Vermont Health Care ReformVermont Health Care Reform

Susan W. Besio, Ph.D.Director of Health Care Reform Implementation

Vermont Agency of Administration

July, 2007

22

Vermont ContextVermont Context

Population: 623,000

19 U.S. cities are larger than Vermont

Ranked 11th for proportion of population insured 1

1 US Census 2005 revised

33

Vermont ContextVermont Context Ranked the 2nd healthiest state overall in 2005 and 2006 1

• Highest percentage (86.4%) of women enter prenatal care in 1st trimester

• Lowest percentage (7.4%) of children living in poverty • 4th lowest re: prevalence of obesity (20.2%)• Decrease in prevalence of smoking from 30.7% to 19.3% since

1990• Lowest rate of motor vehicle deaths• Lowest premature death rate (years of potential life lost before age 75)

Vermont is considered an “aging state,” where the older population is growing faster than the younger population• Vermont has approximately 78,000 (12.6%) residents age 65 or older.

• By the year 2030, 25% of Vermont’s population will be age 65 and older

1 United Health Foundation

44

Vermont Context – Health Care CostsVermont Context – Health Care Costs Growing cost of health care is unsustainable

• Annual expenditures of $3.5 billion

• 15.2% of Vermont’s gross state product

• Vermont’s per capita costs still less than national average, but spending growth rates have been higher than national average for last 6 years

Health Care Expenditures(2005)

Vermont U.S.Total (billions) $3.5 $2,016Per capita $5,636 $6,682Annual Change (2004-2005) 7.2% 7.4%Average Annual Change (1995 -2005) 7.9% 7.0%Share of Gross State/Domestic Product 15.2% 16.2%

Over 60,000 Vermonters are uninsured, and the number is growing

An estimated 50% of Vermonters with chronic conditions account for 70% of health care spending, but only 55% get the right care at the right time

55

Vermont Context – The InsuredVermont Context – The Insured Private Health Insurance

• 59.4% (370,000) have private insurance as primary coverage– 91% receive employer-sponsored insurance– 5% purchase their own coverage in the individual market– Remaining covered by higher education, COBRA, etc.

Medicaid: • 14.5% (90,350) have Medicaid as primary coverage

– Traditional Medicaid – up to 125% FPL– Dr. Dynasaur – Children in households up to 300% FPL (34% of

Vermont’s children)– Vermont Health Access Plan (VHAP) – Adults up to 150% FPL and

caretakers of dependent children up to 185% FPL

• Largest Insurer in Vermont (9,000 Enrolled Providers)

Medicare: 14.5% (90,100) Military Insurance: 1.7% (10,500)

66

Vermont Data (2005) – The InsuredVermont Data (2005) – The Insured 91.2% of Vermonters, 95.1% of Vermont children91.2% of Vermonters, 95.1% of Vermont children

Private Insurance

61.5% (382,239) of insured have private insurance- A decline of 2.1% since 2000 (63.6%)

- 90.9% (347,435) have employer-sponsored insurance

4.9 % (18,658) purchase their own coverage in the individual market Enrollees decreased by 47% from 2002 to 2005

Another 4.2% covered by higher education, COBRA, etc.

77

Vermont Data (2005) – The InsuredVermont Data (2005) – The Insured 91.2% of Vermonters, 95.1% of Vermont children91.2% of Vermonters, 95.1% of Vermont children

Medicaid / VHAP / Dr. Dynasaur

19.1% (118,388) of insured are enrolled in Medicaid programs- An increase of 0.6% since 2000 (18.5%)

- 22% (26,442) are employed adults

- 14.5% (90,352) are enrolled in a Medicaid program as primary coverage

41% (58,000) of Vermont children under age 18 are enrolled in Dr. Dynasaur- 86% of these (50,000) rely exclusively on Medicaid

Largest Insurer in Vermont (9,000 Enrolled Providers)

88

Vermont Context – The UninsuredVermont Context – The Uninsured 9.8% of Vermonters, 4.9% of Vermont children9.8% of Vermonters, 4.9% of Vermont children

• An 1.4% increase in the rate of uninsured since 2000 (8.4%)

• 51% are eligible for Medicaid programs but not enrolled• 79% of uninsured children; 49% of uninsured adults (18 – 64)

• 87% are interested in enrolling; 57% believe they are not eligible

• 27% have household income between 150-185% and 300% FPL and are not eligible for a Medicaid program but cannot afford private insurance

99

Vermont Data 2005 – The UninsuredVermont Data 2005 – The Uninsured9.8% of Vermonters, 4.9% of Vermont children9.8% of Vermonters, 4.9% of Vermont children

69% have been without insurance for more than a year

77% reported cost as the main reason for being uninsured

30% of uninsured children and 40% of uninsured adults did not see a health care professional in past year

45% of uninsured children did not see a physician for routine care (compared to 7% of insured children) Much more likely to go to ER or urgent care (8.6% vs .7%)

25% of uninsured adults reported not seeking needed medical care due to cost

1010

Vermont Context – The UninsuredVermont Context – The Uninsured 9.8% - A 1.4% increase in the rate of uninsured since 2000 (8.4%)

Uninsured Adults (18 to 64) –13.4% of adults (N = 53,708)• Young: 38% are between ages18 -24; over 25% between 25 - 34

• Male: 60% are male

• Educated: 50% have high school /GED; 21% have up to college degree; 18% have college degree or more

• Employed: 81% are employed– 60% work full-time– 30% work for employers that provide health insurance benefits

Uninsured Children (0 to17) – 4.9% of all children (N = 6,942)• Adolescents: 60% of uninsured children are between ages 11 - 17

• Male: Over 60% of uninsured children ages 0 to 17 are male

• Uninsured Families: 70% of adults with uninsured children are also uninsured

1111

Vermont Context – The UninsuredVermont Context – The Uninsured 51% are eligible for Medicaid programs but not enrolled

• 79% of uninsured children; 49% of uninsured adults (18 – 64)• 87% are interested in enrolling; 57% believe they are not eligible

27% have household income between 150-185% and 300% FPL and are not eligible for a Medicaid program but would be eligible for new Premium Assistance

• 1 person: $15,315 - $30,630• 2 person: $20,535 - $41,070• 4 person: $30,975 - $61,950

69% have been without insurance for more than a year

77% reported cost as the main reason for being uninsured

45% of uninsured children did not see a physician for routine care (compared to 7% of insured children) Much more likely to go to ER or urgent care for medical care (8.6% vs .7%)

25% of uninsured adults reported not seeking needed medical care due to cost

1212

What the Data Tell Us What the Data Tell Us Many of the uninsured are

people who cannot afford coverage

We have very specific demographic data about the uninsured

51% of uninsured are eligible for Medicaid programs; 87% are interested; over half think they are not eligible

Catamount Health must be affordable

We need to provide premium assistance to people to enroll in Catamount Health or ESI

Outreach will be designed for and targeted to specific groups

We will re-tool our outreach and enrollment processes to enroll more people

1313

Vermont’s ResponseVermont’s Response

2006 Legislation• Health Care Affordability Acts (Acts 190, 191)

• Common Sense Initiatives (Appropriations Bill)

• Sorry Works! (Act 142)

• Safe Staffing and Quality Patient Care (Act 153)

2007 Legislation• Corrections and Clarifications to the Health Care Affordability Acts of

2006 (Act 70)

• An Act relating to Ensuring Success in Health Care Reform (Act 71)

Joint Legislative Commission on Health Care Reform

Administration Director of Health Care Reform Implementation

1414

Health Care Reform GoalsHealth Care Reform Goals

Increase Access Improve Quality

Contain Costs

1515

Goal: Increase Access to Affordable Goal: Increase Access to Affordable Health Care CoverageHealth Care Coverage

Enhance Private Insurance Coverage• Catamount Health Plan for the Uninsured• Non-Group Market Reform• Promotion of Employer-Sponsored Insurance• Local Health Care Coverage Planning Grant• Potential Individual Insurance Mandate

Improve Outreach to Uninsured• Medicaid Enrollment Study • Comprehensive Marketing, Outreach• Single Enrollment Web-site• 1-800 number

Assist with Affordability• Premium Assistance (ESI, Catamount)• Reduction in VHAP Premiums

1616

Goal: Improve Quality of CareGoal: Improve Quality of CareChronic Care Management• Expand Blueprint Statewide• OVHA Chronic Care Management Program• State Employee Health Plan• ESI Premium Assistance plan approval, cost-sharing• Catamount Health coverage, cost-sharing• Care Coordination • Payment Reforms

Increase Provider Accessto Patient Information•Health Information Technology •Electronic Medical Records•Master Provider Index•Multi-payer DatabasePromote Quality Improvement

•Consumer Health Care Price & Quality System•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

1717

Goal: Contain CostsGoal: Contain CostsIncrease Access to Coverage and Care

Decrease Uncompensated Care Lower Premium Costs

Decrease Cost Shift• Increase 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 Appropriate Care, Better Information Lower Costs

Simplify Administration• Common Claims and Procedures• Uniform Provider Credentialing

1818

Insurance CoverageInsurance Coverage

1919

Why is Coverage Important?Why is Coverage Important?

Un-reimbursed care increases private insurance premiums Makes insurance less affordable

• Fewer people are covered• Benefits are decreased and/or people choose non-comprehensive plans to

make plans affordable

People with comprehensive insurance coverage are more likely to participate in preventive care Increases quality of life Decreases cost of health care overall

2020

Catamount HealthCatamount Health A non-group insurance product for uninsured Vermont

residents

Offered as a preferred provider organization plan by two private insurers, 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.

2121

Catamount HealthCatamount 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 & Chronic Care*: $0 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

2222

Catamount HealthCatamount Health

PROVIDER REIMBURSEMENT• Health Care Professionals: Medicare +10% in 2006, increasing as

per Medicare reimbursement methodology • Hospitals: Cost +10%, increasing as per Medicare economic index

OVERSIGHT• Insurers go through the usual rate-setting process at the

Department of Banking, Insurance, Securities and Health Care Administration (BISHCA)

• Emergency Board will suspend enrollment in Catamount Health premium assistance if there is not enough money

• Commission on Health Care Reform to review Catamount Health Plan by October 1, 2009 for cost effectiveness may trigger a self-insured plan if current structure is not cost effective

2323

Catamount Health CostsCatamount Health Costs The cost will depend on individual / household income

Cost for Individual Coverage with Premium Assistance:Cost for Individual Coverage with Premium Assistance:

Individual Income by federal poverty level Monthly premium cost *(1 person/annual in 2007)

• Below 200% FPL ($20,420) $60.00 • 200-225% ($20,421 – 22,973) $90.00• 225-250% ($22,974 – 25,525) $110.00 • 250-275% ($25,526 – 28,077) $125.00 • 275-300% ($28,078 – 30,630) $135.00

* Cost for two-person coverage will be double these amounts

Estimated Full Cost for Individuals/Households over 300% FPL:Estimated Full Cost for Individuals/Households over 300% FPL:• Single $ 390 / month• Two Person $ 780 / month• Family $1,750 / month

2424

Catamount Health EligibilityCatamount Health Eligibility You can purchase Catamount Health if you are an

uninsured Vermont resident, are 18+, and are not eligible for an Employer-Sponsored Insurance (ESI) plan *.

Uninsured means:• You have insurance which only covers hospital care OR doctor’s

visits (but not both)

• You have not had private insurance for the past 12 months

• You had VHAP or Medicaid but became ineligible for those programs

• You had private insurance but lost it because you: Lost your job Got divorced No longer have COBRA coverage Had insurance through someone else who died Are no longer a dependent on your parent’s insurance Graduated, took a leave of absence, or finished college or university and got

your insurance through school

2525

Catamount Health EligibilityCatamount Health Eligibility

You can purchase Catamount Health even if you are eligible for an Employer-Sponsored Insurance (ESI) plan IF you have an income under 300% FPL, AND

Your ESI plan is not approved by the state as comprehensive and affordable (with state assistance)

ORIt is more cost effective to the state to provide premium assistance for you to enroll in a Catamount Health plan than providing premium assistance for you to enroll in your ESI

ORIt is more cost effective to the state to provide premium assistance for you to enroll in your ESI than providing premium assistance for you to enroll in Catamount Health, but you must wait until the next open enrollment period for your ESI (at which point you must switch to your ESI to receive premium assistance)

2626

Key DatesKey Dates CATAMOUNT HEALTH

September 8, 2006 Rules filed with Secretary of State

October 7, 2006 Carriers submitted Letters of Intent(BCBS-VT, MVP, CDPHP)

Mid-March, 2007 Carriers file forms and rates

October 1, 2007 Catamount Health Insurance available to uninsured Vermonters

October 1, 2009 Legislative review re: cost effectiveness; may trigger a self-insured plan

2727

Premium AssistancePremium Assistance Catamount Health

• Vermonters who qualify for Catamount Health with income less than or equal to 300% of Federal Poverty Level (FPL) ($29,500 for one person) may receive premium assistance from the state

Employer-Sponsored Insurance (ESI)• Uninsured Vermonters with income less than or equal to 300% FPL

may apply for ESI premium assistance• ESI plans must offer comprehensive benefits and be affordable

in order for the individual to receive premium assistanceAffordable = maximum individual in-network deductible of $500Comprehensive = covers physician, inpatient care, outpatient,

prescription drugs, emergency room, ambulance, mental health, substance abuse, medical equipment/supplies, and maternity care

Employers do not have to contribute to the plan for it to qualify

2828

Premium AssistancePremium Assistance Cost Effectiveness TestCost Effectiveness Test

VHAP Applicants (under 150 -185% FPL)• If providing premium assistance to the individual to enroll in their ESI

plan is more cost-effective to the state than enrollment in VHAP, the applicant will be required to enroll in their ESI plan to get state assistance.

Catamount Health Applicants (at or under 300% FPL)• If providing premium assistance to the individual to enroll in their ESI

plan is more cost-effective to the state than providing premium assistance for the Catamount Health Plan, the applicant will only receive state assistance to enroll in their ESI plan.

2929

How will Premium Assistance be Paid?How will Premium Assistance be Paid?

Catamount Health Premium Assistance• Beneficiary will pay his or her share to state

• State will pay total premium to carrier

ESI Premium Assistance• Employee will pay total premium to employer through payroll

deduction

• State will pay employee prospectively for premium assistance

• Employers will not have to modify payroll or accounting systems

• Employers may have to provide information on the plan’s cost to the employee to assist with enrollment in the premium assistance program

3030

Key Dates: Key Dates: PREMIUM ASSISTANCE FOR PREMIUM ASSISTANCE FOR ESI / CATAMOUNTESI / CATAMOUNT

September, 2006 Waiver Amendment Request submitted to CMS for approval of premium assistance programs

November, 2006 Report to Legislative Committees on fiscal implications (estimated costs and savings)

April, 2007 Draft Rules for Premium Assistance Eligibility Determination

July, 2007 Finalize Rules for Premium Assistance Eligibility Determination

October 1, 2007 Premium Assistance enrollment for ESI and Catamount to eligible Vermonters

3131

OVERVIEW OF VERMONT EDUCATION, OVERVIEW OF VERMONT EDUCATION, OUTREACH AND ENROLLMENT STRATEGYOUTREACH AND ENROLLMENT STRATEGY

Goal: To develop and implement a comprehensive, integrated and aggressive education, outreach and enrollment strategy:

across a continuum of solutions for the uninsured, including Medicaid, VHAP, Dr Dynasaur and Catamount Health Plans

using a unified multi-stakeholder campaign,

with specialized interventions for specific uninsured populations, and

targeted at multiple stakeholders (health care providers, community-based providers, grass-roots organizations, advocate organizations, state employees, employers)

3232

Outreach and EnrollmentOutreach and Enrollment

Integrated Medicaid, Catamount Outreach and Enrollment Strategies• Aggressive Marketing and Education Campaign in Late

Summer, Fall 2007• Using state and local staff, partners and volunteers• 1-800 number • New web-site

Possible Re-branding

Re-tooling of Existing Application and Enrollment Processes

3333

Key ElementsKey Elements

Broad-based Outreach and Enrollment Steering Committee: to guide and inform outreach and enrollment efforts (see attached membership list)

Health Care Marketing Firm to Develop:• A broad-based, compelling message that conveys to all Vermonters why

it is important to have health insurance coverage; • Promotion of all available insurance products and subsidies, including

private market options.• Coordination of the broad message with education, outreach and

enrollment activities that are nuanced to address targeted populations, including

1) specific uninsured sub-populations (using the 2005 Vermont Family Health Insurance Survey data), and

2) partners who can assist with the coverage efforts (e.g., employers, health care providers, human services providers and other community organizations, schools, the faith community).

• Use of health literacy research, such as that produced by the Harvard School of Public Health, to inform our effort

3434

Key Elements,Key Elements, continuedcontinued

Revisions to Current Enrollment Tools: The above must be coupled with the tools needed for effective screening and enrollment, including shifting

FROMCurrent relatively passive approach:

Examples: using brochures, 1-800 number, paper applications and office-based staff

TOPro-active and consumer-friendly approach:

Examples: all of above, plus one-to-one and community-based outreach, user-friendly web-based screening tools, simplified application forms, ability to track application status and change in eligibility over time to prevent program

drop-out, etc.

Outreach and Enrollment Coordinator to facilitate the implementation and interface between all of the above activities.

3535

Revisions for Medicaid/VHAP/Dr. Dynasaur Revisions for Medicaid/VHAP/Dr. Dynasaur Eligibility Determination and EnrollmentEligibility Determination and Enrollment

Explore streamlining Medicaid/VHAP/Dr Dynasaur application form

Pro-actively assist with eligibility screening and applications (complete forms for people at key junctures)

Actively engage AHS employees and partners (providers, regional partnerships, clergy, accountants, others to help people complete eligibility screening tool and / or application

Add a contract/grant provision to state contracts/grants that have natural connections to the target populations

Change VHAP coverage date to be the date of application receipt

Move from 6 month to 12 month VHAP renewals

Solicit feedback from individuals about the enrollment and renewal processes to inform additional refinements

3636

Revisions for Medicaid/VHAP/Dr. Dynasaur Revisions for Medicaid/VHAP/Dr. Dynasaur Eligibility Determination and EnrollmentEligibility Determination and Enrollment

Create the Vermont Health Care Portal - an on-line system to access information and enrollment processes for all Vermont health care programs, designed to:

• streamline the application and eligibility process, and reduce the burden of program rules;

• interface in real time with other systems to verify information needed to grant eligibility and to disseminate notification of coverage;

• utilize the health information exchange being created by VITL in a way that improves the sharing of health care data;

• quickly incorporate changes in eligibility rules;

• reduce the need for paper by managing applications, notifications and billing electronically whenever possible; and

• enable caseworkers to be more focused on personally serving Vermonters because they need less time for data entry, managing paperwork, and getting accurate, timely results from the enrollment system.

3737

Vermont Health Care Portal, Vermont Health Care Portal, continuedcontinued

(This proposal is still under discussion and may be altered as more detailed information evolves about implementation issues – e.g., technical challenges, timelines, cost)

Phase 1 (by August 2007): • Web-based simple screening tool• Links to information about Vermont’s healthcare programs and application processes• Down-loadable pdf version of the application form that can be completed and mailed or faxed• Automated contact form that the individual can submit to request a follow-up phone call

Phase 2 (by October 2008): • Phase 1 plus:• On-line application that can be submitted electronically• Expanded links to educational health-related materials and sites

Phase 3 (by June 2010): • On-line application and renewal processes linked to back-end eligibility/enrollment/renewal system• From any place with internet access, an individual will be able to:

read and download current information about health care programs; complete an anonymous self-screening to determine if they may be eligible for assistance; fill out and submit an automated application or recertification that connects with the processing system; chat immediately with a caseworker to get answers to questions, help completing the application and an

explanation of remaining requirements; submit verification, and receive notification letters and reminders, electronically; check the status of their case and gather the details of their benefit package; pay their premiums and select their providers; and, review information about the services and costs paid by Vermont health care programs for their household .

• This project will be a component of the vision for the “Medicaid enterprise’ which also entails replacement of the Medicaid Management Information System (MMIS)

3838

Other Initiatives to Enhance Other Initiatives to Enhance Private Insurance CoveragePrivate Insurance Coverage

Non-Group Market Reform

Promotion of Employer-Sponsored Insurance

Local Health Care Coverage Planning Grant

3939

CHRONIC CARE MANAGEMENTCHRONIC CARE MANAGEMENT

4040

Blueprint for HealthBlueprint for Health State’s Plan for Better Management and Prevention

of Chronic Illnesses across All Payers and Providers

Vision: Vermont will have a standardized statewide system of care that improves the lives of individuals with and at risk for chronic

conditions.

To achieve this vision, the Blueprint is:• Statewide system reform based on the Chronic Care Model• A public-private collaborative• Recognizes the central role of the patient and community• Designed around “Core System Competencies” rather than

disease programs• Is the state’s mandated standard for chronic care management

across all payers and providers

4141

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 ModelBlueprint for Health Model

HealthierVVeerrmmoonntteerrss

4242

Examples of Blueprint ComponentsExamples of Blueprint Components

Public Policy Blueprint legislation and fundingExecutive Director at Governor’s Office levelIntegration of health disparities/minority healthInternal coordination—Chronic Disease

Community Blueprint physical activity opportunitiesWalking maps, walking programs

Self-Management Healthier Living Workshop—All conditionsOver 40 statewide; 500+ enrolled+60% reduction in MD and ED visits post at one year

Information Systems Practice based disease registries EMRs

Health Care Practice Consensus treatment standards—Diabetes and AsthmaPhysician coordination—dedicated medical director6 Communities (HSAs); 200 primary care practices

Health Systems Insurance company collaborationRequired payment reform in 2 pilots in 2008

4343

Other Chronic Care Strategies Other Chronic Care Strategies To Be Aligned with the BlueprintTo Be Aligned with the Blueprint

Medicaid Chronic Care Management Program

State Employee Health Benefit Programs

State-approved Employer-Sponsored Insurance (ESI) Plans for Premium Assistance

Catamount Health Plans

4444

Medicaid Chronic Care Management Medicaid Chronic Care Management Program (CCMP)Program (CCMP)

Establish a Chronic Care Management Program (CCMP) for the Medicaid and VHAP populations

Contract with external vendors for two components:• Program intervention• Monitoring, evaluation and payment

4545

CCMP InterventionsCCMP Interventions Identify Medicaid enrollees with one or more chronic

conditions (using claims data)

Conduct health risk assessments (HRAs) for all beneficiaries identified

Stratify the population into high, middle, low risk groups

Conduct evidence-based care management interventions for each risk group (intensity varies by group)

Coordinate CCMP activities with: • Care coordination program (coordinating the care needs of the 1-2%

most complex Medicaid enrollees) • Blueprint for Health • Choices for Care 1115 Waiver (Long-term Care Waiver)

4646

Blueprint Alignment TopicsBlueprint Alignment TopicsAcross Chronic Care ProgramsAcross Chronic Care Programs

Coordination of care across the multiple programs working with the same providers and patients

Agreement on best practices for all chronic diseases

Use of a consistent health risk assessment

Referrals to patient self-management resources

Coordination of IT initiatives to improve access and support clinical decision making

Use of consistent metrics for provider feedback, profiling and measurement

Changing and aligning payer fee structures to provide incentive to reward quality (e.g., pay-for performance, payment reforms)

4747

Blueprint Impact on Health Care CostsBlueprint Impact on Health Care Costs It will not SAVE money – but it will reduce the rise in

cost of care

We do expect to reduce the cost per case for chronic illness by:• reducing hospitalizations• reducing complications• reducing specialist visits

So why doesn’t that save money?• Because when we take better care of chronic illness we prolong productive

life• Because more people are developing chronic illness, especially with the

obesity epidemic• That means more people in Vermont with chronic illness• More cases at less cost per case still means more total health care cost for

the population

4848

Health Information TechnologyHealth Information Technology

VITL = Statewide Regional Health Information Organization (RHIO)

• State Health Information Technology Plan• Medication History Pilot Project

Implemented at 2 Hospital Emergency Rooms in April, 2007

Chronic Care Information System (Disease Registry)• First community site (Mt. Ascutney) for diabetes will be implemented

in December, 2007

Electronic Health Records supported statewide

Master Provider Index, Multi-payer Database

4949

PREVENTIONPREVENTION

5050

CHAMPPSCHAMPPS (Coordinated Healthy Activity, (Coordinated Healthy Activity, Motivation and Prevention Programs)Motivation and Prevention Programs)

Competitive multi-year grants to communities starting July 1, 2007

Projects must be:• Comprehensive approaches to promote healthy behavior

and disease preventionAcross the communityAcross the lifespan

• Consistent with the Blueprint and community goals• Goal and outcome driven• Based on effective strategies • Able to provide data for evaluating and monitoring progress

5151

Healthy Lifestyles Insurance DiscountsHealthy Lifestyles Insurance Discounts

Permits BISHCA regulations to allow carriers to establish rewards, premium discounts, rebates, or waive/modify cost-sharing in return for member’s adherence to programs of health promotion and disease

Allows discounts of up to 15% of premium for compliance with health promotion program

Limits total deviation from community rate to 30% (including these discounts) in the individual and small group insurance markets

Rules developed in Fall, 2007

Also allowed in Catamount Health plans

5252

Other Prevention InitiativesOther Prevention Initiatives

Agency of Human Services inventory of state wellness initiatives and funding

Clinically recommended immunizations provided to all Vermonters at no cost

• January 15, 2007 - Report on Methods to Ensure Universal Access to Immunizations

Catamount Health Plan: waiver of cost-sharing for prevention

5353

Quality Improvement InitiativesQuality Improvement Initiatives

Consumer Health Care Price & Quality System

Hospital Adverse Events Monitoring System

Hospital-acquired Infections Data

Hospital Safe Staffing Reporting

SorryWorks!

Advanced Directives Registry, Forms and Stickers

5454

Administrative SimplificationAdministrative Simplification Common Claims and Procedures

• Maximization of the electronic claims process to support accurate and timely payment of claims

Standardizing ID cards

• Simplification of Explanation of Benefits and patient bills

• Pre-authorization comparisons for commonality and variation

• Improving the efficiency of claims adjudication through common policies that determine how a claim may be adjudicated

• Simplification of Workers Compensation claims processing

• Credentialing standardization for provider application and billing eligibility

Uniform Provider Credentialing Form• Council for Affordable Quality Healthcare (CAQH) form will be used

by hospitals and insurers for provider credentialing

5555

Strategies to Address Cost ShiftStrategies to Address Cost Shift

Medicaid Rate Increases for Primary Care Providers, Hospitals and Dentists (January 1, 2007)

Cost Shift Task Force

Hospital Cost Shift Reporting Reforms

Standardized Policy for Hospital Uncompensated Care and Bad Debt

5656

Financing of ReformsFinancing of Reforms

Based on the principle that everybody is covered and everybody pays:• Catamount Health Plan: individuals pay sliding scale

premiums based on income

• Employers pay an assessment based on number of uncovered employees

• Increases in tobacco taxes

• VHAP savings due to Employer-Sponsored Insurance (ESI) enrollment

• Cost avoidance due to better chronic care management

• Matching federal dollars via Global Commitment 1115 waiver

5757

Employer ContributionEmployer Contribution Assessment for “uncovered FTEs”

• Employers without a plan that pays some part of the cost of insurance of its workers must pay the health care assessment on all employees.

• Employers who offer coverage* must pay the assessment on:

Workers who are ineligible to participate in the plan

• New amendment: If the employer offers insurance to all full time employees, they do not have to pay the assessment on seasonal or part-time employees

who have coverage from another source (unless it is Medicaid or VHAP).

Workers who refuse the employer’s coverage and do not have coverage from some other source.

Assessment does NOT enroll employees in Catamount Health!

* Employers plan must include hospital and physician coverage to qualify

5858

Employer ContributionEmployer Contribution Employee = any individual 18 years or older on employer’s unemployment

insurance filing• Based on the unemployment insurance definition of employee; excludes the following:

Workers on small farms Full time college students working at the college in a program designed to provide financial assistance Elected officials Emergency volunteers such as volunteer fire fighters Licensed insurance and real estate sales Foreigners temporarily in Vermont on cultural exchange (J-1) visas Foreigners in Vermont on temporary foreign agricultural (H-2A) visa

$365 / year Fee per Uninsured FTE (2007)• Assessed quarterly - $91.25 / FTE / Qtr• FTE = number of employee hours worked during a calendar quarter divided by 520 (based

on 40 hour work week maximum)• Exempts 8 FTEs in 2007 & 2008; 6 FTEs in 2009; 4 FTEs thereafter

Annual Fee indexed to Catamount Health premium increases

*

5959

Key DatesKey Dates

EMPLOYER CONTRIBUTION

September, 2006 Draft Rules Distributed for Public Comment

December 13, 2006 Final Rules Approved

January 15, 2007 Report on Inclusion of Seasonal Employees

April 1, 2007 Assessment Implemented (to be paid at end of 4th Quarter – June 30, 2007)

6060

Reform OversightReform Oversight Joint Legislative Commission on Health Care Reform

• Monthly meetings

Reports on Reform Progress

• Five-year plan for Health Care Reform Implementation, including recommendations for administration or legislation (December 1, 2006)

• Annual Administration Reports on Reform Progress (January 15)

• Multiple Reports on Enrollment, Costs

Universal Coverage/Individual Mandate - 2011• If Vermont has less than 96% of the population insured in 2010, the

Health Care Reform Commission must submit a plan to increase health care coverage to ensure universal access, including individual mandates

6161

Opportunities for TransferabilityOpportunities for Transferability Make health care affordable and accessible to uninsured

Manage and coordinate chronic care for all

Health Information Technology infrastructure

Administration Simplification

Build on Employer-Sponsored Insurance (ESI)

Outreach to Medicaid eligible uninsured

Reduce cost shift by:• Insuring the currently uninsured and reimbursing at 110% of cost• Providing better chronic care• Increasing Medicaid reimbursement

Finding common ground: building broad based coalitions

6262

Vermont Health Care Reform Web-site

www.hcr.vermont.gov

6363

For more information about enrollment

Member Services: 800-250-8427