It's no secret to say that health care has been undergoing radical change in this country. But what's less well-known is that the state of Connecticut is going beyond the current changes in the Affordable Care Act to address the way we deliver care and pay for medical services. And some consumer advocates are disturbed by the results.
For months now, a 20-person steering committee has been meeting to discuss how you get your health care, and how your doctor is paid for that. "It's the piece of the Affordable Care Act that people don't really talk about," said Connecticut's health care advocate, Vicki Veltri, who is project director for the effort. "It's the one piece that finally takes on the challenge of improving quality of care and controlling costs."
It's called the State Innovation Model, or SIM. While the health care exchanges we've all heard so much about are changing people's access to insurance, this part of the act is all about the physicians and the patients. It's developing a uniform set of quality standards for care that it hopes eventually all insurers and all health care providers will agree to.
But it's the other major piece of the model that's likely to cause the most controversy: "To change from the way we've traditionally paid for health care," said Veltri, "which is just on a fee-for-service basis, to paying for value. That is the biggest single change in the system."
The proposal is that patients will be cared for in what's been called an advanced medical home. That means your primary care provider will coordinate all of your care around a core set of expectations. They'll be asked to offer extended hours for patients, and they'll provide better links to social services. They'll also be responsible for the total cost of your care in an effort to reduce waste and inefficiency. And here's the controversial piece: if they meet their targets for reducing costs, they'll get a share in those savings.
That might sound like an invitation to cut corners, but Veltri said there will be a safeguards in place. She said, "No provider will be rewarded in this program if they do not achieve the quality standards that we set forth."
But Sheldon Toubman of the New Haven Legal Assistance Association disagrees. He said, "The most important consumer protection is completely absent in their plan, as they've written it." Toubman represents many Medicaid patients. "There are significant incentives for that primary care provider not to send out for the tests," he said, "not to send out for specialists, not to prescribe more expensive drugs. Because all of those expenses will count against the provider in terms of how much they get paid."
And he said the model's reliance on quality standards is inadequate. "Although they say they will not have shared savings given out to a provider who doesn't meet quality metrics," he said, "they very carefully make clear that one of the quality metrics will not be that the person, the provider, is inappropriately denying access to services."
The State Innovation Model that Connecticut is working on is one of 16 around the nation, funded by an initial federal grant. The plan must be submitted to the federal government by the end of this year to apply for a further $45 million in funding to work towards its implementation. While insurers and doctors have been intimately included in the planning process so far, patient advocates complain they've been shut out.
"True independent consumer advocates have no influence on this process at all right now," according to Kevin Galvin, who chairs Small Business for a Healthy Connecticut, and who's been involved in health care reform for the past ten years. He said he's disappointed in how the SIM model has been put together. "I won't say the relationship between the SIM committees and the advocates is bad right now," he said. "It's just isn't. There are great ideas, and great people, being left on the sideline."
The first draft of the model was released late last week. It will now go out for public comment for the next two months. Consumer advocate groups are due to meet with Lieutenant Governor Nancy Wyman, who chairs the SIM committee this week. Project director Vicki Veltri said she is open to change. "My belief is that there will be change. Frankly, we haven't reached every single person, and every single constituency, and we still need to do that. But the hope is that we've done enough up front work to have answered some of the questions."
SIM aims big. If it's implemented, the new model will apply to 80 percent of state residents within five years, and it says it can save ten percent of the $29 billion Connecticut spends on health care each year.