Connecticut policymakers are at work on a plan, called the State Innovation Model (SIM), to fundamentally transform our fragmented health care system — both how care is delivered by doctors, hospitals and other providers, and how it is paid for. SIM is meant to cover at least three million state residents — Medicare, Medicaid, employer benefits, and private insurance — within five years. With health care costs skyrocketing and quality slipping, there has never been a greater need for reform.
If you haven’t heard about this planning process, you aren’t alone. Small committees met over just a few evenings this summer, in an office building in Rocky Hill, to design the plan. There were no public notices or cameras, and no legislators, legislative staff, consumers, or advocates included on the committees.
The exclusion of consumers and their advocates is especially troubling. Most of the improvements in our state’s health system have come through the work of advocates. Without advocates, we would still be overpaying HUSKY insurance companies millions of dollars for poor performance and inadequate care for more than 400,000 Connecticut children and their parents. As a legislator for 18 years and a health care provider for 40 years, I have come to respect the critical role that independent advocates play in ensuring that public programs work in the real world.
Since advocates were excluded from the planning, it should come as no surprise that the proposed SIM payment model, “total cost of care,” serves the needs of health care providers, insurers, employers, and government, but could put patients in harm’s way. Total cost of care gives providers unparalleled control over health care finances, allowing them to share in any savings they are able to generate on their own patients’ health care. This payment model is very new; sophisticated groups in other states are struggling to make this work. There are at least three problems with implementing this model in Connecticut now.
First, currently physicians don’t have all the tools they need to keep costs under control and provide the level of care their ethics and principles require. Your doctor has little control over what happens to you when you enter a hospital or are referred to a specialist.
Second, there are essentially two ways to save money on health care. The right way is to eliminate duplicate tests, unnecessary care, and inappropriate overtreatment. The other way is to withhold necessary care, which is what routinely happened in managed care, when we granted financial control to insurance companies under a total cost of care model. Unfortunately, unlike other states, Connecticut does not have a robust quality monitoring system to distinguish between the two ways to save. Implementing total cost of care before we have a strong quality monitoring system in place is irresponsible.
Third, Connecticut’s health care community is undergoing seismic shifts right now. The Affordable Care Act is making thousands of changes, big and small. Several hospitals are in various stages of converting to for-profit status, raising grave concerns about quality when profits are driving care decisions. Compounding this, a growing number of private practices are being purchased by hospitals.
Fortunately, we have innovative health care models in our state with wide support showing great promise. Our new Person-Centered Medical Home program is already providing expanded access to efficient, coordinated care to more than 200,000 Medicaid consumers and attracting primary care doctors to the program. Providers in that program who excel in delivering quality care are receiving performance bonuses. Building on this success, we are poised to implement Health Neighborhood pilots for frail elders and people with disabilities engaging the entire health care system with social supports to keep people well, promote quality care, protect patients, and responsibly share savings with providers. Both programs were designed in inclusive public processes, engaging the wisdom of all voices, and the final models are much stronger for it.
Twenty four consumer advocates have signed a letter calling on state leaders to fix the current SIM proposal to build a robust quality monitoring system, while having an inclusive, well-informed discussion about payment reform to design a model that will work and won’t cause harm. Past history has taught us that we must have strong quality monitoring in place well before financing changes, or the consequences could be dire
Perhaps the worst part of this is the missed opportunity to have a broad, thoughtful process to achieve real reform of our state’s broken health care system. We need to fix SIM — it may be a very long time until we have another chance like this.
Vickie Nardello is a former lawmaker and chair of the Connecticut Health Policy Project Board of Directors.