Transcript AHIP UHIA Annual Presentation 2014 - sli[...]

Creating an Affordable, Stable and
Accessible System for Consumers
Grace Campbell
Regional Director State Advocacy
Utah Health Insurance Association Annual Health Care Conference
December 4, 2014
Outline
 What Happens in DC
 A Critical Framework
 In Focus:
 Affordability
 Provider Charges
 Specialty Drug Costs




Health Insurance Tax
2015
Network Adequacy
Medicaid Expansion
What Happens in DC
2016
Supreme
Court
Rifle
Shot
“Fixes”
Repeal
&
What?
A Critical Framework
Affordability
Accessibility
Stability
Choice
In Focus: Affordability
Underlying Cost of Health
Care
Provider Networks
Specialty Drug Prices
Health Insurance Tax
Deeper Dive: Underlying Cost of Care
SOURCE: PricewaterhouseCooper’s Health Research Institute
Deeper Dive: Provider Consolidation
“That drive toward hospitals forming
bigger
conglomerations
ofshows
networks
“Since
the
primaryresearch
driver of
growth
in and
“Very
substantial
very
physician
practices
has
reduced
private
spending
in recent
years
has been
strongly
that
increased
concentration
in
Bigger
Hospitals
Mean
Higher
Prices,
Not
competition,
and
in
a
non-Medicare
price
increases
for
health
care services,
a
hospital
markets
leads
to
higher
prices
—
Better
Care has enabled hospital systems
population,
compelling
caninbe
made
for
up to 40 orargument
50 percent
some
cases”
in many
parts
of the
to charge far
putting
the
brakes
on country
consolidation”
- BusinessWeek
- said by Martin Gaynor, the more.”
FTC’s Director of the Bureau of
-Economics
New England Journal of Medicine, January 2014
- said by Dr. John Birkmeyer, a researcher and adjunct professor
at the Dartmouth Institute
Deeper Dive: Specialty Drug Prices
“CVS Caremark, a pharmacy benefit manager, reported last
week that, among its clients, spending on specialty drugs
increased by 15.6 percent in 2013, compared with spending on
traditional medications, which grew by only 0.8 percent.
Express Scripts, another drug benefit manager, found that while
growth in spending on specialty drugs was at its lowest point in six
years — 14.1 percent — it is forecast to increase significantly. The
country’s spending on specialty drugs will increase an additional
63 percent between 2014 and 2016, the company predicted.”
-- NY Times, April 15, 2014 “Prices Soaring for Specialty Drugs, Research Finds
Deeper Dive: Health Insurance Tax
Working to Provide Affordable
Coverage in the New Marketplace
2015
Considerations for 2015
• Enrollment mix and risk pool composition issues
• Addressing technical challenges—particularly on
back-office functionality of exchange
• Other factors affecting premiums in 2015
• Need to address underlying health care cost
growth
State Exchange Governance and IT Platform
Decisions for the 2015 Benefit Year
Exchange Governance Model
State-Based Marketplace
(SBM) (13 plus DC)
(as of September 2014)
Supported State-Based
Marketplace (SSBM) (2)
Federally-Facilitated
Marketplace (FFM) (18)
WA
MT
ME
ND
OR
New Marketplace
Partnership Agreements (7)
MN
ID
WI
SD
WY
MI
PA
IA
NE
NV
UT
IL
OH
IN
WV
CO
CA
KS
AZ
MO
NC
TN
AR
SC
MS
TX
VA
KY
OK
NM
AK
AL
GA
LA
FL
HI
* This map represents state Exchange governance and IT platform decisions as they are structured going into the 2015 benefit plan
year. For a copy of the 2014 benefit year Exchange governance determinations, click here.
© America’s Health Insurance Plans 2014
State Partnership
Exchanges (7)
NY
VT
NH
MA
RI
CT
NJ
DE
MD
DC
HHS will run an Exchange in
the individual market while
the state runs the statebased SHOP Exchange. (3)
13 states plus DC have a
State-Based Exchange.
37 states function under a
FFM IT platform.
Changes in IT Platforms for
2015
The state is retiring their 2014
state-based IT platform, and
implementing a new statebased IT platform in 2015. (2)
The state is launching a statebased IT platform in 2015, but
used the FFM IT platform in
2014. (1)
The state is using the FFM IT
platform in 2015. While NM was
already using the FFM IT
platform in 2014, OR and NV
are switching from a statebased IT platform. (3)
Protecting Health Plan Networks
to Provide an Affordable Quality
Health Care System
Three Key Areas of Consideration
Flexibility
Choice
Holistic Look at
Requirements
Meet Needs of
Consumers &
Employers
Affordable, High
Value Networks
Transparency,
Access, &
Affordability
How Networks Are Built
Deliberative Process
Active Cooperation and
Collaboration
Performance Measured
Quality Metrics
Meet Robust Standards for
Adequacy and Access
Deeper Dive: Provider Networks
CHOICE:
90% of individuals with
access to broad
networks*
92% of individuals with
access to narrow
networks*
AFFORDABILITY:
Premiums
5 to 20% lower
compared to
broader network
plans**
Source:
*McKinsey Report on Networks on the Exchanges (June)
**Milliman, High-Value Healthcare Provider Networks
QUALITY:
McKinsey:
“There is no meaningful
performance difference
between broad and
narrowed exchange
networks based on key CMS
hospital metrics.”*
Commitment to Consumers
 Providing accessible, understandable, and upto-date information about which providers are in
a network and timely notice to consumers when
providers leave the network.
 Providing summary information about how
plans put together tailored networks to balance
cost, quality, and access considerations.
 Providing information about how consumers
can appeal plan decisions, submit complaints,
or access out-of-network care when necessary.
Shared Responsibility
 Continuity of Care & OON Arrangements
 Health Plan Coordinating Role
 Prohibit Balance Billing for COC or OON
Care Arrangement Process
 Disclosure of OON Status outside of COC or
OON Care Arrangement Process
 In-Network Hospital & Hospital-Based
Provider Cooperation
Network Standards Summary
 Be Mindful of Unintended Consequences
(AWP, quality impacts, payment reforms)
 Need for Modernization
 Proceed Cautiously:
 Avoid costly new formats and frequency of
reporting;
 Explore the value of accrediting standards
and intersection with state regulation;
 Take costs into account (administrative and
health care costs)
MEDICAID EXPANSION
Medicaid Expansion
• Pre-ACA: Medicaid eligibility was determined by
income and categories, including children,
pregnant women, parents of dependent children,
individuals with disabilities, and the elderly.
• Pre-ACA: Childless adults were not eligible for
Medicaid coverage in most states
• Post-ACA: States may choose to expand
Medicaid coverage to childless adults with
incomes at or below 138% of the federal poverty
level
Medicaid Expansion Funding
• Medicaid is jointly funded by states and the
federal government.
– Federal government’s average contribution: 57%
• Federal government’s contribution for newly
eligible expansion population
–
–
–
–
–
2014-2016: 100% of expansion costs
2017: 95% of expansion costs
2018: 94% of expansion costs
2019: 93% of expansion costs
2020 and beyond: 90% of expansion costs
Medicaid Expansion
Innovation
• 24 states + DC are implementing standard
Medicaid expansion
• 3 states are implementing Medicaid expansion
with waivers
– Arkansas and Iowa (100-138% FPL): provide
premium assistance for individuals to purchase QHPs
on the Marketplace
– Michigan: covers the expansion population through
the existing Medicaid Managed Care structure
– All 3 states require cost sharing and also offer
financial incentives tied to healthy behaviors
Medicaid Expansion-State Implementation of ACA
(as of November 2014)
Implementing Standard Medicaid
Expansion (24 plus DC)
WA
MT
ME
ND
OR
MN
ID
VT NH
WI
SD
NY
WY
PA
IA
NE
UT
IL
OH
IN
KS
AZ
MO
OK
NM
TX
NC
TN
AR
SC
AL
GA
LA
FL
HI
© America’s Health Insurance Plans, 2014
VA
KY
MS
AK
MD
DC
WV
CO
CA
MA
CT RI
MI
NV
Not Implementing Medicaid
Expansion (17)
NJ
Implementing Medicaid
Expansion with Waiver (3)
In Discussions about Expansion
(6)
DE
Pursuing Alternative
Options/Expansion Through
Waivers
www.timeforaffordability.org