ACA

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.

UConn Health Works to Reduce Complications, Costs In Common Procedures

illustration of a nervous man from the Operation Board Game receiving a partial large intestine transplant. Illustration by Yesenia Carrero / UConn-University Communications


Just seven procedures account for most of the costs and complications of emergency surgeries in the U.S. each year, according to a study in The Journal of the American Medical Association April 27.

UConn Health’s surgeon-in-chief Dr. David McFadden is not surprised. These seven procedures are some of the most common, including gallbladder and appendix removal, and it makes sense that the most common surgeries are also responsible for most of the costs. And since UConn Health is on a constant quest to provide the best care possible, the surgery department was already working on some of the issues discussed in the study.

Just seven procedures account for most of the costs and complications of emergency surgeries in the U.S. each year.

For example, UConn Health participates in the National Surgical Quality Improvement Project (NSQIP), a service that tracks surgical complications such as infections, strokes and heart attacks, and alerts the surgeons to patterns. Catheter-associated urinary tract infections are one such common complication that happens in hospitals across the country. UConn Health surgeons decided that they would no longer accept that.

“We have started a focused, all-out war on catheter-associated urinary tract infections,” says Dr. Stephen Lahey, chief of the Department of Cardiothoracic Surgery and vice chair of quality improvement in the Department of Surgery. The NSQIP data has shown that there are subsets of patients who are much more likely to get urinary tract infections. The surgery department now focuses on those patients and has significantly reduced this type of infection. Reducing post-operative pneumonia in vulnerable populations is the department’s next project, Lahey says.

UConn Health’s work in this area is part of a national focus on improved population health care that stems from the passage of the Affordable Care Act, commonly known as Obamacare. Medicare has begun listing surgical complications that should happen rarely or never, and will lower or deny reimbursement to hospitals where they commonly occur. Private insurers are following suit. This can be a potent incentive for hospitals to support what medical personnel want to do anyway: find and reduce or eliminate the sources of complications.

“While lowering or denying reimbursement for certain patient events such as hospital readmission is a powerful incentive for hospitals to minimize their occurrence, we must never lose sight of the primary reason we do this — providing the best and most appropriate care to our patients,” Lahey says.

The main goal, he says, is “to alleviate suffering and improve the health of the population we serve. If we do that well, the finances will take care of themselves.”