Catherine Dodd, RN, PhD Director, Health Service System

Transcription

1 Catherine Dodd, RN, PhD Director, Joint Labor Management Wellness Committee Presentation January 2013 Total Medical Premium Costs Kaiser $282.6M Blue Shield $275.6M City Plan $65.5M Kaiser and Blue Shield outpatient services are capitated. 1 1

2 Population Risk Scores: Methodology Population risk is the primary factor in premium ratings/costs. Aon Hewitt obtains demographic data and detailed pharmacy data to create individual risk scores for each member. (Data is de-identified to protect patient privacy.) Scores are based on a number of factors, including demographics (age and gender) and therapeutic class of prescribed drugs. Participants without pharmacy claims are scored based on demographics only (age and gender). This method is recognized as an industry standard risk scoring tool. It is six times more accurate than demographic-only scores at predicting individual health care costs 2 Risk Scores: Active Employees Risk score of an active employee is lower than would be expected based on age/gender alone, indicating a lower than normal risk for future healthcare costs. Dependent risk scores are lower than active employees, and reduce the risk of the insured pool overall. A few male dependent age bands have higher risk scores than would be expected. Female employees and dependents have a higher risk than male employees and dependents in all age bands below For adult women this is attributable to child-bearing. 3 2

3 Risk Scores: Active Employees (All Employers) Score of 1.0 = average risk. Yellow bands highlight above average risk. 4 Risk Scores: Early Retirees 5,911 members with average age of 60.2 years. (Does not include under age 65 disability retirements with Medicare.) Early retirees have a higher risk score than would be expected based on their age/gender. This is particularly significant in males age Female dependents of early retirees have a lower risk score than would be expected based on their age/gender alone. Male dependents of early retirees have a higher risk than would be expected based on their age/gender alone at all age bands except

4 Risk Scores: Early Retirees Score of 1.0 = average risk. Yellow bands highlight above average risk. 6 Aon Hewitt Analysis: Kaiser Migration

5 Aon Hewitt Analysis: Blue Shield Migration Aon Hewitt Analysis: City Plan Migration

6 Cost Drivers Transparency, Efficiency, Collaboration Utilization Cost of Services and Goods - Provider consolidation/monopoly pricing - Shadow pricing - Adverse selection, high risk pools - Lack of data transparency - Uncoordinated care - Unwarranted/unnecessary services and medical errors - HSS population risk (age, gender, health status) - Chronic disease management - High cost claims (catastrophic care) - State and federal healthcare mandates - Preventive care - Personnel - Investment in new technologies - Facility, material, pharmacy costs 10 Cost Drivers: Hospital Consolidation Affiliation Total $/Yr Dys/1000 Adm/1000 Cal Pacific Sutter $21,573, UCSF UCSF $9,481, Alta Bates Sutter $6,306, Seton Seton $4,223, Mills Pen Sutter $3,467, John Muir John Muir $3,052, SF General Community $2,848, St. Mary s Dignity $2,546, Marin Gen Community $831, HSS active members: Blue Shield top hospitals 11 6

7 Cost Drivers: Shadow Pricing Sutter charges the highest fees. Many providers in Bay area market, (including Kaiser) shadow Sutter s prices, regardless of the true cost of providing care. Kaiser Sutter Other 12 Cost Drivers: Adverse Selection 10% to 20% of an insured pool drives 70% to 80% of health care costs. Healthier enrollees cushion the risk of paying for sicker people. (Chart based on large employer medical claims data from Thomas Reuters MarketScan, 2006.) 13 7

8 Cost Drivers: Adverse Selection Unbalanced Risk Pools Kaiser Risk =.871 Blue Shield Risk = City Plan Risk = HSS Dependent Migration = Adverse Selection Increasing premium contribution of employee +2 has driven driven families to leave the Blue Shield plan Total Dependents Blue Shield Dependents Kaiser Dependents Plan Year 15 8

9 Cost Drivers: Uncoordinated Care, Medical Errors, Lack of Data Transparency National Data Avoidable hospital readmissions 1 in 5 patients $17.4 billion/year Hospital-acquired infections 1 in 20 patients $45 billion/year Inappropriate use of emergency room 1 in 5 patients $21 billion/year Adverse medication interactions Chronic condition; multiple providers who are not communicating 1 in 3 patients over age 65 $5 billion/year 1 in 10 patients 70% of all medical costs Accountable Care Organizations formed by HSS and Blue Shield in 2011 are effectively addressing some of these trends in HSS Blue Shield. 16 Cost Drivers: Unnecessary Care National Data Brand name vs generic medications 1 in 5 patients $21 billion/year End-of-life interventions 725,000 patients/yr $20 billion/year Inappropriate imaging tests 1 in 10 $16 billion/year Unnecessary office visits 1 in 10 visits $10 billion/year Treatment deviates from evidencebased medicine 1 in 3 patients over age 65 $5 billion/year Accountable Care Organizations formed by HSS and Blue Shield in 2011 are effectively addressing some of these trends (except end-of-life) in HSS Blue Shield. 17 9

10 Accountable Care Organizations (ACOs) For twelve months ending in August 2012, AonHewitt reports the trend for noncapitated fee-for-service medical cost in the Blue Shield plan is negative at -3.52%. ACOs are succeeding at improving coordination of care, and ensuring right care is delivered in the right place. (For example, reducing hospital readmissions and unnecessary emergency room visits for Blue Shield enrollees.) Stabilizing HSS member premium contributions also helped bend the cost curve, by maintaining a balanced risk pool in the Blue Shield plan for the past three Open Enrollments. 18 Accountable Care Organizations HSS/Blue Shield ACOs have improved care and cost trends. Time in months as of August

11 Cost Drivers: Illness Burden/Chronic Disease Undiagnosed, untreated chronic disease Diagnosed w/chronic disease; poor medication adherence Late stage cancer diagnosis 1 in 3 patients w/ chronic disease 5 in 10 w/chronic disease 2-5 in 10 w/cancer National Data Significant financial cost, but more importantly, significantly worse clinical outcomes 20 Cost Drivers: Population Risk 58% of HSS covered lives are age 45 or older. HSS Member Data (2012 Kaiser Only) Adult Overweight 34.7% Adult Obese 30.5% Child Overweight 15.8% Child Obese 17.3% Smoker 11.5% Borderline Cholesterol 28.3% High Cholesterol 8.9% High Blood Pressure 9.9% High Glucose among Diabetics 20.3% 21 11

12 Cost Drivers: Holdovers as of 12/19/12 Holdover Benefits Count Employer Annual Premium Costs Medical 98 $ 983,427 Dental 96 $ 115,267 TOTAL $ 1,098,694 Holdovers may be enrolled in medical or dental or both. 1 holdover to end in 2017 (4.6 years remaining). 7 holdovers to end in 2016 (3.0 to 3.7 years remaining). 43 holdovers to end in 2015 (2.6 to 2.2 years remaining). 53 holdovers to end in 2014 (1.1 to 2.0 years remaining). 4 holdovers to end in 2013 (.3 to.8 years remaining). 22 Long Term Cost Drivers (2015 and beyond) Hospital consolidation prevents value-based contracting. Sutter expanding market share. Sutter prevents offering differential premiums between medical groups (Hill Physicians, Brown & Toland), which reduces competition. Sutter prevents financial transparency. Premium contribution incentive for Kaiser lowest priced plan in collective bargaining encourages migration of healthy individuals and families, increases Blue Shield risk, causing adverse selection

13 Long Term Cost Drivers (2015 and beyond) Increasing average age and chronic illness elevates risk in HSS population. More risk increases premium costs. California and other healthcare exchanges may change the market statewide. Federal healthcare reform will impose Cadillac excise tax on employer-provided health benefits in 2018, setting limitation on what can be spent without penalty. 24 PEC Suggestions: Reference Based Pricing (RBP) With RBP, the employer sets price ceiling on an array of common ambulatory care procedures, offered at recommended facilities with high quality ratings. (Example: CalPERS uses RBP for simple hip or knee replacement.) Enrollees who choose higher cost options at other facilities pay difference out-of-pocket. RBP is not feasible in the Bay area because Sutter owns nearly all of the ambulatory care facilities, and they are not inclined to contract based on a price ceiling set by the employer. There would not be sufficient facilities to serve our population without Sutter. The introduction of competing ambulatory care facilities in the Bay area market could make RBP feasible for the City and other employers

14 PEC Suggestions: CCSF Hospitals and Clinics Through the Department of Public Health, the City of San Francisco operates a number of hospitals and medical facilities. These are primarily safety net facilities (emergency trauma, uninsured, etc). Blue Shield has attempted to contract with SF General and other City facilities in-network. However, these facilities cannot afford innetwork rates. They rely on out-of-network rates to offset the significant amount of uncompensated, or under-compensated, care that they provide to the community. Plans like Healthy San Francisco and San Francisco Health Plan, which offer access to City facilities, are anticipating a large influx of individual subscribers due to federal healthcare reform. They are not able to engage in commercial contracts with large employers. 26 PEC Suggestions: Alternative Pharmacy Purchasing The HSS COO, who is a licensed pharmacist, actively reviews and manages pharmacy purchasing of HMO and PPO plans on an ongoing basis, to take advantage of latest trends in maintaining quality and reducing costs. Blue Shield manages its own pharmacy benefits which HSS closely monitors. In the past three years, HSS has made significant changes to pharmacy benefits and purchasing to increase efficiency, maximize federal subsidies, and encourage use of mail order and generic medications. Administering a separate pharmacy benefit is not possible with our current structure. HSS does not directly manage providers

15 PEC Suggestions: Coordination of Benefits HSS Rules L.2 states members are required to disclose to HSS dual health plan coverage for the member and any enrolled dependents. For the past three years, HSS has required members to disclose this information on enrollment applications. 28 PEC Suggestions: Wellness Wellness is an area that offers significant opportunity. Collaborative analysis is currently underway, coordinated by the Controller. Wellness typically is a long-term strategy; it takes time (2-3 years) to implement, monitor and see the positive effects