Board of Directors Regular Meeting
March 10, 2010
Meeting Minutes
Board Attendees: Nancy Wyman, Comptroller, co-chair; Jeannette DeJesus; Bruce Gould; Paul Grady; Bonita Grubbs; Norma Gyle; David Henderson; Jeffrey Kramer; Estela Lopez; Joseph McDonagh; Jamie Mooney; Lucy Nolan; Marlene Schwartz; Marie Smith; Marie Spivey; Paul Lombardo; Cristine Vogel; Tory Westbrook; Frances Padilla; Chris Murphy; Stan Dorn
Office of the Healthcare Advocate: Vicki Veltri; Africka Hinds-Ayala, Michael F. Mitchell
Office of the State Comptroller: David Krause
Absent: Kevin Lembo, Co-chair; Ellen Andrews; Mark Boxer; Michael Critelli; Margaret Flinter; Sal Luciano; Rafael Perez-Escamilla; Andrew Salner; Michael Starkowski; Todd Staub
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Nancy Wyman opened the meeting by asking members to introduce themselves. Nancy asked for approval of minutes from the 1/13/10 meeting. Minutes were approved unanimously with no changes.
The following people were approved as new Advisory Committee members:
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Health Disparities and Equity
· Marie Spivey, Co-chair
· M. Natalie Achong
· Luis Miguel Anez
· Sandra Brown
· Esperanza Diaz |
Health Information Technology
· Enrique Juncadella
· Darlene Kish-Thompson
· Ryan O’Connell
· Jeffrey Asher
· Robert Tessier |
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Preventive Healthcare
· Nancy Heaton, Co-chair
· Stephen R. Levinson
· Dorothy Shearer
· Carlos Sanchez-Fuentes |
Health Information Technology (cont’d)
· Jody Bishop-Pullan
· Joel Cruz
· Judith Fifield |
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Healthcare Quality and Provider Advisory
· Linda Berger-Spivak |
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Advisory Committee/Task Force Updates
Health Information Technology Advisory Committee
Marie Smith reported that this group is in the educational phase, gathering data and looking at the state and national landscapes regarding HIT. Subcommittees formed to develop reports for recommendations for the final report. The Committee welcomes co-chairs of other Task Forces and Committees to make recommendations for IT implications. Nancy said that she received a call from a person from CIGNA who is interested in learning the fiscal side of IT and healthcare. Marie said she’d be willing to contact that person.
Healthcare Work Force Task Force
David Henderson reported that this Task Force had a series of webinars, which are posted online. The group is currently in the process of creating a list of the most significant issues uncovered and proposing solutions.
Health Disparities and Equity Advisory Committee
Marie Spivey reported that co-chairs were selected. This Committee has reviewed and agreed upon the definition of health disparities. The group agreed to maintain continuous contact with other Committees and Task Forces to see if they have identified inequities, and to provide and receive guidance from them. Data is under review to ensure that the Committee has a clear understanding of CT’s health environment.
Patient Centered Medical Home Advisory Committee
Tory Westbrook reported that this Committee uses webinars as an educational tool to help define medical homes. They drafted a rough outline of options and needs, including funding, options other states used, incentives for physicians, and coordination of payors. They are also considering the different pools of patient populations and how to mix these pools to create a very large sized group to work with.
Preventive Healthcare Advisory Committee
Norma Gyle reported that Nancy Heaton agreed to be co-chair of this group. They are working on narrowing their focus to where they can get best practices and the best return on investments. Subcommittees were formed, and members agreed that there is a need to integrate with other Committees and Task Forces.
Healthcare Quality and Provider Advisory Committee
Paul Grady reported that this Committee developed principles around reimbursement and quality. They identified thorny issues including medical liability reform, appropriate accountability for adherence to standards of care, low levels of Medicaid reimbursement, and the lack of empirical studies that support the approaches the Committee is considering. The Committee identified a goal of funding new initiatives such as medical homes while reducing overall spending. Paul said that the Committee identified as an obstacle the lack of professional support when it is time to write recommendations.
Tobacco and Smoking Cessation Task Force
Jeannette DeJesus said that this Task Force has held several meetings, focusing on articulating a process to identify policy priorities. Two subgroups were formed, and they are currently making an inventory what’s going on in CT, bringing together best practices by gathering relevant data that will allow the subgroups to make recommendations to the larger group.
Nancy spoke of the difficulty of scheduling the Board of Directors’ retreat. She suggested that the 4/14/10 meeting could be used for a retreat, having a facilitator help with bringing people together. The May Board of Directors’ meeting could also be used for a retreat if necessary.
Nancy gave a public thank you to the CT Health Foundation, especially to Pat Baker for her help with securing a $300,000 grant to support project management and expertise for the Committees. Nancy also thanked Frances Padilla from the Universal Healthcare Foundation who will help with managing funds. Frances spoke briefly about a meeting of people working toward the goals of SustiNet that was sponsored by the Foundation. She said it was a very hopeful discussion, with Kevin Lembo and Nancy Wyman speaking of the work of the various SustiNet Committees and Task Forces, and where CT is headed.
Congressman Chris Murphy joined the meeting by teleconference, saying that things are moving in the right direction for healthcare reform. He expressed optimism that there will be an outline from the house for a reconciliation bill this week that will partner with the Senate bill. In addition to changing subsidy levels and fixing the excise tax problem, it is expected that the reconciliation bill would incorporate some ideas from Republicans, such as stronger proposals on malpractice reform and trying to reconcile proposals between state based versus national exchanges. Chris said that he didn’t think that national exchanges would pass with this reconciliation process, but that it’s possible that states could be given choices to join with other states. He also said that the hope is to wrap this up by the end of March. The package won’t be perfect, but it will reset the healthcare policy platform to guarantee coverage for people who need it, will still make massive new investments in urban healthcare and preventive healthcare, and will begin to change the way healthcare is paid for. This bill leaves an enormous role for states to play, and SustiNet is helping CT greatly in this regard. Nancy asked if there are deadlines for individual states to implement their changes. Chris replied that the exchanges are expected to take three to four years to put into place, and the same is true of Medicaid expansion. He said that after the bill passes, there will be a summary drawn up that shows what the states’ obligations are, including a timeline.
Bruce Gould asked if there was a website showing a synopsis of bills including updates. Chris recommended www.whitehouse.gov. He said that the bills can be followed on Chris Dodd’s website or on the House website; the Senate bill is HR 3590 and the House bill is HR 3962. The reconciliation bill won’t be a public document until next week or so. This will be on the House website also. The outline of the reconciliation bill can be seen now on the White House webpage.
Paul said that the original SustiNet bill included medical malpractice reform measures but they were stripped out during the legislative process. He said that President Obama is considering adding funding for pilots for malpractice reform in different states. Paul asked Chris if he thought this would happen, and if so, how CT could position itself to receive some of the funding. Chris said that he thinks that some measure of malpractice will be included. It may be that CT is already doing some of the things being proposed, as CT passed a malpractice reform law a few years ago. It is too early to predict how this will play out. In response to Paul’s comment that medical malpractice language should be included in SustiNet recommendations to the Legislature, Chris said that he feels that this should be done, but cautioned that the states with the highest per patient medical costs are the ones with the strongest malpractice laws, so this doesn’t fit in with lower healthcare costs.
Stan Dorn spoke via teleconference about how SustiNet could move forward. He said there are two critical issues, the first being to increase subsidies relative to where CT is today, building on Husky and using automated enrollment strategies to increase the number of enrollees. Secondly, Stan suggested using the existing critical mass of Medicaid, Husky, state employees and retirees as a basis for a new publicly administered health plan, SustiNet, that would implement critical healthcare delivery system reforms like HIT, patient centered medical homes, care coordination, incentives for evidence based medicine, etc.
Having a critical mass will make it easier to leverage changes to the healthcare delivery system. SustiNet would be available in the private marketplace for individuals or employers to purchase as an alternative to private health plans. Stan continued, saying that there is a short term priority at the federal level to develop legislative history. An example of this is clarifying the option for the state to cash out federal dollars and spend them more efficiently, making it clear that the option will be available for a SustiNet type approach. Stan also said that there will be adjustments required to deal with wrinkles created by federal legislation. For example, SustiNet would need to get a license to sell insurance in CT in order for it to be offered on the exchange, so there is a need to look at CT licensure requirements. Stan concluded by saying that CT has made great strides in creating SustiNet, putting it at the forefront of other states in accessing some of the upcoming federal opportunities.
Nancy opened the discussion for questions, asking Stan about state retirees, and whether the federal government will help with their healthcare benefits, since their benefits have already been negotiated with unions. Stan said that provisions in the reform bill would make reinsurance available for retirees between the ages of 55 and 64, until Medicare kicks in. If an individual’s claim is over a certain amount, the federal government will pay 80%. The statute isn’t clear, but it appears to cover any early retirees, not just state retirees. There will need to be reforms made in order to qualify for this provision, dealing with chronic illness and care coordination, among other things. Stan said that collective bargaining agreements must be respected, but CT should be able to figure out how to work with them. Reimbursement would be to the state, not to individuals. This could have the effect of lowering premiums or reducing payments by employees.
Paul raised the concern that there needs to be a good factual basis for making decisions, for example, the number of uninsured by income level. He asked what the cost would be if Medicaid was extended to all who are now uninsured. Paul also asked about the Gruber model, wondering if it was accurate. He said that MA hired the Rand organization to help in controlling healthcare spending. MA was unwilling to model many of the things CT is talking about because there was no empirical evidence that these things actually saved money. Stan said that the American Communities Survey would be a good resource for this data. He said that in MA, state government conducted its own survey to determine the number of uninsured, and it underestimated. Also MA automatically enrolled people into coverage based on available data, and it proved to be very effective. These things had nothing to do with the Gruber model. Stan said that Universal Healthcare Foundation and CT Healthcare Foundation have been working with Jon Gruber to model the effects of various policy changes and this will continue going forward. Stan has worked with three different models and has found Jon’s to be excellent. He agreed to share data from the Gruber model with Paul. Stan said that he was unfamiliar with the Rand report, but said that all reforms must be done thoughtfully in order to save money. There is data on medical homes showing great savings with chronically ill populations. Additionally, Stan said that there will be better strategies that emerge over time. Part of the SustiNet model was to create a learning institution and not just provide a governing entity.
Cristine Vogel asked whether SustiNet would be a closed model, i.e. would all state employees, retirees, Husky recipients, etc. be required to use only certain providers. Stan replied that collective bargaining agreements would not limit enrollment, and that the SustiNet plan is open-ended. There may be an incentive system for enrollees, providing them with increased coverage for enrolling in medical homes. Another possibility is to simply educate beneficiaries, making them aware that they’d receive better care coordination in a medical home. Cristine said that cost savings would only be realized if this went beyond incentivizing and required chronically ill people to be part of a good management program. She continued by saying that in Obama’s proposal, there will two exchanges, one for subsidized programs and one for individual small businesses, and wanted to know how SustiNet would fit. Stan replied that these are things that will need to be addressed by the Board of Directors in its recommendations, and then the General Assembly would make the determination. Stan said that SustiNet could compete in both of these exchanges.
Cristine asked how a SustiNet premium could compete in a small business market. Stan said that state employees and retirees are an important part of SustiNet. In competing with private insurance in a large and small market, SustiNet would not be limited to the benefit package offered to state employees and retirees. It would offer other benefit packages, allowing it to compete in the market. If healthcare reform passes, SustiNet would be able to offer lower cost deals, at least until the private insurance industry adopted the reforms.
An unidentified speaker asked Nancy how the financial modeling will work and where the data will come from. Nancy said that she’d like to invite Jon Gruber to assist with this. The state employee plan is now being worked out with two healthcare carriers, Anthem and United Healthcare.
Lucy Nolan and Marlene Schwartz gave an overview of the work of the Childhood and Adult Obesity Task Force. Lucy said that this Task Force has been gauging initiatives around the state. There are many local community based initiatives, but the Task Force has learned that some of them are not effective. They are often expensive, making them difficult to maintain, and are usually specific to certain groups. The Task Force has looked at national and local efforts and is looking at health disparities related to food insecurity and obesity and overweight issues. The federal government and the USDA are currently very supportive of this type of effort. Marlene said that the Task Force is looking more at policies than at programs. The efforts of CT’s Obesity Council have provided valuable insights, but it has become clear it would be helpful for CT to have a permanent council on child and adult obesity that has statutory authority. The Task Force is working on a list of people who should sit on this council. The Task Force is also recommending a better surveillance system throughout the state for body mass index (BMI). The various presentations and minutes of this Task Force can be found on the website www.ct.gov/sustinet.
Estela Lopez expressed concern over the collection of BMI, saying that there needs to be a meaningful way of doing this. Marlene said that the Task Force will work with the Department of Education to see how BMI is collected and maintained, ensuring that all information is de-identified before it’s released. Jeannette strongly suggested that there be people sitting on an obesity council from diverse backgrounds, including people of color and people from different cultures who have differing ideas of obesity. Marie said that parents and other adults who provide guidance to children need an educational process as well, and that it will need to be different than what there was in the past, not simply sending literature home with students but engaging parents on healthy lifestyles, taking into consideration cultural backgrounds. Estela said that with recent immigrants, food choices are healthier than with people who have been here longer. She said that children accept fast food more readily than their parents. Jeannette said that assimilation and acculturation is actually bad for one’s health. People who are here for only a short time maintain their cultures’ food habits. The longer people live here, the more junk food they eat. Jeannette also said that parents feed their children chips and soda because that’s what they can afford, and this is a very serious problem. When the Hispanic Council did outreach, it was found that people didn’t know how to prepare vegetables, showing that there is a very big educational component needed.
Bruce said that one of his roles is Medical Director for the City of Hartford Health Department. That Department has been looking at access to fruits and vegetables in Hartford and also at exercise options. He emphasized the need to look at cities as a whole, ensuring that there is access for pedestrians and bikes. He also suggested that by using taxation, making poor food choices more expensive and good choices less expensive, people would be encouraged to eat better foods. Marlene said that many states are considering taxing soda. The revenue generated could be used for doing things within SNAP and WIC programs, or working with corner stores to change the environment by making healthier foods more available and affordable.
Bruce said that another of his roles is Medical Director of Burgdorf Clinic in Hartford. Patients come in and want to know where they can go to get healthy foods and what exercise options are available. The City Health Department is hoping to post this information online, so that an address could be entered and information about resources that are close by would be accessible. This may be something that fits in with medical homes.
An unidentified speaker questioned the need for the new obesity council that Marlene spoke of, asking what the benefit would be and how the Task Force determined it was needed. Marlene said that there is a current Obesity Council, but that they have been acting unofficially. She said that the intention isn’t to create something new but rather to shore up something that’s already in place, giving it some authority.
Nancy said that today’s meeting showed how all parts of SustiNet are connected, and that all are affecting healthcare.
Meeting was adjourned.
Next meeting will be on April 14, 2010 at 9:00 am.
