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

Shifting From Fee-for-Service to Value Based Provider/Hospital Reimbursements

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


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


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.


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.


Driving Employee Engagement to Hold Down Costs

EMPLOYEE ENGAGEMENT PROGRAM MAGNIFY

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:

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ANALYTICS AND INSIGHTS

TARGETED CAMPAIGNS

Identify areas of savings opportunity

• Targeted Incentives • Personalized Alerts • Tailored Campaigns

FOR EMPLOYEES:

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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

Addressing Pharmacy Costs


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


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


Common Plan Design Smart Choice Design

Consumer Decision Aides

Know your meds and take action

Sean Karbowicz October 7, 2016

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


• 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


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


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


http://www.bemedsavvy.com/

MedSavvy Grades


Live Demo Sean Karbowicz, Business Founder, MedSavvy


THANK YOU Sean Karbowicz Founder, Lead Pharmacist [email protected] MedSavvy.com

mailto:[email protected]

Open Discussion

Thank You

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