2015 BAW Conference SHP Update 2016 Laura Smoak and Rob Tester.
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Transcript of 2015 BAW Conference SHP Update 2016 Laura Smoak and Rob Tester.
2015 BAW Conference
SHP Update 2016
Laura Smoak and Rob Tester
Monthly contributions effective January 1, 2016
• 4.5 percent increase for employers in 2016
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Employer rates 2015 2016
Enrollee only $344.58 $360.10
Enrollee/spouse $682.54 $713.26
Enrollee/child $528.88 $552.68
Full family $854.58 $893.04
Monthly contributions effective January 1, 2016
• No increase for enrollees in 2016
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Savings PlanStandard Plan/
Medicare Supplement
Enrollee only $9.70 $97.68
Enrollee/spouse $77.40 $253.36
Enrollee/child $20.48 $143.86
Full family $113.00 $306.56
Benefit designeffective January 1, 2016
• In general, there are no increases to the deductible, copayments or coinsurance amounts.
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Patient-Centered Medical Home
• Patient-Centered Medical Home (PCMH) is a health care delivery model that strengthens the physician-patient relationship through a team of providers who meet all the patient’s health care needs
• By the end of 2015, BCBSSC anticipates certifying 225 physician practices in South Carolina as participating PCMHs (approximately 751 physicians)
• Effective January 1, 2016:• Waive member’s $12 physician office visit copay at participating
PCMH• Member coinsurance will be paid at 10 percent versus 20
percent at a participating PCHM
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BCBSSC’s Patient-Centered Medical Home ProgramNoreen O’Donnell August - September 2015
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A move from reactive care to proactive care
The Patient-Centered Medical Home (PCMH) is a model of care designed to strengthen the physician-patient relationship by moving from episodic (reactive) care to coordinated (proactive) care.
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Source: “Joint Principles of a Patient-Centered Medical Home,” Adopted March 2007 by: American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association
Personal physician
Physician directed
team
Whole person
orientation
Coordinated, integrated
care
Emphasis on
quality and
safety
Enhanced access
Appropriate payment structure
Member Care Team
Patient-Centered Medical Home
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PCMH: changing the way we care
PCMH Care
• Coordinated (proactive) care
• Care for patient overall health
• Same-day appointments
• Care delivered by physician-led team with right skills at right time
• PCMH coordinates all patient’s care
• Coordinated referrals within the PCMH
• Ongoing follow-up care to avoid disease and improve health
Today’s Care
• Episodic (reactive) care
• Treat patient symptoms
• Appointments unavailable
• Care varies by scheduled time and memory or skill of the doctor
• Patients are responsible for coordinating care among their providers
• Uncoordinated referrals that lead to less-than-optimal treatment and gaps in care
• Limited follow-up care
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PCMH: continuous quality improvement
Robust IT infrastructure
A PCMH continuously monitors performance:
-Health improvement
-Gaps in care
-Patient satisfaction
-Health outcomes
-Cost measures
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Why use a PCMH?Three dimensions of value
Population health
Population health
Experience of care
Experience of care
Per capita cost
Per capita cost
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Value
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Why use a PCMH?
• PCMH recognition through the National Committee for Quality Assurance (NCQA)
• 40,000 practitioners
• 8,100 locations across the country
• Reasons to support the PCMH model.
─ Overall reduction in costs ─ Proactive instead of reactive care─ Reduction in hospital admission rates─ Reduction in ER Visits─ Improved staff satisfaction in PCMH practices─ Improved patient health outcomes
The model is recognized globally as key to reform.
Outpatient visits; pharmacy utilization
ER visits; inpatient visit
South Carolina’s
PCMH Program
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BCBSSC’s PCMH practice transformation
• Achieve PCMH recognition• National Committee for Quality Assurance (NCQA) or other
accrediting body
• BCBSSC Innovation Specialists “transformation roadmaps”• Based on practice goals, needs and resources• Help achieve NCQA PCMH Recognition Standards requirements
• “Must pass” elements of NCQA PCMH recognition • Patient-centered access• Team based care• Population health management• Care management and support• Care coordination and care transition• Performance measurement and quality improvement
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PCMH growthRapid expansion in the last three years
PCMH 2012 2013 2014 EOY 2015
Practices 56 111 176 225
Physicians 195 414 601 751
SHP chronic members 11,226 15,528 22,821 28,516
SHP total membership 31,612 52,689 81,885 102,321
PCMH physiciansPCMH physicians Chronic membersChronic members Total membersTotal members
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BCBSSC’s PCMHsConcentration of PCMH practices by county
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BCBSSC’s PCMH programTypes of conditions targeted for PCMH care and coordination fees
Adult diabetesAdult diabetes
Adult congestive heart failure (CHF)Adult congestive
heart failure (CHF)
Pediatric wellnessPediatric wellness
Adult hypertension (HTN)
Adult hypertension (HTN) Pediatric asthmaPediatric asthma
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How do we measure quality?
Adult diabetesAdult diabetes
Percentage of eligible population who have had:
• BP exam in the past 12 months
• BP exam in the past 12 months that is < 140/90
• HgA1C exam in the past 12 months
• HgA1C exam in the past 12 months with the most recent exam being < 8%
• LDL-Chol exam in the past 12 months
• LDL-Chol exam in the past 12 months that is < 100
• Microalbumin exam in the past 12 months
• Diabetic retinal exam in the past 12 months
• BMI documentation in the past 12 months
• BMI improvement since baseline
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How do we measure quality?
Percentage of eligible population who have had:
• BP exam in the past 12 months
• BP exam in the past 12 months with the most recent being < 140/90
• BMI documentation in the past 12 months
• BMI < 30
• Creatinine measurement in the past 12 months
• Been prescribed a generic prescription for medications related to hypertension control
• Tobacco usage assessed
Adult hypertension (HTN)
Adult hypertension (HTN)
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Population Health Management and Reporting tool
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Robust data collection: structured and unstructured
Transforms disparate data into meaningful, actionable data:
•Instant patient view – individual and population level
•Gaps in care
•Performance tracking
•Robust data source for enhanced reporting and analytics such as risk stratification and predictive modeling
Easy to share and integrate:
•Instantly shared with our practice partners
•Easily integrated into other platforms such as DM/CM
Population Health and Reporting
Platform
Outcomes
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Cost and utilization
• 1 percent savings for all claims for SHP diabetic members in PCMH practices versus those in non-PCMH practices
• 5 percent savings on ER for SHP hypertension members in PCMH practices versus those in non-PCMH practices
• 5 percent fewer admissions per 1,000 for SHP diabetic members in PCMH practices and 12 percent fewer admissions per 1,000 for SHP hypertension members, versus those in non-PCMH practices
• 13.2 percent fewer ER visits for SHP members with hypertension in PCMH practices versus those in non-PCMH practices
2014 Outcomes
Questions?
Value-based health initiatives
• In 2015, the State Health Plan began covering at no cost to the member:
• Preventive biometric screening (worksite screening)• Zostavax (shingles vaccine)• Flu vaccine
• These “no cost to the member” value-based health initiatives are in addition to the Generic Copay Waiver program implemented in 2011
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Value-based health initiatives
• In 2016, the State Health Plan will expand coverage of its value-based health initiatives, PEBA Perks, at no cost to the member:
• Colonoscopies to include consultation, prep kit, colonoscopy and associated anesthesia for both diagnostic and routine screenings based on United States Preventive Services Task Force (USPSTF) specified age guidelines
• Adult vaccinations as recommended by the CDC (http://www.cdc.gov/vaccines/schedules/hcp/adult.html)
• Tobacco cessation (Chantix, generic Zyban)• Diabetes education
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Coverage for contraceptives
• No member cost share for covered contraceptives effective January 1, 2016 (mandated in Proviso 108.13 of fiscal 2016 Appropriations Act)
• Coverage of contraceptives remains the same under the State Health Plan
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Flexible benefits (MoneyPlus)
Effective January 1, 2016:•Elimination of one-year waiting period for new hires to establish a Medical Spending account•Establish a $1,500 limit on Dependent Care Spending Account for highly-compensated employees (HCE) in order to address passage of federal non-discrimination test
• For 2016, a HCE is defined as earning $120,000 or greater in calendar year 2015
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Vendor update
• Effective January 1, 2016, Express Scripts will be the pharmacy benefits manager (PBM)
• Basic dental and Dental Plus: vendor announcement pending completion of the Request for Proposal (RFP) process
• Basic dental rates for employers and enrollees will not change in 2016
• Dental Plus rates effective January 1, 2016, could change based on the outcome of the RFP process
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Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 30
2016 Prescription Drug Program
Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 31
What to expect in 2016 New ID cards and welcome
kits: Mailing December 2015
Medicare Plan D participants will receive communications starting October 2015
Pharmacy network: Retail pharmacies
Mail order pharmacy – Express Scripts
Specialty pharmacy – Accredo
Formulary/coverage review:
Insulin/test strips
Step therapies
Prior authorization
Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 32
Online tools and mobile app help patients connect Online prescription management:
Refills, renewals and order status Worry-free Fills ® Transfer to mail Claims, balances and history Locate a pharmacy Preferences
Benefit education and management:Benefit highlightsForms and cardsPricing and coverage detailsAccessibility features
Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 33
My Rx Choices® Lower the cost of prescriptions with My Rx Choices®
Features include: Personal assessment of cost-saving opportunities
Print a kit to help their doctor better understand the economic impact of different medication alternatives
Alternative medications are based upon greatest cost savings to you presented in order, starting with the highest value
Brand-to-generic and retail-to-mail comparisons are shown
Simply visit www.express-scripts.com or call Express Scripts Member Services on the member ID card
Prices can vary at different retail pharmacies, so it is important to shop around
Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 34
My Rx Choices®
Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 35
Information resources Open enrollment website – www.express-scripts.com/SCPEBA
(Available on October 1, 2015)• Pharmacy benefit highlights• Members cannot select benefits via this site
Express Scripts mobile app (FREE) – search for “Express Scripts” Express Scripts member website – www.express-scripts.com
(Available on January 1, 2016)• Formulary information• Locate a participating pharmacy• Health and wellness information• My Rx Choices®/price a medication• Online ordering• Express Scripts mobile app• Order home delivery pharmacy refills• Caregiver resources• Download forms
Customer Service Number: 855.612.3128
Confidential and Proprietary Information© 2012 Express Scripts Holding Company. All Rights Reserved. 36
Thank You
Questions
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Disclaimer
This presentation does not constitute a comprehensive or binding representation regarding the employee benefits offered by the South Carolina Public Employee Benefit Authority (PEBA). The terms and conditions of the retirement and insurance benefit plans offered by PEBA are set out in the applicable statutes and plan documents and are subject to change. Please contact PEBA for the most current information. The language used in this presentation does not create any contractual rights or entitlements for any person.
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