What is Catamount?FAQ List

• An extinct(?) Vermont mountain lion

•One of Vermont’s first and finest microbreweries.

(Also extinct)

• 1/38th of Vermont’s landmark health reform legislation:

Act 191. Sec. 15. 8 V.S.A. § 4080f. CATAMOUNT HEALTH (2) “Catamount Health” means the plan for coverage of primary care, preventive care, chronic care, acute episodic care, and hospital services as established in this section to be provided through a health insurance policy, a nonprofit hospital or medical service corporation service contract, or a health maintenance organization subscriber contract which is offered or issued to an individual and which meets the requirements of this section.

Areas to cover in this presentation:

• Quick review of “the back story” (politics and Medicaid)

• Is it better to pass imperfect legislation than to wait for the ideal?

• The new Catamount health insurance benefit: center of the compromise

• What’s the deal with the Blueprint for Health?Vermont’s statewide quest for “systemness”

• Resources for learning more about the other 37/38ths of Vermont’s Health Reform

• The bottom line: first step? Half a step?

Recent Health Policy history highlights

• Broad citizen support for systemic reform

• 2004 election: Rep. Gov., Dem. legislature

• New House Health Care Cmt. created: H.524

• Governor’s Veto

• Health Care Reform Commission, summer listening tour, & Governor’s Health Care Summit

• “consensus” initiative; common sense initiative (CSI Montpelier): S.310… Dr. Ken Thorpe… new focus on chronic care: H.864

“Global Commitment” 1115 WaiverOriginal Medicaid waiver provided coverage of kids to 300% of FPL, Parents to 185%, & childless adults to 150%. A new block grant waiver was a key element of Gov.’s budget in 2005. Submitted in April. Approved 9/30/05.

“Global Commitment” How the MCO is FundedCurrent State Medicaid Available Revenue (All)

Other Health Spending PremiumFederal Match

Reserves

or new spending

Medicaid SpendingOther health spending

Managed Care Organization (OVHA)

New Match

See more VT Legislative Council & Joint Fiscal Office info on Vermont Medicaid at http://www.leg.state.vt.us/jfo/Healthcare.htm And the Medicaid “Global Commitment” home page at http://www.ovha.state.vt.us/globalhome.cfm

Leveraged Federal Match

$0.0

$200.0

$400.0

$600.0

$800.0

$1,000.0

$1,200.0

2007 2008 2009 2010

Cap

Projected Spend

Avail Rev. Spend w/ GCAvail. Rev. Spend

Room under cap

Remaining shortfall

Value of Global Commitment

Key to Catamount financing. (And means DRA citizenship & identity applies to Catamount.) Reduced Medicaid deficit in short term. But the state at risk. Federal participation capped. Trade off: fixed trend rate, Special Terms & Conditions #39

http://www.leg.state.vt.us/HealthCare/catamount.htm

The Compromise

http://hcr.vt.gov/

Implementation

Catamount Health A non-group insurance product for uninsured

Vermont residents

Offered as a Preferred Provider Organization Plan by private insurers in the small group market, beginning October 1, 2007

Is required to be a comprehensive insurance package covering:

• Primary care• Preventative care• Acute episodic care• Chronic care• Hospital services • Pharmaceutical coverage

Individuals may choose which insurer they would like to use.

http://hcr.vt.gov/See the entire PowerPoint from which the next 3 slides are borrowed (with permission) in their complete, original form:

Catamount Health The cost of Catamount Health will depend on your

income and which insurer you sign up with.

For the least expensive plan, Catamount Health will cost:

Income by federal poverty level Monthly premium cost(1 person/annual in 2006)– Below 200% FPL ($19,600) $60.00– 200-225% ($19,600 – 22,050) $90.00– 225-250% ($22,050 – 24,500) $110.00– 250-275% ($24,500 – 26,950) $125.00– 275-300% ($26,950 – 29,400) $135.00– Over 300%  ($29,400)  Full cost, estimated at $340.00

Catamount HealthLEGISLATIVELY-MANDATED COST-SHARING:

• Deductibles: In-Network: Out-of-Network: $250/individual $500/individual

$500/family $1,000/family

• Co-Payment: $10/office visit

• Prescription Drugs: No deductible Co‑payments: $10 generic drugs

$30 drugs on preferred drug list

$50 non-preferred drugs • Preventive Care & $0

Chronic Care*: Not subject to deductible, co-insurance, co-payments

• Out-of-Pocket Maximum In-Network: Out-of-Network: (excluding Premium) $800/individual $1,500/individual

$1,600/family $3,000/family

* For people enrolled in Chronic Care Management Program

But what about that other 37/38ths of VT Reform?

Vermont’s Quest for Systemness

We know the Health Care “system” is Not Monolithic

It’s not

THE HEALTH CARE

SYSTEM

It’s

MANY

SYSTEMS

MANY

MANY

HEALTH CARE

Actually it’s worse: it’s Many Overlapping Systems

It’s

MANY

SYSTEMS

MANY

MANY

HEALTH CARE

MANY

MANY

Health Care Reform Goals

Increase Access Improve Quality

Contain Costs

http://hcr.vt.gov/See the entire PowerPoint from which the next 3 slides are borrowed (with permission) in their complete, original form:

Goal: Increase Access to Affordable Health Care Coverage

Everyone InEnhance Private Insurance Coverage• Catamount Health Plan for the Uninsured• Non-Group Market Reform• Promotion of traditional Employer-sponsored Insurance• Local Health Care Coverage Planning Grant• Potential Individual Insurance Mandate (2010)

Improve Outreach to Uninsured•Bi-State Report findings and recommendations more or less adopted in total to be implemented as the plan…• Comprehensive, integrated approach: a continuum of options for a continuum of uninsured.• Aggressive, community-based outreach coordinators• web-based screening and enrollment tracking tool

Assist with Affordability• Premium Assistance (ESI, Catamount)• Reduction in VHAP Premiums• Non-Group Market Security Trust to reduce premiums

Goal: Improve Quality of CareChronic Care Management• Expand Blueprint Statewide• OVHA Chronic Care Management Program• Medicaid Reimbursement Incentives• State Employee Health Plan• ESI Premium Assistance plan approval, cost-sharing• Catamount Health coverage, cost-sharing• Chronic Fatigue Syndrome Information

Increase Provider Accessto Patient Information•Health Information Technology •Electronic Medical Records Loans•Master Provider Index

Promote Quality Improvement•Consumer Health Care Price & Quality System•Multi-payer Database•Adverse Events Monitoring System•Hospital-acquired Infections data•Safe staffing reporting•SorryWorks!•Advanced Directives

Increase Provider Availability•Loan Repayment Program•Loan Forgiveness Program•FQHC Look-alike Funding•Uncompensated Care Pool

Promote Wellness• Immunizations• CHAMPPS Grants• Catamount Health Coverage, Cost-sharing• Healthy Lifestyles Insurance Discounts• AHS Inventory of Health and Wellness Programs

Goal: Contain CostsIncreased Access to Coverage and Care

Decreased Uncompensated Care Lower Premium Costs

Decrease Cost Shift• Increased Medicaid provider rates• Cost Shift Task Force • Standardize Policy for Hospital Uncompensated Care and Bad Debt• Hospital Cost Shift Reporting Reforms

Improve Quality of Health Care Less Unnecessary Care Lower Costs

Simplify Administration• Common Claims and Procedures• Uniform Provider Credentialing

And then there’s the BlueprintThe Core of Act 191

Chronic Disease Prevention and Care

ManagementTakes the Ed Wagner (Group Health) / Don Berwick (IHI) practice level population disease management model and applies it statewide as a population-based public health initiative. Except it’s a “public/private” health partnership. Legislature codified it in statute more than it had been. Still a work in progress.

Public PolicyPublic Health

Health Systems

Community

HealthProvider Team

Patients and Families

•Policies•Infrastructure•Financing•Resources•Advocacy•Regulation•Info. Systems

•System policy•Quality care•Service development•Reimbursement•Financing•Continuity•Coordination•Info. Systems

•Built environment•Programs and services•Health awareness•Healthy options•Info. Systems

•Practice standards•Info. Systems •Decision support•Office systems•Coaching/support

•Health knowledge•Self-management •Skill and practice•Supportive home •Environment•Info. Systems

Blueprint for Health Model

HealthierVVeerrmmoonntteerrss

Centralized Decentralized Distributed

Blueprint Principles

OVHA

VDHESI

CatamountCCMRFP Care

Coordination

Third Party Payers

Blueprint Implementation

State Employees Health Plan

Other Commercial

Products

AHS Chronic Care Coordination

Team

Blueprint Executive Committee

BISHCADCF

Blueprint Alignment

But how to actually change payment incentives & align motivations in a public/private partnership? Answer remains elusive.

Problematic, Unresolved issues:

• Catamount reinforces the link of insurance to employment

• Through ESI and the employer assessment as well as traditional commercial insurance paradigm. • Creates more risk pools instead of fewer

• Arguably, it means we’re going in the wrong direction.

• Core problem is that the risk is borne by private capital, not the public capital, so the carriers pass off the risk to others and will to do continue so in pursuit of profit. They’re in business to make money, not to assure care.

• Change the health care financing paradigm: Why isn’t it like other Public Structures (schools, fire departments)?

More papers, reports, Power Points, and policy details than most normal people would want to see are available at:

Legislative Sitehttp://www.leg.state.vt.us/HealthCare/catamount.htm

Susan Besio’s Sitehttp://hcr.vt.gov/

Bi-State Outreach Reporthttp://www.bistatepca.org

Hunt Blair: hblair@bistatepca.org 802-229-0002