Too often policymakers, advocates and others return from conferences or read reports highlighting great ideas that are working in other states. But when we try to implement them here in Connecticut, they too often fail. Not every good idea fails, but too many do.
Each failure erodes our enthusiasm for reform and builds cynicism. This problem isn’t limited to Connecticut, but it happens a lot here. While each failure is unique, there are a few Connecticut-specific themes – politics, failure to monitor and evaluate, conflicts of interest, and missing the essential point of the good idea.
Politics is probably the first good idea trap that comes to mind. Healthcare is a big jobs program in Connecticut and industry lobbyists are very powerful. Political leadership for change is often lacking from the beginning or eventually the good idea is sacrificed for a different priority. Sometimes politicians are excited by a good idea, pass a bill, even allocate funds, but the agency tasked with implementation is not committed and the idea is slowly forgotten. The final blow to a good idea is being relegated to a taskforce or study group.
Money can be the problem, and money is always a political issue. Given state budget pressures, good ideas are often starved for resources. Trying to do big things on a shoestring is a common trap. Even worse is expecting immediate, sizeable savings from a good idea. We’ll spend billions to treat health care failures, but only pennies to prevent problems.
However, the converse is also true. Sometimes throwing too much money at a good idea is the problem. Connecticut has made several very costly attempts to implement a health information exchange (HIE) and each has failed spectacularly. In states with functional HIEs, providers can coordinate care for each patient, medical errors are avoided, and there is data for planning. Connecticut patients and taxpayers deserve a functioning HIE but when there’s lots of money available, stakeholders worry more about getting their piece of the pie than collaborating to make it work. It’s gotten so bad that our state’s medical society has given up on government ever getting this right, and are doing it with their own money, borrowing from Kansas’s successful HIE.
Connecticut has a long history of weak monitoring and regulation of public programs; implementing a new idea and just walking away is a recipe for failure. Moving Medicaid into managed care plans in 1995 is a textbook case of poor monitoring and accountability.
The contracts with insurers were quite good with clear expectations and penalties for non-performance, but they weren’t enforced. Since we reversed that decision in 2012, Medicaid quality of care is up, more providers are participating, and taxpayers have saved hundreds of millions of dollars. Despite this lesson, Medicaid is once again venturing into a questionable payment experiment without any meaningful monitoring or evaluation. Conveniently if there is no evaluation, no problems will be identified.
Connecticut policymaking is a data-free zone. Despite lots of talk about transparency, it is very difficult to get information on state government health care spending. Both Medicaid and state employee health benefits, representing over $3 billion this year, are each contained in only one line item in the budget. Getting more detailed information is difficult to impossible.
Quality information is even worse. Responses to specific questions are usually carefully crafted bullets on Powerpoint slides — not data. Regulation is further hampered by consolidation in healthcare markets. Both insurers and health systems have become too big to regulate. We can’t afford to lose any of them so they have us over a barrel.
For decades, we’ve lamented this problem, but nothing’s been done. Evaluation and accountability can be annoying and messy, and, even worse, it may not give us the answer we want. We must do it anyway.
Straight up conflicts of interest are a common block to implementing good ideas. Connecticut is the land of steady habits. Policymakers regularly go back to a small group of favored vendors and consultants to implement initiatives and it rarely works well. The favorites have no reason to make an effort on a project, as they know they will get the next one anyway; the non-favorites have no reason to bother at all. And once a group has a contract, it is very hard to switch, regardless of non-performance. Transitions are disruptive, take time, cost money and agencies aren’t held accountable for non-performance.
Our State Innovation Model (SIM) federal program has a history of giving large grants to organizations represented by members appointed by policymakers to influential SIM committees. Bills to close a loophole in ethics law correcting this problem keep dying in the legislature. Compared to other states, our state’s SIM program has a lackluster record of accomplishing little to improve Connecticut’s health system.
The last bucket of reasons good ideas fail is that we often miss the point. Too often we try an idea that is working elsewhere, but when we customize it for Connecticut’s unique environment we miss a critical element that sabotages the good idea. It looks like it should work, but it doesn’t.
We also need to be sure the new idea is really a good one, not just the latest shiny new policy toy. Beware of proposals that sound so simple that nothing could go wrong. Nothing is simple in healthcare. Smart economists test ideas carefully and monitor for harm, so bad ideas can be stopped or fixed. Particularly troubling are the Econ 101 ideas – that we will just “align” incentives, and everything else will fall into place.
In the 1990’s we put financial risk for the costs of healthcare onto insurers hoping they would control spending but managed care failed. In the 2000’s we shifted financial risk onto consumers in high-deductible plans, but costs kept rising. Now we are shifting risk onto providers and large health systems and hoping for a different outcome. Not surprisingly, it doesn’t work. But that hasn’t stopped Connecticut’s Medicaid program from implementing the experimental model.
There is a lot of good research on what works to improve health care quality and lower costs – coordinating care, prevention, managing chronic conditions, and connecting to social services. It may be old-fashioned and it is a lot harder than just aligning incentives, but we don’t have a choice. We shouldn’t “fix” what isn’t broken; we should build on it. Let’s start a constructive, non-blaming, inclusive, non-personal, non-turf conversation about barriers to improving Connecticut’s health system. But that takes principled leadership, which is probably our first problem.
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