SEOW Attachment 1 January 8, 2019

SEOW Attachment 1 January 8, 2019

of 4

Oregon Educators Benefit Board

Strategies on Evidence and Outcomes Workgroup

December 4, 2018

Meeting Synopsis

The Strategies on Evidence and Outcomes Workgroup (SEOW) of the Oregon Educators Benefit

Board held a meeting on December 4, 2018 at the Oregon Health Licensing Office.

Attendees:

Workgroup Members:

Tom Syltebo, SEOW Chair

Geoff Brown

Robert Young

Ron Gallinat

Staff/Consultant:

Glenn Baly, OEBB

Ali Hassoun, PEBB/OEBB

Jenny Marks, Willis Towers Watson

Steve Carlson, Willis Towers Watson

Dr. Jeff Thompson, Willis Towers Watson

Brad Lawson, Willis Towers Watson

Carriers/Other Representatives:

Kraig Anderson, Moda Health

Dr. Jim Rickards, Moda Health

Erica Hedberg, Moda Health

Dr. Keith Bachman, Kaiser Permanente

1. November 2018 SEOW Meeting Synopsis (SEOW Attachment 1)

SEOW approved the November 2018 meeting synopsis without any changes.

2. OEBB Coordinated Care Model: Focusing on Primary Care (SEOW Handout A)

Dr. Jim Rickards & Kraig Anderson reviewed Moda’s proposal to redesign the current

Summit/Synergy Plans for the 2019-20 Plan Year, including:

• Summit/Synergy background and need for redesign

• Redesign Concept


of 4

o Merge Synergy/Summit and Connexus Plans

o C-3 like benefits enrollment

o Incentivize through member benefits not price

o Align incentives between member, provider, and payer

SEOW Action/Information Request

Geoff Brown sad OEBB needs to develop a communications plan to explain the benefits of

Summit/Synergy and the medical home model (PCPCH)

Tom Sytebo said SEOW should look at cost / quality relationship in July 2019 Tom Syltebo asked that Moda provide an expanded presentation on development and

implementation of quality and performance metrics that are part of the Data Collaboration in

Summit/Synergy, including:

• Where is Moda going with the Collaborative (goals)?

• What metrics are being considered as part of the move from a claims/payment based model to quality/performance based model?

• Which clinics / providers are involved in the data sharing now and how is the arena of participating providers being expanded?

• Type of data collected, including health risk and outcome data. Deidentified quality

report.

• What is the state of data sharing between Urgent Care Centers and Moda? What are the

plans to expand data sharing between/among Urgent Care Centers and Moda?

• What are Moda’s plans for expanded data sharing in their market outside of OEBB?

Geoff Brown asked that a price variation comparison report be provided major joint surgery

under reference pricing and Summit/Synergy.

Tom Syltebo asked for more detailed review of the total cost of care model and CCM 2.0.

Tom Sytebo said that premium impact data needs to be provided for CCM 2.0 and would like

to review and discuss what happens to existing renewal guarantees

Ron Gallinat asked what implementation challenges Moda foresees for CCM 2.0

Robert Young asked if CCM 2.0 would cause navigation challenges for members.

Tom Syltebo asked what changes need to occur with the current model to incorporate the

External Forces (below) if OEBB decides to stay with the current model


of 4

• SB 1067 - 200% of Medicare

• SB 934 - Medical Primary Care spend requirements

• HB 2009 - Patient Centered Primary Care Homes

• CPC+ Program

• CCO 2.0

3. Utilization and Claim Review: OEBB Opportunity Analysis (SEOW Attachment 2)

Jenny Marks and Dr. Jeff Thompson reviewed the opportunity analysis related to a review of

OEBB claims and utilization, including

• Project objectives

• Scope/Process

• Overview of Findings (claimant examples)

• Carrier next steps

• Carrier report back


SEOW would like additional information re: Ardon Health and Medical Use Evaluation

programs

Tom Syltebo highlighted 3 things from Kaiser to work on /follow up:

• Addressing mental health/compliance with depression medications

• Infusion Rooms

• Proactive chart review by teams for members with high ER utilization

And three 3 things for Moda to work on/follow up:

• Addressing HCC through engagement of members in C3

• Case Management for members with multiple ER visits

• Review potential for Site of Care program for cancer treatment

Tom Syltebo asked what the HbA1c performance measures wants for Kaiser Moda.

4. OEBB Wellness Program – 2019-20 Program Recommendations (SEOW Attachment #3)

Glenn Baly and Jenny Marks reviewed the 2019-20 recommendations for OEBB wellness

programs, including:


of 4

• Overview of Wellness Subgroup Work

• Program/Vendor Review Key Findings

• Weight Watchers Recommendations

• Healthy Team Healthy U Recommendations

• Better Choices Better Health/Virtual Lifestyle Management Recommendations

• Next Steps


SEOW will decide on the wellness program recommendations at the January 8 meeting when

pricing options are provided.

4. New Business (12/4 Board Meeting Request)

• Benefit Change Request – Infertility Benefits

Areas to Consider:

• Types of Infertility Benefits (What’s covered and What isn’t)

• Market prevalence/utilization of infertility benefits

• Number of affected people (level of fertility issues)

• Costs and Premium Impacts

• Any other concerns

No public comment.

willistowerswatson.com

OEBB Wellness ProgramProposed Carrier/Vendor Renewal Costs

January 8, 2019

SEOW Attachment 2

© 2019 Willis Towers Watson. All rights reserved.


Agenda

Summary of current and projected program costs

Proposed vendor renewals — detailed

Better Choices Better Health

Diabetes Prevention/Virtual Lifestyle Management

Healthy Team Healthy U

Weight Watchers

Recommendations

2© 2019 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.

http://natct.internal.towerswatson.com/clients/612555/OEBB2018HB/Documents/January_SEOW_Wellness.pptx

This report was prepared for your sole and exclusive use and on the basis agreed with you. It was not prepared for use by any other party and

may not address their needs, concerns or objectives. This report should not be disclosed or distributed to any third party other than as agreed with

you in writing. We do not assume any responsibility, or accept any duty of care or liability to any third party who may obtain a copy of this report

and any reliance placed by such party on it is entirely at their own risk .


Summary of Current Costs

Program Participants

Costs

2018 – 2019 (Projected)2019 – 2020

(Projected)

Canary Health:

Better Choices Better Health 442 $82,000 $98,000

Canary Health:

Virtual Lifestyle Management572 $130,000 $161,000

Healthy Team Healthy U 7,527 $749,000 $749,000

Weight Watchers 8,935 $1,848,000 $1,250,000

Moda Health Coaching 472 $1,860,000 $1,860,000

Moda Weight Management Included above $580,000 $580,000

Moda Tobacco Cessation 36 $471,000 $471,000

Kaiser Health Coaching 1,390 $251,000 $251,000

Total $5,971,000 $5,420,000

3

2018 – 2019 projected costs are based on participation numbers achieved during the 2017 – 2018 plan year

2019 – 2020 projected costs are based on participation assumptions from the 2017 – 2018 plan year

Actual participation levels for each year may yield higher or lower costs

© 2019 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.


willistowerswatson.comwillistowerswatson.com

Proposed Vendor Renewals




Canary Health

Better Choices Better Health

5

Current offering: chronic condition management peer group support

Access to BCBH application

Small group support system with trained peer moderators

Living a Health Life with Chronic Conditions book/e-book

Weekly lessons and action planning tools

Engagement rate in 2017 – 2018:

Initial enrollment: 442

Completed program: 63

Current and proposed cost structure:

MilestoneCurrent

Cost/milestone

Renewal

Cost/milestone

Initial enrollment in the

program$160 $195

Completion of the six-week

program$175 $195

Projected annual cost $82,000 $98,000




Canary Health

Virtual Lifestyle Management

6

Current offering: diabetes prevention program

Access to VLM application including lessons, weight tracking and group chat

Online coaching support

Activity monitoring and tracking tools

Digital scale with feeds to online tracking tool

Engagement rate in 2017 – 2018:

Initial enrollment/orientation: 423

4 lessons completed: 174



Current cost structure:

$255/initial enrollment

$65/completion of each 4,8 and 16 lesson milestones




Canary Health

Virtual Lifestyle Management (Continued)

7

Canary Health proposed two options for renewal cost structure

Lesson completed approach (similar to current arrangement)

Time based and weight loss milestones

Lesson completed Time and Weight Loss

Initial enrollment/

orientation$195

Initial enrollment/

orientation$195

4 lessons completed $195 Active 1 month $195

8 lessons completed $195 Active 2 – 3 months $195

16 lessons completed $195 5% weight loss $195

Annual projected cost $148,000 $161,000




Healthy Team Health U

Renewal Current Offerings

8

HTHU 1.0, HTHU 2.0 and HTHU 3.0 – 12-week lifestyle behavior change

programs

Supporting Products/Services

Activity/Blood Pressure Monitor

Web Platform/Mobile App

Health Risk Assessment

Guided Meditation App Subscription

Advanced Activity Tracking

Online Coaching

Exercise video series, healthy recipes, digital health games




Healthy Team Healthy U

Renewal Proposal

Participants EnrolledCurrent and Renewal Cost

Structure (PPPY)

Up to 10,000 $84.00

10,001 – 14,999 $81.48

15,000 – 19,999 $79.04

20,000 – 24,999 $76.66

25,000 – 29,999 $74.36

9

Number of Participants

2017 – 2018Projected Annual Cost

7,527 $749,000

Additional costs include activity and blood pressure monitors




Weight Watchers

10

Current offering:

Workplace workshops + digital (13 week voucher)

Community workshops + digital (13 week voucher)

Digital only (three-month subscription)

Initial 13-week program is provided at no charge to the member; subsequent 13-week programs

are available at no charge if the member can demonstrate participation in at least 10 of the 13

weeks

Current cost structure

13-Week Cost

Workplace workshops + digital $163.10 (12.55/week)

Community workshops + digital $125.80 ($9.68/week)

Digital only $57.75 ($4.44/week)




Weight Watchers (Continued)

11

Weight Watchers proposed two alternate pricing structures renewal consideration

Fixed fee of $1,250,000/year for a two-year period with a performance guarantee

Per participant per month structure

Fixed Fee Per Participant Per Month

Workplace workshops + digital

$1,250,000

$44.95 ($10.37/week)

Community workshops + digital $44.95 ($10.37/week)

Digital only $19.95 ($4.60/week)

Projected annual cost $1,250,000 $3,900,000




Recommendations

OEBB staff and consultants recommend accepting the following renewals:

Canary Health’s BCBH renewal as proposed

Canary Health’s VLM proposal for engagement time/weight loss achieved

Renewal of Staywell’s Healthy Team Healthy U program (no change)

Weight Watcher’s fixed fee renewal proposal



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

JANUARY 8, 2019

Robert Valdez, CEBS, FLMI

Principal

P E B B D R A F T R O A D M A P

SEOW Attachment 3

1Copyright © 2019 Mercer (US) Inc. All rights reserved.

P E B B ’ S R O A D M A P V S . O H A’ S C C O 2 . 0

O H A R O A D M A P

2021

• 20% VBP target

2022

• 35% VBP target

2023

• 50% VBP target

2024

• 60% VBP target

2025

• 70% VBP target

• Mercer recommends PEBB consider more aggressive Value-Based-Payment targets:

‒ 2021-2024: Category 2C, transitioning to Category 3

‒ By 2025: Category 3B (APMs with Shared Savings and Downside Risk)

‒ ACO/CCO will be required to have a minimum Category 4 payment model after six years of

development/implementation

2020

• 20% VBP target

2021

• 35% VBP target

2022

• 50% VBP target

2023

• 60% VBP target

2024

• 70% VBP target

• OHA’s CCO payments to providers must be in the form of a VBP and fall within LAN Category 2C (Pay for

Performance) or higher

P E B B D R A F T R O A D M A P

Presenter

Presentation Notes

Voting Do you agree PEBB’s targets aligning with OHA? Do you agree PEBB should be more aggressive than OHA?


P E B B ’ S R O A D M A P V S . O H A’ S C C O 2 . 0

F I N A N C I A L R O A D M A P

Source: APM Framework, HCP-LAN,2017

OEBB Data Roadmap

SEOW Meeting

SEOW Attachment 4

January 8, 2019


Agenda

© 2019 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only. 2

Overview/review of return on investment and value of investment

OEBB data sources

How to measure success

High-level data plan strategy

Vendor-partner data and measurement opportunities

http://natct.internal.towerswatson.com/clients/612555/OEBB2018HB/Documents/SEOW_OEBB%20Data%20Plan_10819_Final.pptx

What do we mean by ROI and VOI?

3

Return on Investment (ROI) measures only medical claims cost savings, while Value on

Investment (VOI) also captures broader impacts of wellbeing programs

ROI VOI

Typically refers to financial benefits divided by program

costs

Claims cost savings targets are typically:

Inpatient admissions and stays

Emergency room visits

Laboratory and imaging tests

Large claims

Pharmacy utilization

Sometimes, ROI calculation includes other easily

monetized savings such as:

Workforce disability

Work absence when available

ROI answers the question — “Did we get cost

savings greater than our wellbeing investment?”

Incorporates a broader range of benefits beyond medical

claims cost reduction alone, that may include:

Population health metrics

Health risks

Biometric measures

Activity, fitness levels

Program participation

Stress, resilience measures

Employee productivity metrics

Absenteeism, lost days from work

Presenteeism

WC, STD, LTD

Other business benefits

Organizational culture of health

Reputation, “employer of choice”

Talent recruitment, retention

Workforce morale

Business competitiveness

Company performance, stock price

VOI answers the question — “What is the total value

we got from our wellbeing investment?”



Full Costs

From Poor Health 30%

70%

Medical Care and

Pharmaceutical Costs

Health-Related

Productivity Costs

Absenteeism Short-term disability

Long-term disability

Presenteeism Overtime

Turnover

Temporary staffing

Administrative costs

Replacement training

Off-site travel for care

Customer dissatisfaction

Variable product quality

ROI is an incomplete measure of potential wellbeing benefits

Conventional ROI analyses only address the tip of this iceberg

4

Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152



Which programs are appropriate for ROI evaluation and which are

appropriate for VOI evaluation?

5

Type of Program Target PopulationImpact on Medical

Claims

Appropriate

Evaluation Method

Wellbeing programs aimed at

improving physical, emotional,

financial and social health

The entire population Little or no impact on

short-term medical

claims costs

VOI

Medical management programs

aimed to better coordinate care of

those with serious illness

High-risk portion of

covered population

Should lower short-term

medical claims costs

ROI

All employer-sponsored programs bring unmeasured additional value to

employers to the extent they are valued by members



OEBB data sources — 2018

6

Kaiser and Moda:

Medical claims and spend

Rx claims and spend

Risk level by chronic condition

Engagement/participation condition management

Outreach condition management

Canary Health:

Annual report — Better Choices Better Health

Annual report — Virtual Lifestyle Management

Weight Watchers:

Annual reporting:

Communication and outreach

Engagement and participation

Outcomes

Modality

Research report with Kaiser

HTHU — StayWell:

Annual report:

Communication

Engagement and completion by program

Self-reported outcomes

Data Warehouse:

Truven warehouse — WTW and carriers

Additional:

BSSE survey

HERO report (Kaiser)

WTW data request spreadsheet to vendors

Program awareness survey

OEA Choice Trust — data on entity activity

Stress and resiliency vendor (Kaiser) (Future)

OEBB website click rate and type (Potential)

Communication outreach and type



How to measure success

© 2019 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only. 7

Sample list

Increase in participation in all programs — from prior year

Increase in completion rates in all programs — from prior year

Increase in entity engagement — from prior year

Verified data indicating reduction of risk factors, i.e., lower blood pressure, increase in HDL

Verified weight loss

Participant vs. non-participant and/or cohort analysis year-over-year: vendor-partner, carrier, data warehouse

Risk migration (low, moderate, high)

Improved overall health risk score

Increase in preventive exams/primary care engagement

Closure of gaps in care for specific conditions

Rx analysis, i.e. individual’s reduction in medication (Metformin)

Employee satisfaction

• Overall

• Specific programs

• Current program offerings

Increased use of OEBB wellbeing communication resources, i.e., website


Data plan overview

8

2019 – 2020 2020 – 2021 2022 – 2023

Engagement & Data Alignment

Identify participation for each

program and offering

Establish benchmarks and

participation goals

Establish cadence of reporting

Measure current year against past

years, benchmarks and goals

Review data against success

metrics established with vendor-

partners

Completion rate

Participation

Identify areas for cohort analysis

Diabetes participants

WW participants

Work with OEA Choice Trust and

Moda’s Wellbeing Consultants to

establish entity participation and

goals

Measurement & Analytics

Continue participation and

engagement measurement

Establish specific program analytic

projects for each vendor-partner

specific to VOI, ROI, participant

vs. non-participant, medical, Rx

claims, etc.

Cohort risk reduction

Verified weight loss

Conduct cost/benefit analysis and

areas of opportunity

Identify opportunities for

measurement within the Truven

data warehouse

Create dashboards for quarterly

and annual review

Ongoing Review & Analysis

Continue prior year’s projects

Enhance measurement scope to

include additional data elements:

(for example)

EAP utilization

Financial programs

Entity engagement

Add, enhance or remove vendor-

partners based on data and

impact



Weight Watchers (WW)

9

Metrics:

Eligible population

Registered for program

Number of sessions/weeks attended

Completion of program

Average reported weight (self-reported or verified)

Average percent of weight loss

Additional program outcomes

Targeted outreach to members

Opportunities:

Engagement and completion metrics by modality and location

Cohort year-over-year reporting

Work with carriers or WTW’s measurement team to assist with ROI analysis (similar to Kaiser and WW report)

Need WW-provided benchmarks for above metrics



Wellbeing vendor — HTHU (StayWell)

10

Metrics:

Eligible population

Employees with registrations

Participation in various program offerings

Completion of various programs started

Self-reported outcomes (pre/post)

Satisfaction

Opportunities:

Verified data, i.e., physician forms, biometrics, digital scale, digital blood pressure, etc.

Aggregate data by location

Cohort data — year over year

Integration with Kaiser and Moda for participant/non-participant analysis

Current data and metrics are suitable for VOI. Verified data integrated with medical claims, etc. could produce ROI

analytics (participant vs. non-participant, program-specific impact analysis, etc.)

Decisions regarding OEBB’s relationship with StayWell will impact metrics and analysis

Decisions regarding incentives and marketing of HTHU with impact metrics and analysis



Metrics BCBH:

Clinically eligible population — Kaiser and Moda

Members signed up

Members started a workshop

Members attended 4 of 6 week “Completion”

Members completing all 6 weeks

Satisfaction

Member outreach

Opportunities:

Verified biometrics

Cohort year-over-year reporting

Aggregate risk migration of identified members, i.e. Low risk in year 1 to moderate risk in year 2

More meaningful metrics around claims and spend — participant vs. non-participant (Canary, carrier, data warehouse)

Work with WTW’s measurement team to assist with ROI analysis (currently receiving claims data from both Kaiser and

Moda)

Identify ways to track member’s participation in online condition management programs for analysis

Need Canary Health provided benchmarks for above metrics

Metrics VLM:

Eligible population — Kaiser and Moda

Members signed up

Members enrolled

Members completed lessons 4, 9 and or 16

Member average weight, BMI and weight loss

% of members that lost at least 5%

Satisfaction

Member outreach

Chronic condition — Canary Health

11

Better Choices Better Health (BCBH) and Virtual Lifestyle Management (VLM)



Chronic condition — Kaiser and Moda

12

Metrics:

Eligible population — medical plan participants with diagnosis of diabetes, asthma, COPD, HF or CAD

Stratification of member risk by condition — low, moderate or high

Confirm only moderate or high-risk members are targeted for condition management programs

Participation in condition management programs ← engagement Completion of condition management programs started

Management of condition, i.e., A1c (HEDIS measures)

Rx and medical claims for analysis (participant vs. non-participant, closure of gaps in care, etc.)

Targeted outreach to members

Opportunities:

100% outreach to moderate and high-risk members

Cohort year-over-year reporting — compliance and Rx dosage and adherence

Aggregate risk migration of identified members, i.e., low risk in year 1 to moderate risk in year 2

Work with WTW’s measurement team to assist with ROI analysis (currently receiving claims data from both Kaiser and

Moda)

Identify ways to track member participation in online condition management programs for analysis

Need Kaiser- and Moda-provided benchmarks for above metrics



13

Sample Dashboard Example

Appendix



VLM, 5%

Canary, 6%

W.W. , 47%

HTHU, 26%

Chronic Condition - Kaiser ,

8%

Virtual Lifestyle Management (DPP Program):

• 16 week core program, followed by eight monthly maintenance lessons

Moda Condition Management:• Engagement in Moda’s chronic

condition management program –moderate and high risk members –was 18%

18%

Healthy Team Healthy U (HTHU):• A clinically validated workplace wellness

program proven to impact behaviors, improve employee health, and deliver outcomes

Blood Pressure:Percentage of subscribers with a recorded blood pressure ≥ 140/90

Smoking:Percentage of subscribers who have indicated they are smokers

Depression:Percentage of subscribers with recorded diagnosis of depression

Weight (BMI):Percentage of subscribers with a recorded BMI ≥ 30

Diabetes:Percentage of subscribers with a recorded diagnosis of diabetes

High Cholesterol:Percentage of subscribers with recorded high cholesterol

Wellness Program Costs:

Health & Lifestyle Risk - Kaiser Annual Wellness Report 2016

Financial

Benchmark: 9% (Kaiser) Benchmark: 6% (Kaiser)Benchmark: 43% (Kaiser)

Benchmark: 35% (Kaiser)

2019 Engagement

7%

SAMPLE - OEBB Wellness Program Dashboard- 2019

Canary Health (Chronic Conditions):• Targeted outreach to Moda members with

COPD, Depression, Diabetes, Hyperlipidemia, Hypertension, or Rheumatoid Arthritis (Kaiser members may opt in)

1.5%

SAMPLE - Program Participation 2018 – 2019

2018 2019 % Change

Chronic Condition

Kaiser

Chronic Condition

Moda

Weight Watchers

HTHU

Canary Health

Virtual Lifestyle

Mgmt

Weight Watchers:• 13 week sessions in the

workplace, local community meeting, or online

• Participants can attend 4 – 5 sessions per year, but must attend 10 – 13 meetings to enroll in the next session

9%

43% 8% 6%

Benchmark: 14% (Kaiser) Benchmark: 8% (Kaiser)

8%7%36%

Results

Low physical activity 72%

Nutrition risk 99%Weight management risk 69%Quality of health – Good/Better 52%Quality of life – Good/Better 68%

Note: Shaded areas denote benchmark value.

Kaiser Total Health Assessment:

6%

Program Costs and % of Total 2015 – 2016

Weight Watchers HTHUChronic

Condition Moda

Chronic Condition

Kaiser

CanaryHealth VLM Total

ProgramCosts

$XXX,XX $YYY,YY $ZZ,ZZZ $AA,AAA $BB,BBB $CC,CCC $XYZ,ABC

Annual Wellness Costs - % ofMedical / Rx premiums:

$2,366,112(Total Wellness Program Cost)

$648,546,743(Total Medical & Rx

Premium)

0.4% of Total Premium)

Individual Program % of Total :




Fertility/Infertility Benefit Coverage

OEBB

January 8, 2019

SEOW Attachment 5



Agenda

Background

Current OEBB plan provisions for infertility

What are other employers offering?

Specialty vendors landscape

Coverage options and examples

Appendix


http://natct.internal.towerswatson.com/clients/612555/OEBB2019HB/Documents/Infertility_Benefit_Overview.pptx

This report was prepared for your sole and exclusive use and on the basis agreed with you. It was not prepared for use by any other party

and may not address their needs, concerns or objectives. This report should not be disclosed or distributed to any third party other than as

agreed with you in writing. We do not assume any responsibility, or accept any duty of care or liability to any third party who may obtain a copy

of this report and any reliance placed by such party on it is entirely at their own risk .


Background

Infertility is a relatively common issue in the

U.S.

11% of women have impaired ability to get pregnant

or carry a baby to term

9.4% of men aged 15 – 44 have some form of

infertility*

Coverage of the diagnosis and conventional treatment of

infertility is relatively common among employer health

plans; however, coverage of higher-cost Assisted

Reproductive Technology (ART) procedures such as In-

Vitro Fertilization (IVF) is still evolving


*Infertility and Impaired Fecundity in the United States, 1982 – 2010: Data From the National Survey of Family Growth, Number 67, August 14, 2013

Assisted Reproductive Technology (ART)

ART-conceived infants contribute to the prevalence of

low birthweight and preterm deliveries and the

percentage of twin ART-conceived infants remains

persistently high1

Women with multiple pregnancies have higher

systemic and localized comorbidities compared with

women with single birth pregnancies2

Pregnancies with delivery of twins

cost ~5X as much as single birth

Pregnancies with delivery of triplets or

more cost nearly 20X as much2

Multiple birth rate varies by 100% across U.S. employers

Evidence-based practices and genetic

screening technology can reduce multiple births,

high-risk pregnancies, complications — and costs

Average adjusted total all-cause health care cost2

$21,458 per delivery with single birth

$104,831 with twins

$407,199 with triplets or more

Twins and triplets or more were more likely to have

stayed in a neonatal intensive care unit than were

singletons2

1Assisted Reproductive Technology Surveillance — United States, 2014, CDC, February 10, 2017; 2Healthcare expenses associated with multiple vs singleton pregnancies in the

United States, AJOG, December 2013; 3Births, Methods of Delivery, CDC, 2015


https://www.cdc.gov/mmwr/volumes/66/ss/ss6606a1.htm

http://www.ajog.org/article/S0002-9378(13)01043-0/fulltext

https://www.cdc.gov/nchs/fastats/delivery.htm


OEBB’s Current Infertility Coverage

OEBB’s contracts with Moda and Kaiser both currently exclude any coverage related to

infertility (office visits, diagnosis and/or treatment of infertility, artificial insemination)

The PEBB program currently provides limited coverage (50% coinsurance) for infertility:

Infertility defined as the inability to become pregnant or the inability to carry a pregnancy to term

as evidence by three consecutive, spontaneous miscarriages. PEBB Plans cover limited infertility

services including:

– Office visits, diagnostic tests and medical and surgical procedures to treat infertility

– Limited coverage for artificial insemination




Willis Towers Watson 2017 Maternity, Family and Fertility Pulse Survey

HighlightsIn 2017, Willis Towers Watson conducted a survey of nearly 500 employers around their maternity, family and fertility

benefits, including their plans for the future.


Sample: Companies with at least 100 employees and offers fertility benefits

Source: 2017 Willis Towers Watson Maternity, Family, Fertility Pulse Survey.

Does your organization include any of the following limits on

the coverage of fertility services?

58%

34%

23%

16%

11%

Lifetime limit medical/surgery

(Median limit: $15,000)

Lifetime limit pharmacy

(Median limit: $10,000)

Other limits

Limit the number of cycles

(Median limit: 3.0 cycles)

No limits

15%

5%

5%

3%

83%

Eggs for medical indications only

(as part of cancer treatment/IVF)

None of the above

Other

Sperm

Eggs for delayed pregnancy at

woman's discretion

Does your organization offer coverage for cryopreservation

for any of the following?

of firms covered fertility

services as part of their

medical benefit plan, with an

additional 10% of firms

expecting to do so by 2019

of firms planned to

enhance their benefit plan

design offering for fertility

services in 2018

of firms covering fertility services

do so for same-sex members

regardless of their underlying

fertility, with an additional 16%

planning to do so by 2019

55% 65%17%



Willis Towers Watson 2017 Maternity, Family and Fertility Pulse Survey

Continued




Integrated Family Assistance is Evolving as a Leading Edge Benefit Design


Maternity,

Infertility

and Family

Assistance-

Related Benefits

Supporting Working Parents

Family Planning Maternal Care

Centers of excellence;

custom networks

Digital health engagement

Family and fertility solution

Infertility treatment

Plan design

Surrogacy and adoption benefits

Behavioral health program

Communication approach

Cost and quality transparency

Health plan maternity care

and management programs

Member education

Pharmacy management

Childcare resources

Data analytics, warehouses

and benchmarking

Employee assistance programs

Flexible work arrangements

Parental leave programs

Leading edge employers tend to focus on a holistic approach to family friendly benefits

approach — supported by a variety of specialty vendors



Marketplace Solutions


Source: CBINSIGHTS Research Briefs, The Femtech Market Map, January 26, 2017


https://www.cbinsights.com/research/femtech-market-map/


Infertility: Evidence-Based Coverage Approach Recommendations

No benefit Unmanaged benefitBest practice:

Evidence-based benefit

Coverage All coverage is paid out-of-pocketCoverage provided with few or no

limits

Coverage provided at Centers of

Excellence (COEs) with eSET,

where appropriate, subject to

benefit limits, where allowed

Patient

Education

Patients have little information

about the highest quality infertility

center

Patients have little information

about the highest quality infertility

center

Patients steered to infertility case

management resources and COEs

Evidence-

based

medicine

Patients seeking success with a

single cycle are more likely to have

multiple embryos transferred

Patients might continue treatment

cycles when there is low likelihood

of pregnancy, raising costs and

delaying consideration of adoption

or other alternatives

Patients utilize:

COEs

Mandatory elective single embryo

transfer (eSET), where

appropriate

Multiple

gestationsHigher rate of multiple gestation Higher rate of multiple gestation Lower rate of multiple gestation

Costs

Low infertility treatment costs as

patients are very cost sensitive

Potentially higher downstream

NICU costs

High infertility treatment costs as

patients demand expensive

treatment

Potentially higher downstream

NICU costs

Moderate infertility treatment

costs

Potentially lower downstream

NICU costs

© 2019 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.9



Potential Coverage Options — Examples


Description Limited Benefit Full Benefit

Level I

Diagnosis and surgical treatment of

the underlying cause of infertility (i.e.,

counseling, testing and treatment of

infertility)

Sterilization reversal

Covered at applicable

deductible/coinsurance level


deductible/coinsurance level

Level II Ovulation induction

Intrauterine insemination

50% coverage up to $15,000

lifetime maximum per

member


deducible/coinsurance level

up to $15,000 lifetime

maximum per member

Level III

Advanced reproductive services:

In-vitro Fertilization (IVF)

Zygote Intra-Fallopian Transfer (ZIFT)

Gamete Intra-Fallopian Transfer

(GIFT)

Pre-Implantation Genetic Diagnosis

(PGD)

Cryopreserved embryo transfers

Intracytoplasmic Sperm Injection

(ICSI); or ovum microsurgery

Not covered


deducible/ coinsurance

level. Separate/Additional

$15,000 lifetime maximum

per member.

RxSeparate Lifetime maximum

of $10,000 per member

Separate Lifetime maximum

of $10,000 per member

OtherUse of COE, warrantees/performance guarantees

Limits on number cycles, age limits


willistowerswatson.comwillistowerswatson.com

Appendix




Infertility Coverage Under PEBB Plans


Moda:

Infertility — covered at 50%

Infertility is defined as the inability to become pregnant or the inability to carry a pregnancy to term as evidence by

three consecutive, spontaneous miscarriages. The Plan covers infertility services including:

Diagnostic testing and related office visits to determine the cause of infertility

Examination, related laboratory testing and medical and surgical procedures to treat infertility

Artificial insemination, limited to a lifetime maximum of six cycles and sperm wash

Acquisition cost for semen

Infertility — covered at 50%

We cover treatment of involuntary infertility and artificial insemination, subject to utilization review using criteria

developed by Medical Group.

Infertility services include diagnostic imaging and laboratory tests, limited to tests to rule out sexually transmitted

diseases, hormone level tests, semen analysis and diagnostic laparoscopy or hysteroscopy. This benefit

includes diagnosis of both male and female infertility, however Services are covered only for the person who is

the member

Exclusions include the cost of donor semen, donor eggs, services related to procurement storage, oral and

injectable drugs used for the treatment of infertility, services related to conception by artificial means and

services to reverse voluntary, surgically induced infertility.


From PEBB’s handbook

Kaiser:


Compliance Issues Around Infertility Coverage

13

The ACA did not mandate expanded infertility coverage, but 19 states include some form

of infertility treatment as part of their state benchmark plan

13 states mandate infertility coverage and nine require IVF coverage1

Mandates vary widely and include various limitations and exclusions

1Listing reflects mandates as of 04/27/2018 from the National Conference of State Legislatures2Mandates that insurers must offer coverage to group policy holders; employers have discretion as to whether to offer to members as a coverage option

Infertility and IVF mandate Infertility mandate only IVF mandate only

Connecticut

Hawaii

Illinois

Maryland

Massachusetts

New Jersey

Rhode Island

California2

Louisiana

Montana — HMOs only

New York

Ohio — HMOs only

West Virginia — HMOs only

Arkansas

Texas2



http://www.ncsl.org/research/health/insurance-coverage-for-infertility-laws.aspx


Wide Variation Among States, Even When IVF Coverage is Mandated:

14

State Applies to:Examples of Allowed

Limitations/Exclusions

Waiting Period for IVF

Coverage*

Arkansas Individual/group health plans

that provide maternity benefits

Lifetime maximum of $15,000

(equivalent to average cost of single

IVF cycle)

Two years of unexplained

fertility

Hawaii

Individual/group health plans,

hospital contracts, medical

service plans providing

pregnancy-related benefits

Coverage not required for first-line

less expensive treatments

One time only benefit

At least a five year history

of infertility using other

infertility treatments

Maryland

Individual and group plans

delivered in-state that provide

pregnancy-related benefits,

HMO’s in some cases

$100,000 lifetime benefit cap

Limit of three attempts/live birth

Two years of attempts with

less costly covered

treatments

Texas

Group health insurance policy

and HMO offering pregnancy-

related benefits

Only mandate to offer not cover

Excludes coverage for first-line less

expensive treatments

At least five year history of

infertility

*Waiting period may be waived in some cases if proof of specified underlying medical condition.

Sources: American Society for Reproductive Medicine (ASRM), http://www.asrm.org/insurance.aspx

Notes

Often allow exemptions for self-insured employers, HMO’s and in some cases government and religious organizations

Many only require coverage for the policyholder or policyholder’s spouse and include conditions requiring that the patient

or policyholder’s eggs be fertilized by the spouse’s sperm, which may exclude unmarried and same-sex couples



SEOW Attachment 1 January 8, 2019

Documents

Transcript of SEOW Attachment 1 January 8, 2019