Employee Wellness Committee – January 29, 2009 Lee Covella / Paul Hackleman / Bill Tugaw.
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Transcript of Employee Wellness Committee – January 29, 2009 Lee Covella / Paul Hackleman / Bill Tugaw.
Employee Wellness Committee – January 29, 2009
Lee Covella / Paul Hackleman / Bill Tugaw
Objectives
• Understand Premium Composition
• Understand County-Specific Trends
• Focus on Design / Other Changes
• Identification of Potential Initiatives
Understand Premium Composition
Premium Rate Components
• Incurred Claims for Rating Period
• Trend / Health Care Inflation• Reinsurance (Unexpected / Catastrophic
Claims)
• Reserves – IBNR
– Pending / Unpaid Claims
Premium Rate Components
• Capitation – Fixed flat amount paid to physicians in exchange for specific services / Typical of HMO Plans
• Credibility Factor – Percentage load applied for groups under 1,000 members
• Demographic Factor – Percentage adjustment for group specific demographics
Premium Rate Components
• Premium Tax – 2% state tax applicable to fully insured plans
• Administrative Costs– Claims Administration– Customer Service– Marketing Materials / EOCs, etc– Utilization Review / Case Management– Vendor Profit– Broker Commission
Premium Components
• Trend Credibility Factor• Reinsurance Capitation• Reserves Demographic
Factor• Administrative Costs Premium Tax
• Incurred Claims
Premium Components you can and cannot control for future cost impact…..
County Health Trends
Health / CPI / Worker Wages - National
Prevalence by Condition (Major Diagnosis)
Prevalence and Cost by Condition
Major Conditions - Historical Overview
4.6%4.7%4.6%5.8%KP Regionally Adjusted Benchmark
5.6%5.6%5.5%7.2%San Mateo County
200720062005 **2004Prevalence
4.6%4.7%4.6%5.8%KP Regionally Adjusted Benchmark
5.6%5.6%5.5%7.2%San Mateo County
200720062005 **2004Prevalence
Diabetes
1.0%0.9%1.0%2.5%KP Regionally Adjusted Benchmark
1.4%1.4%1.5%3.0%San Mateo County
200720062005 **2004Prevalence
1.0%0.9%1.0%2.5%KP Regionally Adjusted Benchmark
1.4%1.4%1.5%3.0%San Mateo County
200720062005 **2004Prevalence
Asthma
0.7%0.6%1.0%1.2%KP Regionally Adjusted Benchmark
0.7%0.7%0.9%1.3%San Mateo County
200720062005 **2004CAD Prevalence
0.7%0.6%1.0%1.2%KP Regionally Adjusted Benchmark
0.7%0.7%0.9%1.3%San Mateo County
200720062005 **2004CAD Prevalence
CAD
5.1%5.2%5.0%5.5%KP Regionally Adjusted Benchmark
5.3%5.6%5.5%5.8%San Mateo County
200720062005 **2004Prevalence
5.1%5.2%5.0%5.5%KP Regionally Adjusted Benchmark
5.3%5.6%5.5%5.8%San Mateo County
200720062005 **2004Prevalence
Depression
Percent of Members Compared to Percent of Cost by Condition
17.0%55.6%All Other
6.3%2.1%Maternity without other conditions
6.1%9.5%Injuries (other than back pain)
3.8%4.0%Arthritis
4.2%4.6%Back pain
9.1%3.6%Cancer
13.7%3.3%Additional Chronic Conditions (any of 41)
26.2%15.0%1 major chronic conditions
13.6%2.2%2 or more major chronic conditions
COSTSMEMBERS
17.0%55.6%All Other
6.3%2.1%Maternity without other conditions
6.1%9.5%Injuries (other than back pain)
3.8%4.0%Arthritis
4.2%4.6%Back pain
9.1%3.6%Cancer
13.7%3.3%Additional Chronic Conditions (any of 41)
26.2%15.0%1 major chronic conditions
13.6%2.2%2 or more major chronic conditions
COSTSMEMBERS
Members Compared to Costs
• 21% of SMC Kaiser members have at least 1 chronic condition. This represents 54% of the total San Mateo County Kaiser cost.
Key Strategic Responses
Plan Design Options
• Change Plan Design/Benefit Policies• Implement Value Based Design Modifications• Modify Network Relationship• Change Financing • Improve Health / Reduce Risk
– Implement/Enhance Wellness Programs
– Member Education
Plan Design Options
Plan Design Options
Illustrative Plan Design Savings for ABC Group
Pct Value Estimatedof Plan Chg Dollar Savings*
$15 Office Visit Copay -1.13% (548,673)$ $20 Office Visit Copay -2.16% (1,048,791)$ $25 Office Visit Copay -3.03% (1,471,220)$
$100 Emergency Room Copay -0.22% (106,821)$
$100 In-patient Admit Fee -0.09% (43,700)$ $100 Out-patient Admit Fee -0.05% (24,278)$
$10/$15 Rx (100 day max) -1.39% (674,916)$ $10/$20 Rx (100 day max) -1.75% (849,715)$ $10/$20 Rx (30 day max) -2.93% (1,422,665)$ $10 $25 Rx (100 day max) -2.04% (990,525)$ $10/$25 Rx (30 day max) -3.30% (1,602,319)$
Elimination of $0 plan and migration of all to $10 plan -1.50% (727,841)$
-8.19% (3,976,179)$ Total Estimated Savings to current costs
Possible Plan Modification
Plan Design Options – Value Based
• Chronic Care Copays
• Surgical Centers for Outpatient Surgeries
Network Options
Network Options
• CalPERS Strategies– Select Physicians based on outcomes
– Aetna model in Washington state
• Discussion with Health Plans
Financing Options
Financing Options
• Self Funding – Self Funded Until 1994• Minimum Premium – Pursued in 2001• Pre-Funding – Pursued in 2001• Bonds – Pursued in 2001
Chronic Chronic Disease Management Disease Management
StrategiesStrategies
Care for Diabetes Checklist
Support and co-manage high risk diabetes patients with care/case
managers.
Assure patients with diabetes have their cholesterol monitored
because they are at risk for heart disease.
Assure patients receive regular eye exams to delay or prevent
loss of vision.
Provide opportunities for plan participants to learn about
diabetes in health education classes
Assure patients are taught self-management skills to care for the
condition.
Care for Depression Checklist
Consider providing a program through a diagnosis either by their
primary care physician or behavioral health specialist.
Because primary care physicians are often the first point of contact and
in a position to spot symptoms, consider developing several tools, such
as pocket reference guides and clinician education programs, to assist in
diagnosis.
Track medication use to ensure that patients are maintaining treatment
plans.
Work with network clinicians to provide training in “rapid cycle
change” methodology to support providers in testing innovative ways of
caring for patients with depression as a co-morbidity
Provide publications to help patients understand depression and its
treatment options.
Cardiovascular Disease Checklist
Assure patients enter a care program based on their use of certain
medications or clinic or hospital visits for heart disease?
Assure patients are on medications for lowering cholesterol and
reducing heart rate and blood pressure.
Provide lifestyle coaching about exercise, weight control, and
smoking cessation.
Asthma Checklist
Assure patients enter a care program based on an office, ER, or hospital visit, which results in an asthma diagnosis or their use of asthma-specific medications.
Minimize patients relying on rescue medications.
Provide self-management plans to teach patients to control their asthma, enabling them to be more productive and have a better quality of life.
Modify lifestyle to obtain weight loss for moderately obese members and smoking cessation.
Disease Management – Conclusion
Identify early at-risk patient through network provider tools.
Streamline electronic sharing of best practices among network
provider physicians nationwide.
Provide culturally appropriate materials in multiple languages
make services accessible to diverse populations.
The approach to treating patients with multiple chronic conditions
should be built into the integrated care.
Increased work productivity leads to better health outcomes,
leading to fewer sick days and greater productivity.
Working together in a collaborative effort is the best way to
leverage the provider(s), employees, retirees, and employer resources
to improve the health of employees / retirees.
SMUD – Reduction of Number of Risks
In Closing……….
Claims can be reduced by:• Disease Management for Chronic Conditions• Early Identification of At-Risk Members• Value Based Plan Designs• Focus on Prevention• Member Education/Member Awareness• Lifestyle Modification Support• More Efficient use of Services• Improved Member Health
Long term savings can best be achieved through a reduction in claims.
Next StepsNext Steps