When Heather Greene’s nine-year-old daughter Hope needed her tonsils out two years ago, Greene had to call a number of surgeons near her home in Waterbury before she found one who would accept her Husky A insurance.
“Finding a specialist who takes Husky is tough,’’ said Greene, a part-time parent advocate at CT Parent Power. “It’s kind of like having another job.”
Beyond uncertainty and wasted time, this experience leads to more costly and uneven health care outcomes. On Jan. 1, 2012, health care advocates say, families like the Greenes will achieve better care, their doctors will have more control over treatment and the state will save millions as the state adopts a new health delivery system.
Instead of managed care companies, the state will switch to an administrative services organization to self insure Husky and other Medicaid programs that serve a total of 600,000 Connecticut residents.
Supporters say the change will improve care while saving the state more than $86 million a year – including $29.5 million for the care of nearly 400,000 Husky patients – by cutting wasteful spending and reducing unnecessary tests and trips to hospital emergency rooms.
“In my opinion, they’re going to be getting better care,’’ Lt. Gov. Nancy Wyman said at the announcement last month. “We can really watch where the dollars are being spent. This is true transparency that we have not seen before.
“The state’s new system will include delivering care through a “person-centered medical home”, Department of Social Services spokesman David Dearborn said.
“With the state moving away from managed health care plans to the ‘administrative services organization’ model, we also plan to move beyond the current scope of our Primary Care Case Management (PCCM) pilot to develop a network of ‘patient-centered medical homes’ and “health homes,’” he said.
“Incorporating what is learned from the PCCM pilot will help in establishing new patient-centered medical home standards,’’ he said. “This will be geared to improve care for all Medicaid-enrolled individuals, including those who are aged or with disability, and who have some of the most challenging serious and chronic health care conditions.’‘
Under the Husky Primary Care, Husky patients will choose a primary care doctor who will be paid $7.50 per month per Husky patient by the state to coordinate all aspects of their care. Doctors will no longer be subject to second-guessing by managed care companies, advocates said.
“What a remarkable difference this will make in people’s lives,’’ said Ellen Andrews, executive director of the Connecticut Health Policy Project. “The doctor will coordinate your care, make your appointments, screen you and help you stay on track.”
Pilot Program, Low Enrollment
Husky Primary Care will expand a 2009 pilot program that has enrolled 514 Husky patients in 25 practices in Waterbury, Windham, Hartford and New Haven, said Dearborn. Putnam and Torrington providers are on tap next, he said.
Andrews called those numbers “pathetic,” and Sheldon V. Toubman, an attorney at the New Haven Legal Assistance Association, said DSS has put up numerous “barriers” to keep patients from enrolling in PCCM. He said doctors could not tell patients about the option unless the patient brought it up first, so the advocates distributed large buttons that said “Ask Me About PCCM.”
“DSS has really had a campaign of restricting enrollment,’’ Toubman said. “It’s been a recipe for failure.”
Dearborn declined to respond directly to the department critics.
Dearborn provided copies of brochures about PCCM that DSS sent to doctors’ offices and reports quoting DSS officials that doctors can discuss PCCM with patients, so long as they don’t “steer” them to it. All Husky A recipients in the pilot areas were sent letters telling them about the PCCM option, records show.
Still, DSS officials told the state’s Medicaid Managed Care Council in February that PCCM is a new concept that is hard to explain to doctors and even harder to explain to patients. They also said many doctors do not offer evening or weekend hours and that getting internists and family physicians to buy in to PCCM is challenging.
Consultants for the Connecticut Health Foundation reported last month on the benefits and drawbacks to PCCM. Consultants Meryl Price, Kip Piper and Marcia Stein found that PCCM offers patients access, choice and control of their health care. But they also found that the rates of payments to doctors may not be adequate, significant staff is required to make it work and the focus is on primary care, not specialty care.
State Rep. Michelle Cook, a Torrington Democrat on the Medicaid Managed Care Council, has previously said that DSS “sabotaged” the pilot program by not marketing it properly. But she says she is hopeful that DSS will make primary care case management a reality Jan. 1.
“This is a totally different administration that’s already made some positive changes,’’ she said. “I don’t want to rehash the past. I’m hopeful about moving forward.”
Patients And Doctors
While home with a sick child in her third-floor apartment, Heather Greene described PCCM as a boon to families like hers.
“You won’t have to go through the HMO middleman. Your doctor will be in charge,’’ Greene, 36, said. “They know you best.”
Her two daughters have been on Husky A for years, and Greene and her husband Tim joined them two years ago when he was laid off from his job as a refuse truck driver. She said he has been unable to find steady, paying work so the family relies on the $1,000 a month she earns as well as food stamps and other state aid.
Having learned how to navigate the Husky system to get prescriptions and specialists’ care, Greene now represents other Husky recipients on the Medicaid council.
“I’ve got a wealth of information that I’d didn’t have before,’’ she said. “I want to get all the Husky patients in a room and teach them what their rights are.”
The state’s change to PCCM has some doctors, such as Dr. Barbara Phillips, a Manchester family practitioner, seeking more information on how it will affect them.
She wonders if the $7.50 per month per patient will be enough to cover her practice’s costs and what the incentives will be for specialists to take Husky patients.
“I see how this would be a lot cheaper for the state, but I’m not sure how it would translate to better care for the patients,’’ said Phillips, who added that she and many family practitioners already coordinate care for their patients.
Dr. M. Alex Geertsma, a Waterbury pediatrician on the Medicaid council, said PCCM can save substantial dollars and improve care if the state gives doctors the right support and incentives.
“Some physicians may change their practice around totally or hire a care coordinator who will prove invaluable to patients and parents,’’ he said.
Dr. Ronald Angoff, a New Haven pediatrician who has been fighting for years to have the state adopt PCCM for Husky patients, said he’s convinced it will improve care for the state’s poorest families.
“The patients need this quality of care, and as a taxpayer, I know it makes sense,’’ he said. “It’s better for everybody.”
I doubt this is going to improve access to subspecialty care like the ENT Ms. Greene had to call around to find. There’s nothing here to indicate that the new plan will be paying practitioners any better than they have been paid in the past by Husky, Medicaid, Charter Oak or SAGA. Hence, many doctors will continue to simply refuse to take patients with this insurance because they will lose money each time they see a patient with what the government pays. It is time to institute a mandatory “pro bono” system so that all physicians in the state are required to have a percentage of patients in their practices who have state health insurance.