maine’s value-based insurance design -101 nancy r. morris communication & member relations...
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Maine’s Value-Based Insurance Design -
101
Nancy R. MorrisCommunication & Member Relations Director
3-18-15
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Value Based Insurance Design
Value-based insurance design (VBID) aims
to increase health care quality and
decrease costs by using financial
incentives to promote high quality, cost
efficient health care services and
consumer choice.
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
63%25%
12%
Preference-sensitivecare
Effective care
Supply-sensitive care
The Dartmouth Institute for Health Policy and Clinical Practice (Wennberg, Weinstein, Fisher, et al.)
Not All Services Are Created Equal
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
CEO Summit Recommendation
Message from clinicians to employers
Develop and offer a benefit plan that supports evidence-based care and allows us to move to outcomes based performance
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
The Cost of Health Care
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
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Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Using EMR’s To Aid in Communication
Slow Down and Review Options
Clearing the Path to High ROI Service Use
Stop and Look at the Evidence Before Proceeding
Goal: Reduce Unnecessary Services $265 Billion IOM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Green Services
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Yellow Services- SDM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Red Services
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
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Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Assuring High Quality Delivery
PCMH’s are the hub. When necessary they refer to:
Quality
High
Costs
Low
Effective & Efficient
Ineffective &
Inefficient
Ineffective & Efficient
Effective &
Inefficient
High Low
Goal: Reduce high prices and inefficiently delivered services $155 Billion IOM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
3
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Reimbursement is Based on Attaining Outcomes
The entry point for all non-emergency care should be the PCMH
Providers/ Patients/ Health Plans and Payors share in savings produced by the reduction in preventable admissions and improved health
• ACO’s• Alternative Quality Contracts
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
4
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Making the Patient Part of the Team
Employ incentives and disincentives to produce healthy lifestyle choices and support management of chronic illness at the:
• Point of service• Community level – Prevention and Wellness Trust
Goal: Take advantage of missed preventive opportunities $55 Billon IOM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
5
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Administrative Simplification
•Identify areas of improvement through provider/member complaint logs and patient, provider, health plan, and advocate insights then simplify processes to reduce administration cost burden through process improvement
•Reduce across complexity through standardization across public and private payers through consistency where possible (claim billing, prior authorization)
•Adjust plan benefits so they encourage the desired behavior in all parties
Goal: Reduce Excessive Administrative Costs $190 Billion IOM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Current Health Plan Rating Display
• Working to standardize VBID benefits
• Working to standardize provider value ratings
• Working to standardize administrative requirements
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Why Work Together?
•The data is more robust•Change is quicker and more coordinated•We have data to serve as neutral arbitrator•Standardization if the foundation of quality improvement
– Operating rules– Quality measurement
• Together we are more attractive to other organizations– EMR vendors– Grantors– Government payors
• We have any opportunity to attract and maintain more primary care physicians
• We are better prepared for a crisis
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
• Aetna• Cigna• Anthem• Harvard Pilgrim Health
Plan• Maine Community
Health Options• Medical Mutual• Geisinger• MaineCare
Health Plans/Payers
Brokers
Providers/Associates
State & Federal
Others
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
• Cross Agency• Holden Agency• USI• Aliant• Acadia
Benefits
State & Federal
Others
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
• HealthReach• Maine Optometric
Association• MaineHealth• Maine General• OMC Wellness• St. Mary’s• Spurwink• MidCoast Health• InterMed• Maine Osteopathic
Association
State & Federal
Others
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
• Centers for Medicare & Medicaid Innovation
• Maine State Employee Health and Benefits Office
• Maine CDC• Veteran’s
Administration• MEABT• Maine BOI• DHHS
State & Federal
Others
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
• Lown Institute-MA• IMD Foundation-MA• City of Portland• Maine Quality Counts• Maine Areas on Aging• Health Care Administrative
Solutions, Inc.-MA• Brian Atchison• Milliman MedInsight – Waste
Calculator-WA• Athena• www.TheNNT.com
State & Federal
Others
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
• Robert Wood Johnson Foundation-NJ
• Oregon State-OR• Internal MHMC staff• Neel Shah, Costs of
Care-MA• Integrated Health
Association-CA• Pacific Business Group
on Health-CA• AARP
State & Federal
Others
Continued
Maine Health Management Coalition | Maine Health Management Coalition-Foundation11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
How Can You Get Involved
http://www.youtube.com/watch?v=hO8MwBZl-Vc
Contact: Robin Allen at [email protected] or 207 844-8106 extension 244 with suggestions or to join a subcommittee