Educational Presentation: Tiered & Limited Provider Networks. City of Boston PEC Meeting December 10, 2013
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1 1 Educational Presentation: Tiered & Limited Provider Networks City of Boston PEC Meeting December 10, 2013
2 2 Discussion Topics Tiered Networks Limited Networks Tier Development City of Boston Utilization
3 3 Tiered Networks A Provider Network in which a Carrier assigns Providers to different benefit tiers based on the Carrier's assessment of a Provider's relative cost and, where available, quality and in which members pay the cost-sharing (copayment, coinsurance or deductible) associated with a Provider's assigned benefit tiers. Maintains member choice by including most providers Helps control health costs and promote use of high quality providers due to the co-pay structure of the tiers Member is engaged as a consumer and is incentivized to choose providers on Tiers for which they pay a lower co-pay
4 Limited Networks 4 A reduced or selective Provider Network, which is smaller than a Carrier s General Provider Network. The Providers who are excluded may be included in the Carrier s general network but upon assessment have been eliminated based on the Provider's relative cost and, where available, quality. Limits member choice by eliminating access to providers who the carrier has determined does not meet certain guidelines for quality and cost There is typically no coverage for non-emergent care from providers outside the network This plan is a good option for members who are already using providers in the limited network or who want to save money by choosing a plan for which they pay a lower premium and also have lower out-of-pocket expenses
5 Network Design 5 Higher Premiums PPO POS HMO Tiered Network Lower Premiums Limited Network Tier 3 Tier 1 Tier 2 no referrals required referrals required only for general network access referrals required General Network No Access to Providers Outside of General Network Access to Providers Outside of General Network- Deductible & Co-insurance Apply No Access to Some Providers in General Network
6 Tiered Networks - Example Deductible (per calendar year) Out of Pocket Maximum Preventive Care Visits & Health Screenings Primary Care Provider Office Visits (Medical/ Mental Health/ Substance Abuse) Specialist Physician Office Visit Physical Therapy Inpatient Hospital Care (Medical/ Mental Health/ Substance Abuse) Outpatient Surgery High-Tech Imaging (e.g., MRI, PET, CT scans) Emergency Room Prescription Drugs Harvard Pilgrim HMO None None $0 per visit $15 per visit $25 per visit $15 per visit for up to 90 consecutive days Covered in full Covered in full Covered in full $100 per visit (waived if admitted) Retail up to 30-day supply: Tier 1: $10 Tier 2: $25 Tier 3: $45 Mail Order up to 90-day supply Tier 1: $20 Tier 2: $50 Tier 3: $100 Services eligible for tiering with example copays: 6 PCP Office Visit Tier 1: $15 per visit Tier 2: $25 per visit Tier 3: $35 per visit Specialist Office Visit* Tier 1: $25 per visit Tier 2: $35 per visit Tier 3: $45 per visit Inpatient Hospital Care** Tier 1: $200 per admission Tier 2: $400 per admission Tier 3: $600 per admission Outpatient Surgery Tier 1: $75 Tier 2: $100 Tier 3: $125 *Physical Therapy, Behavioral Health, Chiropractic care, etc. are treated as Tier 1 **Behavioral Health/Substance Abuse inpatient admissions are treated as Tier 1 **Hospital admissions through ER are treated as Tier 1
7 7 Tier Assignments Overall, providers are evaluated against a quality threshold, which most Boston area providers meet, so cost becomes the primary factor in determining tiers. Tier 1 ALL HPHC TUFTS BCBS Physicians/Hospitals who meet Quality Threshold with Low Cost All Behavioral Health, non-medical providers (i.e. physical therapy, chiropractors), ER and ER related Hospital visits Tier 2 Physicians/Hospitals that meet Quality Threshold with Moderate Cost All providers with insufficient data for evaluation. Physicians/ Hospitals that fail Quality Threshold with Low or Moderate Cost Hospitals that fail Quality Threshold with Low or Moderate Cost Tier 3 Physicians/Hospitals with High Cost, Regardless of Quality Physicians/ Hospitals who fail Quality Threshold, regardless of Cost Physicians who fail Quality Threshold, regardless of Cost
8 8 Tier Development - Basis for Evaluation Providers are evaluated on cost and quality. HPHC, Tufts Health Plan and BCBS use similar approaches with differences in details Physicians are generally evaluated as part of a group, not individually. All physicians in the same group are assigned to same tier. Hospitals are evaluated individually Tufts Health Plan aims to place hospital and affiliated physicians in the same tier; generally BCBS and HPHC do not Not every provider is evaluated Behavioral Health, Physical Therapy and Optometry, Emergency Room Visits and Hospital stays resulting from ER are all Tier 1, regardless of cost and quality BCBS does not tier specialists; Tufts Health Plan and HPHC do If there is insufficient data available for a provider, they are placed in Tier 2
9 9 Tier Development: Evaluating Quality The quality of physicians and hospitals is scored using Nationally Recognized Standards (e.g., HEDIS, Leapfrog, CMS) Quality measures include: Quality of care provided: e.g., are patients receiving recommended standard of care for specific conditions and for preventive services Patient safety: are providers meeting safety standard, e.g., what is the hospital infection rate compared to a benchmark Patient Experience: e.g., using responses to standardized patient survey questions (CAHPS) to determine if doctors are responsive to patient needs Carriers set a quality threshold using their preferred standard; providers are either above or below the threshold HPHC reported for 2014 that 11 hospitals and 8 providers failed the quality standards will be in Tier 2 BCBS reported for 2014 that 1 hospital failed the quality standard THP reported for 2014 that 2 hospitals failed the quality standard and will be in Tier 3
10 10 Tier Development - Evaluating Costs Cost scores are calculated based on: Total Medical Claims Expense (at contracted rates) per member per month Claims are adjusted by: Health risk of population Pediatric vs. adult In-patient and outpatient hospital costs Large claims Geographic location The carriers compare relative cost scores among providers to determine low, moderate or high costs
11 11 Current Utilization by Tier PCP This chart illustrates the current distribution of physician primary care groups by tier using the City s actual utilization for FY 2013 versus HPHC ChoiceNet 2014 tiering of providers. This is an example based on the City s current plans and utilization and the HPHC network. Tiered Network results will vary by insurer and, as such, the suitability of a tiered network will vary by insurer. Primary Care Group Tier Members Total Members in Tier Harvard Vanguard Medical Associates, Chestnut Hill Tier 1 7.5% Harvard Vanguard Medical Associates, Kenmore Tier 1 7.0% Boston Medical Center Management Services Tier 1 6.4% Pediatric Physician's Organization at Children's Tier 1 6.4% Harvard Vanguard Medical Associates, Braintree Tier 1 4.4% Dedham Medical Associates Tier 1 2.8% New England Quality Care Alliance Tier 1 2.7% Harvard Vanguard Medical Associates, Copley Tier 1 1.9% Other Tier 1 Providers Tier % Beth Israel Deaconess Physician Organization, LLC Tier 2 8.4% The Physicians of Tufts-New England Medical Center, Inc. Tier 2 2.7% Other Tier 2 Providers Tier % Brigham And Women's PHO Prime Tier 3 6.6% Massachusetts General Hospital Physicians Organization Tier 3 6.0% Steward Greater Boston West Local Chapter Tier 3 5.1% South Shore PHO Tier 3 2.3% Other Tier 3 Providers Tier 3 3.5% Chart includes primary care groups of the primary care physicians for the City s members from July 1, 2012 to June 30, % 22.1% 23.5%
12 PCP Tier by Health Plan 12 This chart illustrates the tier assigned to primary care physician groups by Harvard Pilgrim Health Plan, Blue Cross Blue Shield of Massachusetts, and Tufts Health Plan. Primary Care Group HPHC BCBS* Tufts Boston Medical Center Management Services Tier 1 Tier 1 Tier 1 New England Quality Care Alliance Tier 1 Tier 2 Tier 1 Beth Israel Deaconess Physician Organization, LLC Tier 2 Tier 1 Tier 1 Pediatric Physician's Organization at Children's Tier 1 Tier 1 Tier 3 Harvard Vanguard Medical Associates, Chestnut Hill Tier 1 Tier 3 Tier 1 Harvard Vanguard Medical Associates, Kenmore Tier 1 Tier 3 Tier 1 Harvard Vanguard Medical Associates, Braintree Tier 1 Tier 3 Tier 1 Harvard Vanguard Medical Associates, Copley Tier 1 Tier 3 Tier 1 Dedham Medical Associates Tier 1 Tier 3 Tier 1 The Physicians of Tufts-New England Medical Center, Inc. Tier 2 Tier 2 Tier 1 Steward Greater Boston West Local Chapter Tier 3 Tier 2 Tier 1 South Shore PHO Tier 3 Tier 2 Tier 1 Brigham And Women's PHO Prime Tier 3 Tier 3 Tier 3 Massachusetts General Hospital Physicians Organization Tier 3 Tier 3 Tier 3 * BCBS tiers vary by site. Tier listing represents the majority of sites
13 13 Current Utilization by Tier Hospital This chart illustrates the current distribution of hospitals by tier using City s actual utilization for FY 2013 versus HPHC ChoiceNet 2014 tiering of providers. This is an example based on the City s current plans and utilization and the HPHC network. Tiered Network results will vary by insurer and, as such, the suitability of a tiered network will vary by insurer. Name of Hospital Tier % of admissions* Total Admissions in Tier* Beth Israel Deaconess Hosp/Milton Tier 1 3.1% Mass Eye and Ear Infirmary Tier 1 0.3% Other Tier 1 Hospitals Tier % Beth Israel Deaconess Medical Center Tier % Tufts Medical Center Tier 2 5.3% Newton-Wellesley Hospital Tier 2 4.2% Boston Medical Center Tier 2 4.2% Brigham and Women's/Faulkner Tier 2 3.1% Steward St Elizabeth's Tier 2 3.1% Dana-Farber Cancer Institute Tier 2 0.2% Other Tier 2 Hospitals Tier % Brigham and Women's Hospital Tier % Mass General Hospital Tier 3 7.3% South Shore Hospital Tier 3 5.5% Children's Hospital Tier 3 4.7% Other Tier 3 Hospitals Tier 3 1.8% 18.7% 42.6% 38.7% *Tier 1 utilization is understated because admission through ER is always counted as tier 1
14 14 Hospital Tier by Health Plan This chart illustrates the tier assigned to hospitals by Harvard Pilgrim Health Plan, Blue Cross Blue Shield of Massachusetts, and Tufts Health Plan. Hospital HPHC* BCBS* Tufts* Beth Israel Deaconess Hosp/Milton Tier 1 Tier 1 Tier 1 Mass Eye and Ear Infirmary Tier 1 Tier 1 Tier 1 Beth Israel Deaconess Medical Center Tier 2 Tier 1 Tier 1 Tufts Medical Center Tier 2 Tier 1 Tier 1 Boston Medical Center Tier 2 Tier 1 Tier 1 Steward St Elizabeth's Tier 2 Tier 1 Tier 1 Newton-Wellesley Hospital Tier 2 Tier 1 Tier 3 Brigham and Women's/Faulkner Tier 2 Tier 1 Tier 3 Dana-Farber Cancer Institute Tier 2 Tier 3 Tier 2 South Shore Hospital Tier 3 Tier 3 Tier 1 Brigham and Women's Hospital Tier 3 Tier 3 Tier 3 Mass General Hospital Tier 3 Tier 3 Tier 3 Children's Hospital Tier 3 Tier 3 Tier 3 *Admission through ER is always counted as tier 1
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Important Questions (Massachusetts ) (New England ) (National ) What is the overall $0.00 Are there other s for specific? Is there an out of pocket limit on my expenses? What is not included in the out
Albany College of Pharmacy and Health Sciences
Albany College of Pharmacy and Health Sciences 08/21/2014-08/20/2015 Individual + Family PPO www.cdphp.com 1-877-269-2134 In-Network: $250 individual/$500 family. Out-of-Network:$500 individual/$1000 family.
RIT Blue Point2 POS B Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at www.excellusbcbs.com or by calling 1-800-499-1275/V;
Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO
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Gold 80 PPO Network Name: Exclusive Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type:
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Non- Choice of Providers Calendar Year Deductible *The Fund s Calendar Year Deductible is never waived. However, some services are not subject to the Deductible. If you live in Nevada, your network of
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PPO Student/Affiliate Plan MIT Student/Affiliate Extended Insurance Plan Coverage Period: 2014-2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Couple,
Capital BlueCross offers a variety of health care choices. Pick the one that s right for you!
Traditional Our traditional product features comprehensive benefits and complete freedom to choose your physician, specialist or hospital. You minimize your out-of-pocket costs by receiving covered services
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.thehealthplan.com or by calling 1-800-447-4000. Important
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health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance.
health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. This Massachusetts Requirement to Purchase Health Insurance: As of January
Highmark Delaware: Shared Cost PPO $1000/100 Coverage Period: 01/01/2014-12/31/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkbcbsde.com or by calling 1-800-633-2563. Important
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You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsil.com or by calling 1-866-826-0913. Important Questions
Your Plan: Premier HMO 20/200A/100 OP Your Network: California Care HMO
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Employee Contributions Family Monthly : $212.14 Bi-Weekly : $106.07 Monthly : $388.36 Bi-Weekly : $194.18 Monthly : $429.88 Bi-Weekly : $214.94 Monthly : $677.30 Bi-Weekly : $338.65 Employee Contributions
What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your medical/vision coverage and costs, you can get the complete terms in the policy or plan document at www.mycigna.com, by calling 1-800-Cigna24,
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Physicians Plus Insurance Corporation Coverage Period: 01/01/2016 12/31/2016
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Important Questions Answers Why this Matters: What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://knowyourbenefits.dfa.ms.gov or by calling 1-866-586-2781.
Highmark Blue Shield: Flex Blue PPO 2100 a Community Blue Plan
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkblueshield.com or by calling 1-888-510-1084.
Health Alliance Plan. Coverage Period: 01/01/2015-12/31/2015. document at www.hap.org or by calling 1-800-422-4641.
Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual+Family Plan Type: HMO This is only a summary.