Kate Brown, Governor - Oregon › oha › PEBB › docs... · 9/18/2018 · Jack and Diane both work for different state agencies. Jack and Diane usually both take the PEBB Medical

HEALTH POLICY AND ANALYTICS

Public Employees’ Benefit Board

Kate Brown, Governor

Chair Shaun Parkman will convene a public meeting of the PEBB Board on Tuesday, September 18, 2018, at 9:30 a.m. The meeting will be held in the boardroom of the Health Licensing Office at 1430 Tandem Ave., Ne, Suite 180, Salem, Oregon.

PEBB BOARD AGENDA

I. 9:30 a.m. – 9:35 a.m. Attachment 1

Welcome & Approval of August 21, 2018 meeting synopses (action) Shaun Parkman, Chair

II. 9:35 a.m. – 9:55 a.m. Attachment 2

Financial Update (information/discussion) Ali Hassoun, OEBB/PEBB Interim Director

III. 9:55 a.m. – 10:15 a.m. Attachment 3

Opt-out and Double Coverage Elimination (SB 1067) Cindy Bowman, OEBB/PEBB Director of Operations Linda Freeze - Benefit Manager

IV. 10:15 a.m. – 10:55 a.m. Attachments 4, 4a and 4b

Network/Access (information/discussion) Dr. Keith Bach, PEBB Medical Director and Sophary Sturdevant, Executive Account Manager, Kaiser Permanente Dr. Jim Rickards, Senior Medical Director and Jill Harland, Director Provider Relations, Moda Health Plans Stephanie Dreyfus, Vice President of Network Development, Providence Health Plans

V. 10:55 a.m. – 12:20 p.m. Attachment 5

Strategic Planning Continued – Next Steps Emery Chen and Robert Valdez, Mercer Health & Benefits, LLC

VI. 12:20 p.m. – 12:25 p.m. Other Business

VII. 12:25 p.m. – 12:30 p.m.

Public Comment

Public Employees’ Benefit Board Page 2 of 2

Adjourn

Page 1 of 2

Attachment 1 PEBB Board Meeting

September 18, 2018

Public Employees’ Benefit Board Meeting Synopsis

August 21, 2018

The Public Employees’ Benefit Board held a regular meeting on August 21, 2018, at the Health Licensing Office, 1430 Tandem Ave. NE, Suite 180, Salem, Oregon. Chair Shaun Parkman called the meeting to order at 10:00 a.m. Attendees Board Members: Shaun Parkman, Chair Kimberly Hendricks, Vic Chair Bill Barr Representative Mitch Greenlick Kim Harman (via phone) Siobhan Martin Jeremy Vandehey Board Members Excused/Absent: Senator Betsy Johnson Dana Hargunani, MD Mark Perlman OEBB Staff: Ali Hassoun, Interim Director Cindy Bowman, Director of Operations Rose Mann, Executive Assistant Brian Olson, Contracts Specialist Consultants (WTW): Nick Albert, Mercer Health and Benefits, LLC (via phone) Emery Chen, Mercer Health and Benefits, LLC Robert Valdez, Mercer Health and Benefits, LLC View meeting agenda and attachments. View the meeting recording

https://www.oregon.gov/oha/PEBB/docs/boardattachments/20180717/BD.All-In20180717.pdf

http://oha.granicus.com/MediaPlayer.php?clip_id=266

Page 2 of 2

Attachment 1 PEBB Board Meeting

September 18, 2018

I. Welcome and approval of July 17, 2018, Board Meeting Synopsis (Attachment 1) - Video Recording 0:02:39

Shaun Parkman introduced new Board member, Jeremy Vandehey, Director of Health Policy and Analytics with OHA.

MOTION - Video Recording 0:04:21 Bill Barr moved to approve the synopsis of the July 17, 2018 PEBB Board meeting. Kim Harman seconded the motion. The motion carried 5 – 0 - 1. Jeremy Vandehey abstained.

II. PEBB Member Advisory Committee (PMAC) Introduction and Health Engagement

Model (HEM) Recommendation (Attachment 2) - Video Recording 00:04:56 Brian Olson, Theresa Cross and Lesa Dixon-Grey presented information on the PMAC and Health Engagement Model.

III. Mercer National Survey of Employer-sponsored Health Plans 2017 (Attachment 3) - Video Recording 00:41:22

Robert Valdez, Mercer Health & Benefits LLC, reported on the results of PEBB’s member utilization for July.

IV. Strategic Planning Presentation (Attachment 4) - Video Recording 01:36:32

Emery Chen and Robert Valdez, Mercer Health and Benefits, LLC, presented information and recommendations for PEBB strategic planning for the future.

V. Other Business/Public Comment - Video Recording 02:54:38

Deborah Tremblay gave public comment requesting Kaiser Dental cover nitrous oxide without additional co-pay.

There being no further business to come before the Board, Chair Shaun Parkman adjourned the meeting at 1:10 p.m.

Place Your Logo Here - Align Center

SB1067“Elimination of Double Coverage and Opt-Out

Incentives”

2

SB1067-What it Does

Double Coverage Elimination“The board may approve more than one carrier for each type of benefit plan offered, but the board shall limit the number of carriers to a number consistent with adequate service to eligible employees and family members who are not enrolled in another health benefit plan offered by the board or the Public Employees’ Benefit Board.”

3

SB1067-What it Does

Opt Out Elimination“An eligible employee who declines coverage in a health benefit plan offered by the Oregon Educators Benefit Board or the Public Employees’ Benefit Board and who is enrolled as a spouse or family member in another health benefit plan offered by the Oregon Educators Benefit Board or the Public Employees’ Benefit Board may not be paid the employer contribution for the plan that was declined.”

Definitions

Health Benefit PlanMedical/RX Plan only (does not include Dental or Vision)

Employer ContributionThis could mean the entire employer contribution or a subset of the employer contribution

4

Double Coverage Scenarios

#1 (PEBB/PEBB)Jack and Diane both work for different state agencies. Jack and Diane usually both take the PEBB Medical Plan and cover their entire family.• Effective January 1, 2020, either Jack OR Diane can cover the

entire family with a PEBB Medical Plan.• Jack could take the coverage for himself and their children and

Diane could take employee only coverage. She would not be able to cover the children with medical if Jack covers them.

• Both Jack and Diane can still double cover the entire family on Dental and Vision.

5

Double Coverage Scenarios#2 (OEBB/PEBB)Jack works for DOC and Diane works for Astoria SD. Jack and Diane usually both take medical coverage via PEBB and OEBB and cover their entire family.• Effective October 1, 2019, Diane will not be able to take the OEBB

medical coverage for Jack, herself or their children if Jack is showing these dependents covered in PEBB.

• PEBB may have to open up their system for a QSC to allow Jack to drop Diane and their children from coverage to allow Diane to enroll them in OEBB coverage during OEBB’s OE.

• OEBB may have to open up their system for a QSC to allow Diane to drop Jack and their children form coverage to allow Jack to enroll them in PEBB coverage during PEBB’s OE.


6

Double Coverage Scenarios

#3 (PEBB/PGE)Jack works for DOC and Diane works for PGE. Jack and Diane usually both take medical coverage via PEBB and PGE and cover their entire family.• Jack and Diane will see no difference in how their plan works.

7

Opt Out Scenarios#1 (PEBB/PEBB)Jack and Diane both work for different state agencies. Jack usually takes the PEBB Medical Plan for the entire family and Diane usually Opts Out of medical and takes the $233 incentive.• Effective January 1, 2020, either Jack OR Diane can cover the

entire family with a PEBB Medical Plan. Neither can take the incentive.

• Jack could take the coverage for himself and their children and Diane could take employee only coverage. She would not be able to cover the children with medical if Jack covers them.


8

Opt Out Scenarios#2 (OEBB/PEBB)Jack works for DOC and Diane works for Astoria SD. Either of them are currently eligible for an Opt Out incentive. But, this incentive now goes away effective October 1, 2019 for Diane and January 1, 2020 for Jack.• Since Diane’s enrollment comes first they may choose to enroll in

the OEBB Medical Plan until January 1, 2020. Jack can still take the incentive until January 1, 2020.

• During Jack’s open enrollment the couple may evaluate PEBB and OEBB Medical Plans. They may evaluate the following:– Out of pocket costs– Richness of medical plan

• It may be likely that we see Diane opt out of the OEBB Medical Plan and Jack enrolls the entire family in the PEBB Medical Plan.


9

Opt Out Scenarios

#3 (PEBB/PGE)Jack works for DOC and Diane works for PGE. Jack and Diane usually both take medical coverage via PEBB and PGE and cover their entire family.• Jack and Diane will see no difference in how their plan works.

10

What have we been doing?

• Rule Construction• DOJ Opinions

• How Incentives Work• Special Contracts• Court Orders• Defining Health Benefit Plan

• Identifying System Changes

11

Rule Construction

• We can add a new SB1067 section• OR• We can add to our existing sections

• Obviously, rules will be a bit more challenging on the OEBB side. Many different monetary incentives exist on the OEBB side than PEBB.

• Rules for system processes will need to be developed• Who gets coverage terminated once double

coverage is discovered via OEBB/PEBB?

12

DOJ Opinion

• What is a monetary incentive versus employer contribution?• The PEBB incentive is $233 and clearly not the employer contribution• The PEBB incentive is cash and added to the payroll• The OEBB incentive could be anything even up to the employer

contribution• The OEBB incentive might not be cash added to the payroll

• Does the incentive have to be paid to the subscriber opting out or can it be paid to their spouse/DP

• Court Orders• Parent has a court order to cover children on medical

• Health Benefit Plan• Can we assume a Health Benefit Plan only refers to medical/RX

13

System Changes• QSCs

– Both OEBB and PEBB will have to allow special QSCs during the other’s enrollment period to add or drop dependents

– Both OEBB and PEBB will have to ask subscribers a series of questions when they click on medical to evaluate their enrollment

• PEBB/PEBB Double Coverage Changes and Language• What if dad is under court order to carry coverage but mom is

enrolled• Who’s coverage gets dropped (birthday rule?)• Stopping subscriber in PEBB/PEBB enrollment when the second

(or third) person tries to double (triple) cover• No matter, extra communication to members for processing

14

System Changes

• OEBB/OEBB Double Coverage Changes and Language• What if dad is under court order to carry coverage but mom is

enrolled• Whose coverage gets dropped (birthday rule?)• Stopping subscriber in OEBB/OEBB enrollment when the

second (or third) person tries to double (triple) cover• We can’t assume the richer plan is the best coverage

– Contributions can differ at each entity (this includes HSA contributions)

15

System Changes• OEBB/PEBB Double Coverage Changes and Language

• This scenario will be the most challenging as the systems are not synchronized

• Instead of stopping the subscriber from enrolling we will have to ask them a series of questions to evaluate their enrollments

• We will have to have protective language in both systems to protect OEBB/PEBB of retro terminations

• Do we hire extra staff to communicate these changes to subscribers

• PEBB Opt Out• PEBB will have to identify an Opt Out that qualifies for the $233

incentive from a subscriber that Opts Out due to other OEBB/PEBB coverage– New codes in PEBB to transfer to payroll– Possibly create a new non-plan called Non- Incentive Opt Out– Rule change around this plan offering

16

OEBB/PEBB Needs• Potential need for OEBB/PEBB to hire staff to facilitate

communications between OEBB/PEBB members needing to drop one coverage

• System changes will be costly and developing sound new processes will take time and effort to complete

17

Thank You!

18

Kaiser PermanenteNETWORK / ACCESS

PEBB Board PresentationSeptember 18, 2018Attachment 4

Presented by: Dr. Keith Bachman, PEBB Medical Director Sophary Sturdevant, Executive Account Manager

10 hospitals

20 dental facilities

47 medical facilities, including6 The Portland Clinic facilities6 PeaceHealth facilities in

Eugene/Springfield

SERVICE AREA

Page 2

2017 - 2018• Tanasbourne Medical Office • Kaiser Permanente Dental at Johnson Creek• Cedar Hills Medical and Dental Office• Care Essentials® by Kaiser Permanente

2019• New facilities in Beaverton• Keizer Station Dental Office

EXPANDED ACCESS

Page 3

Beaverton Medical and Dental Office• 90,000 SF of integrated Medical/Dental• Public Square• New technology to alleviate wait times and

provide ease of communication• Larger exam rooms that encourage patient-

provider conversation• Patient-centered design and technology

NEW BEAVERTON FACILITY

Page 4

CARE ESSENTIALS

Care Essentials Clinics:• Treat non-emergency health care needs, including minor illnesses and injuries • Provide preventive services, including checkups, vaccinations, and some lab

and diagnostic testing

EasyConvenientNeighborhood-Based

Pearl District

Hawthorne – Open Now!

Page 5

Presenter

Presentation Notes

THE PORTLAND CLINICSince 2011 Kaiser Permanente and The Portland Clinic have partnered with the shared goal to improve community health and make care more affordable.• Primary Care plus over 30 specialties • Six locations with a seventh opening soon• Members can utilize services with ease at Kaiser Permanente or The Portland Clinic

Page 6

• Kaiser Permanente Downtown Eugene Medical Office

• PeaceHealth Medical Group Cottage Grove

• PeaceHealth Medical Group Santa Clara

• PeaceHealth Internal Medicine Florence

• PeaceHealth Medical Group RiverBend Pavilion

EUGENE-SPRINGFIELDSERVICE AREA

Page 7

Provider Stats• 1,255 NW Physicians • Average tenure of NW Physicians is 8 yrs.• 176 new physicians hired in 3 years

KP Specialty Care• Integrated model allows for coordinated

care among PCP and Specialty Care• Kaiser Permanente has over 60 specialty

care departments in house

Partner Hospitals• OHSU• Doernbecher• Legacy Salmon Creek Medical Center• Salem Hospital• PeaceHealth

• 38 Hospitals• 19,000+ Physicians• 651 Medical Offices• 1 Medical School (opening in 2019)

Care and Expertise Beyond the NW

Page 8

Presenter

Presentation Notes

CARE WHEN AND WHERE YOU WANT IT

ADVICE NURSE SECURE EMAIL PHONE APPOINTMENTS VIDEO VISITS

Page 9

Presenter

Presentation Notes

TELEHEALTH STATISTICS

Page 10

Presenter

Presentation Notes

PEBB VIRTUAL ACCESS2017 Data

Services Office Visits Telephone Appointments

Coded Unscheduled

CallsVideo Visits

Virtual Dermatology

Assist% Virtual

Continuing Care 93 19 96 2 0 56%Mental Health/ADDM 7,834 1,288 977 116 0 23%Peds Sub Specialty 377 97 19 5 0 24%Primary Care 43,366 8,005 1,012 204 0 18%Specialty Care 33,797 3,122 757 337 714 13%TRC 0 0 601 0 0 100%Total 85,467 12,531 3,462 664 714 17%

Services Email Threads Individual Emails

Continuing Care 50 155Mental Health/ADDM 4,090 9,362Peds Sub Specialty 395 852Primary Care 29,450 60,844Specialty Care 16,725 32,918Total 50,710 104,131

Page 11

Thank you!

PEBB Synergy/Summit Network OverviewSeptember 18, 2018

1

Dr. Jim Rickards, Senior Medical DirectorJill Harland, Director Provider Relations

Attachment 4a

• Focus on Primary Care & PCPCH Model

• Network Access

• Telemedicine

Presentation Overview

2

Primary Care & PCPCH Model

Synergy - Organized System of CareNetwork Management Primary Care Support

Per member per month payments to recognized Medical Homes based on tier

Population Based payments

Coordinated care model promoting regional collaboration

Regional Risk Model

Primary care providers incentivized for meeting quality metrics

Performance Based payments

Statewide payer alignmentCPC+ program

• Hospital• Primary Care• Specialty Care• Pharmacy

Risk Areas

4

Synergy background

Developed in collaboration with major health system providers in 2014

Modeled on the CCO concept of regional risk models & provider collaboration

More than 9,000 primary care and specialty care providers

Promotes Oregon’s Patient Centered Primary Care home program through care management

5

Provider risk model overview

Premium-based allocation model

Expected costs used to develop the premium are the budget

Actual costs are compared to expected costs at a regional level

If actual costs are less than expected costs, the model generates a surplus that is shared with providers

If actual costs are higher than expected costs, the model is in deficit

Providers at risk for their share of the deficit

6

Network Access – Focus on Primary Care

CPC+ - Comprehensive Primary Care + Program

PCPCH - Patient Centered Primary Care Home

SB934 – Primary Care Payment Reform Workgroup

7

Support a PCPCH focus in the following domains:

Network Design –Migrate to a PCPCH focused network

Payment Strategy – Align PCPCH Value Based Contracting with SB934 & Purchaser Performance Guarantees

Benefit Design – Incentivize members for PCPCH participation

Member Tools – Engage & educate members to PCPCH value

Delivery System Partnership – Member outreach plan to connect members with PCPs, if needed

PCPCH Support

8

For all networks, Moda is implementing a payment model with four key components:

• Advanced Primary Care Infrastructure - (Per-member, per-month [PMPM] payments) - Risk stratified care management, care coordination, behavioral health integration, integrated pharmacist, and non-visit-based care

• Performance-based Incentive payments – Measure performance

• Fee-for-service payments – Value added services eg. mental health

Primary Care Payment Reform

9

Network Access

Synergy and Summit Network Service Area

11

Presenter

Presentation Notes

No change

• Total Number of PCPs: 4,350

• Total Number of High Volume/High Impact Specialists: 2,185− High Volume specialties

◦ Cardiology◦ Dermatology◦ OB/GYN◦ Orthopedics◦ Radiology

− High Impact specialties◦ Endocrinology◦ Gastroenterology◦ Oncology◦ Rheumatology

Synergy/Summit Network Access

12

PEBB Membership by CountyCurrent as of August 2018

Total PEBB Membership: 10,42213

Hospitals: Average Distance to nearest Synergy/Summit HospitalBased on PEBB Membership as of Aug 2018

14

Primary Care: Average Distance to nearest Synergy/Summit PCPBased on PEBB Membership as of Aug 2018

Average industry standard is 8-10 miles15

• Areas where challenges exist due to the rural nature of the county:

− Dermatology: Harney County− Endocrinology: Lake County− Gastroenterology: Grant, Lake

and Harney Counties

• There are currently no providers available to recruit in these areas to increase access

Specialty Care: Average Distance to nearest Synergy/Summit High Volume or High Impact SpecialistBased on PEBB Membership as of Aug 2018

16

• OHSU Specialty Care− High Volume/High Impact Specialists:

◦ Cardiology: 71◦ Dermatology: 30◦ Endocrinology: 30◦ Gastroenterology: 36◦ OB/GYN: 39◦ Oncology: 105◦ Orthopedics: 27◦ Radiology: 55◦ Rheumatology: 11

− Other specialists: 1,389

Synergy/Summit Network in the Portland Metro

17

• Includes the state’s two premier Pediatric Hospitals –Doernbecher and Randall’s

Synergy/Summit Network in the Portland Metro

Pediatric Services Offered Doernbecher at OHSU Randall's at LegacyAllergy x xBurn xCardiology x xChild Abuse x xCraniofacial xCritical Care x xDermatology x xDevelopment x xEar, Nose & Throat x xEndocrincology x xEye Care x xGastroenterology x xGenetics & Birth Defects xHematology Oncology x xInfectious Diseases x xMetabolism xNeonatology x xNephrology x xNeurology x xOrthopedics x xPain Management xPhysical Therapy x xPschiatry x xPulmonology x xRheumatology xSleep Medicine x xSurgery x xUrology x

18

• Synergy/Summit − Total BH Practitioners: 4,007 (17.0% growth since 2016)− Total Clinics: 2,371− Total Chemical Dependency Facilities: 180− Total Inpatient Psychiatric Facilities : 21

• Behavioral Health providers include− Psychiatrists, Licensed Professional Counselors, Licensed Marriage &

Family Therapists, Licensed Clinical Social Workers, and Mental Health Counselors

• Annual recruitment outreach based on PEBB member utilization− This year we are targeting 202 providers/clinics statewide

Behavioral Health Network

19

Telemedicine

• A telehealth solution bringing behavioral health providers to areas with limited access by means of real time interaction

• Available to PEBB members statewide

• If you are a member and are experiencing limited access to a behavioral healthcare provider that can treat your condition, you can call Moda Health and ask to speak to a Behavioral Health Care Coordinator, and we will tell you about Forefront Telecare. Our Behavioral Health Care team will then send your information to Forefront, where they will connect you with a credentialed Behavioral Health provider via webcam in either your PCPs office or in the comfort of your own home

• Forefront TeleCare became available to PEBB members on 8/10/18.

Forefront TeleCare

21

22

Sample communications that we have shared with our groups

Moda-OHSU Virtual Visits partnership

© 2018 Private & Confidential

PEBB Board PresentationPHP Network Access and Availability

Attachment 4bPEBB Board - September 18, 2018

© 2018 Private & Confidential 2

Choice Medical Homes

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018Total 24 25 29 33 51 106 109 150 188 227 266 291 330

0

50

100

150

200

250

300

350

Num

ber o

f Med

ical

Hom

es


PEBB Statewide PPO

Full access to the national Providence Signature Network and non-network providers

In network providers across the U.S. through our national network

Enrolled subscribers*19,503

Enrolled members*52,558

*as of 09/07/18


Total Number of Hospitals: 58

Total Number of PCPs: 3,127At 5,528 Locations

Total Number Specialists: 11,581At 24,057 Locations

Signature Network Access (Statewide)

PCPCH Clinics included in Signature


PEBB Providence Choice

Collaborative medical home model emphasizing patient-centered primary care

Available in most Oregon counties

Enrolled subscribers*18,989

Enrolled members*48,979

*as of 09/07/18


Total Number of Hospitals: 35

Total Number of PCPs: 2289At 4286 Locations

Total Number of Specialists: 11451At 19709 Locations

PEBB Choice Network Access


PCPCH Clinics

Total PCPCH: 655

PCPCH In Network: 497

PCPCH not In Network: 158• Over 100 in Portland Metro area with 91 within 5 provider organizations • Cannot meet credentialing or PCP criteria• Indian Health Services, School Based Clinic• Not interested in being a medical home in the network• Other

76% of all PCPCH Clinics are in Network

53 Medical Homes are Providence Clinics

© 2018 Private & Confidential

Thank you!

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

SEPTEMBER 18, 2018

O R E G O N P E B B S T R A T E G I C P L A N N I N G P A R T I I D I S C U S S I O N G U I D E

Attachment 3

2 Copyright © 2018 Mercer (US) Inc. All rights reserved.

A G E N D A & O B J E C T I V E S

WHERE WE LEFT OFF 1

STRATEGY FOR ACTION—DELIVERY

AND ASSOCIATED PAYMENTS

2

NEXT STEPS 4

A G E N D A O B J E C T I V E S

Y O U R S T R A T E G Y

F O R A C T I O N

• Setting ground on where we

left off, and where PEBB has

been

• Start developing a strategic

plan to support PEBB’s vision

• Explore priority areas for

future consideration

• Agree on timing and next

steps

CARE TRANSFORMATION AND

ALTERNATIVE PAYMENT MODELS

3


WHERE WE LEFT OFF


W H E R E W E L E F T O F F

W H AT W E H E A R D

• What strategies has PEBB tried and what are the results? • Minimal care transformation, mostly vendor driver, and mostly related to

benefit plan design changes

What have we done?

• Multiple stakeholders have responsibility: local communities, legislature, health plans, providers, members, the board

Who is responsible?

• Consider multiple segmented strategies with staged timeframes (this will be a multi-year process, not a quick fix)

• Include a specific rural strategy

• Drive what the innovations workgroup will address

How should we approach strategy?

• Focus on payment reform, including alternative payment models

• Social determinants of health

• Expert medical opinion to improve outcomes

Are there specific actions of interest?

• Wellness subcommittee

• CCO 2.0 - How can PEBB utilize this transformation?

• Potential board retreat in November

What is on the calendar?



W H E R E TO TA R G E T ?

PROVIDERS — To adhere to evidence-based clinical guidelines, improve quality, and enhance

the patient experience

R E S P O N S I B I L I T Y F O R E N S U R I N G P L A N M E M B E R S

R E C E I V E H I G H Q U A L I T Y C A R E I S S H A R E D

PEBB — To select health plans and provider networks with the highest quality standards

and optimal plan design

CARE MANAGERS — To navigate patients across the care continuum to the right providers

at the right time

HEALTH PLANS — To manage high quality provider networks, improve the member experience,

and promote transparency

PLAN MEMBERS — To be informed, self-manage whenever possible, and seek the best care

COMMUNITY — To provide leadership via legislative and local initiatives to shape health care



B U I L D I N G O N H I S TO RY – S I N C E 2 0 1 5 M E D I C A L R F P

Unit Prices

• SB 1067

• Out-of-network

reimbursement

decreases for Moda

• Self-insure Moda

Benefit Coverage

• Out-of-Network plan

changes

• ER copay changes

• Eliminate AllCare

• Closed formulary for

Moda

Delivery and

Associated

Payments

• Bundled payments

(deliveries, CABG,

knees & hip

surgeries) for select

Providence facilities

• Kaiser integrated

care model

• Patient Centered

Primary Care

Medical Home

models

Patient Behavior

• Workplace Wellness

CONTINUUM OF STRATEGIES TO IMPACT COSTS

TRADITIONAL AND EASIER INNOVATIVE AND MORE CHALLENGING

Payment Model

with Risk Sharing

• AllCare risk corridor

• Total cost of care

contract with Marion

County providers

through Providence


Short term solutions do not adequately address long standing

issues with medical costs and member outcomes 1

Developing a strategic plan aligned with PEBB’s

vision is critical 2

Agreeing on timing and next steps for priorities, vetting of

solutions, and follow up discussions 4

Need to identify and address the barriers to deciding,

adopting and implementing new programs 5

Creating a path with specific, measurable initiatives can

improve focus 3


C A L L TO A C T I O N

How can we help the Board move forward? 6


STRATEGY FOR ACTION

– STRATEGIC PLAN


S T R AT E G Y F O R A C T I O N

E X P L O R I N G T H E P O S S I B I L I T I E S

Unit Prices

• Directly negotiate

rural fee schedule

prices

• Contract with efficient

CCMs by county

• Reference based

pricing

• Exclusive specialty

drug vendor

• High cost claim

management

Benefit Coverage

• RFP for medical plans

• Advocacy care

management

• Stricter medical and

benefit policies

• Adjust plan values to

benchmark

• Risk adjust premiums

for contributions

• Point solutions

Delivery and

Associated

Payments

• Bundled payments

• Centers of Excellence

• Health alliance to

influence how

providers operate

• Better integration of

behavioral health and

EAP with medical

• Single electronic

health record provider

Patient Behavior

• Concierge vendor

Statewide Plan

• Transparency tool

• Require use of shared

decision support tool

• Single telemedicine

solution

• Consumer directed

medical plan

• Expert medical

opinion vendor

• Address social

determinants of health

CONTINUUM OF STRATEGIES TO IMPACT COSTS

TRADITIONAL AND EASIER INNOVATIVE AND MORE CHALLENGING

Payment Model

with Risk Sharing

• Upside and downside

risk

• Create ACO

• Changing in-network

to only include risk

bearing providers

PEBB’s focus has historically been on

these four categories

Changing patient behavior can be challenging, and

a possible area of focus for long-term strategy


D E T E R M I N I N G S T R AT E G I E S

M E T H O D S O F P U R S U I N G S T R AT E G I E S

Possibilities:

• Consumer-driven health plans

• Bundled payments for select services

• Centers of excellence

• Stricter medical and benefit clinical policies

• Increased upside and downside risk

sharing from providers

• Network tiering of providers

Possibilities:

• Concierge vendor for Statewide plan

• Accountable Care Organizations

• Expert medical opinion

• CCMs in efficient counties

• Direct contracting with providers

• Single telemedicine solution

HEALTH PLANS INNOVATIONS WORK GROUP

PEBB / MERCER

For which topics does the PEBB Board need more information?


I L L U S T R AT I V E R O A D M A P

SHORT TERM MEDIUM TERM LONG TERM

• Introduce concierge vendor for

Statewide PPO

• Implement expert medical opinion

vendor to provide second

opinions for non-urgent care for

members while helping to select

high quality providers

• Introduce HSA-qualified

consumer directed health plan(s)

• Restrict counties where CCM

plans are offered to those with

demonstrated efficiencies and

improved outcomes

• Select and implement bundled

payments for high volume

services with high variance in

costs. Enhance travel benefit or

in conjunction with Centers of

Excellence

• Investigate areas of misuse or

overuse and work with providers

to address issues

• Evolve CCM to ACO model with a

closed network of coordinated

providers with lower

reimbursement, risk sharing, and

performance guarantees based

on quality metrics and trend

• Address social determinants of

health for holistic approach

towards healthcare

• Form health alliance of employers

and government entities to

reshape how healthcare is

delivered



I L L U S T R AT I V E S AV I N G S

2020 2021 2022 2023

Needed Savings $3 Million $36 Million $72 Million $111 Million

Savings Opportunities

• Concierge for Statewide $5 Million $11 Million $17 Million $23 Million

• Expert Medical Opinion $2 Million $3 Million $5 Million $7 Million

• HSA Plan $3 Million $7 Million $10 Million $14 Million

• Double Spousal Surcharge $3 Million $5 Million $8 Million

• CCMs In Efficient Counties $1 Million $2 Million $3 Million

• Bundled Payments $2 Million $4 Million $6 Million

• Accountable Care Organization $6 Million $12 Million

Total Savings $9 Million $27 Million $49 Million $73 Million

Remaining Gap None $9 Million $23 Million $38 Million

Annual savings from members selecting CCM plans has historically been between $4M and $7M


CARE TRANSFORMATION

AND ALTERNATIVE

PAYMENT MODELS


A LT E R N AT I V E PAY M E N T M O D E L S

• Fee for service with no link to quality and value

Category 1

• Fee for service linked to quality and value

‒ Foundational payments for infrastructure & operations (e.g. care coordination, Health Information Technology investments)

‒ Pay for reporting

‒ Pay for Performance (bonuses for quality)

Category 2

• Alternative payment models built on fee-for-service

‒ Shared savings (upside risk only)

‒ Shared savings (episode-based payments and upside and downside risk)

Category 3

• Population-based payments

‒ Condition-specific (e.g. payments for specialty services, such as oncology or mental health)

‒ Comprehensive population-based payments (global budget or percent of premium)

‒ Integrated finance & delivery (global budget or percent of premium in integrated systems)

Category 4


A LT E R N AT I V E PAY M E N T M O D E L S

R B P, C O E , A N D B U N D L E D PAY M E N T S

Centers of Excellence

• Expertise and facilities for a specific medical condition

• Provides services in a comprehensive fashion

• Selected due to a high level of quality

• Potential COEs (2017 Allowed Cost)

• Deliveries - $24 Million

• Knee and Hip replacement - $15 Million

• Spinal Fusion - $6 Million

• Circulatory System - $21 Million

Bundled Payment

• A set of services to treat a condition or perform a procedure

• Expected total costs for a clinically defined episode of services

• Potentially improves quality and outcomes

• Best practices include shared decision support

• Typically included improvements

• Lower out-of-pocket costs for members

• Transportation and accommodations (with COE)

• Warranties for specified complications

• Shared decision making support

Reference Based Payment

• Maximum allowed price for a condition or procedure

• Set for a clinically defined set of services

• Charges above the reference price are paid for by the member

• In 2016, Montana set pricing for all hospital services at 234% of Medicare

• All but one hospital agreed to reduce allowed fees to the reference price

• Estimated 2018 savings of $15 million.


C O E A N D B U N D L E D PAY M E N T S

H O W I T W O R K S

A patient with pain in the knee sees their doctor. After attempting physical therapy, the doctor recommends surgery. The member contacts their health plan and talks through the bundled payment program with a concierge.

The member and doctor gather medical records, go through decision support, and submits to the health plan. A COE services team reviews the records and makes the determination.

The patient is approved for surgery, the concierge helps set up the surgery date and travel for the patient and their care companion at a COE. Member out-of-pocket costs are lower and travel is paid for by participating in the program.

After the surgery, the COE services team helps transition the member and their care companion from the hospital back to the home.

The patient has follow ups visits and rehabilitation. Any potential issues are addressed with the COE services team.


C O M PA R I N G C C M S TO A C O S

• Health care providers contracted through

Providence and Moda

• Members select a medical home (typically a

tiered Patient-Centered Primary Care Home)

• Services can be obtained outside the contracted

network at a decreased benefit level

• Plans support data sharing with providers

• Hospital and physician systems, while contracted,

are often financially separate

• Moda determines risk sharing with providers by

region based on expected versus actual cost;

primary care providers have upside risk for their

attributed members, while specialists and

hospitals have upside and downside risk

• Bonuses are available for meeting quality goals

• Providence in Salem has a total cost of care

agreement with providers and facilities with a

3.4% total cost of care trend guarantee

• Health care providers who offering services across

the continuum who agree to share responsibility

for the quality, cost, member experience and

engagement

• Members primarily receive care within the ACO

• Entire organization of providers assume risks for

meeting financial and performance (quality and

satisfaction) benchmarks with upside and

downside risk sharing

• Electronic medical records, claims data, and

reporting is shared among all providers to increase

the coordination between providers

• Focus is patient centered, to improved customer

service and create higher patient satisfaction

• ACOs must meet quality and member experience

and engagement scores to qualify for bonus

payments

OREGON PEBB COORDINATED

CARE PLANS

ACCOUNTABLE CARE ORGANIZATIONS

(ACO) – IDEAL STATE



W H AT I S WA S H I N G TO N D O I N G ? AC O AN D B U N D L E D PAY M E N T S

ACO

Bundled

Payment

Targets / Enhances

• Shared Risk Model

• Member experience

• Care transformation

• Timely data

• Incentives with benefit designs

Demonstrating Value

• 17,000 members in 9 counties representing 52%

growth between 2016 and 2017

• Both networks received 100% credit in 2016 for clinical

quality improvement

• 19,281 PCP visits

• Range of member annual savings: Premium $300-

$828; deductible up to $375

• 44% premium differential for 2018

• 89% member retention

Targets / Enhances

• Concierge experience for

members with total joint

replacements

• Virginia Mason designated COE

through competitive procurement

• Based on Bree Collaborative

recommendations

Demonstrating Value

• 10-15% cost savings first year of COE

• About $1,000 out of pocket cost savings to member

• 100% of members would use COE again and

recommend it

• 23 more members currently pursuing surgeries at COE

• Expansion of COE to spinal fusions



R U R A L PAY M E N T S T R AT E G Y

Vermont ACO

Model

Washington

State

• Limits per capita health care growth to 3.5% annually

• Focuses on outcomes and quality, specifically on access to care, substance abuse

disorder, suicides, and chronic conditions

Pennsylvania

• Prospectively sets global budget for participating rural hospitals, based on historical

revenue

• Rural hospitals will redesign delivery of care to improve quality and meet health needs

of local communities

• Patient centered solutions to reward rural providers for value of care and incent based

on improved outcomes

• Address access and sustainability concerns along with community needs

• Integrated delivery systems and redefine primary care for rural populations

• Ensure that members are engaged with local health delivery systems

• Create payments based on total cost of care with encounter-based payments


NEXT STEPS


B O A R D C O N S I D E R AT I O N S

Work with PEBB to determine which items need to procured and in what methods

Distinguish PEBB-led strategies from Innovations Workgroup strategies

Determine acceptable level of member impact/disruption to drive savings

Determine level of cooperation and involvement in strategy setting between PEBB, OEBB, and Innovations Workgroup

Work with carriers to gain commitment to taking an active role in finding solutions to the challenges facing PEBB

Narrow list of considerations to get PEBB closer to the savings needed


APPENDIX



U N I T P R I C E S ACTION POTENTIAL STEPS POTENTIAL BARRIERS SAVINGS TIMEFRAME

Addressing

Provider

Reimbursements

Direct negotiations with rural area

providers or creating a narrower

network with mandated

reimbursement levels and annual

increases

Maintaining adequate access,

ensuring quality providers,

disruption to members

$ Medium

Addressing

Provider

Reimbursements

Restricting counties where CCM

plans are offered to those with

demonstrated efficiencies and

improved outcomes

Member noise, shifting members

into the unmanaged Statewide

PPO plan

$$ Medium

Referenced

Based Pricing

Determining high volume services

with large regional cost variations,

e.g. knee and hip surgeries,

colonoscopies

Provider acceptance, travel

benefits, member

communications and usage,

coordination of care and referrals

with PCPs

$ Medium

Pharmacy

Contracting

Contract with one pharmacy vendor

for all self-insured plans

Impact on contracting with

current vendors

$ Medium

Specialty Drug

Management

Carving out all specialty drug

coverage to a specialized vendor,

preemptive specialty drug

contracting, direct contracting with

infusion centers

Contractual agreements with

vendors, care integration, direct

contracting with facilities, impact

on members including travel

$$ Medium

High Cost Claim

Management

Add clinical oversight /surveillance

services for self-funded plans

Cooperation from vendors $ Short



B E N E F I T C O V E R A G E ACTION POTENTIAL STEPS POTENTIAL BARRIERS SAVINGS TIMEFRAME

Request for

Proposal or

Information

Conduct a marketing exercise of

medical plan vendors

Timing and expense of new

marketing

$-$$ Medium

Concierge vendor

for Statewide

PPO

Adjusting plan design to add third

network where members receive

the highest level of benefit when

receiving care through a concierge

care management vendor.

Communication with members,

member noise, contractual

agreements with Providence

$$ Short

Stricter medical

and benefit

policies

Audit for deficiencies, identify areas

for stricter utilization controls, and

implement best practices care

management.

Communication with members,

member noise, provider

acceptance due to administrative

burden

$ Short

Benchmarking Adjust benefit design based on

comparison with a representative

group of companies, unions, and

governments.

Member impact $$ Medium

Risk Adjust

Premiums

Incent members to select more

efficient plans by normalizing plan

premiums to an average PEBB

member with risk adjustment.

Member noise, shifting members

into most efficient plans creates

communication challenges

$ Short

Point Solutions Review and implement third party

vendors for key conditions to

provide targeted solutions for higher

cost PEBB members

Integration with current plans

may be an issue, integration and

coordination challenges

$-$$ Short



C A R E D E L I V E RY A N D A S S O C I AT E D PAY M E N T S ACTION POTENTIAL STEPS POTENTIAL BARRIERS SAVINGS TIMEFRAME

Bundled

Payments

Select and implement bundled

payments for high volume services

with high variance in costs.

Enhance travel benefit or in

conjunction with Centers of

Excellence

Multiple carrier partners; carrier

contracting and agreements;

member disruption

$-$$ Medium

Centers of

Excellence

Create a network for certain

services around facilities with high

quality metrics and outcomes.

Maybe be in conjunction with APM.

Multiple carrier partners; carrier

contracting and agreements;

member disruption

$-$$ Medium

Oregon Health

Alliance

Create alliance with companies,

purchasers, providers, and hospital

systems to improve quality and cost

by reducing overuse, underuse, and

misuse of health care services

Multiple stakeholders $-$$ Long

Integration of

Physical Health,

Behavioral

Health, and EAP

Improve integration between

medical, behavioral health, and EAP

ensuring provider access and

improved coordination

Behavioral health integration is

still a challenge for providers,

carriers, and vendors

$ Medium

Data from

Electronic Health

Records

Require providers serving PEBB

members to provide clinically

relevant data using a common data

feed for information on improvement

opportunities

Defining the data format, multiple

carrier partners, diverse provider

groups

$$ Long



PAY M E N T M O D E L W I T H R I S K S H A R I N G ACTION POTENTIAL STEPS POTENTIAL BARRIERS SAVINGS TIMEFRAME

Revisiting

Performance

Guarantees with

Current Vendors

Strengthening performance

guarantees with upside and

downside risk sharing with

outcomes and additional metrics

Carrier contracting; willingness of

providers to “play-ball” and

accept downside risk

$ Medium

Accountable Care

Organization

Work with provider groups and

hospital organizations to create a

closed network of coordinated

providers with lower reimbursement,

risk sharing, and performance

guarantees based on quality metrics

and trend

Carrier contracting and

agreements; member disruption

$$ Long

Changing

Preferred

Network of

Providers

Require the in-network providers to

be high performing health systems

using evidence-based clinical

guidelines, patient experience

metrics, and accepting fees at risk

Carrier contracting and

agreements; member disruption

$$ Medium



PAT I E N T B E H AV I O R ACTION POTENTIAL STEPS POTENTIAL BARRIERS SAVINGS TIMEFRAME

Transparency

Tool

Implement a cost and quality tool for

members to search for low cost,

high quality providers

Member education,

communication, and usage rate.

Increased usage potentially

when in conjunction with

advocacy program

$ Short

Shared Decision

Tools

Require health plans and providers

to incorporate and document the

use of patient decision aids

Multiple carrier partners;

member usage, selection of

tools

$ Medium

Telemedicine Offer PEBB-wide telemedicine

solution

Multiple carrier partners;

member usage

$ Medium

Consumer

Directed Health

Plans

Include a high deductible medical

plan with health savings account to

incent consumerism in members

and potential tax savings

Incenting members to select

consumer directed health plans

with current contribution

structure, member education

and communication

$$$ Short

Expert Medical

Opinion

Implement third party vendor to

provide second opinions on care for

members or help in selecting high

quality providers

Member usage, integration with

health plans and providers

$ Short

Social

Determinants of

Health

Identify environmental factors

impacting members’ health and

implement actions to address those

factors

Segmenting population and

determining factors to address,

cost and scope of actions to

address factors

$$ Long


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