Maine’s Value-Based Insurance Design -101 Nancy R. Morris Communication & Member Relations...

Maine’s Value-Based Insurance Design -

Nancy R. MorrisCommunication & Member Relations Director

3-18-15

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.

63%25%

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

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

The Cost of Health Care

MHMC VBID Plan Design

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

Green Services

Yellow Services- SDM

Red Services

Assuring High Quality Delivery

PCMH’s are the hub. When necessary they refer to:

Quality

Effective & Efficient

Ineffective &

Inefficient

Ineffective & Efficient

Effective &

Inefficient

High Low

Goal: Reduce high prices and inefficiently delivered services $155 Billion IOM

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

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

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

Current Health Plan Rating Display

• Working to standardize VBID benefits

• Working to standardize provider value ratings

• Working to standardize administrative requirements

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

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

Community Effort

Health Plans/Payers

Brokers

• Cross Agency• Holden Agency• USI• Aliant• Acadia

Benefits

State & Federal

Others

Community Effort

Health Plans/Payers

Brokers

• HealthReach• Maine Optometric

Association• MaineHealth• Maine General• OMC Wellness• St. Mary’s• Spurwink• MidCoast Health• InterMed• Maine Osteopathic

Association

State & Federal

Others

Community Effort

Health Plans/Payers

Brokers

• Centers for Medicare & Medicaid Innovation

• Maine State Employee Health and Benefits Office

• Maine CDC• Veteran’s

Administration• MEABT• Maine BOI• DHHS

State & Federal

Others

Community Effort

Health Plans/Payers

Brokers

• 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

Community Effort

Health Plans/Payers

Brokers

• 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

How Can You Get Involved

http://www.youtube.com/watch?v=hO8MwBZl-Vc

Contact: Robin Allen at rallen@mehmc.org or 207 844-8106 extension 244 with suggestions or to join a subcommittee

Maine’s Value-Based Insurance Design -101 Nancy R. Morris Communication & Member Relations...

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