Public Policy

Fighting for Equity

By Kim Krieger

an ipad with the following math equation demonstrating the  complex medical math you must do to figure out your own bill. How much will Robert Pay? Robert receives a bill for $530. The member rate charged by his in-network doctor to remove a wart from Robert’s foot in early January. Robert has a $30 co-pay. The amount paid at the time of the visit, which doesn’t count toward the deductible. His plan includes a $100 deductible. That’s how much Robert must pay before insurance kicks in. A 20 percent coinsurance applies to the visit. Robert has to pay this much of any covered service. Answer: $210


Working in the health care industry is no defense against insurance jargon, it seems. When Dr. Victor Villagra, director of policy at UConn’s Health Disparities Institute (HDI), recently posed the question at left to the audience at a health care industry conference luncheon, very few attendees answered correctly. And yet everyday people shopping for health insurance for their family or small business must routinely solve these types of questions to accurately compare plans — or risk making an expensive mistake. Many doctors are effectively small business owners and face these same complex calculations when choosing health insurance for their employees.

And doctors face a different, but related, dilemma on the other side of the equation, when a patient with a high deductible insurance plan suddenly cannot pay the full deductible amount. High deductible plans set the stage for an adversarial relationship between a doctor and patient, where the doctor feels compelled to hire a debt collector to get paid. The patient feels betrayed, and the caring relationship deteriorates beyond repair.

“New insurance designs are extremely complex. Patients don’t know how to use their insurance,” and often doctors get stuck in the middle, Villagra says.

If it were complex and equitable, I could deal with it. But it’s not equitable.

Besides confusing calculations, health insurance is rife with obscure vocabulary. A Kaiser Family Foundation survey found that 58 percent of uninsured survey participants didn’t know what a “health insurance formulary” was — it’s the list of drugs covered by that insurance provider — and 9 percent of those surveyed thought it was “the form you send to your insurance company when you need to have a medical bill paid.” Additionally, many did not know what a “health insurance physician network” was — some believed it was a collection of computers doctors use to talk to each other. Further, almost half the survey respondents could not pick out the correct definition of “deductible” on a multiple choice test.

More Americans have health insurance than ever before thanks to the Affordable Care Act, but a variety of factors still make it hard for many to access quality care. Villagra and his colleagues at the HDI are aiming to change that, by increasing literacy and lobbying for policies that help people choose the best care and coverage available.
They believe raising health insurance literacy is the best, and most immediate, way to help people avoid bad insurance policies — and broken relationships with their doctors. The question is, how?

In the near term, Villagra and his colleagues want to train “health insurance helpers” who can station themselves in libraries and community centers during open enrollment and help people shopping for health insurance make wiser choices. These helpers will be especially important in poorer communities and areas where many people do not speak English well, do not own their own computers, and may find the health insurance descriptions impenetrable. The HDI also wants to persuade health insurance companies to make insurance easier to use by writing the plan descriptions and subscriber agreements in plain English rather than legalese.

But the HDI is primarily engaged in research and policy development. In order to change the system, the HDI is partnering with organizations directly involved in providing health insurance to consumers. For example, the HDI is working with Access Health CT to make a computer app that can help people more easily compare benefits between health care plans.

Access Health CT is the operator of Connecticut’s health insurance exchange. Small business owners and private citizens without health coverage currently use the exchange to figure out which plans and subsidies they qualify for under the ACA, or Obamacare. After a rough start in 2014, when the exchange website malfunctioned and shut out many would-be enrollees, Access Health CT has rallied. It’s now considered one of the most successful exchanges in the U.S. But Access Health CT still has a lot of challenges to deal with, both in getting people covered and then helping them use the insurance they — or state taxpayers — are paying for. A majority of people who enroll in a health care plan through Access Health CT are eligible for Medicaid, and one of those challenges occurs when they ‘price out’ and are no longer poor enough to qualify.

For example, consider M., a carpenter living in central Connecticut who asked not to be identified. He had health insurance through his wife’s job as a certified nursing assistant until 2013, when her facility closed. M. lost his job six months later, and his family of four became eligible for Medicaid. They were able to enroll relatively easily by calling Access Health CT.

In order to change the system, the HDI is partnering with organizations directly involved in providing health insurance to consumers.

“My dentist didn’t take the insurance anymore, my dermatologist didn’t take it, but we made do,” M. says. The family switched dentists and worked a deal with the dermatologist. Their primary care doctors continued to accept their new insurance because they were existing patients. M. considers himself lucky.

But his income went up due to overtime this past year, and state law lowered the Medicaid income threshold for a family of four to just $37,665, down from $48,830 the year before. His wife called Access Health CT and spoke with someone about the family’s new situation. She was told they could purchase health insurance for somewhere in the range of $1,400-$1,800 a month.

“That’s a mortgage payment,” M. says. “I’d have to take on two more jobs.”
His wife is in nursing school now and he hopes they can get insurance through her new employer when she graduates. Until then, he hasn’t heard anything concrete about when they’ll lose their current coverage.

For Access Health CT, helping people obtain coverage and cope with the financial realities of health insurance in Connecticut is just the start of its mission. Now, the exchange wants to move forward with helping people find doctors who will treat them, and getting them the right type of care, focused on prevention and wellness, according to CEO Jim Wadleigh. And that’s where the HDI and Access Health CT intersect. HDI can give Access Health CT policy support and research backing, and Access Health CT can actually implement it.

“They are the lever of change,” says Pat Baker about Access Health CT. Baker is president of the Connecticut Health Foundation. The organization granted the HDI $155,244 this year to increase health literacy in the state, and is glad to see them partnering with other agencies. The Connecticut Health Foundation’s primary focus is increasing health equity in Connecticut, and Baker finds it particularly disturbing that half of African Americans and Latinos newly insured under the ACA in 2014 haven’t used their health insurance yet. Many of the non-users receive large subsidies. It’s an enormous transfer of wealth from taxpayers to private companies. Society isn’t doing that so citizens can stay sick or be turned away from doctors who “don’t take Obamacare,” Baker says.

Substantive change is needed, and in addition to Access Health CT and the Connecticut Health Foundation, the HDI is working with the Connecticut State Medical Society, the state Office of the Healthcare Advocate, ConnectiCare, the Department of Social Services, and many local community groups. Over the long term, HDI policy director Villagra has very specific goals. For example, he hopes the number of health plans available in marketplaces will be reduced, allowing consumers to choose from fewer, but better, options. This would also help insurance companies cross-subsidize risk across large populations. Another long-term goal would introduce performance-based regulation to make health insurance costs more transparent, similar to the rules that protect consumers from abuse by public utilities. And last but not least, Villagra hopes high-deductible plans will be eliminated and turned into insurance that provides better value and stays out of the doctor-patient relationship.

“We are in the health insurance capital of the world,” Villagra says, referring to Cigna and Aetna headquarters and many other insurance companies that have large presences in Connecticut. Villagra used to work at Cigna, and he doesn’t intend to cast a shadow over the industry.

“If it were complex and equitable, I could live with it,” he says. “But it’s not equitable.” Until it is, Villagra and his partners at the HDI and institutions across the state will work for a better, fairer system of health insurance.

How Should Medical Providers Prepare for Value-Based Care?

Q&A with Dr. Andrew Agwunobi, chief executive officer & executive vice president for health affairs at UConn Health

UConn Health University Tower

Q

What exactly is value-based care?

Value-based care means that future health care payments to medical providers by patients, insurance companies, and governmental agencies will most likely be formulated using a combination of key high-quality care metrics of each hospital’s or doctor’s office’s performance, along with an average of state or national health care service costs.

Medicare has indicated that by 2018 it will move to a value-based payment model. It is anticipated that commercial payers such as insurance companies will follow suit. Failure to provide value-based care in the future will potentially result in decreased payer reimbursements, financial penalties by the Centers for Medicare & Medicaid Services (CMS), and a shrinking number of patients using a medical provider’s services.


Q

How can medical providers best adapt to this new growing trend?

All medical providers, small and large, need to ensure delivery of health care is as cost-effective as possible, and is truly improving patients’ experiences and outcomes. Providers need to implement quality improvement initiatives, track them closely, and make sure key clinical quality metrics are measured and met. But they must also focus on improving the “value” of care, contemporarily defined as health outcomes achieved per dollar spent.

To meet these new expectations and to remain competitive, many health care providers across the nation have been joining or creating accountable care organizations (ACOs). An ACO is a voluntary collaboration of doctors, hospitals, and other health care providers who coordinate care and adhere to quality and efficiency standards in order to provide the best patient care at the most affordable cost possible.


Q

How is UConn Health preparing for value-based care?

UConn Health recently completed a successful large-scale, aggressive cost and savings initiative that is yielding ongoing annual operating and financial efficiencies. Now to remain even more competitive and provide great care at the best cost, we are currently looking at creative affiliation opportunities. We are exploring joining one or more existing ACOs in Connecticut at a leadership level. Our goal is to increase patient access to health care, while improving quality of care and our patient outcomes, and reducing the costs of achieving such good outcomes for our patients.

As part of our efforts toward value-based care, this spring we will begin the implementation process for a new, integrated electronic medical record (EMR) system called Epic. This is a nationally recognized clinical documentation system with the functionality and the capability to integrate all of UConn Health’s patient information across clinical care locations, physician offices, and medical providers into one accessible database.

This EMR will allow the sharing and receiving of the latest medical history of patients being cared for both at UConn Health and at other institutions, while providing our clinicians, researchers, and educators with a state-of-the-art clinical platform to support their ongoing missions. This EMR endeavor will enhance high-quality and cost-effective health care delivery for our patients and people of our region, and will allow for increased population health management.

How Does the Supreme Court’s Latest ACA Decision Impact Physicians?

Q&A With UConn Law Professor John A. Cogan Jr.

Q

What was the immediate effect of the Supreme Court’s ruling in King v. Burwell?

The major effect was to cement the federal government’s implementation of the law. The case dealt with a very specific issue: the subsidies offered to low- and moderate-income people. Unlike the previous ACA case, King v. Burwell wasn’t a constitutional challenge, it was based purely on a question of statutory interpretation: Could the government give out subsidies? The Supreme Court said yes. Since the constitutional and major statutory challenges have failed, we may see opponents attempt to chip away at portions of the ACA they do not like, but I think it’s safe to say we won’t see any more major cases attempting to unravel the whole law.


Q

In the wake of the decision, we saw announcements by insurer Aetna that it intended to buy competitor Humana, and then that Anthem would buy Cigna. That would bring the number of major health insurers in the U.S. from five to three, with UnitedHealth the third. How will these mergers benefit the insurance companies, and how will they affect health care providers?

The post-merger companies will each have a larger share of the market, thereby consolidating their power. Consolidation allows insurers to increase profits through efficiency gains. But these larger insurers will also gain bargaining power with healthcare providers. This is important because providers are paid directly by insurers. If you have doctors and hospitals negotiating with several different insurers, they have the ability to walk away from any one of those insurers, giving providers some leverage. But if there are only two insurers, that leverage is diminished. Major hospital systems and large physician groups will still have some bargaining power because of their size, but individual physicians will see their bargaining power diminish further.


Q

Will the effect of the mergers be in line with the intent of the law?

The ACA’s express intent was to expand coverage, and it worked. There’s nothing in the ACA regarding industry consolidation. Nevertheless, the fallout of the ACA’s expansion of coverage – efforts by insurers to consolidate market share – was foreseeable. Now that the ACA is here to stay, federal and state regulators will have to wrestle with consolidation issues.