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Consumer protections had a good start in Connecticut’s latest health reform plan. But, as always, the devil is in the details. Unfortunately insurers are working to sabotage those protections to benefit their bottom line.

Health care consumes a large share of our state’s economy, and there is a growing consensus that the way we pay for care is part of the problem. Our wacky system results in too much of some care and too little of other care. Connecticut’s State Innovation Model (SIM), developed by the Malloy administration, is seeking to radically transform our state’s $30-billion health system and has chosen a shared savings payment model for those reforms.

The idea behind shared savings is that large health systems will invest in innovative services and reduce duplication to improve our health and, in exchange, they will share in the resulting savings. However the other possible result is that some may generate savings by denying consumers the care they need. Medicaid consumers are at much higher risk for underservice as providers are paid less for care.

Recent cuts to physician payment rates in the program, especially for obstetrics and radiology, are only going to make the problem worse. Shared savings is very new; there is little experience from other states to guide us.

Understandably, physicians and advocates are concerned about protecting people from underservice. We were successful in getting a commitment in the SIM final plan that large health systems that “are determined to have achieved savings through systematic under-service, will not receive shared savings.” This should remove any incentive to deny needed care, but no state has done this before. We have to figure out how to monitor for underservice, how to prevent it, and how to fix it if it happens. The responsibility to develop a plan to implement this provision fell to the SIM Equity and Access Council (EAC).

As members of the EAC, we spent long hours over the last year in difficult discussions about sensitive issues. By pouring over complex policies and finding common ground, the Council was able to come to consensus on all but one recommendation.

The recommendations we agreed to include full information on shared savings — risks and benefits — for consumers and providers from the beginning, recognition of existing doctor-patient relationships, cost estimates based on patient needs, provider appeal rights, rewards for quality improvement, and resources to care for more challenging patients, among others.

But the only recommendation we couldn’t all agree to is critical to making shared savings work. Under SIM’s plan, when savings are denied because they were generated by denying people appropriate care, by default those savings would remain with the insurer. We believe that those savings generated at the expense of necessary care should be returned to the original purpose — to build value.

The controversial recommendation would devote those savings to fixing the underservice problem by directing the funds to quality improvement and expanding access to care. Without this provision, all the savings (both halves) generated by underservice would remain with the insurer, giving them twice the incentive to foster underservice. Physicians, other providers, and consumer advocates on the EAC strongly supported this provision; only insurers objected.

Insurers have powerful tools to encourage underservice that often result in denials of necessary care, such as prior authorization and formularies. In fact, insurers used these tools often in the 1990’s under managed care. Since insurers will know which metrics are being monitored for underservice, but providers will not, insurers are potentially both in a position to engineer underservice and to double their profits from it. Teachers don’t tell their students what will be on the test, but they also don’t get paid double for students who get F’s.

No one is more committed to real reform in Connecticut’s broken health care system than consumers and doctors. Consumers pay for health care — through our premiums, out-of-pocket costs, taxes, and lost wages — and physicians provide the care we rely upon for our health. We are proud to serve on the EAC and are fully invested in supporting meaningful reforms that control health costs, improve quality, and protect people. To do that, SIM needs to adopt all of the EAC’s recommendations.

Ellen Andrews is executive director of the Connecticut Health Policy Project and Dr. Robert Russo is the head of Robert D. Russo M.D. and Associates Radiology and also president of the Connecticut State Medical Society.

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