marketplace plans what to expect in 2017 and beyond
TRANSCRIPT
© 2016 Enroll America | StateOfEnrollment.org
05.12.16
Marketplace Plans: What to Expect in 2017 and Beyond
© 2016 Enroll America | StateOfEnrollment.org
1. Get everyone up to speed on changes coming in 2017
Quality ratings Standardized plans
2. Review trends in marketplace plans
Session Objectives
© 2016 Enroll America | StateOfEnrollment.org
Today’s Speakers
Paul Cotton Director of Federal Affairs, National Committee for Quality Assurance
Lydia Mitts Senior Policy Analyst, Families USA
Jason Bello Associate Partner, Center fro U.S. Health System Reform, McKinsey & Company
Molly Warren (moderator)
Senior Policy Analyst, Best Practices Institute, Enroll America
© 2016 Enroll America | StateOfEnrollment.org
MARKETPLACE QUALITY MEASURES & REPORT CARDS
Paul Cotton, National Committee for Quality Assurance
© 2016 Enroll America | StateOfEnrollment.org
• The National Committee for Quality Assurance• ACA Requirement for ‘Performance-Based
Marketplace Qualified Health Plan Accreditation
• Marketplace Quality Measures
• Marketplace Report Cards
• Your Feedback Needed & Wanted!
AGENDA
© 2016 Enroll America | StateOfEnrollment.org 6
NCQA: a non-profit that works to improve quality, cost & experience of care through:
• Measurement• Transparency• Accountability
America’s largest health plan accreditor• ACA mandated ‘performance-based’
accreditation reviews actual quality of care, patient protections & ‘experience of care’ plans have delivered
• NCQA Accredited plans cover 224M+ Americans, ~85% of Marketplace QHPs
National Committee for Quality Assurance
© 2016 Enroll America | StateOfEnrollment.org
NCQA Health Plan Accreditation
Structure &
Process
50% of Score
Performance-Based Accreditation
CAHPS: Consumer Assessment of
Health Providers & Systems
50% of Score
HEDIS: Health Care Effectiveness
Data & Information Set
© 2016 Enroll America | StateOfEnrollment.org
Quality Improvement• Managing, coordinating & improving care
Utilization Management• Coverage & appeals
Credentialing• Verifying provider qualifications
Member Rights & Responsibilities• Helping enrollees understand & use benefits
Member Connections• Self-care & patient services
Network Management• Adequacy, transparency, out-of-network requests
Structure & Process Standards
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Marketplace QHPs must report measures on:• Clinical Quality, (31) including HEDIS:
• Diabetes Care• Cancer screenings• Blood Pressure Control• Prenatal & Postpartum Care• Use of Imaging for Low Back Pain (overuse)
• Enrollee Satisfaction Survey (ESS -12):• Care Coordination• Cultural Competence• Rating of Plan & Doctor• Access to Care & Information
Marketplace Quality Measures
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Results Feed Quality Ratings System (QRS) • For 2017 open enrollment season this fall, plans
will be rated on a 5-Star scale• Similar to Medicare Advantage ratings @ medicare.gov
• CMS will pilot in Michigan, Ohio, Pennsylvania, Virginia, & Wisconsin
• State-based Marketplaces may choose to also display
• Not like YELP! Based on:• Objective, independently verified measures of the
clinical quality plans have delivered, & • Survey of random enrollee sample• Not subjective reviews by self-selected individuals
Marketplace Plan Report Cards
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Medicare Health Plan Compare
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Marketplaces bring quality ratings & report cards to new audiences of navigators, brokers, other assisters & consumers themselves
Your Feedback Needed & Wanted!
• Pilots are a significant opportunity to test what Marketplace consumers find helpful
• This can contribute to larger effort to make measures & ratings more helpful for making informed choices
© 2016 Enroll America | StateOfEnrollment.org
Paul Cotton (202) 955 5162 – [email protected]
© 2016 Enroll America | StateOfEnrollment.org
NEW PLANS AND TOOLS COMING TO HEALTHCARE.GOV IN 2017
Lydia Mitts, Families USA
FamiliesUSA.org
Who We Are and What We Do
Families USA is a national, non-profit, non-partisan consumer advocacy organization dedicated to the achievement of high-quality, affordable health care and improved health for all. In our work, we:
Advance health care policies that improve access, affordability, and quality of care
Research and produce timely reports and other resources on health care issues
Provide policy technical assistance to advocates at the state and community levels
FamiliesUSA.org
Roadmap
Overview of new provider network labels on healthcare.gov
Overview of new standardized plans on healthcare.gov
Key things to consider when comparing standardized plans
How will the healthcare.gov website feature standardized plans?
FamiliesUSA.org
All QHPs will have label to distinguish network breadth
Label is based on breadth of network for:
Primary Care Physicians Pediatric Primary Care
Physicians Hospitals
Label is only based on how QHP compares to other QHPs
New Network Breadth Ratings on Healthcare.gov
Basic
Standard
Broad
QHP Network Labels
FamiliesUSA.org
Standardized Plans in Federally Facilitated Marketplaces
Federal government designed Bronze, Silver, Silver CSR, and Gold metal level plans – called “standardized plans”
HHS has defined what cost-sharing must be for the majority (but not all) types of care in these standardized plans
Standardized plans will be available in federally-facilitated marketplaces in 2017 but…
Insurers are not required to sell these standardized plans
FamiliesUSA.org
Snapshot: Federal Standardized Silver Plan
Deductible $3,500 (Double for Family Plan)Annual Out-of-Pocket Limit $7,150 (Double for Family Plan)
Covered Pre-Deductible Cost-SharingPrimary Care Visits X $30 Specialty Care Visits X $65 Mental Health/SUD Visits X $30 Lab Services 20%X-Rays 20%Imaging 20%Rehab Speech/Physical Therapy 20%Urgent Care X $75Emergency Room Care $400Outpatient Facility Fee 20%Outpatient Surgery-Physician Fee 20%Inpatient Care 20%Generic Drugs X $15 Preferred Brand Drugs X $50 Non-Preferred Brand Drugs X $100 Specialty Drugs X 40%
FamiliesUSA.org
Benefits of Standardized Plans
1. Can compare multiple insurers’ standardized plans based on differences other than cost-sharing
2. Likely to have similar premiums to existing plans on the market
3. Standardized silver plan helps pay for many types of outpatient services before the deductible: Primary Care Specialty Care Mental Health/Substance Use Disorder Visits Urgent Care All Prescription Drugs
FamiliesUSA.org
What isn’t standard in the standardized plans?
Two insurers’ standardized plans could have different:
Premiums Provider networks Rx they cover, formulary tier for an Rx Additional covered benefits, eg. Dental Cost-sharing for services that HHS has not defined
HHS has not defined the cost-sharing in standardized plans for:
Durable Medical Equipment Habilitative Services Home Health Services Pediatric Dental/Vision
FamiliesUSA.org
How will the standardized plans look?
HHS plans to develop consumer-tested tools on healthcare.gov that help identify standardized plans
Website tools that consumer groups have discussed: Ability to filter plans, only show standardized plans Prompt at start of plan selection, explains standardized
plans/asks if you want to see these plans first Automatic plan sort shows standardized plans at top of the
plan options
What are your thoughts on how best to feature these plans on healthcare.gov
1201 New York Avenue, NW, Suite 1100Washington, DC 20005
main 202-628-3030 / fax 202-347-2417
Additional Families USA Resources: HHS Finalizes Health Insurance Plan Standards, Enrollment for 2017: http://
familiesusa.org/blog/2016/03/cms-finalizes-health-insurance-plan-standards-enrollment-2017
Non-Group Health Insurance: Many Insured Americans with High Out-of-Pocket Costs Forgo Needed Health Care: http://familiesusa.org/product/non-group-health-insurance-many-insured-americans-high-out-pocket-costs-forgo-needed-health
Designing Silver Plans with Affordable Out-of-Pocket Costs for Lower– and Moderate-Income Consumers: http://familiesusa.org/product/designing-silver-health-plans-affordable-out-pocket-costs-lower-and-moderate-income
Standardized Health Plans: Promoting Plans with Affordable Upfront Out-of-Pocket Costs: http://familiesusa.org/product/standardized-health-plans-promoting-plans-affordable-upfront-out-pocket-costs
Lydia MittsSenior Policy AnalystFamilies [email protected](202)628-3030
© 2016 Enroll America | StateOfEnrollment.org
EXCHANGES: LESSONS LEARNED THREE YEARS IN
Jason Bello, Center For U.S. Health System Reform, McKinsey & Company
25healthcare.mckinsey.com | Center for US Health System Reform
Disclaimer: McKinsey is not an investment adviser, and thus McKinsey cannot and does not provide investment advice. Opinions and information contained in this material constitute our judgment as of April 15, 2014 and are subject to change without notice. They do not take into account your individual circumstances, objectives, or needs.
Nothing herein is intended to serve as investment advice, or a recommendation of any particular transaction or investment. Nothing herein is intended to serve as investment advice, or a recommendation of any particular transaction or investment, any type of transaction or investment, the merits of purchasing or selling securities, or an invitation or inducement to engage in investment activity. While this material is based on sources believed to be reliable, McKinsey does not warrant its completeness or accuracy.
26healthcare.mckinsey.com | Center for US Health System Reform
In 2016 OEP, what offerings were available to consumers, and how has
this evolved since 2014?
27healthcare.mckinsey.com | Center for US Health System Reform
In 2016, close to two-thirds of consumers saw a carrier exit their market, while nearly half had a new carrier choice on exchange
2014 carriers 2015 withdrawals 2015 new entrants 2015 carriers 2016 withdrawals 2016 new entrants 2016 carriers
282
19
70
333
49 31
315
63%of consumers sawan exit by a carrier
47% of consumers saw a new entrant on the exchange
28healthcare.mckinsey.com | Center for US Health System Reform
Many consumers saw new price leaders in 2016 and may have had to switch carriers to get the lowest-price option% of QHP-eligible consumers seeing given carrier type offering lowest-price silver plan in their county
201620152014
26 24
45
10
17
10
18
1013
18
2420
25
15
Blue Regional/local Provider National CO-OPMedicaid
12
28
3
58%of consumers saw a new silver-tier price leader in 2016
29healthcare.mckinsey.com | Center for US Health System Reform
Consumers also saw more managed, narrow network plans on exchanges…
2014 2015 2016
38 3730
4 44
33 3340
25 26 26
% of competitively priced (<10% lowest-price) silver plan offerings by plan type across years
% of competitively priced silver plan offerings in rating areas with at least one narrowed network by network breadth across years1
PPO
POS
HMO
EPO
2014 2015 2016
8 8 8
5035
27
7
1014
3547 51
Tiered
Broad
Ultra-narrow
Narrow
1 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing.
30healthcare.mckinsey.com | Center for US Health System Reform
…with fewer network choices overall% of QHP-eligible consumers with access to various network types1
Narrowed only
Both
Broad only
8
83
9
2014
5
86
9
2015
14
74
12
2016
1 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing. Narrowed networks comprise Ultra-narrow, Narrow and tiered networks.
31healthcare.mckinsey.com | Center for US Health System Reform
Even broad networks have become more managed
% of silver network offerings by plan type and network breadth1,2,3
2014 2015 2016 2014 2015 2016 2014 2015 2016
8 5 9 7 6 5 8 10 6
48 5235
30 2620
25 1615
17 15
19
1210
1512
1411
26 2837
52 59 60 56 6069
Broad Narrow Ultra-narrow
1,148 1,548 1,295 507 623 612 443 479 451
EPO
PPO
POS
HMO
1 Plan types reported were taken directly from exchange websites and Summary of Benefits and Coverage (SBC) documents.
2 When multiple silver plans are available on a single network we use the plan type associated with the lowest-price silver plan in that network.
3 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing.
32healthcare.mckinsey.com | Center for US Health System Reform
The shift toward managed and narrower varies by market for consumers
–15% or less
–15% to 0%
0% to 15%
KEY:-100%
-50% to -25%
KEY:
-75% to -50%
-99% to -75%
-25% to 0%
No PPOs in 2015 and 2016
75%+
25% to 50%
50% to 75%
0% to 25%
% change in number of PPO offerings by county from 2015 to 2016
% change in broad hospital networks by county from 2015 to 20161
15% to 30%
30% to 45%
45% to 100%
Not available2
1 Broad networks have more than 70% of hospitals participating in a rating area2 Network breadth unavailable due to lack of hospitals in the rating area
33healthcare.mckinsey.com | Center for US Health System Reform
Many consumers are seeing lower premiums, as managed and narrowed network plans continue to have lower rate increases…Median silver premium increases among re-filed 2014 and 2015 plans
By re-filed plan type
%
By network type1
%
10
12
BroadNarrowed1
2015-16
1 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing. Narrowed networks comprise Ultra-narrow, Narrow and tiered networks.
8
16
PPOHMO
34healthcare.mckinsey.com | Center for US Health System Reform
… and the premium difference between narrowed and broad continues to widen
2016
2015
2014
% difference between median premium for broad and narrowed networks from the same carrier and plan type1,2,3
BRONZE
+11
+15
+17
SILVER
+16
+16
+22
GOLD
+16
+16
+23
PLATINUM
+17
+23
+33
1 Broad: more than 70% of hospitals participating in a rating area; Narrowed: includes networks with multiple tiers or non-tiered networks with less than or equal to 70% of hospitals participating. Narrowed networks for this analysis include narrow and ultra-narrow networks but do not include tiered networks.
2 Plan types include PPO, HMO, EPO, and POS2 Median prices are based on premiums for a 40–year-old single non-smoker. When a network has multiple
plans, the lowest-price plan is used as price of the network. If there are multiple networks available for selection as “narrowed,” the narrowest is selected. If there are multiple networks available for selection as broad, the broadest is selected.
35healthcare.mckinsey.com | Center for US Health System Reform
Across these offering trends, what has payors’ performance been to date?
36healthcare.mckinsey.com | Center for US Health System Reform
Most states saw negative margins across their individual line of business
State-level post-3R post-tax 2014 margin across individual line of business Percent
▪ States varied widely in their margins: 9 states reported positive aggregate margins, 41 states and DC reported negative margins
▪ The three states with the most positive margins include WA (+8% margin), CA (+6%) and VT (+5%)
▪ The states with the most negative margins are MT (-21%), NE (-23%) and UT (-28%)
SOURCE: McKisney Payor financial database; McKinsey Center for US Health System Reform
Nationwide, the individual market lost $2.7B in 2014, with only ~30% of payors having positive margins
37healthcare.mckinsey.com | Center for US Health System Reform
Exchange carriers with narrower networks had better margins and lower claims, in aggregate, than those offering broad networks
2014 post-3R, post-tax individual market financial metrics across exchange carriers1
Weighted average by QHP membership
Weighted-average network breadth2,3
Post-3R post-tax margin, %
Risk adjustment, % of premiums4
Reinsurance, % of premiums
Risk corridors, % of premiums5 Claims PMPM, $
Ultra-narrow
Narrow
Broad -8
-7
-2
0
-3
-6
18
17
13
0.5
0
346
307
301-0.6
0.5
1 Carrier performance was determined at the NAIC/HIOS state-level entity level. Analysis only includes entities HIOS ID’s associated with on-exchange plans in 2014, with >1K 2014 QHP members.2 In this analysis, tiered networks are assigned to the ultra-narrow, narrow, or broad category based on the breadth of the first tier.3 Network breadth for each entity is rolled-up to a state-level (from county) using QHP-eligible population and the network associated with the lowest-price silver plan. Each state-level entity is then associated with
their respective breadth category (broad, narrow, ultra-narrow). The financial metrics for all entities in each breadth category are weighted by their 2014 QHP lives, obtained from CMS MLR reports.4 Risk adjustment does not total to 0 as data reflects only those entities with on-exchange presence in 2014. Negative values indicate payment into the program. In aggregate, risk adjustment for all exchange entities
amounted to –1% of premiums.5 Net risk corridor payments across these carriers amount to -$17M.
38healthcare.mckinsey.com | Center for US Health System Reform
Thank YouFor more information,
please go to healthcare.mckinsey.com/reformor email [email protected]
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QUESTIONS?