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Vermont Health Care Reform

Vermont Health Care Reform. Susan W. Besio, Ph.D. Director of Health Care Reform Implementation Vermont Agency of Administration. July, 2007. Vermont Context. Population: 623,000 19 U.S. cities are larger than Vermont Ranked 11th for proportion of population insured 1

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Vermont Health Care Reform

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  1. Vermont Health Care Reform Susan W. Besio, Ph.D. Director of Health Care Reform Implementation Vermont Agency of Administration July, 2007

  2. Vermont Context • Population: 623,000 • 19 U.S. cities are larger than Vermont • Ranked 11th for proportion of population insured 1 1US Census 2005 revised

  3. Vermont Context • Ranked the 2nd healthiest state overall in 2005 and 2006 1 • Highest percentage (86.4%) of women enter prenatal care in 1st trimester • Lowest percentage (7.4%) of children living in poverty • 4th lowest re: prevalence of obesity (20.2%) • Decrease in prevalence of smoking from 30.7% to 19.3% since 1990 • Lowest rate of motor vehicle deaths • Lowest premature death rate (years of potential life lost before age 75) • Vermont is considered an “aging state,” where the older population is growing faster than the younger population • Vermont has approximately 78,000 (12.6%) residents age 65 or older. • By the year 2030, 25% of Vermont’s population will be age 65 and older 1United Health Foundation

  4. Vermont Context – Health Care Costs • Growing cost of health care is unsustainable • Annual expenditures of $3.5 billion • 15.2% of Vermont’s gross state product • Vermont’s per capita costs still less than national average, but spending growth rates have been higher than national average for last 6 years Health Care Expenditures(2005) VermontU.S. Total (billions) $3.5 $2,016 Per capita $5,636 $6,682 Annual Change (2004-2005) 7.2% 7.4% Average Annual Change (1995 -2005) 7.9% 7.0% Share of Gross State/Domestic Product 15.2% 16.2% • Over 60,000 Vermonters are uninsured, and the number is growing • An estimated 50% of Vermonters with chronic conditions account for 70% of health care spending, but only 55% get the right care at the right time

  5. Vermont Context – The Insured • Private Health Insurance • 59.4% (370,000) have private insurance as primary coverage • 91% receive employer-sponsored insurance • 5% purchase their own coverage in the individual market • Remaining covered by higher education, COBRA, etc. • Medicaid: • 14.5% (90,350) have Medicaid as primary coverage • Traditional Medicaid – up to 125% FPL • Dr. Dynasaur – Children in households up to 300% FPL (34% of Vermont’s children) • Vermont Health Access Plan (VHAP) – Adults up to 150% FPL and caretakers of dependent children up to 185% FPL • Largest Insurer in Vermont (9,000 Enrolled Providers) • Medicare: 14.5% (90,100) • Military Insurance: 1.7% (10,500)

  6. Vermont Data (2005) – The Insured91.2% of Vermonters, 95.1% of Vermont children Private Insurance • 61.5% (382,239) of insured have private insurance • A decline of 2.1% since 2000 (63.6%) • 90.9% (347,435) have employer-sponsored insurance • 4.9 % (18,658) purchase their own coverage in the individual market • Enrollees decreased by 47% from 2002 to 2005 • Another 4.2% covered by higher education, COBRA, etc.

  7. Vermont Data (2005) – The Insured91.2% of Vermonters, 95.1% of Vermont children Medicaid / VHAP / Dr. Dynasaur • 19.1% (118,388) of insured are enrolled in Medicaid programs • An increase of 0.6% since 2000 (18.5%) • 22% (26,442) are employed adults • 14.5% (90,352) are enrolled in a Medicaid program as primary coverage • 41% (58,000) of Vermont children under age 18 are enrolled in Dr. Dynasaur • 86% of these (50,000) rely exclusively on Medicaid • Largest Insurer in Vermont (9,000 Enrolled Providers)

  8. Vermont Context – The Uninsured9.8% of Vermonters, 4.9% of Vermont children • An 1.4% increase in the rate of uninsured since 2000 (8.4%) • 51% are eligible for Medicaid programs but not enrolled • 79% of uninsured children; 49% of uninsured adults (18 – 64) • 87% are interested in enrolling; 57% believe they are not eligible • 27% have household income between 150-185% and 300% FPL and are not eligible for a Medicaid program but cannot afford private insurance

  9. Vermont Data 2005 – The Uninsured9.8% of Vermonters, 4.9% of Vermont children • 69% have been without insurance for more than a year • 77% reported cost as the main reason for being uninsured • 30% of uninsured children and 40% of uninsured adults did not see a health care professional in past year • 45% of uninsured children did not see a physician for routine care (compared to 7% of insured children) • Much more likely to go to ER or urgent care (8.6% vs .7%) • 25% of uninsured adults reported not seeking needed medical care due to cost

  10. Vermont Context – The Uninsured • 9.8% - A 1.4% increase in the rate of uninsured since 2000 (8.4%) • Uninsured Adults (18 to 64) –13.4% of adults (N = 53,708) • Young: 38% are between ages18 -24; over 25% between 25 - 34 • Male: 60% are male • Educated: 50% have high school /GED; 21% have up to college degree; 18% have college degree or more • Employed: 81% are employed • 60% work full-time • 30% work for employers that provide health insurance benefits • Uninsured Children (0 to17) – 4.9% of all children (N = 6,942) • Adolescents: 60% of uninsured children are between ages 11 - 17 • Male: Over 60% of uninsured children ages 0 to 17 are male • Uninsured Families: 70% of adults with uninsured children are also uninsured

  11. Vermont Context – The Uninsured • 51% are eligible for Medicaid programs but not enrolled • 79% of uninsured children; 49% of uninsured adults (18 – 64) • 87% are interested in enrolling; 57% believe they are not eligible • 27% have household income between 150-185% and 300% FPL and are not eligible for a Medicaid program but would be eligible for new Premium Assistance • 1 person: $15,315 - $30,630 • 2 person: $20,535 - $41,070 • 4 person: $30,975 - $61,950 • 69% have been without insurance for more than a year • 77% reported cost as the main reason for being uninsured • 45% of uninsured children did not see a physician for routine care (compared to 7% of insured children) • Much more likely to go to ER or urgent care for medical care (8.6% vs .7%) • 25% of uninsured adults reported not seeking needed medical care due to cost

  12. Many of the uninsured are people who cannot afford coverage We have very specific demographic data about the uninsured 51% of uninsured are eligible for Medicaid programs; 87% are interested; over half think they are not eligible Catamount Health must be affordable We need to provide premium assistance to people to enroll in Catamount Health or ESI Outreach will be designed for and targeted to specific groups We will re-tool our outreach and enrollment processes to enroll more people What the Data Tell Us

  13. Vermont’s Response • 2006 Legislation • Health Care Affordability Acts (Acts 190, 191) • Common Sense Initiatives (Appropriations Bill) • Sorry Works! (Act 142) • Safe Staffing and Quality Patient Care (Act 153) • 2007 Legislation • Corrections and Clarifications to the Health Care Affordability Acts of 2006 (Act 70) • An Act relating to Ensuring Success in Health Care Reform (Act 71) • Joint Legislative Commission on Health Care Reform • Administration Director of Health Care Reform Implementation

  14. Health Care Reform Goals Increase Access Improve Quality Contain Costs

  15. Goal: Increase Access to Affordable Health Care Coverage • Enhance Private Insurance Coverage • Catamount Health Plan for the Uninsured • Non-Group Market Reform • Promotion of Employer-Sponsored Insurance • Local Health Care Coverage Planning Grant • Potential Individual Insurance Mandate • Improve Outreach to • Uninsured • Medicaid Enrollment Study • Comprehensive Marketing, Outreach • Single Enrollment Web-site • 1-800 number • Assist with Affordability • Premium Assistance (ESI, Catamount) • Reduction in VHAP Premiums

  16. Goal: Improve Quality of Care • Chronic Care Management • Expand Blueprint Statewide • OVHA Chronic Care Management Program • State Employee Health Plan • ESI Premium Assistance plan approval, cost-sharing • Catamount Health coverage, cost-sharing • Care Coordination • Payment Reforms • Increase Provider Availability • Loan Repayment Program • Loan Forgiveness Program • FQHC Look-alike Funding • Uncompensated Care Pool • Increase Provider Access • to Patient Information • Health Information Technology • Electronic Medical Records • Master Provider Index • Multi-payer Database • Promote Quality Improvement • Consumer Health Care Price & Quality System • Adverse Events Monitoring System • Hospital-acquired Infections Data • Safe Staffing Reporting • SorryWorks! • Advanced Directives • Promote Wellness • Immunizations • CHAMPPS Grants • Catamount Health Coverage, cost-sharing • Healthy Lifestyles Insurance Discounts • AHS Inventory of Health and Wellness Programs

  17. Goal: Contain Costs Increase Access to Coverage and Care  Decrease Uncompensated Care  Lower Premium Costs • Decrease Cost Shift • Increase Medicaid Provider Rates • Cost Shift Task Force • Standardize Policy for Hospital • Uncompensated Care and Bad Debt • Hospital Cost Shift Reporting Reforms • Simplify Administration • Common Claims and Procedures • Uniform Provider Credentialing Improve Quality of Health Care  Appropriate Care, Better Information  Lower Costs

  18. Insurance Coverage

  19. Why is Coverage Important? • Un-reimbursed care increases private insurance premiums • Makes insurance less affordable • Fewer people are covered • Benefits are decreased and/or people choose non-comprehensive plans to make plans affordable • People with comprehensive insurance coverage are more likely to participate in preventive care • Increases quality of life • Decreases cost of health care overall

  20. Catamount Health • A non-group insurance product for uninsured Vermont residents • Offered as a preferred provider organization plan by two private insurers, beginning October 1, 2007 • Is required to be a comprehensive insurance package covering: • Primary care • Preventative care • Acute episodic care • Chronic care • Hospital services • Pharmaceutical coverage • Individuals may choose which insurer they would like to use.

  21. Catamount Health LEGISLATIVELY-MANDATED COST-SHARING Deductibles: In-Network:Out-of-Network: $250/individual $500/individual $500/family $1,000/family Co-Payment: $10/office visit Prescription Drugs: No deductible Co‑payments: $10 generic drugs $30 drugs on preferred drug list $50 non-preferred drugs Preventive Care & Chronic Care*: $0 Not subject to deductible, co-insurance, co-payments Out-of-Pocket Maximum: In-Network:Out-of-Network: (excluding Premium)$800/individual $1,500/individual $1,600/family$3,000/family * For people enrolled in Chronic Care Management Program

  22. Catamount Health • PROVIDER REIMBURSEMENT • Health Care Professionals: Medicare +10% in 2006, increasing as per Medicare reimbursement methodology • Hospitals: Cost +10%, increasing as per Medicare economic index • OVERSIGHT • Insurers go through the usual rate-setting process at the Department of Banking, Insurance, Securities and Health Care Administration (BISHCA) • Emergency Board will suspend enrollment in Catamount Health premium assistance if there is not enough money • Commission on Health Care Reform to review Catamount Health Plan by October 1, 2009 for cost effectiveness  may trigger a self-insured plan if current structure is not cost effective

  23. Catamount Health Costs • The cost will depend on individual / household income Cost for Individual Coverage with Premium Assistance: Individual Income by federal poverty levelMonthly premium cost * (1 person/annual in 2007) • Below 200% FPL ($20,420) $60.00 • 200-225% ($20,421 – 22,973) $90.00 • 225-250% ($22,974 – 25,525) $110.00 • 250-275% ($25,526 – 28,077) $125.00 • 275-300% ($28,078 – 30,630) $135.00 *Cost for two-person coverage will be double these amounts Estimated Full Cost for Individuals/Households over 300% FPL: • Single $ 390 / month • Two Person $ 780 / month • Family $1,750 / month

  24. Catamount Health Eligibility • You can purchase Catamount Health if you are an uninsured Vermont resident, are 18+, and are not eligible for an Employer-Sponsored Insurance (ESI) plan *. Uninsured means: • You have insurance which only covers hospital care OR doctor’s visits (but not both) • You have not had private insurance for the past 12 months • You had VHAP or Medicaid but became ineligible for those programs • You had private insurance but lost it because you: • Lost your job • Got divorced • No longer have COBRA coverage • Had insurance through someone else who died • Are no longer a dependent on your parent’s insurance • Graduated, took a leave of absence, or finished college or university and got your insurance through school

  25. Catamount Health Eligibility • You can purchase Catamount Health even if you are eligible for an Employer-Sponsored Insurance (ESI) plan IF you have an income under 300% FPL, AND Your ESI plan is not approved by the state as comprehensive and affordable (with state assistance) OR It is more cost effective to the state to provide premium assistance for you to enroll in a Catamount Health plan than providing premium assistance for you to enroll in your ESI OR It is more cost effective to the state to provide premium assistance for you to enroll in your ESI than providing premium assistance for you to enroll in Catamount Health, but you must wait until the next open enrollment period for your ESI (at which point you must switch to your ESI to receive premium assistance)

  26. Key Dates • CATAMOUNT HEALTH September 8, 2006 Rules filed with Secretary of State October 7, 2006 Carriers submitted Letters of Intent (BCBS-VT, MVP, CDPHP) Mid-March, 2007 Carriers file forms and rates October 1, 2007 Catamount Health Insurance available to uninsured Vermonters October 1, 2009 Legislative review re: cost effectiveness; may trigger a self-insured plan

  27. Premium Assistance • Catamount Health • Vermonters who qualify for Catamount Health with income less than or equal to 300% of Federal Poverty Level (FPL) ($29,500 for one person) may receive premium assistance from the state • Employer-Sponsored Insurance (ESI) • Uninsured Vermonters with income less than or equal to 300% FPL may apply for ESI premium assistance • ESI plans must offer comprehensive benefits and be affordable in order for the individual to receive premium assistance • Affordable = maximum individual in-network deductible of $500 • Comprehensive = covers physician, inpatient care, outpatient, prescription drugs, emergency room, ambulance, mental health, substance abuse, medical equipment/supplies, and maternity care • Employers do not have to contribute to the plan for it to qualify

  28. Premium AssistanceCost Effectiveness Test • VHAP Applicants (under 150 -185% FPL) • If providing premium assistance to the individual to enroll in their ESI plan is more cost-effective to the state than enrollment in VHAP, the applicant will be required to enroll in their ESI plan to get state assistance. • Catamount Health Applicants (at or under 300% FPL) • If providing premium assistance to the individual to enroll in their ESI plan is more cost-effective to the state than providing premium assistance for the Catamount Health Plan, the applicant will only receive state assistance to enroll in their ESI plan.

  29. How will Premium Assistance be Paid? • Catamount Health Premium Assistance • Beneficiary will pay his or her share to state • State will pay total premium to carrier • ESI Premium Assistance • Employee will pay total premium to employer through payroll deduction • State will pay employee prospectively for premium assistance • Employers will not have to modify payroll or accounting systems • Employers may have to provide information on the plan’s cost to the employee to assist with enrollment in the premium assistance program

  30. Key Dates: PREMIUM ASSISTANCE FOR ESI / CATAMOUNT September, 2006 Waiver Amendment Request submitted to CMS for approval of premium assistance programs November, 2006 Report to Legislative Committees on fiscal implications (estimated costs and savings) April, 2007 Draft Rules for Premium Assistance Eligibility Determination July, 2007 Finalize Rules for Premium Assistance Eligibility Determination October 1, 2007 Premium Assistance enrollment for ESI and Catamount to eligible Vermonters

  31. OVERVIEW OF VERMONT EDUCATION, OUTREACH AND ENROLLMENT STRATEGY Goal:To develop and implement a comprehensive, integrated and aggressive education, outreach and enrollment strategy: • across a continuum of solutions for the uninsured, including Medicaid, VHAP, Dr Dynasaur and Catamount Health Plans • using a unified multi-stakeholder campaign, • with specialized interventions for specific uninsured populations, and • targeted at multiple stakeholders (health care providers, community-based providers, grass-roots organizations, advocate organizations, state employees, employers)

  32. Outreach and Enrollment • Integrated Medicaid, Catamount Outreach and Enrollment Strategies • Aggressive Marketing and Education Campaign in Late Summer, Fall 2007 • Using state and local staff, partners and volunteers • 1-800 number • New web-site • Possible Re-branding • Re-tooling of Existing Application and Enrollment Processes

  33. Key Elements • Broad-based Outreach and Enrollment Steering Committee: to guide and inform outreach and enrollment efforts (see attached membership list) • Health Care Marketing Firm to Develop: • A broad-based, compelling message that conveys to all Vermonters why it is important to have health insurance coverage; • Promotion of all available insurance products and subsidies, including private market options. • Coordination of the broad message with education, outreach and enrollment activities that are nuanced to address targeted populations, including • 1) specific uninsured sub-populations (using the 2005 Vermont Family Health Insurance Survey data), and • 2) partners who can assist with the coverage efforts (e.g., employers, health care providers, human services providers and other community organizations, schools, the faith community). • Use of health literacy research, such as that produced by the Harvard School of Public Health, to inform our effort

  34. Key Elements,continued • Revisions to Current Enrollment Tools: The above must be coupled with the tools needed for effective screening and enrollment, including shifting FROM Current relatively passive approach: Examples: • using brochures, • 1-800 number, • paper applications and • office-based staff TO Pro-active and consumer-friendly approach: Examples: • all of above, plus • one-to-one and community-based outreach, • user-friendly web-based screening tools, • simplified application forms, • ability to track application status and change in eligibility over time to prevent program drop-out, etc. • Outreach and Enrollment Coordinator to facilitate the implementation and interface between all of the above activities.

  35. Revisions for Medicaid/VHAP/Dr. Dynasaur Eligibility Determination and Enrollment • Explore streamlining Medicaid/VHAP/Dr Dynasaur application form • Pro-actively assist with eligibility screening and applications (complete forms for people at key junctures) • Actively engage AHS employeesand partners (providers, regional partnerships, clergy, accountants, others to help people complete eligibility screening tool and / or application • Add a contract/grant provision to state contracts/grants that have natural connections to the target populations • Change VHAP coverage date to be the date of application receipt • Move from 6 month to 12 month VHAP renewals • Solicit feedback from individuals about the enrollment and renewal processes to inform additional refinements

  36. Revisions for Medicaid/VHAP/Dr. Dynasaur Eligibility Determination and Enrollment • Create the Vermont Health Care Portal - an on-line system to access information and enrollment processes for all Vermont health care programs, designed to: • streamline the application and eligibility process, and reduce the burden of program rules; • interface in real time with other systems to verify information needed to grant eligibility and to disseminate notification of coverage; • utilize the health information exchange being created by VITL in a way that improves the sharing of health care data; • quickly incorporate changes in eligibility rules; • reduce the need for paper by managing applications, notifications and billing electronically whenever possible; and • enable caseworkers to be more focused on personally serving Vermonters because they need less time for data entry, managing paperwork, and getting accurate, timely results from the enrollment system.

  37. Vermont Health Care Portal, continued (This proposal is still under discussion and may be altered as more detailed information evolves about implementation issues – e.g., technical challenges, timelines, cost) • Phase 1 (by August 2007): • Web-based simple screening tool • Links to information about Vermont’s healthcare programs and application processes • Down-loadable pdf version of the application form that can be completed and mailed or faxed • Automated contact form that the individual can submit to request a follow-up phone call • Phase 2 (by October 2008): • Phase 1 plus: • On-line application that can be submitted electronically • Expanded links to educational health-related materials and sites • Phase 3 (by June 2010): • On-line application and renewal processes linked to back-end eligibility/enrollment/renewal system • From any place with internet access, an individual will be able to: • read and download current information about health care programs; • complete an anonymous self-screening to determine if they may be eligible for assistance; • fill out and submit an automated application or recertification that connects with the processing system; • chat immediately with a caseworker to get answers to questions, help completing the application and an explanation of remaining requirements; • submit verification, and receive notification letters and reminders, electronically; • check the status of their case and gather the details of their benefit package; • pay their premiums and select their providers; and, • review information about the services and costs paid by Vermont health care programs for their household. • This project will be a component of the vision for the “Medicaid enterprise’ which also entails replacement of the Medicaid Management Information System (MMIS)

  38. Other Initiatives to Enhance Private Insurance Coverage • Non-Group Market Reform • Promotion of Employer-Sponsored Insurance • Local Health Care Coverage Planning Grant

  39. CHRONIC CARE MANAGEMENT

  40. Blueprint for Health • State’s Plan for Better Management and Prevention of Chronic Illnesses across All Payers and Providers • Vision:Vermont will have a standardized statewide system of care that improves the lives of individuals with and at risk for chronic conditions. • To achieve this vision, the Blueprint is: • Statewide system reform based on the Chronic Care Model • A public-private collaborative • Recognizes the central role of the patient and community • Designed around “Core System Competencies” rather than disease programs • Is the state’s mandated standard for chronic care management across all payers and providers

  41. Blueprint for Health Model Public Policy Public Health Community Healthier • Policies • Infrastructure • Financing • Resources • Advocacy • Regulation • Info. Systems • Built Environment • Programs and Services • Health Awareness • Healthy Options • Info. Systems V e r m o n t e r s Patients and Families • Health Knowledge • Self-Management • Skill and Practice • Supportive Home • Environment • Info. Systems Health Provider Team Health Systems • System Policy • Quality Care • Service Development • Reimbursement • Financing • Continuity • Coordination • Info. Systems • Practice Standards • Info. Systems • Decision Support • Office Systems • Coaching/Support

  42. Examples of Blueprint Components

  43. Other Chronic Care Strategies To Be Aligned with the Blueprint • Medicaid Chronic Care Management Program • State Employee Health Benefit Programs • State-approved Employer-Sponsored Insurance (ESI) Plans for Premium Assistance • Catamount Health Plans

  44. Medicaid Chronic Care Management Program (CCMP) • Establish a Chronic Care Management Program (CCMP) for the Medicaid and VHAP populations • Contract with external vendors for two components: • Program intervention • Monitoring, evaluation and payment

  45. CCMP Interventions • Identify Medicaid enrollees with one or more chronic conditions (using claims data) • Conduct health risk assessments (HRAs) for all beneficiaries identified • Stratify the population into high, middle, low risk groups • Conduct evidence-based care management interventions for each risk group (intensity varies by group) • Coordinate CCMP activities with: • Care coordination program (coordinating the care needs of the 1-2% most complex Medicaid enrollees) • Blueprint for Health • Choices for Care 1115 Waiver (Long-term Care Waiver)

  46. Blueprint Alignment TopicsAcross Chronic Care Programs • Coordination of care across the multiple programs working with the same providers and patients • Agreement on best practices for all chronic diseases • Use of a consistent health risk assessment • Referrals to patient self-management resources • Coordination of IT initiatives to improve access and support clinical decision making • Use of consistent metrics for provider feedback, profiling and measurement • Changing and aligning payer fee structures to provide incentive to reward quality (e.g., pay-for performance, payment reforms)

  47. Blueprint Impact on Health Care Costs • It will not SAVE money – but it will reduce the rise in cost of care • We do expect to reduce the cost per case for chronic illness by: • reducing hospitalizations • reducing complications • reducing specialist visits • So why doesn’t that save money? • Because when we take better care of chronic illness we prolong productive life • Because more people are developing chronic illness, especially with the obesity epidemic • That means more people in Vermont with chronic illness • More cases at less cost per case still means more total health care cost for the population

  48. Health Information Technology • VITL = Statewide Regional Health Information Organization (RHIO) • State Health Information Technology Plan • Medication History Pilot Project • Implemented at 2 Hospital Emergency Rooms in April, 2007 • Chronic Care Information System (Disease Registry) • First community site (Mt. Ascutney) for diabetes will be implemented in December, 2007 • Electronic Health Records supported statewide • Master Provider Index, Multi-payer Database

  49. PREVENTION

  50. CHAMPPS(Coordinated Healthy Activity, Motivation and Prevention Programs) • Competitive multi-year grants to communities starting July 1, 2007 • Projects must be: • Comprehensive approaches to promote healthy behavior and disease prevention • Across the community • Across the lifespan • Consistent with the Blueprint and community goals • Goal and outcome driven • Based on effective strategies • Able to provide data for evaluating and monitoring progress

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