NEW HAVEN, CT — Last week the state Office of Health Strategy held a public hearing on a plan to transfer 28,500 mostly Medicaid patients, now served by three Yale-New Haven (YNHH) neighborhood primary care clinics, to a new site on Long Wharf.
All staff at the current three YNHH sites will transfer to the new site with the patients. But in a twist that could cost the state millions, those patients will technically become patients of New Haven’s two community health centers, Fairhaven and Cornell Scott Hill Health Center. Patients will be administratively assigned to the two community health centers, but will be cared for by the same YNHH staff in a less accessible setting owned by YNHH.
Community health centers are paid higher rates, often three times more, by the state than other providers of care. The hospital and the two health centers argue that the new proposal will lower overall costs by improving continuity of care, expanding behavioral health services, and lowering expensive emergency room visits. But advocates, providers, community representatives, and patients have serious concerns about the proposal.
Advocates are concerned that higher state costs under this plan will precipitate Medicaid cuts. YNHH’s proposal states that “Shifting active management to [the community health centers] allows for increased reimbursement through the FQHC [federally qualified health center] enhanced Medicaid rate structure.”
In addition, the community health centers will receive over $1 million more each year under a new and controversial Medicaid program called PCMH Plus. Both YNHH and the community health centers expect to profit from the deal, but if revenues change, which is very possible given looming state deficits, YNHH’s liability is capped. In that case, the community health centers would have to absorb those losses, potentially cutting care for patients at all sites across the city.
Surprising many in the room, YNHH also agreed to give bonuses of up to $68,665 to executives at both community health centers when the deal is completed. Claudette Kidd, a New Haven community health center patient, testified that the process “has become all about the financial profit schemes and not about the patient.”
YNHH is not the first Connecticut hospital to consider this financial scheme, nor are they likely to be the last. If approved, YNHH would be the sixth hospital in the state to shift payment for primary care clinics to community health centers, but keep providing the same services with the same staff. The state has not evaluated how much this is increasing state spending.
In addition to higher state costs, advocates and providers are very concerned about significantly higher costs for patients if the plan is approved. YNHH does not charge uninsured patients with incomes below 2½ times the federal poverty level or $30,350 a year for a single person, and provides discounts above that level. In contrast, both community health centers charge all uninsured patients, regardless of income, for almost all care, from $20 up to hundreds of dollars.
In response to these concerns, YNHH announced at the hearing that they are considering creating a new “hardship fund” for patients having trouble paying those bills, but no details were provided.
The proposal also raises serious transportation concerns. Long Wharf is not in a residential neighborhood. Travel from the other three clinics by bus during the day ranges from 20 to 45 minutes, including up to 29 minutes of walking and two buses. As acknowledged by YNHH, patients could shift their care to closer current community health center sites, adding to long wait times. YNHH stated that they would consider options to ease travel including a shuttle or Uber rides, but made no commitments.
There are deep concerns about access to services under the proposal. YNHH is proposing to significantly increase the number of patients providers must see each day. While the proposed addition of behavioral health services is helpful, the loss of access to in-house or close-by pharmacies and financial assistance to afford medications is very troubling. Concerns about access to family planning and abortion services were also raised in public comment.
Serious quality concerns about the proposal were also voiced. Marge Eichler, a Registered Nurse and New Haven resident, stated that when she and her children were community health center patients, they had long waits for appointments, had difficulty getting care, and had to come back often for prescription refills. But since they transferred to YNHH’s clinic, they’ve received high quality, respectful care from dedicated staff. In 2015, Connecticut’s community health centers performed worse than other Medicaid providers in 11 of 12 quality measures. Community health center patients, including New Haven’s two centers, are far more likely to visit an ER than other Medicaid members, even those without a usual source of care.
There has been very little publicity and no community outreach about the plan. In answer to a question by state regulators, YNHH stated that they haven’t consulted the community because all the decisions haven’t yet been finalized.
State regulators have asked for more information before making a decision. Connecticut’s state budget is facing significant deficits. We cannot afford to pay more for the same (or less) care, to the same patients, delivered by the same clinicians, that is harder to access.
Ellen Andrews, PhD, is the executive director of the CT Health Policy Project. Follow her on Twitter @CTHealthNotes.
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