Download - AFSCME Health Plan Design Update
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8/6/2019 AFSCME Health Plan Design Update
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DianeLovell
OregonAFSCMECouncil75
May11,2011
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AGENDA
SemiFinalPlanDesigns
MedicalandDentalRenewals
PreferenceSensitive/EvidenceBasedChangesUnderConsideration
RetireeOptions
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TheScenariosScenarioAPY2012andPY2013fundingPEPMisbasedon5%
increasesover2011reprojectedcostsof$1,214.05PEPM
withtheApril1,2011changesandMarch2011data.
ScenarioBPY2012andPY2013fundingPEPMisbasedon0%
increasesover2011reprojectedcostsof$1,214.05PEPMwiththeApril1,2011changesandMarch2011data
ScenarioC2012to2013fundingPEPMisbasedon0%increasefrom
proposedGovernorsBudgetof$1,149.04PEPM
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PlanDesignChanges:Theseplandesignchanges(madetotheProvidenceStatewideandChoiceplans)willachieveazerodollardeficitattheendofyear2013tothe
midpointoftherecommendedlowandmiddleRBC,withallplandesignchangesoccurringin2012.
ScenarioA
ScenarioB
ScenarioC
AddmoreprocedurestotheAdditionalcostTier(beingconsideredbyOEBB)
$5,000,000 $5,000,000 $5,000,000
OutofpocketMax:$1,500,(ScenarioB&C$2,000OOP) $6,200,000 $10,800,000 $10,800,000
$50/monthSpouseorDomesticPartnerSurcharge $12,000,000 $12,000,000 $12,000,000
HealthEngagementModel $0 $0 $0
Deductible:$250Innetwork,$500Outofnetwork(4officevisitsnotsubject)(ScenarioCDeductible:$500Innetwork,$1,000Outofnetwork)
$12,900,000 $12,900,000 $27,600,000
TobaccoSurchargeforEmployeesandSpouses$25/month $2,400,000 $2,400,000 $2,400,000
RateRetireesSeparatelyGoingForward(1.9Msavingsstartingin2013) $0 $0
OfficeVisitCoInsurance:20%PCP,35%Specialist $5,600,000 $5,600,000
RxTiers:$0Value$10Generic,$30Brand,$100SpecialtyMailOrder:2.5xRetail,notiersexceptions,$50RxDeductibleforallValuedrugs
$10,300,000 $10,300,000 $10,300,000
ReduceChronicCareCoinsurance(Asthma,Hypertension,Diabetes,COPD,CHF,Cholesterol)*
($2,800,000) ($2,800,000) (2,800,000)
AdditionalFunding $43,000,000 $67,000,0
SubtotalEstimatedSavings $46,000,000 $99,000,000 $137,900,000
$1,000outofpocketmaxforRx ($1,000,000) ($1,000,000) ($1,000,000)
Pharmacytierexceptions ($2,140,000) ($2,140,000) ($2,140,000)
StrategiestoEnhanceEnrollmentinChoiceandKaiser N/A N/A
WeightWatchersforDependents* TBD TBD TBD
OptionalSavings ($3,140,000) ($3,140,000) (3,140,000)
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TwoYearPlanDesignChangesThechangesmadeineachofthescenariosare
intendedtobetheonlychangesmadeduringthe
biennium.Thiswillholdtrueunlessutilization,costofcareor
numeroushighexpenseclaimsdrivecostsabovethepredicted9.7%trend.
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2012MedicalandDentalRenewalsKaiserMedical8.6%ImplementSleepStudyandImagingcoinsurancepreviously
implementedforourProvidencePlansProvidenceChoice(4.4%)andProvidenceStatewidePlan(4%)Plandesignchangesexplainedonpreviousslide
ODS(.2%)NoPlanChanges
Kaiser(3.1%)Noreductions,newPreventaMaxBenefitaddedatnoadditionalcost
WillametteDental(0%)Implementa$5copayOrthodontiacopayincreasesfrom$1,200to$1,500Increaseappliestopatientsthathavenotbeenbandedattimeof
implementation
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PreferenceSensitiveConditions Tryingtofind$5Minsavingsthroughevidencebasedmedicineandpreferencesensitiveconditions
Evidencebasedmedicine(EBM)orevidencebasedpractice(EBP)aimstoapplythebestavailableevidencegainedfromthescientificmethodtoclinicaldecisionmaking.[1]Itseekstoassessthestrengthofevidenceoftherisksandbenefitsoftreatments(includinglackoftreatment)and
diagnostictests.[2]Evidencequalitycanrangefrommetaanalysesandsystematicreviewsofdoubleblind,placebocontrolledclinicaltrialsatthetopend,downtoconventionalwisdomatthebottom.
PreferenceSensitiveConditionsarethoseforwhichtwoormorevalidtreatmentchoicesareavailableformostpatients.Chronicbackpain,earlystagebreastcancer,earlystageprostatecancer,andbenignprostatichypertrophyareconsideredpreferencesensitiveconditions.Treatmentchoicesfortheseconditionsshouldbemadebywellinformedpatientswhobasetheirdecisionsonthebestavailableevidenceaswellastheirpersonalvaluesandpreferences
PEBBisreviewingalistof28conditionswherethereislittleevidencedemonstratingthatthetreatmentimproveshealthorforwhichtherearetwoormorevalidtreatments.APEBBsubcommitteewillreviewthisinformationandmakearecommendationtothefullBoard.ThelistisacompilationoftreatmentsunderreviewbytheOregonEmployeesBenefitsBoard(OEBB),ontiersthreeorfouroftheOregonHealthAuthoritysessentialbenefitsmodelandeithernotcoveredorlowonthelistofeffectivetreatmentsasdeterminedbytheOregonHealthServicesCommission.
Ifweareunabletofind$5Minsavings,wewillhavetomakeotheradditionalcutstoScenarioAtomakeupthedifference.
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RetireeOptionsPEBBhasnotmadeanydecisionstochangeRetiree
inclusioninPEBBPlans2,101retireescomprise4.1%ofthePEBBplan.Thisnumber
hasdeclinedeachofthelastfouryears.Retireesdohaveotheroptionsforhealthcare PERS COBRAOMIP IndividualMarket
OregonsHealthExchangein2014PERSplansarevaluedbetween93%and97%ofPEBBfull
timeplansbasedonexistingplandesignfeatures.WhenPEBBimplementschangesin2012thisgapwillnarrowevenmore.
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NextStepsMay17BoardMeetingAgenda:
ReviewPreferenceSensitiveSubcommitteeworkReviewfees,consultantcommissionsandprovidertax
Approve2012PlanYearcompositerates
ApproveHEMplandesignandframework
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