2015 baw conference shp update 2016 laura smoak and rob tester

2015 BAW Conference

SHP Update 2016

Laura Smoak and Rob Tester

Monthly contributions effective January 1, 2016

• 4.5 percent increase for employers in 2016

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Employer rates 2015 2016

Enrollee only $344.58 $360.10

Enrollee/spouse $682.54 $713.26

Enrollee/child $528.88 $552.68

Full family $854.58 $893.04

Monthly contributions effective January 1, 2016

• No increase for enrollees in 2016

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Savings PlanStandard Plan/

Medicare Supplement

Enrollee only $9.70 $97.68

Enrollee/spouse $77.40 $253.36

Enrollee/child $20.48 $143.86

Full family $113.00 $306.56

Benefit designeffective January 1, 2016

• In general, there are no increases to the deductible, copayments or coinsurance amounts.

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Patient-Centered Medical Home

• Patient-Centered Medical Home (PCMH) is a health care delivery model that strengthens the physician-patient relationship through a team of providers who meet all the patient’s health care needs

• By the end of 2015, BCBSSC anticipates certifying 225 physician practices in South Carolina as participating PCMHs (approximately 751 physicians)

• Effective January 1, 2016:• Waive member’s $12 physician office visit copay at participating

PCMH• Member coinsurance will be paid at 10 percent versus 20

percent at a participating PCHM

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BCBSSC’s Patient-Centered Medical Home ProgramNoreen O’Donnell August - September 2015

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A move from reactive care to proactive care

The Patient-Centered Medical Home (PCMH) is a model of care designed to strengthen the physician-patient relationship by moving from episodic (reactive) care to coordinated (proactive) care.

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Source: “Joint Principles of a Patient-Centered Medical Home,” Adopted March 2007 by: American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association

Personal physician

Physician directed

team

Whole person

orientation

Coordinated, integrated

care

Emphasis on

quality and

safety

Enhanced access

Appropriate payment structure

Member Care Team

Patient-Centered Medical Home

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PCMH: changing the way we care

PCMH Care

• Coordinated (proactive) care

• Care for patient overall health

• Same-day appointments

• Care delivered by physician-led team with right skills at right time

• PCMH coordinates all patient’s care

• Coordinated referrals within the PCMH

• Ongoing follow-up care to avoid disease and improve health

Today’s Care

• Episodic (reactive) care

• Treat patient symptoms

• Appointments unavailable

• Care varies by scheduled time and memory or skill of the doctor

• Patients are responsible for coordinating care among their providers

• Uncoordinated referrals that lead to less-than-optimal treatment and gaps in care

• Limited follow-up care

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PCMH: continuous quality improvement

Robust IT infrastructure

A PCMH continuously monitors performance:

-Health improvement

-Gaps in care

-Patient satisfaction

-Health outcomes

-Cost measures

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Why use a PCMH?Three dimensions of value

Population health

Population health

Experience of care

Experience of care

Per capita cost

Per capita cost

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Value

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Why use a PCMH?

• PCMH recognition through the National Committee for Quality Assurance (NCQA)

• 40,000 practitioners

• 8,100 locations across the country

• Reasons to support the PCMH model.

─ Overall reduction in costs ─ Proactive instead of reactive care─ Reduction in hospital admission rates─ Reduction in ER Visits─ Improved staff satisfaction in PCMH practices─ Improved patient health outcomes

The model is recognized globally as key to reform.

Outpatient visits; pharmacy utilization

ER visits; inpatient visit

South Carolina’s

PCMH Program

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BCBSSC’s PCMH practice transformation

• Achieve PCMH recognition• National Committee for Quality Assurance (NCQA) or other

accrediting body

• BCBSSC Innovation Specialists “transformation roadmaps”• Based on practice goals, needs and resources• Help achieve NCQA PCMH Recognition Standards requirements

• “Must pass” elements of NCQA PCMH recognition • Patient-centered access• Team based care• Population health management• Care management and support• Care coordination and care transition• Performance measurement and quality improvement

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PCMH growthRapid expansion in the last three years

PCMH 2012 2013 2014 EOY 2015

Practices 56 111 176 225

Physicians 195 414 601 751

SHP chronic members 11,226 15,528 22,821 28,516

SHP total membership 31,612 52,689 81,885 102,321

PCMH physiciansPCMH physicians Chronic membersChronic members Total membersTotal members

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BCBSSC’s PCMHsConcentration of PCMH practices by county

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BCBSSC’s PCMH programTypes of conditions targeted for PCMH care and coordination fees

Adult diabetesAdult diabetes

Adult congestive heart failure (CHF)Adult congestive

heart failure (CHF)

Pediatric wellnessPediatric wellness

Adult hypertension (HTN)

Adult hypertension (HTN) Pediatric asthmaPediatric asthma

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How do we measure quality?

Adult diabetesAdult diabetes

Percentage of eligible population who have had:

• BP exam in the past 12 months

• BP exam in the past 12 months that is < 140/90

• HgA1C exam in the past 12 months

• HgA1C exam in the past 12 months with the most recent exam being < 8%

• LDL-Chol exam in the past 12 months

• LDL-Chol exam in the past 12 months that is < 100

• Microalbumin exam in the past 12 months

• Diabetic retinal exam in the past 12 months

• BMI documentation in the past 12 months

• BMI improvement since baseline

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How do we measure quality?

Percentage of eligible population who have had:

• BP exam in the past 12 months

• BP exam in the past 12 months with the most recent being < 140/90

• BMI documentation in the past 12 months

• BMI < 30

• Creatinine measurement in the past 12 months

• Been prescribed a generic prescription for medications related to hypertension control

• Tobacco usage assessed

Adult hypertension (HTN)

Adult hypertension (HTN)

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Population Health Management and Reporting tool

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Robust data collection: structured and unstructured

Transforms disparate data into meaningful, actionable data:

•Instant patient view – individual and population level

•Gaps in care

•Performance tracking

•Robust data source for enhanced reporting and analytics such as risk stratification and predictive modeling

Easy to share and integrate:

•Instantly shared with our practice partners

•Easily integrated into other platforms such as DM/CM

Population Health and Reporting

Platform

Outcomes

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Cost and utilization

• 1 percent savings for all claims for SHP diabetic members in PCMH practices versus those in non-PCMH practices

• 5 percent savings on ER for SHP hypertension members in PCMH practices versus those in non-PCMH practices

• 5 percent fewer admissions per 1,000 for SHP diabetic members in PCMH practices and 12 percent fewer admissions per 1,000 for SHP hypertension members, versus those in non-PCMH practices

• 13.2 percent fewer ER visits for SHP members with hypertension in PCMH practices versus those in non-PCMH practices

2014 Outcomes

Questions?

Value-based health initiatives

• In 2015, the State Health Plan began covering at no cost to the member:

• Preventive biometric screening (worksite screening)• Zostavax (shingles vaccine)• Flu vaccine

• These “no cost to the member” value-based health initiatives are in addition to the Generic Copay Waiver program implemented in 2011

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Value-based health initiatives

• In 2016, the State Health Plan will expand coverage of its value-based health initiatives, PEBA Perks, at no cost to the member:

• Colonoscopies to include consultation, prep kit, colonoscopy and associated anesthesia for both diagnostic and routine screenings based on United States Preventive Services Task Force (USPSTF) specified age guidelines

• Adult vaccinations as recommended by the CDC (http://www.cdc.gov/vaccines/schedules/hcp/adult.html)

• Tobacco cessation (Chantix, generic Zyban)• Diabetes education

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Coverage for contraceptives

• No member cost share for covered contraceptives effective January 1, 2016 (mandated in Proviso 108.13 of fiscal 2016 Appropriations Act)

• Coverage of contraceptives remains the same under the State Health Plan

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Flexible benefits (MoneyPlus)

Effective January 1, 2016:•Elimination of one-year waiting period for new hires to establish a Medical Spending account•Establish a $1,500 limit on Dependent Care Spending Account for highly-compensated employees (HCE) in order to address passage of federal non-discrimination test

• For 2016, a HCE is defined as earning $120,000 or greater in calendar year 2015

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Vendor update

• Effective January 1, 2016, Express Scripts will be the pharmacy benefits manager (PBM)

• Basic dental and Dental Plus: vendor announcement pending completion of the Request for Proposal (RFP) process

• Basic dental rates for employers and enrollees will not change in 2016

• Dental Plus rates effective January 1, 2016, could change based on the outcome of the RFP process

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Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 30

2016 Prescription Drug Program

Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 31

What to expect in 2016 New ID cards and welcome

kits: Mailing December 2015

Medicare Plan D participants will receive communications starting October 2015

Pharmacy network: Retail pharmacies

Mail order pharmacy – Express Scripts

Specialty pharmacy – Accredo

Formulary/coverage review:

Insulin/test strips

Step therapies

Prior authorization

Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 32

Online tools and mobile app help patients connect Online prescription management:

Refills, renewals and order status Worry-free Fills ® Transfer to mail Claims, balances and history Locate a pharmacy Preferences

Benefit education and management:Benefit highlightsForms and cardsPricing and coverage detailsAccessibility features

Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 33

My Rx Choices® Lower the cost of prescriptions with My Rx Choices®

Features include: Personal assessment of cost-saving opportunities

Print a kit to help their doctor better understand the economic impact of different medication alternatives

Alternative medications are based upon greatest cost savings to you presented in order, starting with the highest value

Brand-to-generic and retail-to-mail comparisons are shown

Simply visit www.express-scripts.com or call Express Scripts Member Services on the member ID card

Prices can vary at different retail pharmacies, so it is important to shop around

Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 34

My Rx Choices®

Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 35

Information resources Open enrollment website – www.express-scripts.com/SCPEBA

(Available on October 1, 2015)• Pharmacy benefit highlights• Members cannot select benefits via this site

Express Scripts mobile app (FREE) – search for “Express Scripts” Express Scripts member website – www.express-scripts.com

(Available on January 1, 2016)• Formulary information• Locate a participating pharmacy• Health and wellness information• My Rx Choices®/price a medication• Online ordering• Express Scripts mobile app• Order home delivery pharmacy refills• Caregiver resources• Download forms

Customer Service Number: 855.612.3128

Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 36

Thank You

Questions

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Disclaimer

This presentation does not constitute a comprehensive or binding representation regarding the employee benefits offered by the South Carolina Public Employee Benefit Authority (PEBA). The terms and conditions of the retirement and insurance benefit plans offered by PEBA are set out in the applicable statutes and plan documents and are subject to change. Please contact PEBA for the most current information. The language used in this presentation does not create any contractual rights or entitlements for any person.

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