This report provides an overview of Connecticut's health care system, in particular access to care, the health care delivery system, the quality of services provided, and health promotion (prevention, wellness, and disease management).

Policymakers in most, if not all, states have been grappling with the issue of the uninsured for several years. And, while new census data shows Connecticut's uninsured rate (11%) is lower than the national average (16%), about 400,000 state residents are without coverage. This report provides an overview of existing laws and programs related to Connecticut's health care system.

Connecticut residents can access health care coverage through private insurance, government programs (e. g. , Medicaid), and the state's high risk pool. State law permits the Department of Public Health (DPH) to provide grants to community providers to expand access to health care coverage in medically underserved areas.

Three major public insurance programs provide comprehensive, primary health care access to lower-income residents: Medicaid, HUSKY B, and SAGA. At least half of the Medicaid and HUSKY B costs are paid by the federal government. Most Medicaid recipients (primarily young families) and HUSKY B (children only) recipients receive their care through managed care organizations (MCOs), while the SAGA population is served primarily by community health centers.

Medicaid. Medicaid, a state-federal, means-tested health insurance entitlement program, offers the state's lowest-income residents access to health care (CGS § 17b-221, et seq. ). The Department of Social Services (DSS) runs the program, which covers numerous groups. Families receive their health care (called HUSKY A) through MCOs, while aged, blind, and disabled individuals' care is provided on a fee-for-service basis. Younger, childless adults are generally not eligible for Medicaid (see SAGA below). Table 1 includes some of the program's major coverage groups and their eligibility criteria.

Table 1: Medicaid -- Primary Care Coverage

Children's Health Care Outreach and Access—DSS, Children's Health Council, and Connecticut Voices for Children. The legislature established the Children's Health Council in 1995 as an outreach arm to ensure that eligible children enrolled in Medicaid (CGS § 17b-297). In addition to outreach, the council was expected to ensure statewide uniform health care access for children.

DSS provided over $ 1 million annually for the council's functions until the legislature cut the funding in half in 2002. The council's funding has continued to dwindle, and its functions have been taken up largely by Voices for Children, a New Haven-based child advocacy group (which also performs independent research on access and quality) receiving some state funding.

DSS currently maintains contracts with 211-Infoline to conduct HUSKY outreach.

HUSKY B. The federal State Children's Health Insurance Program (SCHIP) provides a block grant to every state to expand health insurance coverage for children. Connecticut used this grant to create the HUSKY B program to cover children not eligible for Medicaid (HUSKY A) (CGS § 17b-290, et seq. ). DSS runs the program and, as with HUSKY A, it contracts with HUSKY A MCOs to provide services. DSS pays the MCOs a monthly, capitated rate for which the MCOs assume full-risk for providing all covered services.

HUSKY B consists of both subsidized and unsubsidized health insurance. As a family's income increases, so does its cost sharing obligation. There is no asset limit. Table 2 provides income limits and associated cost sharing.

Table 2: HUSKY B Coverage

SAGA Medical Assistance. Very poor residents who do not qualify for Medicaid may qualify for the state-funded, State-Administered General Assistance (SAGA) program (CGS § 17b-192). The income limit is the same as Medicaid for aged, blind, and disabled people residing in the community but with a $ 150 earnings deduction and no deduction of unearned income. SAGA recipients generally receive their health care from the state's federally qualified health centers (FQHC). As of August 2006, SAGA enrollment was 32,103.

Federal law acknowledges that states have shortages of health professionals, especially in poor urban and rural areas, which leads to access problems. It designates these areas as Health Professional Shortage Areas (HPSA) or Medically Underserved Area or Population (MUA/P). These designations entitle the state to federal grants to offset costs associated with increasing the supply of providers. HPSAs include shortages in the areas of primary care, mental health, and dental care.

According to DPH, more than 34 federal programs depend on the shortage designation to determine either eligibility or preference for federal funding. As of November 2005, 33 municipalities had an MUA/P designation, with New Haven, Fairfield, and Hartford counties having the most. There were 84 HPSA designations, and each county had a shortage in at least one area.

Since 1990, state law has permitted DPH to provide grants to community providers to expand access to health care coverage to the underserved areas of the state (CGS § 19a-7d, et seq. ). The money can be used for (1) direct services, (2) recruiting and retaining primary care clinicians, and (3) capital expenditures. Primary care clinicians include family practitioners, obstetricians-gynecologists, and dentists, among others. As part of these efforts, DPH offers loan repayment assistance to providers who agree to work a minimum number of years in these areas.

For more information on the MUA/P or HPSAs designation, go to www. dph. state. ct. us/PB/HISR/HPSA. htm.

Health Reinsurance Association (HRA). HRA is a high-risk pool that guarantees access to comprehensive health insurance coverage for individuals who have not been able to obtain coverage elsewhere because of their pre-existing conditions. It is a state-created nonprofit association comprised of all private insurance companies, HMOs, and self-insurers doing business in the state (CGS § 38a-556). HRA plans usually cost more than commercially provided insurance coverage. The rates are statutorily capped at between 125% and 150% of standard market rates.

High-risk pools, by their nature, lose money because of the high cost of catastrophic claims they cover. By law, net losses are equitably assessed to all participating members. Net gains, if any, are held to offset future losses or allocated to reduce future premiums.

Pool Administrators Inc. administers HRA. Its staff provides administrative services, such as premium billing and collection, accounting, and financial services (other than claim services). HRA contracts with United HealthCare for its PPO network and Health Net for its HMO network. As of September 30, 2006, 2,539 people are enrolled in HRA plans.

There are six health care centers (HMOs) licensed to operate in Connecticut: Aetna Health Inc. of CT; Anthem Blue Cross & Blue Shield of CT, Inc. ; CIGNA HealthCare of CT, Inc. ; ConnectiCare, Inc. ; Health Net of CT, Inc. ; and Oxford Health Plans (CT), Inc. Over 500 insurance companies licensed to operate in Connecticut have the authority to write health insurance policies. The Connecticut Insurance Department does not track market data, so it does not know how many companies are actively marketing policies.

Connecticut Business and Industry Association's (CBIA) Health Connections. CBIA, a statewide private business organization, launched its purchasing cooperative, Health Connections, in 1995. Health Connections is designed for companies with three to 100 employees. The program gives employers a choice of plans from leading health care companies (CIGNA HealthCare, ConnectiCare, Health Net, and Oxford Health Plans). CBIA is the sole administrator for the program.

As of October 1, 2006, 5,847 employer groups (member companies) participate in Health Connections. The program covers 48,151 employees and 40,155 dependents, for a total of 88,306 covered lives. (These numbers are based on active employers and enrollees as of October 1, 2006 and do not reflect prior groups that have since terminated. )

State law permits small employers (groups of one to 50 employees, including a self-employed person) to group together for the purpose of securing group health insurance (CGS § 38a-560). An absence of a statutory prohibition permits health insurance plans to be sold through associations, which are defined by federal law, according to the insurance department.

Connecticut Small Employer Reinsurance Pool (CSERP). Connecticut operates a nonsubsidized reinsurance pool, CSERP, for the small group market (employers with one to 50 employees) (CGS § 38a-569). Any insurer of a small employer may purchase reinsurance from the pool for certain individuals or entire groups. The reinsurance coverage has a $ 5,000 deductible per covered life.

CSERP is funded by the reinsurance premiums paid by the insurers purchasing the coverage and annual assessments the insurers pay based on their small employer market share.

Municipal Employees Health Insurance Program (MEHIP). MEHIP was created in 1998 to help cities and towns provide health coverage for municipal employees (CGS § 5-259(i)). It was later opened to other groups. The law creating MEHIP requires that (1) MEHIP not affect the rates the state pays for state employee health plans and (2) the participating municipalities and other groups bear all MEHIP administrative costs. The law also prohibits MEHIP from turning away any group of employees due to past or future health care costs or claims experience. The state comptroller, who by statute oversees the program, contracts with Marsh Advantage America to administer MEHIP.

Since the program was created, subsequent legislation expanded the definition of a municipality to include regional telecommunications centers and tourism districts. It previously included towns, school districts, taxing districts, fire districts, housing authorities, regional planning agencies, transit districts, and other entities. Legislation also opened MEHIP to:

1. nonprofit corporations that do business with the state,

2. community action agencies,

3. personal care assistant associations,

4. small businesses,

5. individuals eligible for a retirement benefit from the Connecticut municipal employees' retirement system, and

6. federally qualified nonprofit corporations that (a) receive any public funding or (b) have federal 501(c)(5) tax-exempt status (e. g. , labor unions).

Employers purchasing group insurance through MEHIP have a choice of plans from Anthem Blue Cross and Blue Shield, Health Net, and Oxford Health Plans.

As of September 29, 2006, 298 groups obtain insurance through MEHIP. The 298 groups are made up of 135 nonprofits, 89 small employers, and 74 municipal groups (including 46 towns, 12 housing authorities, 10 boards of education, four government councils, and two unions). The plans cover 7,323 employees and 6,684 dependents for a total of 14,007 covered lives. The annual average premium cost is $ 4,860 per covered life or $ 8,863 per covered employee, according to the Office of the Comptroller.

The law allows pharmacists and physicians to enter into collaborative practice agreements to manage patients' drug therapy (CGS §§ 20-631 & 631a).   Physicians and hospital pharmacists, as well as physicians and pharmacists working in nursing homes, can enter into collaborative agreements. These agreements must be (1) based on patient-specific written protocols and (2) approved by the hospital or nursing home, respectively. The protocols can authorize a pharmacist to implement, modify, or discontinue a drug therapy the physician prescribes, order associated lab tests, and administer drugs.   The hospital or nursing home employing the pharmacist must determine the pharmacist's competency to participate.

Initially, the hospital-based agreements were only for inpatient care. But PA 05-217 also allows agreements to manage the drug therapy of patients receiving outpatient hospital care or services for diabetes, asthma, hypertension, hyperlipidemia, osteoporosis, congestive heart failure, or smoking cessation.   The protocols must be patient-specific and established by the treating physician in consultation with the pharmacist. Patients can include those who qualify under the Medicare Part D prescription drug benefit. The hospital must determine the pharmacist's competency to participate.

PA 05-217 also establishes a two-year pilot program for collaborative drug therapy arrangements between pharmacists and community pharmacies.   The Department of Consumer Protection (DCP) is responsible for establishing the pilot.

Community Health Centers (CHCs). CHCs are public or nonprofit organizations whose main purpose is to provide comprehensive primary care services to low-income, uninsured, and underinsured people of all ages. Teams of interdisciplinary health care professionals work in CHCs.   The state's CHCs were initially established in the 1960s. Since their inception, CHCs have evolved in number, size, and scope of services. Currently, 12 centers in the state provide care at over 50 different sites. Health center staff matches patients with programs such as SAGA, Medicaid, HUSKY, and WIC and assist them in completing the respective application processes. (See, CGS §§ 19a-490a, 19a-59b, 19a-17m, and 17b-349; DPH Regs. §§ 19-13-D45 to D53; and the Federal Public Health Services Act. )

Over 830,000 visits were made to Connecticut's CHCs in 2005 by individuals from over 150 municipalities, according to the Connecticut Primary Care Association (CPCA). CPCA reports that one in every 17 Connecticut residents, more than 200,000 people, received their health services at CHCs in 2005.   Nearly a third of those were uninsured, and many were from working families whose jobs either offered no or unaffordable health coverage. More than 65% of CHC patients are at or below the poverty level, and over a third of the centers' patients are children.

CHC funding comes from a variety of public and private sources.   This includes Medicaid, state and local funds, the State Children's Health Insurance Program (HUSKY), federal grants, Medicare, and the patients themselves. The current General Fund appropriation (FY 07) for CHCs is $ 5,031,725.

Federally Qualified Health Centers (FQHCs). FQHCs are CHCs that receive federal funding and meet specific federal criteria, including those governing the services they provide. FQHCs provide their services to all people regardless of ability to pay and charge for services on a sliding-fee scale basis. Section 340B of the federal Public Health Services Act requires drug manufacturers to enter into agreements with the federal Department of Health and Human Services (HHS) to provide outpatient drugs to FQHCs and other entities at discounted prices. Generally, the prices are as good as those paid by state Medicaid agencies. An FQHC must adhere to certain requirements to receive the discounted pricing. It must (1) be the purchaser and owner of the covered drugs and (2) dispense them only to patients of the health center. Most of the state's CHCs are designated as FQHCs.

State law allows licensed health care institutions to create, maintain, or use medical records or medical record systems in electronic format, paper, or both if the system can store medical records and patient health care information in a reproducible and secure manner. State law also allows health care providers with prescriptive authority to use electronic prescribing systems (CGS §§ 19a-25b & 19a-25c).

All 30 Connecticut acute care hospitals provide 24-hour emergency care. Federal law (the Emergency Medical Treatment and Labor Act) requires them to provide (1) an appropriate medical screening exam to anyone who comes to the emergency department (ED) asking for treatment and (2) necessary stabilizing treatment or transfer to another medical facility if the exam reveals an emergency medical condition.

Connecticut's ED usage rate is slightly higher than the national rate (420 visits per 1,000 population, compared to 400). ED use in Connecticut has increased by about 7% since 2001 to nearly 1. 5 million visits in 2004. ED use ends with a patient either being discharged or admitted to the hospital or transferred to another facility. On average, about 15% of ED patients are admitted to hospitals.

Nationally, hospitals report increased use of EDs for primary care (nonurgent or semi-urgent reasons), especially by Medicaid patients and those without insurance. Hospitals also report more people with serious mental illness presenting in EDs and staying there for prolonged periods because inpatient and other treatment beds are not available.

A health care center (commonly known as a health maintenance organization or HMO) is a company that provides, offers, or arranges for coverage of plan members' health services for a fixed, prepaid premium. The Connecticut Insurance Department licenses and regulates health care centers in accordance with Title 38a of the Connecticut General Statutes. Six licensed health care centers operate in Connecticut: Aetna Health Inc. of CT; Anthem Blue Cross & Blue Shield of CT, Inc. ; CIGNA HealthCare of CT, Inc. ; ConnectiCare, Inc. ; Health Net of CT, Inc. ; and Oxford Health Plans (CT), Inc.

There are 30 acute care hospitals in Connecticut; all but one (Essent/Sharon Hospital) are nonprofit. (On October 1, 2006, New Britain General Hospital and Bradley Memorial Hospital merged to form the Hospital of Central Connecticut). Four hospitals have religious affiliations, and 18 are teaching hospitals. On October 1, Bradley Memorial and New Britain General hospitals merged, but are maintaining separate campuses.   For FY 05, OHCA reports that Connecticut's hospitals had a total of (1) 9,247 licensed beds, but on average just 7,223 are staffed; (2) 2. 08 million patient days; (3) 422,921 inpatient discharges; (4) $ 8. 21 billion inpatient charges; (5) 1. 46 million emergency room visits; (6) 4. 7 million other outpatient visits; (7) $ 6. 18 billion net revenue from operations; and (8) $ 6. 05 billion hospital operating expenses.   The hospitals' total margin was 3. 3% with an operating margin of 1. 68%. Average daily census for all hospitals was 5,694 with 79% of the staffed beds occupied and an average length of stay of 4. 9 days.

Hospitals must be licensed by DPH under the department's authority to license health care institutions (CGS § 19a-490). The Public Health Code sets out various regulatory requirements for hospitals addressing the physical plant, administration, medical staff, nursing services, medical records, pharmacy, emergencies, infection control, and other

matters (DPH Regs. §§ 19-13-D1 to D3). OHCA collects a variety of health care data on hospitals and issues an annual report on their financial status. Also, any hospital proposal requiring a certificate of need would come under the jurisdiction of OHCA.

Hospitals receive payment from a variety of nongovernment and government sources. According to a recent Program Review and Investigation report, in FY 05 the contributing payer mix for hospitals was 49% nongovernment, 41% Medicare, 9 % Medicaid and other state medical assistance, and about 1% uninsured and other.   Hospitals negotiate payment rates with private insurers and managed care companies.   Typically, the payments are a percentage discount off hospital charges.   PA 03-266 addressed debt collection practices of Connecticut hospitals, availability of hospital bed funds, and services to and payments for uninsured patients.

Uncompensated care (UCC) represents the level of charges for which hospitals do not receive reimbursement.   It generally includes a hospital's free care and bad debt, as well as under-compensated care associated with government payers.   In Connecticut, UCC increased by 3. 7% in FY 05 to $ 170 million.   The Disproportionate Share Hospital program (DSH) reimburses hospitals for care provided to a high volume of Medicaid and other low-income patients.   There are several DSH accounts in the state, the largest being the uncompensated care account.  UCC funding for FY 05 totaled $ 62. 5 million, funded through General Fund appropriations, which are federally reimbursable under Medicaid at 50%. (Other DSH accounts are for urban distressed hospitals, the veteran's hospital, and the children's hospital.   DSS administers the majority of the DSH programs. )

DPH regulations define an outpatient clinic as an organization operated by a municipality or a corporation other than a hospital that provides (1) ambulatory medical or dental care for diagnosis, treatment, and care of people with chronic or acute conditions that do not require overnight care or (2) medical or dental care to well persons, including preventive services and health maintenance (DPH Regs. §§ 19-13-D45 to D53). (Such clinics are also referred to as “ambulatory care centers. ”)  Such clinics must be licensed by DPH and meet standards and criteria on buildings and equipment, administration, professional staff, records, nursing personnel, pharmaceuticals, maintenance, and inspection.    (CHCs and school-based health centers are also governed by these regulations. )

If an outpatient clinic is part of a hospital's operation, it is licensed as a satellite site of the hospital and does not have a separate outpatient clinic license. An “urgent care center” may also be part of a hospital; if so, it is licensed as a satellite site of the hospital.   If it is not part of a hospital and does not meet the definition of a licensed outpatient clinic, then DPH considers such an “urgent,” “immediate,” or “walk-in” care center a doctor's office. In that case, DPH licenses the practitioners (physicians, nurses, physician assistants, nurse practitioners, advanced practice registered nurses), but not the office or center itself (see “Walk-In Clinics” below).

An outpatient surgical facility is an entity, individual, firm, partnership, corporation, limited liability company, or association, other than a hospital, providing surgical services or diagnostic procedures that include the use of moderate or deep sedation, moderate or deep analgesia, or general anesthesia. (See, CGS §§ 19a-490, 19a-493b, 19a-127l, and 19a-504b and DPH Regs. § 19-13-D56. )

State law requires that entities providing such services in physician offices or similar settings be licensed as an outpatient surgical facility by DPH by March 30, 2007 (CGS § 19a-493(b)). The law exempts from the outpatient surgical facility definition a medical office owned and operated exclusively by one or more licensed physicians if it does not (1) have an operating room or designated surgical area, (2) bill facility fees to third party payers, or (3) administer deep sedation or general anesthesia.   Exempt facilities may perform only minor surgical procedures incidental to the work done in the office and use only light or moderate sedation or analgesia.

School-based health centers (SBHCs) are comprehensive primary health care facilities located in schools or on school grounds.   SBHC services are aimed at, but not limited to, students who do not have access to a family physician or whose families have little or no health insurance.   They serve students in grades pre-K through 12.   SBHCs are licensed as outpatient clinics and are staffed by multidisciplinary teams of pediatric and adolescent health specialists, including nurse practitioners, physician assistants, social workers, physicians, and in some cases, dentists and dental hygienists.  SBHCs emphasize prevention, as well as the early identification and treatment of physical and mental health concerns. SBHC services are confidential, and parents must sign a permission form in order for students to receive services.

The first Connecticut SBHC was established in New Haven in 1981. There are now 69 SBHCs in the state located in 21 communities, including a few in the planning stages.   They operate under a variety of management models that include boards of education, local public health departments, human service and mental health agencies, hospitals, and community health centers.

SBHCs operate with a combination of public and private dollars, including federal block grant funds, state General Fund appropriations, local private and foundation funds, municipal funding, and community agency contributions. SBHCs are also able to bill HUSKY A and B plans for services provided to students covered by these plans.   The state appropriation for SBHCs for FY 07 is $ 7,676,461.

PA 06-195 (§ 51) requires the DPH commissioner to establish an ad hoc committee to assist him in examining statutory and regulatory changes to improve health care through access to SBHCs.    The committee expects to report in December.

“Walk-In” health clinics are a service delivery option for some health care consumers. Such clinics generally are viewed as a physician's office and thus do not require a separate health care facility license. Rather, the practitioner's license is sufficient for the clinic to operate.

A new type of walk-in clinic is beginning to operate in such sites as supermarkets, drug stores, and “big box” chain stores.   These clinics are staffed mainly by nurse practitioners who are licensed to treat a wide range of minor illnesses and prescribe medications. In Connecticut, a large group of primary care physicians, ProHealth Physicians, has signed an agreement to open several walk-in clinics in Price Chopper grocery stores. These will be staffed by nurse practitioners, with physicians expected to visit the clinics on a regular basis. The first such clinic has opened in the Putnam store. ProHealth's clinics, which operate under the name Med-Access, will follow a model similar to the one used by retail clinic chains such as MinuteClinic, RediClinic, and Take Care that have opened in other parts of the country.

DPH considers these newer retail clinics as physicians' offices, so only the practitioners, and not the office, must be licensed.

Connecticut's first effort in medical error reporting, PA 02-125, required hospitals and outpatient surgical facilities to report adverse events to the Department of Public Health (DPH). Generally, adverse events were injuries caused by or associated with medical management that resulted in death or measurable disability. The act classified adverse events as A through D, with Class A being the most serious (CGS § 19a-127n).   Adverse event reports generally became public information six months after their filing with DPH.

PA 04-164 amended the 2002 law by replacing the adverse event classification reporting system with a list of reportable events identified by the National Quality Forum (NQF), or by DPH. DPH has added six Connecticut-specific adverse event definitions to supplement the NQF list.   (NQF is a nonprofit membership organization created to develop and implement a national strategy for health care quality management and reporting. )  Falls resulting in serious disability and perforation during open, laparoscopic, and endoscopic procedures are the most commonly reported events. The 2004 act restricts disclosure of adverse events.

State law requires DPH to establish a quality of care program for health care facilities (CGS § 19a-127l). It also directs the department to develop a health care quality performance measurement and reporting system initially applicable to the state's hospitals. Other health care facilities may be included in the quality program in later years.

Responsibility for the program lies with DPH's Health Care Systems Branch and its Planning Branch. DPH produces an annual report to the General Assembly on its quality of care program; the most recent report was issued in June 2006.

An advisory committee, chaired by the DPH commissioner, advises the program. It has established a number of subcommittees and working groups. These are:

1. health promotion and illness prevention;

2. physician profilers;

3. continuum of care;

4. regulations;

5. settlement agreements/tort reform;

6. promotion of quality and safe practices (Working Group I-Hospital Performance Comparisons, Working Group II-Patient Satisfaction Survey);

7. best practices and adverse events;

8. legislative; and

9. cardiac care (see below).

PA 05-167 amended the law to require the advisory committee to examine and evaluate (1) possible approaches that would aid in using an existing data collection system to measure cardiac outcomes and (2) the potential for statewide use of a collection cardiac outcome data collection system.  It must report by December 1, 2007. To meet this requirement, the advisory committee created a subcommittee on cardiac care in fall 2005.

In February 2006, DPH issued a report on the quality of care in Connecticut Hospitals, “Hospital Performance Comparisons, 2004” as part of its quality program initiative.

Racial and ethnic health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.   In Connecticut, as in most of the United States, data indicate that African Americans, Latino, Native Americans, and some Asian communities are disproportionately affected by health disparities. Generally, this means that these communities receive a lower quality of care than the majority white population, even when factors such as a patient's insurance status and income are equal. The sources of the disparities are complex, involving both historical and current social conditions, as well as the health care system. (See, CGS § 19a-4k. )

In June 2006, the Connecticut Health Foundation (CHF) awarded DPH a two-year grant of $ 539,317 to improve the statewide infrastructure for documenting, reporting, and addressing health disparities among racial and ethnic minorities. The “Connecticut Health Disparities Project” is designed to collect and evaluate relevant sociodemographic information from across DPH databases with the idea of improving data collection as well as coordinating all DPH planning objectives related to eliminating health disparities. Additional objectives include publishing a comprehensive Connecticut health disparities surveillance report and developing a statewide network of researchers and policy analysts focused on the measurement of health disparities in the state.

Additional partners in the project are DPH's Office of Multicultural Health, the Connecticut Multicultural Health Advisory Commission, the Connecticut Center for Eliminating Health Disparities Among Latinos, and the University of Connecticut.    Other state agencies will also be involved.

JCAHO evaluates and accredits about 15,000 health care organizations and programs in the United States. It is an independent, nonprofit organization that maintains standards that focus on improving the quality and safety of care provided by health care organizations. The commission's accreditation process evaluates a health care organization's compliance with these standards and other requirements. To earn and maintain JCAHO's “Gold Seal of Approval,” an organization must undergo an on-site survey by a commission survey team at least every three years. Laboratories must be surveyed every two years.

JCAHO evaluates and accredits the following types of health care organizations:

1. general, psychiatric, children's, and rehabilitation hospitals;

2. critical access hospitals;

3. medical equipment services, hospice services, and other home care organizations;

4. nursing homes and other long term care facilities;

5. behavioral health care organizations' addiction services;

6. rehabilitation centers, group practices, office-based surgeries, and other ambulatory care providers; and

7. independent or freestanding laboratories.

JCAHO reviews organizations' activities in response to sentinel events in its accreditation process, including all full accreditation surveys and unannounced surveys and, as appropriate, for-cause surveys. A “sentinel event” is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation that would carry a significant chance of a serious adverse outcome if it recurred. These events are called “sentinel” because they signal the need for immediate investigation and response. JCAHO notes that the terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.

The insurance commissioner, after consultation with the DPH commissioner, annually publishes a consumer report card on all managed care organizations (CGS § 38a-478l).   The document, developed as a comparison guide, includes information on all Connecticut-licensed health care centers (HMOs) and the 15 largest insurers that offer managed care plans in the state.

For each organization, the guide includes general information, the number of participating providers per county, quality measures, utilization review data, and member satisfaction survey results.   Quality measures include statistics on board certified primary care physicians and specialists, provider turnover, breast and cervical cancer screening, prenatal and postpartum care, childhood immunizations, adult access to care, eye exams for diabetics, beta blocker treatments after a heart attack, and outpatient prescription drug utilization.

Fee-For-Service Program. The state-federal Medicaid fee-for-service program mainly covers very poor elderly and disabled people to the extent their primary, acute, and long-term care medical needs are not covered by Medicare, which covers mostly short-term rehabilitative care in nursing homes or home health care after a hospital stay.

2003 legislation required the Department of Social Services (DSS) commissioner to design and implement a case enhancement and disease management initiative to create an integrated and systematic approach for managing health care needs of high-cost Medicaid recipients (PA 03-3, June 30 Spec. Sess. ). 2005 legislation changed the law to allow, rather than require the commissioner to do this if she determines that it will be cost effective (PA 05-209). The commissioner has not yet implemented such a program.

Medicaid Managed Care. In 1994, the state began moving certain Medicaid (HUSKY A) recipients (children and certain caretaker relatives) from a fee-for-service to a managed care service delivery model. The legislature created the Medicaid Managed Care Advisory Council to plan and implement the program. Since then, the council, whose membership comprises legislators, executive branch employees, health care providers, and advocates, has functioned as an ongoing oversight body, monitoring the program's operations in areas such as quality, accessibility, and sufficiency of provider networks. The council has a quality assurance subcommittee. (See, CGS §§ 17b-28 and 17b-298. )

Medicaid quality-of-care standards also affect children receiving services under HUSKY B. State law requires the DSS commissioner to adopt regulations to establish appropriate contract standards to oversee and ensure the quality of care provided under HUSKY B. It also requires her to (1) develop criteria for assessing the outcomes of health care provided and (2) contract for external quality review of the program.

As a condition of receiving federal funds for HUSKY A and B, states are expected to measure the performance of the managed care organizations they use to ensure they meet certain quality standards. DSS maintains contracts with the Mercer Government Human Services Consulting, which conducts ongoing quality reviews.

In 2003, when the legislature moved the SAGA medical assistance population from fee-for-service to a clinic service delivery model, the council began monitoring that program, including its quality results, as well. The 2006 legislature formally added SAGA oversight to the council's scope (PA 06-188).

Medicare Background. Most of Connecticut's senior citizens age 65 and older and qualifying younger disabled people receive the major part of their health care through the Medicare program, which is funded solely with federal money. Medicare now consists of four parts: Part A covers hospital stays, B covers outpatient care and doctor's bills, C covers Medicare HMOs, and D covers prescriptions. Seniors can either participate in the program's fee-for-service portion, which lets them see any health care provider without a referral, or they can join a Medicare HMO. Connecticut has three such Medicare HMOs (Health Net, Oxford, and Wellcare) and two similar preferred provider organizations (United Health Care and Secure Horizons, which mainly serve frail elderly and people in nursing homes). The state had almost 520,000 Medicare beneficiaries in 2005.

Medicare beneficiaries in the fee-for-service portion of the program often buy supplemental insurance (known as “Medigap”) to cover the portion of doctor's bills that Medicare does not pay (people enrolled in the Medicare HMOs do not need this extra insurance). Medicare beneficiaries with very low incomes and assets can qualify for the Qualified Medicare Beneficiary (QMB) and several similar programs, where Medicaid pays their monthly Medicare premiums and functions as Medigap insurance.

Medicare Quality Improvement Programs. The federal Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS), which administers Medicare, is taking several steps to improve quality of care. It has conducted or begun numerous demonstrations aimed at improving quality of care by hospitals, physicians, nursing homes, and home health care agencies. Few demonstrations are occurring in Connecticut, but Medicare patients here can later benefit from their results.

One demonstration being conducted in Connecticut is the Medicare Pay for Performance Demonstration begun in 2005, which includes 10 large physician groups throughout the country. One is Middlesex Health System in Middletown. The physician groups receive fee-for-service payments plus bonus payments at the end of the year based on their performance.

Other examples of quality initiatives and demonstrations include:

1. the Hospital Quality Initiative, in which nearly all hospitals in the U. S. , including most in Connecticut, receive higher payments for submitting data on the level of recommended care they provided (Hospital Compare on the Medicare website is one result of these efforts);

2. the Premier Hospital Quality Incentive Demonstration, which pays bonuses to around 280 hospitals (none in Connecticut) if they achieve high performance in treating five specified clinical conditions;

3. the Chronic Care Improvement Program, Medicare's first large pay-for-performance program to reduce health risks for chronically ill beneficiaries;

4. the Coordinated Care Demonstration, which tests whether providing coordinated care services to beneficiaries with complex chronic conditions can yield better patient outcomes without increasing program costs;

5. the Care Management Performance Demonstration, which tests methods to promote use of health information technology to improve care quality for chronically ill Medicare patients;

6. development of standard performance measures; and

7. the Senior Risk Reduction Program, upcoming in spring 2007, which will determine whether private sector health risk reduction programs can be tailored to Medicare beneficiaries. It will address multiple risk factors contributing to chronic diseases, such as physical inactivity, obesity, smoking, depression, high blood pressure, high cholesterol, and high blood sugar.

Medicare has also created Nursing Home and Home Health Compare websites to provide quality of care information to people looking for a nursing home or a home health agency.

NCQA is a private, nonprofit organization concerned with improving health care quality.   It is considered a “watchdog” for the managed care industry. Employers and consumers use information NCQA provides to make more informed health care choices. It began accrediting managed care organizations in 1991 in response to the need for standardized, objective information about their quality. The accreditation program is voluntary; more than half of the HMOs in the U. S. have been reviewed. Several states recognize NCQA accreditation as meeting certain regulatory requirements for health plans, eliminating the need for a separate state review. (Connecticut apparently is not one of them. ) All six of Connecticut's licensed HMOs are NCQA accredited.

For an organization to receive NCQA accreditation, it must undergo a rigorous survey and meet certain standards designed to evaluate its clinical and administrative systems. In particular, NCQA evaluates plans in the areas of patient safety, confidentiality, consumer protection, access, service, and continuous improvement.

Legislation enacted in 1994 and 1995 created OHCA as the successor agency to the Commission on Hospitals and Health Care.   OHCA oversees the state's health care delivery system to ensure that access to affordable, quality care is available to the state's citizens (CGS §§ 19a-610 to 689). The office's major functions are health care data collection, analysis and reporting; hospital finance review and reporting; and administration of the certificate of need program. OHCA does not license health care professionals or facilities.

OHCA collects utilization data on all discharges from the state's acute care hospitals.   This includes demographic, utilization, clinical, charge, payer, and provider information. Also, the office gathers, verifies, analyzes, and reports on a wide range of hospital financial data such as expenses, revenues, uncompensated care, volume, and other data as needed.

PA 04-164 allowed DPH to designate as PSOs public or private organizations whose primary mission involves patient safety improvement activities (CGS § 19a-127o).   PSOs collect, aggregate, analyze, and process medical or health-related information submitted to them by health care providers. This “patient work product” may include reports, records, policies, procedures, or root cause analyses prepared exclusively for disclosure to the PSO. Patient safety work product is confidential and not subject to use or access except to PSOs and health care providers.   PSOs will disseminate appropriate information or recommendations on best medical practices or potential system changes to improve patient care to the health care providers, DPH, the Quality of Care Advisory Committee (see above), and the public.

PA 05-275 required each hospital, by January 1, 2006, to (1) contract with a PSO to gather medical or health care related data from the hospital and recommend ways to improve patient care and safety and (2) provide documentation to DPH that the hospital has complied (CGS § 19a-127p). The PSO must do this by collecting, aggregating, analyzing, or processing medical or health care-related information it receives from health care providers.  

The law requires DPH to establish a profile for each licensed physician in the state (CGS § 20-13j). The profiles, based on physicians' completion of a DPH survey, include (1) general physician information (license number, practice locations, and hospital and nursing home affiliations); (2) medical specialty areas; (3) education, including post graduate training; (4) malpractice information, including the name of the physician's professional liability insurance carrier; (5) hospital discipline within the last 10 years; (6) felony convictions within the last 10 years; (7) disciplinary action taken against the physician by DPH, the state Medical Examining Board, or any professional licensing or disciplinary body in another jurisdiction; (8) medical educational responsibility (providing this information is voluntary); and (9) publications, professional services, activities, and awards (also voluntary).

The physician profile law also requires physicians to update periodically certain information in the profile, including hospital disciplinary actions and malpractice judgments, arbitration awards, and settlements.

Strategic Prevention Framework. This plan and its related State Incentive Grants program are designed to prevent alcohol abuse, with a special emphasis on underage drinking. Grants go to groups whose proposals address their sub-region's priority substance problems. (Agency: Department of Mental Health and Addiction Services)

Drug and Alcohol Prevention. Grants go to community-based substance abuse prevention and early intervention service providers to improve adolescents' social skills and promote positive youth development. (Agency: Department of Children and Families)

Safe and Drug-Free Schools and Communities. These grants support age-appropriate, research-based drug and violence prevention programs for students, training for school personnel, policy development, and counseling. (Agency: State Department of Education)

Combating Underage Drinking. Grants go to local governments and private agencies to develop a comprehensive approach to combating underage drinking, including education, public awareness, and enforcement. (Agency: Office of Policy and Management)

Family Strengthening Program. This science-based program develops effective prevention interventions for children of substance abusing parents through local community-based organizations. (Agency: Department of Mental Health and Addiction Services)

Local Prevention Councils. Over 150 councils increase public awareness of alcohol, tobacco, and other drug prevention initiatives and stimulate the development and implementation of local actions focusing on youth. (Agency: Department of Mental Health and Addiction Services)

Best Practices Initiative. This program applies science- and research-based innovations to populations of all ages. Its 13 projects use multiple prevention strategies and other research-based best practices with specific populations on a regional basis. (Agency: Department of Mental Health and Addiction Services)

Governor's Prevention Partnership. This nonprofit partnership between state government and business leaders seeks to keep Connecticut's youth safe and drug-free. It helps schools, communities, youth organizations, colleges, and businesses create and sustain programs to help (1) communities build coalitions and programs to address underage drinking; (2) schools develop and implement effective drug and violence prevention programming; (3) colleges address issues and behavior related to alcohol abuse.

Primary Mental Health. This program provides grants to schools to support early detection and prevention of school maladjustment. It focuses on primary grade children experiencing problems (e. g. , poor peer relations, aggressiveness, withdrawn behavior) that interfere with learning. (Agency: State Department of Education)

Help Me Grow. This program identifies children at risk for behavioral or developmental problems and connects them to existing community resources. It consists of four components: (1) training child health providers in effective developmental surveillance; (2) inventorying community-based programs that support child development and families; (3) developing a statewide referral system that links young children and families to services and support; and (4) collecting and analyzing data. (Agency: Children's Trust Fund)

The Breast and Cervical Cancer Screening Program's primary objective is to increase significantly the number of medically underserved women who receive breast and cervical cancer screening services and diagnostic follow-up. These screening and diagnostic services include office visits, mammograms, clinical breast exams, breast biopsies and ultrasounds, fine needle aspirations, pap tests, colposcopies and colposcopy-directed biopsies, and surgical consultations. (Agency: Department of Public Health)

The WISEWOMAN program seeks to reduce morbidity and mortality from cardiovascular risk factors and provide education and behavioral interventions to at-risk women. It offers cardiovascular disease screening and intervention services at nine of the current 18 breast and cervical cancer early detection program (see above) provider sites. It is open to low-income women ages 40 to 64 who are un- or underinsured. WISEWOMAN services include height, weight, blood pressure, cholesterol, blood glucose testing, and selected nutrition and physical activity interventions for those with abnormal screening results. (Agency: Department of Public Health)

State law requires children to be immunized against eight diseases before they can attend public school and requires students attending Connecticut colleges to be vaccinated against two diseases. The state purchases vaccines, provides educational materials, and operates an immunization registry. (Agency: Department of Public Health)

The Injury Prevention Program contracts with community-based programs to address risk and resiliency factors associated with, and implement strategies to decrease, unintentional and intentional injuries (see violence and suicide, below). It provides funds to local health departments for such activities as correct use of safety belts and child safety seats, pedestrian safety education, and fall prevention. (Agency: Department of Public Health)

The state's Childhood Lead Poisoning Elimination Plan calls for decreasing the rate of children under six residing in CT with elevated blood lead levels by (1) focusing on primary prevention efforts, especially in areas where incidence is currently highest; (2) increasing the number and rate of children screened; (3) providing environmental inspections and intensive case management services to children with a elevated blood lead levels (4) decreasing the numbers of at-risk properties and increasing the availability of lead-safe low income housing; and (5) enhancing community knowledge of and interest in childhood lead poisoning prevention and elimination. (Agency: Department of Public Health)

Genetic. Connecticut newborns are screened for a variety of inborn genetic disorders that can potentially cause severe health consequences. Parents of newborns whose screens are positive receive counseling about the disease and interventions. (Agency: Department of Public Health)

Hearing. Newborns are also screened to detect whether they have hearing loss. Those who do are enrolled in an early intervention program, if eligible. (Agency: Department of Public Health)

Health Promotion Plan. A 2005 state plan calls for, among other things, (1) designing a statewide surveillance system for tracking nutrition and physical activity indicators; (2) identifying and adopting best practices related to preventing, screening, assessing, and treating obesity and promoting physical activity; (3) providing healthy school nutrition environments; (4) helping communities develop comprehensive plans that support healthy choices; and (5) developing common practices among health insurers to address overweight and obesity. (Agency: Department of Public Health)

WIC. WIC (Women, Infants, and Children) is a supplemental nutrition program that provides nutritious food to pregnant women, new mothers, and young children under five at no cost. (Agency: Department of Public Health)

School Nutrition. Pursuant to PA 06-63, the State Department of Education has adopted a set of nutrition standards for all food items that students purchase separately from a reimbursable school lunch or breakfast food items. School districts that participate in the National School Lunch Program can receive additional funding if they certify all that all food items they sell to students in these circumstances meet the standards. (Agency: State Department of Education)

An Oral Public Health Office is implementing a series of initiatives including creating a collaborative to develop a state oral health plan; developing best practice models for statewide dental sealant programs; distributing a statewide newsletter, Oral Health Matters, containing the latest information on oral health prevention activities; and disseminating education and training programs to parents and practitioners. (Agency: Department of Public Health)

The HIV/STD Prevention Program provides research-based training and technical assistance to school personnel on a wide range of HIV/STD and sexuality topics, including classroom strategies, targeting students at higher risk, and parental notification. (Agency: State Department of Education)

Tobacco Use Prevention and Control Plan. This plan contains four goals: (1) prevent young people from starting to smoke, (2) promote smoking cessation among youth and adults, (3) eliminate exposure to environmental smoke, and (4) eliminate smoking disparities among different populations. It recommends a variety of strategies, including establishing a toll-free quitline, using marketing and media to promote healthy behavior, working with health care professionals to advise patients against smoking, adopting tobacco-free school policies, and promoting community education programs. (Agency: Department of Public Health)

Tobacco Prevention and Enforcement Program. This program (1) informs cigarette dealers, youth, and the public about the laws prohibiting the sale of cigarettes and tobacco products to youth under the age of 18: (2) conducts compliance inspections at retail outlets; and (3) promotes awareness about the health risk associated with tobacco use. (Agency: Department of Mental Health and Addiction Services)

Grants go to community and local government agencies for educational, medical, and social service activities directed at preventing teen pregnancy. (Agency: Department of Social Services)

Violence Prevention. This program focuses on middle and high school aged youth. It provides training in conflict resolution strategies, mediation, anger management, and job readiness. (Agency: Department of Public Health)

Intimate Partner Violence Prevention. Workshops teach health and human service providers, students, and others how to identify, assess, intervene with, and appropriately refer women who are victims of partner violence. (Agency: Department of Public Health)

Nurturing Families. Operating through hospitals, this program provides parenting education and support to families with newborns who are at high risk of abuse or neglect. It provides screening and short-term support; intensive, long-term home visiting; and parenting groups. (Agency: Children's Trust Fund)

Shaken Baby. This program offers new parents information about shaken baby syndrome through in-hospital videos, discussion, and follow-up by hospital staff. (Agency: Children's Trust Fund)

EPSDT. The Early and Periodic Screening, Diagnostic, and Treatment program provides comprehensive health services for infants, children, and adolescents enrolled in Medicaid. Federal law prescribes screening services states must offer, although it allows them some flexibility in setting when and how often screenings should be conducted. Screenings include (1) comprehensive health and developmental history, including a developmental assessment of physical and mental health; (2) comprehensive physical exams; (3) immunizations; (4) laboratory tests, including mandatory lead screening; and (5) vision, hearing, and dental screening. (Agency: Department of Social Services)

HMO Wellness Programs. Each of the state's six HMOs promotes wellness among its members. For example, Aetna operates an online program that provides personalized plans for members who complete a health risk assessment. It also offers wellness counseling by nurses and dieticians. Anthem reminds members about hypertension; diabetes; and breast, cervical, and colon cancer screenings. Oxford sends reminders about physical exams for teens, childhood immunizations, flu shots, mammograms, and pap smears. ConnectiCare's healthy babies program provides educational materials to pregnant women and around-the-clock telephone access to counseling by a nurse.

The Youth Suicide Advisory Board increases public awareness of youth suicide, promotes ways to prevent it, and makes related recommendations to the Department of Children and Families Commissioner. (Agency: Department of Children and Families)

A suicide-prevention training contractor conducts two training sessions in each of five regions for college age students, providers, and parents. (Agency: Department of Public Health)

State Asthma Plan. This plan calls for, among other components, (1) increasing patients' awareness of the signs, symptoms and seriousness of asthma and asthma management; (2) identifying and reducing environmental risk factors in the homes of people at risk; (3) improving indoor air quality and reducing exposure to environmental asthma triggers in schools; (4) reducing exposure to second hand smoke, outdoor air pollutants, and known occupational asthma-causing agents; (5) increasing the number of asthma patients with asthma-related insurance coverage; (6) incorporating an asthma curriculum based on National Asthma Education and Prevention Program guidelines in Connecticut institutions providing professional healthcare education. (Agency: Department of Public Health)

HMO Management Programs. Most HMOs have programs to help patients manage their asthma conditions. Programs provide educational materials, support calls from asthma specialists, and calendars to track peak flow meter readings.

The Birth-to-Three program provides diagnostic and evaluative, therapy, social work, and other services to children up to age three who (1) have a diagnosed medical condition such as Down syndrome, spina bifida, autism, blindness, and deafness that have a high probability of resulting in a developmental delay or (2) show significant delays in development such as talking or walking.    An individualized family service plan specifies the services to be provided.   (Agency: Department of Mental Retardation)

The CT Diabetes Prevention and Control Program seeks to improve care for people diagnosed with diabetes, initiate health promotion efforts in collaboration with other chronic disease programs, and reduce the burden of diabetes for Connecticut residents in high-risk racial and ethnic populations. The CT Diabetes Surveillance System provides timely and relevant information about diabetes and its complications, as well as related risk factor information. (Agency: Department of Public Health)

Most HMOs have programs to help patients with cardiovascular disease manage their conditions. Typically, they provide education on exercise and diet, telephone support, and on-line disease management tools.

The state funds HIV counseling and testing sites that (1) identify individuals with HIV infection for case management;  (2) provide knowledge and tools to individuals in order to change HIV risk behaviors;  (3) provide training and continuing education options to counselors; and (4) identify all seropositive individuals and offer spousal and partner notification services. (Agency: Department of Public Health)

In addition to their asthma, diabetes, cardiovascular disease management programs, most Connecticut HMOs have programs to help patients manage other chronic conditions such as weight, depression and low-back pain. Typically, they provide education on exercise and diet, telephone support, and on-line management tools.

RC/JLK/JK/SS: ts