Where’s the Value?

The recently settled dispute between Anthem and Connecticut Children’s Medical Center, which left children and their families hanging for almost 2 months, is an example of how broken our health care system is in Connecticut.  It is unconscionable that already over-burdened parents of children with serious health conditions had to worry about where their children would receive care and whether their insurer would pay for that care.  As this clash illustrated so vividly, we have a system that is increasingly unstable and unaffordable; one that pits providers and insurers against each other in a contest of wills where the clear losers are the patients. 

What we SHOULD have is a system that encourages partnership between insurers, providers, employers and consumers, a system that prioritizes health and is designed to achieve the “triple aim” of: 

  • better care
  • lower costs, and
  • improving the overall health of the population.

At a recent Health Care Cabinet meeting, the Business Plan Work Group presented a vision for how Connecticut can achieve such a system.  The work group is charged with identifying the gaps in coverage, quality and affordability that exist in our current health care system, which is dominated by national, for-profit insurers, and recommending one or more alternatives to close those gaps. 

The presentation focused on the concept of a value-based health care system.  The term “value-based” can be somewhat abstract. At its heart, it means a health care system where Connecticut consumers get more, much more, for the dollars they spend on health and health care.  Our current fragmented, contentious system is not designed to achieve value.  Individuals and employers who purchase health care and health insurance need providers and payers to be aiming for improved health outcomes, not increased volume or higher corporate or shareholder profits. 

The work group made four major recommendations to the Cabinet.  These recommendations will be finalized in a report to the Governor and the Connecticut General Assembly this fall.

1.  Diversify the Connecticut insurance marketplace by promoting new health plan entrants (nonprofit, public, and/or private health plans) and using the State’s purchasing and convening power to influence existing health plans to pursue a value health strategy.  

Some key building blocks are already in place to meet this recommendation.  With regard to promoting new entrants, the recent announcement that a Consumer Operated and Oriented Plan (CO-OP) will be funded in Connecticut is a welcome step forward.  The state government, too, has several initiatives underway that are leveraging its dollars to drive the health care system in the direction of rewarding better, more cost effective care.  Both Medicaid and the state employee health plan are offering incentives to primary care physicians to create patient-centered medical homes (PCMH) to provide care that emphasizes prevention and chronic disease management.  The state employee plan has also implemented a health enhancement program to encourage employees to follow preventive health guidelines.  Those with chronic conditions such as diabetes or high blood pressure participate in disease education programs and receive reduced or waived co-pays for office visits and medications related to their conditions.   As reported at the Cabinet meeting by State Comptroller Kevin Lembo, this program is already starting to produce dips in costly utilization.

While these are important building blocks, Connecticut lags behind other states in implementing innovative ways of organizing and paying for health care.  Much more needs to be done to diversify the State’s insurance market.

2.  Establish qualifying criteria for plans to be offered in the Health Insurance Exchange that promote a value health strategy over the long term.

When the Exchange opens for business in the fall of 2013, it will need to offer a sufficient selection of qualified health plans for individuals and small businesses to consider.  At the same time, the Exchange can be another crucial vehicle to promote innovative care and payment models to move Connecticut toward a value-based health system.  The Exchange should make every effort to capitalize on this opportunity to influence the market.

3.  Address the gaps in access to affordable, quality care that will continue for individuals and groups, even with the implementation of the Affordable Care Act (ACA).

Even if the ACA is fully implemented, there will be many people in Connecticut that will lack access to quality, affordable coverage and care.  Undocumented immigrants will not be eligible for Medicaid or for Exchange subsidies. Their reliance on intermittent visits to safety net providers and hospital emergency rooms will continue.  This lack of coordinated, accessible care ultimately leads to higher costs for everyone.  Another coverage gap will occur for those residents between 133 percent and 200 percent of the Federal Poverty Limit (FPL).  Their incomes are just above Medicaid eligibility under the ACA, but they will be unable to afford the out-of-pocket expenses of the Exchange.  Either Connecticut must establish a State Basic Health Program under the ACA to provide affordable access, or another coverage alternative will have to be found. 

4.  Ensure a trusted and effective forum exists for public agencies, private sector purchasers, providers and consumers to focus on identifying solutions and innovations in health care.

If Connecticut is going to be a leader in health reform, collaboration among public and private stakeholders as well as consumers to promote value and innovation must be prioritized.  Maintaining the status quo is not an option.

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2 Responses to Where’s the Value?

  1. Pingback: Where's the Value? | Universal Health Care Foundation of CT | Breksat . CoM

  2. Pingback: Where’s the Value? | America Insurance

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