Medical Services Board Discussion Kim Bimestefer, Executive Director - PowerPoint PPT Presentation

Medical Services Board Discussion Kim Bimestefer, Executive Director April 12, 2019

• Building Personal Care and Home Care Work Force to support growing Seniors and Individuals with Disabilities populations – Workforce Development Workstream including Training, tracking workforce against needs, $20M budget action for 2019-20 • CIVHC Foundational S upport: $4M funding including $2.5M in this budget, which funds the APCD. Advisory Board refocus. Employer Data. Some HCPF Budget • Funded three more Medicaid Fraud Inspectors. Renewed focus on this. Requests • Improved Member Service Technology (but not enough). Provider service support is solid (< 60 sec AS A) • Primary Care Providers Incentive Model support 2

Focus: Getting Colorado Covered In Process Work • CHAS S urvey Insights • Other hired consultants to help define the uninsured drivers • Public Option work (bill 1004) **National Uninsured: 8.8% S ources: Colorado insurance coverage percent ages are f rom t he Colorado Healt h Access S urvey, S ept ember 2017. ***Nat ional insurance coverage percent ages are f rom U.S . Census Bureau Current Populat ion Report , Healt h Insurance Coverage in t he Unit ed S t at es: 2017, issued S ept ember 2018. 2017 Colorado Health Access S urvey 3

Lt. Governor’s New Cabinet: Lower healthcare costs to save people money on healthcare 4

Focus: Healthcare Affordability Colorado Private S ector (Consumers and Employers) 1 $20,940 $65,718 2016 average cost of 2016 median income private insurance Medicaid consumes Health Care is 33% 32% of median household S tate’s Total Budget (25% of General income Fund) 1 Source: Income data from Colorado DOLA LMI Gateway, US Census Median Household Income 2. CO Department of Health Care Policy and Financing 5

Some Initial Affordability Pathways 1. Constrain prices, especially hospital and prescription drugs. 2. Champion alternative payment models. 3. Align and strengthen data infrastructure. 4. Improve our population health. 5. Maximize innovation. 6

Centers of Excellence Alternate Payment Methodology, Policy Discussion, in Collaboration with the AG’s Office Solution: Drive more Consistency in Hospital Price and Quality. Drive the community to the higher quality, Each bubble reflect s hospit al volume for a non- emergent procedure. The posit ion of the bubble lower cost locations reflect s cost / qualit y met rics at t hat hospit al. Such (sometimes called Centers of chart s are being produced for a number of procedures Excellence). t o help ident ify Cent ers of Excellence. 7

Other Hospital Affordability Solutions Efficiency Aligned Quality, Incentives Accountability • • Value based payments to hospitals • Hospital Transparency Out of Network contracting and to reward appropriate referrals • Community Health Needs reimbursement that improve cost, quality Assessment transparency and Community Boards engagement • Hospital Transformation Program 8 8

Medicaid Rx Cost Trends Medicaid generates about Pharmacy Average PMPM $1B in Rx claim costs (before rebates) $70.00 $60.00 Over the last six (6) fiscal years, 2012/13 through 2017/18: $50.00 $40.00 Generic Rx costs down 8% or 1.3% / year Brand name Rx up 30% , or 5% / year $30.00 SRx up 171% , or 28.5% / year Total Rx spend is up 51% , or 8.5% a year $20.00 $10.00 Of this total 51% Rx trend, more than 75% is due to $0.00 FY1213 FY1314 FY1415 FY1516 FY1617 FY1718 Specialty Drugs. S PECIALTY AVERAGE PMPM NON SPECIALTY AVERAGE PMPM GENERIC AVERAGE PMPM OVERALL AVERAGE PMPM 9

Specialty Drug Impact 0.9 Impact of Specialty Drugs on Medicaid spend 0.8 1.25% of CO Medicaid 0.7 prescriptions (specialty drugs) 0.6 are so expensive, they are 0.5 consuming > 40% of Medicaid’s NON Rx resources (before rebates). This 0.4 SPECIALTY DRUG is in line with national and 0.3 SPECIALTY DRUG commercial carrier trends. 0.2 0.1 0 FY1213 FY1314 FY1415 FY1516 FY1617 FY1718 10

Specialty Drugs: we’re at the beginning 42 new drugs launched in 2017. 75% were specialty drugs $12 billion spent on new drugs in 2017. 80% was spent on specialty drugs specialty drugs dominate FDA approval pipeline. S ource: IQVIA Medicine Use and S pending in 11 t he US , 2017.

Drug Price Increases are a Problem, Too The US General Accounting Office found that 315 different drugs experienced 351 “ extraordinary price increases” at least a doubling in price year- to-year. 12

No, The High Cost is NOT Due to Research Drug companies spend about $40B a year MORE on marketing and administrative expenses than on research and the development of new drugs 13

Innovations and Shared System Solutions Physician Prescribing Shared Tool • Assists prescribing based on cost and quality efficacy of prescription vs. DTC ads or manufacturer incentives to influence specific Rx use. • Loads payer/ carrier formularies, reimbursements, copay structures, and PAR rules • Will also host carrier/ payer programs by patient so prescriber can inform patient about health improvement programs (functional medicine). • Department Request to Negotiate to be released May/ June 2019 (needs CMS approval). Prometheus – potentially avoidable costs and quality tool, rolling out now Tele Health / Tele Medicine– rural & front range opportunities • Key opportunity to address the Disability Community, Behavioral Health, access in rural communities, S pecialty care access • Awaiting the roadmap from University 14

Implementation of 18-266 Medicaid Cost Management 12+ Teams Actively Strategizing and Implementing Cost Control and Quality Improvement Solutions: • Hospital Costs, Claim S ystem, Rx, PACE / S eniors, Fraud-Waste-Abuse, FQHC/ PCP, etc. Medicaid Cost Control Bill SB18-266 passed unanimously, signed into law May 2018. Now in implement at ion! • Innovations that Improve Quality Outcomes and Costs :  Prometheus – RAEs have been t rained, Hospit als/ PCMH/ FQHCs – in t raining  Physician Rx Prescriber Tool – Q4 t arget cont ract • Medicaid Catch-up with Colorado’s Commercial Carriers  Hospital Review – March 2019 Implement ed  Modernize Medicaid Claim Edits - t hroughout lat er 2019 • New HCPF Cost Control & Quality Improvement Office  HCPF Medicaid Quality analytics and reporting  HCPF Care Support and Cost Control analytics and programs  Affordability Roadmap for Coloradans 15

35 Health Care bills in process . S ome of the more interesting: • Exchange Reinsurance bill • Public Plan • Out of Network bill • Transparency bill – Hospital ( signed int o law ) Key • Transparency bill - Pharma Healthcare • Drug Importation bill Legislation • Investments in Primary Care • Lots of Behavioral Health bills • More t o come! 16