Health Meeting June 10-12, 2013 Baltimore, MD. Session 18 PD, The Implications of ACO: Opportunity and Risk. Moderator: Greger J Vigen FSA

Transcription

1 Health Meeting June 10-12, 2013 Baltimore, MD Session 18 PD, The Implications of ACO: Opportunity and Risk Moderator: Greger J Vigen FSA Presenters: John D Shatto FSA William T OBrien FSA,MAAA Kimberley Kay Hiemenz FSA,MAAA

2 SOA 2013 Health Meeting Session 18 - The Implications of ACO: Opportunities and Risk Presented by: Kimberley K. Hiemenz, FSA, MAAA Consulting Actuary June 10, 2013 This presentation is intended for informational purposes only. It reflects the opinions of the presenters, and does not represent any formal views held by Milliman, Inc. Milliman makes no representations or warranties regarding the contents of this presentation. Milliman does not intend to benefit or create a legal duty to any recipient of this presentation. Copyright 2013, Milliman, Inc. Agenda Recap of case studies from January 2013 webinar Two examples Other opportunities and risks 2 June 10, 2013 [Enter presentation title in footer] June 25,

3 Recap of Key Take Away Items Dig In Understand the Environment Future Implications 3 June 10, 2013 OB Example: Straight Data Pull Client Avg. Payment Allowed per admit Dollars Competitor Avg. Payment per admit Allowed DRG DRG Description Dollars Admits Admits C-Section w 765 CC/MCC $141, $11,766 $98, $4,667 C-Section w/o 766 CC/MCC 340, , , , Vaginal Delivery w Complicating Diagnoses 139, ,316 40, ,684 Vaginal Delivery w/o Complicating Diagnoses 579, , , ,564 Total 1 1,200, , , ,200 1 Before Case Mix Index (CMI) Adjustment 4 June 10, 2013 [Enter presentation title in footer] June 25,

4 OB Example: After Analysis Average Payment Per Discharge Difference: Client - DRG DRG Description Client Competitor Competitor 765 C-Section w CC/MCC $11,766 $14,057 ($2,291) 766 C-Section w/o CC/MCC 10,980 12,323 (1,343) Vaginal Delivery w Complicating Diagnoses 7,316 10,023 (2,707) Vaginal Delivery w/o Complicating Diagnoses 5,977 9,355 (3,378) Total 1 7,550 11,037 (3,487) 1 Before Case Mix Index (CMI) Adjustment 5 June 10, 2013 Future Implications Example PN Description Met in Jan? Met in Feb? Met in Mar? Met in April? 2 Pneumococcal vaccination Y Y Y N 3a Blood culture within 24 hours of arrival (ICU) Y N Y Y 3b Blood culture prior to initial antibiotic (ED) Y Y Y N 4 Smoking cessation advice/counseling Y N Y Y 5c Antibiotic received within 6 hours Y N Y N 6a Antibiotic selection for ICU patients Y Y Y Y 6b Antibiotic selection for non-icu patients N Y Y N 7 Influenza vaccination Y Y Y Y 6 June 10, 2013 [Enter presentation title in footer] June 25,

5 Think Outside the Box Market share angle Walgreens example Hybrid payment structure 7 June 10, 2013 Revenue Still Matters Payment rate example Reasonable margin expectations 8 June 10, 2013 [Enter presentation title in footer] June 25,

6 Are We There Yet? 9 June 10, 2013 Nope Just Getting Started! Price transparency Expanding to other populations Tiered networks Assisting provider partners Risk adjustment and ICD-10 Measuring quality Tweaks based on initial results... (the list could go on and on) 10 June 10, 2013 [Enter presentation title in footer] June 25,

7 Thank you! Kim Hiemenz, FSA, MAAA Consulting Actuary June 10, 2013 [Enter presentation title in footer] June 25,

8 Issues within ACOs SOA Spring Health Meeting 2013 Bill O Brien, FSA, MAAA Chief Actuary & VP, Product Evolent Health Agenda 1. Summarize SOA Sponsored research to be published Evaluation of ACO efficiency as measured by episode-based risk adjustment 2. New developments in the ACO world Evolent Health, as an example of actuarial opportunities within new organizations helping ACOs 2

9 SOA-Sponsored Research Thesis: Could more claims cost variance be explained by using risk adjustment at the episode level? Objective: Develop HCC-type risk adjustment at Episode level Use demographics and recent diagnostic coding within claims Measure correlation to episode costs and to utilization of services Include analysis at detailed service-type level Provide enough data for ACO to evaluate own experience Data Source: Truven Market Scan Commercial Claims Total of 19.2 Million patient Episodes over 2 year period 16.9 Million Complete episodes included 3 Episode Cost Summary Episode Type: Number of Episode Included * Included Episodes per Thousand Member per Year * Cost per Included Episode PMPM Asthma # 236, $911 $3.09 Cerebral Vascular Disease # 20, $5,922 $1.71 Chronic Obstructive Pulmonary Disease # 32, $1,764 $0.83 Congestive Heart Failure # 11, $4,135 $0.66 Diabetes # 233, $2,131 $7.11 Hyperlipidemia # 398, $483 $2.76 Hypertension # 654, $733 $6.86 Ischemic Heart Disease # 76, $7,584 $8.32 Joint Degeneration, localized - back # 193, $2,827 $7.84 Pregnancy with Delivery # 44, $13,429 $8.47 Total 1,902, $1,750 $

10 Episode Incidence Rates Table 8. Incidence Rates of Complete Episodes Over a Two Year Period Episodes per thousand enrollees Mean 25% 50% 75% 90% Asthma Cerebral Vascular Disease Chronic Obstructive Pulmonary Disease Congestive Heart Failure Diabetes Hyperlipidemia Hypertension Ischemic Heart Disease Joint Degeneration, localized back Pregnancy with Delivery Average Cost per Episode by Component Table 1. Overall Average Cost Per Complete Episode Episode Type IP Cost OP Cost Professiona l/ Other Prescription Drugs Total Episode Asthma $41 $155 $227 $501 $925 Cerebral Vascular Disease $2,976 $1,346 $1,467 $190 $5,979 Chronic Obstructive Pulmonary Disease $415 $426 $489 $552 $1,882 Congestive Heart Failure $1,955 $852 $872 $200 $3,879 Diabetes $48 $232 $521 $1,357 $2,159 Hyperlipidemia $0 $62 $121 $326 $508 Hypertension $1 $179 $234 $297 $712 Ischemic Heart Disease $3,448 $1,409 $1,392 $758 $7,007 Joint Degeneration, localized back $418 $861 $1,283 $294 $2,856 Pregnancy with Delivery $6,835 $2,108 $5,166 $156 $14,266 6

11 Episode Cost Distribution Table 3. Episode Cost Distribution Before Risk Adjustment Episode Type 25% 50% 75% 90% 95% Coefficient of Variation Asthma $144 $424 $1,172 $2,331 $3, Cerebral Vascular Disease $321 $1,398 $5,224 $18,204 $28, Chronic Obstructive Pulmonary Disease $142 $473 $1,860 $4,838 $8, Congestive Heart Failure $193 $730 $2,290 $10,797 $19, Diabetes $371 $1,130 $3,035 $5,604 $7, Hyperlipidemia $107 $248 $733 $1,368 $1, Hypertension $159 $398 $943 $1,659 $2, Ischemic Heart Disease $548 $1,853 $4,994 $20,145 $36, Joint Degeneration, localized back $300 $1,025 $2,840 $6,641 $11, Pregnancy with Delivery $10,480 $13,239 $17,137 $22,067 $26, Episode Model R-squared values indicate much cost variance left unexplained Episode Cost Measures IP Cost OP Cost Professional/ Other Cost Prescription Drugs Cost Asthma 2.40% 3.06% 7.22% 1.56% 4.96% Cerebral Vascular Disease 19.38% 20.59% 28.39% 0.91% 32.25% Total Chronic Obstructive Pulmonary Disease 9.91% 3.93% 13.30% 3.84% 13.42% Congestive Heart Failure 8.77% 2.60% 6.96% 0.39% 5.31% Diabetes 5.19% 11.59% 39.42% 11.13% 21.29% Hyperlipidemia 0.00% 0.08% 0.80% 5.39% 3.31% Hypertension 0.11% 11.12% 7.71% 2.15% 5.53% Ischemic Heart Disease 27.58% 15.91% 39.27% 1.74% 37.84% Joint Degeneration, Localized Back 2.63% 18.42% 5.72% 3.18% 23.74% Pregnancy with Delivery 83.57% 34.30% 85.80% 12.46% 86.83% 8

12 Cost & Utilization per Episode Base ETG Asthma - All (Episode Included: 236,976 ) Utilization per Thousand Episodes Normalized Allowed Cost per Unit within Episode Cost Per Episode Inpatient Med/Surg Admissions 6.4 6, $ $ $ 0.09 Other Inpatient 0.0 6, $ $ Total Inpatient 6.4 6, $ Outpatient Avoidable_ER $ $ 1.08 $ Advanced Imaging $ $ ER - Urgent $ $ 1.76 OP Surgery 1.1 1, $ $ Radiology - General $ $ 9.04 Pathology_FOP $ $ 0.13 Therapies $ $ Other Outpatient $ $ Total Outpatient Professional/Other Office Visits 1, $ $ $ ER Visits $ $ Consults $ $ 0.32 Inpatient Surgery $ $ 0.79 Outpatient Surgery $ $ 3.56 Inpatient Visits $ $ 2.54 Preventive Services $ $ 4.02 Pathology_PROF $ $ 7.20 Radiology $ $ 0.19 Physical Therapy $ $ 4.57 Cardiovascular $ $ Durable Medical Equip $ $ 1.39 Home Health $ $ Other Pro/Other 1, $ $ Total Pro/Other Pharmacy Branded Drugs 3, $ $ $ Non-Branded Drugs $ $ Total Pharmacy 4, $ Total $ PMPM Cost by Episode - Asthma Base ETG Asthma - All (Episode Included: 243,272 ) Utilization per Thousand Members per Year Normalized Allowed Cost per unit PMPM cost Inpatient Med/Surg Admissions , $ $ 0.44 $ 0.02 Other Inpatient , $ $ 0.46 Total Inpatient , $ Outpatient Avoidable_ER $ $ 0.00 $ 0.04 Advanced Imaging 0.5 1, $ $ 0.14 ER - Urgent $ $ 0.01 OP Surgery 0.1 1, $ $ 0.05 Radiology - General $ $ 0.04 Pathology_FOP $ $ 0.00 Therapies $ $ 0.39 Other Outpatient $ $ Total Outpatient 0.67 Professional/Other Office Visits $ $ 0.36 $ 0.06 ER Visits $ $ 0.04 Consults $ $ 0.00 Inpatient Surgery $ $ 0.00 Outpatient Surgery $ $ 0.03 Inpatient Visits $ $ 0.01 Preventive Services $ $ 0.02 Pathology_PROF $ $ 0.03 Radiology $ $ 0.00 Physical Therapy $ $ 0.02 Cardiovascular $ $ 0.08 Durable Medical Equip $ $ 0.02 Home Health $ $ 0.26 Other Pro/Other $ $ Total Pro/Other 0.94 Pharmacy Branded Drugs , $ $ 1.76 $ 0.12 Non-Branded Drugs $ $ 1.88 Total Pharmacy $ Total $

13 Distribution of Costs by Type of Service - Asthma Mean Percentiles - Cost Normalized Risk Adjusted - Ranked by Cost by Type of Service Service Type Unit 25th 50th 75th 90th 95th 99th Inpatient Cost per Episode Outpatient Cost per Episode Professional/Other Cost per Episode Pharmacy Cost per Episode Total Cost per Episode ,052 1,260 1,438 2, Agenda New developments in the ACO world Evolent Health, as an example of actuarial opportunities within new organizations helping ACOs 12

14 Evolent Health Founded by three The Advisory Board executives Frank Williams, Former CEO Seth Blackley, Former Executive Director Tom Peterson, Former Executive Director, Analytics Funding for Startup Company from: UPMC Health Plan Contributed identifi care management system The Advisory Board Contributed professional contacts network & IP 13 Evolent Health Business Model Goal - Assist Health Systems move to value-based payments Strategy consultants from health system perspective Payer Agnostic Financial Alignment Gain Share results Clinical Integration & Transformation services & staffing Population Health Management implementation & staffing Employee health plan benefits consultants Care management systems delivery - identifi Turn-Key Health Plan or Payer Risk Administration & Implementation Ongoing health plan operations management (BPO) 14

15 Value-Based Care Framework Benefits of a Value- Based Care Strategy Engaged and Competent Physician Network Cost Structure Enabling Attractive End Market Pricing Central and Accountable Infrastructure to Support Scale Well Positioned Health System Broad Base of Aligned Contracts (Payer or Health Plan) Direct to Consumer / Employer Capability Solidifies referral streams and maximizes volume under fee for service Higher net system margins under successful managed care approach Well positioned for rapid fee for service price declines Improved patient experience, quality; mission alignment 15 Evolent Health Client Engagements Client Project Stages: Business Development Blueprint strategic review of system, market, competitors, etc Recommended Strategy with Implementation plan and Business Case Implementation Turn-key health plan, other development License Applications Network Development Product Development & Pricing Sales & Marketing Development Ongoing Operations Partnership arrangement with Client health plan Participation in financial results 16

16 Company Snapshot A provider-led population health management company providing the people, process, and technology to assist health systems in the movement to value-based care Building a National Network of Leading Health Systems Offerings I. Strategic Direction Value Based Care Blueprint II. MSO Population Management & Network Analytics & Workflow Engine Health Plan Payer-Agnostic Population Platform Health System Employees Create employee EPO, improve utilization of domestic care Lower health spend and absence Medicare Advantage/ACO Launch ACO and/or MA plan End-to-end care management and health plan back office infrastructure Commercial Payers Create narrow network / gainshare contracts with payers Full population health platform Managed Medicaid Launch own Medicaid HMO End-to-end care management and health plan back office infrastructure Engaged Partner Active Discussions Commercial Health Plan Launch own Commercial HMO End-to-end care management and health plan back office infrastructure 17 Evolent Health Differentiators The Advisory Board credibility Most health systems are members Allows for access to decision makers, Boards Pipeline is full - >40 systems in advanced discussions IT-based tools come from within the health system IT delivery Part of desktop delivery within physician practices Proven health mgmt. programs, ipad-based, web-enabled National Model = scale & savings Costs spread across many clients, locations Lower admin costs & Best of breed systems from day 1 Talent Evolent draws top talent looking for a unique opportunity 18

17 UPMC Case Study: Profitable Growth Engine Unlocking the Market Potential of Provider-Led Population Health 10,000,000 9,000,000 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 Revenue $ 000s 13.9% CAGR $8.8B , , , , , , , , ,000 0 EBITDA $ 000s $801M 15.7% CAGR % 58% Inpatient Commercial Market Share Medicare Advantage Medicaid 44% 42% 32% 26% 18% 15% 20% 28% 17% 24% 23% 11% 32% 23% Allegheny County SW Region Allegheny SW Region County Allegheny SW Region County Allegheny SW Region County UPMC Case Study: Population Health Outcomes Demonstrated Mastery of Population Health Superior patient engagement Indexed to Compounding Effect of Lowering Trend PMPM Trend: UPMC vs. Industry 400 Industry Average 350 UPMC Average Plan leads to lower trend Employee 2011 trend 8.5% $65,732,231 5-year savings 1.1% UPMC National Median* 200 Savings by Year $4.5M $6.9M $3.3M $15.4M $35. 6M Achieving outcomes at scale Admin Costs as % of Revenue 14% 12% 7% and earning top marks for health plan quality NCQA JD Powers National Business Group on Health UPMC Plan Average New Plan Average Excellent for HMO, POS, Highest Member Medicaid HMO, and MA Satisfaction in 2011 MyHealth programs recognized for excellence in health and wellness. 20

18 Identifi: Fully Integrated Population Health Management Platform View operational, clinical and financial KPI reports Registry and dashboards enable drill down views Key measures and gaps in care are viewable across populations and at patient specific levels. Workflow can be triggered from reporting dashboards Configurable stratification & rules logic Prioritized, role-based work lists Track care coordination across settings and care team members Care Management Workflow Reporting and Insights Enables physician directed clinical content delivery across online and mobile channels Combines benefit content with care plan related information including incentives for care plan completion Health Plan 2.0 Patient Engagement Secure bi-directional messaging platform Fully integrated claims and enrollment platform allow customer service teams to support care plan goals Connected administrative platform reduces friction and automates key plan functions like UM, Authorization and RAF Scoring Claims logic incorporated into CRM driven enrollment and retention campaigns 21 Evolent Integrated Support Model Local Population Health Entity Local Health Plan Population Health & Identifi Strategy & Physician Alignment Network Mgt & Credentialing Network & Provider Services Provider National Network Relations 2.0 Risk Adjustment Blueprint Care Management Support Clinical Workflow Mgt Support & Remote Care Mgt Utilization Governance Support Reimbursement / Deal Structure Programs Stratification redesign Local Training Analytics Health Economics, Actuarial & Member Serv Risk Scoring Management Reporting / Scorecards Compensation Toolkit Technology Delegation oversight Identifi Care Management Identifi MA / Caid / Com Portals Health Plan 2.0 Identifi Funds Flow Sales Remote Outreach Risk and Financial Infrastructure Corporate Services Claims Mgt. Support Claims Payment PBM Formulary Dev/Mgmt Broker Networks Benefit Design SIU Clinical Programs Sales Tools Financial Services Claims Recovery Specialty Rx Legal Auto Adjudication Purchasing 22

19 Medicare & Medicaid Payment Innovation John D. Shatto, FSA June 10, 2013 The CMS Innovation Center The purpose of the Center is to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing the quality of care furnished. - The Affordable Act Resources: $10 billion funding for FY2011 through

20 The CMS Innovation Center Focus on models that are expected to reduce program costs No need to ensure budget neutrality Evaluation of each model tested Annual Report to Congress Opportunity to scale up : The HHS Secretary has the authority to expand successful models to the national level 3 Model Creation Process Solicit ideas for new models Select the most promising models Innovation Center investment plan (ICIP) Funding opportunity announcement Panel review of applications Select participants Pilot programs last 3-5 years 4

21 Innovation Center Portfolio Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Accountable Care Organizations (ACOs) Medicare Shared Savings Program Pioneer ACO Model Advance Payment ACO Model PGP Transition Demonstration Comprehensive ESRD Care Initiative Bundled Payment for Care Improvement Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care Capacity to Spread Innovation Partnership for Patients Community-Based Care Transitions Million Hearts Innovation Advisors Program Imaging Demonstration Health Care Innovation Awards State Innovation Models Initiative Initiatives Focused on the Medicaid Population Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicare-Medicaid Enrollees Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents 5 CPC Initiative GOAL: Test a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. CMS is inviting public and private insurers to collaborate in purchasing high value primary care in communities they serve. Requires investment across multiple payers, because individual health plans, covering only their members, cannot provide enough resources to transform primary care delivery. Medicare will pay approximately $20 per beneficiary per month (PBPM) then move towards smaller PBPM to be combined with shared savings opportunity. The 7 markets selected: Ohio (Dayton), Oklahoma (Tulsa), Arkansas, Colorado, New Jersey, Oregon, New York (Hudson Valley) 6

22 Comprehensive Primary Care (CPC) Initiative 7 Independence at Home GOAL: Use home-based primary care teams designed to improve health outcomes and reduce expenditures for Medicare beneficiaries with multiple chronic conditions. Primary care team includes physician assistants, pharmacists, social workers, and other staff. Spend more time with patients Perform assessments in patient s home 8

23 Bundled Payments for Care Improvement GOAL: Drive care redesign by aligning incentives that improve coordination across services and reduce the cost of care. Four patient-centered approaches: 1. Acute care hospital stay only 2. Acute care hospital stay plus post-acute care 3. Post-acute care only 4. Prospective payment of all services during inpatient stay 9 Bundled Payment: 4 Different Models Model 1 Model 2 Model 3 Model 4 Episode All acute patients, all DRGs Selected DRGs + post-acute period Post acute only for selected DRGs Selected DRGs Services included in the bundle All part A DRGbased payments Part A and B services during the initial inpatient stay, postacute period and readmissions Part A and B services during the post-acute period and readmissions All Part A and B services (hospital, physician) and readmissions Payment Retrospective Retrospective Retrospective Prospective 10 10

24 Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents GOAL: Reducing preventable inpatient hospitalizations among residents of nursing facilities. Providing preventive care and treatment without hospital visits. 40 percent of hospital admissions among Medicare-Medicaid enrollees who were nursing facility residents were preventable in Currently, financial incentives encourage hospitalizations. Open to independent organizations, who will implement evidencebased interventions at interested facilities. 11 Financial Alignment Initiative GOAL: Increase access to quality, seamless integrated programs for the 9 million Medicare- Medicaid enrollees. Last July, CMS announced new models to integrate the service delivery and financing of the Medicare and Medicaid programs through a Federal-State demonstration to better serve the population. Two Demonstration Models: Capitated Model: Three-way contract among State, CMS and health plan to provide comprehensive, coordinated care in a more cost-effective way. Managed FFS Model: Agreement between State and CMS under which States would be eligible to benefit from savings resulting from initiatives to reduce costs in both Medicaid and Medicare. 12

25 Partnership for Patients Better Care at Lower Costs: Nationwide publicprivate partnership to tackle all forms of harm to patients. 3 - Y E A R G O A L S : 40% Reduction in Preventable Hospital- Acquired Conditions 1.8 Million Fewer Injuries 60,000 Lives Saved 20% Reduction in 30-Day Readmissions 1.6 Million Patients Recover without Readmission $35 Billion Dollars Saved in Three Years 13 Health Care Innovation Awards GOAL: To identify and support a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs through improvement in communities across the nation. Nearly 3000 applications received Applications were accepted from providers, payers, local government, publicprivate partnerships and multi-payer collaboratives. 107 Projects Awarded in 2 Batches: 5/8 and 6/15 Awards range from approximately $1 million to $30 million for a three-year period. Will impact all 50 states Just announced HCIA round

26 Health Care Innovation Awards Number of HCIA Projects operating in each state Strong Start: Enhanced Prenatal Care Delivery GOAL: To reduce pre-term births, the Strong Start initiative will provide a funding opportunity to test and evaluate 3 approaches to the delivery of enhanced prenatal care Targets women receiving Medicaid and at risk for having a preterm birth $43 million funding opportunity for providers, States, managed care plans, and conveners Approaches: Group Visits peer-to-peer interaction in a facilitated setting Birth Centers includes case management and counseling Maternity Care Homes broader array of health services 16

27 Actuarial Involvement Statutory Responsibilities Testing Phase Post Evaluation Payment Model Design Cost Estimates Model Evaluation 17 Statutory Responsibilities For Model Expansion: A model can be expanded if the Secretary determines that it is expected to Reduce spending without reducing the quality of care Improve the quality of care without increasing spending And the Chief Actuary of CMS certifies that such expansion would reduce (or not increase) net program spending 18

28 Statutory Responsibilities Rapid Cycle Evaluation: Once testing has begun, the Secretary shall terminate of modify the design of a model unless it has Reduce spending without reducing the quality of care Improve the quality of care without increasing spending And the Chief Actuary of CMS certifies that such expansion would reduce (or not increase) net program spending 19 Payment Model Design & Evaluation Assist with the financial aspects of the new payment model Impact of claim fluctuations Minimum savings requirements Shared savings Assist with the design of the evaluation Comparison groups Overlap with other programs Parameters to compare 20

29 Cost Estimates OACT Estimate: ACOs Review of Innovation Center Estimate: Comprehensive Primary Care Range of possible outcomes based on studies Bundle Payment Models Interaction with ACOs Incentives for increased utilization Incentives to provide care at discounted hospitals Calculation Review: Partnership for Patients No Review: Innovation Challenge 21 Actuarial Certification Issues Overlapping programs Expected timing for the impact of the program Program shows savings, but is not statistically significant Expansion is different from the pilot program Current law payment updates 22