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SEOW Attachment 1 December 4, 2018
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Oregon Educators Benefit Board Strategies on Evidence and Outcomes Workgroup
November 6, 2018 Meeting Synopsis
The Strategies on Evidence and Outcomes Workgroup (SEOW) of the Oregon Educators Benefit Board held a meeting on November 6, 2018 at the Oregon Health Licensing Office. Attendees: Workgroup Members: Tom Syltebo, SEOW Chair Geoff Brown Robert Young Cheri Maas-Anderson Ron Gallinat Staff/Consultant: Glenn Baly, OEBB Ali Hassoun, PEBB/OEBB Jenny Marks, Willis Towers Watson Steve Carlson, Willis Towers Watson Carriers/Other Representatives: BethAnne Darby, Moda Health Kraig Anderson, Moda Health Dr. Jim Rickards, Moda Health Carly Rodriquez, Moda Health Bill Dwyer, Moda Health Erica Hedberg, Moda Health 1. October 2018 SEOW Meeting Synopsis (SEOW Attachment 1) SEOW approved the October 2018 meeting synopsis without any changes. 2. Moda Value-Based Purchasing/Benefit Design (SEOW Attachment 2) BethAnne Darby, Kraig Anderson, Dr. Jim Rickards, Carly Rodriquez and Bill Dwyer provided a review of Moda’s value-based purchasing and benefit design efforts, including:
SEOW Attachment 1 December 4, 2018
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• Value Based Benefit Design Initiatives (annual wellness visits, chronic condition office visits, home infusions with preferred provider, Qwest Labs and Additional Cost Tier).
• Major Joint Replacement Reference Pricing • Pharmacy Management: Site of Care • OPDP/Northwest Prescription Drug Consortium • PCPCH Program • Synergy/Summit • Moda-OHSU Virtual Visits • C3 Program • Next Steps SEOW Action/Information Request Tom Syltebo asked that a more detailed review be done on the Additional Cost Tier, including looking at individual procedures, cost point for assigning copays, other elements. Tom Syltebo asked that a more detailed review be done on the Reference Pricing program, including adding more procedures. Tom Syltebo and Glenn Baly asked for regular reports from OHA on the PCPCH program including next steps. Tom Sytebo asked that a more detailed review of Centers of Excellence be conducted Tom Syltebo asked the carriers to determine how OEBB can assist them with the CPC+ program. 3. Value-Based Purchasing – Market Scan (SEOW Attachment 3) Jenny Marks reviewed value-based purchasing initiatives in the market, including
• Definition of value-based purchasing • Types of value-based purchasing • Market prevalence • Measuring value-based purchasing • OEBB accomplishments and opportunities • Next steps
SEOW Action/Information Request
SEOW Attachment 1 December 4, 2018
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Tom Syltebo wants to review quality outcome comparison between Synergy/Summit and PPO plans in early 2019. Tom Sytebo asked for further research on public entities use of memo of understandings to address outliers in outcomes/quality/cost. No public comment.
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Utilization and Claim ReviewOEBB Opportunity Analysis
December 04, 2018
SEOW Attachment 2
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Presentation to SEOW
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OEBB Medical and Pharmacy Opportunity Analysis Agenda
Project objectives Scope/process Overview of findings Claimant examples
Carrier next steps Carrier report back
2© 2018 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.
Willis Towers Watson has prepared this material for OEBB’s sole and exclusive use and on the basis agreed with you. It was not prepared for use by any other party and may not address their needs, concerns or objectives. This material should not be disclosed or distributed to any third party other than as agreed with you in writing. Willis Towers Watson does not assume any responsibility, or accept any duty of care or liability to any third party who may obtain a copy of this material and any reliance placed by such party on it is entirely at their own risk.
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Project Objectives
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Project Objectives
Each year, Willis Towers Watson delivers an annual report overview of cost, claims and utilization of medical and pharmacy services by OEBB members. As a follow-up to this review, SEOW directed Willis Towers Watson, Moda and Kaiser to take a deeper look at the top conditions identified in the report.
Willis Towers Watson also incorporated findings from the Avoidable Claims and Conditions study conducted in 2017
The areas for additional review included: Cancer Arthritis Cardiovascular care Mental health Diabetes Additionally, we reviewed the claims data for general patterns of care related to hospital
readmissions, multiple ER visits, Pharmacy adherence, multiple pharmacy prescribers and other red flags
The project was a collaborative effort between Willis Towers Watson, Moda and Kaiser to identify areas of opportunity for improved care processes and to encourage efficient and value-based care (lower cost, higher quality/better outcomes)
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Project Objectives (Continued)
Willis Towers Watson reviewed claims costs and utilization patterns of OEBB members within the Moda and Kaiser data for general utilization patterns with particular focus on the five major condition areas below:
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Assessment Metrics Common to All Conditions
Assessment Measures Specific to the Condition
Cancer care Appropriate hospital admissions or readmissions
Medication adherence and opiate use
Review for unnecessary or frequent use of emergency room and advanced radiology
Indications of poor coordination of care and notifications
Site of service (less costly) Chemotherapy/oncology
management
Arthritis: osteoarthritis (OA) and rheumatoid arthritis (RA) and musculoskeletal (MSK)
Pharmacy management (effective UM edits, site of care/channel management)
Mental health Screening, prevention and red flags (depression, ER and opiates)
Cardiovascular care Heart/valve procedures Preventable adverse events
Diabetes Medication adherence and associated ER/admits
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Background: Finding Evidence of Efficient and Value-Based CareLinking data, outcomes and costs
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MED — Morphine Equivalent DoseMPR — Medication Possession Ratio
Claims: Inefficient care
Claims: Poor pharmacy adherence or
utilizationmanagement
Claims & Electronic Medical Record:
-Variation in cost/outcomes-Engagement with PCPCH
-Population health
Policies:-Target specific providers
-Develop programs to drive better efficiencies
Benefit: Steer with value-
based plan design
Payments: Based on better
value
Easier
Moderate
Harder
Level of Effort
Step 2: Benchmarks defining inefficient care — examples(diagnoses, venue, provider)
Step 1: Finding the gaps Step 3: Closing gaps with right solutions
(member and provider solutions)
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Evidence of Efficient and Value-Based Care
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Step 1: Finding the gaps
Step 2:Benchmarks defining inefficient or sub-optimal care
Easier (Medical claims) Claim review for utilization red flags
>5 ER visits/year >3 admissions/year >3 advance radiology/year 30 day readmits (all cause)
Moderate(Rx claims)
Pharmacy claim review for medication adherence, poly-pharmacy and poly-prescribers
>15 medication PMPY >10 prescribers PMPY <80% MPR (by Rx class and member)
Site of Rx for OA/RA/chemo >100 MED (opiate) Generic fill rate >90%
Harder(Electronic medical record and clinical data)
Variation of Cost/Quality/Outcomes by provider
Member engagement with PCPCH Effectiveness of case management
and coaching
NQF (HEDIS Metrics #) Cardiac stents (NCDR stds.)(proof of trial of Rx and
EST) Depression remission (171) and Rx (105) Cancer therapy (breast/GI timely chemo (559)) Gene mutation testing (GI (1859/60) and breast
(1857/8))
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Step 3: Develop programs, policies, benefit design or payment model reforms based on specific outcomes
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Scope of Review
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Scope of Experience Review
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Detailed medical paid claims data from OEBB’s data warehouse (Truven) Data was provided for OEBB’s population and their dependents Approximately three years of incurred claims data
The reporting periods by carriers are as follows:
All cost figures, unless noted, are allowed charges (before plan deductible and coinsurance)
Medical — What Claims Did We Review?
Kaiser ModaIncurred July 1, 2014 to June 30, 2015, paid through
September 30, 2017*Incurred October 1, 2014 to September 30, 2015, paid through
December 31, 2017*Incurred July 1, 2015 to June 30, 2016, paid through
September 30, 2017Incurred October 1, 2015 to September 30, 2016, paid through
December 31, 2017Incurred July 1, 2016 to June 30, 2017, paid through
September 30, 2017Incurred October 1, 2016 to September 30, 2017, paid through
December 31, 2017*2014 data not complete
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Scope of Experience Review
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Focused on specific services for high-cost claimants, safety issues and inefficiencies Multiple inpatient admissions and/or preventable 30-day readmissions Use of emergency room (ER) services Use of radiology services:
CT scans MRI scans PET scans Low value radiology services Breast imaging
High-cost claimants (HCCs) are defined as a member with $50,000 or more total allowed medical costs in a particular 12-month period
High utilizers are defined as a member using a particular service greater than or equal to the thresholds noted below during a 12-month period Three or more Inpatient admissions and readmissions Five or more ER visits Three or more advanced radiology services
Medical — What Were We Looking For?
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Scope of Experience Review
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Methodology Willis Towers Watson reviewed paid pharmacy claims data between January 1, 2017 through
December 31, 2017 for OEBB Claims data was obtained directly from Moda and Kaiser using a standardized request for
information containing fields required to capture pharmacy care performance
The objective of the analysis was to identify critical gaps in pharmacy care for high-cost claimants with an excess of $5,000 in pharmacy spend over the time period.
The analysis focused on the following four clinical metrics:
Adherence to medications used to treat high blood pressure, high cholesterol, diabetes, depression, antipsychotics and asthma/COPD and specialty drugs used to treat multiple sclerosis and rheumatoid arthritis
Opioid utilization Multiple unique prescribers per member (poly-prescribers) Unique prescriptions per member (poly-prescriptions)
Pharmacy — What Were We Looking For?
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Medical and PharmacySummary of Findings
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Overview of Initial Findings:
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Medical
Area of Focus What We Looked For What We Learned
Cancer
Preventable admits and readmits Preventable conditions (sepsis) Venues of service (same service
at lower costs)
No patterns of cancer readmission or sepsis typical in other carrier program reviews
Some excessive use of CT/MRI/PET in cancers in both plans
Cardiovascular Adverse events by locations, provider and services
No excessive ER or admissions noted in cardiovascular
Arthritis 30-day readmit for joint and
spine surgery Rx adherence in DMART Rx
No excessive ER or admissions noted in osteoarthritis (i.e., major joint replacement and spine surgery) or rheumatoid arthritis
Diabetes Poor adherence leading to preventable ER and admits
No excessive ER or admissions noted in for members with diabetes
Mental Health
30-day readmits without office follow up
Poor adherence to Rx MH and SA related ER over use
Several members had excessive ER with migraine and substance abuse diagnosis
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Area ofReview What We Looked For What We Learned (Moda and Kaiser)
High-cost claimants
Opiate usage Morphine usage Preventable ER visits Preventable
admissions or re-admissions
Little to no opiate overuse issues and excessive ER visits Morphine Equivalent Dose (MED) (>90 MED 3 – 6 months) % population Moda – 0.1%; Kaiser – 0% # members Moda – 34; Kaiser – 0
>5 ER visits per year highly correlated serial admissions (>3/year) and 30-day readmissions in the OEBB population Little evidence of excessive use of ER and admissions in
cancer, cardiovascular, arthritis (MSK) and DM Salem and OHSU were more likely to have >5 ER and >3
admissions Preventable readmissions and 30-day admissions have a
significant potential savings and quality improvement
Overview of Initial Findings:Medical (Continued)
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Overview of Initial Findings:Pharmacy — Medication Adherence
Area of Focus What we Looked For What we Learned
Cancer No gaps in therapy during oral chemotherapy treatment.
Oral cancer Rx adherence (avg. MPR) (Moda – 97%; Kaiser – data not available)
Cardiovascular
Mean possession ratio (MPR) ≥ 80%
Surrogate marker for medication adherence
High cholesterol Rx adherence (avg. MPR) (Moda – 84%; Kaiser – 79%)
High blood pressure Rx adherence (avg. MPR) (Moda – 83%; Kaiser – 77%)
Diabetes Diabetes Rx adherence (avg. MPR) Moda – 75%; Kaiser – 71%)
Mental health
Antidepressants Rx adherence (avg. MPR) (Moda – 50%; Kaiser – 54%)
Antipsychotic Rx adherence (avg. MPR) (Moda – 79%; Kaiser – 74%)
Rheumatoid Arthritis (RA)
Specialty RA medication adherence (average MPR) Moda – 77%; Kaiser – 54% Adherence stat was based on a defined list of
specialty medications commonly used to treat RA
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Area of Review What We Learned
Poly-pharmacy/Poly-prescriber
Poly-prescriber (>10 unique prescribers) Moda:182 unique members with greater than ten unique
prescribers
Poly-pharmacy (15 different medications) Kaiser: 71 unique members taking between 11 – 25 prescriptions Moda: 36 unique members taking ≥ 30 prescriptions
Site of Care (Offering home infusion instead of in-office infusions where appropriate)
Potential opportunity for high-cost specialty medications used to treat auto-immune disorders such as Rheumatoid Arthritis, Crohn’s and Ulcerative Colitis
Example (Moda) Remicaide:Avg. allowed/home infusion: $2,795Avg. allowed/office infusion : $6,558# home infusions in 2017: 7# office infusions in 2017: 57
Overview of Initial Findings:Pharmacy — Poly-prescriber and Poly-pharmacy
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High-Cost Claimants and/or Inefficient Care: Member Examples
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2016 2017Oct Nov Dec 2017 Feb Mar Apr May Jun Jul Aug Sep
ER Crohn's disease
Oct 17
Office Crohn's disease
Oct 24
ER Nail disorders
Oct 25
Office Crohn's disease
Oct 31
Office Crohn's disease
Nov 1
ER Calculus of kidney and ureter
Nov 16
ER Abdominal and pelvic pain
Nov 18
ER Crohn's disease
Nov 24
Office Crohn's disease
Dec 9
ER Other disorders of eye and adnexa
Dec 26
Office Dorsalgia
Dec 29
ER UNKNOWN
Jan 3
Jan 4
Office Pain, not elsewhere classified
Jan 9
ER Abdominal and pelvic pain
Jan 12
Inpatient Hospital Crohn's disease
Jan 14
Inpatient Hospital Other sepsis
Jan 28
ER Phlebitis and thrombophlebitis
Feb 6
ER Abdominal and pelvic pain
Feb 15
Office Scoliosis
Feb 16
ER Nausea and vomiting
Feb 17
Office Scoliosis
Mar 17
Office Dorsalgia
Mar 24
ER Crohn's disease
Mar 29
Apr 9
ER Other diseases of digestive system
Apr 10
Apr 11
Office Spondylosis
Apr 14
ER Psychotropic drugs, not elsewhere classified
Apr 16
Urgent Care Facility Asthma
Apr 17
Office Conjunctivitis
Apr 18
May 5
Office Other anxiety disorders
Jun 2
ER Abdominal and pelvic pain
Jun 3
Office Abdominal and pelvic pain
Jun 15
ER Pediculosis and phthiriasis
Jul 25
Jul 29
ER Crohn's disease
Jul 31
Office Bipolar disorder
Aug 15
ER UNKNOWN
Aug 20
ER UNKNOWN
Aug 21
Urgent Care Facility UNKNOWN
Aug 23
ER Nausea and vomiting
Aug 26
ER UNKNOWN
Sep 3
ER Abdominal and pelvic pain
Sep 9
Sep 20
ER Nausea and vomiting
Sep 22
ER Abdominal and pelvic pain
Sep 27
Oct 1 - Oct 2 OOS1 Crohn's disease
Oct 18 - Oct 19 OOS1 Crohn's disease
Nov 6 - Nov 10 OOS1 Abdominal and pelvic painJan 28 - Jan 29OOS1 Other sepsis
Feb 7 - Feb 8OOS1 Phlebitis and thrombophlebitisMay 28 - Jun 2OOS2 Crohn's disease
Sep 1 - Sep 9OOS3 Alcohol related disorders
Service Type 2016 CountER 39Inpatient hospital 7Office 32Urgent care facility 9Grand total 89
Hospitalizations
Example: OEBB Member (Moda)
Office or ER VisitHospitalizations
OOS = Out of state (number for each hospital)
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2017Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep2016 2017
ER VisitOct 10
ER VisitNov 4
ER VisitNov 14
Doctor VisitNov 17
ER VisitDec 4
ER VisitDec 5
Doctor VisitDec 15
Doctor VisitDec 29
Doctor VisitDec 31
Doctor VisitJan 6
ER VisitJan 8
Doctor VisitJan 28
Doctor VisitFeb 10
Doctor VisitFeb 13
Doctor VisitMar 5
Doctor VisitMar 13
Doctor VisitMar 20
ER VisitMar 30
ER VisitMar 31
ER VisitApr 2
ER VisitApr 3
Doctor VisitApr 4
Doctor VisitApr 7
Doctor VisitApr 14
ER VisitApr 24
Doctor VisitApr 26
Doctor VisitMay 1
Doctor VisitMay 10
ER VisitMay 30
ER VisitJun 8
Doctor VisitJun 29
ER VisitAug 15
ER VisitAug 21
Doctor VisitAug 22
Doctor VisitAug 23
ER VisitSep 12
ER VisitSep 13
ER VisitSep 24Doctor VisitSep 25
Diagnoses Dorsalgia/apondylosis/LPB Open wound hand/soft tissue
disorders Opioid related disorders Unknown Abnormal involuntary movements Idiopathic neuropathy/enthesopathies Transient cerebral ischemic Cellulitis and acute lymphangitis Unspecified disorder Burn lower limb Cutaneous abscess Hordeolum Epididymitis Persons encountering health services Reaction to severe stress
Example: OEBB Member (Moda)18 ER visits, 40 Unique Prescribers, 27 Unique Medications
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Venue of Service Visit Count Emergency room — hospital 44Federally qualified health center 3Office 14Urgent care facility 6Total 67
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2017Jul Aug Sep Oct Nov Dec 2017 Feb Mar Apr May Jun
Doctor VisitJul 7
Doctor VisitJul 21
Doctor VisitNov 26
ER VisitFeb 26
Doctor VisitMar 20
ER VisitMar 21
Doctor VisitMar 24
Doctor VisitMay 12
Doctor VisitMay 23
Doctor VisitJun 15
Feb 26Hospital Complications of transplanted organs and tissue
Mar 5
Mar 5Hospital Complications of transplanted organs and tissue
Mar 8
Mar 13Hospital Complications of transplanted organs and tissue
Mar 16
Diagnoses Abdominal and pelvic pain Encounter for screening for malignant
neoplasms Transplanted organ and tissue status Elevated blood glucose level Drug or chemical induced diabetes
mellitus Unknown Acute bronchitis
Example: OEBB Member (Kaiser)Rx Profile: Non Compliant with Meal Time and Basal Insulin, Sporadic Fill History of Testing Supplies, 20 Unique Medications
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2016 2017Oct Nov Dec 2017 Feb Mar Apr May Jun Jul Aug Sep
Doctor VisitOct 17
Doctor VisitOct 24
ER VisitNov 1
Doctor VisitNov 8
Doctor VisitNov 22
ER VisitDec 7
Doctor VisitDec 13
Doctor VisitDec 14
Doctor VisitDec 22
ER VisitDec 28
ER VisitDec 30
ER VisitJan 6
ER VisitJan 7
ER VisitJan 8
Doctor VisitJan 12
Doctor VisitJan 16
Doctor VisitJan 23
Doctor VisitFeb 20
ER VisitFeb 22
ER VisitMar 6
Doctor VisitMar 27
Doctor VisitMar 30
ER VisitApr 10
ER VisitApr 13
Doctor VisitApr 25
Doctor VisitMay 17
Doctor VisitMay 24
ER VisitMay 30
ER VisitMay 31
Doctor VisitJun 22
ER VisitJun 27
ER VisitJul 7
Doctor VisitJul 18
Doctor VisitJul 19
Doctor VisitJul 24
ER VisitJul 30
Doctor VisitAug 2
ER VisitAug 3
ER VisitAug 16
Doctor VisitAug 16
Doctor VisitSep 20
ER VisitSep 25
ER VisitSep 28
Diagnoses Abdominal and pelvic pain Ulcerative colitis Pain in throat and chest Other joint disorder, not elsewhere
classified Asthma Unknown GI and abdomen Acute pharyngitis Shoulder lesions Abnormal results of function studies Candidiasis Nausea and vomiting
Example: OEBB Member (Moda)Rx profile: Overall Med Compliance 30.7%, 6 Unique Prescribers for Vicodin, 20 Unique Medications
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Carrier Review
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Carrier Review of Findings
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On April 12, 2018, Willis Towers Watson reviewed the preliminary findings with OEBB staff, Moda and Kaiser
Moda and Kaiser were asked to review the top “red-flag” members and report back:
Did the member have a Patient Centered Primary Care Home?
Were the members engaged with a health coach or in a PCPCH care plan?
Moda and Kaiser were each provided with a specific list of areas to review for general utilization or care pattern improvements
In September, Willis Towers Watson, Moda, Kaiser and OEBB staff met to review carrier findings and research
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Next Steps
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Kaiser
Areas of Additional Research for Kaiser Review members with high readmissions — opportunities to address transition of care/reduce
readmissions Review members with higher ER utilization — opportunity to address outlining support/education
and assessment of social needs Cancer care — review opportunity to address lower cost medications — infused to oral, high
admissions, care management, reduce readmissions Pharmacy — MS related — review opportunities for medication cost reduction Coding: review large claimant inpatient diagnoses for “Never Events” and investigate correct coding
of location of service in data feeds to Truven Claim coding for “encounter of aftercare” and “unknown” diagnosis — identify opportunities to
capture more specific diagnosis Review members with poly-prescriber/poly-pharmacy (red-flag members)
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Next Steps
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Moda
Areas of Additional Research for Moda Review high ER utilizers for all hospitals and identify avoidable vs. unavoidable — review
PCPCH/C3 attribution of these members Review medication adherence for members with diabetes and rheumatoid arthritis Review members with poly-prescriber/poly-pharmacy (red-flag members); identify potential process
improvement or PCP communication opportunities Claim coding for “encounter of aftercare” and “unknown” diagnosis- identify opportunities to capture
more specific diagnosis (lower order Z codes) Review large claimant inpatient diagnoses for “Never Events” Review opportunities for site of care program related to chemotherapy Arthritis: cost review of biosimilar substitution and compo therapies for rheumatoid arthritis and
utilization of low dose alternatives
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Carrier Report Back
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Carrier Response
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Kaiser
Area of Review Kaiser Response
Very high-cost claimant (>$250k) opportunities
Claimants tend to need care at contracted hospitals Transplant process is well coordinated and subject to multiple reviews Case managers assigned to all transplant cases OEBB’s number of very high cost claimants is lower than Kaiser book of
business
Cancer care opportunities
Kaiser had very few cancer patients with admissions for sepsis Medication optimization Rituxan biosimilar coming soon 12 – 16 hour infusion rooms Expanding cancer navigation programs
ER utilizationopportunities
OEBB ER utilization within Kaiser is low Mental health issues common among highest ER utilizers. Mental
health support could be better integrated into case management programs.
Proactive chart review by teams for all members with high ER use may discover additional opportunities
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Carrier Response
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Kaiser
Area of Review Kaiser Response
High readmissionopportunities
Improve transition of care experience Home visits Social needs assessments TBC enrollment
Uncontrolled diabetes in admissions and readmissions are reliable triggers for case management follow-up
Medical coding opportunities
Providers do appropriately code claims for the Kaiser system — but they are looking at improvements needed in their data feed process for sending to the data warehouse
Poly-prescriber/poly-pharmacy programs
Poly-prescriber — not an issue in the Kaiser system Polypharmacy — develop process to alert care providers and care
management team of issues as they arise
High-cost Rx coding opportunities
Kaiser currently does not have coded diagnosis of primary condition information for high-cost medicines when medicine/pharmacy is the highest claim category
Opportunity is to provide supplemental data or algorithms to complete the data picture
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Carrier Response
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Moda
Area of Review Moda Response
High-cost claimant opportunities
Of the 19 HCC that Moda was asked to review, five were participating in the C3 program. Moda determined to reach out to the additional 14 in an effort to engage them in the program.
ER utilizationopportunities
18.7% of Moda ER visits identified as not avoidable or mental health 15% identified as avoidable 19.5% identified as being PCP treatable Moda is in the process of implementing the Premanage (EDIE) program
to support managing ER utilization for the OEBB population Moda recently added a virtual visit option which may help to further
reduce ER visits
Poly-prescriber/poly-pharmacy programs
Medication Therapy Management (MTM) program designed to assist patients are those with multiple chronic conditions or multiple medications (has not yet been implemented for commercial clients)
Moda's specialty pharmacy partner, Ardon Health supports comprehensive disease specific patient management/clinical programs that include MTM evaluations with every fill of a specialty medication
Medication Use Evaluation (MUE) program evaluates medication-use patterns of members with the goal of improving patient health outcomes
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Carrier Response
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Moda
Area of Review Moda ResponseClaim coding for “encounter of aftercare” and “unknown” diagnosis
Effective October 1, 2017 Moda will return claims to the provider that are not billed out to the highest level of specificity
Chemotherapy site of care program
Chemotherapy agents are a topic for discussion and consideration in the next phase of the site of care program
Arthritis: review of biosimilar substitution and compo therapies for rheumatoid arthritis and utilization of low dose DMARD and MTX
Self-administered biosimilar used to manage RA have been approved by the FDA, but none of these products are currently available on the market
At the point that they become commercially available, Moda will ensure our utilization management strategies encourage the use of the most clinically appropriate and cost-effective medications
Moda is conducting a retrospective Medication Use Evaluation (MUE) initiative for all lines of business Outreach via mailings to members with a RA diagnosis, who do not
have a prescription for a disease-modifying antirheumatic drug (DMARD). Mailings will also go out to the providers of the members who were identified.
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Carrier Response
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Moda
Area of Review Moda ResponseReview medication adherence for members with diabetes and rheumatoid arthritis
The majority of the OEBB population are adherent to their therapy
Review large claimant inpatient diagnoses for Never Events
Moda clinical editing identifies potential hospital acquired conditions andNever Events
Nurse auditors review the itemized bill to determine which charges to deny and then they route the claim to the inpatient processing role with instructions of services to be denied and what ex code to use
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OEBB WELLNESS PROGRAM 2019-20 Program Recommendations
December 4, 2018SEOW Attachment 3
Glenn BalyPolicy/Program Development Coordinator
Jenny MarksWillis Towers Watson
Agenda
• OEBB Wellness Program Subgroup Work• Wellness Program/Benefits Review• Program/Benefit Recommendations • Next Steps
2
Executive Summary Background:
• In 2017, OEBB established a subgroup to formally review its current health risk-based well-being offerings to determine overall strategy, baseline metrics, communication opportunities, vendor / market review, member awareness and interests and identify gaps or duplicative offerings.
Milestones of the review:
• Creation of well-being program Mission statement, goals and strategies • Identification of stakeholders• Establishment of collaborative workgroups including OEBB Board and staff members, OEA
Choice Trust, Kaiser, and Moda and Willis Towers Watson representatives.• Comprehensive review of all vendors, program offerings, communications, participation
and outcomes. Reported at October 2018 SEOW Meeting • Review of incentive program options
• Vendor communications audit • Focus groups with members at the statewide annual Oregon School Employee Wellness
Conference as well as fielded an employee interest survey
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Executive SummaryVendor Review Key Findings
Participation and engagement• Overall participation is low• Completion/engagement rates for programs is low• Lack of uniformity among vendors in definitions of participation, engagement,
eligibility and outcomes • OEBB members primarily use Kaiser and Moda wellness offerings for chronic
condition education and management • Highest interest / awareness among members is with Weight Watchers and
Healthy Futures
Vendors and programs
OEBB’s current wellness vendor partners have top tier resources, tools and tracking mechanisms
There are duplicative efforts from vendors to address various health risks:• Diabetes prevention — Weight Watchers and Virtual Lifestyle Management
(VLM), VLM (StayWell has a buy-up option) • Chronic conditions — Kaiser, Moda, Canary Health’s Better Choices Better
Health (BCBH)
4
Vendor Review and RecommendationsWeight Watchers
• Program Modalities – At-work Meetings, Local Community Meetings and Weight Watchers Online
• Weight Watchers has committed to enhancing their own communications and marketing and is expanding its brand to provide more wellness services with weight management still a core function
• Weight Watchers received recognition as a CDC-certified diabetes prevention program.
• A single portal is being developed to improve member enrollment, renewal and participation.
• Developing the ability to track OEBB/PEBB participants and provide participation, engagement and outcome data (BMI).
• Developing population based and per participant pricing options
Recommendation
• Recommend the Board maintain Weight Watchers in the 2019-20 renewal negotiations with specific pricing option determined by the Board.
5
6
• Health Team Healthy U is a 12-week team-based worksite program that addresses multiple health conditions/risks
• HTHU has three program options (HTHU 1.0, HTHU 2.0 and HTHU 3.0) and is available through offline and online participation
• HTHU’s company, Provata Health, was acquired by StayWell (parent company Merck Rx.)
• Staywell has agreed to phase out offline participation due the lack of verification and work with OEBB to enhance verifiable outcome data.
• Staywell is developing multiple pricing options (per participant, PEPM, etc.)
• Staywell offers a number of additional programs/services separate from the HTHU Program for an additional cost, including:• Customizable Incentives Point Bank/Rewards Software• Telephone/Virtual Coaching• Biometric Screening• Weight Management Program• Language Translations• Staywell Dashboard Enhancements• Critical Learning Modules/programs (Financial wellness, DPP, pain management, professional development,
pregnancy)• Custom Challenges• Tobacco cessation
Recommendations:• Recommend that the Board maintain the current Healthy Team Healthy U benefit (minus offsite participation)
for 2019-20 with specific pricing options determine by the Board• Evaluate additional Staywell capabilities for cost and duplication with current OEBB services for the 2020-21
plan year.
Vendor Review and RecommendationsHealthy Team Healthy U
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Better Choices Better Health• A six-week, online program that helps those with chronic conditions develop self-
management skills through action planning, experience sharing and mutual support. • BCBH supplements, but does not replace, chronic disease management services
obtained through members health plans.
Virtual Lifestyle Management• 12-month online diabetes prevention program that promotes healthy habits for
increasing activity and losing weight.• Weight Watchers is also a CDC-certified diabetes prevention program and Kaiser offers a
diabetes prevention program.
Recommendations:• Recommend that the Board maintain the current BCBH benefit for 2019-20• Recommend that the Board maintain with VLM benefit with the addition of a digital
scale to collect verifiable data.• Evaluate the effectiveness of BCBH and VLM against other similar OEBB programs.
Vendor Review and RecommendationsCanary Health
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Next Steps
• Present the wellness program/benefit recommendations with pricing at the January 2019 Board Meeting.
• Continue implementation of OEBB Wellness Plan strategies.