Committee Attendees: Margaret Flinter, Co-chair; Todd Staub, Co-chair; Paul Grady; Rodney Hornbake; Mike Hudson; Jean Rexford; Claudia Gruss; Linda Ross; Marcia Petrillo; Steve Karp; Rick Liva; Matt Pagano; Bob Scalletar; Teresa Dotson; Alison Hong; Lynne Garner; Linda Berger Spivak; Jerry Hardison; Mark Thompson; Jean Rexford; Clarice Begemann; Sarah Long; Vicki Veltri; Robert McLean; Nelson Shub; Jane Deane Clark; Tom Meehan
SustiNet Consultant: Anya Rader Wallack
Absent: William Kohlhepp; Willard Kasoff; Pieter Joost van Wattum; Bill Handelman; Kathy Grimaud; Kevin Galvin; Tina Brown-Stevenson; Francois de Brantes; Christine Shea Bianchi; Lisa Reynolds; Bryte Johnson; Joseph Treadwell; Mark Thompson; Sara Parker McKernan; Mark Belsky; Arthur Tedesco; Jeff Walter; Jody Rowell; Mark Belsky; Richard Torres
Margaret Flinter welcomed all members and attendees. She said that today's meeting would focus on the final report to be submitted to the SustiNet Board of Directors by July 1, 2010. She thanked everyone for the comments that were sent to her on the report.
The minutes of the May 20, 2010 meeting were approved with no changes.
Paul Grady reported on Board of Directors’ activities. He said the Board has been reviewing Task Force and Committee reports. With the help of the consultants, the Board has created a work plan for the remainder of the year. Paul discussed the design components of the SustiNet final report that will be examined at each upcoming Board meeting.
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July |
Covered Populations |
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August |
Covered benefits/public-health investments |
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September |
Delivery system design |
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October |
Governance and Administration |
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November |
Financing |
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December |
Review |
Paul said there were still gaps that need to be filled in. He said that Anya Rader Wallack and her colleagues are providing valuable assistance in educating the Board.
Anya said she sees two major spheres that the Board will need to examine, the existing covered population and programs, and new coverage for populations that aren't covered now or that have coverage but may become part of SustiNet. Anya said that each of the meetings will begin with the base of the proposal that Stan Dorn produced in September. The Board will also be looking at federal legislation to see how that will impact upon SustiNet. There will be a consideration of the evaluation, metrics and data gathering needs around each component of SustiNet.
Bob Scalletar said that it seems this has all been done in a financial vacuum. He said there are many good ideas in SustiNet, but it doesn't seem that there will be funding for all the things being added. Paul responded that has been one of his frustrations with the process, that there hasn't been a focus on cost. He said that Stan Dorn and Jon Gruber will be providing a macro economic model that assesses the impact of SustiNet. Paul said he’d like to see more focused estimates of the financial impact in addition to the economic model.
Margaret said SustiNet will encompass populations that CT is already buying care for. The newly insured and the formerly unable to be insured can enter the exchange in 2014. The question is whether SustiNet will be an option in the exchange. Margaret said she felt this was a critical issue that needs economic data before a determination can be made. Paul replied that it's an important consideration, adding that the Medicaid population will be moved from an insured basis to a self-insured basis, potentially changing the benefits. The benefits are somewhat defined by federal law; the Board doesn't fully understand how the recommendations being made will impact Medicaid. This goes beyond the expansion of coverage to a concern with how the cost will affect the existing program. Margaret asked if the approach of SustiNet is similar to what the Obama administration faces regarding cost calculations. Paul replied that he didn't know which arm of the government will be making these calculations. He said he didn't believe there were concrete numbers available about the return of the investment in SustiNet.
Rod Hornbake said that one of the recommendations made was the reduction or elimination of growth in costs while maintaining quality of care. He said if the plan is looked at as a set of benefits, this effort will fail. He said there were two things that were needed in order for SustiNet to reach its goal. First, reform the delivery system by the establishment of patient centered medical homes. Second, Rod said he felt it was necessary to hold provider organizations accountable, so that they understand that medical homes will require funding up front, but the provider organizations must be willing to give a money back guarantee that savings will be achieved. If that is done, it becomes affordable, and costs can be projected because of the performance guarantee. Rod said that all state and private contracts include performance guarantees, and it's time for physicians and hospitals to jointly step up to the plate. Paul said that it's unknown how many providers will accept that proposition; maybe there will be enough to provide care for the covered members. Rod replied that SustiNet could promote the development of accountable organizations willing to step up to the plate. He continued that there are a great number of physicians who are ready to step up. He said that if this is structured properly with funding up front for a reformed delivery system, it would be possible to extract a performance guarantee in conjunction with shared savings. In order to take this to the next step, for these organizations to grow, develop and invest in infrastructure, they must create a revenue stream supporting that. Robert McLean said that Yale New Haven Hospital is looking at accountable care modeling and perhaps could provide assistance.
Margaret asked about whether Medicaid elderly living in nursing homes would be enrolled in SustiNet. Anya said the board would address this in July. She felt it was less logical to include long-term care, but more logical to include dually eligible persons for management of chronic diseases. Margaret mentioned that CT is way above the national average in the percentage of elderly living in nursing homes, at a great expense. This will be something to keep in mind when discussing the impact of federal health reform and funding for patient centered medical homes and a broader range of services. Margaret asked Paul and Anya about the administration and governance of SustiNet, and the establishment of a standing committee. She asked if the standing committee’s role would be to establish principles rather than oversee operation. Anya replied that this will be addressed in the October meeting. Paul said he thought it would be helpful if this Committee made a recommendation on making SustiNet operational. Margaret agreed, saying there have already been recommendations made for separate quality and safety committees.
Margaret opened the discussion of the final report. She said she and Todd Staub attended a Board of Directors meeting where co-chairs of each Committee and Task Force presented their reports. This was invaluable in showing how the various Committees complement each other. Anya led the review of the report, saying that she would do an executive summary after all sections had been reviewed. After much discussion, it was agreed that there would be a strong statement made about adhering to evidence-based practice, and making that a requirement for participating providers. Mike Hudson said the report should more strongly emphasize the use of HIE, saying this should be part of design criteria.
There was discussion about cultural competency and how it is defined and measured. Linda Berger Spivak pointed out that this is an issue that should be addressed by the Healthcare Work Force Task Force. An unidentified speaker said this issue should be tackled by the accountable organizations that are providing health care. Robert McLean said that if the system is set up with accountability at the provider level and outcomes are measured, specifically among ethnic groups, it will be seen whether cultural competency is an issue or not. Jane Deane Clark said there are national standards on culturally and linguistically appropriate services called CLAS, which are recognized by the Office of Minority Health, which is within Health and Human Services.
Next Anya discussed hospital safety, noting that this Committee addressed safety in other areas in addition to hospitals. There was discussion about principles for cost control. There was agreement that the principle contained in the report would be revised thusly: Cost control will be achieved through a combination of price control and system redesign. Nelson Shub spoke of the importance of obtaining legislative approval for this principle. Margaret said that providers need to have evidence-based reasons for deviations from the standards, using clear documentation, and the Legislature shouldn't be involved in approving standards. An unidentified speaker said there needs to be some change in the tort system that would provide protection for providers. The same speaker continued, saying that a positive defense against a charge of malpractice is that evidence-based standards were followed in a clinical setting. Robert McLean suggested this Committee make a statement that in order for this to work and to cut down on overutilization, there needs to be liability protection if standards are being followed. Vicki Veltri asked how procedures that are not yet evidence-based should be dealt with, such as investigational or experimental procedures. Rod commented that care within the context of registered clinical trials is covered, according to federal standards. Robert McLean said he thought Vicki’s concerns were addressed under the principles of quality and safety.
Next Anya opened the discussion for principles for payment systems and methodology. Rod suggested adding a bullet designating accountability for financial outcomes related to avoidable hospital admissions and unnecessary specialty services. He also said that this level of accountability has to be on the organizational level rather than on individual practices. He emphasized that reforms will need to be pre-funded at the primary care level; in exchange for that, there must be accountability. Margaret said this principle will need to be included within payment systems and methodology.
Anya turned the discussion to the recommendations section of the report. Margaret said that if there is going to be a committee for quality and another one for safety, there should be one for payment systems and methodology. Robert McLean said he thought payment and methodology should be included with the quality committee. An unidentified speaker made the point that healthcare disparities need to be clearly addressed in all recommendations. Paul suggested adding language in recommendations that prioritization of standards should be focused on areas where there are the biggest cost-saving opportunities. Robert McLean said there needs to be a mechanism so that all specialties and subspecialties are communicated to appropriately regarding standards so that information flows to the providers. Margaret said because SustiNet will be such a dominant plan in Connecticut, it will be a real challenge to keep communication flowing. Marcia Petrillo expressed concern that patient safety and quality of care intersect. She said if they become two separate committees, it needs to be clear that they will coordinate with each other on topics of mutual interest. Paul suggested that recommendations include HIT requirements as an initial priority.
Anya asked for comments on the recommendations regarding cost control. Rod said it's important to be explicit that SustiNet will promote the development of accountable care organizations. Regarding recommendations for payment systems and methodology, Rod said that provider organizations should be accountable not only for quality but also for organizational structures and financial outcomes associated with higher quality. Claudia Gruss said that most CT practices consist of small groups of providers, and that proposing a complete re-organization of medical care delivery may prove to be traumatic for them. In the short term, it may not be feasible without significant structural changes put into place. She said Rod's recommendation is idealistic, and while SustiNet should endeavor to provide this, realistically, it may adversely impact medical care delivery in the short term. Rod recommended the AMA health system reform website which shows how physicians can thrive in the new, emerging environment.
Margaret said the revised report would be sent to Committee members via e-mail, and asked everyone to e-mail comments they might have, as this is the final meeting before the report is due. Margaret thanked everyone for their steadfast participation. Todd expressed his appreciation, saying the report will be powerful and effective. Paul thanked everyone on behalf of the Board, saying that there may be additional information needed by the Board.
Meeting was adjourned.
