Connecticut Moves Away from Medicaid Managed Care
Connecticut’s Rod Bremby is finding novel ways to connect health and human services.
At a time when states across the country are turning to private health plans to provide Medicaid managed care, Connecticut is taking a different approach. This year, the state ended private insurer participation in the state Medicaid program. Mark Schaefer, Connecticut's Medicaid director, told Kaiser Health News that "there has been a diminishing confidence in the value of what they are providing." Instead, the state is taking responsibility for managing care for some half a million parents and children directly, using an administrative services organization (ASO) model. Heading the effort is Department of Social Services (DSS) Commissioner Roderick Bremby.
Bremby's career has run the gamut of state and local government. A former assistant city manager in Lawrence, Kan., he headed the Kansas Department of Health and Environment, under then-Gov. Kathleen Sebelius, who now serves as secretary for the U.S. Department of Health and Human Services. As Connecticut's commissioner, he has sought to modernize and coordinate the state's health and human services operation, while also executing the state's closely-watched move away from private Medicaid managed care. I spoke to him about the state's plans in this edited transcript.
Could you explain exactly what Connecticut is doing and why?
Roderick Bremby: The first thing is that we're not demonizing private insurance companies as we move forward to acquire better health care for our clients. It's just that we've used a model here in Connecticut for 15 years, and we believe it's time to try something different. We hope to achieve greater transparency and accountability for the 600,000 people in our system, as well as cost savings through less administration.
What was the Medicaid managed care landscape like previously?
We spent about $860 million dollars on Medicaid managed care. It was primarily for our Medicaid program for children and their parents. We employed three plans to manage that program for us.
What the administration of Gov. Dannel Malloy and Lt. Gov. Nancy Wyman decided to do in this new construct is not only to bring our Medicaid program for kids and parents to the ASO model, but also our Medicaid for the aged, blind and disabled, and low-income, childless adults. Also included are the Children's Health Insurance Program (CHIP) and the state-sponsored Charter Oak Health Plan for uninsured adults.
A primary goal is to bring people into this new arrangement who have not had intensive case management previously. In Connecticut, four percent of our population drives about 49 percent of our costs. Put another way, there are 28,000 people in the program that consume $2.3 billion of medical care every year. Trying to identify that four percent, those 28,000 people, across three capitated managed-care plans was not easily done. By aggregating everyone in a group or pool, we'll be able to identify them. We'll be able to assure that they get the continuity and type of service that they need at the right time.
A couple of questions about this ASO model: What's the governance structure? Is this a new state entity? Is it something else?
Our model permitted us to go out into the marketplace and contract with a provider to be our ASO for medical services. [So the] new structural organization, if you will, is the state of Connecticut, DSS, interfacing with the ASO and our network of providers.
Are there models elsewhere for what Connecticut is trying to do here?
Yes. Oklahoma has been in this space for quite some time and has had pretty good outcomes. Oklahoma does this, though, through a different governing structure. They have an authority that runs their Medicaid program. But the model, the provision of care, is clearly one that's been in operation for some time, and has had some success.
I ask everyone a question about the Affordable Care Act (ACA). What, in your opinion, did that legislation get right? What did it miss?
By and large, it got a great many things right. There are unique opportunities to drive down costs and improve health outcomes. There's also a huge, historic allocation of money for prevention. The ACA also tied in with the [American Recovery and Reinvestment Act] legislation to provide the technical support for electronic health records and exchanges. There's a major investment in developing and improving information systems that I believe is really essential to any real, meaningful improvement in health outcomes.
When you led the Kansas Department of Health & Environment, you were known for your work bringing Web-based services to the department. Technology and modernization have also been a focus for you in Connecticut. Can you talk about some of your efforts in that regard?
In Kansas, we worked on Web services, as well as trying to align systems such as county immunization registries. We also had a claims database that was available to apply analytics to the health-care experience.
Moving that forward here in Connecticut is a major goal. Our department has had a lack of investment over 20 years in the systems needed to support efficient and effective operations. At DSS, we receive 890,000 phone calls and process 3.7 million pieces of paper every month. Our regional offices are overwhelmed by the amount of work and effort that it takes to perform work manually.
We now have a modernization effort underway. We call it the ConneCT initiative. It will enable us to come up to current technological service standards. We're going to move beyond that critical deployment and seek to replace the integrated eligibility management system, which is 22 years old. It's fairly stable day to day, but any changes in the system create significant challenges. We're working on those solutions internally. Lastly, we are planning to link our human services eligibility determination systems with the health insurance exchange eligibility platform. Those are the three fundamental areas of technology that we're bringing resources to improve and modernize operations at DSS.
Some state officials I've spoken with, particularly in smaller states, have expressed anxiety about the technical challenges of developing eligibility determination systems. There's a concern about whether the private sector resources will be there for everyone. Is that a concern for you?
No. Time is of the essence. States have to move, and they have to move quickly to take advantage of the opportunity that is out there. This is an unprecedented opportunity, fiscally as well as organizationally, to partner with the federal government to bring about change that we've all been talking about for a very long time. If states wait or are delayed in their deployment considerations, they may have difficulty finding the private-sector market solutions in a timely manner. We're having no difficulties finding very capable and forward-leaning organizations to assist us in bringing solutions to bear. But you have to move, and you have to move fairly quickly.
States may want to look to partner with each other. Those are solutions that we really haven't seriously entertained in the past. But given the requirements of the ACA and the opportunity for funding that's available, it's a great time to be creative.
There's a widespread sense that care coordination, particularly for the dual eligibles, is a very promising area. However, evaluations of disease-management programs and other strategies have found only very modest improvements. Are hopes for dramatic improvements realistic?
I think that people may forget that the health-delivery system that we have today continues to evolve. It's based on a system of care that is outdated. These innovations, by their very nature, are experimental. We're trying to find the right model to solve this problem. I'm hopeful that we will find one or more successful care delivery models in the near term. But the very fact that the effort is being made, and the investment is being made, is essential to us getting there. The result is that it takes more than what we have been doing in the past.
We've focused almost exclusively on the medical intervention, and we haven't been focused on all of those other life experiences that help maintain or restore health. We have to focus on the continuity of care in a much broader construct. We know that environmental factors drive a lot of the physical manifestations of health. We know that dental health is connected with cardiovascular health. We're beginning to look at many relationships to determine better models to take care of the whole person. The long term potential is enormous.
Starting next month, my colleague David Levine will take over the Health newsletter. I’ll still be at Governing, focusing on feature stories. If you have a story idea for me, please contact me at email@example.com. Thank you for all the time you’ve spent with this column over the years.
-- The success of health reform may depend on whether the United States can add enough primary care doctors to cover the uninsured, writes the Washington Post's Sarah Kliff. However, Jonathan Zasloff says policymakers are ignoring an obvious fix -- primary care providers other than doctors, like nurse practitioners, can also fill the gap.
-- What would happen to the Affordable Care Act if President Obama is not reelected, asks University of Chicago professor Harold Pollack. His answer: It's toast.
-- Health policy experts continue to debate the decision made by the U.S. Department of Health and Human Services to give states discretion to define essential health benefits, with some applauding the department's commitment to federalism and others warning of inequities.
-- Finally, the Urban Institute and the Association for Community Affiliated Plans make a strong argument that states should pay closer attention to the "little-known" Basic Health Program.
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