CT’s Medicaid success: Access and quality are up, costs are down

Since 2012, when CT’s Medicaid program shifted from a capitated payment model to a self-insured model based on care coordination, the program has enjoyed significant improvements in quality, access and cost control, as predicted. A new analysis finds that the number of providers participating the in the program is up 32%, person-centered medical homes are up 35%, hospital admissions are down 3.2%, non-urgent ED visits are down 3.2%, and total per member costs are down 1.9%. Impressive results – saving money for the state and improving care to people. Congratulations to DSS and CHN for their hard work to implement the shift and for working with consumers and advocates to make the vision successful.

Exchange enrollment growing, but how many were uninsured?

A CT Mirror report looking underneath AccessHealthCT’s enrollment numbers finds that we don’t know how many of the 94,000 people enrollees were previously uninsured. A national study finds that only 11% of exchange enrollees were uninsured; our exchange estimates that rate between 25% and 50%. Even the most generous estimate makes clear that we are not reaching the majority of CT’s 380,000 residents who are either uninsured or in recently discontinued plans. The exchange expects to have better information about the question later this month.

CT Health reform dashboard – progress up to 28.7%

As the ACA’s individual mandate, exchange coverage and dozens of other provisions became effective last month, CT has only achieved 28.7% of necessary benchmarks for effective health care reform, according to this month’s CT Health Reform Dashboard. This is up slightly from 28.3% for the last two months. Uncertainty and a lack of protections in the SIM process and unaffordable coverage in the insurance exchange are holding CT back. Medicaid and patient-centered medical homes are once again CT highlights.

February CT Health Policy Webquiz – enrollment in CT’s health insurance exchange

Test your knowledge of enrollment in CT’s health insurance exchange. Take the February CT Health Policy Webquiz.

PRI report: Recommendations to lower Medicaid ED use

Friday, the legislative Program Review and Investigations Committee released results of their study on Medicaid ED use finding that while per capita Medicaid members’ use of the ED fell slightly between 2010 and 2012, Medicaid still makes up the largest source of ED users in CT at 36%. Despite the per capita decrease, Medicaid members are three times more likely to visit an ED than the average CT resident. The report considers alternatives to the ED including expanding access to alternative care including improving Medicaid provider participation, increased primary care payment rates under the ACA, and patient-centered medical homes. The report makes several recommendations to reduce Medicaid clients’ reliance on EDs including patient education about alternatives, linking people to providers, secret shopper surveys to accurately assess capacity, continuous eligibility, telemedicine to improve access to specialty care and better coordination with behavioral health programs.

Fascinating interactive infographic on international health care spending gap

It’s not news that the US spends far more per person on health care than other high-income countries (and we get less for that spending, but that’s another blog), but an interactive infographic  from the New England Journal of Medicine breaks it down by year and category of spending. Like the best cool graphics, this one carries a lot of interesting content. The US is an outlier in all categories but we have some limited competition for the biggest spender in a few categories, including Canada for public health service spending per person (we are a bit higher). The worst gaps between the US and the rest of the world are in total spending and private insurance spending (no surprise). Most countries spend more on either government or private/out-of-pocket spending (depending on their model) but we are the highest spender on both. The worst trending gap between the US and the rest of the world is in health administration and insurance – we are not only the highest spender but also growing faster than anyone else.  Comparisons are in Purchasing Power Parity (PPP) $ US which controls for the value in goods and services between countries. Graphics like this give hope that we can fix our system – there is clearly enough money being spent.

Advocates meeting with SIM staff

Yesterday’s meeting with advocates called by SIM staff included some good news but more challenges focusing on process over content. Advocates were encouraged that the SIM planners are now interested in getting input from both “real” consumers, especially from under-served populations, and from professional, independent advocates who follow complex policy proposals on behalf of Connecticut consumers. The state’s SIM plan, now finalized, has been criticized for missing the input of critical stakeholders including consumers, and for overstating the minimal input they’ve gotten from independent consumers and advocates. They are now seeking our input on how to implement the plan they have created.

While it is encouraging that the SIM planners are now seeking consumer and advocate input for new committees, there are many challenges.  Advocates pointed out that we have key unanswered questions about the plan, this administration’s intentions, and how it could affect people if implemented. Many advocates have not yet decided whether to support or oppose the state’s application for a federal grant to implement the final SIM plan and the answers to those questions are key. Advocates also await their commitment to, and degree of, genuine consumer involvement in decision-making going forward.

Advocates expressed concerns about SIM planner’s over-attentiveness to the interests of insurers – arguing that consumers should be SIM’s key constituency as both the ultimate payers and ultimate consumers of health care. Advocates made it clear that just listening to advocates is not sufficient – it is critical that they be in decision-making roles and that their input from a variety of means is incorporated into policy. Advocates repeatedly objected to SIM staff plans to have only a few consumers or advocates on each committee, placing them in a minority position. Advocates repeatedly urged SIM to focus less on getting a few “perfect” consumer representatives for their committees, as consumers are not organized into trade associations like other stakeholders, but to open the decision-making process to include and incorporate public input. Advocates gave SIM numerous examples of successful and respectful past policy decision-making models. Advocates urged SIM to ensure that consumers and advocates make up a majority of members of all committees, as in many of those successful models. Advocates also expressed concern that membership would be at the sole discretion of the administration, unlike successful models like the Medicaid Oversight Council whose membership is set in statute. SIM staff resisted that recommendation concerned about sustaining that effort and making enough space for other stakeholders, specifically insurers.

Points I wasn’t given the opportunity to make during the meeting include a concern that these committees, even if they include consumer voices, will still be three levels below where decisions are made on the SIM organizational chart. There is a history in CT of overruling consumer committee input at higher level boards. It is also critical that in any online communications about public input, that consumers be allowed to check whether their input was included or not. Too often policymakers incorrectly believe they have faithfully included consumers’ input but have missed critical points. It is also critical that meetings, especially those with insurers about payment models, be public and transparent rather than private. It is important to note that no advocate asked to be included in secret meetings, we have repeatedly asked that there not be secret meetings. Nothing was decided at the meeting; we await answers to our questions about the plan’s impact on the Medicaid program, CT’s public health system, and promising medical home programs as well as responses to advocates’ strong recommendations for consumer/advocate majority representation on all committees and for transparency and meaningful public input in decision making beyond the committee structure. We look forward to a constructive process that works to foster successful, responsible reforms of CT’s health care system.