Report to the Connecticut General Assembly from the Sustinet Health Partnership Board of Directors January 2011

Report to the Connecticut General Assembly From the SustiNet Health Partnership Board of Directors January 2011

SustiNet Health Partnership Acknowledgements

This report reflects the work of many dedicated individuals, agencies and organizations across the state and beyond. We’d like to acknowledge the work of the Board members:

Nancy Wyman (Co-Chair) • Kevin Lembo (Co-Chair) Bruce Gould • Paul Grady • Bonita Grubbs • Norma Gyle • Jeffrey Kramer Estela Lopez • Sal Luciano • Joseph McDonagh • Jamie Mooney*

And members of the five advisory committees and three task forces: Health Disparities and Equity Advisory Committee Health Information Technology Advisory Committee Patient Centered Medical Home Advisory Committee Preventive Healthcare Advisory Committee Healthcare Quality and Provider Advisory Committee Healthcare Work Force Task Force Tobacco and Smoking Cessation Task Force Childhood and Adult Obesity Task Force

Outstanding guidance provided by the consultant team comprised of: Stan Dorn, Urban Institute Anya Rader Wallack, Arrowhead Health Analytics Katharine London, University of Massachusetts Medical School, Center for Health Law and Economics Linda Green, Goddard Associates Jonathan Gruber, MIT Department of Economics

We thank four foundations for generously supporting the Board’s work: Connecticut Health Foundation Universal Health Care Foundation of Connecticut Jessie B. Cox Charitable Lead Trust State Coverage Initiatives program, a national program of the Robert Wood Johnson Foundation, administered by AcademyHealth

And a final note of thanks to the staff of the Office of the State Comptroller and the Office of the Health- care Advocate who provided continuous support to the Board and its committees and task forces.

This report is hereby submitted to the Connecticut General Assembly on January 7, 2011:

Nancy Wyman, Lt. Governor Kevin Lembo, State Comptroller

* Jamie Mooney recently resigned her Board post; we thank her for her contributions. Table of Contents

Executive Summary ...... 2 Background ...... 4 2009 SustiNet Legislation ...... 4 The Work of the SustiNet Board and Its Committees and Task Forces ...... 4 Why Action is Necessary ...... 5 How this Report is Organized ...... 7 Federal Health Care Reform ...... 7 Our Findings and Central Recommendations ...... 8 Covered Populations ...... 8 BOARD RECOMMENDATION ...... 11 Benefits ...... 12 BOARD RECOMMENDATION ...... 13 Delivery System and Payment Reform ...... 14 BOARD RECOMMENDATION ...... 16 Governance and Administration ...... 16 BOARD RECOMMENDATION ...... 17 Coverage and Access ...... 19 BOARD RECOMMENDATION...... 21 Prevention and Public Health Investments...... 22 BOARD RECOMMENDATION...... 22 Coverage and Cost Estimates...... 23 Coverage...... 23 Cost...... 24 Detailed Recommendations to the General Assembly...... 32 Governance and Location Within State Government...... 32 Policy-making Duties and Responsibilities of the Authority Board...... 33 Administrative Duties and Responsibilities of the Authority...... 34 Reforming Health Care Delivery and Payment...... 35 Expanding Medicaid Coverage and Access to Care...... 38 State Public Health Investments...... 38 Timeline for Implementing SustiNet and Affordable Care Act...... 40 Conclusion...... 42 Endnotes...... 42 Executive Summary

Connecticut residents, businesses, and state To flesh out this vision in detail, the 2009 law government face deep and growing problems established the SustiNet Health Partnership Board with health care and coverage. Costs are rising to of Directors (Board), requiring the Board to develop unsustainable levels, hundreds of thousands of people recommendations for further legislative action. lack insurance, quality is inconsistent, purchasers are After twenty open meetings, two public briefings, unsure of the value they receive for their premium a legislative briefing, and numerous meetings of dollar, and disparities along racial and ethnic lines advisory committees and task forces staffed by affect both health status and access to essential care. nearly two hundred volunteer citizen/experts, we If policymakers do nothing and recent trends in are proud to present our recommendations to the Connecticut continue unabated, the end of this decade Connecticut General Assembly and the Governor. will see private employers spending $14.8 billion Thanks to the Affordable Care Act, the Legislature’s a year on insurance premiums, and nearly 390,000 vision of SustiNet can now be implemented without people will be uninsured. increasing state spending. In fact, the combination of federal reforms and our proposal for expanding Fortunately, two developments now put coverage, slowing cost growth, and improving Connecticut’s leaders in a strong position to quality will reduce state budget deficits, according address these longstanding problems, despite the to estimates from Dr. Jonathan Gruber of the state’s daunting budget deficit. First, the federal Massachusetts Institute of Technology, one of the government passed the Patient Protection and country’s leading health economists. Affordable Care Act (Affordable Care Act or ACA). Among its features, this legislation offers substantial We recommend a policy with the following features: new federal resources to states that aggressively tackle issues of coverage, cost, and quality. Second, • The SustiNet health plan will implement the General Assembly’s 2009 SustiNet legislation delivery system and payment reforms that move laid the foundation for using these new federal towards a more coordinated, patient-centered, resources to effectively address the state’s health evidence-based approach to health care. care problems by applying innovative strategies that will place Connecticut in the front ranks of • The plan will be administered by a quasi- American states. governmental agency governed by a board of directors appointed by the Governor and the The SustiNet law embodied a distinctive vision. Legislature. Initially, staff and administrative Uninsured, low-income residents will get the help support will be provided by the Office of the they need to afford coverage, and insurers will Comptroller. no longer be permitted to discriminate against • SustiNet will begin by serving state employees consumers with preexisting conditions. At the and retirees along with Medicaid and HUSKY same time, a new, publicly-administered health beneficiaries, none of whom will see reduced plan—dubbed “SustiNet,” from the state motto— benefits or increased costs because of the shift to will implement the country’s best thinking about SustiNet. However, SustiNet’s delivery system reforming health care delivery to slow cost growth and payment reforms will immediately seek while improving quality. SustiNet will begin to achieve savings for state taxpayers while with existing state-sponsored populations, state improving quality of care and health outcomes employees and retirees as well as Medicaid and for consumers. HUSKY beneficiaries. SustiNet will then become a new health coverage option for municipalities, • SustiNet will become a new health insurance private employers, and families. choice for municipalities, private employers, and households. Connecticut’s cities and towns will quickly gain the ability to enroll their 2 workers in SustiNet. SustiNet will then gear up Even if SustiNet fails to slow cost growth, to offer commercial-style insurance to small implementing national reform in the way that employers and non-profits, if possible before we propose will still save Connecticut taxpayers 2014. Effective on January 1, 2014, when most between $226 million and $277 million a year, federal reforms become operational, SustiNet starting in 2014. Such savings will result from will offer comprehensive, commercial benefits to substituting newly available federal dollars for all of the state’s employers and households. This current state spending on health coverage for new health insurance choice will be available low-income residents. And if SustiNet slows cost both inside and outside Connecticut’s new growth by just one percentage point per year, the health insurance exchange, established under state budget will improve by $355 million in 2014, the ACA. SustiNet will undertake feasibility with gains reaching more than $500 million a year, studies, develop business plans, conduct a risk starting in 2019. assessment, and take any other steps needed to ensure that the new competitive option is viable To support these efforts, we recommend that and adds value in the marketplace. the Legislature work with state officials to find the resources needed for vigorous campaigns to • HUSKY will expand to cover all adults with reduce obesity and tobacco use, improve the state’s incomes up to 200 percent of the Federal infrastructure for furnishing preventive care and Poverty Level. By drawing down the maximum promoting healthy behaviors, eliminate health- possible amount of federal funding, the state related racial and ethnic disparities, and develop can extend HUSKY’s current safeguards to Connecticut’s health care workforce. To address the additional vulnerable adults while reducing the access problems that result from low reimbursement amount state taxpayers must spend to cover low- rates for HUSKY providers, we recommend that income residents. the state comprehensively realign Medicaid and HUSKY payment, allowing targeted, budget-neutral As HUSKY expands to cover the lowest-income payment increases that address particularly serious uninsured, SustiNet will play two distinct roles. First, access problems. After that realignment, we urge the SustiNet will seek to lower the cost and improve Legislature and the Administration to implement a the quality of services provided to state-sponsored multi-year initiative that gradually raises HUSKY populations. Second, SustiNet will offer all employers payments to at least Medicare levels. and families a new, competitive health insurance option that reforms health care delivery and payment The baton now passes to the Legislature for further to improve value and slow premium growth. progress down the path it began in 2009. We are

confident that 2011 will see Connecticut enact some These reforms will spark broader change throughout of America’s most thoughtful and strategic health Connecticut. Leading by example, SustiNet’s reforms, benefiting the state’s taxpayers, employers, innovations will make it easier for others to follow and families for years to come. a similar path. Our proposal harnesses the power of competition, ensuring that successful SustiNet reforms will be replicated by private insurers seeking to preserve their market share. SustiNet will also work collaboratively to implement multi-payer reforms that help the state’s providers give their patients high- value, quality care. And by enrolling a large number of consumers, SustiNet will gain the leverage it needs to reform health care delivery and payment. 3 Background

2009 SustiNet legislation The Work of the SustiNet The SustiNet Health Partnership Board of Directors Board and Its Committees (Board) was established in 2009 by the Connecticut and Task Forces General Assembly (Public Act No. 09-148) and tasked with the responsibility of proposing to the Beginning its work in September 2009, the Board is Legislature a “SustiNet Plan … designed to (1) co-chaired by Nancy Wyman, State Comptroller, and improve the health of state residents; (2) improve the Kevin Lembo, State Healthcare Advocate. The Board quality of health care and access to health care; (3) includes a physician, representatives of allied health provide health insurance coverage to Connecticut professions, organized labor, small business, the faith residents who would otherwise be uninsured; (4) community, and individuals with expertise in employee increase the range of health care insurance coverage benefit plans, health economics, health information options available to residents and employers; (5) technology, actuarial science, and racial and ethnic slow the growth of per capita health care spending disparities in health care. To carry out its charge, both in the short-term and in the long-term; and (6) the Board appointed advisory committees related implement reforms to the health care delivery system to health disparities and equity, health information that will apply to all SustiNet Plan members…” technology, patient-centered medical homes, preventive health care, and health care quality and providers. The 2009 law provided the broad outline for The Board likewise appointed task forces to develop the SustiNet plan, but left many details open. comprehensive plans to strengthen the state’s health The General Assembly charged the Board with care work force, prevent tobacco use and increase addressing these details, including how to: effective smoking cessation, and combat obesity. Embodying an extraordinary breadth of background • Structure and govern the plan; and expertise, more than 160 Connecticut residents • Launch plan operations; volunteered countless hours to serve on these advisory • Integrate SustiNet with existing state coverage committees and task forces, which communicated programs; detailed recommendations to the SustiNet Board and • Equip SustiNet to function effectively and add the General Assembly on July 1, 2010. These reports value within the private insurance marketplace; were invaluable, and we are grateful for the hard work • Reduce the number of state residents without of our committees and task forces. insurance coverage; and • Integrate SustiNet with the structures to be The Board itself held 20 open meetings, each with created under federal health care reform. advance public notice as well as agendas, background materials, minutes, and presentations posted on The General Assembly had a clear vision that the internet. We also held two briefings in which SustiNet would offer publicly-sponsored insurance we invited public testimony, and we conducted an coverage to many Connecticut residents and embed additional briefing for state legislators. Dr. Jonathan in that insurance coverage health care delivery system Gruber of the Massachusetts Institute of Technology reforms that could improve health, reduce disparities, (MIT), one of the country’s most respected health and slow cost growth. The goal of this new health economists, estimated the cost and coverage effects insurance option would be to lead by example, of policy options under consideration. implementing the country’s best thinking about how to restructure health care delivery and financing. Within 60 days of the federal government’s enactment of the Patient Protection and Affordable Care Act (Affordable Care Act or ACA), we

4 issued a report analyzing the impact of this federal are likewise struggling under the weight of burgeoning legislation on SustiNet.1 We noted the many costs for Medicaid and coverage for state employees common elements shared by SustiNet and federal and retirees. At the same time, the number of uninsured reform. At the same time, we raised important residents, in Connecticut and elsewhere, has steadily questions for further discussion. increased, in good economic times and bad. If recent trends continue, by the end of this decade, among Answering both these and other questions, this final Connecticut residents under age 65: report contains our specific recommendations to the General Assembly on some, but not all, of the issues • Nearly 390,000 people will be uninsured; involved in launching and operating SustiNet. We • Net state costs for Medicaid, HUSKY, and state recommend further analysis to guide decisions on employee/retiree insurance will climb from $3.2 the remaining issues. billion in 2012 to $4.5 billion in 2019; and • Premiums for private employers will increase The Board was assisted by consultants who from $9.6 billion a year in 2012 to $14.8 billion included, in addition to Jonathan Gruber, Stan (Figure 1)—a 55 percent rise. Dorn of the Urban Institute, Anya Rader Wallack of Arrowhead Health Analytics, Katharine London of the University of Massachusetts Medical School Center for Health Law and Economics, and Linda Green of Goddard Associates. Their work was funded by the Connecticut Health Foundation, the Jesse B. Cox Charitable Lead Trust, the State Coverage Initiatives program of AcademyHealth, which is a program office of the Robert Wood Johnson Foundation, and the Universal Health Care Foundation of Connecticut. We appreciate the generous financial support of these funders.

Why action is necessary SustiNet was conceived in the context of an ever- worsening health care cost and access crisis. Employers cannot afford double-digit cost increases even when economic growth is hardy, much less when it is negligible. State governments, including Connecticut’s,

5 Figure 1.

Projected number of uninsured, net state health coverage costs, and private employer premiums for Connecticut residents under age 65: 2012-2019, without reform

Source: Gruber Microsimulation Model 2010. Notes: State costs shown here are net General Fund outlays. They do not include federal matching funds that are subject to the state’s spending cap. “SEHP” refers to state employee and retiree coverage. All costs are for residents under age 65 and shown in 2010 dollars.

These problems are not unique to Connecticut, of $8 billion a year in health care spending on state course. But given the resources and talent in this state, employees and retirees, public program beneficiaries, the Board believes that Connecticut can and should and others. By improving how we manage these funds be a national leader in providing consumers with high and the coverage we provide, fully implementing quality, affordable health coverage. To achieve this federal health care reform and making SustiNet broadly goal, state government’s health care functions need available, we can achieve several goals: to be reorganized and refocused. Our vision is that SustiNet will help lead the way, galvanizing the state’s Slowing the growth of public and private health efforts to become a national frontrunner in reforming care spending in Connecticut; health care to slow cost growth, improve quality, and 1 make affordable, high-value coverage available to all. Ensuring that all residents have access to 2 affordable, high-quality, comprehensive coverage; Counting both federal and state dollars, and including Implementing delivery system and payment services provided to residents of all ages, Connecticut 3 reforms that benefit all residents; state government currently oversees approximately 6 Providing Connecticut’s employers and families The ACA allows each state to either create a state-based 4 with a new health plan option—namely, an health insurance exchange or join a federal exchange. independent, transparently managed plan for Beginning on January 1, 2014, the exchange will Connecticut consumers, health care providers, facilitate comparison-shopping for health insurance. and employers; New federal tax credits and cost-sharing subsidies will Improving access to care among low-income be offered to low-income individuals who purchase residents; and insurance through the exchange. At the same time, 5 Medicaid coverage of adults will expand to 138 percent Reducing racial and ethnic disparities related to of the federal poverty level (FPL).3 During 2014- 6health care access and quality. 2016, the federal government will pay all the costs of Like nearly all states, Connecticut is suffering Medicaid’s newly eligible adults. Beginning in 2017, tremendous fiscal stress. It is our belief that we the federal share of these expenses will begin falling, can and should achieve SustiNet’s goals without reaching 90 percent in 2020 and staying at that level calling for substantial new infusions of General thereafter. One important source of new federal dollars Fund dollars. This can be done by making prudent is an increase in the Medicare payroll tax for families investments that reap both short- and long-term earning more than $250,000 a year. dividends, maximizing the state’s utilization of available federal resources, and carefully managing the state’s health care expenditures. In addition to new federal subsidies and expanded Medicaid, the ACA’s mandate for individuals to obtain and incentives for firms to offer coverage will reduce How this Report is Organized the number of uninsured. The latter incentives include tax credits for small employers that insure their workers The body of this report covers the following topics: and penalties for larger firms that do not. The ACA also • Key features of federal health care reform; reforms insurance markets by requiring insurers to devote • Our findings and general recommendations; at least a minimum percentage of premiums to health • The coverage and cost effects of our care costs, forbidding discrimination against consumers recommended policy direction, based on the based on preexisting conditions, strengthening review research conducted by Dr. Gruber; mechanisms for premium increases, etc. In addition, • Our policy recommendations in detail; and the Affordable Care Act includes numerous initiatives to reform health care delivery and payment, including • Our suggested timeline for implementation. grants and demonstration projects.

The appendix to this report includes the full As explained in our earlier report, the General recommendations of the Board’s advisory Assembly’s 2009 vision of a substantial increase in committees and task forces; a “cross-walk” coverage, accompanied by a new, publicly administered comparing our recommendations to the relevant health insurance option offered to the state’s residents and provisions of the 2009 SustiNet law; and a brief employers, can now be implemented more effectively description of the model Dr. Gruber used to project 2 and with much more favorable fiscal effects than was cost and coverage effects. anticipated in 2009. The combination of newly available federal funds to cover low-income consumers and the potential impact of delivery system and payment reforms Federal Health Care Reform could allow substantial savings to the state General Fund, SustiNet was envisioned prior to the passage of the as we explain later. ACA, but state legislators were well aware in 2009 that federal legislative efforts were under way. SustiNet’s goals and structure are thus consistent with the framework established by the ACA. 7 Our Findings and Central Recommendations

The Board organized its effort to understand options for whom the state is currently responsible—that for SustiNet design into six major subject areas: is, state employees and retirees as well as Medicaid covered populations; covered benefits; delivery and HUSKY beneficiaries. The initial focus of our system and payment reform; governance and recommended proposal will thus involve slowing cost administration; coverage and access to care; and growth, rather than increasing coverage. However, as public health investments. To examine each subject eligibility for Medicaid and HUSKY expands, so too area, we conducted major policy meetings at which will SustiNet enrollment. our consultants outlined policy options and applicable trade-offs. As an interim step in moving beyond state-sponsored populations, SustiNet will be offered as an option for In this section, we describe the policy options we small firms, municipalities, and non-profit corporations. considered and our central recommendations. Our Municipalities will be the first employer group outside full recommendations are detailed in a later portion state agencies to gain access to SustiNet, allowing cities of the report. and towns to purchase the same coverage received by state employees and retirees. Local taxpayers could thus benefit from economies of scale and leverage already exerted by state government. At the same time, we propose that a municipality and SustiNet should be allowed to negotiate covered benefits that differ from those offered to state workers, such as the more SustiNet represents a unique commercial-style coverage that SustiNet will offer to

“opportunity to develop and private firms and individuals. nurture a coordinated, cost- We recognize that gearing up to offer such commercial effective health care delivery coverage will not be a quick and easy task. Accordingly,

we recommend that SustiNet’s governing entity should system for the state...all move forward as feasible to serve small firms and non- profits during the interim stage before 2014, without possible efforts should be “ statutorily imposed deadlines. made to assure its success By contrast, we recommend that the Legislature create and move it forward. a clear statutory deadline for the final stage of offering SustiNet Board Member SustiNet as an option to all Connecticut employers and residents outside state government. Under our suggested approach, SustiNet will be available for any state resident or employer to purchase beginning on January 1, 2014—the date when the main provisions of the Affordable Care Act go into effect, including Covered populations operation of the health insurance exchange. Under our proposal, SustiNet would be offered both inside and outside Connecticut’s exchange.4 We envision that the SustiNet health plan will provide a common platform for reforming health care delivery and payment. The plan will begin by covering those

8 In serving employers and individuals outside state government, SustiNet will offer the option of commercial-style benefits, as explained below. SustiNet will thus need to meet legal standards that apply to commercial coverage, including benefit requirements under state and federal law. To prevent SustiNet from becoming a magnet for high-risk enrollees, it will follow the same rules that apply to other plans in the applicable market, whether group or individual, including rules that govern premium variation. With public and private employers large enough to self-insure, SustiNet will avoid such adverse selection through steps that could include experience-rating premiums.

Of course, we understand that work will be required before offering commercial coverage. A state insurance license will be needed to offer coverage in the exchange, for example, but we are convinced that this should not create an insuperable obstacle. Publicly administered health plans at the county level in California have operated with insurance licenses for many years, even though capital requirements for licensure are much higher in that state than here. And SustiNet will need to develop a business plan, with a feasibility study and risk assessment, to ensure that it offers a competitive option that adds value, compared to other choices available to firms and individuals. For SustiNet to commit to this work and succeed, we believe the Legislature needs to lay down clear markers in statute.

We value the role that employers play in offering health insurance to workers and their families. Our goal is to strengthen rather than undermine that role by offering Connecticut businesses a new option for insuring their employees. We believe that increasing competitive choices in this way could improve the Connecticut business climate, particularly if SustiNet slows cost growth and shares those savings with employers.

9 Table 1.

Provisions of SustiNet Law Regarding Populations in SustiNet

Population Date of potential Board may or Restrictions or coverage in shall develop other specifications SustiNet recommendations

State employees, Not specified May Any changes in benefits retirees and subject to collective dependents bargaining agreements

Non-state public On or after July 1, 2012 May employees

HUSKY Plan Not specified Shall Part A and B

Medicaid Not specified Shall

Enrollees in state- Not specified Shall administered general assistance (SAGA)

State residents On or after July 1, 2012 Shall Premium variation limited not offered ESI to that allowed under small and not eligible group law for Medicaid, HUSKY or SAGA

Employer groups On or after July 1, 2012, Shall for small firms. No date specified for larger firms.

State residents Not specified Shall The Board may recommend offered ESI, mechanism for collecting whose incomes payments from employers are below 400% FPL

10 Coordinating the design of health insurance coverage and other states, including Washington and Massachusetts, procurement of services across these populations offers where joint procurement processes are in place for many potential advantages, including the following: multiple state-covered populations.

• When applied to a larger population, The Board also considered the advice of our Advisory synchronized efforts at delivery system and Committees on the issue of integration, which included payment reform can have a greater influence the following recommendations: on provider behavior and the diffusion of innovation; • SustiNet should use common quality • A larger population may give the state added measurement, payment innovations, public leverage to lower prices and improve value in health initiatives, and delivery system reforms purchasing goods and services; and across all populations, to the greatest extent possible, to achieve maximum impact. • The system will be simplified for both providers and consumers if reforms are consistent across • SustiNet should pursue an integrated approach to multiple populations. reducing or eliminating health disparities across all populations. On the other hand, there are major differences between potential SustiNet populations, including covered Put simply, much of the coverage received by these benefits, health care needs, and applicable legal different groups will continue to differ under SustiNet, requirements. Connecticut’s Medicaid and HUSKY including applicable legal requirements, funding sources, programs cover in excess of 530,000 people, more than population characteristics, provider networks and half of whom are children.5 Medicaid benefits, cost- payment levels, cost-sharing, and covered benefits. At sharing, eligibility, and administration are governed by the same time, key elements of health care delivery can federal statutes and regulations as well as the decisions of and, in our view, should be addressed using a common the Centers for Medicare and Medicaid Services (CMS). platform across all of SustiNet’s membership groups. Medicaid is also shaped by Connecticut statutes and As later sections of this report make clear, this common judicial decisions that interpret both federal and state law. platform will seek to add value and slow cost growth for both publicly and privately funded health coverage. And The State Employees Health Plan (SEHP) covers we urge that, as our recommendations (described below) over 200,000 active employees, retirees, and their for increasing HUSKY and Medicaid payment go into dependents. This coverage is governed by collective effect, SustiNet should commit to the goal of eliminating bargaining agreements between the state and public any differential between groups of SustiNet members in employee unions. their access to participating health care providers.

When SustiNet becomes an option in the group BOARD RECOMMENDATION: and individual markets, which currently include We recommend that the future SustiNet governing approximately 2.1 million and 150,000 non-elderly board (which will be described later) should residents, respectively,6 the above constraints will not immediately begin working with the State Comptroller apply. SustiNet will still need to follow applicable and the Department of Social Services to reform health state and federal laws, however, including state care delivery and payment for state employees and benefit requirements. retirees as well as individuals receiving coverage under Medicaid and HUSKY. The Board considered a range of options for integrating SustiNet populations. We learned about examples from

11 We further recommend that the SustiNet governing board • SustiNet coverage of 15 service categories; 7 should take all necessary actions (which may include • SustiNet compliance with all applicable state conducting a feasibility study and risk assessment, coverage and utilization review mandates; developing financial projections, and obtaining a state • No copayments for preventive care; license as an insurance carrier) to offer a SustiNet health insurance plan as an option for employers and individuals • Behavioral health parity; to purchase, as follows: • Dental coverage comparable to that offered by large employers; and • Beginning as soon as possible, SustiNet should • Compliance with collective bargaining be offered to Connecticut municipalities, agreements for state employee and retiree allowing them to purchase the same coverage coverage. that state employees and retirees receive. However, a municipality and the SustiNet Lastly, we reviewed benefit requirements under the governing board can agree on a different package federal Affordable Care Act, which include: of covered benefits. • To the extent feasible before 2014, SustiNet • An “essential benefits” requirement, including should be offered to other employers, with a various service categories,8 with specific special focus on small firms and non-profit standards to be set by the U.S. Department of corporations. Health and Human Services based on “typical • Beginning on January 1, 2014, SustiNet should employer coverage;” be offered to all employers and individuals, both • A prohibition on lifetime and (beginning in inside and outside the health insurance exchange. 2014) annual coverage limits; • A requirement that plans be offered in each In offering this coverage, every effort should be made state’s exchange at 60, 70, and 80 percent of the to coordinate the design, delivery, and administration of actuarial value of the essential benefits standard;9 benefits to maximize the positive impact of SustiNet on: • Limits on out-of-pocket expenditures; and • Leveraging delivery system and payment • Required coverage of preventive services with reforms; no out-of-pocket cost-sharing. • Slowing health care cost growth; We found that current covered benefits for Medicaid • Simplifying administration; and state employees are comprehensive in scope. Both • Improving health care quality; and include services like those required under the SustiNet • Reducing racial and ethnic disparities. law and the federal ACA, and both limit or bar cost- sharing for preventive services. Benefits The Board examined benefits currently provided We found, however, that neither the SEHP nor Medicaid to groups intended for inclusion in SustiNet. We covers tobacco cessation, nutritional counseling, or also examined the extent to which current programs wellness programs, all of which were recommended by our Preventive Care Advisory Committee and the incorporate prevention and reflect the cutting-edge 10 of value-based insurance design, thereby providing a Obesity and Tobacco Cessation Task Forces. solid foundation for future efforts at cost containment Table 2 compares benefits currently offered to potential and quality improvement. In addition, we reviewed the SustiNet groups. SustiNet law, which requires:

12 Table 2.

Covered benefits and cost-sharing for selected coverage categories

BOARD RECOMMENDATION: the role of the Cost Containment Committee in overseeing collectively bargained benefits for state In general, we reaffirm the direction given to us in employees and retirees. the SustiNet law: benefits under SustiNet should be comprehensive, emphasize prevention, and integrate We recommend that insurance plans for the commercial physical and behavioral health. marketplace should be approached quite differently. In that context, the eventual SustiNet governing board In serving existing state-sponsored membership should ensure that plan designs: groups—namely, state employees and retirees as well as beneficiaries of Medicaid and HUSKY, including those who qualify for the expanded coverage described Offer a variety of benefits and out-of- later in this report—SustiNet would not change covered apocket costs, with each package providing benefits, premiums, or out-of-pocket costs. Current comprehensive, commercial-style benefits, consumer safeguards should likewise continue to apply, including dental care and parity of coverage for including such things as Medicaid appeals and physical and mental health conditions;

13 Include, to the maximum feasible extent consistent with commercial viability,

bpatient-centered medical homes, integration of medical and behavioral health care, an emphasis

on prevention, encouraging and supporting If we can make Connecticut individual responsibility for controllable health a healthier place we are all risks, and other design features that make “ “ SustiNet stand out as a high-quality option that is saving money and having a attractive in the marketplace; and better quality of life. Include cost-effective preventive services SustiNet Board Member that address physiological, emotional, mental, andc developmental conditions for members throughout their life span from birth to the end of life. SustiNet should review and periodically revise its coverage of preventive care based on the most current and reliable evidence available, including results of SustiNet prevention Delivery system and payment initiatives. reform

In offering commercial coverage that is financed The SustiNet law emphasized three central entirely by premium payments and federal tax credits, components of delivery system reform: without any state General Fund dollars, we believe the SustiNet governing board should have the flexibility • Patient-centered medical homes (PCMH) that to change benefits and cost-sharing arrangements over combine a designated source of primary care time, within the constraints of applicable state and with patient education, coordination of services, federal laws, including state benefit mandates, and and enhanced access to medical consultation based on evidence about the most effective benefit when the patient is outside the clinician’s office; designs, categories of covered services, and cost- • Health information technology (HIT) that sharing arrangements. supports cost and quality management; and We further recommend that the design of SustiNet • Incentives for providers to practice evidence- benefits: based medicine.

• Encourages personal responsibility for The Board reviewed the evidence that each of these controllable health risks, while providing the initiatives would improve quality and control cost support that consumers need to exercise that growth. We also reviewed the recommendations responsibility effectively; and of our Patient-Centered Medical Home Advisory Committee, our Provider and Quality Advisory • Promotes reductions in health disparities. Committee, our Workforce Task Force, and our Health

Information Technology Advisory Committee. Lastly, we examined federal efforts to encourage and finance these reforms.

Our Advisory Committees and Task Forces supported implementation of the PCMH model through SustiNet, 14 which builds on work already under way with recommended that SustiNet leverage these efforts, HUSKY’s Primary Care Case Management (PCCM) rather than undertake unrelated efforts to encourage Program as well as a multi-payer pilot project led by HIT diffusion. Our Committee further recommended the Comptroller. Our Committees and Task Forces formal representation of SustiNet on the HITECT recommended that PCMHs should eventually be Board. It also proposed that SustiNet seek to influence required to meet nationally promulgated accreditation the requirements established for EMRs in Connecticut or certification standards. However, clinicians who to assure that systems meet basic analytic needs and serve as medical homes should not be required to capture race and ethnicity data that will allow for provide all services directly in the office, according ongoing measurement of health disparities. to our committees. In particular, small practices could share support services to meet PCMH standards. For The Provider and Quality Advisory Committee example, the ACA authorizes funding for community supported the use of evidence-based standards of health teams to perform functions that might not be care in practices serving SustiNet members, applying undertaken within a one- or two-physician office. Our in Connecticut guidelines that have already been PCMH Advisory Committee further recommended promulgated by national and international authorities. that SustiNet create a “learning collaborative” through The committee also supported payment reform that which practices could support each other in becoming promotes provider accountability for costs, reduces medical homes—a strategy that also may be supported unnecessary care, and provides incentives for improving by the ACA. Federal legislation further permits states, quality and safety while reducing disparities. beginning in 2011, to provide chronically ill Medicaid beneficiaries with PCMH services, with a 90 percent The Workforce Task Force highlighted a shortage of federal match rate applying to the first 8 calendar primary care providers in Connecticut, which might quarters. The ACA appropriated $25 million in state undermine efforts to implement delivery system reform. planning grants for such an initiative, starting in 2011. The Task Force made recommendations for increasing the supply of primary care clinicians through targeted We also learned that efforts to develop coordinated, efforts such as debt relief and broadening scope of multi-payer reforms can be hindered by anti-trust practice of some non-physician primary care providers. law. To overcome those barriers, a regulatory The Task Force also recommended specific efforts to program supervised by the State of Connecticut can train clinicians in working within the patient-centered be established to permit and encourage cooperative medical home model, including changes to nursing agreements between health care purchasers, hospitals, curricula to reflect the needs of the PCMH. The Task and other health care providers. Such a program is Force recommended that the state develop its capacity allowed when its benefits outweigh the disadvantages to assess the demand for and supply of primary care caused by potential adverse effects on competition. providers through an overall state strategic plan for its health care workforce. We likewise found that a significant federal and state effort is under way to coordinate and finance We found that our recommended interventions implementation of electronic medical records (EMRs) (PCMH, HIT, evidence-based care guidelines, and and interoperable electronic health records (EHRs). payment reform) have limited use in Connecticut at Connecticut has created the Health Information present, and SustiNet could play a key role helping Technology Exchange of Connecticut (HITECT) to expand these efforts. The State Employees Health to oversee efforts to meet federal requirements and Benefits Plan’s (SEHP) large-scale pilot program for maximize federal support. In addition, Connecticut has PCMH, noted above, exemplifies the leadership that received a grant to support a regional extension center SustiNet could provide on a much wider scale. that will provide support and training to practices implementing EMRs. Our HIT Advisory Committee 15 BOARD RECOMMENDATION: for assessing and enhancing both the overall supply We recommend that SustiNet: of primary care clinicians in the state and available • Strongly encourage and provide incentives training in the PCMH model. and technical and other assistance for SustiNet providers to implement patient-centered medical Governance and homes. administration • In appropriate areas, implement alternatives to fee-for-service provider payment that encourage The Board considered questions related to SustiNet’s the provision of care that improves health governance and administration, including the and safety. Such payment mechanisms could following: include pay-for-performance, bundled payments, global payments, or other innovations that are • How should SustiNet relate to existing state supported by emerging research. agencies? • Provide incentives for evidence-based care that • What governance structure is most appropriate encourage providers to follow evidence-based for SustiNet? clinical guidelines. Such encouragement should • What powers and duties should the SustiNet be carefully structured to preserve clinicians’ governing body have? ability to provide patients with care that • What administrative structures and capacities are meets their individual needs, even when such necessary to implement SustiNet? personalized care goes outside approved clinical guidelines. We considered three basic options for governance, as • Establish a Pay-for-Performance system to follows: reward providers for improving health care quality and safety and reducing racial and ethnic SustiNet as quasi-governmental agency disparities in health access, utilization, quality of administering a health plan. Under this option, care, and health outcomes. 1 a SustiNet governing board would oversee a quasi- • Encourage, support, and eventually require governmental agency that administers the SustiNet SustiNet providers to use interoperable EHRs to health plan. SustiNet would contract with the document and manage care. Comptroller’s Office and the Department of Social • Integrate into every component of the SustiNet Services (DSS) to provide health insurance coverage plan strategies for reducing and eliminating to state employees and enrollees in Medicaid and racial and ethnic disparities. HUSKY. • Take all steps necessary to collect and publish SustiNet as overseer and health plan. Under provider price information that will help 2this option, the SustiNet governing body would, consumers make informed choices. in addition to administering the SustiNet health plan, oversee the Comptroller’s Office and DSS In addition, we recommend that the Legislature with respect to all rules, regulations, and procedures establish convener authority, consistent with state and related to SEHP, Medicaid, and HUSKY. federal anti-trust law, that will allow collaboration SustiNet as superagency and health plan. among multiple payers and providers in developing Under this option, SustiNet would be a new state and applying payment and delivery system 3 agency going beyond health plan administration to innovations. The legislature also should examine the oversee SEHP, Medicaid, and HUSKY. method recommended by the Workforce Task Force

16 Each option assumes that SustiNet would develop and reduction, health care quality and payment, the capacity by 2014 to offer coverage to groups and health care safety, preventive health care, and individuals both within and outside the state’s Health health disparities and equity. Insurance Exchange. BOARD RECOMMENDATION: The Board was provided with examples of each The Board recommends the establishment of the governance model and considered their advantages SustiNet Authority as a quasi-governmental agency and disadvantages. The Board was particularly (option #1 described above), as soon as possible. concerned with minimizing disruption to current We recommend that the authority be governed by a coverage arrangements, maximizing coordination board of directors, which could include members of across programs and plans, and minimizing (in the the current Board, and that the SustiNet governing short term, while Connecticut is faced with serious board should have overall responsibility for SustiNet. budget shortfalls) the need for new, state-funded staff We further recommend including as board members and administrative infrastructure. both consumer representatives and individuals with specific expertise needed to oversee the operation of We also examined the administrative capacities the SustiNet health plan. We believe that the SustiNet that would be necessary in SustiNet, regardless of governing board will be more effective if it is as small its governance model. These include enrollment; as possible. premium billing and collection; marketing; provider contracting, management, and payment; customer We recommend that staffing and other administrative relations; and data collection and analysis. In addition, support for SustiNet should be provided initially a system for determining eligibility and calculating by the Office of the Comptroller and that such staff subsidies will be needed for SustiNet to accomplish should help the SustiNet governing board obtain its coverage goals. We observed that existing state resources (including federal and philanthropic funds) agencies possess many of these capacities, which to support meeting its administrative needs, in both could be leveraged for SustiNet. the short and long term. We believe that a strong and adequately funded administrative infrastructure will be Lastly, the Board reviewed the recommendations of essential to SustiNet’s success. our Advisory Committees and Task Forces related to governance and administration. These included the Table 3 summarizes our concept of how SustiNet following: governance and administration could evolve from 2011 through 2014. • SustiNet should have strong links with all state-run health agencies, including DSS, the Department of Public Health, the Department of Mental Health and Addiction Services, and the Department of Children and Families; • SustiNet should have a strong link to HITECT, as discussed above; • The SustiNet governing board should include representation of SustiNet enrollees and individuals with experience in reducing health disparities; and • The SustiNet governing board should establish standing advisory committees on the Patient- Centered Medical Home, obesity prevention 17 Table 3.

Possible timeline for evolution of SustiNet governance and administration, Calendar Years 2011-2014

2011 2012 2013 2014

SustiNet Board Appointed and take Transition to Independent office by 9/1/2011. independence from from Comptroller Housed within the Comptroller’s no later than the Office of the Office. 1/1/2013. Comptroller.

SustiNet Authority begins no Authority later than 3/1/2012.

SustiNet staff Existing state After sufficient Staff fully agencies provide resources are independent staff. identified outside no later than the General Fund, 1/1/2013. Executive Director begins work no later than 3/1/2012. Transition to independent staff.

Responsibilities Begin advising Move forward, Assume direct Beginning Comptroller and DSS as feasible, with responsibility for 1/1/2014, offer about delivery system offering SustiNet to administering SustiNet to all and payment reforms small firms and non- SustiNet plan employers and for SEHP and profit corporations. no later than individuals, Medicaid/HUSKY. Begin preparing 1/1/2013. inside and ASAP, give to meet 1/1/14 Contract with outside the municipalities deadline for offering Comptroller exchange. the option to buy SustiNet to firms and DSS to SustiNet. and individuals. serve SEHP Analyze feasibility of and Medicaid/ offering SustiNet to HUSKY. small firms and non- profit corporations.

18 Coverage and access Considerable evidence suggests that cost-sharing imposed on low-income households can deter One of SustiNet’s central goals is to ensure that as many enrollment into coverage and prevent utilization of essential services, with potentially significant adverse Connecticut residents as possible obtain affordable, 11 high-quality, comprehensive health coverage. After effects on patient health. We were thus concerned devoting significant time to understanding the impact about the impact of cost-sharing on two groups: 16,000 of federal legislation, we learned that the ACA provides HUSKY parents with incomes between 138 and 185 significantly increased federal support for subsidized percent FPL, who today receive comprehensive benefits coverage along with a mandate for individuals to obtain and are not charged premiums or copayments; and coverage and incentives for employers to offer it; the 41,000 other low-income adults with incomes between 138 and 200 FPL, many of whom will be unable to latter incentives include tax credits for small firms that 12 provide insurance and penalties for larger companies afford what they will be charged in the exchange. that do not. To prevent today’s HUSKY parents from encountering However, we were troubled by the limits on ACA new barriers to accessing care as well as to improve subsidies for adults with incomes above 138 percent coverage and access for other low-income adults, we FPL, who fall outside the legislation’s increase in believe that, beginning on January 1, 2014, Connecticut required Medicaid eligibility. Subsidies for coverage in should implement the Basic Health Program (BH) the exchange will leave these adults facing significant option provided under federal law. With BH, Medicaid- costs, as illustrated by Table 4. ineligible adults with incomes at or below 200 percent of FPL are covered through state contracts with

Table 4. Premium and out-of-pocket costs for a single, uninsured adult receiving subsidies in the exchange under the ACA, at various income levels

FPL Monthly pre-tax Monthly premium Average out- income of-pocket cost- sharing

150 $1,354 $54.15 6%

175 $1,579 $81.34 13%

200 $1,805 $113.72 13%

225 $2,031 $145.70 27%

250 staff $2,256 $181.63 27%

Source: Urban Institute, 2010. Notes: Dollar amounts assume 2010 FPL levels and enrollment into the second-lowest cost “silver” plan under the ACA, which is the plan on which ACA subsidies are based. Out-of-pocket cost-sharing represents the average percentage of covered services paid by the consumer, taking into account deductibles, copayments, and co-insurance. These costs would apply under the ACA anywhere in the country, so they are not limited to Connecticut. 19 health plans or providers. Such adults either (a) have as the state uses BH to extend HUSKY, in its current incomes too high to qualify for federally-matched configuration of covered benefits, cost-sharing rules, Medicaid or (b) are lawfully resident immigrants and consumer safeguards, to adults with incomes up to whose immigration status makes them ineligible for 200 percent FPL, the excess of federal BH payments federally-matched Medicaid (most often because their over baseline HUSKY costs should be used to raise status was granted within the last 5 years). To fund the payment rates for adults with incomes above 138 state’s BH contracts, the federal government provides percent FPL. 95 percent of what it would have spent on subsidies if BH members had received coverage through the Not only would this approach make coverage and care exchange. State contracts must have “attributes of more affordable for low-income adults, it would also managed care,” which can involve primary care case save money for the state General Fund. By moving management systems, such as patient-centered medical HUSKY parents above 138 percent FPL from Medicaid, homes, rather than risk-bearing, fully capitated, private for which the state pays 50 percent of all costs, into BH, insurance. Federal BH dollars must be placed in a trust where the federal government will pay all expenses, fund and spent only to benefit BH members. Covered Connecticut taxpayers will save approximately $50 benefits and cost-sharing protections may not fall million a year in net General Fund costs, according to below federally-specified minimums. However, states Dr. Gruber’s modeling. may provide more comprehensive benefits with lower cost-sharing (such as the benefits and cost-sharing Under the approach we recommend, a single, integrated protections that states furnish through federally- HUSKY program will provide subsidized coverage reimbursed Medicaid). to all otherwise uninsured adults with incomes up to 200 percent FPL and children up to 300 percent FPL. To be clear, we would not recommend implementing Not only will this make coverage more affordable, our the Basic Health option if the state provided no more recommended strategy will also improve continuity than the minimum level of coverage required by of care. Income levels fluctuate greatly for many low- federal law. Rather, the purpose of our proposed BH income households. Under the recommended policy, implementation is two-fold: to preserve, for populations income fluctuations that move families above or below covered by current law, HUSKY’s existing affordability 138 percent of FPL will not force a change between and comprehensiveness of coverage, so that, from the HUSKY and the very different systems of coverage member’s perspective, benefits would be exactly what and care that will be available in the exchange. Rather, Medicaid now provides; and to extend that same level coverage and care will be continuous, so long as of assistance to other low-income, uninsured adults. household income does not exceed 200 percent of FPL.

One disadvantage of providing HUSKY rather than We also considered two other policy options that, subsidies in the exchange is that provider payment unlike BH, would increase state General Fund costs. rates are now much lower in HUSKY than in the kind First, HUSKY eligibility could expand before enhanced of commercial coverage likely to be offered in the federal funding is first available in 2014. If HUSKY exchange. While we believe that, for this particular served all adults up to 185 percent FPL, rather than population, access to care is typically impaired more by just parents, approximately 60,000 uninsured residents cost-sharing than by HUSKY’s provider participation would gain coverage, according to Dr. Gruber’s limits, the BH option allows a modest improvement estimates. However, because federal matching funds of provider payment rates at no cost to the General would pay only 50 percent of Medicaid costs before Fund. According to Dr. Gruber’s modeling, federal 2014, the resulting net expense to the state General BH payments will exceed HUSKY costs for low- Fund would be approximately $100 million to $150 income adults by at least 7 to 13 percent. Accordingly, million a year.

20 Second, as noted above, HUSKY reimbursement, as a We further recommend that the state begin down a general matter, now falls far below private levels. As path of increasing Medicaid and HUSKY provider a result, many providers are unwilling to see HUSKY payments to at least Medicare levels (except for discrete patients. Access to care could improve considerably if populations and services where a different benchmark HUSKY payment rates increased. than Medicare is needed). The first step down this path would occur in fiscal year 2012, when the Department To address this longstanding problem, we considered of Social Services would undertake a comprehensive a policy option that would have increased HUSKY analysis of current reimbursement practices. Based on payment rates to the point that per capita costs would that review, a budget-neutral realignment of provider equal those paid by large employers—in effect, raising payments would take place in fiscal year 2013. After HUSKY payment to private levels. According to Dr. that point, further payment increases would require a Gruber’s estimates, this would cost the state General net increase in state General Fund spending. We believe Fund approximately $180 million to $190 million a year. that such higher payments will be essential for HUSKY to provide adequate access to essential care, particularly We also considered the less expensive approach of with the expanded population the program will serve in using Medicare rather than private levels as the goal the future. We also believe that, as this increase goes into for increased Medicaid payment. We learned that, with effect, SustiNet should embrace the goal that Medicaid some populations (children and pregnant women, for and HUSKY coverage should not impair members’ example), Medicare levels are problematic, so a different access to SustiNet providers; and that Medicaid and benchmark would be needed in such cases. We further HUSKY members should receive the same access to care learned that, with some services, current Medicaid that is enjoyed by the privately insured, based on specific reimbursement is sufficient or even excessive, suggesting standards adopted by the SustiNet Authority. the need for a broader analysis and realignment of payment practices. We urge the General Assembly and state agencies to work together to find the resources necessary both for One final issue involves maximizing the number of this increase in HUSKY payment and, before 2014, to eligible uninsured who sign up for coverage. According expand HUSKY eligibility for childless adults to the to Dr. Gruber’s estimates, nearly half (47 percent) highest possible income level—if possible, to the same of Connecticut residents who would remain without 185 percent FPL threshold that now applies to parents. coverage under our recommendations will qualify for subsidies, either through HUSKY or the exchange. To We also urge the Legislature to examine ways in reach this group of uninsured, the state will need to go which Connecticut can increase its supply of primary beyond the minimum requirements of federal law. care clinicians through methods other than increasing payment levels, consistent with the recommendations of BOARD RECOMMENDATION: the Workforce Task Force. As part of SustiNet, we recommend that, beginning on January 1, 2014, HUSKY eligibility for adults should Finally, we recommend that SustiNet, the Department increase to 200 percent of FPL, continuing the same of Social Services, other state agencies, and benefits, cost-sharing limits, and consumer protections Connecticut’s health insurance exchange should work that apply under current law. Federal funding for this together to maximize identification of the uninsured, coverage should be maximized by implementing the determine their eligibility for assistance, and enroll Basic Health Program (BH) option for individuals who them into coverage. are ineligible for federally-matched Medicaid. To the extent federal BH dollars exceed baseline HUSKY costs, payment rates should increase for the BH-eligible population with incomes above 138 percent of FPL. 21 Prevention and public health immunizations, assessments of behavioral health investments needs, and other evidence-based care; • Dental services; The SustiNet law placed a strong emphasis on health • An annual Individual Preventive Care Plan; insurance coverage for preventive care and increased • Chronic care planning and support, including investment in public health. The Board considered promoting healthy nutrition, sleep, exercise, and several issues related to preventive care and public tobacco and substance abuse cessation; and health investments. These included: • Counseling and education about sexually- transmitted disease, infectious disease control, • The extent to which current coverage for domestic violence, and environmental toxins. potential SustiNet populations includes appropriate preventive care; The Obesity Task Force and the Tobacco Use and • The extent to which coverage offered in Cessation Task Force also offered guidance about the future to privately-insured groups and preventive benefits and public health investments. individuals should include preventive care; On benefits, they recommended coverage for nutrition • The appropriate role of the SustiNet plan in counseling and smoking cessation treatment. promoting public health; and • The highest priorities for state investments in Those task forces also recommended statewide efforts to: public health outside SustiNet’s membership, with coordination between the Department of • Enhance surveillance related to key health Public Health and the SustiNet plan to maximize indicators; opportunities for success. • Provide more tobacco cessation services; • Include in K-12 education tobacco, drug, and We also considered the recommendations of our alcohol use prevention, as well as nutrition, stress Preventive Health Care Advisory Committee. That management, and exercise; and committee broadly defined its charge to improve health • Improve the nutrition environment in schools for SustiNet members, addressing the needs of the while reducing unhealthy marketing to children. whole person, including physical health, mental health, addictive behaviors, and oral health. The Committee In addition, the PCMH Advisory Committee recognized recommended that SustiNet cover a comprehensive that public education would be necessary to maximize package of preventive services, without requiring cost the use of preventive services through the medical home sharing. These services included: model, and the Workforce Task Force recommended • A basic set of preventive services (including investment in the public health workforce to support items receiving an “A” or “B” rating on the broader public health efforts. U.S. Preventive Services Task Force list) addressing physiological, emotional, mental, BOARD RECOMMENDATION: and developmental conditions for members from The Board recommends that SustiNet continue birth to the end of life; to emphasize preventive health and public health • All Early and Periodic Screening, Diagnosis, promotion by: and Treatment (EPSDT) services for Medicaid children13 • Incorporating the best available knowledge about the return on investment from preventive care in • Regularly scheduled screenings and other benefit designs for both current state-sponsored preventive services, such as mammograms, 22 Coverage and Cost Estimates

groups and populations that might purchase Coverage the SustiNet plan as a competitive option in the marketplace; and Based on Dr. Gruber’s projections, our proposal, along • Appropriately investing in the health of its with national legislation, would substantially increase covered population through education and support insurance coverage in Connecticut. Taking 2017 as a services that might go beyond traditional health representative year, the number of uninsured would fall insurance but could have a clear, positive impact by at least 55 percent, compared to levels in the absence on health. of reform.14 More than 200,000 otherwise uninsured residents would gain coverage. In addition, the Board recommends that the General Assembly, in collaboration with state agencies, the The availability of subsidies would cause a minority SustiNet Board, and other appropriate stakeholders, of firms with 100 or fewer employees to stop offering identify necessary resources and enact legislation to insurance. These are companies that, today, cover invest in statewide primary prevention efforts that mostly low-wage workers who, beginning in 2014, promote healthy nutrition, sleep, physical exercise, and would be better off if their employers stopped offering the prevention and cessation of the use of tobacco and insurance so the employees could qualify for subsidies. other addictive substances. The Board also supports As a result, the number of people covered by small investments in: employers would fall by 9 to 10 percent. More than 70 percent of affected workers would shift to subsidized • Improving community infrastructure and coverage in the exchange or other individual insurance, investing in workforce training to support and the overall proportion of small firm employees healthy lifestyles and furnish preventive care; without coverage would decline from 45 percent to • Including public health workforce capacity between 26 and 27 percent. in state health care workforce assessment and strategic planning; The overall impact on Connecticut coverage would • Reducing racial and ethnic disparities in access include a sizable reduction in the proportion of to resources that improve health while increasing residents without insurance, a significant increase in the support for healthy living by families from percentage of Connecticut citizens receiving subsidies, multiple, diverse cultures; and and a small drop in employer-sponsored insurance (ESI) (Figure 2). • Facilitating the receipt of funds for health care workforce training and development, including efforts to promote cultural and linguistic competence in serving the state’s diverse residents.

23 Figure 2.

Coverage of residents under age 65, with and without reform: 2017

6% 12% 3%

12% 17% Uninsured 4% Tax Credits 4% Public Individual ESI 72% 70%

Without Reform With Reform Source: Gruber Microsimulation Model. Notes: “ESI” means employer-sponsored insurance. Public coverage includes Medicaid and HUSKY. With reform, “individual” coverage includes both subsidized and unsubsidized coverage in the exchange as well as nongroup insurance outside the exchange. This figure assumes that SustiNet’s delivery system and payment reforms have no effect slowing cost growth.

Cost HUSKY payment rates to at least Medicare levels. As explained earlier, these two initiatives Our discussion of cost requires several preliminary will require the Legislature, SustiNet, and the comments: Administration to collaborate in finding new resources to fund the resulting costs. The costs of 15 • Like the rest of Dr. Gruber’s estimates, the these proposals, to the extent they are known, are analysis is limited to effects involving residents set forth in the earlier discussion, rather than here. under age 65. State costs itemized below represent net charges to • Costs are stated in 2010 dollars. the State General Fund. They do not include matching • The combined policies under discussion do federal dollars, even if those funds are subject to the not include either (a) an expansion of HUSKY state’s spending cap. eligibility before 2014 or (b) an increase in

24 An important question involves the extent to which On the other hand, reform will increase state costs in SustiNet slows cost growth. To address this question, several areas: Dr. Gruber produced estimates reflecting two different scenarios: a pessimistic scenario, in which SustiNet has • Enrollment is likely to increase in existing no effect on cost growth; and an optimistic scenario, categories of Medicaid and HUSKY eligibility, in which SustiNet slows cost growth by 1 percentage for which the state pays 50 percent of all costs. point per year. In neither case did Dr. Gruber assume • For newly eligible Medicaid adults with incomes any “spillover” effects, through which a reduction in at or below 138 percent of FPL, the federal uninsurance (and a consequent decrease in shifting government pays less than 100 percent of their uncompensated care costs to private insurance) or costs after 2016. While the state’s share will be a spread of SustiNet reforms to other health plans small, gradually rising to 10 percent in 2020 and would slow cost growth outside the four corners of the remaining at that level thereafter, there will be SustiNet plan. some state costs for these adults beginning in Beginning in 2014, the proposal we recommend, 2017. combined with national reform, would improve the • Enrollment into state employee coverage is state’s fiscal situation, in several ways: likely to increase modestly because of the individual mandate. • Implementing the Medicaid expansion required Altogether, state budget gains will outweigh new by the ACA will greatly increase federal funding costs by a substantial margin. Figure 3 illustrates the for the population formerly covered by State magnitude of the above factors under the pessimistic Administered General Assistance (SAGA). scenario, through which SustiNet has no effect in By converting SAGA into a new category of moderating health care cost growth. Under this Medicaid eligibility (Medicaid for Low-Income assumption, total state budget deficits would fall Adults, or LIA), Governor Rell reduced the by $224 million in 2017, compared to levels in the proportion of costs paid by Connecticut from absence of reform. 90 percent to 54 percent.16 Beginning in 2014, the state share will fall to 9 percent, yielding significant savings. • By implementing the Basic Health Program option, the state will shift the cost of covering 16,000 HUSKY parents from Medicaid, for which the federal government pays 50 percent of all expenses, into BH, where the federal government pays all costs. • The above-described small decline in ESI will result in a modest increase in wages, based on research showing that employers increase pay, to some degree, when they achieve health care cost savings. A slight wage increase will, in turn, raise state income tax revenues. • If SustiNet slows health care cost growth, state Medicaid and HUSKY spending will decline, compared to projected spending without reform. The state will likewise achieve savings in providing employees and retirees with health coverage. 25 Figure 3.

Effects on state spending and revenue for residents under age 65, pessimistic scenario: 2017 (millions)

Source: Gruber Microsimulation Model. Notes: Savings from shifting HUSKY parents into BH are included in the cost estimates for existing Medicaid/HUSKY populations. Savings for the conversion of SAGA to Medicaid for low-income adults are shown against a baseline in which SAGA was not converted into Medicaid coverage of low-income adults. Cost estimates do not include any savings for state-funded immigrants with incomes at or below 138 percent of FPL, who will be shifted into federally-funded BH under our proposal.

Figure 4 shows state fiscal effects in 2017 if SustiNet succeeds in slowing cost growth by 1 percentage point per year. Under this more optimistic scenario, the state budget will improve by $425 million.

26 Figure 4.

Effects on state spending and revenue for residents under age 65, optimistic scenario: 2017 (millions)

Source: Gruber Microsimulation Model. Note: This figure assumes that, in SustiNet, delivery system and payment reforms slow cost growth by 1 percentage point per year, beginning in 2012. See also notes to Figure 3.

The state’s net budget gains over time are displayed in Figure 5. Under the pessimistic scenario, savings gradually decline as the federal government reduces its share of Medicaid costs for newly eligible adults. Under the optimistic scenario, the impact of SustiNet on health care spending outweighs this modest decline in federal support, so net state budget gains increase.

27 Figure 5.

Net state budget savings for residents under age 65, optimistic and pessimistic scenarios: 2014-2019 (millions)

Source: Gruber Microsimulation Model. Notes: State budget effects include both outlays and revenues. The pessimistic scenario assumes that SustiNet does not affect cost growth. Under the optimistic scenario, SustiNet slows cost growth by 1 percentage point per year. See also notes to Figure 3.

Our proposal will also have implications for private sector costs. As noted earlier, small firm coverage will decline by 9 to 10 percent in 2017. As a result, small firms will save approximately $380 to $400 million in premiums. Ironically, these companies will save slightly less if SustiNet is more effective in slowing cost growth, because fewer small firms will drop coverage.

Although premium savings will be the most significant cost effect for small employers, some firms with fewer than 50 workers will also receive tax credits created by the ACA. A few companies with between 50 and 100 employees will pay penalties because they fail to offer ESI. In addition, any firms that drop coverage and increase wages will see their payroll taxes rise. The net effect of all these factors is that companies with 100 or fewer workers will realize gains of $399 to $415 million in 2017. Figure 6, below, shows how all these factors are projected to play out under the scenario in which small employers’ costs are higher because SustiNet slows cost growth to the point that a few additional firms offer coverage.

28 Figure 6.

Effects on health insurance costs and taxes for firms with 100 or fewer workers, scenario in which SustiNet slows cost growth, allowing more such firms to offer coverage: 2017 (millions)

Source: Gruber Microsimulation Model. Notes: This figure assumes that SustiNet is effective in slowing cost growth. Under a scenario in which SustiNet has no effect slowing cost growth, premium savings will equal $403 million, tax credit amounts will total $52 million, payroll taxes will increase by $34 rather than $32 million, and penalties for not offering coverage will remain at $6 million.

Among larger firms, the effects of reform are estimated to be negligible. In 2017, total costs for companies with more than 100 employers are projected to decline by roughly $50 to $70 million, or less than one-half of 1 percent

Similarly, total household post-tax purchasing power will be essentially unchanged under the combination of federal reform and our proposal, rising between $416 and $420 million a year, or less than one-half of 1 percent. Wages will increase modestly when some firms stop offering coverage, as explained above. Connecticut residents will receive more public-sector assistance in purchasing health coverage because of expanded Medicaid and HUSKY as well as newly created subsidies in the exchange. On the other hand, taxes will rise, mainly because the ACA increases Medicare payroll taxes for families earning more than $250,000 a year. Premium payments will go up because more people enroll in coverage, but out-of-pocket costs will decline slightly. Figure 7 shows how these effects balance out, under the pessimistic scenario in which SustiNet fails to slow cost growth. 29 Figure 7.

Effects on household purchasing power for residents under age 65, scenario in which SustiNet fails to slow cost growth: 2017 (millions)

Source: Gruber Microsimulation Model. Notes: Health insurance subsidies include Medicaid and HUSKY and premium and cost-sharing subsidies in the exchange. This figure assumes that SustiNet does not slow cost growth. Under a different scenario in which SustiNet slows cost growth by 1 percentage point per year beginning in 2012, wages will increase by $452 million, health insurance subsidies will grow by $1.055 billion, premium payments will rise by $72 million, out-of-pocket costs will fall by $13 million, and taxes will increase by $1.028 billion.

More broadly, SustiNet aims to spark broader reform improving quality and value, then private insurers of health care delivery and payment in Connecticut, will need to implement similar reforms to preserve using several strategies. First, SustiNet will lead market share. by example, rather than compulsion.17 It will demonstrate the impact of nimbly implementing cutting-edge reforms that seek to improve quality, Third, SustiNet’s continuity of coverage will strengthen safety, and health outcomes while slowing cost the business case for savings. Today, both commercial growth. If SustiNet proves effective, it will be easier insurers and Medicaid expect that a substantial fraction for others to move in similar directions. of their members will soon be gone, which reduces incentives to invest in long-term wellness. In the commercial world, an employer may change carriers, Second, SustiNet will galvanize broader change by or a worker receiving ESI may move to a new job that harnessing the power of competition. If SustiNet’s offers different insurance. In Medicaid, small changes initiatives slow cost growth while maintaining or in income and failure to complete necessary paperwork

30 cause caseload “churning,” with members leaving the Fifth and, in some ways, most important, as SustiNet program. Under our proposal, by contrast, regardless enrollment increases, SustiNet’s leverage to bring about of changes of income (and in some cases, even if delivery system and payment reforms will likewise workers move from job to job), SustiNet’s members increase. The number of commercial enrollees who join will typically stay with the plan for the foreseeable SustiNet depends, in part, on whether SustiNet achieves future, thus enhancing the return on investment from cost savings. But Dr. Gruber found that, under both efforts that increase preventive care, reduce obesity pessimistic and optimistic scenarios, SustiNet is likely and tobacco use, or successfully intervene in the early to gain a significant share of the state’s small group and development of other ongoing health problems. individual markets, along with a modest share of the large group market (Table 5). Fourth, SustiNet will work with other payers to implement coordinated efforts to help providers make necessary changes to health care delivery. Already, the Comptroller’s office is leading such a multi-payer initiative to pilot-test patient-centered medical homes, as noted above.

Table 5. Estimated SustiNet enrollment, outside state-sponsored groups: 2017

Small firm Large firm Individual enrollment enrollment enrollment

Covered Share of Covered Share of Covered Share of lives small firm lives large firm lives individual coverage coverage market

Pessimistic 136,000 24% 126,000 8% 32,000 14% scenario

Optimistic 164,000 29% 165,000 10% 33,000 15% scenario

31 Detailed Recommendations to the General Assembly Governance and location Our detailed recommendations address six core areas within state government related to SustiNet: A quasi-governmental agency (the SustiNet Governance and location within state government; 1Authority) should be established to oversee and 1 operate the SustiNet plan. The Authority should Policy-making duties and responsibilities of the generally be modeled after the Connecticut Health 2Authority Board; and Educational Facilities Authority and should be bound by the highest legal standards of ethics, Administrative duties and responsibilities of the transparency, and accountability. The Authority 3Authority; should be structured to reflect governance principles that embody the country’s best thinking about Reforming health care delivery and payment; effective and accountable administration (such 4 as those recommended by the Pew Center for the Expanding coverage and access to care; and States), including providing the public with regular 5 performance information. State public health investments. The Authority should be established as soon as 6 2possible and in no event later than March 1, 2012. As detailed above, during our sixteen months of The Authority should be governed by a deliberations we reviewed many of the challenges 3reconstituted board of directors (the Authority that make it difficult to simply “flip the switch” Board), which should be appointed and begin service and begin SustiNet operations. These challenges as soon as possible, no later than September 1, 2011. include different benefits, reimbursement levels, The Authority Board should be responsible for setting and provider networks across state-funded groups; overall policy for the SustiNet health plan. constraints of collective bargaining agreements and Medicaid law; and the need to obtain a state license The Authority Board, which could include to offer SustiNet in Connecticut’s health insurance 4members of the current Board, should be exchange. In addition to securing licensure, SustiNet appointed by a combination of elected officials in the will need to undertake considerable work developing Executive and Legislative branches of Connecticut state a new, publicly-administered, competitive health government and various stakeholder groups. Board insurance option that can succeed in the commercial members should be required to have specified areas marketplace. Moreover, the lack of an adequate of expertise. The Board should have the authority to primary care workforce and low Medicaid payment increase its membership to bring in additional expertise. levels must be overcome if SustiNet is to be fully At the same time, the Board should be as small as successful. We have attempted, in crafting the possible, to facilitate effective decision-making. following recommendations, to address these issues The Authority Board should establish a Consumer and design a solid foundation for future success. Advisory Committee, with broad consumer We believe strongly that the potential benefits of the 5 representation, and provide it with appropriate levels SustiNet plan warrant addressing the operational, of independent staffing. The Consumer Advisory technical, and fiscal challenges inherent in start-up. Committee should elect two representatives (one of whom can be a professional consumer advocate) to sit as voting members on the Authority Board and to

32 report the full breadth of advice from the Committee HUSKY. The Board should likewise be authorized to the Board. The Consumer Advisory Committee to make recommendations to the General Assembly, should be responsible for preparing Consumer Impact state agencies, and non-governmental organizations Statements describing the effects on consumers of the about changes in law, policy, practice, or procedure that Authority Board’s major policy decisions (identified would slow health care cost growth, improve health care as such by the Committee). These statements would quality or safety, increase access to health care, improve be published to accompany the final version of the population health, or reduce racial and ethnic disparities. Authority Board’s decisions when they are made available to the public. The Authority Board should take all necessary 4actions (which may include conducting feasibility Until the SustiNet Authority obtains funding and and risk assessment studies, developing financial 6staffing, the Office of the Comptroller should projections, and obtaining a state insurance license) to provide administrative support to the Authority Board offer a SustiNet health insurance plan as an option for and help such Board maximize its access to resources employers and individuals to purchase, as follows: outside the General Fund, including federal funds and Beginning as soon as possible in calendar year philanthropic grants. This interim staffing arrangement a2011, SustiNet should be an option for should terminate as soon as possible and in no event purchase by municipalities, using the same benefits later than January 1, 2013. and out-of-pocket costs that apply to state employees and retirees. If requested by a particular municipality Policy-making duties and and approved by the Authority Board, SustiNet may responsibilities of the provide the municipality’s enrollees with different Authority Board benefits or cost-sharing rules, including (but not limited to) commercial benefits like those described below. Coverage should be provided consistently with The Authority Board should be responsible for small group rules, for municipal employers subject to overseeing the SustiNet plan. This role includes 1 those rules. With larger municipal employers, SustiNet setting binding policy for delivery system and payment should take necessary steps to avoid adverse selection, reform affecting coverage received by SustiNet including experience-rating premiums. members, except where such policy conflicts with state or federal law or with collective bargaining agreements. To the extent feasible, taking into account other The Board should work with the Legislature and with bduties of the Authority, SustiNet should be other state agencies to identify funding sources needed available before 2014 to small firms and non-profit to cover any necessary initial investments. corporations, with SustiNet offering commercial benefits, as described below. The Authority Board should be authorized to 2convene committees and advisory groups as it deems Beginning on January 1, 2014, SustiNet should necessary to address such issues as implementation of the cbe offered to all Connecticut employers and patient-centered medical home, health care quality, health individuals, both inside and outside the exchange. care safety, incentives for evidence-based care, provider In structuring insurance plans for the commercial payment, prevention, health disparities and equity, and marketplace, the Authority Board should ensure health information technology. 5 that plan designs: In addition to its policy-making authority described Offer a variety of benefits and out-of- 3above, the Authority Board should be authorized apocket costs, with each package providing to advise the State Comptroller and the Department comprehensive, commercial-style benefits, including of Social Services on other matters related to health dental care and parity of coverage for physical and insurance coverage for state employees and retirees mental health conditions. and individuals covered through Medicaid and 33 Include, to the maximum feasible extent and ethnic disparities involving health care and health bconsistent with commercial viability, patient- outcomes, and reducing the number of state residents centered medical homes, integration of medical and without insurance. The Authority should monitor the behavioral health care, an emphasis on prevention, accomplishment of such objectives and modify action encouraging and supporting individual responsibility plans as necessary. for controllable health risks, and other design features that make SustiNet stand out as a high-quality option The Authority should be authorized to conduct that is attractive in the marketplace. 11public education and outreach campaigns to inform state residents about the SustiNet Plan Include cost-effective preventive services that and to encourage enrollment. In seeking to cover caddress physiological, emotional, mental, and the uninsured, such campaigns could partner with developmental conditions for members throughout community-based organizations and target populations their life span from birth to the end of life. The that are underserved by the health care delivery SustiNet Authority should periodically review and, if system. The Authority Board should monitor the necessary, revise its coverage of preventive care based effectiveness of such campaigns and modify strategies on the most current and reliable evidence available, as necessary. including results of SustiNet prevention initiatives. The Authority should, within available The Comptroller, DSS, other appropriate 12appropriations, develop and implement 6government agencies, and SustiNet should systematic policies and practices to identify, qualify encourage inclusion of cost-effective smoking for subsidies, enroll, and retain in coverage otherwise cessation services within covered benefits for all uninsured individuals. Such policies and practices SustiNet populations, at the earliest possible date. may include collaboration with Connecticut’s health insurance exchange, the Department of Revenue When sold in the individual or group market, Services, the Labor Department, and other local, state, SustiNet should be subject to the same rules that 7 and federal agencies, as well as health care providers, apply in that market, including rules for permitted including hospitals and community health centers, and premium variation. The Authority may use channels of other nongovernmental organizations, as appropriate. distribution and sale that apply to other plans in those markets, including the use of brokers and agents. Administrative duties and The Authority should prevent harmful adverse responsibilities of the 8selection when commercial enrollees choose SustiNet. This may include experience-rating Authority premiums when SustiNet is sold outside the exchange to firms large enough to self-insure. The Authority, with approval from the Authority Board, should be authorized and empowered to: To cover unexpected differences between plan 9expenditures and premiums, the Authority should Recruit and hire an Executive Director, who will maintain prudent reserves and should be authorized to 1implement the administrative operations of the take other appropriate steps, such as purchasing stop- SustiNet Authority. The Executive Director should loss coverage or reinsurance. have the authority to hire staff and enter into contracts, consistent with the Board’s overall direction and The Authority should implement multi- budget. After sufficient resources are identified outside 10year action plans to achieve measurable the state General Fund, the Executive Director should objectives in such areas as the effective prevention be hired to begin work as soon as possible, not later and management of chronic illness, reducing racial than March 1, 2012.

34 Adopt guidelines, policies, and regulations its duties and the execution of its powers under 2necessary to carry out its duties. its enabling legislation, including contracts and agreements for professional services, including but Contract with one or more insurers or other not limited to financial consultants, actuaries, bond 3entities for administrative purposes, such as claims counsel, underwriters, technical specialists, attorneys, processing, credentialing of providers, and establishing accountants, medical professionals, consultants, bio- provider networks, provided that any such administrative ethicists, and such other independent professionals or contract should pay per enrollee or on another basis that employees as the Authority shall deem necessary. does not provide an incentive for administrators to delay or deny coverage of necessary services. Enter into interagency agreements for performance 9of the Authority’s duties where such duties can be Contract with the Comptroller and the Department implemented at lower cost or more cost-effectively by 4of Social Services to provide health insurance contracting with a state agency. coverage for the following populations: State employees and retirees; and 10Establish policies and procedures: a Governing the use of new and existing channels Individuals who receive Medicaid, HUSKY aof sale to employers, including public and b(including with the eligibility expansions private purchasing pools, agents and brokers; described below), and (if approved by the Authority Board) other state-arranged or state-funded health Allowing the offering to employers of multi- coverage. byear contracts with predictable premiums; and Ensuring that employers can easily and Enrolling these populations in SustiNet should not cconveniently purchase SustiNet Plan coverage for be construed as authorization to modify premiums, their workers and dependents. Policies and procedures in covered benefits, out-of-pocket cost-sharing, or this area may include, but are not limited to, participation access to out-of-state providers for these membership requirements, timing of enrollment, open enrollment, categories. enrollment length, and other matters deemed appropriate by the Authority Board. Solicit bids from individual providers and provider 5organizations and arrange with insurers and others Apply for and receive grant funding from for access to existing or new provider networks 11private and public sources to support functions and take such other steps as are needed to provide consistent with its mission. all SustiNet Plan members with access to timely, Make optimum use of opportunities created by high-quality care throughout the state and medically the federal government for securing new and necessary care outside the state’s borders. 12 increased federal funding. Commission surveys of consumers, employers, 6and providers on issues related to health care and Reforming health care health care coverage. delivery and payment Negotiate on behalf of providers participating in 7the SustiNet Plan to obtain discounted prices for The Authority should be authorized to: vaccines and other goods and services. Implement changes in health care delivery and Make and enter into all contracts and agreements 1payment for the populations covered in the 8necessary or incidental to the performance of SustiNet plan, within the constraints of collective 35 bargaining agreements and federal law (including Provide incentives for evidence-based care Medicaid). Such changes may include provider 6that encourage providers to follow evidence- contracting requirements and, to the extent consistent based clinical guidelines. Any system that rewards with the above constraints as well as other state providers for meeting such guidelines should provide statutes, benefit design modifications that do not mechanisms for documenting reasons to depart from increase net state-funded costs. In reforming health guidelines because of, for example, an individual care delivery and payment, the Authority Board should patient’s clinical condition. prioritize strategies that offer the greatest potential for slowing cost growth. Establish a Pay-for-Performance system to reward 7providers for improvements in health care quality Integrate strategies for reducing and eliminating and safety and reductions in racial and ethnic disparities 2racial and ethnic disparities into every component in health access, utilization, quality of care, and health of the SustiNet plan, including outreach, enrollment, outcomes. Such Pay-for-Performance systems could benefit design, provider networks, financial incentives, reward providers for (a) making improvement as well quality measurement, provider credentialing, enrollee as for meeting benchmarks; (b) having an effective plan communications, and appeals. in place for preventing illness and improving health Establish payment methods for licensed health status; and (c) caring for patients with the most complex 3care providers that reflect evolving research and least well-controlled conditions. and experience both within the state and elsewhere, Encourage, support, and eventually require promote access to care and patient health and safety, 8SustiNet providers to use interoperable electronic prevent unnecessary spending, and ensure, to the health records to document and manage care. The maximum extent feasible, sufficient compensation to Authority Board should work with other organizations cover the reasonable cost of an efficient provider to within the state to maximize the usefulness and provide necessary care. minimize the cost to providers of this transformation, Strongly encourage and provide incentives taking advantage of available federal resources while 4and technical and other assistance for SustiNet leveraging the combined purchasing power of the providers to implement patient-centered medical state’s health care providers to obtain goods and homes. The Authority should establish a timeline for services of lower cost and higher value. ensuring that all SustiNet members can receive care In all SustiNet systems for data intake and storage, from a patient-centered medical home. 9include fields that record members’ race, ethnicity, In appropriate cases, implement alternatives to and language in addition to age, gender, and other 5fee-for-service provider payment. To encourage the demographic data, thereby creating the capacity provision of care that is safe and improves health, such to track disparities in health outcomes and health alternatives may include pay-for-performance, bundled care services. Data systems should enable coding of payments, global payments, or other innovations. multiple races and ethnicities for a single individual. To the extent warranted by available evidence, the Report provider performance in health care Authority Board should establish goals for increasing 10quality, efficiency, safety, and racial and the percentage of SustiNet expenditures made under ethnic disparities in health access, utilization, quality alternative payment methodologies over time. Based of care, and health outcomes by geographic area on experience in Connecticut and elsewhere, the Board and by provider or organization, where feasible, should evaluate the effect of alternative payment with outcomes risk-adjusted based on patient methodologies on quality, safety, and cost growth.

36 characteristics, to the maximum extent possible. Modify the above-described delivery and The SustiNet Authority would: 16payment reforms as warranted by evolving provide information to each provider evidence. aorganization comparing its performance to benchmarks and to other providers; To maximize the effectiveness of the above-described reforms, the General Assembly should make the provide guidance to providers on specific following statutory changes: bactions that they can take to improve their performance; and Where necessary, modify scope of practice laws give providers an opportunity to review their 1involving such provider groups as physician cown data, suggest revisions, and take corrective assistants and advance practice nurses to help these action before results are made public. providers function effectively as part of a patient- centered medical home. As soon as possible, create and maintain a data 11warehouse tracking health care utilization by Modify medical malpractice liability laws to (a) SustiNet members and other state-sponsored populations. 2provide a “safe harbor” that precludes liability for patient injury caused by clinicians appropriately Whether through such data warehouse or following approved clinical guidelines; and (b) 12otherwise, capture information necessary to ensure that patients, in such circumstances, receive publish provider price comparisons that will help compensation for the harm they suffer. consumers make informed choices. Authorize SustiNet or another state agency, 3with appropriate convener authority, to provide Work with state agencies to develop a data direction, supervision, and control over approved 13system that efficiently captures information cooperative agreements and to give health care measuring cost and quality and that allows for providers, health provider networks, and purchasers eventual integration of claims data and clinical who participate in discussions or negotiations information from electronic medical records. In authorized by this program immunity from civil doing so, the Board should coordinate with state liability and criminal prosecution under federal and efforts to upgrade Medicaid and other information state antitrust laws. The purpose of such actions systems to implement the Affordable Care Act, and is to facilitate the exchange of information among the state should maximize the use of available federal hospitals, other health care providers, and other funding for such purposes. Whenever possible, the appropriate entities to encourage the development of data development referenced in this provision should cooperative agreements, delivery arrangements, and be included within broader procurement efforts relationships intended to promote more cost-effective undertaken by state government, whether to meet health care delivery. requirements of the Affordable Care Act or otherwise. To the extent that delivery system and payment Ensure that privacy and data security are 4reforms implemented by the SustiNet plan achieve 14fully protected by the data systems described cost savings, the SustiNet Authority should be permitted above, including but not limited to compliance with to retain most of the savings to invest in further applicable federal requirements. improvements in services provided to SustiNet members. Work with other health plans and organizations 15inside Connecticut to facilitate multi-payer initiatives to reform health care delivery and payment.

37 Expanding Medicaid coverage FY 2013 should be part of a cost-neutral, overall and access to care realignment of payment levels and methods. In subsequent years, payment should gradually increase As of January 1, 2014, HUSKY should expand to to the levels described above. As that increase takes cover uninsured adults with incomes at or below 200 effect, SustiNet should commit to the goal that percent FPL. Such expansion would receive federal Medicaid and HUSKY beneficiaries will not, by virtue financial support as follows: of that status, experience impaired access to providers who serve other SustiNet members. Federal Medicaid matching funds should be Adopt specific standards that define access of care. 1claimed up to 138 percent FPL;18 and 3Pursuant to those standards, HUSKY and Medicaid Federal funding under the Basic Health Program beneficiaries would have access to care no less than 2should be claimed for individuals up to 200 that received by the privately insured. For example, percent of FPL for whom federal Medicaid funds such standards could define access in terms of the are unavailable. Any excess in federal Basic Health number of providers within geographic areas that funding over baseline HUSKY costs should be paid include a specified number of members, travel times out in the form of increased payment rates to providers required to reach participating providers (taking into serving HUSKY members with incomes above 138 account different populations’ use of mass transit), etc. percent FPL. For all HUSKY adults, benefits, cost- sharing arrangements, and other consumer protections State public health (such as appeals) should equal what current law investments provides to HUSKY parents. The General Assembly, in collaboration with state The General Assembly, in collaboration with the agencies, the Authority Board, and other appropriate Department of Social Services (DSS), other state stakeholders, should identify necessary resources and agencies as appropriate, and the Authority Board, should enact legislation to accomplish the following goals: take the following steps, and identify revenue sources or cost savings that are sufficient to pay for them: Invest in primary prevention efforts to promote healthy nutrition, sleep, physical exercise, and the Expand HUSKY eligibility to include childless 1 prevention and cessation of the use of tobacco and adults up to 185 percent FPL from July 1, 2012 1 other addictive substances. through December 31, 2013. Improve community infrastructure to support Gradually increase HUSKY and Medicaid provider healthy lifestyles and furnish preventive care. Such payment to at least Medicare levels for clinical 2 2 investments could include, for example, creating safe services for which current rates are inadequate, spaces for low-income children to play. They should beginning on July 1, 2012. Such plan should include also include efforts to increase the availability of tests, payment increases to another appropriate benchmark immunizations, and other preventive services at work, for services as to which Medicare fee schedules are at school, and in the community. insufficient, such as services to pregnant women and children. Such rate increases should be part of a Implement and sustain a statewide, telephone broader reform to Medicaid payment methodologies, 3quit-line for smoking cessation that provides both which should be developed by DSS during FY 2012. counseling and nicotine reduction products. Any Medicaid or HUSKY payment increases in

38 Increase the number and types of Tobacco Use Reduce racial and ethnic disparities in access 4Cessation (TUC) services available in diverse 13to resources that improve health and increase settings and develop and provide educational health literacy and support for healthy living by opportunities for training traditional and non- families from multiple, diverse cultures. traditional TUC service providers. Provide or otherwise facilitate the receipt of Require age-appropriate life skill education in 14funds for health care workforce training and 5grades K-12 that addresses anti-tobacco education, development, including efforts to promote cultural and prevention of drug and alcohol use, nutrition, stress linguistic competence in serving the state’s diverse management, exercise, health literacy, the rights and residents. responsibilities of health insurance consumers, and other appropriate topics. Update, adopt, implement, fund, and sustain the 6Connecticut Tobacco Use Prevention and Control Plan.

Implement statewide surveillance of key health 7indicators, using standard national surveys. Improve the nutrition environment in schools and 8day care facilities, including providing breakfast in school and providing healthy school lunches.

Reduce unhealthy food marketing to children, 9including making schools “ad-free” zones. Provide or otherwise facilitate the receipt of funds 10to expand the state’s public health workforce. Include public health workforce capacity in 11state health care workforce assessment and strategic planning. Develop and implement an overall strategic plan 12for assessing and addressing shortages in the state’s health workforce (including but not limited to those involving primary care), potentially incorporating such policies as targeted debt relief, broadening the permitted scope of practice for non-physician providers, training in new approaches to practice (such as those involving patient-centered medical homes and health information technology), and taking full advantage of available federal resources.

39 Timeline for Implementing SustiNet and the Affordable Care Act

2011 2012 2013 2014

SustiNet Board appointed Authority Independent from Board and by 9/1/2011. operational no Comptroller no later than Authority later than 3/1/2012 1/1/2013. Housed within the Office of the Comptroller.

SustiNet Existing state Executive staff agencies provide Director begins Staff fully independent no staff. work no later later than 1/1/2013. than 3/1/2012, as resources are identified outside General Fund.

SustiNet Includes current As soon as As soon as feasible, Offer SustiNet to coverage Medicaid possible, offer offer SustiNet to small all individuals and and HUSKY SustiNet to small businesses and non- employers through the enrollees and businesses and profits. Exchange and other state employee non-profits. channels, 1/1/2014. Expand HUSKY to and retiree health Expand HUSKY childless adults up to Expand HUSKY to benefit program to childless adults 185% FPL, if funding adults up to 200% (SEHP). up to 185% identified. FPL, using Medicaid As soon as FPL, if funding and Basic Health to feasible, identified. maximize federal municipalities funds. Excess federal can buy SustiNet. funds increase payment rates for BH.

Delivery Begin advising Implement Assume direct System Comptroller budget-neutral responsibility for and and DSS on re-alignment administering SustiNet Payment delivery system of Medicaid/ plan and implementing and payment HUSKY rates, delivery system and Reform reforms for SEHP 7/1/12. payment reforms, no later and Medicaid/ than 1/1/2013. HUSKY. Begin multi-year initiative Review Medicaid/ to increase Medicaid HUSKY payment rates, 7/1/13, with goal of methods and rates, reaching Medicare levels starting 7/1/11. over time. Contract with Comptroller and DSS to serve SEHP and Medicaid/HUSKY. . 40 Continued >> 2011 2012 2013 2014

Federal States may Medicaid payment Reform: provide Medicaid rates for certain Coverage to childless adults primary care & Funding (standard federal services increased matching rate), to Medicare levels, beginning 2010. with full federal Federal planning funding (2013 and grants and 2014). enhanced federal matching rates for medical home services available in Medicaid, 1/1/2011. Tax credits for some small businesses to purchase coverage, beginning 2010.

Federal Minimum States must establish Reform: medical loss ratio. an Exchange or the Insurance Insurance market federal government Market reforms prohibit will. rescissions, Insurance market lifetime caps, pre- reforms establish existing condition community rating, exclusions eliminate pre-existing for children, condition exclusions, beginning 2010. limit waiting periods to 90 days, etc.

41 Conclusion

The state of Connecticut faces daunting budget 4Perhaps the most important reason to offer SustiNet challenges. Those challenges make it more important outside the exchange is that adverse selection by large than ever to address serious problems involving limited employers can be prevented more effectively than access to health coverage and care for thousands of inside the exchange. state residents; misdirected incentives that interfere with the provision of high-quality, efficient care by 5In Federal Fiscal Year 2007, 530,000 Connecticut doctors, nurses, hospitals, and clinics; and health care residents received Medicaid and CHIP, of whom cost increases that are unsustainable for public and 52.7 percent were children, according to Urban private sectors alike. Our goal has been to develop Institute and Kaiser Commission on Medicaid and recommendations for the Connecticut General Assembly, the Uninsured estimates based on 2010 data from the Administration, and SustiNet’s future governing Medicaid Statistical Information System reports entity that, while cognizant of today’s budget challenges, from CMS. From June 2007 through June 2009, will help Connecticut assume a leadership role in total Medicaid and CHIP enrollment increased by addressing these pressing problems, which are national more than 14 percent in Connecticut, according to in scope. We urge Connecticut’s policymakers to move data compiled in 2010 by the Health Management towards a more rational and fair system of health care Associates from state Medicaid enrollment reports delivery and coverage, making wise choices in 2011 that for the Kaiser Commission on Medicaid and the yield major gains for the state’s taxpayers, employers, Uninsured. and families for years to come. 6The Urban Institute and the Kaiser Commission on Medicaid and the Uninsured, The Uninsured: A Endnotes Primer, December 2010 (state data for 2008-2009).

1 Implementing SustiNet Following Federal Enactment 7Section 1(2)(A) of the 2009 SustiNet law required of the Patient Protection and Affordable Care Act “coverage of medical home services; inpatient and of 2010: A Preliminary Report to the Connecticut outpatient hospital care; generic and name-brand General Assembly, May 27, 2010. The report is prescription drugs; laboratory and x-ray services; posted on the SustiNet website at http://www.ct.gov/ durable medical equipment; speech, physical and sustinet/lib/sustinet/board_of_directors_files/reports/ occupational therapy; home health care; vision care; sustinet_60_day_report_05272010.pdf. family planning; emergency transportation; hospice;

2 prosthetics; podiatry; short-term rehabilitation; the A more comprehensive description of Dr. Gruber’s identification and treatment of developmental delays model is posted on the SustiNet website at http://www. from birth through age three; and wellness programs, ct.gov/sustinet/lib/sustinet/board_of_directors_files/ provided convincing scientific evidence demonstrates resources/grubermodellongerdescription.pdf. that such programs are effective in reducing the severity or incidence of chronic disease.” 3Medicaid will expand to individuals with incomes up to 133 percent FPL. However, in calculating income, 8These categories include ambulatory care, emergency 5 FPL percentage points will be subtracted from services, hospitalization, maternity and newborn Modified Adjusted Gross Income. Accordingly, as a care, mental health and substance abuse services, practical matter, Medicaid coverage will reach 138 prescription drugs, rehabilitative and habilitative percent FPL. services, laboratory services, preventive and wellness services, chronic disease management, and pediatric services (including oral and vision care). ACA §1302(b)(1). 42 9This means that, for the average enrollee, health 14Dr. Gruber’s projections suggest that, under a insurance will pay the listed percentage of all health pessimistic scenario in which SustiNet does not slow care costs included within the essential benefits cost growth, the number of uninsured will fall by standard. 38 percent in 2014, 48 percent in 2015, 53 percent in 2016, and 55 percent in 2017 and later years. If 10However, SEHP covers associated office visits, SustiNet slows cost growth by 1 percentage point per prescription drugs, lab tests, and other services. year, that will increase the number of insured, because fewer small firms will drop coverage. Under the latter, 11See, e.g., Julie Hudman and Molly O’Malley, Health more optimistic scenario, the number of uninsured will Insurance Premiums and Cost-Sharing: Findings fall by 56 percent in 2017 and later years—slightly from the Research on Low-Income Populations, more than the level stated in the text. Kaiser Commission on Medicaid and the Uninsured, March 2003; Bill J. Wright, Matthew J. Carlson, Heidi 15The proposed increase in HUSKY payments cannot Allen, Alyssa L. Holmgren and D. Leif Rustvold, currently be modeled, because it requires a thorough “Raising Premiums And Other Costs For Oregon analysis and revision of HUSKY and Medicaid Health Plan Enrollees Drove Many To Drop Out,” payment. The precise details of changed payment Health Affairs, December 2010; 29(12): 2311-2316; rules will not be known until this analysis is complete. Dana P. Goldman; Geoffrey F. Joyce; Yuhui Zheng, After that, modeling cost effects should be much more “Prescription Drug Cost Sharing: Associations With feasible. Medication and Medical Utilization and Spending and Health,” Journal of the American Medical Association, 16In estimating savings, Dr. Gruber compared the July 4, 2007; 298(1):61-69; Becky A. Briesacher, Jerry policy that will exist when federal and state reforms H. Gurwitz, and Stephen B. Soumerai, “Patients At- are fully implemented, beginning in 2014, with the Risk for Cost-Related Medication Nonadherence: A policy that preceded this step by Governor Rell. Review of the Literature,” Journal of General Internal Medicine, June 2007; 22(6): 864–871; Samantha 17This general formulation was articulated by Howard Artiga and Molly O’Malley, Increasing Premiums and Kahn, the Chief Executive Officer of L.A. Care, at our Cost-Sharing in Medicaid and SCHIP: Recent State meeting on October 13, 2010. Experiences, Kaiser Commission on Medicaid and the Uninsured, May 2005. Of course, this research 18Nominally, Medicaid will expand to individuals was done before enactment of an individual mandate, with Modified Adjusted Gross Incomes (MAGI) up to which, all else equal, will increase enrollment. 133 percent FPL. However, in determining income, 5 FPL percentage points are subtracted from MAGI. 12These population estimates were developed by the Accordingly, the effective eligibility threshold is 138 Gruber Microsimulation Model. percent FPL.

13Under current federal law, these services are provided to all Medicaid children, without cost- sharing.

43 APPENDIX

A. SustiNet Health Plan – Compiled Final Reports a. Advisory Committees i. Health Disparities & Equity ii. Health Information & Technology iii. Patient Centered Medical Home iv. Preventive Healthcare v. Healthcare Quality & Provider

b. Task Forces i. Healthcare Work Force ii. Tobacco & Smoking Cessation iii. Childhood & Adult Obesity

B. Jonathan Gruber, Ph.D. – Microsimulation Model Summary

C. SustiNet Legislative Cross-Walk APPENDIX A

SustiNet Health Plan Compiled Final Reports

Advisory Committees

Health Disparities & Equity Health Information & Technology Patient Centered Medical Home Preventive Healthcare Healthcare Quality & Provider

Task Forces

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!"#$%&'(' Source: “Health Insurance Technology Exchange of Connecticut Strategic Plan, Draft, June 2010”http://www.ct.gov/dph/lib/dph/research_&_development/hite- ct_strategic_plan_draft_v2.0.pdf !

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Friedberg, et. al., Primary Care: A Critical Review of the Evidence on Quality and Costs of Health Care, Health Affairs 29:766-772, May 2010. v Yale University Library multi-database article search, 6/16/2010. vi E. Andrews and S. Toubman, Patient-Centered Medical Home: Improving Health Care by Shifting the Focus to Patients, CT Medicine 73:479-480, September 2009. vii P. Grundy, et. al., The Multi-Stakeholder Movement for Primary Care Renewal and Reform, Health Affairs 29:791-797, May 2010. viii J DeVoe, et. al., Amer J Pub Hlth, 93:786, May 2003 ix K. Grumbach et. al., The Outcomes of Implementing Patient-Centered Medical Home Interventions, Patient- Centered Primary Care Collaborative, August 2009, A. Milstein and E. Gilbertson, American Medical Home Runs, Health Affairs 28:1317-1326, September 2009, R. Reid, et. al., The Group Health Medical Home at Year Two, Health Affairs 29:835-843, May 2010. x Christopher Atchison, presentation at Building a Medical Home: Issues and Decisions for State Policy Makers, NASHP, 10/5/08, Tampa, FL xi C Hull, The Medical Home Model and Family Health Teams, Research and Education Services, Legislative Assembly of Ontario, 5/11/09. xii Multi-payer Advanced Primary Care Practice Demonstration Solicitation, CMS, June 2010. xiii Patient Centered medical homes in the Patient Protection and Affordable Care Act, CT Health Policy Project, April 2010. xiv C DesRoches, et. al., New Engl J Med online, July 3, 2008 xv Personal communication, Matt Katz, CT State Medical Society. xvi Primary Care Coalition of Connecticut, March 2010. xvii Supporting Small Practices, NCQA, June 2009. xviii P Nutting, et. al., Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home, Annals of Family Medicine, 7:254-260, May/June 2009. xix !"#$%&'()*+#,-.#/"#01(231&4#015#6&,2'#718+#9#:8#;1-<=#9#>-#?8>2,8@#$,8&4#0&,(=%#ABB,>8'#CDEFGHIFGD4#J,@# CKLK" xx Physician Practice Connections – Patient Centered Medical Home, NCQA, www.ncqa.org xxi NCQA, September 2009. xxii Primary Care Case Management, CT Health Policy Project, http://www.cthealthpolicy.org/pccm/index.htm xxiii ACS HUSKY enrollment reports, June 2010. xxiv PA 10-166, An Act Concerning Expansion of the Primary Care Case Management Pilot Program, 2010 General Assembly session. xxv Patient Centered Medical Home Initiative with ProHealth, presentation to committee, April 21, 2010. xxvi Ron Preston, presentation to committee, May 26, 2010, personal communications with VT state health policymakers. xxvii CT’s population projections, US Census. xxviii CT State Data Center. MM>M#$6<'#0&,(=%#$,8ˎ+B18*&E#N-.&8#$1-'=8)*=>1-4#!8>&B>-O#P,P&8#B18#=%&#Q)'=>R&=#0&,(=%#$,8ˎ+B18*,'+# S18*&4#S,>8B>&(.#$1)-=@#!)'>-&''#$1)-*>(4#6,-@,#$1)8=4#J,@#CKLK4#!"#$(&,8@4#&="#,("4#/MP,-.>-O#=%&#$,P,*>=@#1B# R)8'>-O#/.)*,=>1-4#0&,(=%#ABB,>8'#CFE5TUHI5THV4#W)-&#LC4#CKKD"# xxx Unpublished survey, CT Health Policy Project. xxxi Addressing Racial and Ethnic Disparities in Health Care Fact Sheet. AHRQ, February 2000. xxxii Lessons for State Policymakers from Kaiser Permanente, Ann Torregrossa, PA GOHCR, Using Payment Reform to Improve Health System Performance, NASHP State Health Policy Conference, Oct. 5, 2009. xxxiii Healthcare Effectiveness Data and Information Set 2011, NCQA. ! ! !

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!! Figure 1 ! An Ecological Model of Obesity (NHLBI) Influences Behaviors Health Outcomes Biological & Demographic Age, sex, race/ethnicity, SES, genes

Psychological Eating Beliefs, preferences, emotions, self-efficacy, intentions, Dietary patterns, pros, cons, behavior change skills, body image, nutrient intake motivation, knowledge

Social/Cultural Social support, modeling, family factors, social norms, cultural beliefs, acculturation Sedentary Behaviors Weight, Organizational TV, computer use, Fat, & driving Distribution Energy

Practices, programs, norms, & policies in schools, worksite, Balance Health care settings, businesses, community orgs

Physical Environment Access to & quality of foods, recreational facilities, cars, Physical Risk Factors, sedentary entertainment; urban design, Activity CVD, transportation infrastructure, information environment Recreation, Diabetes, transportation, Cancers, occupation, Costs domestic Policies/Incentives Cost of foods, physical activities, & sedentary behaviors; incentives for behaviors; regulation of environments

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Jonathan Gruber, Ph.D.

Microsimulation Model Summary

Short Description of Gruber Microsimulation Model

The model allows the user to input a set of policy parameters, and output the impact of that policy on public sector costs and the distribution of insurance coverage. The modeling approach used here is the type of “microsimulation” modeling used by the Treasury Department, CBO, and other government entities. This approach consists of drawing on the best evidence available in the health economics literature to model how individuals will respond to the changes in the insurance environment induced by changes in government policy.

The model takes as its base the February and March Current Population Surveys. The March survey contains information on family demographics, tax rates, and insurance coverage. The February survey contains information on insurance offering by employers. I match to these surveys information on:

• Group insurance costs and the distribution of premiums across employers and employees, imputed by firm location and firm size; • Nongroup insurance costs, which use a base cost estimated from existing nongroup insurance pricing, adjusted by age, sex, and health status; • Public insurance costs; and • Underlying health care costs, which are imputed by age and health status.

This base set of data is then used to compute, for every possible policy change, the impact of that policy change on the eligibility for, and price of, various types of insurance. These price and eligibility changes are then run through a detailed and integrated set of behavioral equations that relate them to behavioral responses by individuals, families, and firms. These behavioral responses are modeled using the best available evidence from the health economics literature, and include responses such as:

• The extent to which the currently uninsured will purchase newly subsidized insurance coverage or take up newly available public coverage; • The extent to which those with existing insurance coverage will take up subsidies to that type of insurance coverage (e.g. to what extent will the nongroup insured take up subsidies to nongroup insurance?); • The extent to which those with one form of insurance coverage will switch to another form if it is subsidized; • The extent to which firms will react to the subsidies to non-employer insurance by dropping their offering of insurance to their employees, or by cutting back on employer premium contributions to insurance; and • The extent to which those employees dropped from group coverage will then take up other forms of insurance coverage.

It is very important to model potential firm responses to these policy changes. To capture firm responses, I have created “synthetic” firms in the CPS by drawing for each worker other “co-workers” in the CPS based on that worker’s wage, industry, firm size, and health insurance offering status. These synthetic co-workers are grouped together to form firms, and I then model firm responses based on the average effects of policies on their workforce. APPENDIX C

SustiNet Legislative Cross-Walk Substitute House Bill No. 6600

Public Act No. 09‐148

AN ACT CONCERNING THE ESTABLISHMENT OF THE SUSTINET PLAN

Crosswalk To Report Section Statute

Be it enacted by the Senate and House of Representatives in General Assembly convened:

1 Section 1. (NEW) (Effective July 1, 2009) As used in sections 1 to 14, inclusive, Definitions: of this act and section 17b‐297b of the general statutes, as amended by this act: No action required (1) "SustiNet Plan" means a self‐insured health care delivery plan, that is designed to ensure that plan members receive high‐quality health care coverage without unnecessary costs;

1 (2) "Standard benefits package" means a set of covered benefits as determined by the public authority, with out‐of‐pocket cost‐sharing limits Benefits and provider network rules, subject to the same coverage mandates described in chapter 700c of the general statutes and the utilization review requirements described in chapter 698a of the general statutes that apply to group health insurance sold in this state. The standard benefits package includes, but is not limited to, the following: (A) Coverage of medical home services; inpatient and outpatient hospital care; generic and name‐brand prescription drugs; laboratory and x‐ray services; durable medical equipment; speech, physical and occupational therapy; home health care; vision care family planning; emergency transportation; hospice; prosthetics; podiatry; short‐term rehabilitation; the identification and treatment of developmental delays from birth through age three; and wellness programs, provided convincing scientific evidence demonstrates that such programs are effective in reducing the severity or incidence of chronic disease; (B) A per individual and per family deductible, provided preventive care or prescription drugs shall not be subject to any deductible; (C) Preventive care requiring no copayment that includes well‐child visits, well‐baby care, prenatal care, annual physical examinations, immunizations and screenings; (D) Office visits for matters other than preventive care for which there shall be a copayment; (E) Prescription drug coverage with copayments for generic, name‐ brand preferred and name‐brand nonpreferred drugs; (F) Coverage of mental and behavioral health services, including tobacco

Crosswalk To Report Section Statute cessation services, substance abuse treatment services, and services that prevent and treat obesity with such services being at parity with the coverage for physical health services; and (G) Dental care coverage that is comparable in scope to the median coverage provided to employees by large employers in the Northeast states; provided, in defining large employers, consideration shall be given to the capacity of available data to yield, without substantial expense, reliable estimates of median dental coverage offered by such employers;

1 (3) "Electronic medical record" means a record of a person's medical Definitions: treatment created by a licensed health care provider and stored in an interoperable and accessible digital format; No action required (4) "Electronic health record" means an electronic record of health‐related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one health care organization; (5) "Northeast states" means the Northeast states as defined by the United States Census Bureau; (6) "Board of directors" means the SustiNet Health Partnership board of directors established pursuant to section 2 of this act; (7) "Public authority" means a public authority or other entity recommended by the SustiNet Health Partnership board of directors in accordance with the provisions of subsection (b) of section 3 of this act; (8) "Small employer" has the same meaning as provided in subparagraph (A) of subdivision (4) of section 38a‐564 of the general statutes; and (9) "Nonstate public employer" means a municipality or other political subdivision of the state, including a board of education, quasi‐public agency or public library.

2 Sec. 2. (NEW) (Effective July 1, 2009) Establishes Board of Directors: (a) There is established the SustiNet Health Partnership board of directors. The board of directors shall consist of nine members, as follows: The No action required Comptroller; the Healthcare Advocate; one appointed by the Governor, who shall be a representative of the nursing or allied health professions; one appointed by the president pro tempore of the Senate, who shall be a primary care physician; one appointed by the speaker of the House of Representatives, who shall be a representative of organized labor; one appointed by the majority leader eof th Senate, who shall have expertise in the provision of employee health benefit plans for small businesses; one appointed by the majority leader of the House of Representatives, who shall have expertise in health care economics or health care policy; one appointed by the minority leader of the Senate, who shall have

Crosswalk To Report Section Statute expertise in health information technology; and one appointed by the minority leader of the House of Representatives, who shall have expertise in the actuarial sciences or insurance underwriting. The Comptroller and the Healthcare Advocate shall serve as the chairpersons of the board of directors. (b) Initial appointments to the board of directors shall be made on or before July 15, 2009.In the event that an appointing authority fails to appoint a board member by July 31, 2009, the president pro tempore of the Senate and the speaker of the House of Representatives shall jointly appoint a board member meeting the required specifications on behalf of such appointing authority and such board member shall serve a full term. The presence of not less than five members shall constitute a quorum for the transaction of business. The initial term for the board member appointed by the Governor shall be for two years. The initial term for board members appointed by the minority leader of the House of Representatives and the minority leader of the Senate shall be for three years. The initial term for board members appointed by the majority leader of the House of Representatives and the majority leader of the Senate shall be for four years. The initial term for the board members appointed by the speaker of the House of Representatives and the president pro tempore of the Senate shall be for five years. Terms pursuant to this subdivision shall expire on June thirtieth in accordance with the provisions of this subdivision.y An vacancy shall be filled by the appointing authority for the balance of the unexpired term. Not later than thirty days prior to the expiration of a term as provided for in this subsection, the appointing authority may reappoint the current board member or shall appoint a new member to the board. Other than an initial term, a board member shall serve for a term of five years and until a successor board member is appointed. A member of the board pursuant to this subdivision shall be eligible for reappointment. Any member of the board may be removed by the appropriate appointing authority for misfeasance, malfeasance or willful neglect of duty.

(c) The SustiNet Health Partnership board of directors shall not be construed to be a department, institution or agency of the state. The staff of the joint standing committee of the General Assembly having cognizance of matters relating to public health shall provide administrative support to the board of directors.

3 Sec. 3. (NEW) (Effective July 1, 2009) Overall Design: (a) The SustiNet Health Partnership board of directors shall design and Addressed in the Board’s, establish implementation procedures to implement the SustiNet Plan. Advisory Committees’ and The SustiNet Plan shall be designed to (1) improve the health of state Task Forces’ residents; (2) improve the quality of health care and access to health recommendations care; (3) provide health insurance coverage to Connecticut residents who would otherwise be uninsured; (4) increase the range of health care insurance coverage options available to residents and employers; (5) slow the growth of per capita health care spending both in the short‐

Crosswalk To Report Section Statute term and in the long‐term; and (6) implement reforms to the health care delivery system that will apply to all SustiNet Plan members, provided any such reforms to health care coverage provided to state employees, retirees and their dependents shall be subject to applicable collective bargaining agreements.

Governance and Location 3 (b) The SustiNet Health Partnership board of directors shall offer within State Government recommendations to the General Assembly on the governance structure of the entity that is best suited to provide oversight and implementation of the SustiNet Plan. Such recommendations may include, but need not be limited to, the establishment of a public authority authorized and empowered:

Administrative Duties and (1) To adopt guidelines, policies and regulations in accordance with Responsibilities of the chapter 54 of the general statutes that are necessary to implement the Authority provisions of sections 1 to 14, inclusive, of this act;

Administrative Duties (2) To contract with insurers or other entities for administrative purposes, such as claims processing and credentialing of providers. Such contracts shall reimburse these entities using "per capita" fees or other methods that do not create incentives to deny care. The selection of such insurers or other entities may take into account their capacity and willingness to (A) offer timely networks of participating providers both within and outside the state, and (B) help finance the administrative costs involved in the establishment and initial operation of the SustiNet Plan;

(3) To solicit bids from individual providers and provider organizations Administrative Duties and to arrange with insurers and others for access to existing or new

provider networks, and take such other steps to provide all SustiNet Plan

members with access to timely, high‐quality care throughout the state

and, in appropriate cases, care that is outside the state's borders;

Administrative Duties (4) To establish appropriate deductibles, standard benefit packages and out‐of‐pocket cost sharing levels for different providers, that may vary based on quality, cost, provider agreement to refrain from balance billing SustiNet Plan members, and other factors relevant to patient care and financial sustainability;

Administrative Duties (5) To commission surveys of consumers, employers and providers on issues related to health care and health care coverage;

Administrative Duties (6) To negotiate on behalf of providers participating in the SustiNet Plan to obtain discounted prices for vaccines and other health care goods and services;

Administrative Duties (7) To make and enter into all contracts and agreements necessary or incidental to the performance of its duties and the execution of its powers under its enabling legislation, including contracts and agreements for such professional services as financial consultants, actuaries, bond

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counsel, underwriters, technical specialists, attorneys, accountants, medical professionals, consultants, bio‐ethicists and such other independent professionals or employees as the board of directors shall deem necessary;

Administrative Duties (8) To purchase reinsurance or stop loss coverage, to set aside reserves, or to take other prudent steps that avoid excess exposure to riske in th administration of a self‐insured plan;

Administrative Duties (9) To enter into interagency agreements for performance of SustiNet Plan duties that may be implemented more efficiently or effectively by an existing state agency;

(10) To set payment methods for licensed health care providers that Reforming Health Care reflect evolving research and experience both within the state and Delivery and Payment elsewhere, promote access to care and patient health, prevent

unnecessary spending, and ensure sufficient compensation to cover the

reasonable cost of furnishing necessary care;

Policy‐Making Duties and (11) To appoint such advisory committees as may be deemed necessary Responsibilities of the for the public authority to successfully implement the SustiNet Plan, Authority Board further the objectives of the public authority and secure necessary input from various experts and stakeholder groups;

Established by current (12) To establish and maintain an Internet web site that provides for board timely posting of all public notices issued by the public authority or the board of directors and such other information as the public authority or board deems relevant in educating the public about the SustiNet Plan;

Included in federal ACA (13) To evaluate the implementation of an individual mandate in concert with guaranteed issue, the elimination of preexisting condition exclusions, and the implementation of auto‐enrollment;

Administrative Duties (14) To raise funds from private and public sources outside of the state budget to contribute toward support of its mission and operations;

(15) To make optimum use of opportunities created by the federal Administrative Duties government for securing new and increased federal funding, including,

but not limited to, increased reimbursement revenues;

(16) In the event of the enactment of federal health care reform, to Submitted report submit preliminary recommendations for the implementation of the SustiNet Plan to the General Assembly not later than sixty days after the date of enactment of such federal health care reform; and

Included in federal ACA (17) To study the feasibility of funding premium subsidies for individuals with income that exceeds three hundred per cent of the federal poverty level but does not exceed four hundred per cent of the federal poverty level.

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3 (c) Not later than January 1, 2011, the SustiNet Health Partnership board of Direction to submit this directors shall submit its design and implementation procedures in the report form of recommended legislation to the joint standing committees of the

General Assembly having cognizance of matters relating to

appropriations and the budgets of state agencies and finance, revenue

and bonding.

(d) All state and municipal agencies, departments, boards, commissions and In process councils shall fully cooperate with the board of directors in carrying out

the purposes enumerated in this section.

4 Sec. 4. (NEW) (Effective July 1, 2009) Overall Design: (a) The board of directors shall develop the procedures and guidelines for Addressed in the Board’s, the SustiNet Plan. Such proceduresd an guidelines shall be specific and Advisory Committees’ and ensure that the SustiNet Plan is established in accordance with the five Task Forces’ following principles to guide health care reform as enumerated by the recommendations Institute of Medicine: (1) Health care coverage should be universal; (2) health care coverage should be continuous; (3) health care coverage should be affordable to individuals and families; (4) the health insurance strategy should be affordable and sustainable for society; and (5) health care coverage should enhance health and well‐being by promoting access to high‐quality care that is effective, efficient, safe, timely, patient‐ centered and equitable. In process (b) The board of directors shall identify all potential funding sources that may be utilized to establish and administer the SustiNet Plan.

Policy‐Making Duties and (c) The board of directors shall recommend that the public authority adopt Responsibilities periodic action plans to achieve measurable objectives in areas that include, but are not limited to, effective management of chronic illness, preventive care, reducing racial and ethnic disparities as related to health care and health outcomes, and reducing the number of state residents without insurance. The board of directors shall include in its recommendations that the public authority monitor the accomplishment of such objectives and modify action plans as necessary.

5 Sec. 5. (NEW) (Effective July 1, 2009) Information Technology Advisory Committee (a) For purposes of this section: (1) "Subscribing provider" means a licensed Recommendations health care provider that: (A) Either is a participating provider in the SustiNet Plan or provides services in this state; and (B) enters into a binding agreement to pay a proportionate share of the cost of the goods and services described in this section, consistent with guidelines adopted by the board; and (2) "approved software" means electronic medical records software approved by the board, after receiving recommendations from the information technology committee, established pursuant to this section. (b) The board of directors shall establish an information technology advisory

Crosswalk To Report Section Statute 5 committee that shall formulate a plan for developing, acquiring, financing, leasing or purchasing fully interoperable electronic medical records software and hardware packages for subscribing providers. Such plan shall include the development of a periodic payment system that allows subscribing providers to acquire approved software and hardware while receiving the services described in this section. The committee shall offer recommendations on matters that include, but are not limited to: (1) The furnishing of approved software to subscribing providers and to participating providers, as the case may be, consistent with the capital acquisition, technical support, reduced‐cost digitization of records,

software updating and software transition procedures described in this section; and (2) the development and implementation of procedures to ensure that physicians, nurses, hospitals and other health care providers gain access to hardware and approved software for interoperable electronic medical records and the establishment of electronic health records for SustiNet Plan members.

(c) The committee shall consult with health information technology specialists, physicians, nurses, hospitals and other health care providers, as deemed appropriate by the committee, to identify potential software

and hardware options that meet the needs of the full array of health care practices in the state. Any electronic medical record package that the committee recommends for future possible purchase shall include, to the maximum extent feasible: (1) A full set of functionalities for pertinent provider categories, including practice management, patient scheduling, claims submission, billing, issuance and tracking of laboratory orders and prescriptions; (2) automated patient reminders concerning upcoming appointments; (3) recommended preventive care services; (4) automated

provision of test results to patients, when appropriate; (5) decision support, including a notice of recommended services not yet received by a patient; (6) notice of potentially duplicative tests and other services; (7) in the case of prescriptions, notice of potential interactions with other drugs and past patient adverse reactions to similar medications; (8) notice of possible violation of patient wishes for end‐of‐life care; (9) notice of services provided inconsistently with care guidelines adopted pursuant to section 8 of this act, along with options that permit the

convenient recording of reasons why such guidelines are not being followed; and (10) such additional functions as may be approved by the information technology committee.

(d) The committee shall offer recommendations on the procurement and development of approved software. Such recommendations may include that any approved software have the capacity to: (1) Gather information pertinent to assessing health care outcomes, including activity limitations, self‐reported health status and other quality of life indicators; and (2) allow the board of directors to track the accomplishment of

clinical care objectives at all levels. The board of directors shall ensure that SustiNet Plan providers who use approved software are able to electronically transmit to, and receive information from, all laboratories and pharmacies participating in the SustiNet Plan, without the need to

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(e) The committee shall offer recommendations on the selection of vendors to provide reduced‐cost, high‐quality digitization of paper medical records for use with approved software. Such vendors shall be bonded, supervised and covered entities under the provisions of the Health Insurance Portability and Accountability Act of 1996 (P. L. 104 191) (HIPAA), as amended from time to time, and in full compliance with other

governing federal law.

(f) The committee shall offer recommendations on an integration system through which electronic medical records used by subscribing providers are integrated into a single electronic health record for each SustiNet Plan member, updated in real time whenever the member seeks or obtains care, and accessible to any participating or subscribing provider

serving the member. Such electronic health record shall be designed to automatically update approved software. Such updates may include incorporating newly approved clinical care guidelines, software patches or other changes. (g) All recommendations concerning electronic medical records and electronic health records shall be developed and administered in a manner that is consistent with guidelines approved by the board of directors for safeguarding privacy and data security and with state and federal law, including any recommendations of the United States

Government Accountability Office. Such guidelines shall include the remedies and sanctions that apply in the event of a provider's failure to comply with privacy or information security requirements. Remedies shall include notice to affected members and may include, in appropriate cases, termination of network privileges and denial or reduction of SustiNet Plan reimbursement. Remedies and sanctions recommended by the board of directors shall be in addition to those otherwise available under state or federal law.

(h) The committee shall develop recommended methods to eliminate or

minimize transition costs for health care providers that, prior to January 1, 2011, have implemented comprehensive systems of electronic medical records or electronic health records. Such methods may include technical assistance in transitioning to new software and development of modules to help existing software connecte to th integration system described in subsection (i) of this section.

(i) The committee shall offer recommendations that permit subscribing providers to receive a proportionate share of systemic cost savings that are specifically attributable to the implementation of electronic medical

records and electronic health records. Such subscribing providers shall include those that, throughout the period of their subscription, have been participating providers in the SustiNet Plan and that, but for the savings shared pursuant to this subsection, would incur net financial

Crosswalk To Report Section Statute 5 losses during their first five years of using approved software. The amount of savings shared by the board with a provider shall be limited to the amount of net financial loss satisfactorily demonstrated by the provider. A provider whose losses resulted from the provider's failure to take reasonable advantage of available technical support and other services offered by the public authority shall not share in the systemic cost savings. (j) The committee shall offer recommendations concerning the use of

electronic health records to facilitate the provision of medical home functions as described in section 6 of this act. The committee shall recommend methods for such electronic health records to generate automatic notices to medical homes that: (1) Report when an enrolled member receives services outside the medical home; (2) describe member compliance or noncompliance with provider instructions, as relate to the filling of prescriptions, referral services, and recommended tests, screenings or other services; and (3) identify the expiration of refillable prescriptions.

(k) The committee shall offer recommendations requiring: (1) That each participating provider use either approved software or other electronic medical record software that is interoperable with approved software and the electronic health record integration system described in subsection (f) of this section; (2) the development and implementation of appropriate financial incentives for early subscriptions by participating providers, including discounted fees for providers who do not delay their subscriptions; (3) that no later than July 1, 2015, the board of directors require as a condition of participatione in th SustiNet Plan that each participating provider use either approved software or other electronic medical record software that is interoperable with approved software and the electronic health record integration system described in subsection (f) of this section; (4) that after July 1, 2015, the board of directors have authority to provide additional support to a provider that demonstrates to the satisfaction of the board that such provider would experience special hardship due to the implementation of electronic medical records and electronic health records requirements within the specified time frame; and (5) that such provider be allowed to qualify for additionald support an an exemption from compliance with the time frame specified in this subsection, but only if such an exemption is necessary to ensure that members in the geographic locality served by the provider continue to receive access to care. (l) The committee shall recommend methods to coordinate the development and implementation of electronic medical records and electronic health records in concert with the Department of Public Health and other state agencies to ensure efficiency and compatibility. The committee shall determine appropriate financing options, including, but not limited to, financing through the Connecticut Health and Educational Facilities Authority established pursuant toa section 10 ‐179 of the general statutes.

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6 Sec. 6. (NEW) (Effective July 1, 2009) Medical Home Advisory (a) The board of directors shall establish a medical home advisory committee Committee that shall develop recommended internal procedures and proposed

Recommendations regulations governing the administration of patient‐centered medical homes that provide health care services to SustiNet Plan members. The medical home advisory committee shall forward their recommended internal procedures and proposed regulations to the board of directors in accordance with such time and format requirements as may be prescribed by said board. The medical home advisory committee shall be composed of physicians, nurses, consumer representatives and other qualified individuals chosen by said board.

(b) Committee recommendations concerning patient‐centered medical homes shall include that: (1) Medical home functions be defined by the board of directors on an ongoing basis that incorporates evolving research concerning the delivery of health care services; and (2) if limitations in provider infrastructure prevent all SustiNet Plan members from being enrolled in patient‐centered medical homes, enrollment in

medical homes be implemented in phases with priority enrollment given to members for whom cost savings appear most likely, including, in appropriate cases, members with chronic health conditions.

(c) Subject to revision by the board of directors, the committee shall offer recommendations that initial medical home functions include the following: (1) Assisting members to safeguard and improve their own health by: (A) Advising members with chronic health conditions of methods to monitor and manage their own conditions; (B) working with members to set and accomplish goals related to exercise, nutrition,

use of tobacco and other addictive substances, sleep, and other behaviors that directly affect such member's health; (C) implementing best practices to ensure that members understand medical instructions and are able to follow such directions; and (D) providing translation services and using culturally competent communication strategies in appropriate cases;

(2) Care coordination that includes: (A) Managing transitions between home and the hospital; (B) proactive monitoring to ensure that the member receives all recommended primary and preventive care services; (C) the provision of basic mental health care, including screening for depression, with referral relationships in place for those members who require additional assistance; (D) strategies to

address stresses that arise in the workplace, home, school and the community, including coordination with and referrals to available employee assistance programs; (E) referrals, in appropriate cases, to nonmedical services such as housing and nutrition programs, 6 domestic violence resources and other support groups; and (F) for a member with a complex health condition that involves care from

Crosswalk To Report Section Statute multiple providers, ensuring that such providers share information about the member, as appropriate, and pursue a single, integrated treatment plan; and

(3) Providing readily accessible, twenty‐four‐hour consultative services by telephone, secure electronic mail or quickly scheduled office appointments for purposes that include reducing the need for hospital emergency room visits.

(d) The committee shall offer recommendations on entities that may serve as a medical home, including that: (1) A licensed health care provider be allowed to serve as a medical home if such provider is authorized to provide all core medical home functions as prescribed by the board and operationally capable of providing such functions; and (2) a group practice or community health center serving as a medical home identify, for each member, a lead provider with primary responsibility for the member's care. In appropriate cases, as determined by the board of directors, a specialist may serve as a medicald home an a patient's medical home may temporarily be with a health care provider who is overseeing the patient's care for the duration of a temporary medical condition, including pregnancy. (e) The committee shall offer recommendations concerning the responsibilities of a medical home provider. Such recommendations shall include that: (1) Each medical home provider be presented with a listing of all medical home functions, including patient education, care coordination and twenty‐four‐hour accessibility; and (2) if a provider does not wish to perform, within his or her office, certain functions outside core medical home functions, such provider shall make arrangements for other qualified entities or individuals to perform such functions, in a manner that integrates such functions into the medical home's clinical practice. Such qualified entities or individuals shall be certified by the board of directors based on factors that include the quality, safety and efficiency of the services provided. eAt th request of a core medical home provider, the board of directors shall make all necessary arrangements required for a qualified entity or individual to perform any medical home function not assumed by the core provider. (f) The medical home advisory committee may develop quality and safety standards for medical home functions that are not covered by existing professional standards, which may include care coordination and member education. (g) The committee shall recommend that the public authority assist in the development of community‐based resources to enhance medical home functions, including, but not limited to: (1) The availability of loans on favorable terms that facilitate the development of necessary health care infrastructure, including community‐based providers of medical home services and

Crosswalk To Report Section Statute community‐based preventive care service providers;

(2) The offering of reduced price consultants that shall assist physicians and other health care providers in restructuring their practices and offices so as to function more effectively and efficiently in response to changes in health care insurance coverage and the health care service delivery system that are attributable to the implementation of the SustiNet Plan; and

(3) The offering of continuing medical education courses that assist physicians, nurses and other clinicians in order to provide better care, consistent with the objectives of the SustiNet Plan, including training in the delivery of linguistically and culturally competent health care services.

(h) The committee shall offer recommendations concerning payment for medical home functions, including that: (1) All of the medical home functions set forth in this section be reimbursable and covered by the SustiNet Plan; (2) to the extent that such functions are generally not covered by commercial insurance, payment levels cover the full cost of performing such functions; and (3) in setting such payment levels, consideration be given to: (A) Utilizing rate‐setting procedures based on those used to set physician payment levels for Medicare; (B) establishing monthly case management fees paid based on demonstrated performance of medical home functions; or (C) taking other steps, as deemed necessary by the board of directors, to make payments that cover the cost of performing each function.

(i) The committee shall offer recommendations that specialty referrals include, under circumstances set forth in the board's guidelines, prior consultation between the specialist and the medical home to ascertain whether such referral is medically necessary. If such referral is medically necessary, the consultation shall identify any tests or other procedures that shall be conducted or arranged by the medical home, prior to the specialty visit, so as to promote economic efficiencies. The SustiNet Plan shall reimburse the medical home and the specialist for time spent in any such consultation.

7 Sec. 7. (NEW) (Effective July 1, 2009) Quality and Provider (a) The board of directors shall establish a health care provider advisory Advisory Committee committee that shall develop recommended clinical care and safety Recommendations guidelines for use by participating health care providers. The committee shall choose from nationally and internationally recognized guidelines for the provision of care, including guidelines for hospital safety and the inpatient and outpatient treatment of particular conditions. The committee shall continually assess the quality of evidence relevant to the costs, risks and benefits of treatments described in such guidelines. The committee shall forward their recommended clinical care and safety guidelines to the board of directors in accordance with such time and

Crosswalk To Report Section Statute 7 format requirements as may be prescribed by said board. The committee shall include both health care consumers and health care providers.

(b) The committee shall offer recommendations that health care providers participating in the SustiNet Plan receive confidential reports comparing their practice patterns with those of their peers. Such reports shall provide information about opportunities for appropriate continuing medical education. (c) The committee shall offer recommendations concerning quality of care standards for the care of particular medical conditions. Such standards may reflect outcomes over the entire care cycle for each health care condition, adjusted for patient risk and general consistency of care with approved guidelines as well as other factors. The committee shall offer recommendations that providers who meet or exceed quality of care standards for a particular medical condition be publicly recognized by the board of directors in such manner as said board determines appropriate. Such recognition shall be effectively communicated to SustiNet Plan members, including those who have been diagnosed with the particular medical condition for which recognition has been extended. Such communication to members shall be in multiple forms and reflect consideration of diversity in primary language, general and health literacy levels, past health‐information‐seeking behaviors, and computer and Internet use among members. (d) The committee shall recommend procedures that require hospitals and their medical staffs, physicians, nurse practitioners, and other participating health care providers to engage in periodic reviews of their quality of care. The purpose of such reviews shall be to develop plans for quality improvement. Such reviews shall include the identification of potential problems manifesting as adverse events or events that could have resulted in negative patient outcomes. As appropriate, such reviews shall incorporate confidential consultation with peers and colleagues, opportunities for continuing medical education, and other interventions and supports to improve performance.e To th maximum extent permissible, such reviews shall incorporate existing peer review mechanisms. The committee's recommendations shall include that any review conducted in accordance with the provisions of this subsection be subject to the protections afforded by section 19a‐17b of the general statutes. (e) The board of directors, in consultation with the committee, shall develop hospital safety standards that shall be implemented in such hospitals. The board of directors shall establish monitoring procedures and sanctions that ensure compliance by each participating hospital with such safety standards and may establish performance incentives to encourage hospitals to exceed such safety standards. (f) The committee shall offer recommendations pertaining to information to be made available to participating providers concerning prescription drugs, medical devices, and other goods and services used in the delivery

Crosswalk To Report Section Statute of health care. Such information may address emerging trends that involve utilization of goods and services that, in judgment of the public authority, are less than optimally cost effective. The committee shall offer recommendations concerning the provision of free samples of generic or other prescription drugs to participating providers. (g) The committee shall recommend policies and procedures that encourage participating providers to furnish and SustiNet Plan members to obtain appropriate evidenced‐based health care.

Preventive Health Care 8 Sec. 8. (NEW) (Effective July 1, 2009) Advisory Committee (a) The board of directors shall establish a preventive health care advisory Recommendations committee that shall use evolving medical research to draft recommendations to improve health outcomes for members in areas involving nutrition, sleep, physical exercise, and the prevention and cessation of the use of tobacco and other addictive substances. The committee shall include providers, consumers and other individuals chosen by said board. Such recommendations may be targeted to member populations where they are most likely to have a beneficial impact on the health of such members and may include behavioral components and financial incentives for participants. Such recommendations shall take into account existing preventive care programs administered by the state, including, but not limited to, state administered educational and awareness campaigns. Not later than July 1, 2010, and annually thereafter, the preventive health care advisory committee shall submit such recommendations to the board of directors. (b) The board of directors shall recommend that the SustiNet Plan provide coverage for community‐based preventive care services and such services be required of all health insurance sold pursuant to the plan to individuals or employers. Community‐based preventive care services are those services identified by the board as capable of being safely administered in community settings. Such services shall include, but not be limited to, immunizations, simple tests and health care screenings. Such services shall be provided by individuals or entities who satisfy board of director approved standards for quality of care. The board of directors shall recommend that: (1) Prior to furnishing a community‐based preventive care service, a provider obtain information from a patient's electronic health record to verify that the service has not been provided in the past and that such services are not contraindicated for the patient; )and (2 a provider promptly furnish relevant information about the service and the results of any test or screening to the patient's medical home or the patient's primary care provider if the patient does not have a medical home. The board of directors shall recommend that community‐based preventive services be allowed to be provided at job sites, schools or other community locations consistent with said board's guidelines.

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9 Sec. 9. (NEW) (Effective July 1, 2009) Policy‐Making Duties and (a) The board of directors may develop recommendations that ensure that Responsibilities on and after July 1, 2012, nonstate public employers are offered the benefits of the SustiNet Plan. The board of directors may develop recommendations that permit the Comptroller to offer the benefits of the SustiNet Plan to state employees, retirees and their dependents. No changes in health care benefits shall be implemented with regard to plans administered under the provisions of subsection (a) of section 5‐259 of the general statutes unless such changes are negotiated and agreed to by the state and the coalition committee established pursuant to subsection (f) of section 5‐278 of the general statutes, through the collective bargaining process.

(b) The board of directors shall develop recommendations that ensure that Policy‐Making Duties and on and after July 1, 2012, employees of nonprofit organizations and small Responsibilities businesses are offered the benefits of the SustiNet Plan. Expanding Medicaid (c) The board of directors shall develop recommendations to ensure that the Coverage and Access to HUSKY Plan Part A and Part B, Medicaid, and state‐administered general Care assistance programs participate in the SustiNet Plan. Such recommendations shall also ensure that HUSKY Plan Part A and Part B benefits are extended, to the extent permitted by federal law, to adults with income at or below three hundred per cent of the federal poverty level.

(d) The board of directors shall make recommendations to ensure that on Policy‐Making Duties and and after July 1, 2012, state residents who are not offered employer‐ Responsibilities sponsored insurance and who do not qualify for HUSKY Plan Part A and Part B, Medicaid, or state‐administered general assistance are permitted to enroll in the SustiNet Plan. Such recommendations shall ensure that premium variation based on member characteristics does not exceed in total amount or in consideration of individual health risk, the variation permitted for a small employer carrier, as defined in subdivision (16) of section 38a4‐56 of the general statutes. Policy‐Making Duties and (e) The board of directors shall make recommendations to provide an option Responsibilities for enrollment into the SustiNet Plan, rather than employer‐sponsored insurance, for certain state residents who are offered employer‐ sponsored insurance but who have a household income at or below four hundred per cent of the federal poverty level. Said board may make recommendations for the establishment of (1) an enrollment procedure for those individuals who demonstrate eligibility to enroll in the SustiNet Plan pursuant to this subsection; and (2) a method for the collection of

payments from employers, whose employees would have received employer‐sponsored insurance, but instead enroll in the SustiNet Plan in accordance with the provisions of this subsection.

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10 Sec. 10.(NEW) (Effective July 1, 2009)

Definition (a) As used in this section "adverse selection" means purchase of SustiNet Plan coverage by employers with unusually high‐cost employees and dependents under circumstances where premium payments do not fully cover the probable claims costs of the employer's members. (b) The board of directors shall offer recommendations concerning:

Administrative Duties (1) The use of new and existing channels of sale to employers, including public and private purchasing pools, agents and brokers; (2) the offering of multi‐year contracts to employers with predictable Administrative Duties premiums;

(3) policies and procedures to be established that ensure that employers Administrative Duties can easily and conveniently purchase SustiNet Plan coverage for their workers and dependents, including, but not limited to, participation requirements, timing of enrollment, open enrollment, enrollment length and other subject matters as deemed appropriate by said board; Policy‐Making Duties and (4) policies and procedures to be established that prevent adverse Responsibilities selection and achieve other goals specified by the board;

Covered Populations; (5) the availability of SustiNet Plan coverage for small employers on and Policy‐Making Duties and after July 1, 2012, with premiums based on member characteristics as Responsibilities permitted for small employer carriers, as defined in subdivision (16) of section 38a‐564 of the general statutes; Covered Populations; (6) the availability of SustiNet Plan coverage for employers who are not Policy‐Making Duties and small employers with premiums charged to such employerst to preven Responsibilities adverse selection, taking into account past claims experience, changes in the characteristics of covered employees and dependents since the most recent time period covered by claims data, and other factors approved by the board of directors; and

Benefits (7) the availability of a standard benefits package to employers purchasing coverage under this section, provided no such benefit package provide less comprehensive coverage than that described in the model benefits packages adopted pursuant to section 12 of this act.

11 Sec. 11.(NEW) (Effective July 1, 2009)

Responsibility of the Office (a) As used in this section, "clearinghouse" means an independent of the Health Care information clearinghouse recommended by the board of directors that Advocate is: (1) Established and overseen by the Office of the Healthcare Advocate; (2) operated by an independent research organization that contracts with the Office of the Healthcare Advocate; and (3) responsible for providing employers, individual purchasers of health coverage, and the general public with comprehensive information about the care covered by the SustiNet Plan and by private health plans licensed in the state of Connecticut.

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(b) The clearinghouse shall develop specifications for data that show for each

health plan, quality of care, outcomes for particular health conditions, access to care, utilization of services, adequacy of provider networks, patient satisfaction, rates of disenrollment, grievances and complaints, and any other factors the Office of the Healthcare Advocate determines relevant to assessing health plan performance and value. In developing such specifications, the Office of the Healthcare Advocate shall consult with private insurers and with the board of directors. (c) The board of directors shall recommend that the following entities shall provide data to the clearinghouse in a time and manner as prescribed by the Office of the Healthcare Advocate: (1) The SustiNet Plan; (2) health insurers, as a condition of licensure; and (3) any self‐insured group plan that volunteers to provide data. Dissemination of any information provided by a self‐insured group plan shall be limited and in conformity with a written agreement governing such dissemination as developed and approved by the group plan and the Office of the Healthcare Advocate. (d) Except as provided for in subsection (c) of this section, the clearinghouse shall make public all information provided pursuant to subsection (b) of this section. The clearinghouse shall not disseminate any information that identifies individual patients or providers. The clearinghouse shall adjust outcomes based on patient risk levels, to the maximum extent possible. The clearinghouse shall make information available in multiple forms and languages, taking into account varying needs for the information and different methods of processing such information. (e) The clearinghouse shall collect data based on each plan's provision of services over continuous twelve‐month periods. Except as provided in subsection (c) of this section, the clearinghouse shall make public all information required by this section no later than August 1, 2013, with updated information provided each August first thereafter.

12 Sec. 12.(NEW) (Effective July 1, 2009) Responsibility of the Office (a) Within available appropriations, the Office of the Healthcare Advocate of the Health Care shall develop and update the model benefit packages, based on evolving Advocate medical evidence and scientific literature, that make the greatest possible contribution to member health for a premium cost typical of private, employer sponsored insurance in the Northeast states. Not later than December 1, 2010, and biennially thereafter, the Office of the Healthcare Advocate shall report to the board of directors on the updated model benefit packages. (b) After the promulgation of the model benefit packages, as provided in subsection (a) of this section, the board of directors may modify the standard benefits package if said board determines that: (1) Such modification would yield better outcomes for an equivalent expenditure of funds; or (2) providing additional coverage or reduced cost sharing for particular services as provided to particular member populations may

Crosswalk To Report Section Statute reduce net costs or provide sufficient improvements to health outcomes to warrant the resulting increase in net costs. Any such modification of the standard benefits package by the board shall ensure compliance with the coverage mandates described in chapter 700c of the general statutes and the utilization review requirements described in chapter 698a of the general statutes. (c) The Office of the Healthcare Advocate shall recommend guidelines for establishing an incentive system that recognizes employers who provide employees with health insurance benefits that are equal to or more comprehensive than the model benefit packages. Such incentives may include public recognition of employers who offer such comprehensive benefits. Not later than December 1, 2012, the Office of the Healthcare Advocate shall report, in accordance with section 11‐4a of the general statutes, on such guidelines and recommendations to the board of directors, the Governor and the joint standing committees of the General Assembly having cognizance of matters relating to public health, labor and public employees, and appropriations and the budgets of state agencies.

13 Sec. 13.(NEW) (Effective July 1, 2011) Policy‐Making Duties and (a) The board of directors shall develop recommendations for public Responsibilities education and outreach campaigns to ensure that state residents are informed about the SustiNet Plan and are encouraged to enroll in the plan. (b) The public education and outreach campaign shall utilize community‐ based organizations and shall include a focus on targeting populations that are underserved by the health care delivery system. (c) The public education and outreach campaign shall be based on evidence of the cost and effectiveness of similar efforts in this state and elsewhere. Such campaign shall incorporate an ongoing evaluation of its effectiveness, with corresponding changes in strategy, as needed.

14 Sec. 14.(NEW) (Effective July 1, 2011) The board of directors, in collaboration with state and municipal agencies, shall, within available appropriations, Policy‐Making Duties and develop and implement systematic recommendations to identify uninsured Responsibilities individuals in the state. Such recommendations may include that:

(1) The Department of Revenue Services modify state income tax forms to request that a taxpayer identify existing health coverage for each member of the taxpayer's household. (2) The Labor Department modify application forms for initial and continuing claims for unemployment insurance to request information about health insurance status for the applicant and the applicant's dependents. (3) Hospitals, community health centers and other providers as determined by the board of directors shall: (A) Identify the health insurance status of

Crosswalk To Report Section Statute individuals who seek health care, and (B) convey such information, via secure electronic mail transmission, to said board to facilitate the potential enrollment of such individuals into health insurance coverage.

15 Sec. 15.Section 17b‐297b of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2011): Responsibilities of Departments of Social (a) To the extent permitted by federal law, the Commissioners of Social Services and Education Services and Education, in consultation with the board of directors, shall jointly establish procedures for the sharing of information contained in applications for free and reduced price meals under the National School Lunch Program for the purpose of determining whether children participating in said program are eligible for coverage under the SustiNet Plan or the HUSKY Plan, Part A and Part B. The Commissioner of Social Services shall take all actions necessary to ensure that children identified as eligible for [either] the SustiNet Plan, or the HUSKY Plan, Part A or Part B, are enrolled in the appropriate plan. (b) The Commissioner of Education shall establish procedures whereby an individual may apply for the SustiNet Plan or the HUSKY Plan, Part A or Part B, at the same time such individual applies for the National School Lunch Program.

16 Sec. 16.(Effective from passage) Childhood and Adult (a) There is established a task force to study childhood and adult obesity. Obesity Task Force The task force shall examine evidence‐based strategies for preventing Recommendations and reducing obesity in children and adults and develop a comprehensive plan that will effectuate a reduction in obesity among children and adults. (b) The task force shall consist of the following members: (1) One appointed by the speaker of the House of Representatives, who shall represent a consumer group with expertise in childhood and adult obesity; (2) One appointed by the president pro tempore ofe th Senate, who shall be an academic expert in childhood and adult obesity; (3) One appointed by the majority leader of the House of Representatives, who shall be a representative of the business community with expertise in childhood and adult obesity; (4) One appointed by the majority leader of the Senate, who shall be a health care practitioner with expertise in childhood and adult obesity; (5) One appointed by the minority leader of the House of Representatives, who shall be a representative of the business community with expertise in childhood and adult obesity;

Crosswalk To Report Section Statute (6) One appointed by the minority leader of the Senate, who shall be a health care practitioner with expertise in childhood and adult obesity; (7) One appointed by the Governor who shall be an academic expert in childhood and adult obesity; and (8) The Commissioners of Public Health, Social Services and Economic and Community Development and a representative of the SustiNet board of directors shall be ex‐officio nonvoting members of the task force. (c) Any member of the task force appointed under subdivision (1), (2), (3), (4), (5) or (6) of subsection (b) of this section may be a member eof th General Assembly. (d) All appointments to the task force shall be made no later than thirty days after the effective date of this section. Any vacancy shall be filled by the appointing authority. (e) The members of the task force appointed by the speaker of the House of Representatives and the president pro tempore of the Senate shall serve as the chairpersons of the task force. Such chairpersons shall schedule the first meeting of the task force, which shall be held no later than thirty days after the effective date of this section. (f) The administrative staff of the joint standing committee of the General Assembly having cognizance of matters relating to public health shall serve as administrative staff of the task force. (g) Not later than July 1, 2010, the task force shall submit a report on its findings and recommendations to the board of directors and the joint standing committee of the General Assembly having cognizance of matters relating to public health, human services and appropriations and the budgets of state agencies in accordance with the provisions of section 11‐4a of the general statutes. The task force shall terminate on the date that it submits such report or January 1, 2011, whichever is later.

17 Sec. 17.(Effective from passage) Tobacco and Smoking (a) There is established a task force to study tobacco use by children and Cessation Task Force adults. The task force shall examine evidence‐based strategies for Recommendations preventing and reducing tobacco use by children and adults, and then develop a comprehensive plan that will effectuate a reduction in tobacco use by children and adults. (b) The task force shall consist of the following members: (1) One appointed by the speaker of the House of Representatives, who shall represent a consumer group with expertise in tobacco use by children and adults; (2) Oned appointe by the president pro tempore of the Senate, who

Crosswalk To Report Section Statute shall be an academic expert in tobacco use by children and adults; (3) One appointed by the majority leader of the House of Representatives, who shall be a representative of the business community with expertise in tobacco use by children and adults; (4) One appointed by the majority leader of the, Senate who shall be a health care practitioner with expertise in tobacco use by children and adults; (5) One appointed by the minority leader of the House of Representatives, who shall be representative of the business community with expertise in tobacco use by children and adults; (6) One appointed by the minority leader of the Senate, who shall be a health care practitioner with expertise in tobacco use by children and adults; (7) One appointed by the Governor who shall be an academic expert in tobacco use by children and adults; and (8) The Commissioners of Public Health, Social Services and Economic and Community Development and a representative of the SustiNet board of directors shall be ex‐officio, nonvoting members of the task force. (c) Any member of the task force appointed under subdivision (1), (2), (3), (4), (5) or (6) of subsection (b) of this section may be a member eof th General Assembly. (d) All appointments to the task force shall be made no later than thirty days after the effective date of this section. Any vacancy shall be filled by the appointing authority. (e) The members of the task force appointed by the speaker of the House of Representatives and the president pro tempore of the Senate shall serve as the chairpersons of the task force. Such chairpersons shall schedule the first meeting of the task force, which shall be held no later than thirty days after the effective date of this section. (f) The administrative staff of the joint standing committee of the General Assembly having cognizance of matters relating to public health shall serve as administrative staff of the task force. (g) Not later than July 1, 2010, the task force shall submit a report on its findings and recommendations to the board of directors and the joint standing committee of the General Assembly having cognizance of matters relating to public health, human services and appropriations and the budgets of state agencies in accordance with the provisions of section 11‐4a of the general statutes. The task force shall terminate on the date that it submits such report yor Januar 1, 2011, whichever is later.

18 Sec. 18.(Effective from passage) Health Care Workforce (a) There is established a task force to study the state's health care

Crosswalk To Report Section Statute Task Force workforce. The task force shall develop a comprehensive plan for Recommendations preventing and remedying state‐wide, regional and local shortage of necessary medical personnel, including, physicians, nurses and allied health professionals. (b) The task force shall consist of the following members: (1) One appointed by the speaker of the House of Representatives, who shall represent a consumer group with expertise in health care; (2) One appointed by the president pro tempore of the Senate, who shall be an academic expert on the health care workforce; (3) One appointed by the majority leader of the House of Representatives, who shall be a representative of the business community with expertise in health care; (4) One appointed by the majority leader of the Senate, who shall be a health care practitioner; (5) One appointed by the minority leader of the House of Representatives, who shall be a representative of the business community with expertise in health care; (6) One appointed by the minority leader of the Senate, who shall be a primary care physician; (7) One appointed by the Governor who shall be an academic expert in health care; and (8) The Commissioners of Public Health, Social Services and Economic and Community Development, the president of The University of Connecticut, the chancellor of the Connecticut State University System, the chancellor of the Regional Community‐Technical Colleges, and a representative of the SustiNet board of directors shall be ex‐officio, nonvoting members of the task force. (c) Any member of the task force appointed under subdivision (1), (2), (3), (4), (5) or (6) of subsection (b) of this section may be a member of the General Assembly. (d) All appointments to the task force shall be made no later than thirty days after the effective date of this section. Any vacancy shall be filled by the appointing authority. (e) The members of the task force appointed by the speaker of the House of Representatives and the president pro tempore of the Senate shall serve as the chairpersons of the task force. Such chairpersons shall schedule the first meeting of the task force, which shall be heldn no later tha thirty days after the effective date of this section. (f) The administrative staff of the joint standing committee of the General Assembly having cognizance of matters relating to public health shall serve as administrative staff of the task force. (g) Not later than July 1, 2010, the task force shall submit a report on its

Crosswalk To Report Section Statute findings and recommendations to the board of directors and the joint standing committee of the General Assembly having cognizance of matters relating to public health, human services and appropriations and the budgets of state agencies in accordance with the provisions of section 11‐4a of the general statutes. The task force shall terminate on the date that it submits such report or January 1, 2011, whichever is later.

No reporting required 19 Sec. 19. (NEW) (Effective July 1, 2009) Any individual who serves on the SustiNet Health Partnership board of directors shall be subject to the provisions of section 1‐83 of the general statutes concerning the filing of a statement of financial interests.