Health Care Cabinet continues to debate reform plan; Medicaid commitment on downside risk reversed

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Yesterday’s Health Care Cabinet meeting started with a statement by the Lieutenant Governor stating that the commitment made last year not to implement downside risk in Medicaid was time-limited to end with the state’s SIM grant in 2019. However that was never conveyed to advocates and, in fact, the state made a clear commitment, without any conditions, not to implement downside risk in Medicaid here, here in their plan to CMS and to potential PCMH+ (formerly MQISSP) applicants in the RFP. The commitment was originally made in negotiations to get partners, including advocates and providers, to participate in designing PCMH+, Medicaid’s plan for upside-only shared savings.
The rest of the meeting focused on proposals to cap health expense growth across the state, setting a target for payment reform contracts in the state, merging state agencies that touch health, HIT, ad comparative effectiveness research, and creating a new Office of Health Reform to set spending caps and payment reform targets among other duties. We then moved onto alternatives plans from many sources, including the CT Heath Policy Project. Other commenters also concerned about the expansive shared/downside risk proposal included AARP, Christian Community Action, and a collaborative alternative signed by twenty independent consumer advocates. Alternatives to the ACO provider coordination/consolidation plan included coordinating care with community-based organizations and building on Medicaid’s successes. Alternatives to the very controversial shared/downside risk proposal included focusing reform on primary care, moving back to global capitation across the state, and continuing to tie more provider/health system compensation to quality and away from volume. Alternatives to the cost growth cap proposal include regulating mergers, direct rate setting and consumer affordability. There were calls not to put the tool before the goals and wait before considering the 1115/DSRIP proposal. A new goal was raised in alternative plans to limit the growth of prescription drug costs – the Cabinet decided to take these up separately.
Unfortunately big areas were ignored (or danced around but not addressed) including the biggest – a pervasive lack of trust – and its corollary – very poor communications. The proposal is entirely silent on the critical issue of underservice*, which is a problem far beyond Medicaid. There was no mention of regulating ACOs as they assume huge control over health care spending and treatment decisions, the need to address high-cost, high-need patients, ensuring we have the workforce to do any of this, integrating behavioral health into medical care, social determinants of health  or addressing the sorry state of health care quality in Connecticut.

We will deliberate and vote on Nov. 1 at 4pm and there will (finally) be an opportunity for public input at the Cabinet’s Nov. 15thmeeting at 9am.