By Doug Maine
Connecticut’s march to the Federal Affordable Care Act, also known as Obamacare, is being shepherded in Connecticut by Jeannette DeJesús, who can be described as Gov. Dannel Malloy’s top cop for health care reform and innovation.
In this role, which she assumed in January 2011, she’s establishing the framework that is going to deliver health insurance to the more than 600,000 residents – half of them children – without it. Her deadline is January 2014.
Latinos are the largest group of uninsured state residents, DeJesús said, with a high percentage of Latinos working at jobs with either no insurance benefit or expensive plans with co-pays so high that they can’t use them, she said.
“The next 3-6 months are going to be really critical to healthcare reform in the state,” she said.
Though her office has made efforts to inform the community about the coming changes in healthcare, “I don’t think they understand how significant the changes are that are coming,” she said.
“I do have very specific concern about the Latino community and (other) communities in which English is not the first language getting information,” she said. “We are going to need help from community leaders in doing this.”
The goal is to make a serious dent in the number of the state’s uninsured. “We have a significant number of uninsured here in the state. We have a 3.4 million population and 600,000 people, including those on Medicaid, without insurance,” DeJesús said. Half of the uninsured, about 300,000, are children, she said.
“No wrong door”
Another important step was the creation of the Office of Healthcare Reform and Innovation within the office of the lieutenant governor. “Prior to all of the reforms, efforts were being undertaken in various agencies,” DeJesús said.
The departments of Social Services, Public Health and Insurance remain involved in putting into place the multiple initiatives that are part of the healthcare reform, but those efforts are now being coordinated and work is being done to ensure that information can be shared by agencies, she said.
The end result for consumers will be a user-friendly system based on the concept of “no wrong door.” That means that when they go to the exchange’s website for insurance, they’ll also be screened to see if they qualify for any subsidy programs and processed through to enrollment without having to complete additional application forms or go through multiple eligibility determinations, DeJesús said.
“You can see the importance of the coordination of this system. My job is to see all of these systems are running interchangeably. There’s a lot of technology involved,” she said.
One of the state’s most important steps toward healthcare reform, she said, has been the establishment of the Connecticut Health Insurance Exchange, created through the passage of enabling legislation by the state legislature in 2011.
DeJesús chairs the exchange, which is charged with reducing the number of uninsured in the state. It will be an online market through which uninsured individuals and small businesses will shop for health insurance among competing private plans.
The exchange’s board of directors is charged with deciding what will be included in the state’s Essential Health Benefits (EHB) package, setting the minimum standards for all health insurance plans that are offered. The complex efforts to develop the exchange are being supported by a total of $107 million that the state has received in federal grants, DeJesús said.
As directed by the federal Department of Health and Human Services, the board’s four subcommittees looked at the large-group plans currently available in the state and at two small-employer plans and at the federal employee plan. A ConnectiCare plan has been recommended for the benchmark plan, a model for the EHB, and the exchange board is expected to vote to adopt it later this month, she said.
Aside from essential benefits required under Obamacare, the state has mandated coverage for certain other types of healthcare services. “We’re considered to be a mandate-rich state,” DeJesús said.
As for the cost, she said, “the federal government said (to states), ‘you choose your health plan and we will cover your mandates for the first two years,'” she said. After that, the costs shift to the state.
“Everything you add to the plan, the insurance companies’ costs go up,” she said, with the result being higher costs for consumers.
“We want to balance cost and comprehensiveness,” DeJesús said. “You don’t want to have a plan that’s so expensive that people won’t buy it.”
DeJesús says the state has already made significant progress toward making healthcare available to its more than half-million residents currently without health insurance and toward making the entire healthcare system more transparent for everyone, enabling them to make better healthcare decisions.
Prior to joining the Malloy administration, DeJesús was a vice president at the Connecticut Hospital Association. She also served for eight years as the president and CEO of the Hispanic Health Council and has co-chaired the SustiNet Tobacco Task Force and the Commission on Health Equity.
“That’s just the system. Then there’s improving healthcare,” DeJesús added. Addressing that will involve greater transparency.
“My office is developing an all-payer claims database,” which will enable anyone to look at all claims data from throughout the state to compare costs and types of medical treatment, dental care and medication prescribed by various providers, as well as the outcomes of that treatment, DeJesús said. Connecticut is just the ninth state to take steps toward setting up such a database.
All insurance claims data, including pharmacy, dental and, eventually, Medicaid information will be available to the public. The only things they won’t see are the names of patients and individual case information, which will remain confidential, she said.
“Two of the things I’m very concerned about are poor health outcomes for people and the cost of healthcare,” she said.
Seeing Hospital Records
“You, as a consumer, may need to have knee surgeries. You’ll be able to go online and see this hospital does more knee surgeries, the cost and the outcomes,” DeJesús said.
This will tell individuals and the state that for the month of June, hypothetically, there were 14 knee surgeries at Hospital X and 18 at Hospital Y. The average paid out was $1,000 for the surgeries done at Hospital X and $800 for those at Hospital Y, she said.
Going further, she said, “Hospital X prescribes this painkiller; when we look at Hospital Y, they prescribe this other painkiller. Then you look at the information and Hospital Y had fewer readmissions. Could it be that Hospital Y is using a better medication?”
Or you might find that the surgery was cheaper at Hospital X, “but if you look at the data, you find Hospital X had more hospital visits,” DeJesús said. “It’s not the type of database where you can say, ‘I’m going to go to the cheaper doctor.
Sound Healthcare Decisions
“The goal is to enable people to make good, sound healthcare decisions,” she said. “For me, development of the all-payer claims database is one of the most significant things we’ve done.”
The database will also help the state, especially in developing a payment structure for the plans that will be offered through the exchange.
“Insurance companies have had this information and they’ve been able to use this data themselves, (but) insurance companies only have their own data. We’ll have access to all of the insurance companies’ data,” DeJesús said.
Having the data also means the state will be able to use the aggregate information to make policy decisions, for example, targeting prevention efforts in the areas where a specific health problem is most prevalent.
The system is also being designed to reward doctors and hospitals for providing preventive care, which should reduce the need for more expensive tests and hospitalization later.
“We’re going to develop a system where if you keep Jane Smith’s blood pressure normal, we’re going to pay you for that,” DeJesús said.
For more information, DeJesús suggested visiting the OHRI website, healthreform.ct.gov.