Search

FAQ ABOUT PROPOSED CAPITATION PROPOSAL IN OHS’ PRIMARY CARE ROADMAP

The Primary Care Roadmap, developed by OHS primarily with associations of

primary care providers and without input from any independent consumers or

advocacy organizations, is largely a solution in search of a problem. But if it is

implemented, it would substantiallyworsenaccess to care, particularly under

Medicaid program, which is the one area where it is likely to be imposed.


Even if we are opposed to the primary care capitation proposal in the

Roadmap, are there any other parts of it which would bring helpful

reforms and which we should support?


Unfortunately, the entire design is fundamentally flawed, in that it intends

to increase expenditures for primary care whilereducing total outlays by

$3.9 billion annually, ensuring that there will have to becuts to other kinds

of health care(unspecified but likely including specialists who already are

underpaid in Medicaid), in addition to capitating payment to primary care

providers. The watering down of the standards to be a patient-centered

medical home by abandoning the gold standard system of certification

through national accrediting agencies, another part of the Road Map,

indicates that none of the Road Map is motivated by a desire to improve

patient care, but just to save money overall (for the state), and increase

revenue and profits and reduce providers’ administrative burdens (for

primary care providers; the Roadmap expressly includes as its number one

goalincreasing primary care providers’ income).


Is “prepayment” different from capitation?


The Road Map refers to its preferred payment scheme as “prepayment” and

avoids the term “capitation.” They are really the same thing; both refer to a

fixed payment per member per month (pmpm) to primary care providers

for all services provided, which the providers get upfront whether they see

a patient one time, several times or not at all in that month. The term

“capitation” has gotten a well-deserved bad name, but using a new term

does not make a bad policy any better.


How is this kind of capitation different from the capitated system run by

Medicaid managed care organizations, which were replaced in CT a

decade ago because of the extensive pattern of substandard care (and

excessive costs) under that system?


Under both systems, payment is made on a per member per month basis,

regardless of services provided. However, under the old “Medicaid

managed care system,” it was an insurance company or managed care

organization (MCO) which took on the financial risk, i.e., was responsible for

making all payments for all services rendered to Medicaid enrollees. Under

the proposed primary care capitation system, it is health care providers

which will take on this financial risk and only for the cost of primary care

services. This just shifts risk to large provider groups (the ones which can

afford to take on financial risk) instead of insurers. In addition, at least

under the capitated managed care system, expensive and unaccountable as

it was, the insurers were financially responsible if care they denied resulted

in the need for very expensive crisis care; under primary care capitation,

primary care provider groups can make more money by denying office visits

and routinely sending patients out to specialists, knowing they will not be

financially responsible for any resulting higher costs. This incentive system

will drive up those other costs.


OHS says they are building off of and aligning with the CT Medicaid

payment model called “PCMH+”, which it declares is a success. Is it, and

how does that model differ from the Medicaid model known as “PCMH”?


PCMH (for Patient-Centered Medical Homes) is a successful care

management model implemented widely for CT Medicaid enrollees at the

time of the abandonment of the capitated Medicaid managed care system

in 2012, in order to actually manage care, something the MCOs promised

but never delivered on. This system pays primary care practices, which

have earned accreditation under rigorous national monitoring systems such

as that run by the National Council on Quality Assurance, for coordinating

the care of their Medicaid patients and also pays them extra for doing well

on certain quality measures – but, critically, saving money on their patients’

health care isnotone of those measures.


Under PCMH+, on the other hand, which is a “shared savings” model, extra

pay to providers is primarily focused on whether the providers saved money on their patients’ total cost of care or not—if they do, they get to keep ½ of the savings no matter how generated, subject to some very easy to satisfy quality measures. Unlike under the successful PCMH program, this incentivizes providers to save money regardless of outcomes, and the evidence indicates that this problematic model may not be saving money after all. It is unwise to build off of a problematic model in favor of capitation, which puts even more financial risk onto primary care providers.


Will the “quality measures” mentioned by OHS, which were not present

under the Medicaid MCO system, serve to protect against the incentives

for under-service under capitation to deny medical appointments because

there is no payment for providing them?


No. OHS’s plan to monitor for under-service is extremely week. As under

PCMH+, these measures of under-service are very limited and easy to

satisfy. There also will be no “control group” to compare against. Primary

care providers can substantially increase their revenue under Medicaid by

increasing their primary care rolls in order to get additional monthly

capitated payments while rarely seeing those Medicaid patients, instead

seeing their patients under other insurance plans which actually pay them

per office visit, while still satisfying all of OHS’s easy-to-satisfy “quality”

measures for their capitated Medicaid patients.


Doesn’t the fact that the proposed payment system is voluntary give

patients the choice to avoid it?


No, it is voluntary only for primary care providers,notfor their patients. If

the providers determine that they can make more money by participating,

their patients under a given payer (particularly Medicaid) will not have a

choice and will have to participate in this system under which doctors have

a direct incentive not to see them in the office (or via telehealth). The only

way to avoid the system will be to change providers entirely, if they can find

one not participating in this new system.


Is it true that fee-for-service has been widely rejected as an appropriate

payment model, as OHS says in its Roadmap document?


No. While strict fee-for-service payment has fallen into disfavor among

some health policy consultants, like the ones being used by OHS, a better


approach is to adopt a hybrid system such as CT Medicaid’s successful

PCMH (no +) payment system which is a form of “managed fee for service.”

Under PCMH, primary care providers get paid on a fee-for-service basis for

office visits, and also get paid extra for coordinating care of their patients

and are financially rewarded for doing well on meaningful performance

measures not tied to saving money.


Why is OHS so insistent on this capitation payment model, given the

failures of the past and the opposition it has generated?


We can’t know for sure what is motivating this agency, but this is a repeat of

its SIM proposal to push financial risk onto providers, which spent tens of

millions of taxpayer dollars but was wildly unsuccessful -- except to the

extent it resulted in the problematic PCMH+ model for Medicaid. OHS may

also be pushing primary care capitation specifically because certain primary

care association groups are promoting it as a way to increase their

corporate revenue. The committee that developed the Roadmap is

dominated by primary care providers, and OHS has largely shut out other

provider groups in the development of this SIM 2.0 model.


The Roadmap document suggests it will help to reduce health disparities.

Is that likely to happen?


Individuals with disabilities, the elderly and Black and brown individuals

have more difficulty than other patients in accessing appropriate services,

while in general having more complex medical problems which warrant

greater attention by primary care providers. But under capitation the more

complex patients, needing more visits than the average patient, are more

likely to be ignored by primary care providers and sent to specialists

instead, since there is no payment for any office visits.Because primary

care is often a better place for managing complex medical problems,

capitation will likely exacerbate, not reduce, health disparities.


Can paying primary care providers on a risk-adjusted capitation basis

protect more vulnerable patients?


No. Adjusting for likely illness of patients, and hence paying higher pmpm

for those who are more likely to need to come in for office visits, is an

unreliable science at this point. The proposed risk-adjusting by OHS will not reflect adjustments for social needs, like language, transportation and

income risks, making patients with these needs less desirable. But even if

this could somehow be done fairly, providers have every incentive not to

see patients and to send them out to specialists instead—indeed, they can

make more money by getting paid higher risk-adjusted pmpm amounts by

enrolling these high-need patients and then sending them out to specialists,

than for other patients who only need one or two visits/year.


Is OHS at least right about the need to focus on improving primary care?


No one questions the importance of primary care and there is room for

improvement. There are many ideas for actually improving primary care,

and these have been developed extensively by the CT Health Policy Project

in an April 2019 report, ignored in the Roadmap. Rather, OHS’s model is entirely

premised on saving money and benefitting primary care providers.

In the case of Medicaid particularly, while there is room for improvement in

reaching under-served populations, primary care is an overwhelming

success, with primary care providers available for almost anyone seeking

one. This is partly due to the fact thatCT already pays primary care

providers in Medicaid 95% of what primary care providers are paid for the

same services under the Medicare program. By contrast, CT Medicaid

generally pays specialists only 57%of what specialists are paid under

Medicare, indicating that this is where resources should be increased- not

decreased, as effectively proposed by the Roadmap.


For more information, see FAQ and Public Comments by CT Health Policy Project at FAQs on OHS’s Primary Care Roadmap – CT Health Policy and Roadmap-publlc-comments-final.pdf (cthealthpolicy.org)


For further information, please contact Sheldon Toubman, Disability Rights CT, at 475-345-3169 or sheldon.toubman@disrightsct.org


Template For Comments to Office of Health Strategy’s “ROADMAP FOR STRENGHTENING AND SUSTAINING PRIMARY CARE” Comments to Primary Care Roadmap (available OHS-Primary-Care-Roadmap-Draft-2021.pdf (ct.gov))

Due on January 14, 2022

  1. Address comments to Tina Hyde at OHS, and send comments to: tina.hyde@ct.gov ,by close of business, Friday, January 14th

  2. State your name and interest or your organization’s interestas representing individuals with any special concerns, particularly those with complex medical problems/disabilities, and individuals already suffering health disparities or difficulties in accessing services. The more detail about access issues they already have, the better. If you mostly represent Medicaid enrollees, please note that.

  3. Endorse the comments of the large coalition of consumer advocates in their letter dated October 22, 2021 (available at Sign on letter voices deep concerns with primary care capitation – CT Health Policy ), if comfortable doing this after reading it.

  4. State objection to the entire Primary Care Roadmap because of the negative impact on the specific people you represent. You can then pick and choose these particular problematic aspects of the Roadmap to talk about (or include all of them), using language such as:

  5. “On behalf of [organization or interest group], we are particularly opposed to the Roadmap because:

  6. “The process to develop the Roadmap was driven by primary care physician groups interested in maximizing their own revenue and did not seek, and then ignored when offered, critical independent consumer-related input (see October 22, 2021 coalition letter to OHS).

  7. “CT Medicaid is already a major success in cost control and in access toprimarycare. OHS’s arbitrary decision to increase primary care spending,costing Connecticut’s health system $3.9 billion annually by 2025, while limiting overall healthcare spending,will necessarily force other cuts in essential health care services, particularly for the Medicaid program—which already reasonably compensates primary care providers (while severely underpaying specialists, relative to Medicare) \

  8. “Although the Roadmap says it will apply to all payers, the state can only control Medicaid and so Medicaid enrollees are those to whom the experiment will most likely be applied, as in the past; the experiment will be performed on the patients with the least resources and least ability to opt to other providers who do not participate in the experiment.

  9. “The Roadmap pushes practices into primary care capitation, a failed payment model with serious risks of under-service to patients: Under capitation, providers are paid the same per member per month regardless of whether they see patients or not, incentivizing them to dramatically increase their rolls to get these monthly payments, not actually seeing (and instead sending to specialists) these patients for office or telehealth visits, and continuing to see patients for whom they can get paid per office visit.Risk-adjusting per member per month payments will not solve the problem, and will in fact incentivize providers to take sicker patients to get the higher pmpm payment but then send them out to specialists, for whom getting appointments is already a problem. Proposed quality measures are too weak to detect, let alone to prevent, the broad under-service incentivized by capitation. “The Roadmap ignores and undermines current initiatives in Connecticut that are improving primary care access and quality, particularly the PCMH (no +) managed fee-for-service Medicaid program, and would harm those models, e.g., by watering down the national accreditation standard for patient-centered medical homes to participate under PCMH.

  10. “The Roadmap promotes a corporate, medical model to provide social and behavioral health services, undermining person-centered community care models that work. “The Roadmap couldworsen Connecticut’s health disparitiesby incentivizing primary care providers to add Medicaid enrollees to their rolls (particularly individuals with [identified medical or disability issues of group]), to get monthly capitated payments which are provided regardless of services rendered, and then to refuse them appointments/regularly refer them to specialists instead, for whom there is already an access problem under Medicaid.”

  11. Consider identifying one or more of the above concerns to elaborate on, based on the 10/22/21 Coalition letter, the 1/1/22 comments in opposition submitted by tbe CT Health Policy Project at Public comment concerns with CT’s primary care plan – CT Health Policy, and the FAQ at FAQs on OHS’s Primary Care Roadmap – CT Health Policy and attached.

  12. Offer to work with OHS to bring real reform where needed, particularly increasing access to specialists under Medicaid,while protecting Medicaid and its enrollees from any cuts and avoiding any further move to push financial risk onto providers, such as problematic shared savings (PCMH+) or capitation (Roadmap proposal).

  13. Thank OHS for reviewing your comments.

Questions? Please contact Sheldon Toubman, Disability Rights CT at sheldon.toubman@disrightsct.org or (475)345-3169.



31 views0 comments