Connecticut’s Medicaid program suffers from a wide range of problems including too few providers, fragmented care and very poor data for program planning. Early this year, Gov. Dannel P. Malloy’s administration announced that it planned to transition to a care coordination model that has successfully addressed many of these issues in other states. Unfortunately, the current plan for making that transition fails to follow the path of those success stories.
Patient centered medical homes (PCMH) are a new way of organizing health care. With the PCMH, each consumer has an identified provider who is responsible for coordinating their care by making appointments with specialists, following up with test results and prevention reminders, and helping patients care for themselves.
In return, consumers commit to go to their assigned provider with problems first rather than going to the emergency room. It will also make them more likely to respond to reminders, and to actively participate in improving their health.
It’s a mutual commitment with proven success including better health outcomes and reduced costs. So with Connecticut moving to implement PCMHs, it is puzzling that the Department of Social Services, which oversees Medicaid, wouldn’t follow those successful examples.
In other states for instance, providers are paid a modest, upfront fee based on the number and complexity of patients. Here, DSS has proposed only a moderate increase in rates providers already get for services. This means that busy practices will hire care coordinators to run the program, but not be paid until much later with no assurance that they will get enough to cover the costs.
Medicaid already pays its providers far less than other payers. Without directly linking a payment to the PCMH services, providers may consider the increased rates a down payment on reasonable compensation for existing services, rather than payment for the new program. Furthermore, with providers already slated to get an even larger increase in 2014 under health care reform, there is even less incentive to join PCMH.
In states with successful PCMH programs, the payment system encourages appropriate treatment and use of services. The proposed program for DSS, by contrast, would have the opposite effect.
In order to get paid for PCMH services, under the proposed system, a provider that has successfully treated a child would be prohibited from following up by phone or email and instead required to schedule an office visit, taking the child out of school, taking a parent out of work, requiring state payment for transportation, and exposing the child to a germ-filled waiting room. For a busy primary care provider, an unnecessary office visit is the waste of precious time that could be available for a sick child.
Patient centered medical homes have been highly successful, and there is no reason they cannot be equally successful here in Connecticut with the right implementation.
The good news is DSS Commissioner Roderick Bremby is listening . He is receptive and understands the problems. We are very optimistic that the current proposal will be fixed and Connecticut Medicaid consumers, providers, and taxpayers will soon enjoy the benefits of PCMHs as in other states.
Ellen Andrews is the executive director of the Connecticut Health Policy Project.