afscme health plan design update

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  • 8/6/2019 AFSCME Health Plan Design Update

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    DianeLovell

    OregonAFSCMECouncil75

    May11,2011

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    AGENDA

    SemiFinalPlanDesigns

    MedicalandDentalRenewals

    PreferenceSensitive/EvidenceBasedChangesUnderConsideration

    RetireeOptions

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    TheScenariosScenarioAPY2012andPY2013fundingPEPMisbasedon5%

    increasesover2011reprojectedcostsof$1,214.05PEPM

    withtheApril1,2011changesandMarch2011data.

    ScenarioBPY2012andPY2013fundingPEPMisbasedon0%

    increasesover2011reprojectedcostsof$1,214.05PEPMwiththeApril1,2011changesandMarch2011data

    ScenarioC2012to2013fundingPEPMisbasedon0%increasefrom

    proposedGovernorsBudgetof$1,149.04PEPM

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    PlanDesignChanges:Theseplandesignchanges(madetotheProvidenceStatewideandChoiceplans)willachieveazerodollardeficitattheendofyear2013tothe

    midpointoftherecommendedlowandmiddleRBC,withallplandesignchangesoccurringin2012.

    ScenarioA

    ScenarioB

    ScenarioC

    AddmoreprocedurestotheAdditionalcostTier(beingconsideredbyOEBB)

    $5,000,000 $5,000,000 $5,000,000

    OutofpocketMax:$1,500,(ScenarioB&C$2,000OOP) $6,200,000 $10,800,000 $10,800,000

    $50/monthSpouseorDomesticPartnerSurcharge $12,000,000 $12,000,000 $12,000,000

    HealthEngagementModel $0 $0 $0

    Deductible:$250Innetwork,$500Outofnetwork(4officevisitsnotsubject)(ScenarioCDeductible:$500Innetwork,$1,000Outofnetwork)

    $12,900,000 $12,900,000 $27,600,000

    TobaccoSurchargeforEmployeesandSpouses$25/month $2,400,000 $2,400,000 $2,400,000

    RateRetireesSeparatelyGoingForward(1.9Msavingsstartingin2013) $0 $0

    OfficeVisitCoInsurance:20%PCP,35%Specialist $5,600,000 $5,600,000

    RxTiers:$0Value$10Generic,$30Brand,$100SpecialtyMailOrder:2.5xRetail,notiersexceptions,$50RxDeductibleforallValuedrugs

    $10,300,000 $10,300,000 $10,300,000

    ReduceChronicCareCoinsurance(Asthma,Hypertension,Diabetes,COPD,CHF,Cholesterol)*

    ($2,800,000) ($2,800,000) (2,800,000)

    AdditionalFunding $43,000,000 $67,000,0

    SubtotalEstimatedSavings $46,000,000 $99,000,000 $137,900,000

    $1,000outofpocketmaxforRx ($1,000,000) ($1,000,000) ($1,000,000)

    Pharmacytierexceptions ($2,140,000) ($2,140,000) ($2,140,000)

    StrategiestoEnhanceEnrollmentinChoiceandKaiser N/A N/A

    WeightWatchersforDependents* TBD TBD TBD

    OptionalSavings ($3,140,000) ($3,140,000) (3,140,000)

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    TwoYearPlanDesignChangesThechangesmadeineachofthescenariosare

    intendedtobetheonlychangesmadeduringthe

    biennium.Thiswillholdtrueunlessutilization,costofcareor

    numeroushighexpenseclaimsdrivecostsabovethepredicted9.7%trend.

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    2012MedicalandDentalRenewalsKaiserMedical8.6%ImplementSleepStudyandImagingcoinsurancepreviously

    implementedforourProvidencePlansProvidenceChoice(4.4%)andProvidenceStatewidePlan(4%)Plandesignchangesexplainedonpreviousslide

    ODS(.2%)NoPlanChanges

    Kaiser(3.1%)Noreductions,newPreventaMaxBenefitaddedatnoadditionalcost

    WillametteDental(0%)Implementa$5copayOrthodontiacopayincreasesfrom$1,200to$1,500Increaseappliestopatientsthathavenotbeenbandedattimeof

    implementation

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    PreferenceSensitiveConditions Tryingtofind$5Minsavingsthroughevidencebasedmedicineandpreferencesensitiveconditions

    Evidencebasedmedicine(EBM)orevidencebasedpractice(EBP)aimstoapplythebestavailableevidencegainedfromthescientificmethodtoclinicaldecisionmaking.[1]Itseekstoassessthestrengthofevidenceoftherisksandbenefitsoftreatments(includinglackoftreatment)and

    diagnostictests.[2]Evidencequalitycanrangefrommetaanalysesandsystematicreviewsofdoubleblind,placebocontrolledclinicaltrialsatthetopend,downtoconventionalwisdomatthebottom.

    PreferenceSensitiveConditionsarethoseforwhichtwoormorevalidtreatmentchoicesareavailableformostpatients.Chronicbackpain,earlystagebreastcancer,earlystageprostatecancer,andbenignprostatichypertrophyareconsideredpreferencesensitiveconditions.Treatmentchoicesfortheseconditionsshouldbemadebywellinformedpatientswhobasetheirdecisionsonthebestavailableevidenceaswellastheirpersonalvaluesandpreferences

    PEBBisreviewingalistof28conditionswherethereislittleevidencedemonstratingthatthetreatmentimproveshealthorforwhichtherearetwoormorevalidtreatments.APEBBsubcommitteewillreviewthisinformationandmakearecommendationtothefullBoard.ThelistisacompilationoftreatmentsunderreviewbytheOregonEmployeesBenefitsBoard(OEBB),ontiersthreeorfouroftheOregonHealthAuthoritysessentialbenefitsmodelandeithernotcoveredorlowonthelistofeffectivetreatmentsasdeterminedbytheOregonHealthServicesCommission.

    Ifweareunabletofind$5Minsavings,wewillhavetomakeotheradditionalcutstoScenarioAtomakeupthedifference.

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    RetireeOptionsPEBBhasnotmadeanydecisionstochangeRetiree

    inclusioninPEBBPlans2,101retireescomprise4.1%ofthePEBBplan.Thisnumber

    hasdeclinedeachofthelastfouryears.Retireesdohaveotheroptionsforhealthcare PERS COBRAOMIP IndividualMarket

    OregonsHealthExchangein2014PERSplansarevaluedbetween93%and97%ofPEBBfull

    timeplansbasedonexistingplandesignfeatures.WhenPEBBimplementschangesin2012thisgapwillnarrowevenmore.

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    NextStepsMay17BoardMeetingAgenda:

    ReviewPreferenceSensitiveSubcommitteeworkReviewfees,consultantcommissionsandprovidertax

    Approve2012PlanYearcompositerates

    ApproveHEMplandesignandframework

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