State Coverage Initiatives Value Based Purchasing and Consumer

State Coverage Initiatives Value Based Purchasing and Consumer

State Coverage Initiatives Value Based Purchasing and Consumer Engagement Strategies in Public Employee Health Plans May 13, 2010 Online Webinar If you cant hear the webinar: Call the following toll-free number: 866-699-3239 When prompted enter the following event code: 790 727 346 Enter your attendee ID number. This can be found

on the info tab at the top of the screen. If you cannot locate your attendee ID number you can still join the audio portion of the webinar by hitting the # sign. If you dont have the presentation: You can download the presentation for this webinar at the following url: http://www.statecoverage.org/node/2335 (you will see the link in the brown box at the left of the screen) Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide Presented by Michael Bailit and Joshua Slen for AcademyHealth May 13, 2010 Definitions Value Based Purchasing (VBP)

a strategy employed by purchasers of health care insurance and health care services to maximize the benefits received at the lowest cost Consumer Engagement (CE) a group of strategies to effect changes in employee, retiree and dependent behavior Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 5 Value-Based Purchasing: The Process 1. Specify what you want to buy (RFP) and select the best contractor(s) 7. Apply incentives/ disincentives 2. Measure if you're getting it 6. Remeasure Value-based Purchasing 3. Identify opportunities for

improvement 5. Collaborate to improve 4. Set improvement goals Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 6 Step One: Specify What You Want to Buy The Massachusetts Group Insurance Commission (GIC) in its RFP for Pharmacy Benefit Manager (PBM) services first communicated a clear set of priority performance goals, and then set forth clear and measurable performance requirements. Requirement 12. Academic Detailing. The selected PBM must have targeted academic detailing programs that can be focused on the GIC Top Prescribing Clinicians. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide

7 Step Two: Measure if Youre Getting It Oregon monitors the performance of its health plans by using a dashboard to review, among other things, Breast Cancer, Cervical Cancer, Colon Cancer, and PSA Screening. Oregon also tracks HEDIS measures for the cancer screenings identified above and compares health plan performance against the national 75th and 90th percentiles. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 8 Step Three: Identify Opportunities for Improvement In South Carolina the evidence-based claims monitoring program provides treatment recommendations directly to physicians using best practice guidelines.

The Care Considerations generated represent opportunities for improvement identified through a rigorous data-driven process. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 9 Step Four: Set Improvement Goals Accelerate contractor performance improvement efforts in areas of high priority to the purchaser. This should be done through the annual establishment of a group of performance improvement goals with the contractor, all with complementary, concrete measures. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 10 Step Five: Collaborate to Improve It is a shared objective of the purchaser and

contractor that the contractor perform well and achieve purchaser-desired levels of performance improvement. The purchaser can enhance the likelihood of contractor success through collaborative activity with one contractor, or several contractors together. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 11 Step Six: Remeasure In Oregon the Quarterly Experience Report includes measures for Cholesterol Screening and Preventive Care Visits. The state seeks to observe improvement over time. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 12 Step Seven: Apply Incentives and/or Disincentives

Minnesotas Bridges to Excellence (BTE) program is an employer-led P4P initiative for physicians. Minnesotas program uses locally developed measures to reward physicians for optimal care in the treatment of diabetes and heart disease. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 13 Value-based Purchasing: Seven (7) Steps State purchasers should focus on the cycle itself and the need to perform and connect the steps.

1. Specify what you want to buy (RFP) and select the best contractor(s) 7. Apply incentives/ disincentives 2. Measure if you're getting it 6. Remeasure Value-based Purchasing 3. Identify opportunities for improvement 5. Collaborate to improve 4. Set improvement goals Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 14 Consumer Engagement: Three Areas Strong Leadership

Consumer Engagement Financial & Non-financial Incentives Value-Based Purchasing and Consumer Engagement: Process-Driven Improvement Support Services 15 Financial and Non-Financial Incentives Financial incentives can take a number of different forms. Most common are modest payments or rewards (e.g., $25 gift card) for enrolling in or completing a wellness program, such as a yoga class. Increasingly of interest are financial incentives that are integrated into the payers plan design. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide

16 Financial and Non-Financial Incentives Minnesota has obtained a 70% completion rate using its enrollee self-reported Health Risk Assessment (HRA) instrument. As an incentive for HRA completion, the state offers a $5 discount on office visit co-payments for both the employee and dependents. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 17 Financial and Non-Financial Incentives Of increasing interest is offering adjustments in premium contributions if specific wellness behaviors are followed, such as participating in a disease management program or completing a personal HRA. Value-Based Purchasing and Consumer Engagement in State Employee Health

Plans: A Purchaser Guide 18 Financial and Non-Financial Incentives Alabama has a body mass index (BMI) screening as part of the HRA utilized at worksite locations and at public health clinics. If the employee is found not to have any risk factors, he or she receives a premium discount of $25 per month. The completion rate through November 2009, during the first calendar year of the program, exceeded 95%. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 19 Support Services Support programs, often disease management and wellness programs, provide the guidance and encouragement by health coaches that

many people need to make and sustain difficult behavioral changes Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 20 Support Services West Virginia offers a diabetes program targeted at the plans 13,000 diabetic enrollees. The diabetes program offers appointments with pharmacists throughout the state. Enrollees receive free diabetic drugs and supplies, but must meet with their participating pharmacist a minimum of once per month and must establish and maintain two goals, such as exercising or eating. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 21 Leadership

Consumer engagement initiatives cannot be viewed as a side project, but as a strategy that is basic to the direction of the organization. In Oregon, the Governor launched a Wellness Initiative in October 2008 that involves the placement of Stay Well Coordinators in 34 different state agencies. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 22 Leadership

Oregon followed-up on this leadership initiative with: agency checklists a diverse and comprehensive slate of activities organized into four categories; activities with public health activities with other employers activities with health plans activities with members ongoing activities that tie together disparate activities (e.g., 2009 HRA completions tied to food drive donations by health plans) Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide Consumer Engagement: Three Areas Leadership, use of financial and nonfinancial incentives,

and integrated support services are all necessary aspects of a successful consumer engagement strategy. Providing Strong Leadership Consumer Engagement Providing Financial and Non-financial Incentives Providing Support Services Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide

Summary Observations For states to maximize value they have to focus on the delivery system and the health behaviors of the population. State purchasers are often engaged in one area or the other, but rarely equally in both. Efforts have to be built with a twin focus on health care market dynamics and the cultural underpinnings of society that drive health behaviors. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 25 Summary Observations continued To be successful, state purchasers must follow a defined series of process steps in a consistent fashion and must measure success. Adherence to structured process that is datadriven will serve states well as they choose among new programs to adopt and existing programs to change or discontinue.

Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 26 Summary Observations continued Trends are towards; a focus on prevention and management of chronic diseases that increasingly involves the practice directly (e.g., medical homes) integration of consumer engagement strategies into plan design (e.g., premium discounts for completing HRAs) the purchase of services and the design of strategies based on data-driven outcome measurement The future holds the promise of better integrated health systems and public payers have the opportunity to play a significant role. Value-Based Purchasing and Consumer Engagement in State Employee Health Plans: A Purchaser Guide 27 Webinar:

State Coverage Initiative Programs Academy Health A Massachusetts Hat Trick? Access, Quality, Cost May 13, 2010 The Big Picture - Access Access Ch. 58 of the Acts of 2006 enacted in April up and running on October 1 Created a Connector Authority (Exchange), Individual mandate Employer mandate Two basic programs one subsidized, one not Defined minimal creditable coverage Wildly successful 97% of Mass. Citizens are insured today.

The Big Picture - Quality Quality Quality and Cost Council created Consumer website created showing hospital rates and quality measures GIC tiers physicians on quality and cost BC/BS initiates alternative contract option with accountable provider groups The Big Picture - Cost Cost Division of Insurance rejects rate requests for small businesses Governor Patrick orders hearings to justify rate increases

over medical CPI Governor Patrick instructs Division of Health Care Finance and Policy to review provider contacts Attorney General reports on hospital prices showing that market clout, not quality, rules the roost GIC offers lower cost limited network choices high cost providers excluded Payment reform Commission recommends end to fee for service Why the CPI Initiative? The rising cost of health care is unsustainable. The GIC itself spends over $1 Billion a year on health care! Variation in practice patterns and care in the United States has been well documented in countless studies. Expert opinion suggests that the best way to save money while improving

the quality of care is to focus reform efforts on the delivery system itself. Transparency + consequences (such as public reporting and tiering) have been shown to drive improvements in performance. Specialists account for most of the spending focus there first History of the GICs Clinical Performance Improvement (CPI) Initiative Launched in the summer of 2003, the GICs CPI initiative was designed to: Control cost increases for employees and the Commonwealth Maintain a comprehensive level of benefits

Maintain participants choice of providers Improve healthcare quality and safety Inform enrollees about provider performance measures of efficiency, affordability and quality Encourage members to maintain good health practices Key Dates in the CPI Initiative First database and efficiency analysis Spring 2004 through 2005

RHIs first quality analysis Fall 2005 2 tiered model for active employee plans Summer 2006 1st Generation Tiered Products Released 3 tiered model for active employee plans Spring/Summer 2008 2nd Generation Released Premier data aggregation firm (ViPS) chosen to develop database Summer 2009 Probability analysis to enrich quality scoring Fall 2009

How Does the CPI Initiative Work? Develop a Database of book-of-business health claims Physicians in tiered specialties receive a Quality and an Efficiency Score All 6 Health Plans receive physician scores and then tier physicians Recommended Distribution: 20% Tier 1, 65% Tier 2, 15% Tier 3 Variation allowed to match data clusters Patient co-pays based on provider tier Ranging from $15 to $45

Goals: 1. To Provide Information to Patient at Point of Purchase 2. To inform physicians as to their relative performance Annual Database Development Process Tufts Data Harvard Pilgrim Data UniCare Data HNE Data

Fallon Data Neighborhood Data Master Provider ID Defined Approximately 142 million claims sent to ViPS ViPS Validation of Claims Standardized Definitions Master Provider File Approximately 15,000 physicians are linked and have specialties defined

Requires extensive review and cross checking by vendors and plans Providers culled from plan data submissions ViPS links providers across plans Health plans review and edit this list Master provider file used

in analysis Quality Methodology Process Overview Resolution Health Inc. (RHI) uses claims-based process measures to evaluate the quality of care provided by a physician. The RHI measures are derived from nationally recognized organizations (such as NQF), specialty societies (such as ACC and AHA) or the peerreviewed medical literature. They are essentially rules of best practice that can be measured using claims data. Analyses are done to identify whether an opportunity for appropriate care presents itself, and whether that care was actually provided. As of 2009 added a probability model developed by a Johns Hopkins biostatistician to enhance the reliability of the quality score by taking into account:

Patient Behavior Measure Difficulty Physician Impact Year 1: Level of Tiering by Plan FY07 Green indicates individual level tiering; Red indicates group level tiering >>> Specialties PPO / Indemnity Plans HPHC THP* HMO Plans PLUS Choice

BASIC HNE NHP* FCHP Cardiology Endocrinology Orthopedics Rheumatology Gastroenterology OB/GYN Otolaryngology/ENT Pulmonology Dermatology Neurology Ophthalmology Allergy/Immunology General Surgery Urology Hematology & Oncology Pediatrics

Internal Medicine / Family Practice Nephrology Podiatry TOTAL 5 0 all all 0 2 0 1 *THP tiered surgical specialties based on their hospital tiering results. NHP built a selective network of clinical group practices for one year only. Year 2: Level of Tiering by Plan FY08 More specialties were tiered in FY08 with an increasing number tiered at the individual level Specialties PPO / Indemnity Plans HMO Plans

HPHC THP PLUS Choice BASIC HNE NHP 9 8 all all all

6 4 FCHP Cardiology Endocrinology Orthopedics Rheumatology Gastroenterology OB/GYN Otolaryngology/ENT Pulmonology Dermatology Neurology Ophthalmology Allergy/Immunology General Surgery Urology Hematology & Oncology Pediatrics Internal Medicine / Family Practice Nephrology

Podiatry TOTAL 5 Year 3: Level of Tiering by Plan FY09 All GIC health plans have committed to tiering the six core specialties that account for 54% of expenditure. Specialties PPO / Indemnity Plans HMO Plans HPHC THP PLUS Choice BASIC

HNE NHP 12 12 all all all 9 5 FCHP Cardiology* Endocrinology* Orthopedics*

Rheumatology* Gastroenterology* OB/GYN* Otolaryngology/ENT Pulmonology Dermatology Neurology Ophthalmology Allergy/Immunology General Surgery Urology Hematology & Oncology Pediatrics Internal Medicine / Family Practice Nephrology Podiatry TOTAL * Indicates the six specialties that were core in FY09 all Year 4: Level of Tiering by Plan FY10

All GIC health plans have committed to tiering the eight core specialties that account for 66% of expenditure. Specialties PPO / Indemnity Plans HMO Plans HPHC THP PLUS Choice BASIC HNE NHP 13

13 all all all 9 9 FCHP Cardiology Endocrinology Orthopedics Rheumatology Gastroenterology OB/GYN Otolaryngology/ENT Pulmonology Dermatology

Neurology Ophthalmology Allergy/Immunology General Surgery Urology Hematology & Oncology Pediatrics Internal Medicine / Family Practice Nephrology Podiatry TOTAL 16 Lessons Learned 1. Timetable is critical 2. Standardization trumps plan flexibility 3.

Opportunity for physician review is imperative 4. Expect physician opposition, it will come! 5. Dont wimp out West Virginia Public Employees Insurance Agencys Evolving Consumer Engagement Model Presented to Academy Health By Nidia Henderson Health Promotions Director, PEIA Rationale Raising awareness regarding health risk factors is insufficient Financial incentives get attention Financial incentives combined with interventions are most effective

Life expectancy Quality of life Cost effectiveness? Evolving use of incentives Began in year 2000 with tobacco free premium discount combined with cessation program Year 2004 began Face to Face Diabetes Program based upon the Asheville NC project Waives copays for diabetic drugs and supplies if member participates with specially trained pharmacists Diabetes Face to Face West Virginia now has one of the highest incidence of diabetes at 11% Based upon the Asheville, North Carolina model Pharmacists as physician extenders Diabetic drugs and lab copayments waived if member is

compliant with plan of care Good process and clinical outcomes, negligible change in claims costs, but May improve quality of life and increase life expectancy F2F Clinical Measures A comparison of F2F participants with NCQA Standard Measure 2004 2005 2006 2007 2008 2009 NCQA

Members enrolled 476 1618 2348 3127 3641 4394 % BMI>30 66% 68% 70%

70% 70% 70% %A1c <7 55% 51% 55% 56% 56% 52% %A1c <9 90%

90% 91% 91% 90% 91% Average Annual A1c 7.08 7.18 7.11 7.11 7.16 7.34

% LDL <100 47% 54% 57% 59% 61% 59% 44% BP <140/90 56% 58% 64%

64% 66% 70% 69% 70% Diabetes program costs Type of Measure Measure Number Result R1 Result

R2 Measure FY 2009 Target FY 2009 Actual Actual number of members enrolled in Face to face ( includes only members with visits) FY 2010 Target FY 2011 Target 4,394 Reduction in medical and pharmacy claim costs $1.76 million

Result R3 Personal improvement in weight loss and biometrics Output O1 Increase new enrollees in the program Demand D1 Number of people requesting enrollment in the program Efficiency E1 Cost per participant

1 Number of Employees Personal Services Employee Benefits Other Funding Total Funding 753 805 $589.34 Resources FY 2009 Actual See report Challenges and Strategies FY 2010 Budget

FY 2011 Request 1. Prevalence of diabetes in the PEIA population is high (13,000 members) and PEIA is enrolling the sicker diabetic members in the F2F program 2. Data reporting compliance from pharmacists has decreased over the last year due to loss of oversight RN position. 3. 55% of pharmacies are underperforming 4. Lipid and blood pressure pressure parameters are above NCQA standards. 5. Acute care utilization rates are decreased for F2F members (ER visits-11%, Admissions-18%) compared to those never enrolled. 5.Estimated annual savings- $1.76 million Recommendation: Continue current program, provide necessary oversight position, and change current claim payment system such that data must be entered into CAMC-HERI system prior to pharmacy payment. Improve Your Score Began in April 2008

Provides cash rebates Uses stop light system Green/healthy Yellow/moderate risk Red/high risk Stop the 2 pd per year creep IYS Measures Till July 1, 2010 Body Mass Index Total Cholesterol Glucose Blood pressure Comes on a color coded report card for each measure and an aggregate score Financial Incentives Drive Participation IYS Report Card Methodology PEIA IYS Score Card Values

Total Score 80 100 = $50 (Green) 60 79 = $25 (Yellow) 0 59 = $0 Scoring for each of the four categories of the health screening: Green = 25 Points Yellow = 12.5 Points Red = 0 Points 1) Blood Pressure: Systolic Green = 120 and below Yellow = 121 -140 Red = 141 and above Blood Pressure: Diastolic Green = 80 or below Yellow = 81 - 90 Red = 91 and above

The worst reading is always taken between the two. For instance is a BP is Green/Red, Red (0 total points) would be counted towards the total score. 2) Waist Circumference Green Yellow Red 3) Glucose Green = 100 and below Yellow = 101 - 125 Red = 126 or above 4) Total Cholesterol Green = 200 and below Yellow = 201 - 245 Red = 246 and above Men < 40 = or > 40 = or > 43 = or > 35 = or > 38 Women

< 35 PEIA Weight Management Program Eligibility: BMI of 30 or greater; or BMI 25 or greater with related condition Uses dietitians and exercise professionals Up to two years in length Individualized Fitness facility based Featured in CDCs Preventing Chronic Disease Journal Change is inevitable! Premium discount v. cash rebate Every other year versus yearly Process versus outcome measures Discount based upon policyholder

Additional discount for advance directive Waist circumference to replace BMI! Lifestyle, Prevention, DM Pathways to Wellness Worksite Dr. Ornish Reversal/Ornish Spectrum Healthy Tomorrows Interventions Face To Face Diabetes PEIA Weight Management Tobacco cessation Games for Health Camp New You Other Outcomes Forty percent tobacco quit rate

Thirty percent of participants weight loss and maintained Claims savings for those who were sedentary and became active Exponential increases in number of worksites participating and number of participants in IYS Challenges Penetration Networks Administrative costs Sustainability Larger environment sabotages our efforts Large number of people will never change Questions? Report Available at:

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