Premera is now offering a much broader range of coverage under the new plan including pharmacy coverage
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- Julius Frederick Harrington
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1 Joint Health Care Committee November 21, 2013 Premera is now offering a much broader range of coverage under the new plan including pharmacy coverage David Testerman: Premera pharmacist Pharmacy is the most used benefit- 80% utilization Premera s customer service center is staffed by pharmacists The largest national PBM (pharmacy benefit management)- Express Scripts Coordination of pharmacy and medical coverage reduces overall cost Benefit Design Algorithm automatically evaluates pharmacy claims Review clinical rules, limits The university developed the co-pay rates/ Premera determines the tiers Tweak the plan based on usage and feedback Prior authorization transferred over from former vendor Some drugs will now require prior authorization If so, there will be a point of sale message to the pharmacist Premera s Pharmacy and Therapeutics Committee Independent physicians Make value assessments determine preferred drugs Review new generics for example Partner with Express Scripts Broad pharmacy network Network discounts and rebates can provide revenue Efficient claims processing Mail service = additional discount Rational med reviews medical claims with pharmacy could stop prescription Provide physician with options Mail order service takes into account AK climate Worry free refills- automatic More savings via mail service for name brand drugs REQUEST: 90-day on-location prescriptions for generic drugs People like to support their local pharmacy, but want 90-day savings P&T Committee diligent regarding drugs Meet quarterly Specialty Pharmacy Program Growing at 18% projected to rise to 50% plan cost Treat complex medical conditions
2 Make sure drugs are properly utilized, dosed, administered 2 vendors Walgrens and Acreedo Cap cost increase at 8% Injectibles sometimes medical claims sometimes pharmacy claims Automatic review of compound products over $200 Clinical counseling suggested but not required Telephonic service from therapeutic centers IHM Integrated Health Management (Generic data provided) Follow-up case management can prevent returning to hospital Identify gaps in care e.g. behavioral health Controlled substance utilization Provide outreach and intervention Peer to peer review Spotting abuse: multiple providers a key indicator Limit multiple prescribers deny claim at P.O.S. Share information on case management members will better understand why their insurance company is calling Utilization management Is it necessary? Is it correct? Is it safe? Nurseline calls Redirect to the right level of care Good utilization so far Number printed on the front of Premera card Disease management program 5 conditions consume 75% of health resources Strong correlation between lifestyle and health Handed off population from Allere Specialists make the calls Motivational interview style (eliza) personal health support coaching Digital Health Coaching Online and newsletters Prior Authorization Non-emergency procedures Online list of all pre-service review procedures Prior authorization done by the provider
3 Penalize? Why prior auth.? Estimated impact Provide information to employees Reinforce using in-network provider Experience report review Claims data July-June Premera website Mobile app Paperless EOB Vendor Summit 2013 November 22, 2013 Purpose: to find ways to work better together Educate vendors on services provided by other vendors Premera- Account team representatives (Did not repeat the presentation from the day before, instead answered questions) Request to clarify language regarding hospice care coverage Personal health support Concerns about depression and mental health 80% patients with health/heart conditions also have depression PH7- seven questions used in diagnosis Depression is addressed with every call Work with behavioral health specialists Screenings are part of the service Request to remove all references to disease management Add pre-diabetic language encourage enrollment early Request 90-day generic scripts on location Provider contracting Alaska-based review Regulatory considerations Bring up minimum payout AK cost of healthcare 3 rd highest (D.C. and NYC) UCR regulation- pay 80 th percentile UCR= Usual and customary reimbursement Frequent high costs with specialists There is no price ceiling
4 New pay to statute introduced by Wess Keller Opposition to it from hospitals Out of network- direct payment Introduce co-signature: member/provider More motivation to contract with network Air ambulance Non-contract is triple the price hold market dominance Work with provider The $100,000 phone call Need a process to inform providers Guardian is $1000,000 more expensive than LifeMed or Airlift North Medical travel support Take advantage of lower costs outside Impacted provider community encouraging contracting Need to educate: it s a member choice expands options 17 procedures covered all safe, travel friendly, demonstrate cost avoidance Guarantee cost savings Cost containment information on web portal Best Doctors Cheryl Warren, account executive Lots of partnership opportunities Benefits communication is always a challenge Best Doctors is a virtual second opinion Work with large employers assist their members Obstacles to effective care make 2 nd opinions common Ensure members have the right diagnosis and service plan Inter consultation confidential 2 nd opinion Ask the Expert don t Google it! Find Best Doc reference service Digital records Only deal with medical cases, not dental or behavioral What are the best next steps? Set up an appointment Assign a team Member authorizes the release of medical record Team gathers info. and summarizes case Top-rated specialists review the case Re-look at everything
5 Write recommendation on whether the treatment or procedure is right Send records back review them with member Answer questions, provide information Offer advice for approaching the original doctor Ask the Expert Answer questions not requiring in-depth review Find Best Doc Match member with in-network specialists or providers Medical records summary Member authorizes multiple records pull Digitize records Provide health summary Send digital records to member via secure or overnight fedex Best Doctors- 30 consultations for UA 23% change diagnosis 71% change in treatment Medical review 4-5 weeks Consultant owns the case In general: 60% wrong diagnosis and/or treatment reason for 2 nd opinion VSP Diabetes is the #1 cause of vision deterioration Regular eye exams are an important part of medical care Setting up data share with Premera 3 Services offered Medical data collection Patient exam and condition report Exam reminder report Extend benefit $20 Jan. 1 VSP benefit/promotion Want to drive members more to the website Website includes frame styles carried by a vision doctor Tru hearing discount partnership
6 ComPsych Allison Madge and Elizabeth Thompson 12 yrs. Health coaching Online health improvement Biometrics Health risk assessments Determine individual journey Build a healthier workforce Projected schedule Launch portal Jan 1 Full launch Feb 1 On-site March Healthyroads.com Personal health assessment Biometric data integration Personal health improvement plans Health trackers Training, courses, library Mobile devices options Wellness, lifestyle, behavioral health Personal scorecard/ dashboard Biometrics and lifestyle 100 online coaching 200 additional coming Personalized SMS/ health tips Daily challenges, share socially Challenges (systemwide) and competitions (individual or group)
7 Biometrics integrate with scorecard Engaging high risk individuals Biometrics #1 UA does not see individual data Targeted messaging HIPPA safe no disclosure to UA Lifestyle coaching Phone in available anywhere Onsite in Fairbanks, Anchorage and Juneau Medical conditions will refer to Premera Lifestyle= coaching Can switch coach; otherwise 1 coach Have Saturday hours (phone) 5 a.m. to 6 p.m. AK standard time Brainstorm session: how to work together Plan for integration of services and warm referrals
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