Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population

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2 Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population November 18, 2013 Diana Dennett EVP, Global Issues and Counsel America s Health Insurance Plans (AHIP)

3 America s Health Insurance Plans: Who We Are Represent Health Plans and Health Insurance Companies o National, Regional Plans and Local Plans o Not-for-Profit and For Profit Member plans provide coverage to over 90 percent of health insured in U.S. and increasing proportion of public programs 2

4 Today s Discussion Role of Private Health Plans in providing coverage to individuals enrolled in a government program Example: MEDICARE 3

5 Medicare Basics Federal health insurance program established in 1965 for people age 65 and older and those with permanent disabilities and individuals with End Stage Renal Disease Provides coverage for over 50 million Americans Social Insurance Program paid for by largely by payroll taxes Accounted for 16% of total federal U.S. spending and 21% of total national health spending in

6 Medicare Enrollment From 1985 to 2023 Medicare Enrollment will have more than doubled Medicare Beneficiaries Enrolled 69 Million 50 Million 31 Million

7 Medicare Spending 2023 Medicare spending is projected to be more than 15x 1985 expenditure levels Medicare Total Spending 1 Trillion 71 Billion 549 Billion

8 Medicare Spending 7

9 Medicare Demographics and Spending Percentage of Beneficiaries Percentage of Spending Aged 83% 77% Disabled 16% 16% ESRD 1% 7% 8

10 Medicare Demographics Diverse Beneficiaries Characteristics of Medicare Population Long Term Care Facility 5% Age ADL Limitation Under 65 Disabled Dually Eligible Cognitive/Mental Health Impairment Fair/Poor Health Status 13% 15% 17% 20% 23% 27% 3+ Chronic Conditions 40% Income below $22, % 9

11 Medicare What s Public What s Private Part A Covers inpatient hospital services, skilled nursing facility, home health, and hospice care. Part B Covers physician, outpatient, home health, and preventive services. Part C Is the private plan option for Medicare beneficiaries (also known as Medicare Advantage); Beneficiaries receive all Medicare-covered benefits and may also receive additional benefits Part D Provides out-patient prescription drugs Offered through private plans that contract with Medicare, including prescription drug-only plans (PDPs) and Medicare Advantage health plans that provide prescription drug benefits(ma-pds) Includes subsidies for low-income individuals 10

12 Medicare What s Public What s Private Part A Part B Part C Part D Percent of Medicare Spending 32% 19% 23% 10% Beneficiary Responsibility $1,184 deductible in 2013 Additional co-pays apply for longer stays $147 deductible in % coinsurance $ monthly premium in 2013(means test applies) Varies by plan Varies by plan Government Responsibility Pays for all hospital and inpatient services outside of deductible and coinsurance Pays for medically necessary outpatient services outside of deductible and coinsurance Pays plans a risk adjusted per capita amount to cover Part A and B benefits Pays plans a per capita amount 11

13 So How Is Part C Working? 16 Medicare Advantage Enrollment (millions) MA enrolls 28% of all Medicare beneficiaries today, an increase from 12% in

14 Medicare Advantage: Key Characteristics -- Payment Medicare Advantage plans submit a bid to CMS based on estimated costs per enrollee for Medicare Parts A and B benefits. Bids are compared to a benchmark, which is established by a statutory formula and varies by county or region. Benchmark is the maximum amount Medicare will pay a plan in a given area. Payments adjusted for demographic and health status (risk adjustment) o Demographic Adjustments: Age, Gender, Medicaid Status, Institutional Status o Health Status: 171 Health Condition Codes (HCCs) 13

15 Medicare Advantage: Key Characteristics -- Enrollment Beneficiaries may enroll.. VOLUNTARILY! o Upon becoming Medicare eligible o Annually (Oct 15 Dec. 7) Availability of Medicare Advantage Plans: Almost all Medicare beneficiaries have access to at least one MA plan 14

16 Medicare Advantage: Examples of Regulated Activities Audits Appeals Benefit Design Bidding Process Contracting Process Data and Reporting Requirements Marketing and Member Materials Provider Access Risk Adjustment 15

17 Medicare Advantage: Quality Measurement Medicare Advantage plans rated on a 5 Star System (5 is highest) System composed of 53 individual measures in areas including: o Staying healthy: screenings, tests, and vaccines o Managing chronic (long term) conditions o Ratings of health plan responsiveness and care o Member Complaints, Problems Getting Services, and Choosing to Leave the Plan o Health plan customer service o Drug plan customer service o Member experience with drug plan o Drug pricing and patient safety Used by beneficiaries to evaluate plan choices and since 2012, as basis for MA plan payment bonuses 16

18 Health Plan Perspective Opportunities Provide coordinated care to Medicare beneficiaries Aging Population Medicare enrollment expected to grow by almost 10 million in the next ten years Allows smooth transition from employment based plans Plans expertise in managing cases needed here Challenges Highly regulated..compliance critical Funding stability.. challenging? Networks in rural areas harder to establish Provider consolidation (hospitals) harder to price competitively 17

19 Government Perspective Opportunities Increase care coordination Alternative to disjointed Traditional Medicare program Improve quality and cost-effectiveness for high needs populations (see next slide) Take advantage of effective private plan tools to reduce fraud and abuse Challenges Determining appropriate payments Establishing environment to promote stability for beneficiaries and plans Auditing plan performance to ensure beneficiary protections 18

20 MA Program: Highlighting Record of Success 2013 Health Affairs: MA plan performance measures for breast cancer screening, diabetes care, and cholesterol testing for cardiovascular were consistently better compared to Traditional Medicare 2012 American Journal of Managed Care(AJMC): Readmission rates in MA plans about 13 percent to 20 percent lower than Traditional Medicare 2012 Health Affairs: Readmission rates among MA enrollees 28% lower than FFS; hospital admission rates 19% lower than Traditional Medicare 2012 AJMC Study: MA plans outperformed Traditional Medicare in 9 out of 11 clinical quality measures 19

21 Beneficiary Perspective Highly valued by beneficiaries Recent survey finds 90% of beneficiaries are satisfied with their plans Additional Benefits -- Medicare Advantage plans provide extra benefits and services that are not included in the Medicare FFS program including: o Case management services o Disease management programs o Coordinated care programs o Wellness and prevention programs o Prescription drug management tools integrated with medical benefits Out-of-Pocket Protection All MA plans offer an out-of-pocket maximum for beneficiary costs o In 2013, 76 percent of enrollees were in plans that have annual outof-pocket maximums of $5,000 or less 20

22 Lessons Learned MA is highly valued by beneficiaries MA plans provide care coordination and high quality care Payment stability critical Increased regulatory flexibility necessary to provide plans more opportunities to promote better health outcomes Compliance is key. Transparency critical Collaboration to align quality incentives, payment, and delivery system requires active participation by the government, health plans and beneficiaries 21

23 For Questions: Please contact: Diana Dennett Executive Vice President Global Issues and Counsel 22

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