Analysis | It's Time To End HUSKY's 'Value-Based' Medicaid Program

Connecticut's Person-Centered Medical Home (PCMH) Plus program has been troubled from its start in 2017, and it's time to go in a new direction.

PCMH Plus was originally billed as a value-based system to improve the quality of Medicaid services and to control costs by allowing providers to share in any savings they could generate. However, according to conversations with policymakers at the time, PCMH Plus was actually developed to increase funding for Community Health Centers (CHCs) and to access more federal money in the failed State Innovation Model (SIM) program. CHCs and SIM got the money but, as for most value-based programs, patients and taxpayers didn't get any benefits.

It needs to go.

From the beginning of PCMH Plus, there was little evidence of quality improvement and rather than saving the state money, the program had significant costs to taxpayers. Advocates raised alarms and called for an end to the program from the beginning. It hasn't improved since.

Unfortunately, our early concerns were valid. There is evidence of participating entities gaming the system (or worse) to increase payments. In the original PCMH Plus applications, all but one applicant believed they were already doing everything required for the program. One applicant was honest enough to state that they won't do anything at all without extra up-front funding and would only do what that extra funding covered. Three applicants planned to rely heavily on unpaid students, volunteers, and interns to provide critical services.

In addition, advocates had to develop a campaign to inform consumers about their providers' incentives to reduce the costs of their care and about their rights. This was necessary because the state Department of Social Services (DSS), in a different administration and under political pressure, removed any reference of risks from a collaborative, consensus consumer notice about the program.It's interesting that PCMH Plus was created to funnel more money to CHCs. There is already a significant disparity between CHCs and other Medicaid providers in base payment rates. Medicaid base rates for a medical visit at a CHC are seven times the rate paid to other Medicaid providers for a doctor's visit. CHC rates are also more than double Medicare's rate and 87% higher than private insurance payment rates in Connecticut. PCMH Plus subsidies and payments are in addition to these rates and other grants.

Last year, the Connecticut Children's Medical Center (CCMC) – the only non-CHC entity in the program – managed to save $15.4 million, dwarfing the savings of the other 10 CHC entities in the program. In fact, the CHCs in the program increased spending by $7.8 million. This was because most CHCs couldn't meet the rather undemanding quality standards requiring any improvement at all on preventable hospital admissions and emergency visits. The CCMC also ranked best in the program in quality scores.

The goal of funneling money to CHCs was boosted by the state's recent changes in PCMH Plus. This year the DSS changed the standards to measures that only apply to narrow populations within HUSKY.

Further backing the argument against continuing PCMH Plus, the latest report highlights long-standing concerns about the quality of care. While quality and access measures are good and rising across our national model HUSKY program, PCMH Plus, and specifically CHC practices, are lagging and having trouble catching up. Those concerns persist into the latest report.

In 2023, PCMH Plus patients were 35% more likely to visit an emergency department than other Medicaid members.

Emergency department visits are a particular problem for CHCs in PCMH Plus. While both the overall program and CHCs are improving slowly on emergency visit rates, it will take years for CHCs to catch up with the statewide rate, and some never will at their current rate of improvement. The change in preventable emergency quality standards to more narrow measures won't help incentivize the CHCs to improve.

PCMH Plus also lags the statewide program in potentially preventable hospital admissions, readmissions within 30 days, and child and adolescent checkups. The December adult patient experience of care survey found that PCMH Plus patient scores were below non-PCMH Plus patient scores on 10 of the 11 measures for adults and all 11 measures for children. PCMH Plus performance has lagged in patient surveys for at least the last three years.

It's important to note that the poor performance of PCMH Plus is in sharp contrast to HUSKY's very successful Person-Centered Medical Home (PCMH, no Plus) program that has improved care and controlled costs since the private Managed Care Organizations (MCOs) left HUSKY in 2014. The latest Connecticut Medicaid landscape study verified that our state's program is a national model for access, quality of care, and cost control. Unfortunately, PCMH Plus is not contributing to Medicaid's improvement.

With severe Medicaid cuts looming at the federal level, we can't afford a program that's not carrying its weight. It's time to end PCMH Plus and work collaboratively with all HUSKY providers and other stakeholders to build an equitable, sustainable program that serves patients and taxpayers.