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News About Health Care
LWVCT
FALL
CONFERENCE DEC. 4, 2010
At South
Congregational
Church, Hartford, Connecticut
Fabulous
program for Fall Conference this year, thanks again so much to
Moderator Kay Maxwell!!!
Moderator Kay Maxwell followed up on last year's Fall
Conference on Health Care by introducing this year's fantastic
presenters and response
panelists, for "One Year Later: Health Care In Our Country And In
Our State."
.
LWVCT President Cheryl Dunson graciously introduced the program, and
closed
the event precisely on time!
FALL CONFERENCE 2010 - Video to be
available in DVD (2 different versions) around the turn of the
year. Contact LWVCT Office to reserve your copies for either
one or both. Version one is the entire conference (approx. 2 1/2
hours). Version two is a one-hour (for Public Access) version
consisting of excerpts from the presentations of the four
speakers. LWVCT office
telephone and e-mail contact information listed just below.
DIRECTIONS TO THE FALL
CONFERENCE BELOW
Federal opinion undermines state's health-pool concept
Mark
Pazniokas, CT MIRROR
May 4, 2012
The U.S. Department of Labor has advised the Malloy administration that
opening Connecticut's state employee and retiree health plan to
nonprofits and small businesses could jeopardize the legal protections
it now enjoys as a government plan.
The advisory opinion sought by Gov. Dannel P. Malloy could undermine a
health care pooling bill passed last year and an expansion proposed by
House Speaker Christopher G. Donovan, D-Meriden, that is now awaiting
action in the House.
The legislature last year passed a law opening the plan to employees of
nonprofits, beginning Jan. 1, 2013. The bill pending in the House would
add employees of small companies, beginning Jan. 1, 2014.
A third aspect of the pooling concept -- opening the state plan to
municipalities -- is unaffected by the opinion. The state comptroller's
office is marketing the state plan to cities and towns.
Malloy sought the opinion Sept. 29, 2011, but the administration
received no response until Monday. For Donovan, one of the state's
biggest backers of the pooling concept as a way to bring down the costs
of health coverage, the timing of the receipt is awkward, at best.
The annual legislative session that ends Wednesday at midnight is his
last as speaker. Donovan is running for Congress and will not be
returning to the state House of Representatives next year.
Donovan said he and his staff are analyzing the advisory opinion issued
by Susan Elizabeth Rees, a senior official in the federal Department of
Labor's Office of Regulations and Interpretations.
Andrew McDonald, the governor's general counsel, declined to comment on
the opinion.
At issue in the opinion is whether opening the state plan to thousands
of private-sector workers would subject the state to the complex
requirements private plans face under ERISA, the Employee Retirement
Income Security Act.
"As a general matter, it would be historic," said state Comptroller
Kevin Lembo, a backer of the pooling concept. "As far as I can tell, I
can't find another state that has voluntarily given up" the exemption
from ERISA.
Some of the ERISA requirements would be no great burden to the state.
Lembo said the state already meets the law's administrative standards
on reporting and benefits design.
But Lembo said there are larger, more complex questions that arise from
the prospect of the state's having to meet ERISA rules.
What does it mean from a legal perspective when someone wants to sue
the state plan? Does the state get dragged into court by any member?
What are fiduciary responsibilities? Who is the fiduciary?
"We don't have those complications" outside of ERISA, Lembo said.
The federal government allows governmental plans to accept a small or
de minimis number of private-sector workers without jeopardizing its
ERISA exemption.
The state plan now covers 100,000 state employees and retirees, plus
their dependents, who are included in the 100,000 population number.
The potential population of nonprofit employees is 175,000.
The question Malloy posed focused on the nonprofits covered by the 2011
law, not the small businesses that would be eligible under the bill
proposed this year.
"The Department would view the participation of private nonprofit
employers in the Connecticut State Plan described in your letter as
more than de minimis, and, therefore, such participation would
adversely affect the status of the State Plan as governmental under
ERISA," Rees wrote.
Malloy did not estimate how many of the 175,000 nonprofit employees
might sign up for the state plan, nor did he ask if the state could
protect its ERISA exemption by capping participation by private
employees at a certain level.
Lembo, who was the state healthcare advocate before being elected
comptroller in 2010, said his responsibility as comptroller is to
protect the state plan, even though he believes pooling is good public
policy.
Under the 2011 law, Lembo has the discretion to refuse to open the
state plan to private employees if the ERISA exemption is jeopardized.
As a practical matter, the state-employees bargaining coalition or the
administration also could block it.
The comptroller's office oversees the state's health and retirement
plans, a major cost of state government.
"We're scrambling to launch the municipal piece. It's big. It's
complicated. As a theoretical matter, it's a good thing based on scale
and pricing," he said.
About a dozen municipalities are weighing the state's plan. One
positive effect, whether they sign up or not, is that the added
competition of the availability of the state plan appears to be driving
down the initial quotes offered by some private insurers, Lembo said.
"Just the specter of this thing is causing the carriers to sharpen
their pencils," Lembo said. One community saw a proposed 11 percent
increase reduced to 1.8 percent, he said. "That's a good impact."
Coming as the U.S. Supreme Court is reviewing the constitutionality of
the Affordable Care Act, both praised and reviled as Obamacare, the
advisory opinion is fuel for a continuing debate about the role of
government in health care in general, Lembo said.
"If the court upends the federal health care law, does more flexibility
get pushed to the states?" Lembo asked. "Even Republicans are back to
saying it should be state-based. Maybe we'll have more flexibility."
Insurance exchange board faces key policy decisions
Arielle
Levin Becker, CT MIRROR
January 19, 2012
There's still
nearly two years before the major pieces of federal health reform roll
out, but for the planners designing Connecticut's health insurance
exchange, one of the central pieces of the law, the time line is much
tighter.
The exchange
will serve as a marketplace for individuals and small businesses to buy
insurance beginning in 2014, and the board at work designing it has a
number of key decisions to make well before people start signing up for
coverage next year.
Among them:
How will the
exchange, a quasi-public agency expected to employ about three dozen
people, be funded?
Will insurance
plans sold on the exchange be required to cover all state-mandated
benefits, which could leave the state with added costs?
And in offering
coverage, should the exchange combine the individual and small group
insurance markets, or keep them separate -- a choice that could have
significant ramifications for the costs each group faces in buying
coverage?
Board members
discussed preliminary recommendations on those and other issues during
a meeting at the State Capital Thursday.
The meeting
also drew a silent protest from critics of the board, who wore
Band-Aids over their mouths and held letters that together read
"Consumers not represented." These critics have taken issue with the
appointment of three former insurance industry executives to the board
and have said the board does not represent consumers and small
businesses that will be most affected by the decisions it makes.
Defenders of the board say it's important to have people who understand
insurance, and point to board member Michael Devine, a small business
owner.
Combining
risk pools?
The exchange
will serve as a more tightly regulated insurance marketplace, through
which individuals and small businesses can buy health plans, most of
which are expected to be offered by commercial insurance carriers.
People earning below 400 percent of the poverty level who don't get
coverage through their jobs will get federal subsidies to buy coverage
on the exchange.
Under the
federal reform law, state exchanges have the option of combining the
risk pools for individuals and small groups, or keeping them separate.
The two markets are now separate in Connecticut, and subject to
different rules. An analysis by the consulting firm Mercer projected
that combining them would raise rates by 4 percent for the small group
market -- which typically serves small businesses -- while lowering
rates 2 percent for individuals.
Currently, the
people covered through the individual market as a whole are healthier
than those in the small group market, in part because rules governing
the individual market allow insurers to deny coverage to a person based
on health status, said Bob Carey, a consultant to the exchange. In the
small group market, by contrast, insurers must offer coverage,
regardless of the group's health status.
But Mercer
projected that under health reform, the individual market's risk pool
will become less healthy than the small group pool. That's because the
rules for the individual market will change in 2014, requiring
insurance carriers to sell coverage to anyone who seeks it, leading
people with medical conditions to join the risk pool.
In addition,
Carey said, the law allows people to avoid buying insurance if the cost
of doing so represents more than 8 percent of their income. People in
that category who are young and healthy might choose not to buy
insurance, he said, while those who are sicker would be more likely to
buy it anyway.
A draft
recommendation suggested that the state maintain separate small
business and individual insurance markets, at least at first. "It's not
as if in 2015 you can't decide to merge the pools," Carey told the
board. "You can merge the pools at any time."
Board members
did not vote on the recommendation but some expressed support for it.
What
benefits to cover?
One of the
matters that must be resolved most quickly is what benefits the plans
sold in the exchange must cover. Carey said the board should make a
decision this summer so it can be vetted by others by the fall and
leave insurance companies time to develop products to offer for the
exchange by late 2013.
Under the law,
plans sold in the exchange must cover a set of "essential health
benefits," which were initially expected to be defined by the federal
government.
But last month,
the federal government announced that it was giving states more
flexibility to define the benefits required for exchange plans. Instead
of issuing a single list of essential benefits, the U.S. Department of
Health and Human Services said it intended to let each state base its
definition of essential health benefits on a "benchmark" plan offered
in the state. States can select as the benchmark a plan that covers
small groups, state employees, federal employees or an HMO offered in
the state's commercial market.
The exchange
board's draft plan calls for creating a task force to examine the four
benchmark plan options, with representation from the exchange,
insurance department, healthcare advocate's office and executive and
legislative leaders.
In deciding
what benefits to require, the exchange will also have to address how to
handle state mandates. Connecticut mandates that insurance plans cover
dozens of benefits, some of which could go beyond what are considered
essential benefits. (The state mandates do not apply to self-insured
plans that are common among large employers, so if the exchange uses
the state employee plan, the federal employee plan or an HMO as the
benchmark, some state mandates might not be considered essential
benefits.)
Under the
federal reform law, the state could still require that exchange plans
cover all its mandated benefits, but Connecticut would have to pay the
cost of that coverage, at least, as of 2016. HHS has said states would
be allowed a "transition period" in 2014 and 2015 to coordinate state
benefit mandates; in that time, states would not likely be required to
pay the cost of those benefits.
How
to pay for it
The federal
government has provided grants to fund the development of the exchange
and will fund its first year of operation. But beginning in 2015, the
exchange must be financially self-sustaining.
There are
multiple ways to raise the funds needed. Massachusetts, which already
operates an exchange known as the Massachusetts Connector, funds it
through an assessment on premiums of plans sold through the exchange.
Mercer estimated that Connecticut's exchange would require an
assessment of about 2.8 percent of premiums on plans sold through the
exchange.
Utah, which
also has an exchange, charges a fixed fee for each insurance contract.
Carey said some
states developing their exchanges are considering broader-based
fundraising methods, such as assessments on all health insurance plans
sold in the state. Other options include charging fees to insurers who
sell health plans in Connecticut but don't offer plans in the exchange,
using the state's existing tax on insurance premiums, or selling
advertising, such as on the exchange's website.
Carey suggested
holding off on a decision until the board can get a better
understanding of the most appropriate way to fund the exchange.
Benjamin
Barnes, secretary of the Office of Policy and Management and a board
member, asked how the method of raising funds for the exchange could
affect insurers' decisions about whether to offer plans through the
exchange or what variety of plans to offer.
Since
participating in the exchange is voluntary for both consumers and
insurers, Carey said it's a major consideration. He noted that a
significant assessment on insurers for participating could limit their
willingness to sell plans through the exchange, but said that insurers
could find that the exchange can save them money if it takes on
functions insurers would otherwise do, like handling billing.
Health
Care Law Will Let States Tailor Benefits
By ROBERT
PEAR, NYTIMES
December
16, 2011
WASHINGTON — In
a major surprise on the politically charged new health care law, the
Obama administration said Friday that it would not define a single
uniform set of “essential health benefits” that must be provided by
insurers for tens of millions of Americans. Instead, it will allow each
state to specify the benefits within broad categories.
The move would
allow significant variations in benefits from state to state, much like
the current differences in state Medicaid programs and the Children’s
Health Insurance Program.
By giving
states the discretion to specify essential benefits, the Obama
administration sought to deflect one of the most powerful arguments
made by Republican critics of President Obama’s health care overhaul —
that it was imposing a rigid, bureaucrat-controlled health system on
Americans and threatening the quality of care. Opponents say that the
federal government is forcing a one-size-fits-all standard for health
insurance and usurping state authority to regulate the industry.
This criticism
has inspired legal challenges to the new law — with the Supreme Court
set to decide next year whether the government can require Americans to
buy health insurance — and helps explain why public opinion of the law
remains deeply divided.
The law is
looming as a central issue in the 2012 presidential race, with
Republican presidential candidates being evaluated on the strength of
their opposition to it. The announcement by the administration follows
its decision this year to jettison a program created in the law to
provide long-term care insurance, a move that disappointed liberal
backers of the program championed by the late Senator Edward M. Kennedy.
The action
Friday prompted questions among supporters of the new health care law.
Prof. Timothy S. Jost, an expert on health law at Washington and Lee
University, said, “The new bulletin perpetuates uncertainty about what
benefits an insurer will be required to cover under the Affordable Care
Act.” From the consumer’s point of view, Professor Jost added, “I wish
the Department of Health and Human Services had signaled that there
would be more uniformity and less flexibility.”
Chris Jacobs, a
health policy analyst for Senate Republicans, said the new policy
“gives states the flexibility to impose more benefit mandates, not
fewer,” and would lead to higher insurance premiums, contrary to what
Mr. Obama promised in the 2008 campaign.
The new law
lists 10 categories of “essential health benefits” that must be
provided by insurance offered in the individual and small-group
markets, starting in January 2014. These include preventive care,
emergency services, maternity care, hospital and doctors’ services, and
prescription drugs.
Kathleen
Sebelius, the secretary of health and human services, had been expected
to provide details of what services and benefits must be provided in
each category. Instead, in an insurance bulletin issued Friday, Ms.
Sebelius said the federal government would respect the states’ role,
giving them “the flexibility to design coverage options that meet their
unique needs.”
Under this
approach, each state would designate an existing health insurance plan
as a benchmark. The benefits provided by that plan would be deemed
essential, and all insurers would have to provide benefits of the same
or greater value. Plans could modify coverage within a benefit category
so long as they did not reduce the value of coverage.
Each state
would choose one of the following health insurance plans as a benchmark:
¶ One of
the three largest small-group plans in the state.
¶ One of
the three largest health plans for state employees.
¶ One of
the three largest national health insurance options for federal
employees.
¶ The
largest health maintenance organization operating in the state’s
commercial insurance market.
While working
on health care legislation in 2009 and 2010, Congress spent many hours
debating how to balance the goals of comprehensive benefits and
affordable coverage.
Sherry A.
Glied, an assistant secretary of health and human services, said the
administration’s approach “builds off the experience of today’s
marketplace and will minimize disruption to it.”
Steven B.
Larsen, deputy administrator of the federal Centers for Medicare and
Medicaid Services, said, “The state is always in control of what the
essential benefits package is in that state.”
In recent
months, federal health officials have taken a number of steps that
could help inoculate Mr. Obama against charges that he was foisting a
rigid, inflexible model of health care on the nation.
Several states
have received temporary waivers from tough new federal standards that
require insurers to spend more of each premium dollar for the benefit
of consumers. Federal officials have also provided temporary exemptions
from some provisions of the law for some employers and labor unions
offering bare-bones coverage.
The new law
says that the scope of essential health benefits must be “equal to the
scope of benefits provided under a typical employer plan.” But the law
itself specifically requires some benefits not widely available in
employer-sponsored health plans, like “habilitative services” for
people with conditions like autism or cerebral palsy.
Under the new
law, each state is supposed to have an insurance exchange or
marketplace where consumers can compare options and buy insurance.
Health plans must offer the essential benefits, regardless of whether
the coverage is sold inside or outside the exchange.
The government
will offer subsidies to help low-income people buy insurance through
exchanges. The subsidies will help cover the cost of essential
benefits. States can require insurers to provide additional benefits,
but states will have to pay much of the extra cost.
The law also
says that the definition of essential benefits must not “discriminate
against individuals because of their age, disability or expected length
of life.”
Sara Rosenbaum,
a professor of health law and policy at George Washington University,
said the new bulletin “does not offer any guidance on this crucial part
of the law.”
What
about the homeless?
Study finds confusion about medical home concept
Arielle
Levin Becker
October 12, 2011
State officials
are developing plans for Medicaid recipients to be cared for in
"medical homes" beginning in January, but they might want to start with
a marketing campaign: In focus groups conducted on behalf of the
Department of Social Services, many people said they were unfamiliar
with the concept--or worse.
Upon hearing
the term "medical home," some people said it sounded like a place you
go to die, said Meryl Price, a consultant working with DSS to design
the medical home program. Other participants said it sounded like an
institution, a place where you go and don't get out.
"That was a
pretty intense finding," Price said Wednesday during a meeting on the
medical home plan.
The focus
groups were meant to gather information from Medicaid recipients that
would inform the design of the medical home program. Although
participants were unfamiliar with medical homes, many of the problems
they identified--a lack of coordination between primary care providers
and specialists, long wait times for services, not being given test
results, even when they ask--are things the medical home model aims to
address.
Despite what
the name might imply, a medical home is not a nursing home or
institution; it's not a physical location at all. Instead, it's a way
of running a medical practice in which the health care providers take a
more active role in meeting patients' needs. There's no single
definition, but the concept involves a medical practice serving as a
patient's regular source of care--hence the word "home"--and
coordinating the care patients get from specialists. To ensure that
patients can access care when they need it, many practices that serve
as medical homes offer extended hours or give patients the option of
communicating with providers by telephone or email.
The model is
frequently called a patient centered medical home, but DSS is calling
its program a person centered medical home in recognition of people
with disabilities who are sensitive to the term "patient." Although
most health care providers in Connecticut currently don't meet the
medical home standards set by multiple accrediting groups, DSS hopes
the model will become common enough that all Medicaid recipients will
have access to a medical home within a few years.
The focus
groups included people recruited by community organizations and DSS,
and included a range of Medicaid clients--low-income adults,
adolescents, people with disabilities, pregnant women, mothers of
newborns, parents of children with special health care needs, and
people with behavioral health needs.
Most
participants reported that they had had a relationship with a primary
care provider for more than a year, and that their doctor treated them
like a "whole person," not a patient or a disease.
But
participants raised concerns about accessing specialists, care
coordination and the way they get treated when they go to the doctor.
People in the
focus groups said their health care providers should be more proactive
in ensuring that they get all the information they need, and said they
need more help identifying specialists that accept Medicaid and in
arranging transportation to get there. Many also reported coordination
problems between their primary care provider and specialists, with gaps
including being asked to repeat information, having trouble getting
their medical records, being asked for details about their medical
conditions that might not be clear to people who are not health care
professionals, and variation in treatment between providers.
Many
participants also described less-than-ideal experiences visiting their
doctors. Medicaid clients believe that the front desk staff at their
doctors' offices are rude, and attribute it to discrimination, Price
said.
"People
perceived the problem as more with the front desk staff and not the
doctors and the rest of the staff," she said.
Participants
were also bothered by doctors interrupting them or leaving the room,
and by front desk staff dismissing their concerns. "I think that
happens to everybody everywhere," Price added.
Many focus
group participants said they felt they had faced discrimination because
they are covered by public insurance, getting rude and disrespectful
treatment from staff and poorer treatment from their doctors.
Price noted
that one participant, referring to the state-run Charter Oak Health
Plan, said, "When they find out you have Charter Oak or whatever, your
appointment is six months out."
Participants
also reported that they felt they were discriminated against or had
received poor treatment from office staff because of their
socioeconomic status or their race. Participants with behavioral health
needs reported discrimination or poor treatment and said providers
dismissed their opinions or concerns after learning about their
psychiatric disability.
Price made
several recommendations based on the finding, pointing to the need for
practices to increase efficiency and the desire among participants to
do business with their doctors by phone. Patients also need better
access to specialty care and to appointments on short notice.
She noted that
DSS is embarking on a major project with the Connecticut Health
Foundation to address health disparities, and suggested looking for
ways to improve communication between patients and providers, including
sensitivity training for providers and office staff, and making sure
providers explain things in layman's terms.
Price also
pointed to the need to make sure that consumers are educated about what
a medical home is, and to use the term consistently. She noted that
some focus group participants have children with special health care
needs whose care is delivered in medical home practices, but even they
were not familiar with the term. Price asked what they thought of their
medical home and they replied, "What's that?"
Alicia Woodsby,
public policy director of the National Alliance on Mental Illness,
Connecticut, said she was struck by the responses. She said it hadn't
occurred to her that people would think medical homes were
institutions, but that it made sense, particularly for people with
disabilities. It's important to work on the marketing of the concept,
she said.
"People might
not think this is a great thing if we don't work on that," she said.
Health insurance exchange board searching for CEO, quickly
CT MIRROR
Arielle Levin
Becker
Oct. 11, 2011
Wanted:
Educated, experienced senior-level manager to develop and run a key
piece of health care reform. Must pass muster with the governor and,
preferably, be willing to start work early next year.
Those are the
basic qualifications to become the first chief executive officer of the
state's health insurance exchange, a marketplace for individuals and
small businesses to buy health insurance that will launch by 2014.
Legislation this year established the exchange as a quasi-public agency.
The job is
expected to be posted in the next couple days, seeking candidates with
advanced degrees and at least five years of senior-level management
experience. The board that oversees the exchange will be charged with
narrowing down the candidates, first through a smaller committee of
board members that will conduct two rounds of interviews, and then the
full board, which will hold the final interviews and recommend three
candidates to Gov. Dannel P. Malloy. Malloy will then select the CEO.
The schedule
for picking the CEO is expected to be tight. A timeline for the search
process calls for having the interviews in December and a CEO in place
in February.
During a
special meeting of the exchange board Tuesday, state Healthcare
Advocate Victoria Veltri, who co-chairs the search committee, praised
the work done so far to identify the qualities needed in a CEO. "The
fact is, and I think it's really important to stress this, that I
believe this description will get us to somebody who's not only
extremely well qualified from an insurance standpoint in understanding
insurance processes, but it also is consumer-driven," she said.
Office of
Policy and Management Secretary Benjamin Barnes, the search committee
co-chair, said he shared Veltri's optimism about the process, but
warned that recruiting someone as critical as the exchange CEO is an
uncertain process that might not produce options the board likes in the
time allotted. If the search doesn't attract what members considers to
be the right kind of applicants, Barnes said, he and other search
committee members might come before the full board and ask for a change
in direction.
SustiNet
cabinet starts work Monday
CT MIRROR
Arielle Levin
Becker
11 September,
2011
The
SustiNet Health Care Cabinet, an advisory board created as part of a
compromise on the proposed SustiNet state-run health plan, will hold
its first meeting Monday.
The cabinet
will be led by Lt. Gov. Nancy Wyman and includes 16 members appointed
by Gov. Dannel P. Malloy, legislative leaders and the board that
developed the SustiNet proposal. Eleven members of Malloy's
administration are on the cabinet as ex-officio members.
SustiNet was
originally proposed as a state-run health plan that would include state
employees and Medicaid recipients and would be available to small
businesses, nonprofits, municipalities and, eventually, anyone in the
state. That plan did not pass, but a compromise that became law this
year created the cabinet to make health care policy recommendations,
including developing a business plan for alternatives to private
insurance.
The compromise
also allows municipalities and some nonprofits to buy health insurance
through the state, and established an Office of Health Reform and
Innovation to coordinate state and federal reform efforts.
The cabinet is
charged with examining several health policy issues, including ways to
ensure an adequate health care workforce, identifying gaps and other
issues created by federal health reform, the possibility of offering
state coverage to people who might otherwise get federal subsidies to
buy insurance, and advising the governor on health policy matters.
Malloy
appointed family physician Dr. Tory Westbrook, Connecticut Health
Foundation President and CEO Patricia Baker, Charter Oak Health Center
CEO Alfreda Turner, health insurance broker Phil Boyle and Jeffrey
Lucht.
Senate
President Pro Tempore Donald E. Williams Jr., D-Brooklyn, picked
Margaret Smith, a dentist. Senate Majority Leader Martin M. Looney,
D-New Haven, selected Robert Tessier, the executive director of the
Connecticut Coalition of Taft-Hartley Health Funds, which represents
health plans for unionized workers.
House Speaker
Christopher G. Donovan, D-Meriden, picked Frances Padilla, vice
president for program, policy and administration at the Universal
Health Care Foundation of Connecticut, which proposed SustiNet. House
Majority Leader J. Brendan Sharkey, D-Hamden, appointed Dr. William
Handelman, a Torrington physician and a former president of the
Connecticut State Medical Society.
The two
Republicans charged with making appointments, Senate Minority Leader
John McKinney of Fairfield and House Minority Leader Lawrence F. Cafero
Jr. of Norwalk, both plan to make appointments but have not done so
yet. Cafero was charged by the statute with appointing a representative
of the health information technology industry, while McKinney was
assigned to appoint an advanced practice registered nurse in active
practice.
The board of
the SustiNet Health Partnership, which developed the SustiNet plan,
appointed Ellen Andrews, executive director of the Connecticut Health
Policy Project; the Rev. Bonita Grubbs, who served on the SustiNet
board; Dr. Steven D. Hanks, executive vice president and chief medical
officer of The Hospital of Central Connecticut; Linda St. Peter, a
realtor who was active in promoting SustiNet; and Joanne Walsh,
president and CEO of Constellation Health Services.
Ex-officio
voting members are State Healthcare Advocate Victoria Veltri;
Department of Public Health Commissioner Dr. Jewel Mullen; Comptroller
Kevin Lembo; Department of Social Services Commissioner Roderick L.
Bremby; Benjamin Barnes, Malloy's budget director; and Jeannette
DeJesús, special advisor to the governor for health care reform
and head of the Office of Health Reform and Innovation.
Ex-officio
members who will not vote are Department of Mental Health and Addiction
Services Commissioner Patricia Rehmer; Department of Children and
Families Commissioner Joette Katz; Department of Developmental Services
Commissioner Terrence Macy; Insurance Commissioner Thomas B. Leonardi;
and Deborah Heinrich, the liaison to the governor for nonprofits.
Report:
There's no consensus on what constitutes 'medical homes'
Arielle
Levin Becker, CT MIRROR
August 16, 2011
The number of
physician practices officially considered "patient centered medical
homes" has grown dramatically in the past six months, helped along when
the state's largest group of primary care practices earned the
designation last week.
The
proliferation mirrors a widespread national push toward the model,
which encourages care coordination and making it easier for patients to
access care. Private insurers are sponsoring pilots to test the model,
and it's being used in state Medicaid programs, Medicare, and the
military's TRICARE health plan, which has a goal of having 2 million
beneficiaries enrolled in medical homes by the end of the year.
Connecticut has
a medical home pilot program for state employees and retirees, and is
developing plans to encourage health care providers to serve as medical
homes for Medicaid patients. Six months ago, just 21 practices and
clinicians in the state had been recognized as medical homes by the
National Committee for Quality Assurance, one of several accrediting
organizations. After the 70 practices of ProHealth Physicians achieved
recognition last week, the number was up to 412.
But despite the
broad-based support for the concept, there is no broad agreement on
what a medical practice must do to be considered a medical home, and no
solid evidence about what pieces are required to improve care and
reduce costs, a report released this month warned.
"The medical
home model does have the potential to transform the way health care is
delivered--but potential is the key word here," wrote the report's
authors, Dr. Robert A. Berenson, Kelly J. Devers and Rachel A. Burton
of the Urban Institute. "The danger posed by the current enthusiasm for
the concept is that it could lead to the adoption of unproven models on
a wide scale nationwide before evaluations of existing pilots can show
us what works in what situations, and what levels of reimbursement are
needed to get providers to engage in all the new activities encompassed
by the medical home model."
What
makes a medical home?
There's no
single definition of a medical home, but the concept centers on making
medical practices more attuned to patients' needs. Doing that includes
making it easier to access care by offering extended hours or
communicating by e-mail. It also involves more actively coordinating
the care a patient receives, including from other providers. In
exchange, the practices receive additional payments, although the
methods for doing so vary.
The report
noted that there are multiple definitions of medical homes, and several
groups that offer medical home accreditation or recognition.
Differences in the standards include whether electronic health records
are needed to coordinate patient care, how quickly patient phone calls
must be returned after hours, and how quality should be measured.
"Part of the
reason for the lack of agreement on how to define the medical home is
that there is not yet rigorous evidence available about which practice
capabilities and processes actually improve the quality of care and
reduce costs--though evidence does support the use of some of them, and
there is evidence of positive benefits associated with primary care
more generally," said the report, which was funded by the Robert Wood
Johnson Foundation.
In addition to
the need for more rigorous research on the model, the report said it
will be important to determine whether the outcomes that early adopters
have had can be replicated by other primary care practices that might
not be as advanced. It also cited research suggesting that small
practices would have to engage in "disruptive innovation" to become
medical homes.
"Until payment
incentives to do so are made permanent, practices may be unlikely to
commit to that level of disruption for an unknown fate," it said.
Proponents of
the medical home model in Connecticut said they're confident in the
concept's promise, in part because it reflects common sense ways to
deliver health care.
"Medical home
is really reinventing primary care and what primary care has
traditionally done for decades, which is try to be there to coordinate
all the health care needs that people would have," said Dr. Charles L.
H. Staub, chairman of ProHealth's board. "In the old days, people would
go see their general practitioner, who would send them to specialists
but always kind of be there in the background coordinating things."
The model, he
said, upgrades the infrastructure used to support what doctors have
long done in their offices. In recent years, ProHealth practices, which
treat 350,000 patients, began using electronic health records, and the
organization opened extended hours facilities so patients could have
access to a primary care doctor after hours, possibly avoiding
emergency room visits.
Sheldon
Toubman, an attorney with New Haven Legal Assistance and a longtime
proponent of medical homes, said he supports the model because
"everybody needs care coordination, whether they have serious multiple
chronic conditions or they're a healthy child."
"Care
coordination is still very important and in the end, it's going to
bring better quality and be more efficient," he said.
But Toubman
said it's important to make sure that medical homes don't exist in name
only, and that care coordination and other services are actually
provided. He said the method chosen to provide the additional payments
is critical, because some that are used--giving providers a larger
amount of money to cover both medical care and medical home activities,
or giving them a portion of the savings the model generates--could give
health care providers incentives to deny care.
The
"hub" of patient care
The Medicaid
medical home program is still being developed, and officials are facing
many of the questions addressed in the report: What set of standards
should be used for medical homes? How should they be paid? And how can
the state encourage providers, particularly the state's many small
practices, to take the costly and time-consuming steps to become a
medical home?
State
Comptroller Kevin Lembo, whose office is overseeing the medical home
pilot program for state employees and retirees and their families, said
his confidence in the model comes in part from research on the elements
of it and the experiences of other places that have employed the
concept. He also cited its design of having the primary care provider
as the "hub" of patient care and having providers available beyond the
standard workday so patients could more easily access primary care.
"While I
wouldn't say that there is a robust body of research, that is one of
the challenges of being ahead of the curve," he said.
The pilot
program for state employees and retirees grew out of discussions by a
joint committee of the state and employee union representatives. They
noticed from claims data that state employees and retirees were
underusing primary care and overusing specialists and hospitals,
including emergency rooms.
In the pilot,
health care providers that are recognized by NCQA as medical homes--in
at least the second of three levels--are eligible for bonus payments as
well as additional payments based on performance on measures including
reducing preventable emergency room visits, giving children and teens
proper vaccinations and well care visits, getting patients with high
blood pressure and diabetes to target levels, and educating patients on
medical conditions they have.
So far,
ProHealth, which treats about 30,000 people covered by the state
employee and retiree health plan, is the only health care provider
participating, although others could be added.
Lembo said
decisions about the pilot were based on "lots of research, but not
research of the thing as a whole."
There's much to
be excited about, Lembo said, but he added that he doesn't want to
oversell it. The best thing, he said, is that the pilot will produce
the data needed to measure whether the medical home model makes a
difference.
"And there is
no shame in saying at the end of a number of years, 'Maybe we're
wrong,'" he said. "The shame is really in just sitting around knowing
the present system is not giving us exactly what we need and doing
nothing to try to make a difference."
Connecticut Will Soon Pick A Board To Oversee State Health Insurance
Exchange
Hartford
Courant
By Matthew
Sturdevant
July 15, 2011
4:17 PM
Connecticut
will soon pick a board and staff members to oversee the development of
a state health insurance exchange, where individuals and small
businesses will be able to compare health plans online or by phone
starting in 2014.
The exchange is
federally mandated as part of healthcare reform and must be available
to consumers by Jan. 1, 2014. U.S. Department of Health and Human
Services offered a framework for developing the exchanges, which will
be a marketplace for health plans first sold to individuals, and, in
later years, to small businesses.
Connecticut is
one of 49 states and Washington D.C. that accepted grants to plan and
develop a state-based health exchange. In September, Connecticut
received a one-year planning grant of $996,848 from the federal
government. The state is applying for $6.6 million to pay for a second
phase of developing the exchange.
"In the past
six months we have taken many critical steps in development of the
exchange and Connecticut is in a good position," said Jeannette
DeJesús, special advisor to Gov. Dannel P. Malloy on federal
healthcare reform. "We have enacted legislation establishing
Connecticut's exchange as a quasi-public agency and have begun working
with multiple stakeholders to address key policy questions. With the
release of these proposed rules, Connecticut can continue moving
steadily forward."
On July 1,
Malloy signed legislation creating the Connecticut Health Insurance
Exchange, a quasi-public agency that will fulfill the requirement of
federal health reform. The next step in Connecticut will be to select
board members. The 14-person board includes 11 voting members -- two
appointed by the governor, six appointed by the legislature, the
Special Advisor to the Governor on Health Care Reform, the secretary of
Connecticut's Office of Policy and Management and the Connecticut
Department of Social Services commissioner.
The board also
includes three non-voting members -- the state insurance commissioner,
the state healthcare advocate and the Department of Public Health
commissioner.
U.S. Health and
Human Services Secretary Kathleen Sebelius spoke to reporters this week
as the federal guidelines were released. She mentioned the high price
of health insurance available to small business owners.
"A business
owner I recently met in Connecticut put it very simply," Sebelius said.
"He said, 'I can afford to pay salaries, or afford to pay health
insurance, but I can't afford both.' That's not right; it's not fair."
All the
exchanges combined are estimated to trade $60 billion in health
insurance premiums during the first year and nearly $200 billion by
2019, according to research by PricewaterhouseCoopers U.S. Health
Research Institute.
Karen Ignagni,
president of the trade group America's Health Insurance Plans, said,
"Exchanges can supplement existing channels for purchasing coverage but
should not be consumers' sole option for obtaining health care
coverage. The establishment of exchanges should not cause consumers to
lose their current coverage if they are satisfied with it."
Controversial 'provider tax' being scrutinzed in debt talks
Deirdre
Shesgreen, CT MIRROR
July 14, 2011
WASHINGTON--One
of the most contentious elements of Gov. Dannel P. Malloy's
recently-passed budget was a new tax on Connecticut hospitals, which
won legislative approval despite fierce opposition from the industry.
Now, policymakers in Washington may restrict the ability of states to
enact such taxes--and they could even force Connecticut to scale back
or eventually repeal its new levy.
So-called
"provider taxes" are one item under discussion in the
increasingly-fraught debt negotiations between the White House and
congressional Republicans.
Critics say
that states use provider taxes as a "gimmick" to raise revenue for
their share of Medicaid spending--and to generate increased federal
matching funds in the process. And they say it's time to stop states
from "gaming" the system by imposing taxes aimed mainly at snagging
more federal dollars.
States say the
provider taxes are a legitimate way to raise desperately needed revenue
to helps pay for the exploding costs of Medicaid, a joint state-federal
health insurance program for the poor. Medicaid is often one of the top
three ticket items in state budgets, and the program's rolls have
swelled with the recession.
As President
Barack Obama and House and Senate leaders look for ways to trim federal
spending, provider taxes have become a target. The shape of any final
budget-and-debt agreement--if there even is one--is still murky at
best. But the scope of state provider taxes could still be an issue
even if a broader debt deal falls apart.
The way it
works is this: States impose a levy on hospitals, nursing homes, or
other health care providers, and then they devote that funding stream
to Medicaid payments that flow back to those providers.
As long as the
taxes are broad based and meet other federal requirements, states can
claim federal matching funds when they dole the money back out to
providers as Medicaid payments.
In Connecticut,
the state legislature approved a two-tiered tax on hospitals, with a
rate of 5.5 percent for inpatient services and 3.8 percent for
outpatient services. In all, that will raise nearly $350 million a year
in revenue. The state will redistribute more than that, almost $400
million, back to the hospitals to pay the cost of caring for Medicaid
patients. In the process, Connecticut's new tax will generate as much
as $150 million in federal matching funds.
"It improves
the fairness of our system of paying for health care for poor people,"
said Ben Barnes, Malloy's secretary of the Office of Policy and
Management. "And it makes health care for poor people more affordable
to states." Barnes conceded that provider taxes are also, as he put it,
as "a grant maximization strategy." But, he added, "it's not a like a
trick or an illegal strategy."
To be sure,
this practice has long been sanctioned by Congress and the federal
Center for Medicare and Medicaid Services (CMS). Current federal law
allows states to impose a tax of up to 5.5 percent on providers that
serve Medicaid patients. And currently, 46 states, plus the District of
Columbia, have such provider taxes on their books.
Connecticut
already had a 5.5 percent provider tax on nursing homes. Barnes noted
that the one just enacted on hospitals was "quite painful" to get
passed because of resistance from the industry. Hospitals opposed the
tax because some will lose significant revenue in the redistribution
process, and the tax was coupled with an $83 million cut to hospitals
for the uncompensated care they provide to the uninsured.
In Washington,
the budget-and-debt talks are all about pain. The idea of nixing
provider taxes to save federal money first popped up in the final
report issued by President Obama's fiscal commission.
The commission
labeled these taxes a "gimmick" used to generate federal funds. And
others have said they essentially allow a state to circumvent its share
of Medicaid costs by borrowing money from providers. "Many states
finance a portion of their Medicaid spending by imposing taxes on the
very same health care providers who are paid by the Medicaid program,
increasing payments to those providers by the same amount and then
using that additional 'spending' to increase their federal match," the
fiscal commission said in its final report. "We recommend restricting
and eventually eliminating this practice."
The
commission's recommendation is now one item on the table in the debt
negotiations, as Obama and congressional leaders seek to craft a deal
that will reduce federal spending in exchange for an increasing in the
nation's borrowing capacity. Nixing these taxes could save the Medicaid
program $5 billion in 2015 and $44 billion through 2020, according to
the fiscal commission's estimates.
It's unclear
how far negotiators have proposed to go on these taxes-whether they
would trim provider taxes or kill them outright. But in his 2012 budget
proposal, Obama called for the former-phasing down provider taxes over
three years, starting in 2015, to 3.5 percent in 2017-rather than
eliminating them entirely.
Critics don't
dispute the argument that eliminating these taxes would save Medicaid
money. But they say it would do so at a huge cost to states and
Medicaid patients.
Judith Solomon,
vice president for health policy at the Center on Budget and Policy
Priorities, a left-leaning research group, says cutting provider taxes
will reduce federal Medicaid costs because states like Connecticut
won't be able to find a replacement revenue stream for Medicaid. States
will then cut Medicaid services and that will lower the federal
matching contributions from Washington.
Stephen Frayne,
a lobbyist for the Connecticut Hospital Association, is no fan of the
tax. But he said he's not itching for it to be repealed either. "We've
had that discussion, and it is what it is."
Frayne
expressed more concern about how it would impact the state's finances.
"The state would lose $150 million in new federal matching dollars," he
noted. "And I would suspect that they would try to look for ways to
recover that."
Indeed, Barnes
said that if Connecticut was forced to eliminate or scale back the tax,
"there are a couple different ways we could deal with it, but all of
them would be calamitous to the state." The state can't afford to lose
the revenue stream, hospitals can't afford to pay the tax without the
redistribution mechanism, and Medicaid patients are "not in a position
to absorb" any kind of hit either.
So would Malloy
and other governors around the country revolt against such a proposal?
"Yes,"
Barnes said.
Last-minute windfall pops up in retiree health care account
Keith
M. Phaneuf, CT MIRROR
May 27, 2011
It almost sounds too good to be true: State budget officials, who
already saw revenues surge by nearly $400 million over the past month,
now say anticipated savings in retired worker health care costs have
grown by some $100 million in the same period.
And though Comptroller Kevin P. Lembo said his office was somewhat
conservative in assessing the account that it controls, he added that a
number of factors made the $117.4 million savings--equal to nearly 20
percent of the entire annual allocation--difficult to predict before
now.
"As soon as you start to see a positive development you can't just jump
up and say, 'We have some extra money here. What do you want to do with
it?'" said Lembo, who inherited the retiree health care account in
mid-fiscal year when he began his first term as comptroller on Jan. 5.
"Since then I've looked at this on a regular basis, but there were a
lot of factors."
One is that state government converted its health insurance coverage,
both for active and retired workers, to a self-insured program. Lembo
said he believes the previous legislature and former Gov. M. Jodi
Rell's administration may have underestimated the savings in shifting
from paying private insurance companies to manage the fiscal risk,
particularly involving the older, generally sicker retired population
Lembo said the reduced spending also results from higher-than-expected
federal cost-sharing for prescription drug coverage and increased
patient use of generic pharmaceuticals.
But the single-largest and most volatile factor, Lembo said, simply
involves a retiree population that has been healthier than in most
years. A 2009 retirement incentive program that coaxed 3,800 senior
state workers to retire at an earlier age than they might have
otherwise could have contributed to that.
Though Lembo didn't provide specific numbers Thursday, he said the
lower utilization totals means officials have to be cautious in
deciding what this year's savings means for the upcoming fiscal year,
which begins July 1.
"I think we can responsibly amend the projected need for the new fiscal
year," Lembo said, adding his office is preparing new cost estimates
for the legislature and administration. "But we have to be careful not
to short the account based on one year's experience."
The $117 million in retiree health savings is what is referred to as a
budget "lapse"--anticipated spending reductions that aren't directly
tied to specific budget cuts. The current year budget included $304
million in lapses; those anticipated savings have grown to $419 million
as of the latest estimate.
For the first several months of the past fiscal year, the Executive
Branch's chief budget agency, the Office of Policy and
Management--using figures provided by the comptroller's
office--projected no savings in the retiree health care account. It was
not until December that OPM projected $1.8 million in reduced spending,
a figure that gradually grew to $16.9 million in April before
skyrocketing this month.
Malloy's budget director, OPM Secretary Benjamin Barnes, said he also
believes a "significant portion" of that $117 million savings also
should be projected for the upcoming fiscal year, though he declined to
speculate on just how much on Thursday.
"This is the first time state government has been operating a
self-insured program," Barnes said, noting the transition typically
creates a one-time savings as the state is relieved of payments to
private insurance companies for a few month before patient claims for
benefits start to come in. "That can affect the numbers. I can
appreciate the comptroller's office not feeling certain about (the
savings) until they have enough information."
The $117 million in savings for this fiscal year, which helped push the
projected state surplus to nearly $680 million, is expected to be used
to cancel nearly $650 million in planned borrowing. Those bonds would
have been repaid with eight years of surcharges on residential and
business electricity bills.
But Deputy House Minority Leader Vincent Candelora, R-North Branford,
former ranking member on the tax-writing Finance, Revenue and Bonding
Committee, said the windfall is just one more example of why the $1.5
billion state tax hike built into next year's state budget by Gov.
Dannel P. Malloy and his fellow Democrats in the legislative majority
is excessive.
"This kind of lapse does shock me," he said. "We are squirreling away a
lot of money."
The $19.83 billion budget approved for next fiscal year has a built in
surplus of $369 million. That surplus, plus any portion of the health
account savings that can be projected for next year, could be used to
repeal some of the tax hikes, Candelora argued.
"We certainly should be looking at where we can make reductions," he
said.
But Malloy and the legislature also have a hole to fill in the new
budget. The tentative union concession deal announced earlier this
month is projected to save $700 million in 2011-12, about $300 million
less than the savings target built into the budget.
Agencies welcome
chance to join state health plan--at the right price
Arielle
Levin Becker, CT MIRROR
May 5, 2011
State leaders
are poised to allow nonprofits to buy insurance through
the state employee health plan, and the agency Patrick J. Johnson Jr.
runs is in many ways an ideal candidate.
The agency, Oak
Hill, serves people with disabilities and has faced
double-digit premium hikes in recent years. Its benefits package is
considered high-end for nonprofits, Johnson says, and its cost--about
$7,000 for an individual and $19,000 for family coverage--is close to
the average cost of a state employee plan.
But it won't be
for long.
"We can't
afford to continue what we're doing," Johnson said. "So we're going to
be cutting back."
Many nonprofit
leaders are in a similar position. They have lobbied for
the chance to buy their health insurance through the state employee and
retiree plan, hoping that it would give them another coverage option.
Being part of a larger risk pool could remove the fluctuations in cost
that can occur when even a few employees in a small pool have major
medical problems, they say.
But many
nonprofits pay less than the state employee plan costs--$5,320
to $9,928 for an individual and $14,364 to $26,807 for a family--and
don't have the money to pay more. The nonprofits that would be allowed
to buy into the state employee pool are those that contract with the
state, and their state funding has been flat for the past three fiscal
years, with no increase expected for the next two.
"I can't
imagine how many nonprofits would be able to buy in at the
full cost of what currently is being paid for state employees. I don't
know how people would do that," said Gary Steck, CEO of Wellpath, which
provides mental health services to children and families. "We love the
level of care and the depth and richness of the benefits, but I just
think it would be impossible."
The details of
the plan, part of a compromise on the proposed SustiNet
state-run health plan, are still being worked out. Under the agreement,
municipalities would be allowed to buy into the state plan beginning
July 1, and the nonprofits would be allowed in a year later.
One possible
option is to offer multiple plans, allowing nonprofits to
buy in at lower rates. Gov. Dannel P. Malloy endorsed that concept when
running for governor, citing the rape crisis center his wife runs.
"They'd never
be able to afford the standard state employee package,"
he said during an August interview. "So giving a not-for-profit like
that access to that pool doesn't do them a lot of good. So we really
have to think about this outside the box."
This week,
Malloy spokeswoman Colleen Flanagan said the governor
supports eventually offering multiple plans through the state employee
pool so nonprofits could have options beyond the existing plan.
Malloy's budget
director, Ben Barnes, said last month that there could
be alternative plans offered under the agreement, and acknowledged that
doing so could be necessary for some communities to buy in.
"The more you
do that, though, you dilute the bulk purchasing qualities
of this," Barnes said. "So I think that's something that the
comptroller's going to have to work out."
Terry
Edelstein, president and CEO of the Connecticut Community
Providers Association, which represents nonprofits that contract with
the state and supports the pooling concept, described the chance to buy
into the state employee plan as "one of a number of options" that would
be available to the agencies.
"It still has
to be affordable," she said.
Although the
state employee plan costs would not be feasible for every
nonprofit, Liza Andrews, public policy director for the Connecticut
Association of Nonprofits, cheered the agreement as a way to help some.
"We're excited
that it's an option," she said. Referring to lawmakers,
she said, "They're going to hear from nonprofits who aren't going to
benefit from it. There are a lot out there who will."
Several
nonprofit leaders said they liked the idea of being able to buy
into the state employee plan. But they said their participation would
depend on the cost. The average cost of a state employee plan is $7,009
for an individual and $18,925 for a family, according to the
legislature's Office of Fiscal Analysis.
Like many
nonprofits, Wellpath, which has 195 employees, has struggled
to negotiate insurance rates. For a high-deductible plan, the agency
pays $4,700 for individuals and $15,500 for families.
"The overall
concept of us collectively buying is a good one," Steck
said. "But only if the thing that we're purchasing is cost-effective."
Barry M. Simon,
executive director and CEO of Gilead Community
Services, would like to buy in to the state employee plan if possible.
Gilead, which provides housing, support services and treatment to
people with mental illness, has 200 employees and has faced health
insurance premium increases between 12 and 30 percent in recent years.
Simon sees buying into the state employee plan as a way to minimize the
yearly increases.
"If it's at all
viable or within reach, then it would be great to get in," he said.
Because the
agency gets 95 percent of its funding from the state, it
has had to cut back on health benefits and cut staff to absorb the
premium hikes. Gilead also changes carriers frequently, Simon said.
The agency
switched to a high-deductible plan last year, which helped
reduce a premium increase from 30 percent to about 10 percent, Simon
said. For an individual, the coverage costs $5,700. An employee and one
other person costs $11,900, and family coverage costs $16,100.
Many nonprofits
have struggled in recent years as state funding has
remained flat while costs, including health insurance, rise. A report
released in March by a state commission on nonprofit health and human
service providers warned that many are in precarious financial
situations. While state payments to providers rose by 21.7 percent from
1999 to 2009, health care premiums increased 135 percent, according to
the report.
Leaders of
nonprofits say they're particularly vulnerable to increased
health care costs because their insurance pools are relatively small,
and having one or two employees with high medical claims can drive up
their premiums.
Dr. Stephen
Becker, president and CEO of Harc, which serves people with
intellectual disabilities, said few health insurance carriers are
willing to bid for their contract. Although the workers are generally
young and healthy, he said that if someone gets a serious or costly
illness, the agency "gets slammed" in costs.
"We need to be
part of a larger plan," he said.
Harc has about
300 employees. The state employee and retiree insurance pool covers
more than 200,000 people.
"I think that
the downside might be is if we had to purchase the level
of health care that the state employees are getting, that might be too
rich for anyone's blood, no matter how many lives we're insuring,"
Becker said.
At Harc, he
total premium for an individual ranges from $4,884 and
$6,473, and Harc pays between 69 percent and 89 percent. For families,
the total cost is $17,543, and Harc pays 46 percent. The premiums rose
26 percent last year, on top of a 16 percent increase the year before,
Becker said. Some employees were unable to afford the increased costs
and dropped coverage, and Becker said some might have relied on HUSKY,
the state program for low-income children and their parents.
"It's
heartbreaking," he said.
Johnson said
anything that gives nonprofits access to a larger
insurance pool and helps to spread the risk among a broader group would
help nonprofits, and could potentially help keep down premium increases.
"If they have
more affordable options, then we would be very interested," he said.
Hospitals facing a double
hit
from Hartford, Washington
Deirdre Shesgreen and Arielle Levin Becker, CT MIRROR
April 25, 2011
WASHINGTON--Frank A. Corvino, the CEO of Greenwich Hospital, is still
reeling from the fiscal punch from Hartford, in the form of a proposed
new tax on hospitals across Connecticut. Now, he's girding for a second
hit from Washington, where federal Medicare officials are fine-tuning a
cut to hospital reimbursement rates.
The two blows, Corvino and other hospital executives say, would ripple
across the health care system and take a toll on the quality of care.
"The combination of these two... is going to have a devastating effect
on patient care in the state," Corvino said. "It's going to pierce the
safety net that hospitals provide for their patients."
Even before Gov. Dannel P. Malloy unveiled a budget plan that included
a new levy on hospitals, Connecticut institutions were focused on a
federal proposal to pare back Medicare payments. The Connecticut
Hospital Association and others have lobbyied against the measure,
drafted by the federal Centers for Medicare and Medicaid (CMS).
But they appear to have lost that battle, at least the first round.
Last week, CMS released a proposal to slice nearly $500 million from
its Medicare payments to hospitals across the country. The Connecticut
Hospital Association said it will file a formal protest against the
rule in June. And it's still subject to public comment, and possibly
revision. But hospitals failed in their efforts to soften a similar cut
imposed at the start of this fiscal year.
CMS officials have said the reduced reimbursements are an effort to
make up for overpayments to hospitals, in Connecticut and around the
country, in previous years. Prior to 2008, hospitals were paid the same
amount for treating an otherwise healthy patient with pneumonia, for
example, as they were for a pneumonia patient who had other
complications.
Since then, CMS has instituted a more sophisticated system, allowing
for more varied levels of diagnosis-and more nuanced payment rates. But
before that went into effect, CMS officials say, some hospitals "bumped
up" patients' diagnoses to a more severe category than was necessary,
resulting in overpayments. Hospitals have adamantly denied that charge
and pressed CMS to abandon the cuts, or at least temper them.
But starting last fall, CMS began recouping half of the alleged
overpayments through an initial Medicare payment cut. And this week,
CMS issued a fresh proposal to gain back the second half, through $498
million in additional Medicare cuts to 3,400 acute care hospitals
around the country.
Kim Hostetler, vice president for administration and communication at
the Connecticut Hospital Association, said CHA is still examining the
proposal to see how it will impact Connecticut's 30 acute care
facilities. She said they're seeking clarification from CMS on some
elements of the cut.
"But it's safe to say that Connecticut will be harder hit than the
national average," she said, adding that Connecticut hospitals are
already only reimbursed 93 cents for every dollar spent caring for
Medicare patients.
The reduction, combined with a lower-than-usual boost for inflation
from CMS, will result in an "unprecedented" cut, she said. "This really
is a double whammy for Connecticut hospitals."
For Greenwich Hospital, Medicare patients make up about 30 to 40
percent of the patient population, so any reduction in reimbursements
will be hard felt, Corvino said. But he knew they were coming and was
prepared to absorb the trim one way or another.
Not so for the budget proposal approved by the Appropriations and
Finance, Revenue and Bonding committees in Hartford this week. That
budget deal would eliminate $83.3 million in state aid that helps
hospitals cover the cost of caring for people who are uninsured or
underinsured; it also levies a new tax on hospitals.
"If it was just the Medicare cuts, we could probably live... with a
couple of million dollars [in lower revenue] here or there," Corvino
said. "But when you up that on top of this devastating budget, the
hospitals are really going to be hard pressed to provide the same level
of service that their currently providing."
By taxing hospitals, the state can capture federal matching funds for
its own coffers-and then redistribute the tax revenue back to the
hospitals. But to get the federal money, the state can't simply give
each hospital back what it paid. Instead, some hospitals have to get
more back than they paid, and some have to get less. The amount
returned is based on each hospital's volume of Medicaid patients and
uncompensated care.
Malloy's original proposal called for raising $266.6 million from
hospitals and returning the same amount to them, with the state keeping
the $133.3 million in federal funds it brings in. The final plan,
agreed to by two legislative committees last week, would raise $349
million from hospitals and give them $399 million. It includes
additional funding for five hospitals in higher-cost areas - Stamford,
Greenwich, New Milford, Danbury and Norwalk hospitals.
Overall, the plan gives hospitals $50 million more than they pay. But
hospital officials say they end up worse off, once the $83.3 million
cut is factored in. Between the tax and the cut, 20 hospitals would
lose money, while eight would make money, according to calculations by
the Connecticut Hospital Association.
"From our perspective, this is still pretty painful," the CHA's
Hostetler said.
The biggest blow would be dealt to Greenwich Hospital, which would lose
$9.6 million from the tax and the cut.
"It will take a small operating gain that we had last year and plunge
that into a significant deficit in the coming year," Corvino said,
adding that it could put the hospital $7 million to $8 million in the
red.
Other hospitals will see a benefit-or no effect at all--from the
proposed tax. St. Vincent's Medical Center in Bridgeport would gain the
most - $3.6 million. Two hospitals--UConn's John Dempsey Hospital and
Connecticut Children's Medical Center--would not be subject to the tax.
Hostetler said hospitals losing money from the budget will "be back to
doing the kinds of things they've had to do in the past." That could
mean curbing services, she said, "but more often, it's delayed
investments in equipment, or in technology, in staff."
That could be particularly difficult for hospitals that need to make
significant capital investments, such as in electronic medical records.
"It's a scary thing when you're not quite sure what your revenue stream
is going to be, particularly when Medicare reimbursement numbers are up
in the air too," Hostetler said.
With the tax and cut going forward, the hospital association has been
trying to get legislators and the Malloy administration to make other
changes that could help hospitals. They include:
Creating a $35 million fund to help hospitals losing
the most from the budget
Writing the tax law to raise a set amount from
hospitals, rather
than taxing them at a rate that could translate to more money if
hospital revenues - the basis for the tax - increase
Making the tax temporary
Revising the hospital payment system by 2014
But Ben Barnes, secretary of the Office of Policy and Management, the
governor's budget office, said he wasn't impressed by the proposals.
"I did not find that to be a compelling package," he said.
Barnes noted that the tax was restructured to leave the hospitals with
more money overall. The tax on health care providers--including nursing
homes and intermediate care facilities for the mentally
retarded--provides an "enormous" net benefit to the state in addressing
the budget deficit, he said, and the sacrifices hospitals will make are
reasonable.
"I think they've overplayed their hand," he said. "I think the tax
proposal that we have is pretty moderate."
SustiNet deal reached, but without a
'public option'
Arielle
Levin Becker, CT MIRROR
April 20, 2011
The Malloy
administration and Democratic legislative leaders have
reached an agreement on the proposed SustiNet state-run health plan,
with a deal that calls for opening the state employee health plan to
municipalities and some nonprofits, but not for offering insurance to
the public.
The agreement
would also establish a "SustiNet cabinet" advisory panel
within the lieutenant governor's office that would be charged with
overseeing health reform efforts in the state, said Ben Barnes, Gov.
Dannel P. Malloy's budget director.
The agreement
does not call for the state to combine the Medicaid and
state employee and retiree health plans into a large pool, as the
current legislative proposal does.
Barnes said the
language for the new proposal is still being developed,
with existing bills and new pieces being combined.
"I doubt
they'll be passed tomorrow, but maybe next week," he said.
The proposed
SustiNet bill, which has drawn passionate support and
opposition, has passed three legislative committees. It calls for
combining state-funded health plans under a quasi-public authority that
would also offer state-run insurance to small businesses,
municipalities, nonprofits and, ultimately, anyone in the state who
wants to buy it.
Supporters have
argued that offering a public insurance option could
provide an alternative to commercial insurance plans and use the
leverage of a large insurance pool to offer affordable coverage to
individuals and small businesses. Opponents have said it could threaten
the insurance industry and could put the state budget at risk. A report
by the legislature's nonpartisan Office of Fiscal Analysis said the
plan could cost hundreds of millions of dollars a year, although
SustiNet supporters have disputed the calculations behind it.
Malloy has said
that he supports the goals of SustiNet, which was
developed as a universal health care plan before federal health reform
passed. But he has expressed concerns about the current proposal,
including about its potential cost and the idea of giving control over
billions of dollars in state health care spending to a quasi-public
authority.
The agreement,
which Barnes said includes House Speaker Christopher G.
Donovan, D-Meriden, and Senate President Pro Tempore Donald E. Williams
Jr., would not include the quasi-public authority or the public option.
Starting in the
next fiscal year, municipalities would be allowed to
buy coverage through the state employee and retiree plan. Nonprofits
that have contracts with the state would be allowed to buy in beginning
the following fiscal year. The state comptroller's office would handle
the plans, and the proposed budget the administration and Democratic
lawmakers agreed to would provide the comptroller's office with
additional staff to try to identify cost-saving measures and payment
reforms in the state employee plan, Barnes said.
The agreement
does not include allowing small businesses to buy
coverage through the state employee plan, although Barnes did not rule
it out for the future.
"I'm not going
to say no, but not as laid out within the next two
years," Barnes said.
Whether the
state health plan is ultimately expanded further will
depend how the initial round of pooling goes and whether expansion is
considered necessary once federal health reform rolls out, he said. As
part of health reform, the state will establish a marketplace for
individuals and small businesses to buy coverage, called an exchange,
by 2014.
The SustiNet
cabinet, an advisory panel, would be chaired by Lt. Gov.
Nancy S. Wyman, who co-chaired the board that created the SustiNet
proposal. Other members would include agency commissioners, appointees
of the governor and legislative leadership, and members of the existing
SustiNet board. It would make recommendations and advise the governor,
Barnes said.
"It will be
charged with carrying out research and policy development,
and will have access to staff and to federal resources that are
available to advance that project," he said.
The specific
statutory language on the SustiNet cabinet has not yet
been worked out, Barnes said.
"This deal has
a few players to be named later, so to speak," he said.
"We've sort of fleshed out the framework."
SustiNet
supporters fought hard for the plan, lobbying Malloy at town
hall meetings across the state. Many backers have said they consider
federal health reform too limited and see the public option as
necessary to any deal they would support. The agreement does not
include a public option, although it does give SustiNet a continued
presence and a role in shaping future health reform efforts.
Ellen Andrews,
executive director of the Connecticut Health Policy
Project and a member of the group that developed the SustiNet plan,
said she was glad there will be a SustiNet cabinet. But she said she
was disappointed, though not surprised, that the agreement does not
include a plan for covering the uninsured.
"That was kind
of the whole point of this from the beginning," she
said. "That's where the political momentum came from."
SustiNet was
originally envisioned as Connecticut's plan to cover the
uninsured, she said. When federal health reform passed, it became the
state's plan for a public option.
Now, she said,
the plan appears to put together groups of people who
already have insurance--potentially good for municipalities, she said,
but not her uninsured clients.
"If all they've
accomplished is putting different groups of people who
have really good insurance together but not expanding to the uninsured,
they haven't helped my clients," she said. "And I think we really
need a public option. Especially in 2014 when we have an individual
mandate, there has to be a public option to protect people. But
hopefully they've left the door open for that."
Donovan, who
has supported the SustiNet proposal, characterized the
plan as not finalized.
"We're still
talking about it, but the idea is to move forward," he
said. "We're not finalized what it is but we're going to move ahead
while we're still working on it."
Donovan
acknowledged that the plan includes pooling and a group that
would look at ways to make health care more affordable and better use
existing health care resources.
Jeannette
DeJesús, special advisor to the governor for health
care reform and a deputy commissioner of public health, who has taken
the lead on implementing federal health reform, said she was glad there
is an agreement to move forward.
"I'm pleased
that we have been able to recognize the importance of
SustiNet and that we are able to move forward now in implementing
health care reform in a way that is inclusive and comprehensive," she
said.
Analysts: SustiNet would cost the state hundreds of millions per year
Arielle
Levin Becker, CT MIRROR
April 4, 2011
The proposed
state-run SustiNet health insurance plan could cost the state hundreds
of millions of dollars a year, according to the legislature's
nonpartisan Office of Fiscal Analysis.
The analysis,
released Monday night, offers the first nonpartisan projection of how
SustiNet could affect the state's finances. Although it does not
provide a total dollar figure, the analysis cites a variety of
potential added costs from the proposal, which calls for reorganizing
existing state-funded health plans and selling state-run insurance to
municipalities, small businesses, nonprofits and, eventually, anyone in
the state who wants it.
Previous
assertions about what SustiNet would cost have offered competing
pictures. Supporters have cited estimates that the state could save
more than $224 million a year with SustiNet, although most of the
projected savings were the result of funding from the federal health
reform law and could be achieved with or without SustiNet. Opponents
have argued that SustiNet would likely increase state spending.
According to
the analysis released Monday, the largest new cost to the
state--between $222.8 million and $478.6 million a year--would come
from offering coverage to low-income adults who earn slightly too much
money to qualify for Medicaid.
Consultants to
the board that developed the SustiNet plan projected that covering
those adults would save the state millions of dollars, because the
state would receive federal funding for it. The Office of Fiscal
Analysis, or OFA, projected that the cost of offering coverage would
exceed the federal funds the state would likely receive.
The SustiNet
proposal has passed three legislative committees but must still receive
approval from at least three more. It has drawn passionate support from
many people who want a public insurance option for the state and say
SustiNet will make health coverage more affordable, and passionate
opposition from business groups and insurers who say it is too costly
and sends a bad message to the state's health insurance industry. Gov.
Dannel P. Malloy has said he shares many of the goals of the proposal,
but has expressed concern about several parts of it, including the
potential cost.
"I believe in
the goals of SustiNet," he said Monday at a town-hall meeting in
Norwalk. "I don't believe in the vehicle as it's currently designed."
SustiNet
backers late Monday issued statements questioning the OFA analysis.
Juan A.
Figueroa, president of the Universal Health Care Foundation of
Connecticut, which created the original plan for SustiNet, raised
concerns about the projections for the cost of covering low-income
adults, and said the OFA report appeared to underestimate the federal
funding the state will get and overestimate the cost of providing
coverage.
"In fact, our
experts, including Dr. Jonathan Gruber, one of the nation's leading
economists at MIT, actually calculated savings of $50 million,"
Figueroa said.
House Speaker
Christopher G. Donovan, D-Meriden and a SustiNet supporter, said the
OFA report needs to be reconciled with other estimates about covering
low-income adults that suggest it will save the state money. Although
the OFA report noted potential costs to the state, including up to $6
million a year for the quasi-public authority that would run SustiNet,
Donovan focused on the report's suggestion that if SustiNet could lower
health care costs by 1 percent, the state could save between $56
million and $58.5 million.
"The fiscal
impact statement demonstrates that better coordinating our health care
purchasing under one agency umbrella is a good investment in the health
future of our state," he said. "Investing up to $6 million to receive
just under $60 million in lower health care costs is a good investment."
Projected
Costs
The SustiNet
bill calls for joining the health plans the state currently pays
for--including the state employee and retiree plan and Medicaid--under
a quasi-public authority. Those plans cover more than 768,000 people
and are estimated to cost $4.67 billion in the 2012 fiscal year,
according to OFA. A premise of the proposal is that having a large
insurance pool and a single purchaser would save money and provide
leverage to make changes that could improve care and slow the growth of
health care spending.
The various
state-funded plans would remain separate coverage pools. The Medicaid
and state employee pools are large and varied enough that it's not
clear whether joining them to hire a benefits manager would produce
savings, the OFA analysis said.
Under the
proposal, the SustiNet Plan Authority would sell coverage in a separate
pool, known as SustiNet G, to municipalities, small businesses and
nonprofits as soon as is feasible. Ultimately, SustiNet G would be
offered to all employers and individuals in the state. That health plan
would be funded by premium payments from participants.
The analysis
estimates that the SustiNet Plan Authority, which would oversee the
plans, would cost less than $4 million in the first year and less than
$6 million a year after that. The bill does not say how the authority
will be funded, according to the analysis.
Additional
state costs, or potential costs, identified in the analysis include:
Covering state benefit mandates in the state employee and retiree plan.
The plan is self-insured and not subject to state laws that require
insurance plans to cover particular benefits. But the SustiNet bill
requires all SustiNet plans to be subject to state insurance mandates,
and the cost of the state employee and retiree plan could increase if
it were required to cover more benefits.
Staffing costs for the state comptroller's office. The bill would allow
non-state public employers to buy coverage through the state employee
and retiree plan, if the coalition of state employee unions agrees. If
many non-state public employers choose to buy into the state employee
plan, the comptroller's office could need two more retirement and
benefits officers, which would cost $185,117 in salaries and fringe
benefits.
Loss of state revenue from the tax paid on health insurance premiums.
Currently, municipalities and other non-state public employers that
provide coverage through private insurers pay a premium tax of 1.75
percent per policy. If those employers shift coverage to the state
employee plan, the state would receive less money from the insurance
premium tax.
The largest
projected cost to the state would come from having the state offer a
"basic health plan" to low-income adults who earn slightly too much to
qualify for Medicaid, beginning in 2014. Under federal health reform,
those adults could buy health insurance with federal subsidies. Or the
state could provide coverage for them and receive 95 percent of what
the federal government would have spent on subsidies.
The state could
offer the plan with or without SustiNet, but the SustiNet bill would
require it.
The OFA
analysis estimated that the basic health plan would cost the state
between $222.8 million and $478.6 million a year to cover approximately
101,250 people. That would include roughly 16,000 adults the state
currently covers in the HUSKY program for low-income children and their
parents.
The state is
projected to spend about $6,000 a year for each adult in HUSKY by 2014.
But it's not clear how much it would cost to cover the other adults who
would be covered by the basic health plan, who don't get state-funded
coverage now. If they are similar to the adults in HUSKY, the basic
health plan would cost $607.5 million. But if they are more like the
adults covered by a new Medicaid program for low-income adults, whose
coverage costs $9,000 a year per person, the program would cost $863.3
million, according to OFA.
The federal
government would help pay for part of the cost, but it's not yet clear
how much.
For its
analysis, OFA estimated that the federal subsidy would be $3,325 a year
per person, leaving the state to cover between $2,675 and $5,675. For
the 16,000 adults moved from HUSKY to the basic health plan, the state
would save $5.2 million. But the added cost of covering the other
85,250 people would far exceed that, OFA projected.
The analysis
noted that the state could save money through delivery system changes
described in the bill. The changes include encouraging--but not
mandating--the use of patient-centered medical homes, electronic
medical records and payment reforms designed to improve care and slow
the growth of health care spending. Because the SustiNet plan would
cover between $5.6 billion and $5.85 billion in costs for state-funded
groups, a 1 percent change in health care costs would mean a change in
$56 million to $58.5 million in state spending. Adding other groups to
SustiNet could increase those figures, the analysis said.
Previous
projections
The projections
provided by the SustiNet board consultants differ from the OFA analysis
in part because they count different things.
The SustiNet
board projections, based on modeling by Massachusetts Institute of
Technology economist Jonathan Gruber, suggested that the state's fiscal
situation could be improved by between $226 million and $535 million by
2019.
But much of the
projected savings come from a change the state already made, converting
the former state-administered general assistance, or SAGA, program into
Medicaid. The move, which occurred last year and was not related to
SustiNet, added to the state's expenses this fiscal year because more
people qualify for the program. But it is expected to save money in the
future because the federal government will pay a significantly larger
share of the costs beginning in 2014 as part of health reform. Gruber
projected the state would save $286 million in 2017 from this change.
The SustiNet
board's projections also said the state could see between $15 million
and $19 million in increased tax revenue because some employers would
stop offering insurance coverage when public coverage becomes available
and increase workers' pay. The OFA analysis did not address any
potential effect on income tax revenues.
Another report,
commissioned by America's Health Insurance Plans, which lobbies for
health insurers, offered a different picture of the proposal and warned
that it would increase state spending.
The report,
prepared by the consulting firm Hay Group, noted that state spending
would increase in the analysis the SustiNet board used if the savings
from the SAGA conversion were not included.
The report also
warned that the state could be at risk if the premiums fail to cover
the costs of providing care to SustiNet recipients. Because the plan
would be self-insured, it would be responsible for paying claims.
"This is a
significant issue given that with the size of the proposed SustiNet
population even a very small underestimate in required premiums could
result in significant liability for the state," the report said.
The state
already self-insures its health plan for state employees and retirees,
and as of next year, will self-insure Medicaid programs too.
The report also
argued that there are limits to the savings that can be achieved from
having a large insurance pool, and that both the state employee pool
and Medicaid pools are large enough that it's not clear that adding to
their size would provide more leverage in rate negotiations or
significant administrative savings.
And it noted that there are not enough specifics to evaluate whether
SustiNet could succeed in reining in spending through delivery system
changes, and that both the public and private sector are already
working on delivery system and payment reforms.
Cardiologists
drop SustiNet support over loss of liability protection
Arielle
Levin Becker, CT MIRROR
March 22, 2011
A group of
cardiologists and cardiac care associates has pulled its support for
the proposed state-run SustiNet health plan because lawmakers removed a
malpractice liability protection provision from the bill.
Four other
medical groups previously expressed concern about the move and warned
that they could reconsider their positions on the proposal. But the
Connecticut Chapter of the American College of Cardiology is the first
medical group to withdraw its support.
The group plans
to make its position known in newspaper advertisements this week that
include an open letter to legislators, Gov. Dannel P. Malloy, and
members of the SustiNet board.
In the letter,
the chapter president, Dr. Neal Lippman, and president-elect, Dr.
Gilead Lancaster, said the group was an early supporter of SustiNet,
but that they cannot support it since lawmakers removed a provision
that would have protected health care providers from liability if they
injure a patient covered by the plan while following clinical care
guidelines.
Without the
protection, they wrote, the plan "would result in a dramatic increase
in the cost of healthcare in Connecticut and expose patients to more
tests of limited value" and fail to attract doctors to participate.
"Without these
protections, we believe that SustiNet will share the fate of the
disastrous Charter Oak insurance plan in which very few doctors are
participating due to its poorly conceived support for quality medical
providers," the doctors wrote, referring to a program created in 2008
to provide coverage for uninsured residents.
The SustiNet
proposal calls for joining state-funded health insurance plans under
common management and, later, offering state-run insurance coverage to
the public. The plan includes several delivery system changes aimed at
improving health while slowing the growth of health care spending.
The bill has
passed the Public Health, Insurance and Real Estate, and Human Services
committees, but its future is not certain. It has drawn staunch
opposition from legislative Republicans, the insurance industry and
some business groups, and Malloy, while supportive of SustiNet's goals
and of federal health reform, has not embraced the proposal.
"We've got a
pretty full agenda right now with everything we have to implement
between now and 2014, and quite honestly, the state's not in a position
to underwrite the expenses at this point that certainly would come as a
result of SustiNet implementation any time before 2014," Malloy told
hospital executives last week.
The plan still
has many backers, including House Speaker Christopher G. Donovan,
D-Meriden, and many social service advocates, unions, small business
owners and health care providers.
Many doctors
had applauded the liability protection provision, which was intended to
promote the use of evidence-based medicine and to reduce physicians'
practice of ordering potentially unnecessary tests and procedures out
of a fear of being sued if they don't cover all bases.
But the
provision proved controversial. People who had been harmed by health
care providers blasted the concept, as did trial lawyers, who
criticized the idea of "giving doctors the right to harm patients
without compensating them simply because they complied with guidelines."
Lawmakers
decided to remove the provision in response to concerns it would create
a double standard between people covered by SustiNet and everyone else
and was using an insurance plan to address a problem in the judicial
system.
The decision
outraged the Connecticut State Medical Society, the Connecticut Chapter
of the American College of Physicians, the Connecticut Academy of
Family Physicians and the Connecticut Chapter of the American Academy
of Pediatrics. Leaders said that without offering liability protection,
SustiNet could have a harder time attracting already-busy physicians to
accept a government insurance plan. Without the savings that could be
achieved by cutting down on tests and procedure ordered to rule out
lawsuits, they said, the plan will struggle to cut down on costs.
Despite
Malloy's support, expansion of medical homes faces obstacles
Arielle
Levin Becker, CT MIRROR
February 17,
2011
Dr. Cliff
O'Callahan's practice submitted an application last week to become
officially recognized as a patient-centered medical home and, in the
process, became critical to Gov. Dannel P. Malloy's administration's
goals for providing health care to more than 500,000 state residents.
As part of an
overhaul of state Medicaid programs, the administration plans to
aggressively expand the use of patient-centered medical homes, an
increasingly popular model for delivering care that is still relatively
rare in practice.
Patient
advocates have long urged the state to embrace the model, which calls
for having health care providers coordinate patients' care. Some were
heartened by Malloy's campaign pledge to expand a small Medicaid pilot
program that pays providers for care coordination.
Details have
not been fleshed out, but the administration has indicated that it
wants to go even further, encouraging providers in Medicaid to become
fully recognized patient-centered medical homes--the designation
O'Callahan's practice is seeking. So far, only four medical practices
in the state have achieved it.
The goal of
expanding medical homes to all Medicaid programs, which serve more than
500,000 people, puts the state in line with physician groups, private
insurers and the federal government in promoting a model that some
studies say can improve care while reducing costs.
But it is
expected to be a gradual process. Recognized medical homes must meet a
wide range of standards, set by the National Committee for Quality
Assurance, including being accessible to patients outside office hours,
prescribing electronically, following up on tests and procedures done
at other facilities, and using data to track patients' hospitalizations
and emergency room visits.
Some practices
meet many of the requirements even if they have not yet gone through
the recognition process. ProHealth Physicians, the largest primary care
practice in Connecticut, is expected to begin a medical home
demonstration project for state employees and Medicaid enrollees next
month, and the project could expand to include other practices.
Still,
ProHealth is unusual in a state dominated by practices with fewer than
five physicians, and O'Callahan's family practice has advantages that
many do not. The Middletown pediatrician receives a salary, so his pay
isn't directly affected if he sees more patients in Medicaid, which
tends to pay less than the cost of care. His patients can get care
coordination through Middlesex Hospital, which owns the practice, and a
social worker paid for by a state program for children with chronic
care needs.
"I don't know,
for all these little practices, how they're going to do it," O'Callahan
said of care coordination. "Except as part of a slightly larger
network."
Money,
Time and Support
Medical homes
are in their infancy in the state, according to a 2009 survey by the
Connecticut State Medical Society, although some elements of them are
more common, including the use of electronic medical records and
scheduling designed to get patients with urgent needs seen quickly.
The Medicaid
pilot program, HUSKY Primary Care, requires providers to coordinate
care but doesn't require the use of electronic medical records or other
hallmarks of a medical home. It will be one option for Medicaid
enrollees in the future. But for now it has only 254 doctors and 517
patients participating.
So what will it
take to get more physician practices to become medical homes?
Money, time,
state support and getting a critical mass of patients and payers
involved will all be essential, those involved say.
The start-up
costs for becoming a medical home can be hard to justify if a practice
isn't certain to get paid for using the model and saving the health
care system money, said Dr. Robert McLean, governor of the American
College of Physicians' Connecticut chapter.
Primary care
doctors are often frustrated that work they do for patients isn't
compensated, and time spent coordinating care often falls into that
category. HUSKY Primary Care pays providers a $7.50 monthly per-patient
care coordination fee, which McLean said is too low to attract many
doctors.
"What is going
to entice doctors to get into this is the opportunity for the state to
take those savings and pay the doctors a fair wage to see these
patients and for an opportunity for the doctors to actually share in
the savings that their hard work garners," McLean said.
With a large
budget deficit to overcome, the state isn't likely to be in a position
to significantly raise Medicaid fees, but it could get some help from a
new federal program aimed at encouraging care coordination for Medicaid
patients with chronic illnesses like asthma, diabetes and obesity.
States can receive federal funding for 90 percent of the money spent
coordinating their care, significantly more than the 50 cents the state
typically receives for each dollar it spends on Medicaid.
A
Better Recruiting Environment?
Even without
significant increases in payments to doctors, patient advocates are
optimistic about getting more to participate in care coordination now
that the Malloy administration has embraced it.
Advocates have
argued that HUSKY Primary Care, which was only open to certain parts of
the state, suffered from a lack of promotion from the Department of
Social Services. Department leaders have disputed the charge.
Sheldon
Toubman, an attorney with Greater New Haven Legal Assistance, said
health care providers have had reservations about joining a program
that did not appear to have support from DSS.
"It's going to be a
lot easier approaching providers and saying 'This is happening, why
don't you get on board now?'" he said.
And broader
forces in health care could help too.
"There is a
very strong trend towards medical homes," Toubman said. "If you're a
primary care provider, that is what you're expected to be doing soon
enough."
For overworked
primary care doctors, the prospect of adding care coordination to their
responsibilities can be daunting. Toubman said the problem can be eased
by getting more patients into the program. A practice getting paid to
coordinate care for 20 patients would get $150 a month for the
coordination--hardly enough to hire a staffer to do the work. But if
enough patients participated, those $7.50 fees could add up to enough
to hire someone.
Alternatively,
some have suggested, practices could team up to share a care
coordinator. Or an outside group could provide care coordination and
receive some or all of the fees the practices would otherwise get.
Having the
state get behind the medical home concept could also help spur more
practices to pursue the model. States that have higher rates of medical
homes tend to be those with state pilot programs or laws that encourage
them, said Andy Reynolds, a spokesman for the National Committee for
Quality Assurance. Vermont and Pennsylvania in particular have had
governors who championed the concept, he said. While Connecticut has 21
clinicians and practices recognized as medical homes, Vermont, with a
fraction of Connecticut's population, has 93. Pennsylvania has 835.
McLean's New
Haven practice already has electronic medical records, but he said it
would have a hard time meeting the full medical home requirements by
the end of the year.
"It can't just
happen overnight," he said. "But it's going to start somewhere."
Hospitals v. Insurance
Companies?
New rankings add complexity to health care choices
Arielle
Levin Becker, CT MIRROR
February 2, 2011
Patients used
to navigating the differences between in-network and out-of-network
providers might soon learn another distinction: tier one and tier two.
A new Aetna
program divides hospitals in the insurer's network into tiers based on
cost and requires patients to pay significantly higher out-of-pocket
charges if they go to those deemed less affordable. A woman who gives
birth at the "tier one" John Dempsey Hospital, for example, might pay
10 percent coinsurance under the plan. But if she had her baby at
MidState Medical Center, a "tier two" hospital, she might pay closer to
35 percent of the total bill.
The program,
"Choose and Save," is small so far, with only a handful of employers,
including Aetna, using it for their workers. But it is part of a larger
push toward making patients more active in controlling medical costs.
And in rating hospitals, the program represents something that even
critics say is likely to become more common as employers and insurers
seek ways to stem the growth of health care costs.
Martha Temple,
president of the New England market for Aetna, recalled that she paid
$5 toward the bill when she had her first child and $10 for her
second--flat rates that don't give patients much reason to pay
attention to the total cost.
But the cost of
childbirth and other procedures varies by thousands of dollars between
hospitals, she noted, and many patients now pay significantly larger
shares of their medical bills as employers raise copayments and
coinsurance levels.
Martha
Temple
The tier system
further reinforces the cost differences, steering patients to the
hospitals Aetna considers less costly. Out-of-network hospitals are
considered "tier three," and patients who use them would pay the
highest rates.
The concept is
controversial among health care providers. Physician groups in multiple
states, including Connecticut, have sued insurers over efforts to rate
doctors in the past, and Connecticut hospital officials have raised
questions about the method used to determine the tiers. Even some who
embrace the concept said the rankings should be more tied to quality
than cost.
"I think that
we're really at the infancy of this, and that what's going to happen
over the longer run, which I think will be a better way to think about
this, is that it just won't be about the hospital costs," said James M.
Blazar, senior vice president and chief strategy officer for Hartford
Hospital, a tier one hospital.
Increasingly
Common, But Effects Vary
In Connecticut,
22 hospitals are in Aetna's tier one, and eight are in tier two. Aetna
officials would not say which hospitals were in each category, but
according to the hospitals, tier one facilities include Dempsey, St.
Francis Hospital and Medical Center and Bristol Hospital. Tier two
hospitals include Midstate and The Hospital of Central Connecticut.
Some hospital
officials are puzzling over their rankings and noted that the program
was not discussed as part of negotiations over rates. Hospital of
Central Connecticut officials have asked Aetna for data to explain the
tier placement. MidState Chief Financial Officer Ralph Becker called
the tier criteria "very subjective."
"This is an
initiative by Aetna to renegotiate and reduce what it pays to
hospitals," he said in a statement.
Becker
predicted that employers would avoid the program "when they find that
their employees are not able to go to their community hospital." Some
payers tried the strategy in the past, he said, but the concept did not
sell.
But other
hospital officials say similar programs are likely to take hold. While
tiered hospital networks are new to Connecticut, they already exist in
other states. In Massachusetts, a law passed last year requires
insurance carriers to offer individuals and small businesses at least
one plan with either a tiered or selective provider network. And
Massachusetts uses tiered networks of hospitals and doctors in the
health plans offered to state employees.
"With the cost
pressures for health care, we'll probably see more of this," said Dr.
Mike Summerer, hospital director at UConn's Dempsey Hospital. "It's my
hope, though, that we'll be able to do it scientifically, and in a way
that's valid. The problem when an insurance company does it using a
methodology that's exclusive to them, it makes it very, very difficult
to be assured that it's a valid measurement, that it's a valid
comparison."
Summerer
previously worked in Massachusetts, and said tier systems changed
patient behavior "to a degree," but not profoundly, in part because the
rankings change from one year to the next, which can confuse patients.
Research
suggests the effects tiered plans have on consumer behavior and overall
medical costs vary.
In a survey of
Massachusetts state employee plan members, 49.5 percent of respondents
said they did not know about the tiers. Fewer than half--42
percent--said they trusted the tiers to tell them which doctors are
better than others.
Asked who they
would trust to decide which doctors should be in the preferred tier,
only one in five respondents said their health plan.
But the survey
authors noted that Massachusetts state employee plan members face only
modest consequences for picking lower-tier physicians, averaging $10 in
copayments.
Larger
financial incentives can have more of an effect on patient choices,
Aetna's experience indicates. The company rates specialists,
designating those who meet clinical performance and efficiency
standards as "Aexcel" providers, and offers employers health plans that
give patients incentives to use those doctors.
Whether
patients used the designated specialists varied by how significant the
incentives were. Those whose plans called for no cost difference or a
small one used the designated specialists at a 2 percent to 3 percent
higher rate than those whose plans did not use the specialist
designation. But patients whose plans had larger cost differences--up
to 30 percent--used Aexcel specialists at between 9 percent and 20
percent higher rates, according to Aetna.
What effect
does it have on overall costs?
The company
says steering patients to designated specialists saved up to 4 percent
for plan sponsors in 2008 and 2009. In Connecticut, where 65 percent of
specialists have the Aexcel designation, the savings were modest. Plans
that covered only Aexcel specialists saved about 1.9 percent on total
medical costs, according to Aetna.
Rating
Methods
About 115,000
people are enrolled in Choose and Save programs nationwide, all through
self-funded employers, which pay their workers' medical claims. Temple
said the company plans to offer the program for fully-insured
companies--which pay the insurer money that is used to pay claims--next
year.
To assign the
hospitals to tiers, the company looked at historical data, the rates
Aetna pays the hospitals and expectations for 2011. The examination was
done market-by-market, Temple said, to determine which hospitals were
at or below average costs, and which were above them.
Dr. Mike
Summerer
Aetna also
looked at the mix of services each hospital offers to avoid penalizing
hospitals that offer higher-cost services. And Temple said the tier
assignments took into account regions, making sure not to cut the only
hospital with a maternity ward in a given area from the top tier.
She said the
company is working with hospitals that want to move up a tier, which
they can do through care management programs or contracting.
As for
decisions about quality, she said, those are made in the decision to
include a hospital in Aetna's network.
In response to
hospital officials' concerns, Aetna spokeswoman Susan G. Millerick
said, the company is working with hospitals to add a quality component
to the tiering system for the future.
"However, it is
important to note that we absolutely stand by the overall quality of
all hospitals in our network, which are each credentialed and
accredited," she said. "That is why we felt comfortable initiating this
new tiering based on cost, took this important first step. Hospitals
remain the fastest growing portion of medical costs today, rising at
rates that exceed physician and other professional services and it is
critical that we all work together to make hospital care more
affordable without sacrificing quality."
Susanne Madden,
president and CEO of The Verden Group, which advises medical practices,
said ratings based on cost can penalize providers who were able to
command higher rates through negotiations with insurers, even if they
were able to do so because they provided high-quality care or were in
demand for other reasons.
A better
system, she said, would be to use pay-for-performance programs that
focus on measurable outcomes, such as incentivizing a medical practice
to improve diabetics' glucose screenings.
Physician
groups have challenged rating systems in the past. In 2007, the
Fairfield County Medical Association filed a class-action lawsuit
against CIGNA over its physician ratings. They ultimately settled, with
an arrangement that allows the company to continue rating physicians
but gives doctors some recourse to appeal their rankings.
Mark Thompson,
the medical association's executive director, considers provider
ratings problematic, but he does not expect them to go away. He pointed
to the public's appetite for ratings for movies, restaurants and books.
"It's what the
employers want and it's what the public wants," he said.
Businesses
Split Over SustiNet
Small firms see savings; large firms
see risk
By Greg
Bordonaro, gbordonaro@HartfordBusiness.com
01/17/11
A major
divide is forming within the business community over the sweeping
health care reform law being proposed in Connecticut.
The plan, which
was recently unveiled by SustiNet board members, calls for Eric George,
lobbyist, CBIAsweeping changes to the state’s health care system and
ultimately establishes a public option open to all Connecticut
residents, including businesses.
That has
created sharp reaction from Connecticut Inc.
Some small
business owners are throwing their support behind the measure, saying a
public health plan that competes with private insurers is the only way
they will be able to find affordable coverage for their workers.
But the state’s
largest business lobbying groups, including the Connecticut Business
and Industry Association and the National Federation of Independent
Business, oppose the idea citing concerns about cost, among other
things.
“Given the
uncertainty surrounding the risk profiles of the people who would be
attracted to the plan, I think it would put the state budget at great
risk,” said Eric George, a lobbyist for the CBIA. “They are adamant to
have a state-run public option and I think that is a very poor policy
decision for Connecticut.”
But Kevin
Galvin, chairman of Small Business for a Healthy Connecticut, a network
of small businesses that support SustiNet, said the lack of affordable
and quality health insurance coverage, especially for companies with
fewer than 10 workers, requires major changes in the marketplace.
And he said new
competition for private insurance companies is the answer.
“If you are an
individual policyholder or small business owner, you don’t have much
choice right now,” said Galvin, who owns his own maintenance repair
shop in West Hartford. “For small businesses to be competitive, they
need to be able to insure people. And if you bring down health care
costs and improve quality you will get small and mid-size businesses to
hire more people. I think SustiNet is the most palatable approach to do
that.”
Small
businesses in Connecticut and across the country are facing increasing
health care costs that are making it difficult for them to do business,
especially in a down economy. Many businesses are being forced to cut
back on how much they contribute to company health plans or void their
coverage altogether, making them less competitive in the market.
The SustiNet
plan was developed by an 11-member board of directors that includes Lt.
Gov. Nancy Wyman and state Comptroller Kevin Lembo. The board was
established by legislation passed by Democratic lawmakers in 2009 in
response to the rising cost of health care and to increase access to
care.
Connecticut’s
state government spends about $8 billion annually on health care for
state employees, retirees, Medicaid recipients and other populations.
The central
component of the plan includes establishing a self-insured state
insurance choice for municipalities that would gradually be expanded to
private employers, small businesses, nonprofits and households.
That option
would be offered both inside and outside the health insurance exchange
that Connecticut is required to setup by 2014 under the new federal
health care reform law.
The plan also
calls for payment reforms including implementing the medical home model
concept and linking provider payments to performance; expanding the
state’s Medicaid program; and investments in electronic health records.
Board members
say SustiNet would be a cost saver for small businesses, in some cases
by allowing them to drop coverage for their workers who would then be
able to enter the new state plan.
The proposal
estimates small firm insurance coverage in the state would decline by
up to 10 percent in 2017. That in turn would save small businesses with
50 or fewer workers about $380 million to $400 million in premiums.
Small employers
that keep coverage could also benefit from tax credits available under
the federal health care law, and the possibility that SustiNet will
slow cost growth. In an optimistic scenario, it is projected that
SustiNet slows cost growth by 1 percent per year.
Among larger
firms, the effects of reform are estimated to be negligible. In 2017,
total costs for companies with more than 100 employees are projected to
decline by roughly $50 million to $70 million, or less than one-half of
1 percent.
SustiNet would
become a major player in the insurance industry.
According to
projections, by 2017 the SustiNet health plan would provide coverage
for up to 30 percent of companies in the state’s small group market and
up to 10 percent of businesses in the large group segment.
George said he
supports some components of the plan — like investing in wellness
programs and electronic medical records and raising Medicaid
reimbursement rates to providers.
But he said
cost is a big and unanswered concern, especially with the state already
facing a $3.5 billion budget deficit.
SustiNet board
members said their proposal could potentially save the state more than
$226 million a year. But most of the projected cost savings, which were
based on modeling by MIT economist Jonathan Gruber, would come from
money allocated under the federal health reform law and assumptions
that SustiNet would help lower health care costs over the long term.
But George said
the proposal doesn’t take into account up-front or ongoing costs. For
example, the plan calls for the establishment of a quasi-governmental
agency to administer SustiNet, which would require staffing.
The level of
benefits offered by SustiNet also have not been defined, so it’s
difficult to gauge those costs as well, George said.
In addition,
George said creating a self-insured plan that is available to anyone,
creates uncertainty over who is going to join the pool and the types of
medical problems they will bring with them.
“The state is
going to be paying medical claims but you don’t know who is coming into
the system,” George said. “If those risks are poor and claims are high
you are going to have a hard time paying for it.”
Galvin said
that it is hard for the CBIA to have an unbiased opinion on the
proposal since CBIA is also an insurance broker. CBIA Health
Connections sells insurance for Connecticare and Aetna through its
exchange.
Beyond that,
Galvin said, creating competition and allowing small businesses to
combine their purchasing power is the key.
“There is
nothing forcing insurance companies to get better with pricing and
quality of product,” Galvin said. “Federal reform didn’t address the
cost issue.”
The SustiNet
proposal now turns into a political debate as it gets turned over to
the state legislature. Many Democrats — the majority party in both the
House and Senate as well as the party of Gov. Dannel Malloy — have
expressed support for the plan. Republicans, including Senate Minority
Leader John McKinney of Fairfield, have expressed concerns over the
costs of the plan.
Insurance
industry says no to repeal of health care reform, but
reticent on details
Deirdre Shesgreen,
CT MIRROR
January 10, 2011
WASHINGTON--As
House Republicans make their first run at the health care reform law,
Democrats say the GOP is doing the bidding of big insurance.
"Why are they
engaged in this effort?" asked Rep. Rosa DeLauro, D-3rd District.
"Because, quite frankly, I believe it's what the insurance companies
want."
It just ain't
so, comes the response from Hartford, where insurance giants such as
CIGNA, Aetna, and UnitedHealthcare all have major corporate offices.
"Our focus
remains on implementing the law and the various provisions that just
recently took effect, from extended dependent coverage to enhance
preventive care and tax credits for small businesses," said Daryl
Richard, a spokesman for UnitedHealthcare.
The true role
of Connecticut's big insurance firms, and other industry players across
the country, remains to be seen. But there's little question they have
much at stake as this new twist in the debate over health reform gets
underway.
The House
proposal to repeal the health care law is almost certain to pass, but
it will likely die in the Senate. (The House vote was originally set
for this week, but it has been delayed in light of the Arizona
shootings that targeted, among others, a Democratic congresswoman from
that state.)
If full repeal
fails, Republican opponents have promised a fresh offensive, going
after the law in bits and pieces.
Health
insurance interests spent millions of dollars on lobbying in 2009 to
help shape the original overhaul. And they've spent millions more in
2010 trying to influence federal bureaucrats charged with writing
regulations to implement the law.
It's unlikely
they will sit on the sidelines now as this new skirmish gets underway.
At least two insurance company CEOs--at Aetna and CIGNA--have said they
don't support overturning the health care law, even if they're not
thrilled with all its particulars.
"I don't think
it's in our society's best interest to expend energy in repealing the
law," Cigna CEO David Cordani said at a health care conference in
November, shortly after the elections that swept the GOP to power in
the House and trimmed Democrats' majority in the Senate. "Our country
expended over a year of sweat equity around the formation of it."
Aetna President
Mark Bertolini told that same audience: "We can't go back. We need to
keep moving forward."
Consumer groups
say it's no wonder the industry is taking this stance.
"There's a very
good reason for that," said Carmen Balber, director of the Washington
office for Consumer Watchdog, a liberal advocacy group that has been
closely tracking health reform.
"They spent
over $80 million lobbying on the bill and they got their two main
goals--they killed the possibility of a public option and they got a
mandate included that requires every American to buy their product,"
Balber said. "That mandate is a money-maker for the industry."
The requirement
that nearly all individuals purchase insurance, which goes into effect
in 2014, could bring some 30 million new customers to the doors of
Aetna and other firms.
"That was
something that they adamantly insisted was necessary to make insurance
market reforms actually work," said Rep. Joe Courtney, D-2nd District.
To be sure, the
mandate and the market reforms went hand-in-hand. The latter include
new consumer protections that prevent insurance companies from denying
coverage to patients with pre-existing conditions, that allow young
adults to stay on their parents' policies until age 26, and that end
lifetime caps on insurance coverage.
Among the
American electorate, those are among the most popular elements of the
law. The mandate is among the least popular.
"If the public
had its way, the most unpopular piece of reform would be repealed and
that's the mandate," said Balber. "But I certainly believe the industry
would pull out all the stops to preserve that provision."
Aetna, United,
and CIGNA all declined to answer specific questions related to heath
reform repeal, such as what provisions they might like to see undone
and what they'd like to see saved.
"We will remain
compliant with the new health care law, and we will continue to
advocate for a stronger focus on improving quality and affordability in
the health care system," said Aetna spokesman Mohit M. Ghose.
A CIGNA
spokeswoman provided some "talking points" from a recent presentation
by the company's top health reform implementation executive, Tom
Richards The reform teams at Cigna "are busy at work and these
efforts will only intensify as we ring in the New Year," Richards'
talking points say.
The insurance
industry's lobby group in Washington, America's Health Insurance Plans,
was only a little bit more forthcoming.
Robert
Zirkelbach, AHIP's spokesman, said the industry wants to see changes in
the law "in order to minimize coverage disruptions and cost increases."
"While the new
law will bring more people into the system, major provisions will raise
costs and disrupt the coverage people have today," he said. "We will
continue to work with members of Congress from both parties to address
these issues."
The provisions
AHIP sees as problematic include, for example, limits on how much more
insurers can charge older patients versus younger patients and
scheduled cuts to Medicare Advantage subsidies, which uses private
insurers to deliver Medicare services.
AHIP and other
insurance interests have also opposed strict regulations allowing
review of "unreasonable" rate increases and new rules requiring
insurance companies to spend at least 80 percent of their customers'
premium payments on medical care, as opposed to administrative expenses
or CEO salaries.
Critics say the
industry would probably like to see those provisions undermined, if not
nixed entirely.
"The industry
won't be publicly for full repeal, but they may be working
behind-the-scenes as hard as they can to weaken enforcement of some of
their least favorite requirements," Balber said, citing the 80 percent
requirement as one juicy target for big insurance firms.
Once the full
repeal vote is over, House Republicans have vowed to go after narrow
provisions in the law. They've also called for trying to block funding
to enforcement and implementation of the law.
It's unclear
just how the insurers will react to these more targeted strikes. Some
industry critics predict they will support any effort to weaken the
measure.
But industry
officials say that blocking funding or implementation could cause chaos
and uncertainty.
Bertolini, of
Aetna, said such efforts could lead the healthcare industry to "a bad
place." A stalemate with a total funding shutdown "would be
problematic," he said at the November conference.
Ghose declined
to elaborate on his boss's remarks.
But another
industry source said that defunding implementation of health reform,
while leaving the law in place, is far from ideal. For starters, health
insurers have spent millions of dollars trying to shape key regulations
and then complying with them.
"If we still
have to abide by it, but there's no ability for federal agencies to
give us clarity on how to do that, I can't imagine that being very good
for us," said the source, who asked for anonymity to be more candid.
"Either have the law, or get rid of it. Having a big in between" would
not be good.
DeLauro
acknowledged the industry's perspective might be more "complicated"
that a full-throated push for repeal. But she said she still believes
the GOP is driven in large part by the industry's wishes. And she said
she thinks that means overturning major protections for consumers.
Insurance
companies "want to make it as difficult as possible to move forward"
with the law, said DeLauro.
Jeanette
DeJesus, CT Hospital Assoc.
Malloy
taps hospital association executive to take the lead on health reform
Arielle Levin
Becker, CT MIRROR
January 4, 2011
Gov.-elect Dan
Malloy has appointed a Connecticut Hospital Association
executive and former head of the Hispanic Health Council to lead state
efforts to implement federal health care reform.
As a deputy
health commissioner and special advisor to Malloy, Jeanette
DeJesús will oversee a wide range of efforts intended to prepare
the
state for an expansion of health care coverage. Although the Patient
Protection and Affordable Care Act does not fully roll out until 2014,
it leaves considerable responsibility to the states.
By 2014, each
state must have a health insurance exchange, a
marketplace for purchasing coverage that will also be charged with
collecting data, reporting to the federal government, certifying and
rating insurance plans, and tracking which employers do not offer
insurance to their workers. By 2015, the exchanges must be financially
self-sustaining.
In addition,
states must prepare to ramp up their Medicaid eligibility
by 2014. Connecticut is projected to have 114,000 new Medicaid
enrollees, which will likely require additional staff to process
applications.
DeJesús
will succeed Cristine Vogel, who led health reform
implementation efforts as a special advisor to Gov. M. Jodi Rell. Vogel
has also led a Health Care Reform Cabinet, which includes the
commissioners of 11 agencies.
As a newcomer
to the health reform role, DeJesús won't be alone. Many
states have political appointees leading health reform implementation
efforts, and with more than two dozen states inaugurating new
governors, many of those positions are likely to change hands.
But
DeJesús already has been involved in efforts to promote health
reform on the state and federal levels. She co-chaired a task force on
tobacco and smoking cessation for the SustiNet Health Partnership
board, which designed a proposal for a state public health insurance
option. In 2009, she spoke as part of U.S. Sen. Christopher Dodd's
"Prescriptions for Change" health care listening tour, and described
working daily with people who had no health insurance and often worked
two or three jobs.
DeJesús,
who has a degree social work from New York University and a
degree in public administration from Harvard, currently works as vice
president for strategic alliances at the Connecticut Hospital
Association. She previously served as president and CEO of the Hispanic
Health Council.
She also
previously served as executive vice president of the National
Conference for Community and Justice, and managed a rape crisis program
at St. Vincent's Hospital in New York.
She also is a
member of the Board of Directors of The Connecticut News
Project, publisher of The Connecticut Mirror. She will resign from that
position.
6
states to watch on health reform
By: Sarah
Kliff, POLITICO
January 3, 2011
04:33 AM EST
Health reform
repeal efforts will generate a lot of noise in the opening weeks of the
112th Congress – but the real action on health reform is going to ramp
up outside the Beltway in state capitals.
“Unless states
move forward as fast and as hard as they can this year, they will be
lost in 2014 when the bulk of health reform hits,” says Stan Dorn, a
senior health policy researcher at the Urban Institute. “The pressure
is just enormous on state policy makers.”
In Washington,
House Republican attempts to repeal the reform law are likely to die in
the Senate – or, failing that – at President Obama’s veto. Meanwhile,
state legislatures, whether they are dominated by Democrats or
Republicans, must brace for a frenetic and fast-paced year of building
the infrastructure needed for reform.
Thirty-three
states have created some entity to implement the new federal health law
and over a dozen require a report on the law by the early part of 2011,
according to the National Conference of State Legislatures.
All 50 states
will take some action on the health reform law in the coming year. Here
are six to watch closely in early 2011:
Wisconsin – The
Badger State has aggressively lead the way on health exchanges,
developing an online prototype that Wisconsinites can already take for
a spin. In late December, Wisconsin applied for an “early innovator”
grant, which would mean increased federal funding and serve as a model
for others.
But Wisconsin’s
assembly, senate, and governorship all flipped from Democratic to
Republican control in November. Republican Governor Scott Walker, who
takes office today, won’t take a firm line against pursuing health
reform grants—but he has also promised to “back off” of a lot of the
state has done so far, moving the work in a different direction.
“I don’t want
to put anything in place that forces us into mandates of what kind of
coverage needs to be provided,” Walker told POLITICO. “The concept of
an exchange itself is not something I’m against…a system where there’s
a defined component to what has to be in the exchange. That to me is
where the problem is.”
Walker will,
however, remain open to pursuing Health and Human Services grants and
working with Secretary Kathleen Sebelius. “I’d like to think we can be
an innovator as well, but from a much different point of view from what
Governor Doyle was doing,” Walker says, noting that he does not plan to
withdraw the state’s early innovator application.
Within days of
his election, Walker began aggressively opposing Wisconsin’s work on
health reform. In a November 12 letter to the state’s Department of
Administration, he requested they “temporarily freeze any new
implementation of the federal health reform law” until after he took
office. The same day, Walker announced he would allow Republican
attorney general J.B. Van Hollen to join an anti-health reform lawsuit.
Walker’s Democratic predecessor had barred Holland from doing so.
Vermont – Newly
sworn-in Democratic Governor Peter Shumlin ran on an aggressive,
single-payer platform. Now, all eyes watch Vermont to see whether it’s
possible to turn the single payer promise into policy—and whether it
can be implemented in tandem with the reform law.
“There’s a lot
we can do under the existing law, but also some clear limitations,”
says Anya Rader Wallack, health policy advisor to the governor. “We
will try and do the maximum we can under the existing law…and I think
seek federal permission for flexibility.”
The
single-payer plan will move forward quickly: by February, Harvard
professor William Hsiao will deliver three design options to provide
state-wide coverage. The report will likely catalyze legislative action.
“We’ve been
pushing this rock up a hill for a long time” says Rader Wallack on the
slow progress on health reform. “It’s time to see if we can move to a
whole new plane. We can only get so far within the current system and
need to do something dramatically different to keep fighting this
fight.”
Alaska – With
Minnesota Gov. Tim Pawlenty no longer in office, Alaska’s Gov. Sean
Parnell arguably snatches the title for most aggressive,
anti-health-reform governor. He has regularly rejected grant
opportunities pursued by the vast majority of states; Alaska was one of
two states not to pursue an exchange planning grant, one of five that
turned down an opportunity for increased rate review funding.
“My sense is
the individual state agencies are tracking the requirements of the law
and implementing those requirements,” says Deborah Erickson, executive
director of the Alaska Health Care Commission, a state agency created
by Gov. Sarah Palin. “Beyond that, there are so many, essentially new
programs that I don’t think Governor Parnell will be pursuing.”
Alaska could
emerge as a key state to watch to understand how HHS will deal with an
adamantly opposed state.
With so much
uncertainty surrounding federal reform’s fate in Alaska, Erickson’s
group will steer clear of making implementation recommendations. When
they issue a report on health reform in Alaska on January 15 it will
only go as far as to summarize what has been done and what deadlines
loom in the future.
California –
Under Republican Gov. Arnold Schwarzenegger, the Golden State
established itself as a health reform leader by passing the first
legislation in the country to authorize a health exchange under the
federal law. A failed California Health Exchange, which opened in 1993
and shuttered five years ago, left the state “with a pool of people who
were will poised to move forward very quickly,” says Dorn of the Urban
Institute. “Now you have an incoming Democratic governor [Jerry Brown]
who is a ‘small is beautiful’ Democrat. What he’s going to do on health
reform, how he uses that pool of expertise, will be interesting to
watch.”
Insurers have
grumbled over the state’s “selective contracting” approach. The
exchange will decide which plans can sell on its market, as opposed to
a more laissez faire model where all insurers meeting basic benefits
qualify. But as the first state out the gate, many others will look to
it as a model.
Schwarzenegger
moved the exchange forward up through the final days of his
administration. He appointed two advisors to the California Health
Exchange Board of Directors on December 31: current California Health
and Human Secretary Kim Belshe and Susan Kennedy, the governor’s chief
of staff.
Connecticut –
If there’s a hope for reviving the public option, it’s strongest in
Connecticut. Since 2009, the governor’s office has been at work on an
ambitious plan to transform its public plans, like Medicaid and state
employee benefits, into a publicly-financed plan that could be sold on
the health exchange come 2014.
The new plan,
dubbed Sustinet, will deliver a progress report to the state
legislature on January 7.
“I think that
if it’s successful, it’s an interesting model,” says Rader Wallack of
Vermont. “It could potentially provide competition from the public
sector within a private business model.”
Massachusetts –
Four years after the health reform law passed, Massachusetts boasted
record coverage: 98.1 percent among adults and 99.8 percent for
children, according to statistics released in December. But
less-heartening numbers loom in the background: the state’s health care
costs continue to rapidly outpace general economic growth.
Cost-control
was a key campaign issue and the governor’s race and is positioned to
become a legislative priority in the coming Massachusetts session.
“It’s quite doable but takes some political courage,” says Rader
Wallack who, previously co-chaired Massachusetts’ Cost Containment
Committee. “What they really need is for the legislature to move on
this and enact something that gets the ball rolling.”
Governor Deval
Patrick has purposed payment reforms similar to the Accountable Care
Organizations championed in the federal health reform law. “The idea,
in oversimplified terms is to move from paying for the amount of care
to paying for wellness,” Patrick told local radio station WBUR in an
October 2010 interview. “There are models for this where we’ve seen
costs managed down.” Rader Wallack cautions against moving too quickly
into an ACO-model and argues in favor of a gradual approach.
“The idea you
flip a switch and everyone be in ACO isn’t necessarily feasible,” she
says. “Having them move in that direction, at a reasonable pace with
incentives to take the next steps, calibrating that all correctly is a
complicated endeavor.”
The
Massachusetts Committee on the Status of Payment Reform Legislation has
its first meeting of the year on January 5.
© 2011
Capitol News Company, LLC
As
it looks going to the Legislature:
http://www.ct.gov/sustinet/lib/sustinet/sn.final_report.appendix.cga.010711.pdf
SustiNet
board approves final proposal 7-1
Political
Mirror
Arielle
Levin Becker
29 December 2010
The SustiNet
board voted Wednesday on its final recommendations for a health
insurance plan that would cover state employees and retirees, Medicaid
and HUSKY recipients, and ultimately be sold to municipalities,
nonprofits, small businesses and the public.
The proposal,
which will be submitted to legislators by Jan. 7, calls for creating a
quasi-public agency to oversee the SustiNet health plan. The agency
would initially be staffed by the state comptroller's office, but under
the proposal, would have its own executive director and staff by 2013.
Under the plan,
state employees and retirees and people covered by state insurance
programs would be joined into one health insurance pool. The pool would
then be opened to municipalities, small businesses and nonprofits, and
by 2014, everyone in the state.
The proposal
includes plans for delivery system reforms including offering
incentives for health care providers to serve as patient-centered
medical homes and eventually requiring providers to use health
information technology like electronic medical records.
It also calls
for the legislature to make changes to state law, including expanding
the scope of practice for nurse practitioners so they can play larger
roles in medical homes and creating "safe harbors" for malpractice
liability for providers who are appropriately following clinical
guidelines.
And the
proposal urges the legislature and SustiNet board to find resources to
expand HUSKY eligibility before 2014, when federal health reform will
expand Medicaid coverage, and to fund public health initiatives such as
preventing tobacco use and obesity, expanding the state's health care
workforce and addressing racial and ethnic disparities.
Seven board
members voted for the proposal during a conference call Wednesday.
Board member Paul Grady cast the lone vote against the proposal.
Grady, a
partner in the consulting firm Mercer, has raised concerns about the
feasibility of offering SustiNet to the public as a plan that competes
with commercial insurers. He has suggested that SustiNet be considered
to have two separate roles. One would be providing "strategic
oversight," promoting delivery system reforms and public health
improvements that could save money. The second is having a health plan
offered to the public, in competition with commercial insurance
companies.
If SustiNet
does not succeed in the private insurance market, Grady has said, the
state should still use the oversight role to help manage the $7 billion
the state already spends on health care for groups including state
employees and retirees and people in public insurance programs.
SustiNet grew
out of an effort to establish universal health care in the state before
the federal health reform law was passed, and supporters are now hoping
it will serve as a public option for Connecticut. Gov. M. Jodi Rell
vetoed the initial legislation creating SustiNet, citing cost concerns,
but the legislature overrode her veto. More recent cost projections
presented by SustiNet board consultants have suggested that SustiNet
could save the state money, largely by capturing federal funds made
available under health care reform.
The legislature
and governor must approve any plan for SustiNet before it becomes law.
Public
weighs in on SustiNet plan
Arielle
Levin Becker, CT MIRROR
December 7, 2010
Members of the
public got their chance to weigh in on the SustiNet plan this week, and
their questions and comments offered a hint at what could lie ahead as
policymakers attempt to create a public health insurance plan for the
state.
Many of those
who spoke at presentations in New Haven and Hartford identified
themselves as supporters of the concept, the details of which are still
being hashed out by a board. Some with a particular interest in the
shape of the plan, including a chiropractor and an optometrist,
wondered how it would affect their fields.
There were
questions about how an expanded state insurance program could be done
in the midst of a massive state budget deficit and whether a public
insurance option would threaten the business of private health
insurers. And some speakers raised concerns or reservations about what
the process would ultimately produce.
The SustiNet
board is expected to make recommendations early next year to the
legislature, which must approve any plan. The board will likely vote on
the recommendations Dec. 15.
Katharine
London, one of the consultants working with the board, described
SustiNet as a publicly run health insurance plan intended to rein in
costs, promote wellness and make better use of the $7 billion the state
spends on health care.
London said
much of the board's discussion has focused not on whether to do certain
things, but when. Board members agree that they want SustiNet to
initially, in 2011, include those covered by state-funded health
insurance--Medicaid and HUSKY enrollees and state employees and
retirees.
The HUSKY
program, which covers some 400,000 mostly low-income children and their
parents, could be expanded to people with higher incomes in 2012 if the
money can be found to do it, she said.
And as soon as
it is feasible, the board would like to allow municipalities, small
businesses and nonprofits to buy into SustiNet for their employees. The
health plan would also be sold to the public, London said.
Among the
issues the board is now addressing, she said: Who should be on the
SustiNet board going forward, as its role moves toward governing the
program, and who should appoint them? And how much flexibility should
the board have over time to make changes and implement them?
Those who spoke
at the presentations Monday and Tuesday had other questions.
One woman asked
whether SustiNet is threatened by the state's fiscal condition, or
whether cost savings are built in.
State
comptroller and lieutenant governor-elect Nancy Wyman, who co-chairs
the board, said SustiNet might need to roll out slower than the board
hoped. There could be federal money to help implement SustiNet and
savings in what the state already spends, she said.
"We spend $7
billion right now on health care in the state of Connecticut," she
said. "We believe that there are savings we can find."
Several
questions addressed issues the board has not yet decided: Could
undocumented immigrants - a group left out of federal health
reform--buy into SustiNet? What specific steps will be taken to address
racial and ethnic disparities?
Two health care
providers raised concerns about the role their fields would play in
Sustinet.
Branford
optometrist Brian Lynch, who spoke on behalf of the Connecticut
Association of Optometrists, asked board to commit SustiNet to covering
particular services, including comprehensive eye care. SustiNet is
expected to promote the use of patient-centered medical homes, in which
teams of health care providers coordinate patients' care, and Lynch
asked that a wide range of health care providers be included as
possible medical homes.
State Healthcare
Advocate Kevin Lembo, the board co-chair and comptroller-elect, said he
did not expect the board would support a plan that did not include
comprehensive benefits currently required by state law. But he noted
that the board's charge now is to put forward a proposal. Going deeper
into issues of what specific items should be covered will likely fall
to the next phase of the board's work.
He offered a
similar answer to West Hartford chiropractor Richard Duenas, who
represented the Connecticut Chiropractic Association and asked whether
the SustiNet program would "take a fair and unbiased look" at
non-physician providers to help relieve the workforce burden and
provide care.
Many speakers
expressed support for SustiNet, including several who said they worked
with people without health insurance.
David Nelson, a
retired minister from Mansfield, said SustiNet will be critical for
people without health coverage.
"People are
literally dying because they don't go to doctors," he said, wearing a
red "healthcare4every1" shirt that SustiNet supporters wore when trying
to get legislators to support the plan last year.
Nelson
acknowledged concerns about whether the state can afford SustiNet, but
said he hopes the state will adopt it.
"It's going to
cost a lot of money, but if we don't, we know what's going to happen,"
he said. "People are going to die and it's going to cost more money
anyway."
The cost of
SustiNet has been a source of dispute. Gov. M. Jodi Rell cited
financial concerns when she vetoed the bill creating SustiNet last
year, pointing to a projection from her budget office that it would
likely cost about $1 billion per year. She warned that SustiNet could
prompt employers to drop health coverage, raising costs even further.
The legislature later overrode the veto.
By contrast, a
recent analysis by Stan Dorn, a consultant to the SustiNet board,
suggested that SustiNet could save the state between $32 million and
$427 million per year, depending on how many groups are included in the
insurance pool. The savings would come largely from the state capturing
additional federal money. Some would also come from the delivery system
changes that are aimed at slowing the growth of health care spending,
including the use of medical homes, electronic medical records, and
payment reform that would reward health care providers for doing the
"right" things, rather than simply doing more tests and procedures.
Dorn's analysis
also showed that one option the board is considering, raising rates
paid to health care providers in HUSKY, could cost the state more
money. The board has agreed that raising HUSKY payment rates is
important, consultant Anya Rader Wallack said, and is now discussing
how to fund it.
The cost
projections will likely be a major source of debate when legislators
consider SustiNet's future. So might the effect it could have on the
state's insurance industry. One speaker addressed that issue Monday,
saying there is concern in the industry that SustiNet will threaten
for-profit insurers.
Lembo said
SustiNet could serve as a model for other insurers if its practices
work and save money.
"I won't
apologize for a group of potentially a million lives that can affect
positive change in this environment," he said. "We've allowed one model
to function and it hasn't worked for many, many, many, many, many of
us."
Who
will lead state's health care reform?
Arielle
Levin Becker, CT MIRROR
November 12,
2010
Grappling with
a $3.3 billion budget deficit and a bad economy might dominate the work
of Governor-elect Dan Malloy's administration, but his staff's to-do
list will also include implementing federal health care reform, a law
that gives considerable responsibility--and work--to the states.
Connecticut is
one of many states expected have a change in leadership in handling the
health care law. Twenty-six states are changing governors, and many,
like Connecticut, have a political appointee in charge of the
implementation effort.
The Patient
Protection and Affordable Care Act won't be fully rolled out until
2014, and it could still be revised if Republicans in Congress get
their way. But some provisions require planning now, including building
the health insurance exchange, a marketplace for purchasing coverage
that must be operational by Jan. 1, 2014.
Connecticut's
lead in implementing health reform, Cristine Vogel, serves as a special
adviser to Gov. M. Jodi Rell and expects to leave the job sometime
before Malloy takes office. Vogel also heads the state's Health Care
Reform Cabinet, which includes the commissioners of 11 agencies.
The Department
of Social Services, which is already facing a surge of new Medicaid
enrollees because of the economy and new eligibility rules, will need
to prepare for a projected 114,000 or more new Medicaid clients under
health reform. The department is certain to get a new leader:
Commissioner Michael Starkowski is already retired and has been leading
the department on a contract basis.
The Connecticut
Insurance Department, which will have more responsibilities as insurers
face more data reporting requirements, also will get new leadership.
Commissioner Thomas Sullivan, who came under fire after approving
double-digit rate hikes for some individual-market health insurance
plans, is leaving the job after this week.
"There's just
so much that the new governor will need to focus on, I'm just hopeful
that health care will pop back up on the radar screen," Vogel said.
"But he does have a lot of work ahead of him."
Malloy's chief
of staff-designee Timothy F. Bannon, who is leading the transition team
along with Lieutenant Governor-elect Nancy Wyman, said there have not
been any major decisions made about health reform implementation
efforts yet.
"Right now,
it's just one of those things that we're trying to figure out how to
best address," he said.
Vogel said
federal officials have acknowledged that many of state officials
working to implement the law across the country are departing.
"They
acknowledge that new governors have a learning curve and they come with
their own different policy approach," she said. "The policymakers down
in Washington DC are changing a little bit too. It's a time of great
flux."
In her
remaining time in the job, Vogel plans to focus on the health insurance
exchange. The state recently received a planning grant and Vogel hopes
to hire a manager for the grant to move forward with research on the
insurance market and information technology infrastructure that will
help inform the exchange-planning process, including determining
whether a state-run exchange is a viable option.
In addition to
making information about health insurance plans available to the
public, the exchange will have a variety of data collection and
reporting functions. It will be responsible for certifying and rating
insurance plans, ensuring that quality and satisfaction are being
measured, reporting to the federal government and tracking which
employers do not offer insurance to their employees.
By 2015, the
exchange must be financially self-sustaining. The state will need
legislation to create the exchange.
It's not clear
how many people would be required to staff such a program; a similar
effort in Massachusetts, called the Health Connector, has dozens of
employees. States have the option of outsourcing the functions, teaming
with other states to create regional exchanges, or having the federal
government run their exchanges.
The Department
of Social Services might also need to add jobs to handle the influx of
applications and inquiries likely as Medicaid eligibility expands to
nearly all state residents with incomes up to 133 percent of the
poverty level in 2014.
Asked what
advice she had for her successor, Vogel said she had many opinions, but
that "I advise Governor Rell."
"We in state
government typically know where our lines are, and so if asked by the
governor-elect, I would at least share my thoughts and opinions with
him," she said. "But during the transition, it's important for him to
create his vision and his policy and make sure his administration knows
what he believes in."
Enrollment
in government health plan
disappoints
New Haven
Register (Associated Press)
Published:
Sunday, November 07, 2010
WASHINGTON —
The Obama administration said Friday it will cut premiums
and upgrade coverage in a new health plan for people with medical
problems, because enrollment has been disappointingly low.
Government
economists had projected that people turned down by private
insurers would flock to the new Pre-Existing Condition Insurance Plan,
with 375,000 expected to sign up this year. But as of last week,
a little more than 8,000 had enrolled, officials said. Part of
the problem is sticker shock. Premiums vary by state, and can range
from $400 to $600 per month or more for people in their 40s and 50s.
Health and
Human Services officials said Friday the program will cut
premiums by about 20 percent next year, as well as offer a choice among
different plans, including one tailored for children only. Prescription
drug coverage will also get better.
But there’s a
catch: Lower-cost plans may not be available
immediately in every state. They will be offered in 23 states and
Washington, D.C., where the federal government directly administers the
program. The remaining 27 states, which opted to run their own plans,
will make their decisions independently.
The plan for
the medically uninsurable was launched this summer, a
centerpiece of the early benefits of President Barack Obama’s health
care overhaul. It offers uninsured people with medical problems
guaranteed coverage at rates similar to what the healthy pay when they
buy coverage directly from an insurance company.
To qualify, you
must have had a problem getting insurance because of a
medical condition, and must have been uninsured for at least six
months. Only U.S. citizens and legal residents can get help.
The program is
intended as a temporary lifeline. It will last until
2014, when the new health law requires insurers to accept all
applicants regardless of medical history. Insurers will also be
prohibited from charging higher premiums to those in poor health. And
many people will be eligible for new tax credits to help pay premiums.
HHS officials
say the changes are an effort to improve the program
based on the lessons they’ve learned so far.
Health
reform reshaping medical practice
Deirdre
Shesgreen, CT MIRROR
October 20, 2010
WASHINGTON-
Patients who suffer from heart failure are getting a radical new
treatment at Hartford Hospital aimed at significantly reducing their
chances of readmission. It's doesn't involve
new medications or a cutting-edge diagnostic. In some ways, it's a lot
more complicated-entailing a more integrated way of practicing medicine
that is being ushered in, in part, by the health care reform law.
Hartford
Hospital's new program for heart failure patients, which relies on
intensive post-discharge follow-up, is one element of a larger effort
to retool that institution and its affiliates into an "accountable care
organization", or ACO. Some experts see
ACOs as the linchpin of health reform-a way to bring down spiraling
health costs while also improving the quality of care. But others are
skeptical of their potential, and worry that Connecticut providers, in
particular, will face unique difficulties in implementing this piece of
health reform.
Under the
health overhaul, ACOs are defined as a network of physicians, working
across specialties and even at different institutions, who team up to
provide a highly integrated continuum of care for their patients. If an
ACO delivers quality care at reduced costs, its members will be able to
share in any financial savings.
"What we're
talking about is a complete and total re-engineering of care," said
Amanda Forster, of Premier Inc., an alliance of hospitals and other
providers that works on improving quality. Premier is helping Hartford
Hospital and others prepare for the new ACO era.
Right now,
hospitals and doctors are paid for every service they provide. So each
surgical procedure, each test, each patient appointment translates into
a reimbursement, whether from an insurance company or the government's
Medicare or Medicaid programs. This fee-for-service
system provides "a perverse incentive," Forster says, because there are
no rewards for keeping a patient healthy or for successfully managing a
disease with minimal complications.
ACOs are
designed to flip the system around.
Under the
health reform law, a group of health care providers will be able to
form an ACO if they can meet certain benchmarks, including the capacity
to provide a full spectrum of health care services to at least 5,000
Medicare patients. The providers in
each ACO will still be reimbursed through Medicare on a fee-for-service
basis; but if they are able to deliver quality care at a lower cost,
they will split the cost savings with the government.
"Everybody
agrees in the abstract that our health care system is wasteful and
costs too much," said Michael Millenson, a health care consultant and
scholar at Northwestern University's Kellogg School of Management. But
few providers think their own systems have such inefficiencies. The ACO model gives
providers a carrot to find waste and root it out.
More broadly,
it also sets up payment incentives for physicians to "step outside of
their silos and their piecemeal approach to health care and to work
across health care settings-and to be accountable across health care
settings," said Alwyn Cassil, of the Center for Studying Health System
Change, a nonpartisan health policy research organization.
Take the
Hartford Hospital example. Instead of discharging a heart-failure
patient with some general instructions, the hospital is now
aggressively working to connect with that patient's primary care doctor
and other providers to ensure the patient gets good follow-up services.
The hospital staff schedules a nurse home-visit within 24 hours of
discharge, and they make sure the patient sees his or her primary care
doctor or cardiologist within 4 days of leaving the hospital.
"All of these
efforts are to ensure that they don't worsen and get readmitted," said
Rocco Orlando, the hospital's chief medical officer who is overseeing
the facility's transition to an ACO.
"The ACOs
represent one of the ways to link financial performance to clinical
performance, by preventing disease and providing better care to achieve
savings," said Orlando. "It's a very viable way to bend that cost
curve."
He noted that
it's part of a broader shift toward so-called "bundled payments," under
which doctors and hospitals would be paid for longer-term episodes of
care, rather than individual tests and appointments. The potential
benefits to patients are immense, if not as immediate.
"If you are a
diabetic with heart disease and high blood pressure, the payoff is over
a 5-to-10-year period, you will have fewer complications and less
illness," Orlando said.
Even though the
ACO provision doesn't go into effect until January 2012, many providers
across the country are already scrambling to form alliances. Orlando
said Hartford Hospital and its affiliates are on schedule to form an
ACO by this time next year.
"It's amazing.
Everyone is doing it," Millenson said. "It's been surprising how fast
it's caught on."
Forster said
providers from Pennsylvania to Illinois to South Carolina are laying
the groundwork to move to an ACO model. Many of these groups are
working with private insurers to set up cost-savings agreements, in
addition to whatever savings they might reap from the health reform's
Medicare ACO plan. But not everyone is
so enthusiastic.
For one thing,
the federal department of Health and Human Services has yet to write
the regulations spelling out how the ACOs will work. And doctors and
hospitals are worried about some legal barriers, such as anti-trust
laws, that could impede collaboration.
"It's not just
add water and stir," said Stephen Frayne, a senior vice president at
the Connecticut Hospital Association. "There's a lot of stuff that has
to be sorted through."
Frayne said it
will take a lot of upfront investment, in terms of both time and money,
to create the systems needed for such broad integration. ACOs will also
have to dedicate resources to new technology systems that will help
them track patients and health care outcomes, a key determinant of
whether an ACO is successful. Frayne and others
also noted Connecticut's health care system is not particularly well
suited to move to the ACO model. That's because nearly 80 percent of
Connecticut doctors currently practice in small groups of four or less,
rather than in larger networks.
"Unlike a lot
of other states, we don't have a lot of integrated health systems,"
said Ken Ferrucci, vice president of public policy and government
affairs for the Connecticut State Medical Society. "The biggest
challenge in Connecticut will be ... finding a way for physician
practices to keep the independence they want and yet be integrated into
an ACO."
The reform
measure could provide a needed impetus "to integrate the system more
swiftly," Ferrucci said. But for now, doctors and other providers are
taking a go-slow approach, studying their options and trying to weigh
the potential benefits against the required investments. Forster said ACOs
will probably look very different from one place to another, since the
law is written broadly to allow for flexibility. But a move toward some
new kind of new payment and care system is inevitable.
She said one of
Premier's alliance members framed the choice this way: "You can either
keep doing business as usual, and die a death of a thousand
fee-for-service payment cuts, or you can transform care and finally do
the things that all providers have in their mission statements, which
is to promote health and wellness."
State
struggles to implement health care reform
Deirdre
Shesgreen, CT MIRROR
August 13, 2010
Huge. Complex.
Difficult.
These are just
a few of the adjectives Cristine Vogel throws out as she tries to
describe her new job: special adviser to Gov. M. Jodi Rell for health
care reform.
At the end of
July, Rell tapped Vogel to oversee implementation of the sweeping
Patient Protection and Affordable Care Act, which President Barack
Obama signed into law last March. A 25-year health care veteran, Vogel
started on July 23, and she already feels way behind. Not to mention
short-staffed and under-funded.
But that's
actually an improvement from a few weeks ago, when Vogel was still
deputy commissioner for Connecticut's Office of Health Care Access,
helping to oversee implementation of the massive reform law on top of
her day job.
"We've just
been putting out fires for the last few months on health care reform,
so I'm looking forward to actually doing it in some coordinated,
cohesive manner," Vogel said in an interview last week, as she was
scrambling to meet the latest grant deadline from the federal
Department of Health and Human Services (HHS). "A little more
predictable and planned out would be nice."
Vogel pulls out
a 3-page summary of what the state had done as of July 30: grant
applications submitted, grant applications due, applications in
progress, with August deadlines looming.
Connecticut not
alone in grappling with the Patient Protection Act. "States are
certainly scrambling to interpret and figure out which parts of the law
they need to be involved with and then what their options are," said
Richard Cauchi, health program director at the National Conference of
State Legislatures. "It's not a simple picture."
Vogel said she
and other key players face a slew of challenges--from the uncertain
political climate in Connecticut to a tight state budget that has left
key state agencies under-resourced as they try to sort out the new law.
"We are in
deficit, and no agency has extra people," she said. That's especially
tough when it comes to snagging some of the millions of new federal
dollars available under the Patient Protection Act. "We try to put
resources toward applying for these grants, but it's an added on
responsibility for our staff," she said, noting that she faced an
imminent deadline for a public health infrastructure grant from HHS
that could help move the state's lagging information technology system
into the 21st Century.
Insurance
Commissioner Thomas Sullivan said the state's dire fiscal situation
also makes him and other officials wary of beefing up operations with
new federal grant money that will likely run out after a few years.
While the state has been "very active" in applying for the health care
reform funds, "we do that with a very jaundiced eye," Sullivan said.
"Anything we apply for, the first question we ask is, 'Is this going to
create an unfunded mandate'" down the line?
But the biggest
immediate policy challenge, Vogel and others said, is laying the
groundwork for the new state-based health insurance "exchanges,"
competitive markets where individuals and small businesses can shop for
insurance.
The insurance
exchanges are the crux of health care reform, with proponents of the
new law saying these new entities will make insurance more accessible
and affordable. They will offer consumers health insurance that is
portable and not tied to their jobs. And they will provide a range of
health plan options.
"People will
have more choice," said Timothy Jost, a health law expert at Washington
and Lee University and a consumer representative to the National
Association of Insurance Commissioners. "They will certainly make a
huge difference in terms of the quality of coverage and how much
[consumers] understand about their coverage."
But while they
offer "the most opportunity for creativity," setting up the exchanges
will be the most complex step for the states, Jost said. He said the
NAIC is now drafting model legislation to help guide states as they
seek to set up these new exchanges.
Under the
federal Patient Protection Act, states can choose an existing state
government agency, a non-profit, or a public-private entity to operate
the exchanges--or they can turn it all over to the federal government.
States can also team up to form regional exchanges, or go it alone.
They can have one exchange for the entire state or several, even
setting up more than one exchange within a single jurisdiction.
Vogel said she
thinks the best way forward in Connecticut is to create a
public-private entity to oversee the new exchanges--a proposal that
would have to go through the legislature.
"This exchange
has an awful lot of power, and it truly is the cornerstone of this
health care reform bill," she said. "If you get the right or the wrong
people leading it ... it makes or breaks the success of the program."
She noted, for
example, that the insurance exchange managers will have the ability to
bargain with health insurers about what benefits they offer at what
price, if those firms want access to these new markets.
"It does have a
lot of leverage to improve access, quality and affordability," she
said. But if an exchange manager doesn't use that leverage, "then it's
just completely a portal, and you let any health plan that wants to
come in and sell."
She said
tapping a state agency for this task puts it under the influence of the
governor's office, potentially subjecting the exchange to shifting
political winds. A quasi-government agency, she said, "appears to be
the most practical way forward, so everyone feels they can be involved
in the process."
Sullivan said
he was less concerned with how the exchanges are governed than with how
they are regulated. "Our work is to ensure that ... it's a level
playing field and we don't lower our regulatory standards," he said.
The deadline
for getting these exchanges set up and able to accept applications is
June 2013, and they're supposed to be fully operational come 2014.
Vogel has just started filling out a new HHS application for a $1
million grant that would give her funding to research and plan for the
exchange.
While the
exchange deadlines may seem like a long way off, Vogel is eager to get
things rolling now. That's in large part because winning approval from
the state legislature to create a new public-private agency could take
considerable time. She envisions the new agency would function as an
advisory board, with members appointed from the public and private
sector, who then select an executive director to run the exchange on a
day-to-day basis.
Cauchi said
that most states are in the initial stages of planning for the
exchanges. The only states that already have such entities are
Massachusetts and Utah, which both had exchanges before Congress passed
health reform. But he said that by the beginning of the 2011
legislative session, most states should have this issue near the top of
their agenda.
Like many
states, Connecticut has a heated gubernatorial election underway, and
it's not clear what approach the next administration will want to take
to health reform. "We're working feverishly to make sure we have the
proper infrastructure in place but we fully realize that some of this
will be in the domain and control of the next administration," said
Sullivan.
Vogel also said
that state lawmakers don't seem eager to tackle the subject in advance
of the elections. But she's worried that waiting until after November
could put the state behind schedule.
If she tries to
draft legislation in the coming months, and "it hits their desks in
February, without them being part of the process, I just don't think it
will gain any momentum," she said. So she hopes lawmakers will engage
now and that will pave a "smoother" path for passage.
Sen. Jonathan
Harris, D-West Hartford, co-chairman of the legislature's Public Health
Committee, dismissed Vogel's contention that the legislature was not
engaged. He said lawmakers were eager to move forward, but Rell didn't
alert them that she had created this new health reform adviser position
or that Vogel had been appointed to it.
"Maybe I was
out of the loop that day, but no one from Deputy Commissioner Vogel's
office or the Department of Social Services or the governor's office
has reached out and said, 'We've made this appointment, please we'd
like to talk'," Harris said. "I'm going to reach out to them now to
find out what's going on."
Harris said a
public-private board may well be the best governing structure for the
exchanges, although he said he had not studied the issue in detail.
More broadly, Harris said he believes Connecticut is very well
positioned to put the reform law into place, noting that state
lawmakers have been looking at health reform issues for years and in
2009 passed the SustiNet law, aimed at increasing health care coverage
in Connecticut. The SustiNet Health Partnership Board was also tasked
with, among other things, making recommendations on implementing
federal reform.
On health
exchanges, the recommendations contemplate how Sustinet could be part
of the exchange, offering a kind of public insurance option next to
private plans.
"We've thought
about it, and now it's just a matter of going through all the pieces
and seeing what needs to be changed and what the fiscal impact, both
positive and negative, is," Harris said.
As Vogel
examines those questions, she also knows that come January, she will
most likely be out of a job as a new governor moves in and puts his own
team in place.
"It's difficult
to work on a project that you're not sure, come January, if somebody's
going to take your direction or not," she said. "I'm hoping that the
next administration continues what we have started, or at least doesn't
go backward."
Where
the League stands on this...
SustiNet board outlines 'public option' for health coverage in
Connecticut
Jacqueline
Rabe, CT MIRROR
May 27, 2010
A plan for a
public health care option in Connecticut - dubbed SustiNet
- was released today in response to the new federal health care law.
"It's an
outline of what we are looking at," said state Comptroller
Nancy Wyman, also the co-chairwoman of the SustiNet Health Partnership
Board that released the report. "We are ahead of most states. We have a
plan that fits perfectly with the federal law. It’s amazing. We really
are in good shape to go forward with the public option.”
Final draft
legislation with detailed recommendations for implementing
SustiNet will be made by the end of the year so the new General
Assembly and governor can consider the package in 2011.
Kevin Lembo,
co-chair of the SustiNet board and the state healthcare
advocate, has said this plan, if adopted, would go above and beyond the
federal reform.
"They set this
new federal floor. Some states will chose to do nothing
additional, but Connecticut I am confident will go above that," Lembo
said two days after the federal law was signed in March by President
Barack Obama.
The SustiNet
plan would offer a public insurance option to employees at
the state's small businesses, non-profits and municipalities beginning
July 1, 2012. The federal health reform does not include a public
option.
But nothing
would take effect without approval by the legislature and governor.
Republican Gov.
M. Jodi Rell is not expected to sign such legislation,
as she vetoed the bill in 2009 that created this panel responsible with
crafting a public option. It took a veto override by the Democratic
majority to launch SustiNet.
With Rell not
seeking re-election, a new governor will consider any
legislation implementing a public insurance plan. If another Republican
wins the office and vetoes the plan, the Democrats' ability to override
will depend on their success in the November legislative elections. If
Republicans win one more seat in the Senate, they will have enough
votes to sustain a veto.
There are
currently 305,000 people - or 10.4 percent of the state's
population- with no insurance, reports the Urban Institute, a national
healthcare non-profit think tank. Of that population, 57,000 people are
currently eligible for Medicaid but have not enrolled.
Rell has
endorsed portions of the federal reform law, but only as long
as it doesn't cost the state money. The state has applied for federal
reimbursements for the state's low-income SAGA health plan - a move
expected to net $49.3 million in new revenue for the state through next
fiscal year if approved.
Rell also wrote
U.S. Health and Human Services Secretary Kathleen
Sebelius last week to inform her the state would be applying soon to
create a federally subsidized high-risk pool for state residents with
preexisting conditions.
SPEAKERS
AT FALL CONFERENCE 2009,
"HEALTH
CARE IN CONNECTICUT: WHAT'S NEXT?"
1. Hon. Nancy Wyman,
Connecticut State Comptroller, who provided
valuable information on SustiNet
(Wikipedia information on
Sustinet), of which she is
Co-Chair.
2. Ms. Carolyn
Salsgiver, Senior Vice President for Planning & Marketing,
Bridgeport Hospital, who
gave a most thoughtful
and informative talk (and a creative thought-sharing process during
Q&A);
3..
Elizabeth
Rosenthal,
MD (Physicians
for a National Health Plan)
roused the audience with her inspiring presentation from the
perspective of a practicing physician.
Moderator Kay Maxwell kept things
moving, the audience had terrific
queries!
President of the LWVCT Jara Burnett
pointed out that unfortunately the
planned insurance industry representative was unable to attend the
event, and thus the balance on the panel was askew; this resulted
in a less comprehensive set of viewpoints than League would ordinarily
provide, and thus she urged those present to be sure to find out
about other views.
For background regarding why and how
the League has studied Health Care, please click
here.
TOP: Gray Hall, site of the Conference; CENTER:
Hon. Nancy Wyman, Comptroller, State of Connecticut; Lyn
Salsgiver, Senior Vice President, Planning and Marketing, Bridgeport
Hospital; Elizabeth Rosenthal, MD, Physicians for a National
Health Plan. BOTTOM: President of the
LWVCT Jara Burnett; Kay Maxwell, moderator.
W A T C H T H I S I M P O R T
A N T D I S C U S S I O N N O W ! ! !
LWVCT FALL CONFERENCE
DECEMBER 5, 2009 VIDEO NOW ONLINE HERE:
Health Care: The League’s History
In 1990, the
LWVUS undertook a two-year study of the funding and delivery of health
care in the United States. Phase 1 studied the delivery and policy
goals of the U.S. health care system; Phase 2 focused on health care
financing and administration. The LWVUS announced its initial health
care position in April 1992 and the final position in April 1993.
The health care
position outlines the goals the LWVUS believes are fundamental for U.S.
health care policy. These include policies that promote access to a
basic level of quality care at an affordable cost for all U.S.
residents and strong cost-control mechanisms to ensure the efficient
and economical delivery of care. The Meeting Basic Human Needs position
also addresses access to health care.
The health care
position enumerates services League members believe are of highest
priority for a basic level of quality care: the prevention of disease,
health promotion and education, primary care (including prenatal and
reproductive health care), acute care, long-term care and mental health
care. Dental, vision and hearing care are recognized as important
services but of lower priority when measured against the added cost
involved. Comments from numerous state and local Leagues, however,
emphasized that these services are essential for children.
To achieve more
equitable distribution of services, the League endorses increasing the
availability of resources in medically underserved areas, training
providers in needed fields of care, standardizing the services provided
under publicly funded health care programs and insurance reforms.
The LWVUS
health care position includes support for strong mechanisms to contain
rising health care costs. Particular methods to promote the efficient
and economical delivery of care in the United States include regional
planning for the allocation of resources, reducing administrative
costs, reforming the malpractice system, copayments and deductibles,
and managed care. In accordance with the position’s call for health
care at an affordable cost, copayments and deductibles are acceptable
cost containment mechanisms only if they are based on an individual’s
ability to pay. In addition, cost containment mechanisms should not
interfere with the delivery of quality health care.
The position
calls for a national health insurance plan financed through general
taxes, commonly known as the “single-payer” approach. The position also
supports an employer-based system that provides universal access to
health care as an important step toward a national health insurance
plan. The League opposes a strictly private market-based model of
financing the health care system. With regard to administration of the
U.S. health care system, the League supports a combination of private
and public sectors or a combination of federal, state and/or regional
agencies. The League supports a general income tax increase to finance
national health care reform.
The LWVUS
strongly believes that should the allocation of resources become
necessary to reform the U.S. health care system, the ability of a
patient to pay for services should not be a consideration. In
determining how health care resources should be allocated, the League
emphasizes the consideration of the following factors, taken together:
the urgency of the medical condition, the life expectancy of the
patient, the expected outcome of the treatment, the cost of the
procedure, the duration of care, the quality of life of the patient
after the treatment, and the wishes of the patient and the family.
As the LWVUS
was completing Phase 2 of the study, the issue of health care reform
was rising to the top of the country’s legislative agenda. In April
1993, as soon as the study results were announced, the LWVUS met with
White House Health Care officials to present the results of the
League’s position. Since then, the League has actively participated in
the health care debate.
The LWVUS
testified in fall 1993 before the House Ways and Means Subcommittee on
Health, the Energy and Commerce Committee and the Education and Labor
Committee, calling for comprehensive health care reform based on the
League position. The League joined two coalitions—one comprised of
consumer, business, labor, provider and senior groups working for
comprehensive health care reform, and the other comprised of groups
supporting the single-payer approach to health care reform.
Throughout
1994, the League actively lobbied in support of comprehensive reform,
including universal coverage, cost containment, single-payer or
employer mandate and a strong benefits package. The League continued to
advocate for the inclusion of the state single-payer option in any
health care package and emphasized LWVUS support for the inclusion of
reproductive health care, including abortion, in any health benefits
package. League leaders participated in countless lobbying visits in
Washington, held grassroots meetings with members of Congress and spoke
out in the media.
Health care
reform advocates, including the League, continued to press for
comprehensive health care reform through September 1994. But
congressional sponsors were unable to reach accord, and comprehensive
reform was declared dead for the 104th Congress. The focus then shifted
to the states, where Leagues have worked in support of health care
reform, while fighting off attempts to cut back on existing health care.
The LWVEF
initiated community education efforts on health care issues with the
“Understanding Health Care Policy Project” in the early 1990s. The
project provided training and resources for Leagues to conduct
broad-based community outreach and education on health care policy
issues with the goal of expanding community participation in the debate.
In spring 1994,
the LWVEF and the Kaiser Family Foundation undertook a major citizen
education effort, “Citizen’s Voice for Citizen’s Choice: A Campaign for
a Public Voice on Health Care Reform.” The project delivered objective
information on health care reform to millions of Americans across the
country. Local and state Leagues sponsored more than 60 town meetings
in major media markets nationwide, involving members of Congress and
other leading policy makers and analysts in health care discussions
with citizens. In September 1994, the LWVEF and the Kaiser Family
Foundation held a National Satellite Town Meeting on Health Care
Reform, with more than 200 downlink sites across the country. The two
organizations also undertook a major television advertising effort to
promote public participation in the health care debate.
In 1997, the
LWVUS joined 100 national, state and local organizations in
successfully urging Congress to pass strong bipartisan child health
care legislation. In 1998, the LWVUS began working for a Patients’ Bill
of Rights, aimed at giving Americans participating in managed care
health plans greater access to specialists without going through a
gatekeeper, the right to emergency room care using the “reasonably
prudent person” standard, a speedy appeals process when there is a
dispute with insurers and other rights.
Also in 1998,
the LWVEF again partnered with the Kaiser Family Foundation and state
and local Leagues on a citizen education project, this time focused on
Medicare reform, patients’ bill of rights and other health care issues.
In the first phase of the project, more than 6,500 citizens
participated in focus groups, community dialogues and public meetings.
Their views were reflected in How Americans Talk About Medicare Reform:
The Public Voice, presented to the National Bipartisan Commission on
the Future of Medicare in March 1999. The report emphasized that people
value Medicare but recognize its flaws. Fairness, responsibility,
efficiency and access were identified as important values for any
reforms of the Medicare system.
In spring 2000,
the LWVEF and KFF developed and distributed two guides, Join the
Debate: Your Guide to Health Issues in the 2000 Election and A Leader’s
Handbook for Holding Community Dialogues. The project focused on five
issues under debate in the election: the uninsured, managed care and
patients’ rights, Medicare reform, prescription drug coverage and
long-term care.
Throughout the
106th Congress, the LWVUS lobbied in support of a strong Patients’ Bill
of Rights. In July 1999, the Senate passed a watered-down version of
patients’ rights legislation opposed by the League. In October, the
House passed a strong, bipartisan bill that guaranteed basic health
care protections supported by the League. Despite several close votes
in 2000, however, Senate opponents continued to block passage of real
patient protection legislation. At Convention 2000, League delegates
lobbied their members of Congress to pass a strong, comprehensive
Patients’ Bill of Rights and send it to the President.
The League’s
efforts in support of passage of real patient protection legislation
continued throughout the 107th Congress. Delegates to Convention 2000
met with their Representatives and Senators in support of the Patients’
Bill of Rights, but the legislation was essentially shelved as Election
2000 drew near.
The LWVUS
lobbied federal lawmakers in support of the Bipartisan Patient
Protection Act of 2001, legislation that would provide patients with
administrative and legal recourse in dealing with insurers and Health
Maintenance Organizations (HMOs). Despite action in both the House and
Senate and pressure from the LWVUS and other health care advocates, the
legislation died in the conference committee that should have resolved
the differences between the two bills.
In the 108th
Congress, the League lobbied Congress in support of the Health Care
Access Resolution, which expressed congressional intent to begin the
debate on how to provide health care access to all. In November 2003,
the League opposed the Medicare Prescription Drug bill that was signed
into law by the President because its particular provisions undermined
universal coverage in Medicare.
In May 2006,
the League urged Senators to oppose the Health Insurance Marketplace
Modernization and Affordability Act (HIMMA). While this proposal
purported to expand healthcare coverage, it in fact limits critical
consumer protections provided in many states.
In 2007 and
2008, the League supported reauthorization of the State Children’s
Health Insurance Program (SCHIP) which provided health care coverage to
six million low-income children in 2007. This support also included
encouraging Senators and Representatives to fully fund the program. The
legislation passed the House and Senate, but was vetoed by President
Bush
