Advocates claim PCCM system is shortchanged in Connecticut

Hartford - In 30 states, some version of the program exists: For clients of Medicaid, all medical care is orchestrated through the office of one primary care doctor.

The same office that performs the physical makes the arrangement to get you to a specialist, arranges for pharmaceuticals, handles your paperwork. No HMO in sight.

In theory, such a system has been on the books for Medicaid clients in Connecticut since 2009. But in practice, advocates of this model of medical care say the program has been shortchanged by the agency that is supposed to run it, the Department of Social Services, and could be on its way to elimination before the state ever gave it a chance to work.

"It's absurd what we have to do to get around the barriers and challenges that are being placed in front of it," said Ellen Andrews, the executive director of the Connecticut Health Policy Project, which has fought for years in favor of the primary care case management (PCCM) model. The program, known here as HUSKY Primary Care, is an alternative to the for-profit HMOs that otherwise handle medical care for those on HUSKY, the program that administers Medicaid in Connecticut.

They have battled for a full year with officials at DSS over what advocates consider the slow rollout of the program and the geographical limits, which have kept doctors who would be willing to participate in the program from doing so.

DSS officials, meanwhile, countered Friday that the primary care model was desirable but not yet ready to be expanded, and said the state has struggled to recruit physicians and patients.

"It's a pilot," Dr. Robert Zavoski, the agency's medical director, told lawmakers. "We're learning. This is not a full program ready for prime time."

He added a few minutes later: "The effects on patient costs and patient care in Connecticut are still unclear."

Zavoski also expressed skepticism that Connecticut could replicate the broad implementation of the primary care management model used in other states, and thus might not be able to reap similar savings.

"This is probably impolitic for me to say, but other states pay their providers a little better than we do, so they get a little more provider interest," Zavoski said.

The department is also undergoing and bracing for major changes of its own, including the proposal in Gov. M. Jodi Rell's budget to jettison the HMOs that currently administer most HUSKY clients' care. Instead, the state would switch to an administrative-service organization model, where an insurance company would run the administrative functions of Medicaid while the state itself absorbed the medical risk.

And caseload - and costs - are steadily rising.

"I think you're going to hear from our commissioner in the next few days that we're not exactly resource-flush right now," Zavoski said.

In the long term, a PCCM program "might be" a major cost-saver for the state, he said. "But there are huge, huge, huge investment costs before we do."

Physicians enrolled in HUSKY Primary Care receive standard Medicaid reimbursement rates for the care they provide, and are paid an additional $7.50 per program member per month to defray the administrative costs of managing their patients' medical care.

The advocates say the system has saved millions in other states and would be a critical improvement in Connecticut, where an audit commissioned last year by State Comptroller Nancy Wyman found that the HMOs administering the HUSKY program had been overpaid by roughly $50 million.

In Oklahoma, which switched from HMOs to a primary care management model in 2004, the state saved $85.5 million in the first fiscal year of the program, while outpatient medicial visits went up and emergency room trips declined.

But Andrews and fellow advocates of the program say that it has been poorly promoted, even as HMOs have used some of the revenue received from the state to market their own programs, including TV and radio spots, free ice cream and haircuts.

"They're paying for some of this stuff on the state buck," said Rep. Betsy Ritter, D-Waterford.

And physicians who want to participate say they are blocked from doing so by the department's geographic restrictions, even when their patients live in towns ostensibly eligible for the program.

Dr. Patrick Alvino, a physician in Branford, has 823 patients on HUSKY who live in New Haven, one of the communities in which HUSKY Primary Care is supposed to be offered. But because Alvino's office is two towns over, he told lawmakers Friday, they can't leave their HMO plans and turn over the management of their care to Alvino and his staff.

"Though they were invited to participate in PCCM, and their nearby primary care providers - that is, those at my office - are willing and able to participate, they cannot do so without changing doctors, which I am sure most of you would agree is not a good solution," Alvino said in written testimony submitted to the committee.

For now, HUSKY Primary Care has just 322 enrollees, which is one reason Andrews is concerned about what is supposed to happen July 1: a review of the cost-effectiveness of the program, one she said would be unrepresentative with so few people yet participating in the program.

"We're very concerned that an invalid evaluation will be used to declare this program a failure," said Andrews, as a host of fellow advocates sat behind her, including a corps of student volunteers who have printed up fliers, passed out lapel pins and tried to alert HUSKY clients in eligible areas to the existence of the program.

Andrews told lawmakers they should consider creating a special master to oversee the primary care case management program, an authority who would be independent of DSS officials and responsible to the legislature to get PCCM off the ground. The authority would also perform some of the promotional work her nonprofit and student volunteers are doing now, in what they say is a vacuum that the state agency should be filling.

"We've done a lot of work and we're happy to do it," Andrews said. "But this is not our job."

t.mann@theday.com