits are down, per person costs are down, and the program has attracted 32% more participating providers, just as program enrollment grows under the ACA. Based on consumer advocacy, a SIM committee will meet tonight to re-consider the SIM decision to reject NCQA in favor of CT-specific standards.