2016 Legislative Interim Committee on State Employee Group ... · 2016 Legislative Interim...
Transcript of 2016 Legislative Interim Committee on State Employee Group ... · 2016 Legislative Interim...
2016 Legislative Interim Committee on State Employee Group Insurance & Benefits
Friday, Oct. 7, 2016
© 2016 Regence BlueShield, all rights reserved.
OBJECTIVES
1. Introduce Regence BlueShield of Idaho
2. Share an employer perspective and a health care vision of the future
3. Share experiences of shifting from fee-for-service to value-based provider/hospital reimbursements
4. Discuss state of the art in transparency and consumer engagement tools
VALUE-BASED REIMBURSEMENT • Encourages collaboration with physicians and
hospitals.
• Provides data and supporting analytics to providers
• Ties reimbursement to quality improvement
• Goal is to lower the cost of care by shifting focus from the quantity of care to the quality of care
© 2016 Regence BlueShield, all rights reserved.
PHYSICIANS: TOTAL COST OF CARE • PPO Network
• Share claims data & provide analytic support: complete transparency for providers
• Agree on cost trend and quality targets
• Shared savings payout tied to quality performance; gain-share only
© 2016 Regence BlueShield, all rights reserved.
HOSPITALS: PAY FOR PERFORMANCE • Three-Year Program • CMS Value-Based Program
• e.g., CMS Hospital Compare; PSI 90; HCAHPs
• Year One: Minimum increase, agree on improvement target • Years Two & Three: increases tied to quality improvement • Meeting or exceeding target results in increased reimbursement • Mitigates cost-shifting to commercial payers from CMS losses • Participants: Portneuf Hospital, St. Alphonsus Hospitals,
Northwest Specialty Hospital, Kootenai Health, EIRMC
© 2015 Regence BlueShield of Idaho, all rights reserved. Private and confidential.
© 2016 Regence BlueShield, all rights reserved.
THE BENEFITS OF VALUE-BASED REIMBURSEMENT
• Prepares Idaho providers for federal requirements coming in 2018
• Rewards quality improvement • Brings an added measure of cost stability • Supports, but does not require, the use of high-
performing networks • Distinctly different emphasis on quality versus
simply the quantity of care
© 2013. Regence BlueShield of Idaho, all rights reserved. Private and confidential.
© 2016 Regence BlueShield, all rights reserved.
78% would have done something different had they known the price of care in advance
76% would use online tools if they were aware
69% are unaware of online tools
THE ISSUE IS THAT PEOPLE AREN’T ENGAGING
10
April 2015 Survey | 1,276 US Consumers
© 2016 HealthSparq, Inc. All Rights Reserved.
HealthSparq Magnify is looking at ways to improve consumer awareness and access to drive higher engagement rates and lower healthcare spend.
11
FOR EMPLOYERS:
12
ANALYTICS AND INSIGHTS
TARGETED CAMPAIGNS
Identify areas of savings opportunity
• Targeted Incentives • Personalized Alerts • Tailored Campaigns
FOR EMPLOYEES:
13
MEASURE EMPLOYEE ENGAGEMENT
Cycle Repeats • Lower
healthcare costs
• Maximize overall return on spend
• Increased employee satisfaction
Employee Engagement
HealthCare Advisors
Online Tools
Wellness/ Telehealth
Incentives/ Rewards
Bill Review
Mobility
© 2016 Regence BlueShield, all rights reserved.
Integrating Medical + Rx for what’s ahead
Citation: 1. Culley EJ, Williams LC, Thomas L. Pharmacy Benefits Carve-In: The Right Prescription for Cost Savings. Benefits & Compensation Digest 2010; 47(11):22-26. http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=da7c8ed3-fd61-4d61-983c-54690231d77a%40sessionmgr11&vid=2&hid=23. Accessed June 28, 2013. 2. Smith-McLallen A. Effects of Pharmacy Benefit Carve-In on Utilization and Medical Costs: A Three-Year Study. Benefits Magazine 2012;49(2):1-6 http://www.ifebp.org/pdf/webexclusive/12feb.pdf. Accessed June 28, 2013. 3. Wells P, Ness D. Pharmacy Carve-In: The Value of Integrated Benefits. Premera Blue Cross. 2011. Washington Healthcare News. http://www/wahcnews.com/newsletters/wa-premera-0412.pdf. Accessed June 28, 2013.
Triple Aim Attainment: Improve patient experience, Improve population health, Reduce costs Better consumerism and plan control is obtained through integrating pharmacy benefits with medical benefits. Results in additional savings from coordinated copayments and coinsurance levels, formulary management, tiered benefit plans, prior authorization, quantity limits, mail order programs and specialty pharmacy programs.
INTEGRATED MEMBERS EXPERIENCE
53% of high cost “budget-buster” Rx drugs will manifest on the medical claims in next 6 years
© 2016 Regence BlueShield, all rights reserved.
Specialty set to eclipse Traditional
Traditonal 78%
Specialty 22%
2014
Traditional 50%
Specialty 50%
2018
Optimum Value List
Specialty Select
Adherence & Compliance
Home Delivery Options
Technology
1. Generic
3. Preferred Brand
lower cost
higher cost
Consumer engagement
1. Preferred Generic 1. Generic
2. Non-Preferred Generic
2. Preferred Brand
3. Non-Preferred Brand
3. Preferred Brand
4. Non-Preferred Brand
5. Preferred Specialty
6. Non-Preferred Specialty
© 2016 Regence BlueShield, all rights reserved.
Common Plan Design Smart Choice Design
Consumer Decision Aides
The Growing Impact of Prescription Drugs
10/11/2016 19 © 2016 MedSavvy – All Rights Reserved
• Drug cost in our country is unsustainable • By 2020, US spending on specialty drugs will go from $48B (2012) to $201B • 6 in 10 Americans took one prescription drug in the last 30 days
$224 $236 $243
$255 $256 $263 $261 $262 $276
$295 $312
$331 $351
$373
$398
$426
$455
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
6.3%
Patients Are Engaging
10/11/2016 20 © 2016 MedSavvy – All Rights Reserved
• Searching to understand evidence • Seeking the wisdom and evidence of a community • Comparing patient ratings and reviews • Looking for ways to save money
Consult online reviews of drugs
Got information, care or support from others with the same condition
Participate in any online social activity related to health in past year
Gather health information online
CAREGIVERS AND HEALTH ACTIVITIES1
24%
30%
52%
72%
37% Asked MD or RPh for less expensive generic
1Pew Internet and American Life Project, 2013 http://www.consumerreports.org/cro/news/2015/08/are-you-paying-more-for-your-meds/index.htm
The Current Prescription Experience
10/11/2016 21 © 2016 MedSavvy – All Rights Reserved
MD Decides
Informed Habits
Patient requests – 7% → 70% of requests are fulfilled by provider
57% Sends to pharmacy
via EMR
43% Hands paper Rx to
patient
2/3 Will fill first Rx
Pharmacy Adjudicates Rx:
Discounts, Fees, Rebates,
Retail Margin
Patient Starts Rx
Sticker Shock: 24% avoid filling prescription
due to cost
Up to 50% stop within 90 days
2.6 callbacks per day per practice; 15+ hours per week
Unclear Costs, Formulary Restrictions
Prescription experience with MedSavvy
10/11/2016 22 © 2016 MedSavvy – All Rights Reserved
MD Decides
57% Sends to pharmacy
via EMR
43% Hands paper Rx to
patient
2/3 Will fill first Rx
Pharmacy Adjudicates Rx:
Discounts, Fees, Rebates,
Retail Margin
Patient Starts Rx
Sticker Shock: 24% avoid filling prescription
due to cost
Up to 50% stop within 90 days
2.6 callbacks per day per practice; 15+ hours per week
Unclear Costs, Formulary Restrictions
Costs, formulary, evidence-based
summaries
Personalized fulfillment options
Clear pricing
Armed with clinical
information
Evidence-based notifications
+ Patient
What is MedSavvy?
• MedSavvy (MedSavvy.com) gives patients and doctors easy access to medication options, effectiveness results, prices and personal experiences to help them find the best treatment at the best cost.
• Our specialized pharmacy team reviews available evidence on how well medications work, how good the science is for that research, and assigns each drug an evidence grade that can be used to easily compare treatment options.
H e l p p a t i e n t s a n d p r e s c r i b e r s m a k e b e t t e r m e d i c a t i o n d e c i s i o n s
10/11/2016 23 © 2016 MedSavvy – All Rights Reserved
10/11/2016 26 © 2016 MedSavvy – All Rights Reserved
THANK YOU Sean Karbowicz Founder, Lead Pharmacist [email protected] MedSavvy.com