Now 21, Plebanek is considering a more convenient method of birth control. Seeking advice from a gynecologist about her options, she was handed a brochure. “I felt that I wasn’t really informed about my options,” Plebanek said.

Plebanek is not alone in being proactive about her birth control options. The majority of women in their childbearing years—65% of the nation’s females ages 15 to 49—use some form of contraception, according to recent data from the Centers for Disease Control and Prevention (CDC).

Planned Parenthood of Southern New England Photo.

Amina Carter, a physician assistant and health center manager at Planned Parenthood of Southern New England, said that it’s “our job to make birth control counseling” comprehensive.

In recent years, there’s been a significant rise in the usage of some contraceptive methods and a decline in others. Female sterilization remains the most popular form of contraception, but its use has steadily declined since the 1970s. The pill remains the second most common contraceptive method, but long-acting reversible contraceptives (LARCs) are gaining traction as a close third.

Despite personal investment in their health and the birth control they choose, women don’t always receive the information they need to make smart, informed decisions.

A 2020 Kaiser Family Foundation women’s health survey reported that only four in 10 women (44%) age 18 to 49 rate their contraceptive care provider as excellent in four areas of contraceptive counseling. The study says only 36% of Black women and 38% of Hispanic women received excellent counseling, compared with 49% of white women. And, low-income and uninsured women were less likely to say that they received excellent care.

The contraceptive counseling areas included: respecting them as a person, letting them say what mattered, taking their preferences about birth control seriously, and giving them enough information to make an informed decision.

Dr. Aileen Gariepy,  associate professor of OB/GYN & Reproductive Services at Yale School of Medicine, is seeing patients grow more interested in what’s going into their bodies. “Over the last five years, there does seem to be increased interest in non-hormonal contraception on the part of patients,” she said.

Kikelomo Otuyelu-Garritano, the sole obstetrician and gynecologist at HER Wellness Health Center in Wilton, agrees but says this desire to be proactive doesn’t always translate to being better informed. “They hear about a friend who went on the pill and gained 30 pounds. They don’t necessarily dig any deeper,” she said. “They hear: If you’re going on birth control, you’re going to gain weight.”

New birth control products that capitalize on a trending interest in hormone-free options include FDA-approved Phexxi®. The first non-hormonal prescription contraceptive vaginal gel works as a barrier and alters the pH of the vagina, immobilizing sperm.

Advertisements for Phexxi emphasize that it is hormone-free. The hormone estrogen, found in certain birth control pills, is known to increase the chance of stroke among users with pre-existing risk factors that include elevated blood pressure, previous thrombotic events, smoking, a history of migraines with aura, and advanced age.

Dr. Aileen Gariepy

“I think Phexxi is a game-changer because it works with the vaginal pH, works with sperm, and is non-hormonal,” Gariepy said. But she acknowledges that there are tradeoffs. For example, a multisite study found Phexxi to be 86% effective at preventing pregnancy when used regularly, compared with the pill’s about 93% effectiveness when used correctly. Also, Phexxi doesn’t allow women to be spontaneous, as it must be applied with an applicator up to an hour before intercourse.

Direct-to-consumer advertising of birth control options like Phexxi doesn’t replace accurate and unbiased information from a health care provider.

Risk Factors, Patient Counseling

Mark Alberts, physician-in-chief of the Hartford HealthCare Neuroscience Institute and chief of neurology at Hartford Hospital, sees plenty of stroke patients. And, he says, many patients are surprised to find after suffering a stroke that they were at increased risk. “Oftentimes, the comment is: I had no idea, or nobody told me about risk factors,” Alberts said.

Fortunately, Alberts says, the amount of estrogen used in birth control pills has steadily declined over the years. “As the doses of these compounds have decreased, the risk of stroke has also decreased,” he said. Nevertheless, women whose health behaviors or medical history raise their risk for stroke would be well-advised to avoid estrogen-containing birth control pills.

But research indicates that medical practitioners don’t always offer this advice. In a recent study of oral contraceptive use among women, only 15% of users with one or more stroke risk factors recalled being advised not to start oral contraceptives; 36% recalled a health care provider recommending that they stop.

“It’s our job to make sure that patient counseling is really comprehensive. Historically, we think of birth control as the pill. But that doesn’t mean it’s the best option,” said Amina Carter, a physician assistant and health center manager at Planned Parenthood of Southern New England. “Sometimes, it’s just a matter of education.”

As birth control options become more accessible, thanks largely to the birth control mandate signed into law by President Obama as part of the Affordable Care Act (ACA), patient education becomes increasingly critical. The act allows more women to choose convenience-oriented options like IUDs, a long-acting reversible contraception (LARC) that provides years-long protection with little investment in time, thought or money.

“It’s ‘set it and forget it,’” Carter said. “It doesn’t require any thought after the initial appointment.”

Dr. Kikelomo Otuyelu-Garritano

But becoming fully informed and prepared to decide to use a LARC or another form of birth control does require thought, and it is most helpful when health care practitioners provide guidance. The ACA even included a provision specifically for counseling and services related to birth control. The health care system, however, doesn’t always allow or encourage sufficient time for such guidance.

Otuyelu-Garritano knows this all too well. She quit medicine three times before finally opening her own practice, which allows her the time she feels is necessary to provide her patients with thorough exams and health information. Otuyelu-Garritano says patients are most likely to find the birth control that’s right for them when they have a health care provider willing to consider the options from various perspectives.

“You have to look at things from all angles,” she said. “The only way that’s going to happen is if there’s time [during the medical visit] to talk.”

It’s the lowest number of hospitals penalized since the program began leveling funding cuts in 2015, data from the Centers for Medicare & Medicaid Services (CMS) show.

The hospitals are among 774 nationwide that will lose funding under the Hospital-Acquired Conditions Reduction Program, according to a Kaiser Health News analysis. The program was created by the Affordable Care Act.

When assessing hospitals, the government examines how many infections and other potentially avoidable complications patients suffered – things like blood clots, sepsis, bedsores and hip fractures. The most recent penalties are based on patients who were hospitalized between mid-2017 and 2019, prior to the COVID-19 pandemic.

Hospitals fared better this year than in any other year of the program. Last year, 14 Connecticut hospitals were penalized; and at least that many had been penalized in every year since 2015.

THOCC.org Photo

The Hospital Central Connecticut is one of only 6 CT hospitals to be financially penalized.

Hospitals statewide have been committed to reducing the number of infections and injuries in recent years, said Dr. Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association.

Over the past years, hospitals have implemented various, ongoing “high reliability” standards. In addition, about three years ago, a Mutual Accountability Collaborative launched that brings together senior executives from every Connecticut hospital in an effort to eliminate hospital-acquired conditions, Cooper said.

“We’re starting to see the results of some of these efforts,” she said, noting hospitals are continually sharing best practices and working together – not competing with each other – on improving the quality of care.

“Everything we do in the hospitals is a team effort,” she said. “It can’t just be one individual; it has to be everybody who is working on things to make sure the patient is safe, to make sure the patient outcome is as good as possible. We really think that’s what’s contributed to a culture change.”

Dr. Mary Cooper

Hospitals also seek feedback from patients and their family members, who serve on advisory councils and, increasingly, are part of problem-solving discussions, Cooper added.

The six hospitals losing 1% of their Medicare reimbursements are: Bridgeport Hospital, Lawrence + Memorial Hospital in New London, Midstate Medical Center in Meriden, Hospital of Central Connecticut in New Britain, Waterbury Hospital, and Windham Community Memorial Hospital in Willimantic.

The lower number of hospitals being penalized is “a very good indication that the system works,” said Lisa Freeman, executive director of the Connecticut Center for Patient Safety. “The transparency that’s demanded by the system works. It’s necessary to have some kind of consequence that’s meaningful to the hospitals, to prioritize the focus and improvement in this area.”

It remains to be seen how much the penalties will cost each hospital, since dollar amounts depend on the volume of Medicare claims each will submit to the government through the end of the current fiscal year, which runs through September.

Four hospitals have never been penalized under the program. They are: Bristol Hospital, Hebrew Home and Hospital in West Hartford, Sharon Hospital, and William W. Backus Hospital in Norwich. Seven hospitals statewide are exempt from the program, including ones that only serve children, veterans or psychiatric patients.

Hospital-acquired injuries and conditions “are usually the result of multiple things that have to go wrong,” rather than a single error made by just one person, noted Freeman.

“With health care, we always have to focus on improvement, and improvement always brings about better health care results,” Freeman said. “Every one of the things that this program works on, with proper support and proper training and proper care, just shouldn’t happen. It’s an unnecessary, bad experience – and potentially life-threatening experience – for any patient to have, when it didn’t have to happen.”

Statewide, 25 of the hospitals evaluated – or 89% – will have reimbursements reduced, to varying degrees, in the 2021 fiscal year that started Oct. 1, according to a Kaiser Health News analysis of CMS data.

Nationwide, almost half of hospitals, or 2,545 of them, will have their Medicare reimbursements cut, according to Kaiser Health News. The latest penalties were calculated using data from June 2016 through June 2019, meaning the influx of patients to hospitals seen amid the pandemic didn’t factor in.

iStock Photo.

Twenty-five hospitals are being penalized for high rates of patients who are readmitted within one month of discharge.

CMS has been imposing reimbursement reductions since the 2013 fiscal year, to penalize hospitals that have high rates of patients who are readmitted within one month of being discharged. The penalties were enacted under the Affordable Care Act.

This year’s penalties come as many hospitals already face financial hardship from the pandemic.

“We’re not really sure why they (CMS) chose to still go through with the readmission criteria,” said Dr. Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association (CHA). Levying penalties at this time “feels insensitive” as hospitals continue to be front-line responders to the COVID-19 crisis, she said.

But hospitals continuously are working to improve readmissions rates, Cooper said.

“We always want to make it better,” she said.

In partnership with Unite Us and United Way’s 2-1-1 information line, the hospital association this year began rolling out programs that connect hospitals with community-based organizations, with the goal of improving care coordination, Cooper said. Hospitals are being given tools that help them assess “other factors that may be affecting their [patients’] health outcomes,” she said, such as social, economic and genetic factors.

The program makes it easier to refer patients to organizations such as food pantries, housing agencies, transportation authorities and other services that can affect patients’ health outcomes once they leave the hospital, Cooper said. Those agencies also can report back to the hospitals.

“This year, more than ever, there’s been such a need for [coordinated care]. The hospitals were just so happy to implement that; we have tremendous buy-in. We’ve never had access to that kind of closed-loop referral before.”

— Dr. Mary Cooper

So far, about one third of hospitals statewide are part of the program, and it is slated to be implemented at all hospitals by the end of 2021, Cooper said. These efforts, though, likely won’t be reflected in readmissions data for a few years, she added.

This year, no Connecticut hospitals received the maximum penalty rate of 3%, but three will lose more than 2% of their Medicare reimbursements. They are: Manchester Memorial Hospital, at 2.89%; Bridgeport Hospital, at 2.62%; and Rockville General Hospital, at 2.02%.

Most hospitals in the state – 20 of them – are losing less than 1% of their reimbursements. They include: Danbury Hospital at 0.39%, Norwalk Hospital at 0.92%, Greenwich Hospital at 0.79%, St. Vincent’s Medical Center in Bridgeport at 0.72%, Griffin Hospital in Derby at 0.33%, Middlesex Hospital at 0.88%, and Charlotte Hungerford Hospital in Torrington at 0.36%.

Stamford Hospital, which for two years in a row was not penalized, will see a 0.07% reduction.

Among the state’s largest hospitals, Hartford Hospital is losing 0.90% of its reimbursement, Yale New Haven Hospital, 0.70% and St. Francis Hospital and Medical Center, 0.50%.

Three hospitals received no penalty: Hebrew Home and Hospital Inc. in West Hartford, Masonicare Health Center in Wallingford, and Sharon Hospital.

Since the program’s inception, most Connecticut hospitals have gotten penalties each year.

“It always concerns me when we have a situation where it’s same story, different year; and that’s what’s we’re having here,” said Lisa Freeman, executive director of the Connecticut Center for Patient Safety.

That shows, she said, that the penalties aren’t having the intended effect of reducing admissions in a meaningful way. Many hospitals are likely just budgeting the penalties into their cost of doing business, she said.

Some hospitals are making strides, but others have a long way to go, Freeman said. A big part of the problem, she said, is poor coordination of care once patients leave the hospital. Ensuring patients have access to doctors for follow-up visits, can get to a pharmacy to fill prescriptions, and are connected to other services they need, for instance, should be considered upon discharge, she said.

“It really does concern me. It’s something that we absolutely have to attend to. Right now, the system is not set up to support the kind of coordination that’s needed. We’re just not thinking the process through, and therefore we’re setting it up to fail.”

— Lisa Freeman

Eight Connecticut hospitals are exempt from the program. They are: Connecticut Children’s Medical Center in Hartford, Connecticut Valley Hospital in Middletown, Natchaug Hospital in Mansfield, Connecticut Mental Health Center in New Haven, Southwest Connecticut Mental Health in Bridgeport, Silver Hill Hospital Inc. in New Canaan, the Connecticut Hospice Inc. in Branford, and Albert J. Solnit Children’s Center in Middletown.

Thanks to the ACA, the law known as Obamacare, a provision allows young adults to remain on their parents’ health insurance policies until age 26. Dinh, of South Windsor, is covered on her mother’s policy.

“If I lost coverage under my parents, I would not know what to do,” Dinh said. “Chances are I would have to handle medical expenses out of pocket, which would definitely cause a financial strain and make me hesitant to go to the doctor’s unless it is a dire emergency.”

“I am also worried about COVID because the risks are too high under current circumstances to be uninsured,” said Dinh. She’s one of  2.3 million young adults who gained coverage through their parents’ plans under the ACA, according to a Kaiser Family Foundation analysis.

Vyanne Dinh, 21, is a senior at New York University, has health insurance through her mother’s plan.

Striking down Obamacare would have a large-scale impact on the country’s health care system and the lives of millions of people who have gained health insurance coverage through the exchanges and the expansion of Medicaid.  One of the most-popular provisions – protecting people with pre-existing medical conditions – would be eliminated along with coverage for many essential benefits.

The stakes for keeping Obamacare in place are even higher now with the addition of Justice Amy Coney Barrett to the high court, a conservative who could provide the vote needed to overturn it.

“The effects of the Affordable Care Act impacted many parts of the health care system,” said Tiffany Donelson, president and CEO of the Connecticut Health Foundation. “It’s going to be extremely difficult to just patch up a new law if this were overturned. It took years for the Obama administration to work on this. This is one of the things that [people] need to realize. We all gained from the Affordable Care Act.”

Roughly 300,000 people in Connecticut have insurance, in one way or another, thanks to the ACA, Donelson said.

“Our uninsured rates are going to skyrocket, undoubtedly, in our state, if we overturn the ACA at the federal level.” 

— Tiffany Donelson

Everyone benefits when all people can access insurance, said Angela Mattie, professor of management and medical sciences at Quinnipiac University’s Frank H. Netter M.D. School of Medicine.

What’s at stake at the Nov. 10 hearing before the Supreme Court “is extremely significant to our entire population. It’s even more tragic that it’s all under the umbrella of a pandemic,” Mattie said.

Medicaid Expansion

“[Many] people don’t realize that the Affordable Care Act also provided for the expansion of Medicaid,” said Mattie.

In 2010, Connecticut became the first state to expand Medicaid, and Mattie said providing coverage to the most vulnerable populations is more cost-effective than letting them go uninsured in the long run.

“We know that when people don’t have medical coverage, they delay care and end up sicker. And they end up eventually seeking care, because it’s life-threatening, and they end up in a health care facility without any form of payment and we, as a society, end up paying for that,” Mattie said.

As of June 2019, there were 276,885 people in Connecticut who enrolled in Medicaid since 2010, according to the Kaiser Family Foundation. Of those, 243,618 were newly eligible specifically due to the expansion, according to state-level data. Nationwide, about 12 million people in 33 states and in Washington, D.C. became eligible for Medicaid under the expansion, through June 2019.

“Community-based organizations, the ones working with people day in and day out, are extremely concerned,” said Donelson, including federally qualified health centers that serve many on Medicaid. “This is really coming to a head, that there is a good chance the ACA could be overturned, and there is no confidence that there’s a replacement.”

Health Insurance Exchange

Connecticut is one of 15 states that has its own fully run health insurance exchange, Access Health Connecticut (AHCT), which is preparing to launch its eighth open enrollment on Nov. 1.

There are 103,955 Connecticut residents enrolled in plans through AHCT, according to the Kaiser Family Foundation. Of those, 72,767 (70%) receive the Advance Premium Tax Credit, which lets individuals lower their monthly insurance premiums; and 35,304 (34%) receive a cost-sharing reduction that lowers deductibles, copayments and coinsurance.

Enrollment in qualified health plans through Access Health CT is up about 5% from a year ago; enrollment in Medicaid through the exchange is up about 10%, according to Marketing Director Andrea Ravitz.

“This is where we work harder to raise awareness,” she said. “Our mission continues to be to reduce the number of uninsured in Connecticut.”

Nationwide, 10.7 million people were enrolled in insurance through an ACA-created marketplace as of February 2020, according to Kaiser Family Foundation.

Medicare Part D

The ACA closed the coverage gap, known as the donut hole, in Medicare Part D. Prior to the legislation, seniors’ prescription drug coverage dropped off once they hit a certain yearly dollar amount, then kicked back in later.

Without the protection offered by the ACA, seniors could see prescription costs skyrocket, Mattie said.

“When you have to start paying out of pocket and you’re on a fixed income – and these drugs are expensive – you have to start making decisions.”

— Angela Mattie

Some seniors may forego prescriptions, in order to afford rent or food, which can lead to health issues, she added.

Preventive Care

Nationwide, about 150 million people are enrolled in employer insurance plans or individual market insurance plans that must provide free preventive care services, such as annual wellness exams, cancer screenings, and vaccinations under the ACA, according to Kaiser Family Foundation.

“Payment for these types of services will go away” if it’s overturned, said Mattie. “If you decrease the amount of screening, you increase the amount of morbidity and mortality.”

“When people are connected to primary care, overall, they are healthier, because they are getting the consistent care that they need,” said Donelson.

For those who don’t have a qualifying event for special enrollment—such as getting married, giving birth or adopting a child—open enrollment for 2021 health insurance plans begins Nov. 1 and runs through Dec. 15.

Consumers can begin “window shopping” and comparing plans on Oct. 26 but can’t enroll or re-enroll in coverage until Nov. 1. Open enrollment is for coverage that begins Jan. 1.

As job cuts continue to mount in the state amid the COVID-19 pandemic, anyone who loses employer-backed insurance coverage qualifies for special enrollment and has 60 days from the time of their job loss to enroll in a plan offered through the marketplace.

“If 2020 has taught us anything, it’s that having and keeping and using health insurance is incredibly important,” said Andrea Ravitz, AHCT’s marketing director. AHCT is closely monitoring reports of layoffs and contacting affected workers as quickly as possible, she said.

“A lot of individuals don’t know that we even exist,” Ravitz said. She said many workers have long held insurance policies through their employers and haven’t needed to secure coverage on their own until now.

To reach a licensed broker to discuss health insurance options call 855-805-4325.

This will be the eighth open enrollment for AHCT, which is the insurance marketplace created by the Affordable Care Act.

For 2021, the exchange will again offer plans from Anthem and ConnectiCare. Earlier this fall, the state Insurance Department reduced the rate increases each company sought. The average rate increase for Anthem plans will be 1.9%, while ConnectiCare customers will see an average rate decrease of 0.1%.

But consumers should not choose plans based solely on premium price tags, Ravitz said.

“Even if you’re experiencing a decrease in your rate, it doesn’t mean that you’re in the right plan,” she said. The “Compare Plans” tool at accesshealthct.com lets consumers view plans while considering their specific doctors, prescription drugs costs and medical habits, giving them a clearer picture of how much each plan will cost them out of pocket.

Currently, nearly 100,000 people are enrolled in qualified health plans through AHCT, up about 5% from a year ago, and about 700,000 are enrolled in Medicaid plans through the exchange, up roughly 10% from a year ago, according to Ravitz.

In the early days of the pandemic, the state and AHCT announced in March a new special enrollment period during which anyone uninsured could enroll in coverage. That period ran from March 19 through April 2 for coverage that began April 1. Around that time—between March 19 and April 17—5,629 people enrolled in qualified health plans and 26,773 individuals enrolled in Medicaid or Children’s Health Insurance Plan (CHIP), according to AHCT.

More than 90% of people who purchased plans through the exchange qualify for financial help or price reductions, she said.

As usual, AHCT will offer consumers multiple ways to connect with licensed brokers who can help them understand plan options: online at accesshealthct.com, by phone at 855-805-4325 and in person.

Six enrollment centers will be open for in-person appointments. Reservations will be required at the sites, which will follow strict COVID safety guidelines, and walk-ins will not be allowed.  Individuals who schedule appointments will be contacted by AHCT before their appointment to ensure they have all necessary documents and information they will need to complete their enrollment at their meeting, Ravitz said.

Enrollment centers will be located at Project Access, 63 York St., New Haven; and Community Renewal Team, 330 Market St., Hartford. Others will be in Bridgeport, Stamford, New Britain and Groton.

AHCT also will hold multiple virtual enrollment fairs this year. During those events, if enrollees want, customer service representatives will walk them through the enrollment process through a screen-sharing feature that allows the AHCT representative and consumer to view forms simultaneously.

While most people must wait until Nov. 1 to enroll in plans, enrollment in Medicaid HUSKY and CHIP is open year-round to eligible individuals and families.

For information on health insurance, you can sign up for a healthy chat scheduled for the following days: Nov. 12, 6-7 p.m. in Spanish only; Nov. 18, 3-4 p.m. or Nov. 19, 6-7 p.m.

Yale Cancer Center researchers analyzed more than 30,000 health records and found that, prior to Medicaid expansion, black adults with advanced or metastatic cancer were 4.8 percentage points less likely than white adults to begin treatments within 30 days of being diagnosed. But in states where Medicaid was expanded, in 2014 or later, the percentage of black patients getting timely treatment rose from 43.5 percent to 49.6 percent.

There also was a small improvement in expansion states among white patients receiving timely treatment – from 48.3 percent to 50.3 percent – bringing the post-expansion difference between the two racial groups to less than one percentage point.

“Our results suggest that Medicaid expansion led to improved health equity,” said study author Amy Davidoff, a senior research scientist at Yale School of Public Health and in Yale Cancer Center’s Cancer Outcomes, Public Policy, and Effectiveness Research Center (COPPER).

Having access to insurance can significantly impact outcomes in cancer patients, she said.

“It’s huge,” she said. “It really starts out with access to screening; just having any insurance coverage is really important in access to screening. Having insurance really dramatically opens that door.”

Often, cancer is diagnosed only after a patient presents with symptoms to a primary care doctor, she added, and having insurance increases the likelihood patients have a primary physician they see regularly. Insurance also helps gain access to specialists, Davidoff said.

Yale School of Public Health Photo.

Amy Davidoff, researcher.

Davidoff and Dr. Cary Gross, director of COPPER, led the research in partnership with Flatiron Health, a New York City-based electronic health record company that provided the data, funded the study and was the impetus for the research. The company specializes in software and services for oncology providers.

Researchers examined 30,386 anonymous electronic health records dated from 2011 to 2019 from Flatiron Health’s database. The analysis looked at timely treatment, provided within 30 days of diagnosis, for eight advanced or metastatic cancer types.

While the study suggests that Medicaid expansion eliminated the racial disparity in timely cancer treatments, it doesn’t prove it, said Davidoff.

“I see this as contributing to our understanding of how the ACA might be affecting the process of cancer care, and how it might affect disparities in that care,” she said. The study was the first of its kind to take a “deep dive” into the process of cancer treatment and disparities therein, she added. It examined the disparity between white and black patients because those groups had the largest sample sizes in the data provided.

“I was actually surprised at how big the effect was,” Davidoff said of the results. “The fact that we saw this pretty huge effect was exciting but surprising.”

In 2010, Connecticut was the first state in the nation to expand Medicaid. The option, available under the ACA, allows states to extend coverage to anyone living in a household where the income is below 138 percent of the federal poverty level. The federal poverty level for a family of four this year is household income of $25,750.

Nationwide 35 other states and Washington, D.C. have expanded Medicaid under the ACA; 14 states have not.

While the patients in this study would need to be tracked over time to see what their outcomes ultimately are, the research is encouraging, said Patricia Baker, president and CEO of the Connecticut Health Foundation.

“It is not surprising that research found that coverage made a difference,” said Baker. “With coverage they were able to access care in a timely manner. This is what many of us hoped coverage would bring with it – not the cure-all for racial disparity, but to give greater opportunity for people to optimize their health.”

The hospitals are among 800 nationwide being penalized – the highest number since the federal Hospital Acquired Conditions Reduction Program started five years ago, according to a Kaiser Health News (KHN) analysis of the CMS data. The penalties will be levied during the current fiscal year, which began in October 2018 and runs through September.

Under the program, which was created by the Affordable Care Act, the government levies penalties based on hospitals’ rates of infection related to colon surgeries, hysterectomies, urinary tract catheters and central lines inserted into veins.  It also reviews infection rates for Methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, known as C. diff, as well as rates of blood clots, sepsis, post-surgery wounds, bedsores and hip fractures, among other injuries.

Photo by CT Post

Bridgeport Hospital has been penalized in all five years of the program.

The Connecticut hospitals losing 1 percent of their reimbursements are: Bridgeport Hospital, Charlotte Hungerford Hospital in Torrington, The Connecticut Hospice Inc. in Branford, Greenwich Hospital, Griffin Hospital in Derby,  Hartford Hospital, The Hospital of Central Connecticut in New Britain, UConn John Dempsey Hospital in Farmington, Masonicare Health Center in Wallingford, MidState Medical Center in Meriden, Rockville General Hospital, St. Vincent’s Medical Center in Bridgeport, Stamford Hospital, Waterbury Hospital, and Windham Community Memorial Hospital & Hatch Hospital in Willimantic.

A growing number of Connecticut hospitals, through enacting “high reliability” standards, are making improvements to reduce preventable infections and conditions, said Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association. The high reliability initiative, which is being embraced by hospitals throughout the state, is intended to reduce instances of preventable patient harm.

Increasingly, hospital staff are looking at ways to reduce infections and conditions and, when they do occur, staff are discussing why they happened and what can be done to prevent them in the future, Cooper said.

“Everybody is working on this. Nobody wants infections, nobody wants complications,” she said. “The work is paying off in many of our hospitals. I am hopeful that this is the beginning of the trend that we’ve been waiting for, with all this work that people have been putting in.”

Fifteen hospitals received penalties under the program last year as well.

This was the first year Griffin Hospital and St. Vincent’s were penalized under the program. Five hospitals have been penalized in all five years of the program: Bridgeport Hospital, The Connecticut Hospice Inc., Hartford Hospital, UConn John Dempsey Hospital and Windham Community Memorial Hospital & Hatch Hospital.

It’s unclear how much the penalties will cost each hospital, since the dollar amounts are tied to the Medicare claims each will submit to the government through the end of the fiscal year.

Hospital leaders and staff seem to be making a more concerted effort to improve – but as long as facility-acquired conditions persist, more needs to be done, said Lisa Freeman, executive director of the Connecticut Center for Patient Safety.

UConn John Dempsey Hospital has been penalized by Medicare since the program began.

“It’s a concern,” Freeman said. “The good news is the hospitals are finally aware that they have to work hard to bring these rates down. They’re not sure if they’re going to reach zero, but they’re really trying to get as close as possible to zero. The effort has become more genuine and more realistic.”

“I am pleased with some of the results that we’re seeing. That being said, it’s always that relative performance,” Cooper said. “If other hospitals around the country improve faster [than Connecticut ones], you’ll see us back on the penalty list.”

Both Cooper and Freeman were pleased to see two of the state’s largest hospitals, St. Francis Hospital and Medical Center and Yale New Haven Hospital, were not penalized under the program this year.

Their strategies should be looked at by smaller hospitals, Freeman said, for insights about how to improve.

To reduce hospital-acquired conditions, Connecticut hospitals need to bolster communication and ensure that standards of care are in place and being followed, Freeman said.

“We still have work to do, but the numbers that are getting better show that they can improve,” she said.

Hospitals can face other fines as well. CMS announced in October that 27 of Connecticut’s 29 hospitals are being penalized this fiscal year with Medicare reimbursement reductions – of varying amounts – for having high rates of patients who were readmitted within a month of being discharged.

Payments for meals, travel and gifts also increased from $3.2 million in 2016 to $3.5 million in 2017, data from the Centers for Medicare & Medicaid Services show.

Of the total $27.2 million in payments, $4.37 million – or 16 percent – went to 10 doctors holding licenses in Connecticut.

The highest paid doctor was Dr. Paul Sethi, an orthopedic surgeon in Greenwich, who accepted slightly more than $1 million in 2017 in royalty fees, consulting work, and other services from several companies, including Arthrex Inc., and Pacira Pharmaceuticals Inc., maker of Exparel. The drug, Exparel, is marketed as an alternative to opioid painkillers post-surgery. Sethi frequently takes to Twitter to promote the use of a non-opioid alternative and is listed on the Pacira website in a case study. He did not respond to C-HIT’s request for an interview.

Dr. Robert Alpern, dean of the Yale School of Medicine, received $524,611 for his work as a director on the boards of Abbott Laboratories and AbbVie Inc. Alpern said that he does not provide paid lectures, does not speak for the pharmaceutical companies, does not see patients or write prescriptions, and that his work on the boards is “fully disclosed to Yale University and Yale New Haven Hospital.”

“I recuse myself from any decisions related to either of these companies,” Alpern said.

The financial relationships between pharmaceutical and medical device companies and doctors, as well as teaching hospitals, have been disclosed since 2013, under the Affordable Care Act. The law is intended to provide transparency into the business connections between health care providers and the industry.

The law is also driving some doctors—like infectious diseases specialist Dr. Roger Echols of Easton—to give up their license to practice medicine. “It’s why I did not revive mine last year,” he said, referring to 2016.

Echols was paid $526,881 in 2017 for his work as a consultant primarily for Japan-headquartered Shionogi & Co., best known as the maker of the cholesterol drug Crestor. Echols said he stopped seeing patients and prescribing medication years ago, when he transitioned to the pharmaceutical industry.

Even practicing doctors, Echols said, are now declining payment when they meet with him to discuss drug research. “They’ve gone so far that they won’t even allow us to provide a bagel or a cup of coffee at a meeting because that has to be reported.”

Overall, non-research payments to Connecticut doctors fell 8 percent from $29.7 million in 2016 to $27.2 million in 2017, the data show. Much of the decline occurred in royalty and license fees on sales of drugs and medical devices, charitable contributions, and ownership or investments in companies.

In research payments to Connecticut doctors, pharma and medical device companies paid $901,196 in 2017, down from $1.1 million in 2016, according to the data.

Nationally in 2017, doctors were paid $2.82 billion by 1,525 pharma and medical devices companies. Research payments totaled $4.66 billion.

Dual Role Of Doctors

The dual role of doctors as providers of health care to patients and marketers for drug and medical device companies has been scrutinized for several years and has been the subject of extensive research.

One report, published in a medical cancer journal that examined several studies concluded, “All the money and attention drug representatives shower on doctors has its intended effect: building relationships with doctors and ultimately changing how they prescribe.”

A study published in October 2017 by the U.S. Library of Medicine, National Institutes of Health; found that gifts from pharmaceutical companies result in higher drug costs: “More prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions.”

“There is strong evidence that pharma payments are associated with higher prescribing of the promoted medications, and with higher costs,” said Ellen Andrews, executive director of the Connecticut Health Policy Project.

Dr. Bruce E. Strober, a professor of dermatology at UConn Health, said, “Nearly all my colleagues—anybody who is a specialist in the field—do speak for drug companies, and I am compensated for my time, yes. Unequivocally, it does not alter my prescribing habits.”

Strober received $174,279 in 2017 primarily in consulting fees from Eli Lilly and Co., Bristol-Myers Squibb Co., Sanofi Genzyme, Novartis Pharma AG and Amgen Inc., among others. In 2016, the latest year on record, Strober made out 61 prescriptions for Amgen’s Enbrel amounting to $239,996, according to a C-HIT analysis of Medicare Part D data.  The same year, Amgen paid him $17,000.

Many doctors see their role as merely educating their peers, and being compensated for their time and expertise.

Dr. Mark Milner, an ophthalmologist in Hamden, received $186,125 in 2017 primarily in consulting and speaking fees from pharma companies specializing in dry eye, including Allergan Inc., maker of the blockbuster drug Restasis.

“There is nothing unethical if I am paid for my time. I give a comprehensive dry eye lecture whether I’m sponsored by Allergan, or Shire [North] or Bausch [formerly Valeant],” Milner said.

Dr. Steven Thornquist, a Waterbury-based ophthalmologist and former president of the Connecticut State Medical Society (CSMS), said, “The onus is on the individual physician to be ethical. I don’t think patients should give their doctor the third degree.”

It’s a fine line. Dr. Claudia Gruss, CSMS president, said physicians should decline a cash gift. “At the same time, there are certain physician experts that other physicians look up to, and educational events allow a very frank interchange between physicians in the field. We don’t want to decrease productive collaboration.” In 2017, Gruss received $120.94 in the general category – the category includes food and beverage at medical conferences.

Dr. Niranjan Sankaranarayanan, a nephrologist in Bloomfield, does not accept money for consulting and speaking engagements from pharma companies, though he did earlier in his career. “I was naïve. They invited me to talk about a medication that I was already prescribing, but after one or two talks, I didn’t feel comfortable,” he said. “This is a gray zone. They entice you with more and more, and there is no ceiling to this,” Sankaranarayanan said.  He received $201.60 in general category in 2017.

Medical ethicists say the public must know that their physicians very often have complex interests. “Medicare has databases but more research needs to be done on incentives ad kickbacks,” said Dr. Howard Forman, a Yale professor of diagnostic radiology, economics and public health, who often speaks about medical ethics.

“We have to prove cause-causation rather than correlation. It’s pernicious how the money flows,” said Forman.

Marie K. Shanahan designed the graphics for this report.

Open enrollment for health plans effective Jan. 1, 2019, will run from Nov. 1 to Dec. 15, giving consumers the least amount of time to enroll in or renew plans since the Affordable Care Act (ACA) became law. Last year, consumers had an additional week.

As a result, Access Health CT (AHCT), Connecticut’s health insurance exchange, is broadening its outreach and marketing efforts and, for the first time, giving consumers a sneak peek at plans.

“A lot of people want to see what options they have ahead of open enrollment,” said AHCT Marketing Director Andrea Ravitz. “Every year, we need to remind individuals that they have choices. We want to make sure they have access to as much information as possible to pick the right plan.”

This year’s marketplace offers plans from ConnectiCare and Anthem. Open enrollment is Nov. 1-Dec. 15.

Consumers can browse plans starting today using a special tool at accesshealthct.com. In addition, AHCT is holding a series of events across the state and offering phone, online and in-person assistance to help individuals choose a plan.

The average ACA monthly premium cost was $689 this year, but for 75 percent of enrollees the average subsidy was $600, according to a report from the Centers for Medicare & Medicaid Services.

The marketplace has two insurance carriers, ConnectiCare and Anthem. Many plans offered for 2019 under both carriers will cost more, but in September state regulators drastically reduced the rate hikes both carriers had sought.

Anthem had proposed a 9.1 percent rate increase for 2019 plans, but regulators approved an average premium increase of 2.7 percent. ConnectiCare had sought a 13 percent increase, which was pared down to an average increase of 4 percent.

As in the past, plans are organized into bronze, silver, gold and platinum categories, and consumers should compare plans to see what works best for them. Platinum plans, for instance, typically have higher premiums but lower out-of-pocket costs, whereas bronze plans have the lowest premiums but highest out-of-pocket costs.

No ‘Opt Out’ Fines

One big change consumers will notice for 2019: There will be no financial penalty for opting not to buy insurance.

In previous years, most consumers had to have insurance or face a fine. Those who had no insurance in 2018 will pay either 2.5 percent of their yearly household income or $695 per person ($347.50 per child), whichever is higher, when they file their 2018 tax returns in early 2019.

Ravitz said AHCT conducted focused groups with about 60 individuals to gauge whether the absence of a penalty would impact enrollment trends for 2019.

“The majority said, with or without the tax penalty, it wouldn’t affect their decision,” she said.

The Marketplace

AHCT is the online marketplace created by the ACA, sweeping health care reform legislation that requires most Americans to have health insurance.

During open enrollment, people without coverage can shop for insurance plans and those with coverage can renew or change their plans.

Ravitz said it is too soon to predict how many people will enroll in plans through the exchange this year, but 114,134 did last year, up more than 2 percent from the previous year. Of those, most—about 73 percent—enrolled in plans offered by ConnectiCare.

Various improvements have been made to AHCT’s website, including enhanced live chat capabilities and a new “Compare Plans” link that will let consumers see various plans’ physician networks, prescription coverage, out-of-pocket expenses and other benefits, Ravitz said.

“This is going to allow people to make better, more informed choices,” she said of the comparison tool. While monthly premium costs often play major roles in which plans consumers choose, she added, “We want to make sure people are able to make better decisions rather than just looking at the price tag.”

After open enrollment ends on Dec. 15, consumers can sign up for 2019 coverage only if they have a qualifying life event, such as loss of insurance, marriage or the birth of a child. New this year, pregnancy is now a qualifying life event.

Consumers can apply online, call AHCT at 855-805-4325, get in-person help, or use AHCT’s free mobile app for smartphones or tablets.

While most people have to wait until Nov.1 to enroll in plans, enrollment in Medicaid HUSKY and the Children’s Health Insurance Plan (CHIP) is open year-round to eligible people and families.

AHCT, now in its sixth year, also will open seven enrollment centers statewide in early November where people can receive in-person help, and will host six enrollment fairs. In addition, it will host a traveling series of educational discussions called “Healthy Chats,” during which experts will speak to groups of people about enrollment options as well as answer questions.

Usually, some people—about 15 percent of those who enroll in plans through AHCT—have trouble verifying the income or citizenship information they must submit once the open enrollment period ends, Ravitz said. AHCT is increasing efforts to reach and help those people too, she added.

Connecticut was ranked 50th in 2015 for teen birth rates, age 15 to 19, reports the U.S. Department of Health & Human Services.

Pregnancy rates for teens have been declining for decades, and have gone down 75 percent from 1991 to 2015. Recently, from 2014 to 2015, the teen pregnancy rate dropped 13 percent.

The cause of this sharp decline in teen birth rates could be attributed to a number of things. Rosemary Richter, coordinator of Teen Pregnancy Prevention at UConn Health, said the Teen Pregnancy Prevention Initiative sponsored by the state Department of Social Services, is somewhat responsible even though it is impossible to prove the exact cause of the decrease.

Madeleine Lefranc

Richter, who is also the Community Health Program supervisor at UConn Health, said this is because “TPPI targets Connecticut communities with the largest proportion of teens who are at increased risk for early parenthood and furthermore utilizes only ‘best practices’ that are science-based approaches to avoid adolescent childbearing.”

She said low-income teens and those who have problems in school or drop out are more at risk of getting pregnant. “Poverty is the single best predictor of teens becoming parents,” Richter said. “There are definitely communities in Connecticut where the incidences of births to teens greatly exceed the statewide average in Connecticut. All of the communities that are plagued by these higher incidences of too-early parenting are communities with more people living at or under the federal poverty level.”

Richter added that diminished access to health care can lead to higher teen pregnancy rates, saying a “lack of access to birth control most definitely increases the incidence of teen pregnancy. Lack of access to abortion increases the likelihood that a teen pregnancy will lead to a birth to a teenage mother.”

Richter said that if the Affordable Care Act is repealed, as promised by the administration of President Donald J. Trump, contraception and abortion will likely follow, leading to “a considerable upswing in births to teen mothers in Connecticut and across the United States.”

Access to proper health care services has been an important factor in decreasing the teenage pregnancy rate, she said.

But Richter said although contraceptives are helpful, “if a teen is not consistently motivated to avoid pregnancy, the risk is still very high.”

Merely providing contraceptives is not the solution; educating and motivating teens is important, she said.

Sex education is also important to reducing teen pregnancy and is a part of the state prevention program. “Teens in our programs, when tested on their knowledge about contraception and sexuality in a pre- and post-test, their knowledge increases are statistically significant,” Richter said.

She added that the teens in the program are more likely to delay engaging in sexual behavior and when they do, are more likely to practice safe sex. Education combined with access to health services and products prove most successful, she said.

In the most recent Youth Risk Behavior Survey from 2017, the percentage of teens that had ever had intercourse decreased from 41.8 percent in 2007 to 32.4 percent.

Madeleine Lefranc is a senior at Simsbury High School.