Two years ago, in response to ever-rising healthcare costs, Gov. Ned Lamont issued an executive order allowing the Office of Health Strategy to create targets — called “benchmarks” — for how much the cost of healthcare should grow each year, and to create metrics that measure the quality of healthcare in the state. The executive order also included a plan to increase the amount of money directed toward primary care doctors.
Now, the legislature is considering turning that executive order into law. But the bill is opposed by various organizations on the grounds that the extra funds for primary care will come at the expense of other specialties, like mental health, as insurance companies make choices about what services are funded and how. These organizations, many of which advocate for individuals with disabilities, also fear that potential changes for reimbursing doctors could put patients with complex health problems at a disadvantage.
The currently proposed bill would increase the amount that the state is spending on primary care from five percent to 10 percent of the total health care expenditures, or approximately $3.9 million by 2025.
In support of the bill, Office of Health Strategy Commissioner Vicki Veltri told CT Examiner that the agency regularly heard from primary care physicians about the difficulty of practicing medicine.
“We hear every day from them how they are burnt out, that they have more to do, that they’re running people through their office and the patient gets about 10 minutes and that’s it. And under that scenario, there’s not a lot of attention to the quality of care being given or whether all the patients’ needs are being addressed and … more importantly, whether we have providers who will stay in primary care and come to primary care in Connecticut,” Veltri said.
Dr. Ron Adelman, the executive director of the Connecticut State Medical Society, agreed that the state does, in fact, need to better attract primary care physicians.
“We’re facing a crisis with primary care losing providers,” he said. “They’re a key part of the healthcare team. They’re at the top of the pyramid in terms of managing healthcare and directing its flow.”
But Adelman said that the bill doesn’t make it clear where the influx of money will come from, and that it will leave the insurance companies with the discretion to determine how to best lower overall costs while increasing money for primary care physicians.
Susan Halpin, executive director for the Connecticut Association of Health Plans, which represents insurance companies, said that her industry supports the bill. But she echoed the concerns about what the increased funding for primary care would mean for other specialties.
“If you want to increase reimbursement, for instance, for primary care, there has to be an offset anticipated under specialist care or under hospital care,” she said. “Otherwise, you’re just going to increase the overall cost of care.”
Ellen Andrews, executive director of the non-profit Connecticut Health Policy Project, said she was particularly concerned that the bill could mean cut funding for behavioral health and for emergency room staff.
Those concerns were echoed by Win Evarts, executive director of the Arc of Connecticut, who warned that the increased funding for primary care could come at the expense of specialist care for disabilities.
“A lot of people with disabilities depend upon specialist care, whether it’s neurologists, whether it’s certain kinds of dentistry, you know, but a bunch of different things,” said Evarts.
Reducing costs by increasing spending on primary care?
Veltri told CT Examiner that the agency was in no way aiming to cut necessary services, such as mental health. Instead, she said, the goal was to create a situation in which primary care doctors could work with specialists to provide the best quality of care.
“Our goal is to better resource the primary care so we can do things like integrate behavioral health into primary care, get community health workers on primary care teams in a sustainable fashion, get pharmacists, nutritionists working with primary care physicians,” she said.
Commissioner Deirdre Gifford of the Connecticut Department of Social Services said that, ultimately, increasing spending on primary care will lead to long-term savings in other areas.
“Primary health care saves money because people stay out of the hospital. They take their medications more consistently. If they are hospitalized, they don’t have to be rehospitalized as frequently. Their mental health issues get addressed more completely and their social determinants of health can be addressed, but we have to resource primary care appropriately to do those things,” said Gifford.
But Andrews said that both Medicare and the Bureau of Veterans Affairs have tried increasing access to primary care, and that it hasn’t worked to lower overall costs of healthcare.
Dr. Howard Selinger, chair of family medicine at Quinnipiac University and member of the Office of Health Strategy’s Quality Council, said that he wasn’t sure that increasing primary care spending would lower overall healthcare spending, given that patients would be more likely to be referred to services they need. But Selinger said he doesn’t see that as a bad thing.
“No one can argue with the data that a more robust primary care healthcare system in the end extends life and improves quality around the world,” said Selinger.
Selinger said he believed that it would be possible to reduce the cost of healthcare by eliminating unnecessary or wasteful practices in medicine, like ordering scans or imaging that aren’t needed or prescribing antibiotics inappropriately. In taking this approach, he said, it would be possible to increase primary care spending without having to take away from other specialty areas.
“You can cut out the waste and grow the things that are appropriate — the mammograms, the colonoscopies, the vaccinations, the dental care, the transportation services, what we refer to also as the social determinants of health,” he said.
“A marker in the ground”
Besides creating a target for primary care spending, the bill also establishes targets for the amount that healthcare costs in total should increase each year, and establishes metrics designed to guarantee that lower costs don’t translate into lower quality.
The Office of Health Strategy would be responsible for creating the targets and metrics and working with hospitals and insurance companies so that they can meet these targets.
Veltri said the overall cost of healthcare has been growing at a far higher rate than the economy or individual income. Estimates from the Office of Healthcare Strategy found that the overall cost of healthcare — driven primarily by hospitalizations and pharmaceuticals — was increasing at a yearly rate of about 5.5 percent.
Both the increase in primary care spending and the cost targets were included in the executive order signed by Gov. Ned Lamont in January 2020, which authorized the agency to develop benchmarks through the year 2025. The bill being proposed now would codify those provisions into law.
Veltri said that making sure that healthcare was affordable was critical, and she said that the high healthcare costs had a particularly negative effect on the small businesses in the state.
Wyatt Bosworth, assistant counsel at the Connecticut Business and Industry Association, said that the cost of health insurance premiums for small businesses has gone up regularly over the last years. He said that this has led some businesses to start shifting more of the cost onto their employees, or even to drop health insurance coverage altogether.
Bosworth, Veltri and Gifford all said that the data collection provisions in the bill are critical to pinpointing the source of the increases in healthcare costs.
Bosworth said that the benchmarks and the data collection will aid lawmakers as they make future policy decisions.
“I think at the very least what the benchmark program does is it sets a marker in the ground and it sets an expectation that that signals … what appropriate costs should be,” he said. “So when we think about the legislature and the governor’s office, I think having that data reported annually … will allow policymakers and lawmakers to craft public policy that is based off of the data that’s collected. And I think that’s something we don’t do right now.”
Halpin said that the benchmarking was a way of holding companies accountable for keeping the cost of healthcare at a certain level.
“I think holding people accountable and putting some sunlight on what is happening, so you know how Connecticut compares to other states and you know whether we’re moving the ball forward are important conversations to have,” she said.
But Adelman of the Connecticut State Medical Society referred to the bill’s goals for healthcare affordability as “highly aspirational.”
“We would all like to see the increasing cost of healthcare slow down a little bit,” he said. “At the same time, this bill commands that quality also increase, and those are — I hate to say it, but they [have] been proven again and again to be conflicting goals.”
Adelman said he was particularly concerned that the insurance companies would respond to the benchmarks by shrinking their networks or reducing payments to providers. He said that physicians can already spend hours on the phone waiting to receive authorizations for medical procedures.
“We go from an examining room, for example, where we … talk about what the problem is for the patient and what we see as the solution. And then we go through the process and the insurance company says, no, we’re denying payment. And now that physician-patient relationship is impacted and the trust that’s critical to deliver care from a physician to a patient is jeopardized,” he said.
The Connecticut Hospital Association wrote in testimony that the benchmarks needed to take into account the high inflation, labor costs and the continued fallout from COVID on the cost of healthcare.
“We started this in the midst of a pandemic,” said Paul Kidwell, senior vice president of policy for the association. “We’re going to need to take all of those things into consideration, especially in these first couple of years, because they will have had a radical effect on delivery and spending.”
Kidwell said the hospital association was working with the state to modify certain portions of the bill.
Improving “process” or positive outcomes
T legislation also puts the Office of Health Strategy in charge of creating metrics to track the quality of care that healthcare systems provide to patients. Currently, three metrics are being used to measure quality of care, and four more will be instituted in 2024. The agency also has 26 “core metrics” that it uses, although insurers are not required to use all of them.
But Andrews said that Medicare has over 1,000 metrics they report on. She also said the majority of the metrics that OHS was proposing deal with process – things like reaching a certain number of well-care visits or follow-up visits after hospitalizations – rather than measuring whether people’s health actually improved.
“Even their menu of [26 core] choices is entirely inadequate and leaves most people unprotected,” said Andrews.
Seligner argued that both types of metrics — ones that measure health and ones that measure what he called “process” — are important.
“You need both, because process begins to speak to the social determinants of health — transportation, food education, cultural competency — and what processes do we have in place to ensure that we’re paying attention to those components. Outcomes lend themselves to numeric measures — the diabetes, the blood pressure, the vaccinations,” he said. “Process is just as important to take you to healthy outcomes.”
A new payment model raises concerns
Opponents of the bill also argue that a possible switch from a per-visit to a per-patient payment model for primary care providers could pose added obstacles for patients with challenging diagnoses.
The bill allows the Office of Health Strategy to oversee “alternative payment methodologies” including one referred to as “capitation” or “prospective payment.” In the current system, doctors are paid a fee per patient visit. Capitation, however, changes the payment to a flat fee per patient that is assigned to them — regardless of how many times the doctor actually sees the patient.
Sheldon Toubman, litigation attorney for Disability Rights Connecticut, said that capitation could incentivize providers to not see patients as frequently, or at all, because they will be paid either way.
Toubman said he believed that this change would have a particularly negative effect on people of color and people with disabilities, who are already underserviced. And bBecause people with disabilities often take up more time during an appointment, he said, it will be an even greater incentive for providers to decline to see patients or to send them directly to specialists.
Veltri said that the word “capitation” appears nowhere in the current bill, and that the Office of Health Strategy does not have the ability to impose on the insurance companies any type of payment model. But Toubman pointed out that a document created by OHS in November 2021 discusses the use of prospective payment at length.
Kathleen Flaherty, executive director for the Connecticut Legal Rights Project, which works with low-income people who have serious mental health conditions, said she shared Toubman’s concerns.
“The clients that we serve tend to be the clients that other people would label as difficult. And, you know, we have had experiences of folks who have just been denied care anyway. So why create a system that potentially could incentivize that?” she said.
A “fundamentally broken” system
“I think the part that seems to be missing in what you’re hearing from some of those that have questions and concerns about this bill … is how fundamentally broken the current system of payment is and how it really doesn’t serve anyone very well,” said Gifford in response to critics of the legislation.
Gifford pointed out that the current system of payment is far from perfect, especially for people with “complex, chronic conditions.” She said that the incentives to not see patients with more challenging diagnoses already exist.
According to Selinger, the current fee-for-service volume was actually counterintuitive to patient-centered care because it focused on volume — churning out as many services as possible.
Karen Seigel, director of policy at the advocacy group Health Equity Solutions, said that the current payment model of fee-for-service also supports “massive disparities” in the healthcare that people of color receive because it doesn’t support the community interventions that are most effective in reaching Black and Latino residents.
“The things that we know are most effective at addressing racial disparities and health outcomes — things like robust community health workers systems and addressing social determinants of health — those things are much more difficult under a strictly fee-for-service system,” she said, speaking of the current payment model.
Seigel said that regardless of the payment model, the important thing is to make sure that limiting disparities is a focal point.
“None of these things is a magic bullet,” she said. “It’s about prioritizing and centering equity and continuing to hold ourselves accountable for not just evaluating progress towards equity, but also course-correcting when we made an assumption that didn’t bear out.”