A Public Option Arrives

It may have flopped in D.C. But a homegrown version of a limited government-run health insurance plan will roll out in New Haven and Hartford Friday —with precious little help from a grudging governor, in the eyes of reform-minded critics.

The roll-out is an experiment in bypassing insurance companies to deliver health care to poor and working families.

The experiment affects 101,000 members from the two cities’ regions who are enrolled in ​“HUSKY A,” the state’s Medicaid health insurance program.

Right now, families in HUSKY A choose among plans run by three private insurance companies — organized as health maintenance organizations (HMOs) or managed care organizations (MCOs). (HUSKY A covers children in families earning up to 185 percent of the federal poverty level. It also covers pregnant women earning up to 250 percent of the poverty level.)

Under the experiment starting Friday, they can sign up with a new choice instead: a Primary Care Case Management (PCCM) plan called HUSKY Primary Care. The PCCM plan would put doctors instead of health insurance companies in charge of coordinating a patient’s care, a concept known as a ​“medical home.

The Democratic-led state legislature ordered Republican Gov. M. Jodi Rell’s administration to launch the test in greater New Haven and Hartford (adding to a smaller test underway in Windham and Waterbury). Now advocates charge the Rell administration with dragging its feet in getting out the word about the PCCM experiment, a charge the administration denies.

“They’re doing their best not to market this thing,” charged Ellen Andrews of the Connecticut Health Policy Project. So she and fellow reformers have organized an ​“army” of students and other volunteers to spread the word. (She’s pictured above with a button volunteers have distributed to doctors.)

State social services spokesman David Dearborn called the criticism unfair. He said the state has ​“aggressively” recruited doctors for the program and informed all 101,000 members about it by direct mail over the past month.

“They’re impatient. They’re advocates,” he said of the critics. ​“The sub-agenda of their criticism is that they are against” private insurers having any role in state managed care.

Rell herself was asked at an unrelated New Haven press event last week about promoting the PCCM alternative; the question drew a blank look. (Click on the play arrow at the top of the story to watch.)

Rell had been telling reporters that the state’s budget crisis may force painful cuts in current state health insurance plans. Asked whether it made sense to promote the PCCM experiment as an alternative, she paused, turned to an aide, said nothing, then told reporters, ​“All right guys!” and turned to leave.

Docs In Charge

Like the ​“public option” plan that Democrats tried to include in the federal health reform bill (until U.S. Sen. Joe Lieberman killed it), the experimental PCCM plan creates a government-run insurance plan as an alternative to private MCO-run plans. It gives people a choice, rather than replacing private options.

Unlike the federal public-option plan, the Connecticut plan — similar to PCCMs adopted in 29 other states — focuses on poorer families already receiving government insurance, rather than on uninsured people.

And it puts doctors in charge of patients’ overall care, a concept known as a ​“medical home.” A primary care doctor replaces insurance companies as the ​“gatekeeper” of patients’ overall care. The doctor OKs referrals to specialists, coordinates tests and transportation to appointments, and coordinates chronic care. In other health plans, insurance company bureaucrats do that. Doctors in a PCCM also agree to make sure patients get prompt urgent care.

Doctors already take part in the care-coordinating process under the other plans. But they work with, and need OKs, from the HMOs.

Click here and here for details about the PCCM plan and how to sign up.

Advocates of a true ​“public option” in Connecticut point to the recently passed SustiNet legislation as an example of a government-funded plan that would be open to a larger pool of participants including the uninsured, small businesses and nonprofits.

2 Takes On State’s Efforts

The PCCM experiment will test the idea that cutting out insurance company middlemen can save taxpayers money — by eliminating high administrative costs and the need to produce profits.

A state comptroller’s study this year found HMOs overcharging the state by more than $40 million to administer HUSKY. Ellen Andrews estimated that fully replacing HUSKY’s HMOs with a PCCM would save taxpayers $55 million a year. (The state’s Dearborn said it’s not so simple just to turn the whole program over to a PCCM.)

The PCCM plan will also test the idea that doctors know best how to oversee patients’ care without for-profit insurance company overseers.

But that idea can’t be tested unless patients and doctors sign up. So far about 100 New Haven-area docs have signed up. Last week’s Rell’s Department of Social Services (DSS) sent notices to the area’s HUSKY A families informing them of the new option. It has also sent out brochures, put up signs at regional government offices, and contacted community organizations.

To health reform advocates, that’s not enough.

“I think there’s a preference for standing pat with the HMOs. I believe there’s a bias toward working with the HMOs as the preferred agency,” said Hamden State Rep. Peter Villano, a PCCM proponent. Villano and Democratic colleagues have pushed to have the alternative offered statewide. ​“We’re going to continue hammering on it,” he vowed.

Legal aid lawyer Sheldon Toubman noted the marketing drive the Rell administration mounted to promote a smaller health insurance program drawn up the governor, called Charter Oak, which contracts with private insurers to cover 13,000 enrollees. The Rell administration issued nine press releases to promote Charter Oak — and none to date for PCCM, Toubman noted.

He and Ellen Andrews also noted that private insurers have an unfair competitive advantage against the new PCCM because their HUSKY contracts allow them to spend taxpayer money to market their plans.

“While authorizing the HUSKY HMOs to spend millions of taxpayer dollars on marketing of their own plans, DSS has done no mass marketing or publicity for this exciting new, cost-effective public option in the HUSKY program,” Toubman said.

In response, the advocates have enlisted Yale students and other health reform volunteers to spread the word themselves.

The advocates also claim that doctors may not volunteer information about PCCM to patients. They can’t urge them to sign up. They can talk about it only if the patients ask first — a Catch-22, since many patients don’t know the plan exists. So the advocates distributed ​“Ask Me About PCCM” buttons for doctors to wear. (Andrews is pictured displaying one.)

The volunteers have also sent mailings, visited churches and schools, put up posters, and made phone calls to inform doctors and patients about the program.

DSS spokesman Dearbon said the critics have have spread ​“misinformation” and ​“mischaracterizations” about the state’s launch of the PCCM plan.

For instance, DSS Commissioner Michael Starkowski has directed staff not to allow the HMOs to use any HUSKY dollars for radio spots, TV spots, local advertisements, or marketing events for the next 12 months, according to Dearborn. That decision was part of a mandated renegotiation of the contracts with HUSKY HMOs aimed at saving money.

In the past it made sense to allow the HMOs to spend money on marketing, Dearborn argued: They were not just marketing their own plans. They were informing the public about HUSKY’s existence.

The families eligible for HUKSY now know about it, he said. So neither the HMOs, nor the state’s new PCCM plan, need to advertise to the population at large. The state got the word out to every enrolled or newly eligible family through the direct mail, he said.

And the state doesn’t need to issue press releases to let them know about it, he argued. The situation was different when the Rell administration launched Charter Oak. The Rell administration issued releases for the launch of Charter Oak, it was reaching to to a new group of people — uninsured adults who don’t qualify for other existing health insurance programs.

As for the charge that doctors aren’t allowed to raise the PCCM plan with patients, Dearborn said advocates may be referring to a different prohibition—
federal guidelines against ​“cold calling.” Doctors are free to discuss PCCM with their patients, he said.

Finally, Dearborn called it unrealistic to argue that the state could just save millions by booting the HMOs and turning all of HUSKY over to a PCCM. ​“We have over 350,000 members in HUSKY,” he said. ​“HUSKY Primary Care could not possibly at this point handle the total membership. We don’t have the luxury to say if they walked we have another system in place. We don’t have that.”

The legislature mandated that the government test out the PCCM in Hartford and New Haven in January, then evaluate the program mid-year before deciding whether to expand it statewide, Dearbon said.

1 Doc’s Reasons

One way the PCCM plan may save money: It pays doctors only $7.50 a month per patient to coordinate coverage, do the paperwork, and serve as ​“gatekeeper.”

Why would a doctor sign up for the PCCM plan?

Certainly not for the money.

Dr. Dennis Durante (pictured) offered other reasons.

One reason: ​“We do it anyway,” he said of coordinating care for patients, filing paperwork, developing strategies to treat people’s asthma or other condition — only in other plans they have to deal with insurance companies for approvals. ​“I anticipate it being a little more pleasant” in the doctor-driven PCCM plan, he said.

Durante has practiced medicine for 36 years. He has lived through many experiments aimed at trying to fix the health care mess. His practice, Long Wharf Pediatrics, occupies the Sargent Drive building where one such experiment hatched in the 1980s, CHCP (Commuinty Health Care Plan, a not-for-profit precursor to for-profit HMOs). Durante and his parents worked at CHCP. They see 20 to 25 patients a day; about 30 percent are on HUSKY. Durante and his colleagues worked in CHCP’s pediatrics department.

After watching successive experiments, Durante doesn’t expect one new program like PCCM to be ​“a panacea cure for all the problems associated with health care.” He doesn’t see insurance companies as villains. Even without having to pay extra for overhead costs associated with for-profit middlemen, health care is still expensive, Durante said.

But if enough people participate, if everyone from government overseers to participating doctors and patients ​“buy in,” he does hope to see a constructive alternative emerge.

That’s another reason his practice is signing up.

“It’s got the potential to be a reasonable option,” Durante said. ​“It’s a challenge. We want to make it work.”