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Healthcare is too expensive, and the costs are growing faster than the rest of the economy, but we aren’t getting the quality or outcomes that justify those costs.
To foster innovative solutions, 34 states were awarded large federal State Innovation Model (SIM) grants to promote reforms in healthcare. Connecticut’s SIM project, run by the Office of Health Strategy (OHS), received $45 million over four years, but we have little to show for it.
SIM is just the last, and most costly, Connecticut healthcare reform plan to disappoint. What went wrong? How can future Connecticut reformers avoid SIM’s mistakes and succeed?
We surveyed independent stakeholders for their feedback on SIM and their best advice to guide future reformers. The most common complaint was that SIM started with a pre-determined plan from the beginning. Stakeholders commented that SIM leaders began with the premise that changing the structure of how we pay for healthcare would organically result in downstream changes in healthcare delivery, prevention, quality, and eventually in improved outcomes.
SIM was described as a “one-trick pony” pushing capitation and related payment models as the single solution to all problems. Under capitation, insurers or large unregulated health systems are paid a set amount per person to cover all healthcare expenses. Capitation, also called “managed care” in the 1980s and 1990s, failed in Connecticut when people were denied appropriate care and provider rates were cut. Related provider risk models give healthcare provider organizations incentives to reduce care.
SIM and their out-of-state consultants mislabeled their payment model to sell it, calling it “shared savings” or “bundles”, which are very different, and less risky, payment models. Ideally, monitoring for inappropriate underservice and lower quality of care protect people from harm, but those provisions weren’t developed.
SIM took advantage of a loophole in state ethics law by awarding large grants to supportive members of SIM committees. In contrast to Connecticut’s usual process, SIM leaders chose who could be on their committees rather than the usual process of bipartisan appointments based on qualifications. According to stakeholders, “Individuals [were] specifically selected for SIM committees because of their favorable view of the pre-ordained SIM initiative.”
It may be counterintuitive, but SIM also had too much money. Too often, large grants lead to groups vying for a piece of the pie rather than figuring out how to work and learn together, come to consensus, and get it done. SIM spent vast sums on consultants, most from outside Connecticut. Consultants were carefully chosen to advance SIM’s predestined model rather than starting with a blank slate, listening to stakeholders, and helping Connecticut find solutions that will work here. As in the past, the consultants were not very successful. SIM and OHS missed an important opportunity to build policy and analytic capacity within the state that wouldn’t leave when the grant ran out.
SIM didn’t listen to communities about their needs but decided for them. SIM’s Health Enhancement Communities (HEC) project stated that they would address community-driven health needs but started with pre-determined goals based on what would attract further federal grants. Under HEC, communities can also work on other, bigger health problems in their area, but they won’t get any funding for those community priorities.
Connecticut stakeholders gave us wonderful, constructive advice to get reform right next time. No one is more invested in fixing our state’s healthcare system than consumers, advocates, and providers. The most common advice was to fully consider all options and not chase federal grants.
Some of the feedback included: “Start with an open mind as to what models are to be explored,” and “don’t try to do something that’s already been tried here and failed.”
Stakeholders also blame SIM’s exclusion of independent voices for its failure. “Involve ALL stakeholders from the beginning, ESPECIALLY those who are most likely to be impacted by whatever it is you’re recommending.”
Connecticut’s trust levels among stakeholders and with state government aren’t great. Without trust, developing policy is pointless and implementation is impossible. Any reform effort needs to address that problem from the beginning with radical openness, the patience to work collaboratively to find feasible solutions, and engage the stakeholders will need to make it work from the beginning. The next reformers must listen and tell the truth, using common, clearly defined terms. They must let the evidence drive decision-making, working through people’s concerns. SIM used expedience over building trust, and it didn’t work; it never does.
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