title goes here - oregon · 3/20/2018 · •high cost counties are based on prior analysis with...

H E A LT H W E A LT H C A R E E R

MARCH 20, 2018

Robert Valdez, CEBS, FLMI

Principal

Emery Chen, ASA, MAAA

Senior Associate

Nick Albert, ASA, MAAA

Associate

M E D I C A L R E N E W A L SR O U N D 2

O R E G O N P E B B

Bdatt.2

2 Copyright © 2018 Mercer (US) Inc. All rights reserved.

AGENDA

OVERALL PLAN COSTS 01

PLAN DESIGN AND RECOMMENDATIONS 02

NEXT MONTH 03

APPENDIX 04

Bdatt.2


EXECUTIVE SUMMARY

Monthly premium rates range from approximately $1,400 (Moda, Choice) to $1,600

(Kaiser, Statewide) • Administration fees as a

percent of premium range from 4.8% to 9.2% and vary by plan

Key cost drivers • Providence - outpatient surgical

costs • Moda – inpatient • Kaiser – professional services

Increased enrollment in higher cost counties contribute to

Moda and Statewide cost trend

Recommended plan changes reduce premium rate increases

significantly • Most plans would be at 3.4% or

lower • PEBB 2019 preliminary

composite rate will be available for April board meeting

While plan design across the Coordinated Care Models has

historically been consistent, the Board may wish to consider

allowing more design differences to help achieve

cost containment requirements

Additional details on how the Plans compare with one another in different areas are provided as

Appendix items

Bdatt.2


OVERALL PLAN COSTS

Bdatt.2


HISTORICAL PROJECTED COMPOSITE RATES

Year

Composite Rate

Using Prior Year’s

March Census % Change

Composite Rate

Using Plan Year’s

March Census % Change

2013 $1,338.48 $1,332.21

2014 $1,333.58 -0.4% $1,327.47 -0.4%

2015 $1,321.53 -0.9% $1,313.06 -1.1%

2016 $1,356.47 2.6% $1,347.31 2.6%

2017 $1,416.93 4.5% $1,405.13 4.3%

2018 $1,465.82 3.5% TBD

Updated composite rate will be provided at April Board meeting.

Bdatt.2


PREMIUM / FEE COMPARISON (PER EE PER MONTH)

RETENTION / ADMIN FEE COMPARISON

$83.58 $96.22

$75.97

$40.92 $58.44

$30.34 $14.37

$13.63

$13.20

$23.03 $21.55

$20.89

$24.79 $20.53

$136.95 $132.14

$96.86

$79.34 $92.17

$0.00

$25.00

$50.00

$75.00

$100.00

$125.00

$150.00

Kaiser Moda FI Moda SI Statewide Choice

1.5% Premium Tax

Margin / Group Specific Benefits/ Triple Aim

Retention / Admin

Premium Rates $1,522 $1,437 $1,392 $1,653 $1,369

Admin as a % of

premium 9.0% 9.2% 7.0% 4.8% 6.7%

Kaiser Moda Fully Insured Moda Self-Insured Choice Statewide

• Member call center • Billing & enrollment • Contracts • Marketing • Sales • Underwriting • Actuarial Specific $ values not given

• Base admin • Rx admin • UM • DM • Coaching • Tobacco • Nurseline • Weight Mgt. • Access Fees • PCORI • I-CORE

$68.28 $5.65 $6.98 $1.08 $3.62 $0.93 $1.22 $1.15 $5.30 $0.58 $1.43

• Base admin • Rx admin • UM • DM • Coaching • Tobacco • Nurseline • Weight Mgt. • Access Fees • PCORI • Injectables

$54.26 $0.001

$6.98 $1.08 $3.62 $0.93 $1.22 $1.15 $5.30 $0.00 $1.43

• Base admin • Rx Admin • Network Fee • MH/CD Admin • Med Mgt. • Nurseline • Life Balance

$35.33 $3.26 $8.93 $4.00 $5.29 $1.09 $0.54

• Base admin • Rx Admin • Network Fee • MH/CD Admin • Med Mgt. • Nurseline • Life Balance

$20.26 $3.25 $6.51 $3.99 $5.49 $1.09 $0.33

1Billed separately as part of OPDP

Bdatt.2


TREND COMPONENTS BY PLAN

WHAT’S DRIVING THE INCREASES?

BY PLAN Largest Component of Increase Other Cost Drivers Approximate Increase

Choice Outpatient, due to OP surgery and specialty

• Inpatient unit costs • Outpatient unit costs

• 9% • 23%

Statewide Outpatient due to OP surgery • Outpatient unit costs • Prescription drug unit costs

• 15% • 10%

Moda Inpatient due to 36% increase in admit days

• Prescription drug unit costs • 15%

Kaiser Physician services due to utilization and cost

• Inpatient and outpatient unit costs

• 27% and 16%, respectively

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

Costshare/Leveraging

Member Health Risk Unit Cost Utilization Total AnnualIncrease

Total PEBB Cost Increase

Unit cost includes reimbursement increases, mix of services change, and technology

Bdatt.2


COUNTY ANALYSIS

ENROLLMENT IN H IGHER COST COUNTIES IMPACTS

MODA AND PROVIDENCE

• High cost counties are based on prior analysis with risk adjusted cost factors 10% above PEBB average • Low cost counties are 10% below PEBB average • “Current” reflects incurred claims through Sep. 30, 2017; “Prior” reflects incurred claims through Sep. 30, 2016

Year-over-year

Differences Kaiser Ded Kaiser HMO Moda Providence Choice Statewide

High -0.1% 0.0% 2.4% 1.2% 0.6%

Average -1.0% 0.2% -2.8% -0.6% -0.6%

Low +1.1% -0.2% 0.4% -0.5% 0.1%

0.1% 0.1%

17.8% 9.3%

28.3%

88.7% 87.7%

76.4% 84.4%

68.0%

11.1% 12.2% 5.9% 6.3% 3.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Kaiser Ded Kaiser HMO Moda Choice Statewide

High

Avg

Low

Percentage of Members by County Cost Factor

Bdatt.2


COUNTY ANALYSIS

ENROLLMENT IN HIGHER COST COUNTIES IMPACTS TREND

-3.3%

5.4%

14.3%

1.0%

-3.1% -0.5% -0.3%

8.2% 6.4%

3.1%

-6.9%

-11.5% -9.7%

0.2%

-15.0%

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Kaiser Ded Kaiser HMO Moda Providence Statewide

High

Avg

Low

Impact to Trend

Due to Shifting Kaiser Ded Kaiser HMO Moda Providence Choice Statewide

% Cost Increase -0.1% 0.0% 0.5% 0.3% 0.1%

100.2%

• High cost counties are based on prior analysis with risk adjusted cost factors 10% above PEBB average • Low cost counties are 10% below PEBB average • “Current” reflects incurred claims through Sep. 30, 2017; “Prior” reflects incurred claims through Sep. 30, 2016

Trend Increase by County Cost Factor

Choice

Bdatt.2


PLAN DESIGN AND

RECOMMENDATIONS

Bdatt.2


PLAN DESIGN PROPOSALS

• Background – Mercer asked each vendor to provide suggested plan design changes to

achieve the 3.4% cap – For each recommendation, vendors provided justification for the change

and which suggestions are more highly recommended than others – Mercer also provided suggested plan changes to each of the vendors

based on Mercer’s National Survey data

Bdatt.2


SUMMARY

IMPACT OF 2019 PLAN CHANGE SUGGESTIONS

Plan

2019 Status Quo

Increase

2019 Increase with

ALL Plan Suggested

Changes

2019 Increase with

ALL Mercer

Changes

2019 Increase with

RECOMMENDED

Mercer Changes

Kaiser HMO 5.9% 3.2% 3.2% 3.4%

Kaiser Deductible 5.9% 3.2% 3.2% 3.4%

Moda 9.3% 6.9% 6.0% 2.2%

Providence Choice 7.3% 5.2% 3.8% 3.6%

Providence Statewide 6.1% 4.0% 2.0% 2.1%

Bdatt.2


KAISER

SUGGESTED 2019 CHANGES REDUCES RENEWAL I NCREASE F RO M 5 . 9% TO 3 . 2%

Recommendations Cost impact Justification Mercer recommended?

FT In-Plan ER

services from $75 to

$100

• -0.3% • ($0.3M)

• Control costs over the long term • Closer alignment to market

‒ Standard ER copay is $200 on Kaiser’s HMO and 10-20% coinsurance after deductible on Deductible plan

‒ Lab/XRay/Spec Diagnostics range from $10-$35 ‒ PCP and Vision copays range from $10-$35 ‒ Specialty Care visit copays range from $20-$45 ‒ Urgent care visit copays range from $30-$60 ‒ Standard prescription drug benefit:

‒ Generic: $10-$20 ‒ Preferred: $20-$40 ‒ Non-Preferred: $40-$60 ‒ Specialty: $150

‒ Standard mail order copay is 2 copays for 90 day refills • Encourage getting care at the right time and place (ER copay)

FT HMO and Ded –

Lab/XRay/diagnostic

from free to $10

copay

• -0.6% • ($0.7M)

FT PC, SC, Vision OV

from $5/$30 to

$10/$40

• -0.7% • ($0.8M)

Rx – increased

copays across all

plans (see appendix)

• -1.2% • ($1.4M)

Total – if all changes

accepted

• -2.7%

• ($3.1M)

Bdatt.2


MODA

SUGGESTED 2019 CHANGES REDUCES RENEWAL I NCREASE F RO M 9 . 3% TO 6 . 9%

Recommendations Cost impact Justification

Mercer

recommended

For clinically administered

drugs, addition of $100 copay

to match the specialty copay

• -0.5% • ($0.2M)

• Align the medical and pharmacy benefit for specialty medications • Aligns with the standard market approach

Increase ER copay to $200 in

combination with increased ED

utilization management

• -0.2% • ($0.1M)

• PEBB population has higher utilization of the ED compared to commercial peers • Data suggests many of the visits could have been treated in a lower cost setting • ER Department Utilization Management program:

‒ Dedicated care management team ‒ Delivery system focus in Synergy and Summit ‒ Promote use of virtual care resources ‒ Member co-payment modifications

Change member cost share for

non-office visits to 5% or 10%

coinsurance

• 5%: -1.0% / ($0.4M)

• 10%: -1.6% / ($0.7M)

• Current design does not incentivize members to understand the underlying cost of the care they receive

• Implementing coinsurance will drive utilization of Moda’s Healthcare Cost Estimator, empowering members to seek lower cost of care

Deny out-of-network services

not prior authorized in advance

• -0.1% • ($0.0M)

• Alignment with Moda book of business

Waive member cost share for

mental health visits for

members enrolled in

Comprehensive Coordinated

Care

• Minimal • Currently the C3 program waives primary care copays for members when they utilize their designated medical home

• Moda proposes expanding the program to also waive copays for mental health to remove barriers for critical members

Total – if all changes accepted • 5% Cost Share: -1.8% / ($0.8M)

• 10% Cost Share: -2.4% / ($1.0M)

Bdatt.2


PROVIDENCE

SUGGESTED 2019 CHANGES REDUCES ACCRU AL I NCREASES F RO M 7 . 3% TO 5 . 2% (CHO I CE)

AND 6 . 1% TO 4 . 0% (STAT EW I DE)

Recommendations Cost impact Justification

Mercer

recommended

Increase Emergency

Room copay from

$100 to $250

• -1.6%

• $10M

• Similar to tenets of additional cost tier, higher copay may encourage members to seek alternative, less costly care methods for non-emergent services

Multi-Tier

Prescription Drug

Formulary (5-Tiers)

• -0.5%

• -$3M

• Rapidly growing pharmacy costs have an impact on total plan costs

• Growing disparity between the preferred and non-preferred medications on PHP’s formulary

• 5-Tier plans are designed to encourage members to help control costs by selecting preferred medications for which PHP has better pricing

Increase specialty

pharmacy copay

from $100 to $200

• Negligible • Increasing copay will equate to small savings for PEBB and will appear to be an added cost to the member

• However – PHP’s preferred specialty pharmacy, Credena Health, encourages 100% of members on specialty medication to apply for copayment assistance

• 85% of members who apply receive assistance

Total – if all changes

accepted

• 2.1%

• $13M

Bdatt.2


PEBB MEDICAL PLANS ( IN -NETWORK SUMMARY)

PPO DESIGN RICHER THAN BENCHMARKS

Full-Time,

Preferred

Network Benefits

2018 PEBB In-Network Design, by Carrier Mercer 2017 Employer Survey

Kaiser

HMO

Kaiser

Deductible Moda

Providence

Choice

Providence

Statewide

State

Government

500+

Oregon

500+

National

500+

Medical

Deductible (Ind/Fam) $0 / $0 $250 / $750 $250 / $750 $250 / $750 $250 / $750 $473 / $945 $500 / $1,500 $650 / $1,500 Out of Pocket Max (Ind/F) $600/ $1,200 $1,500/ $4,500 $1,500 / $4,500 $1,500 / $4,500 $1,500 / $4,500 $2,868 / $5,735 $2,500 / $6,600 $3,000 / $6,850 Primary Care OV1 $5 $5 $10 $10 15% $25 $25 $25 Specialist OV $5 $5 $10 $10 15% $40 No data $40 Inpatient Hospital $50/day to

$250 $50/day to

$250 $50/day to

$250 $50/day to

$250 15% 20%

(72% of employers)

20% (96% of

employers)

20% (77% of

employers)

Outpatient Hospital $5 $5 $10 $10 15% 20% 20% 20% Emergency Room $75 $75 $100 $100 $100 $113 $150 $150 Urgent Care Visit $25 $25 $25 $25 $25 No data No data No data Pharmacy

Deductible n/a n/a $50 / $150 $50 / $150 $50 / $150 No data No data No data OOP Max n/a n/a $1,000 / $3,000 $1,000 / $3,000 $1,000 / $3,000 No data No data No data Retail2 • Generic

• Prf Brand • NP Brand • Specialty

$1 $15 $15 $50

$5 $25

50% to $100 $50

$10 $30 $30 $100

$10 $30 $30 $100

$10 $30 $30 $100

$9 $30 $58 $131

$12 $33 $46

No data

$11 $33 $56 $115

Mail-Order2

• Generic • Prf Brand • NP Brand • Specialty

$1 $15 $15 $50

$5 $25

50% to $100 $50

$25 $75 $75 $250

$25 $75 $75 $250

$25 $75 $75 $250

$20 $72 $135 $282

$24 $62 $86

No data

$22 $68 $117 $186

1Preventive services covered in full 2Value drugs are available at a $0 copay and are not subject to deductible

Bdatt.2


MERCER SUGGESTED 2019 CHANGES

BASED ON MORE CLOSELY ALIGINING WITH

BENCHMARKS FROM MERCER’S 2017 SURVEY DATA

# Plan Change Kaiser HMO Kaiser Ded. Moda Prov Choice Prov Statewide

1. INN Deductible $100 $350 / $1,050 $350 / $1,050 $350 / $1,050 $350 / $1,050

2. INN Med OOP Max (excludes Ded)

$750 / $1,500 $2,000 / $6,000 $2,000 / $6,000 $2,000 / $6,000 $2,500 / $7,500

3. INN Coinsurance n/a n/a n/a n/a 20%

4. Primary Care Copay $10 $10; eliminate waiving deductible

Eliminate waiving ded. for 1st 4 visits



5. Specialty Care Copay

$10 $25 $25 $25 20%

6. OP Surgery Copay $50 $100 $100 $100 20%

7. IP Hospital Copay $100/day to $500 max

$100/day to $500 max



20%

8. ER Copay $150 $150 $150 $150 $150 + 20%

9. Additional Cost Tier Copays

Increase $100 to $150

Increase $100/$500 to $150/$1,000

Increase $100/$500 to $150/$1,000

Increase $100/$500 to $150/$1,000

Increase $100/$500 to $150/$1,000

10. Rx OOP Max n/a $1,500 / $4,500 $1,500 / $4,500 $1,500 / $4,500 $1,500 / $4,500

Bdatt.2


KAISER

MERCER SUGGESTED CHANGES

Current Design Design Changes Cost Impact Mercer recommended

HMO Ded. HMO Ded. HMO / Ded Combined HMO Ded.

INN Deductible $0 $250 / $750 $100 $350 / $1,050 -1.2% / ($1.4M)

INN Med OOP Max (excludes Ded)

$600 / $1,200 $1,500 / $4,500 $750 / $1,500 $2,000 / $6,000 -0.3% / ($0.3M)

INN Coinsurance n/a n/a n/a n/a n/a

Primary Care Copay $5 $5, ded. waived $10 $10; eliminate waiving deductible

-0.3% / ($0.4M)

Specialty Care Copay

$5 $5, ded. waived $10 $25 -0.3% / ($0.4M)

OP Surgery Copay $0 $5 $50 $100 0% (Ded. plans currently have coinsurance, negating cost savings on HMO plan)

IP Hospital Copay $50/day to $250 max

$50/day to $250 max



-0.2% / ($0.2M)

ER Copay $75 $75 $150 $150 -0.2% / ($0.3M)

Additional Cost Tier Copays

$100 $100 / $500 $150 $150/$1,000 -0.3% / ($0.3M)

Rx OOP Max n/a n/a n/a $1,500 / $4,500 n/a (Kaiser does not administer separate Rx OOPM for other groups; if PEBB is interested in this design change, Kaiser will devote time/resources to cost impact)

Bdatt.2


MODA


Current Design Design Changes Cost Impact

Mercer

recommended

INN Deductible $250 / $750 $350 / $1,050 • -1.2% / ($0.5M)

INN Med OOP Max (excludes Ded)

$1,500 / $4,500 $2,000 / $6,000 • -1.1% / ($0.5M)

INN Coinsurance n/a n/a • n/a

Primary Care Copay $10, ded. waived for 1st 4 visits

Eliminated waiving deductible for 1st 4 visits

• Minimal

Specialty Care Copay $10 $25 • -0.3% / ($0.1M)

OP Surgery Copay $10 $100 • -0.2% / ($0.1M)

IP Hospital Copay $50/day to $250 max $100/day to $500 max • -0.1% / ($0.04M)

ER Copay $100 $150 • -0.1% / ($0.04M)

Additional Cost Tier Copays $100 / $500 $150/$1,000 • -0.3% / ($0.1M)

Rx OOP Max $1,000 / $3,000 $1,500 / $4,500 • Minimal

Self-Insurance Fully-Insured Self-Insured • -3.8% / ($1.5M)

Bdatt.2


PROVIDENCE


Current Design Design Changes Cost Impact Mercer

recommended Choice Statewide Choice Statewide Choice Statewide

INN Deductible $250 / $750 $250 / $750 $350 / $1,050 $350 / $1,050 -0.9% / ($2.3M) -0.9% / ($3.2M)

INN Med OOP Max (excl. Ded)

$1,500 / $4,500 $1,500 / $4,500 $2,000 / $6,000 $2,500 / $7,000 -0.3% / ($0.6M) -1.5% / ($5.3M)

INN Coinsurance n/a 15% n/a 20% n/a -0.8% / ($2.9M)

Primary Care Copay

$10, ded. Waived for 1st 4 visits

15%, ded. Waived for 1st 4 visits



-0.4% / ($1.1M) -0.4% / ($1.5M)

Specialty Care Copay

$10 15% $25 n/a captured in coinsurance above

-0.4% / ($1.0M) n/a captured in coinsurance above

OP Surgery Copay $10 15% $100 -1.2% / ($3.1M)

IP Hospital Copay $50/day to $250 max

15% $100/day to $500 max

-0.2% / ($0.5M)

ER Copay $100 $100 $150 $150 + 20% -0.2% / ($0.6M) -0.3% / ($0.9M)

Additional Cost Tier Copays

$100 / $500 $100 / $500 $150/$1,000 $150/$1,000 Minimal Minimal

Rx OOP Max $1,000 / $3,000 $1,000 / $3,000 $1,500 / $4,500 $1,500 / $4,500 Minimal -0.1%

Bdatt.2


RECOMMENDATIONS

SUMMARY

Consider copay and ER plan changes increase cost sharing for higher cost or preference sensitive services

Recommended Rx plan designs are another step towards value based plan design

• The pharmacy market check currently being performed by Mercer may provide additional savings without member abrasion

Deductible and OOP maximum changes would bring plans in alignment with health care inflation as cost sharing has not changed since 2012

Mercer-recommended changes outlined in the previous pages and summarized on the following page are expected to reduce the renewal increases nearly $30M in 2019

While the focus of these suggested plan changes is on in-network services for full-time employees, there will be corresponding out-of-network plan changes, as well as changes to the part-time plans

•These will be detailed for the Board as 2019 decisions are being made

Bdatt.2


RECOMMENDATIONS

PLAN-SPECIF IC CHANGES

Vendor Recommendations Cost Impact

Kaiser • IP Hospital copay to $100/day (up to $500) • ER copay to $150 • Additional cost tier to $150 / $1,000 • FT HMO and Ded – Lab/Xray/diagnostic to $10 copay • Rx copay Increases

• -0.2% / ($0.2M) • -0.2% / ($0.3M) • -0.3% / ($0.3M) • -0.6% / ($0.7M) • -1.2% / ($1.4M) • Total = 2.5% / ($2.9M)

Moda • INN Ded. To $350 / $1,050 • INN Med OOPM to $2,000 / $6,000 • Specialty care copay to $25 • OP Surgery copay to $100 • IP Hospital copay to $100/day up to $500 max • ER copay to $150 • Additional cost tier to $150 / $1,000 • Self-Insurance

• -1.2% / ($0.5M) • -1.1% / ($0.5M) • -0.3% / ($0.1M) • -0.2% / ($0.1M) • -0.1% / ($0.04M) • -0.1% / ($0.04M) • -0.3% / ($0.1M) • -3.8% / ($1.5M) • Total = 7.1% / ($2.9M)

Providence Choice • INN Ded. To $350 / $1,050 • INN Med OOPM to $2,000 / $6,000 • Specialty care copay to $25 • OP Surgery copay to $100 • IP Hospital copay to $100/day up to

$500 max • ER copay to $150 • Additional cost tier to $150 / $1,000 • 5-Tier Rx Plan

Statewide • INN Ded. To $350 / $1,050 • INN Med OOPM to $2,500 / $7,000 • INN coinsurance to 20% • ER copay to $150 • Additional cost tier to $150 / $1,000 • 5-Tier Rx plan

Choice • -0.9% / ($2.3M) • -0.3% / ($0.6M) • -0.4% / ($1.0M) • -1.2% / ($3.1M) • -0.2% / ($0.6M) • -0.2% / ($0.6M) • Minimal • -0.5% / ($1.4M) • Total = 3.7% /

($9.6M)

Statewide • -0.9% / ($3.2M) • -1.5% / ($5.3M) • -0.8% / ($2.9M) • -0.3% / ($0.9M) • Minimal • -0.5% ($2.0M) • Total = 4.0% /

($14.3M)

Bdatt.2


NEXT MONTH

Bdatt.2


APRIL 17 BOARD MEETING

Round 3 Renewal Responses 1

Geographic Analysis: Discounts and Disruption by County 2

Pharmacy market check 3

2019 Plan Design Decisions 4

Bdatt.2


NEXT MONTH

RENEWAL OVERVIEW AND T IMELINE

2018 DATE ACTION ITEM RESPONSIBLE PARTY

Feb. 20 Board Meeting – Overview of Round One Responses PEBB and Mercer

Feb. 23 Round Two renewal letters sent to carriers PEBB and Mercer

March 7 Carriers responses to Round Two renewal letters due Carriers

March 13 Final Materials of Round Two responses due to PEBB Mercer

March 20 Board meeting — Overview of Round Two responses - to include in person

carrier Q&A on rates and programs

PEBB, Mercer and

Carriers

March 23 Best and Final renewal requests sent to carriers PEBB and Mercer

April 4 Carrier responses to Best and final letters due PEBB and Mercer

April 10 Best and Final responses/materials due to PEBB Mercer

April 17 Board meeting — Review of Best and Final Offers PEBB and Mercer

May 10 Final materials for approval of best and final offers and final rates due to PEBB Board Mercer

May 15 Board meeting – Approval of Best and Final offers and final rates PEBB and Mercer

May 18 Final 2018 renewal letters sent to carriers for signature PEBB and Mercer

May 31 Signed final renewal letters returned to PEBB and Mercer Carriers

Bdatt.2


APPENDIX

Bdatt.2


OTHER RENEWAL

RESPONSES

Bdatt.2


PCPCH UTIL IZATION BY PLAN

• Plans were asked to provide a list of PCPCHs by each tier, and utilization for each of those PCPCHs

• Weighted star ratings for each plan:

Plan Count Of Providers Count Of Members Paid / Allowed1

Providence 3.6 3.7 3.8

Moda 3.7 3.7 3.4

Kaiser 3.7 3.9 n/a

1 Providence based on paid charges; Moda based on allowed charges

Bdatt.2


COMPREHENSIVE PRIMARY CARE + (CPC+)

• Definition: Five year pilot program to test a set of comprehensive primary care functions, supported by enhanced payment and data sharing by participating providers – Two payment models:

- Track 1: Adds care management fee to fee-for-service payments - Track 2: Includes care management fee, but converts a portion of fee for

service payments into a prospective, partial capitation payment

• Results:

Providence Moda Kaiser

2017 Consisted of: • Amending provider contracts • Designing and operationalizing Track 2

payments for 2018 • Enhancing data sharing with practices • Collaborating with provider groups on

care management strategies

• Provider financial support with care management fees, incentive payments, and data sharing

• Offered advanced CPC+ providers the option to be reimbursed via a hybrid payment that combines FFS and fixed PMPM

• Data aggregation initiatives to support patient care and reduce admin burden

• Does not participate in CPC+

Bdatt.2


BUNDLED PAYMENT OPPORTUNITIES

• PEBB already participates in alternative payment programs such as pay-for-performance (P4P) and care packages for total joint replacements

• Analyzed reference pricing in the past – Sets a maximum DRG rate for a service

with a hospital – Procedures must be conducted at

specific facilities to receive the highest benefit level

– If the provider is unable to agree to the set reference price, the member would be required to travel to receive care

• Moda evaluating pilots in certain geographies for bundled payment arrangements for joint replacement and select cancer treatments

Bdatt.2


CENTERS OF EXCELLENCE (COE)

• PEBB does not have COE’s in place

• Providence has limited facilities for which we authorize services such as bariatric surgery and transplants

• Members access COE/preferred provider through the prior authorization process

• Bariatric surgery — Moda’s facilities are

those recommended by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery

• Back/spine and joint replacements — Moda works with preferred providers based on access, cost, and quality

Bdatt.2


SUCCESS IN WORKING WITH MEDICAID POPULATION

• PHP provides similar care management services across all lines of business

• Examples: – PHP focused on interventions in ER department

to proactively engage members with severe, persistent mental illness or mental health crisis, ensuring follow-up care from their PCP or behavioral health specialist

– Care management integration with physician groups and clinics

– High cost medication support to assist with adherence and side-effect management as well as financial assistance

– Focus on preventing readmissions for high risk members

• Value Based Payment Arrangements – Provider performance based quality payments – Shared savings – Care management fees – Cultivation of PCPCH Focused primary care

network

• Payer Provider Data Sharing Efforts – Arcadia Solutions allows providers to have

integrated claims and clinical data available to them and enhanced real time reporting; helping providers meet clinical quality guidelines and improve reporting efforts

– Efforts have begun to use similar data capture and sharing strategies with providers serving commercial members in both Synergy and Summit

Bdatt.2


RISK SCORES & OTHER

STATISTICS

Bdatt.2


HISTORICAL RISK SCORES

1.06

0.90

1.02 1.06

0.90

1.02 0.97

1.15

0.90

1.06

0.89

1.08

0.92

1.10

-

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Kaiser Moda Prov Choice Statewide

2013

2014

2015

2016

Bdatt.2


C O S T F A C T O R S B Y C O U N T Y

P R O V I D E D I N J A N U A R Y 2 0 1 8 B O A R D M E E T I N G 15%+ more expensive 5% to 15% more expensive 5% cheaper to 5% more expensive 5%+ cheaper

Washington State

Clark County, WA Cowlitz County, WA Lewis County, WA Skamania County, WA

Idaho

Payette County, ID

Bdatt.2


MEDICAL ENROLLMENT

ENROLLMENT BY PLAN AND T IER

0

5,000

10,000

15,000

20,000

25,000

Statewide Choice Moda KaiserHMO

KaiserDed.

Employee Only

Employee & Partner

Employee & Child(ren)

Employee & Family

Child(ren) Only

Statewide Choice Moda Kaiser HMO Kaiser Ded. Medical Total

Employee Only 4,414 5,143 956 2,163 491 13,167 Employee &

Partner 5,093 3,983 740 1,654 223 11,693 Employee &

Child(ren) 2,115 2,207 460 1,154 117 6,053 Employee & Family 8,047 7,183 1,546 3,042 304 20,122 Child(ren) Only 7 2 2 1 0 12 Total 19,676 18,518 3,704 8,014 1,135 51,047

Statewide 39%

Choice 36%

Moda 7%

Kaiser HMO 16%

Kaiser Ded. 2%

Source: January 2018 Census

Bdatt.2


MEDICAL ENROLLMENT

EMPLOYEES BY COUNTY

County Prov –

Statewide Prov – Choice Moda Kaiser HMO Kaiser Ded.

Medical Total

(Excluding Opt-Outs)

Marion 3,243 4,023 570 3,152 453 11,441 Lane County 3,041 2,807 263 9 2 6,122 Multnomah 1,099 1,911 441 1,676 262 5,389 Benton 1,657 1,717 226 57 18 3,675 Polk 1,133 1,186 187 811 103 3,420 Washington 636 1,068 147 797 108 2,756 Clackamas 603 1,058 155 741 94 2,651 Linn 835 1,083 210 194 27 2,349 Jackson 687 636 306 0 0 1,629 Umatilla 972 223 126 0 0 1,321 Deschutes 437 547 103 1 0 1,088 Klamath 538 123 99 0 0 760 Yamhill 245 348 31 115 15 754 Union 405 256 55 0 0 716 Douglas 487 133 63 0 0 683 Clark (WA) 116 130 31 267 30 574 Coos 217 223 50 0 0 490 Josephine 224 149 89 0 0 462 Malheur 336 35 31 0 0 402


Bdatt.2


MEDICAL ENROLLMENT

EMPLOYEES BY COUNTY

County Prov – Statewide Prov – Choice Moda Kaiser HMO Kaiser Ded. Medical Total

(Excluding Opt-Outs)

Lincoln 217 121 48 2 0 388 Clatsop 154 65 66 1 0 286 Columbia 75 33 30 107 9 254 Baker 152 66 20 0 0 238 Tillamook 118 27 80 2 0 227 Wasco 110 46 57 1 0 214 Jefferson 125 59 9 0 0 193 Lake 145 0 29 0 0 174 Crook 72 75 8 0 0 155 Hood River 68 69 7 5 0 149 Curry 78 31 16 0 0 125 Grant 84 6 28 0 0 118 Harney 75 21 14 0 0 110 Morrow 83 7 8 0 0 98 Wallowa 47 23 10 0 0 80 Gilliam 21 0 1 0 0 22 Sherman 17 1 2 0 0 20 Wheeler 17 2 1 0 0 20 All Other

Counties 1,107 210 88 76 14 1,495


Bdatt.2


MEDICAL ENROLLMENT

EMPLOYEES BY REPRESENTATION


Type Prov –

Statewide Prov – Choice Moda Kaiser HMO Kaiser Ded.

Medical Total

(Excluding

Opt-Outs)

Union 11,682 11,957 2,508 5,922 836 32,905 Non Union 5,633 4,322 779 1,155 153 12,042 Exec Service 1,792 1,677 331 836 117 4,753

11,682 11,957

2,508

5,922

836

5,633

4,322

779 1,155 153

1,792 1,677

331 836 117

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Prov – Statewide Prov – Choice Moda Kaiser HMO Kaiser Ded.

Union

Non Union

Executive/Management

Bdatt.2


MEDICAL PLAN COSTS AND VALUES

PEPM RATES AND ACTUARIAL VALUES

FULL-TIME Prov – Statewide Prov – Choice Moda Kaiser HMO Kaiser Ded.

2018 PEPM RATES

EE Only $764.90 $653.54 $678.84 $753.61 $688.39

EE + Spouse $1,529.80 $1,307.08 $1,357.69 $1,507.23 $1,376.79

EE + Ch(ren) $1,300.33 $1,111.02 $1,154.03 $1,281.14 $1,170.27

EE + Family $2,065.23 $1,764.56 $1,832.87 $2,034.76 $1,858.67

Child Only $650.17 $555.51 $549.65 $605.93 $557.12

ACTUARIAL PLAN VALUES 90% 94% 94% 97% 95%

2019 PRELIM % INCREASE 6.1% 7.3% 9.3% 5.9% 5.9%


Bdatt.2


MEMBER OUT-OF-POCKET COSTS

BY PLAN

FULL-TIME

Average Member OOP (PEPM)

Rolling 12; incl. through Sept 17

Average Contribution (PEPM)

2017 Data Total OOP Cost (PEPM)

Choice $139 $12 $151 Statewide $269 $74 $343 Moda $162 $12 $174 Kaiser Deductible $29 $11 $40 Kaiser HMO $18 $70 $87

$151

$343

$174

$40

$87

$0

$50

$100

$150

$200

$250

$300

$350

$400

Choice Statewide Moda KaiserDeductible

Kaiser HMO

Average Member OOP (PEPM)Rolling 12; Inc. through Sept 17

Average Contribution (PEPM)2017 Full-Year Data

Total OOP Cost (PEPM)

Choice, Moda, and Kaiser Deductible contributions are 1% for illustrative purposes

Bdatt.2


Bdatt.2

title goes here - oregon · 3/20/2018 · •high cost counties are based on prior analysis with...

Documents