Premera’s Norm Compared to UA University Of Alaska Norm City State % of Total City State % of Total FAIRBANKS AK 45% ANCHORAGE AK 29% ANCHORAGE AK 25% FAIRBANKS AK 14% JUNEAU AK 5% JUNEAU AK 7% NORTH POLE AK 4% WASILLA AK 4% EAGLE RIVER AK 3% EAGLE RIVER AK 3% WASILLA AK 2% SITKA AK 3% PALMER AK 2% PALMER AK 2% BETHEL AK 1% NORTH POLE AK 2% SOLDOTNA AK 1% DILLINGHAM AK 2% SITKA AK 1% VALDEZ AK 2% ESTER AK 1% CHUGIAK AK 1% KETCHIKAN AK 1% KOTZEBUE AK 1% AUKE BAY AK 1% KETCHIKAN AK 1% KODIAK AK 1% BARROW AK 1% VALDEZ AK 1% WRANGELL AK 1% CHUGIAK AK 1% SOLDOTNA AK 1% KENAI AK 1% KENAI AK 1% DILLINGHAM AK 1% CORDOVA AK 1% HOMER AK 0% METLAKATLA AK 1% NOME AK 0% SAN ANTONIO TX 1% 25 All Other AK 4% All Other 24% E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Table 1 - Service Category Comparison between PY 2008/2009 and PY 2007/2008 Table 1 - Service Category Comparison between PY 2008/2009 and PY 2007/2008 Table 1 - Service Category Comparison between PY 2008/2009 and PY 2007/2008 Service Categories >1% of Total Paid Claims Paid Claims % of Total Paid Claims Service Category % Change Current Current Prior $2,940,000 Office Visits 12% 14% 2% $2,743,000 Outpatient Surgery 12% 12% 10% Physical/Occupational Therapy 12% $2,090,000 9% 9% $2,071,000 Rad Office 9% 10% -3% $1,481,000 Path Office 6% 7% -3% $1,348,000 6% 5% 21% Office Surgery $1,248,000 5% 5% 16% IP Surgery - Primary Surgeon Miscellaneous Medical - Supplies $1,064,000 111% 4% 2% $956,000 Miscellaneous Medical - Services 4% 3% 33% $807,000 OP Psychiatric 3% 4% 9% Physical Exams $678,000 3% 3% 19% $659,000 Therapeutic Injections - Supplies 3% 3% 25% $648,000 Cardiovascular 3% 2% 49% Chiropractor 19% $636,000 3% 3% Rad OP Professional $518,000 2% 2% 21% $499,000 Outpatient Anesthesia 2% 2% 18% $398,000 Consults 2% 2% 16% $396,000 Emergency Room Visits 2% 2% -1% Massage Therapy 32% $317,000 1% 1% IP Surgery - Anesthesia $295,000 1% 1% 4% $274,000 Hospital Visits (excl MH and CD) 1% 1% 13% Incurred Period: 7/1/2008 - 6/30/2009 Paid Through: 9/30/2009 26 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Top Two - Office Visits and Outpatient Surgery Significant increases in Miscellaneous Medical- Supplies and Services, as well as Cardiovascular, Chiropractic and Massage Therapy. Emergency Room utilization decreased 13% increase in professional services category 27 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Chiropractic Increased 19% Premera’s norm - 6.8 visits UA’s average – 9 visits 62 members received 30 or more visits during the reporting period 86% of visits appear to be unrelated to surgical or inpatient follow-up 28 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Chiropractic Visits Detail Average Member Range Visit Count per Count Member 50+ 15 1,021 68 46-49 2 95 48 41-45 13 551 42 31-40 32 1,132 35 25-30 40 1,073 27 21-24 57 1,281 22 11-20 259 3,696 14 2-10 833 4,136 5 1 207 207 1 TOTAL 1,458 13,192 9 29 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Physical and Massage Therapy Premera’s norm - 8.7 visits UA’s average – 11.6 visits 174 members received 30 or more visits during the reporting period 77% of visits appear to be unrelated to surgical or inpatient follow-up 30 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Physical and Massage Therapy Visits Detail Average Member Range Visit Count per Count Member 50+ 59 4,240 72 46-49 20 954 48 41-45 20 862 43 31-40 75 2,642 35 25-30 67 1,818 27 21-24 70 1,568 22 11-20 346 5,049 15 2-10 946 4,717 5 1 299 299 1 TOTAL 1,902 22,149 12 31 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Miscellaneous Medical Supplies PY 2008/2009 PY 2007/2008 Description Svcs Paid Description Svcs Paid RITUXIMAB 100 MG 21 $159,004 IRINOTECAN, 20 MG 22 $148,620 TRASTUZUMAB 10 MG 62 $151,012 RITUXIMAB 100 MG 16 $114,250 CYCLOPHOSPHAMIDE, 100 MG 19 $94,965 TRASTUZUMAB 10 MG 33 $85,586 DOCETAXEL, 20 MG 20 $89,503 DOCETAXEL, 20 MG 23 $44,849 INJECTION, OXALIPLATIN, 0.5 MG 20 $88,534 INJECTION, PEMETREXED, 10 MG 2 $23,250 LEUPROLIDE ACETATE (FOR DEPOT DOXORUBICIN HCL, 10 MG 15 $88,514 SUSPENSION), 7.5 MG 9 $21,194 INJECTION, BEVACIZUMAB, 10 MG 23 $74,496 INJECTION, OXALIPLATIN, 0.5 MG 3 $14,316 INJECTION, PEMETREXED, 10 MG 6 $60,000 CARBOPLATIN, 50 MG 6 $12,207 IRINOTECAN, 20 MG 9 $50,637 LEUPROLIDE ACETATE IMPLANT 1 $6,821 HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER GEMCITABINE HC1, 200 MG 14 $49,775 DOSE. 14 $6,036 TOTAL 209 $906,440 129 $477,129 32 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Medical Supplies Premera manages drugs covered under the medical benefit (J-Code billing) through medical necessity review. Biotechnology Initiative has received national recognition for its comprehensive approach and was described in Health Affairs , Sept/Oct 2006. Premera is not able to integrate management of medical and pharmacy drugs as effectively since PBM is no longer Medco. Installation of the iCES Claims Editor in 2007 adds ability to set dose limits to detect office billing errors as well as dosing in excess of standard practice. 33 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Inpatient, Outpatient, and Professional Services Utilization Category 2008/2009 Norm PY 2007/2008 PY 2008/2009 Inpatient Paid Claims Per Member Per Month $62 $81 $75 Admissions Per 1000 Members 45.0 45.9 56.8 Days Per 1000 Members 174.2 226.9 265.2 4.9 Average Length of Stay 3.9 4.7 $21,116 Paid Claims Per Admission $16,541 $15,867 Outpatient $87 Paid Claims Per Member Per Month $71 $80 Visits Per 1000 Members ² 779 1024 1093 Paid Claims Per Visit $1,014 $1,101 $882 Services Per 1000 Members 3597 4464 4720 Services Per Visit 4.6 4.4 4.3 Paid Claims Per Service $239 $233 $204 ER Utilization: Paid Claims PMPM $6 $6 $6 ER Utilization: Visits Per 1000 Members 109 105 159 $668 ER Utilization: Paid Claims Per Visit $655 $463 Professional Provider Paid Claims Per Member Per Month $205 $181 $157 Services Per 1000 Members 17,159 14,826 17466 Paid Claims Per Service $143 $124 $127 $388 Medical Total PMPM $329 $334 Incurred Period: 7/1/2008 - 6/30/2009 Paid Through: 9/30/2009 34 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Upward Trend in Most Categories 35 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Emergency Room Visits • Top 10 Reported Symptoms • PMPM Significantly Above Norm Emergency Room Dx Description Visits Paid OPEN WOUND OF FINGERS, WITHOUT MENTION OF COMPLICATION 29 $15,808.61 ACUTE UPPER RESPIRATORY INFECTIONS OF UNSPECIFIED SITE 26 $12,469.35 OTHER ACUTE PAIN 20 $21,266.84 ACUTE PHARYNGITIS 20 $7,091.90 UNSPECIFIED OTITIS MEDIA 20 $5,342.46 ABDOMINAL PAIN, UNSPECIFIED SITE 19 $19,951.96 HEADACHE 12 $9,342.86 FEVER, UNSPECIFIED CHILLS WITH FEVER 11 $11,438.42 VOMITING ALONE 11 $10,680.62 ASTHMA, UNSPECIFIED WITH ACUTE EXACERBATION 11 $8,197.00 36 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Top 20 Emergency Room Providers Provider Visits Paid % of Total FAIRBANKS MEMORIAL HOSPITAL 414 $360,419 53% PROVIDENCE ALASKA MEDICAL CENTER 180 $90,390 13% MAT SU REGIONAL MEDICAL CENTER 32 $32,650 5% CENTRAL PENINSULA GENERAL HOSPITAL 29 $22,670 3% BARTLETT REGIONAL HOSPITAL 58 $21,112 3% ALASKA REGIONAL HOSPITAL 30 $18,509 3% PROVIDENCE VALDEZ MEDICAL CENTER 14 $18,150 3% ALASKA NATIVE MEDICAL CENTER 26 $14,464 2% YUKON KUSKOKWIM REGIONAL HOSPITAL 19 $7,664 1% BRISTOL BAY AREA HEALTH CORPORATION 26 $7,343 1% SOUTH PENINSULA HOSPITAL 8 $7,154 1% PROVIDENCE KODIAK ISLAND MEDICAL CENTER 9 $5,336 1% SITKA COMMUNITY HOSPITAL 13 $4,700 1% KETCHIKAN GENERAL HOSPITAL 10 $3,573 1% ALASKA VA HEALTHCARE SYSTEM AND REGIONAL OFFICE 5 $3,566 1% PROVIDENCE SEWARD MEDICAL AND CARE CENTE 2 $3,435 1% VALLEY HOSPITAL MEDICAL C 2 $2,984 0% CHILDRENS HOSPITAL AND REGIONAL MED CENTER 3 $2,815 0% DAUGHTERS OF CHARITY HEALTH 1 $2,700 0% BASSETT ARMY COMMUNITY HOSPITAL 19 $2,698 0% All Others 119 $48,717 7% GRAND TOTAL 1,019 $681,046 100% 37 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Major Diagnostic Categories Inpatient Utilization All Claims Major Diagnosis Category % of Admits per Days per 1000 Average Paid Total Paid Overall 1000 Members Members Length of Stay PMPM Claims Total Musculoskeletal System 2.89 11.99 4.14 $63.99 $7,426,798.89 16.49% Neoplasms 4.14 17.78 4.30 $43.54 $5,053,877.47 11.22% Health Status & Services 3.93 37.63 9.58 $39.69 $4,606,458.19 10.23% Circulatory System 4.55 18.82 4.14 $34.74 $4,032,038.77 8.95% Ill-Defined Conditions 1.14 2.48 2.18 $34.56 $4,011,414.20 8.91% Incurred Period: 7/1/2008 - 6/30/2009 Paid Through: 9/30/2009 “Health Status & Services” includes maternity, cancer screening, and general exams. “Ill-Defined Conditions” includes fever, convulsions, chest pain, abdominal pain. Research has shown that the Major Diagnostic Categories that are most closely related to lifestyle behaviors are: • Neoplasm (Cancer) • Circulatory • Respiratory • Digestive • Genito-urinary • Low birth rate, premature births 38 • Musculoskeletal • Endocrine/Metabolic E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Priority Health Recommendations The July 2009 Health Risk Assessment Aggregate Report Identified the following priorities based on Health Risk Assessment Results (ie no biometric or claims data): Fitness Promotion Correlates with data shown in Weight Management Major Diagnostic Categories Good Nutrition Osteoporosis Sleep Blood Pressure Reduction 39 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Low Member Cost-Share on Medical Benefit Type of Responsibility Member Responsibility % of Total Allowed Deductibles $1,590,760 3% Coinsurance $2,951,055 5% Amounts Over Benefit $0 0% Maximum/Limitations Total $4,541,829 8% Premera’s Norm is 14%. National Average is 15 to 20% 40 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
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43 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Premera’s Top Two Plans 1st Most Popular 2nd Most Popular: Deductible: $1,000 Deductible: $200 Office Visit Copay: $25 Office Visit Copay: Ded & Coinsurance Coinsurance: 20%/50% Coinsurance: 20%/40% OOPM: $5,000 OOPM: $3,000 44 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Anti-selection PMPM average for the Deluxe plan is almost double that of the Standard plan and five times the Economy plan 48% of the claims on the Deluxe plan and more than 30% of the claims on the Standard plan were in excess of $50,000 pointing to a catastrophic illness burden concentrated in the Deluxe plan. The illness burden between plans outpaces the age/gender differences by plan 45 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Plan Enrollment by Type 46 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Anti-Selection Evidence 2008/2009 Medical Claims PMPM 47 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Large Claims – Above Norm According the Center for Disease Control, chronic diseases which are largely preventable and attributed to lifestyle choices, accounted for 5 of the 6 leading causes of disease in the United States. 48 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Number of Claimants Increasing Claimants with Claims % of Total Claimants Above PY 07/08 PY 08/09 $10,000 10.01 % 11.03 % $25,000 3.52 % 3.77 % $50,000 1.18 % 1.49 % $75,000 0.58 % 0.89 % $100,000 0.34 % 0.60 % $150,000 0.15 % 0.30 % $250,000 0.03 % 0.12 % 49 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Pharmacy Utilization 2008 strategies yielded positive results: PY2007/2008 7.8% versus -6.7% in PY 2008/2009. An increase in the generic dispense rate combined with a decrease in the brand dispensing rate contributed to the positive change. Note this is a one time change; true trends are still on the rise There is still room for improvement: The generic dispensing rate – 55% – is below industry average of 62% Mail order utilization – 41% of scripts are maintenance drugs that are filled at retail instead of mail order Medication adherence ratio is low Caremark estimates that for every 1% increase in Generic Dispensing Rates 1% in Gross Pharmacy Costs are saved 50 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Medication Adherence Chronic Condition Number Optimal Number Sub- Estimated Savings New Users Who optimal Per Conversion to Dropped After Optimal First Fill Asthma/COPD 126 345 $276 137 Diabetes 182 125 $2,253 20 Heart Failure 6 0 $2,998 0 Hyperlipidemia 500 291 $314 53 Hypertension 687 366 $1,304 70 How much would be saved if even 30% were converted to optimal? $300,000 51 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Medication Adherence, Cont’d. Reported Reasons for Medical Non-Adherence Forgot 15% 24% 10% Side Effects 14% Cost 20% 17% Decided didn't need Difficulties in filling Rx Other Note: Based on a national study by Caremark, not UA data. 52 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Neglected data Year-end reporting for plan and disease management just produced by Premera Quarterly reporting and analysis is needed to quickly identify and target utilization categories that are increasing $60 Million Plan – Regular review and analysis is imperative to manage costs The analysis needed is beyond the time available to in house staff Fall River will provide a proposal for continual year round data analysis and recommendations Refer to Attachment 1 – List of Premera and Caremark Reports 53 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
3b): Engage Members Through Plan Design www.fallriverconsulting.com
Top 5 Recommendations Rx Plan Changes Address Highly Utilized Benefits Consumer Driven Design Possibilities Value Based Benefit Designs Redesign Incentive Structures 55 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Rx Plan Changes Implement plan design changes proposed by Caremark and presented to committee: Performance Step Therapy Eliminate Dispense as Written “Escape Clause” Specialty Guideline Management Consider Copay Changes 56 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Rx plan changes Implement Caremark’s Additional No- Charge Services No Additional Cost to University Not Intrusive Standard Practice in Market 57 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Rx Plan Changes Two other possibilities: Changing member cost sharing from copays to coinsurance Raise out of pocket limit from $800 to $1000 or more Little price impacts on day one but may create better incentives over time Refer to Attachment 2 – Pharmacy Options 58 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Address Highly Utilized Benefits Implement Visit Limits on Chiropractic, Massage, Physical Therapy and Hospitalization Current analysis suggests 26 visit limit on each of Chiro, massage therapy, and physical therapy Consider member being able to recertify for another 26 visits for physical therapy Additional data drill down needed, but preliminary savings estimates are around $400,000 59 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Consumer Directed Healthcare Brief discussion of HDHPs and HSAs Review Health Reimbursement Arragement Concept 60 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Consumerism – Studies that Prove Concept Consumerism is about increasing healthcare efficiency – not avoiding care CIGNA recently published the results of their study over several years which analyzes the healthcare behavior trends and cost trends of 440,000 members under CIGNA coverage in either a Consumer Directed Health Plan (CDHP), an HMO, or a PPO 61 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Consumerism Continued Patients with chronic diseases, such as diabetes and hypertension, costs were reduced by 20% and 18%, respectively, while there was no change in their treatment trend , suggesting the cost-saving devices were better choices and not a choice to simply neglect healthcare needs In just the first year of the study, a 10% reduction of pharmacy expenses was observed, along with a 5% increase in preference for generic pharmaceuticals Preventative care was 8% higher for individuals covered in the CDHP Refer to Attachment 3 – Consumerism Article 62 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Health Reimbursement Arrangement Design Possibility Add plan with high deductible and coinsurance Members have account to draw expenses from to cover part of deductible Additional HRA funds available with incentives for completing defined wellness initiatives 63 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Value Based Benefit Designs (VBBD) According to the Center for Health Value Innovation, as published in their book “Leveraging Health,” there are three major levers employers can use: Condition Management Provider Guidance Individual Health Competency The goal in each of these areas is to address the problems of: Access Avoidance Relevance 64 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Value Based Benefit Designs (VBBD) Condition Management: In national study, 17% of those who did not comply with optimal medication for chronic condition cited cost as the primary reason Recommend benefits designs that would remove these access barriers Provider Guidance: Physician report cards are available on a limited basis in Alaska; part of communication strategy is to educate members to use these Getting care in appropriate setting (PCP and urgent care vs. ER) should be part of communication campaign Individual Health Competency: Wellness Initiatives 65 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Value Based Benefit Designs (VBBD) Eliminate cost sharing barriers and encourage desired member behavior, such as participating in Disease Management or completing wellness initiatives: Waive deductible for active Disease Management participation Waive all Rx copays (or set to $5) for all drugs for certain disease states Provide deductible credits to those meeting wellness targets Caremark able to administer a number of different designs currently Premera piloting programs and can begin basic VBBD administration by 2010, but July 2011 is the first realistic implementation date 66 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Medical Plan Design Options Review attachment detailing medical plan options Refer to Attachment 4 – Medical Plan Design Options 67 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Redesign Incentive Structures Providing incentives and rewards sends an important message - the organization is committed to improving employee health and will share the rewards that these changes will bring Numerous studies support the value of providing incentives, depending on the structure some have achieved participation rates in excess of 80% According to a 2009 Towers Perrin survey, 45% of survey respondents have, will or are considering introducing or increasing penalties for nonparticipation in wellness or health promotion activities. 68 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Incentive Strategies – Legal Requirements Incentives that are conditioned upon an individual satisfying a standard related to a health factor must meet HIPAA’s 5-point compliance standard: 1. The reward must not exceed 20% of the value of the healthcare plan 2. Members must be able to qualify at least annually 3. Standard must be reasonably designed to improve health and prevent disease 4. The program must allow a reasonable alternative standard for obtaining the reward to any individual for whom it is unreasonably difficult due to a medical condition to meet the original standard (i.e. if the member can’t quit smoking then they must have access to an alternative method of obtaining reward). 5. All plan materials must use specific language as defined by HIPAA that clearly discloses the terms of the program, ability to qualify annually, and the availability of an alternative standard. 69 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Incentive Strategies – Legal, Cont’d. Fall River recently obtained a general legal opinion at its own expense to clarify recent EEOC guidance as it pertained to incentive programs and the ADA. Legal guidance was that it may no longer be defensible to condition the entire benefit on compliance, and that Health Risk Assessment and other wellness incentives need to be reasonable in amount to be considered “voluntary”. It is our belief that all of our recommendations would meet the requirements of HIPAA and the ADA. However, this is an area of developing law and due to the potential risks, we highly recommend that the University seek its own legal counsel before implementing any new incentive structures. 70 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Employee Premium Strategies Gordian, a provider of wellness services, strongly encourages its clients to integrate incentives into employee premiums or member benefits, and has seen participation rates rise to between 70 percent and 90 percent with this method. A case study completed by WELCOA also demonstrates the impact of integrated premium incentives. The case study discusses how the City of Holland, Michigan engages 85% of its employees in organization-wide wellness offerings by linking employee health care costs to wellness program participation ultimately resulting in lower medical claims and healthier employees. 71 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Employee Incentive Strategy Review attachment detailing incentive strategies Refer to Attachment 5 – Incentive Options 72 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
3c): Member Health Promotion www.fallriverconsulting.com
Why is it Important? Overwhelming evidence in industry research that wellness programs return their investment many times over. Center for Disease Control and Prevention reported that wellness programs average over 300% ROI over a three to five year period. Cardiovascular disease, stroke, cancer, and diabetes are all linked by common risk factors, behaviors and/or health habits associated with physical inactivity and poor nutrition. 74 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Key Areas Wellness Benchmarking Survey Nurse Line Disease Management 75 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Wellness Benchmarking Survey Review handouts Wellness Inquiry WIN for Alaska Cost Benefit Analysis 76 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Wellness Benchmarking Survey A thorough review of the WIN for Alaska services provided for the University showed the following strengths: Meaningful success stories within the IHP program Familiarity with the Alaska market Significant onsite presence through a variety of wellness programs and fitness events A great deal of customization geared specifically to the UA program and local events Flexibility in scheduling and coordination of space 77 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Wellness Benchmarking Survey Key Areas for Improvement: Increase the amount of available coaching, improve current participation rates and reduce no-shows Stratify members based on HRA and bio screens and target more aggressive communications at highest risk individuals HRA results should be shared with disease management vendor with consent of participant 78 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Wellness Benchmarking Survey Key Areas for Improvement Continued: Space should be identified for the IHP program so participant confidentiality is respected and resources aren’t wasted in identifying open office space ROI analysis tied to medical and Rx claims data, essential in evaluating program effectiveness, should be completed annually Refer to Attachments 6 and 7 79 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Wellness Program - Evaluation Tool Worksheet to evaluate program and identify areas for improvement Use for ongoing planning Refer to Attachment 8 – Self Evaluation of Key Wellness Program Elements 80 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Reintroduce Nurseline Premera shared positive outcomes from recent case study; however confidentiality prevented getting details in time for presentation Important uses of Nurseline: Triage to determine best place to receive care Access in rural areas – may replace some physician contact where that is difficult to obtain Education for consumer initiatives such as self care 81 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Reintroduce Nurseline - Pricing Vendor Comments Pricing Estimates Premera Included unlimited calls. $0.99 PEPM Can attempt general reporting; cannot ~ $50,000 Annually guarantee accuracy because member data is not routinely collected based on individual health plan. WIN for Alaska Will provide reports, facilitation and ~$36,000 Annually (Up to 125 calls per month) customization to Alaska participants. $20 per each call exceeding monthly limit $9,000 one-time setup fee Sirona Health We conducted a general inquiry with an ~$30,000 Annually (Up to 120 calls per month) outside vendor. The University’s name $21 per each call exceeding monthly limit was not released. $2,500 one-time setup fee Sirona is URAC accredited and does business in Alaska. Online client reporting portal with 150 standard reports. 82 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Retool Disease Management Strategy Review DM vendor comparison and consider a switch to Accordant Need more clinical outcomes reporting Need greater integration between vendors to optimize value of DM and wellness Include Value Based Benefit Design to further incent DM participation 83 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Disease Management Vendor Analysis Compared Premera (Healthways) program with Caremark (Accordant) program, with emphasis on: Program components Member outreach Reporting ROI methodology Pricing Refer to Attachment 9 – Disease Management Analysis 84 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Disease Management – Clinical Outcomes Only detail reporting was for Diabetes, CHF, and CAD (even when Asthma and other programs in place), and is greatly delayed (reviewing CY 07 stats in Nov 08) Hospital admissions and ER visits were down for diabetes and CHF but both were up for CAD Categorization of members by how well they are managing disease indicated several concerns: All CHF patients had an ER or hospital visit in the past year, meaning that’s the only way Premera found them 0% of diabetics are classified as “Managing Condition Effectively” without an elevated risk of exacerbation % of Opt Outs increased in most programs Savings calculation seems to indicate that claims dropped dramatically in 2006 after the 2005 baseline year, and then increased quite a bit again in 2007. Appears to be taking credit for reversion to the mean. Need additional reporting and on a more timely basis. Accordant offers this service. 85 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Disease Management Integration Incent integration of HRA results and biometric screens with DM vendor (members will need to provide consent) Use value based benefit designs to further incent active Disease Management engagement 86 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
3d): Create Savvy Healthcare Consumers www.fallriverconsulting.com
Top 3 Recommendations Conduct Knowledge Survey Incorporate Consumerism into More Communication Vehicles Develop and Proactively Educate Members On Top 10 Topics 88 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Knowledge Survey Consumerism is about teaching members to use the same smart shopping skills they have in other areas of their lives Focus messages on how these skills and tips will help the member save on their own out of pocket costs Surveys have shown that members don’t always believe they are responsible for helping to control healthcare costs Some members don’t realize there are tools and resources that are available Distribute consumer survey, ideally a series of surveys, to assess current member knowledge of healthcare system and tools Tie completion of surveys to incentive rewards Refer to Attachment 10 – Consumer Knowledge Survey 89 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Incorporate Consumerism into More Vehicles Use results from Consumer Knowledge Survey to develop education topics for communication pieces Electronic WIN e-newsletter Print newsletter Ad hoc emails Flyers and Posters Enrollment guide 90 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Proactively Educate - Top 10 Topics Develop “Top 10” based on: Survey results High utilization areas Wellness initiatives HRA and biometric screening results Member resources and tools Consumer or industry trends 91 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Top 10 - Some Suggestions to Start With Getting care in the most appropriate setting – ER versus, urgent, versus self-care or PCP How to use Premera and Caremark member websites for cost and quality Pharmacy – generic versus brand. Different pricing from pharmacies. Where can you compare costs, and how much can you save? 92 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Top 10 Suggestions Continued Promote SAFER S peak up – About medical history and medications A sk questions – Question tests and procedures F ind the facts – Ingredients, uses, warnings, etc. E valuate your choices – Get a second opinion R ead the label - Follow directions! 93 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Compare Cost of Emergency Care Example from Premera’s member website 94 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Find Physicians –Certified or Not? Example from Premera’s member website 95 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Health Challenges Example from Premera’s member website 96 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Symptom Checker Example from Premera’s member website 97 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
Compare Generic and Brand Costs Example from Caremark’s member website 98 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
3e): Communicate Constantly www.fallriverconsulting.com
100 E XPERT E MPLOYEE B ENEFITS & A CTUARIAL C ONSULTING
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