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MBGH ANNUAL CONFERENCE MAY 10-11, 2007 Health Benefits GPS-Mapping Your 2008 Strategy Paying For Quality Health Care Benefits With Actions, Not Cash Hank Scheff, American Federation of State, County and Municipal Employees (AFSCME) Council 31

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MBGH ANNUAL CONFERENCEMAY 10-11, 2007 Health Benefits GPS-Mapping Your 2008 Strategy

Paying For Quality Health Care Benefits With Actions, Not Cash

Hank Scheff, American Federation of State, County and Municipal Employees (AFSCME) Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

Health Care Benefits at AFSCME: History

  • What is AFSCME Council 31?

  • 254 adult participants (165 employees/retirees)

  • Comprehensive PPO, self funded, with modest cost sharing

  • Like everywhere else, costs threaten the status quo

  • Voluntary screenings, Health Risk Assessments and medical self care training

  • Negotiated with employees

  • Employees as negotiators are health benefits savvy

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

A New Direction in 2007

  • Build on what was in place

  • Preserve quality benefits by upping the behavioral ante for participants

  • Stress participant competencies essential to better communications with health professionals and health-affecting decision making

  • Adopt a “Value Based Benefits” strategy-

    Integrate innovative benefit cost sharing and “sculpting” with mandatory education, training and (nurse) care counseling to cause participants to be value co-creators – not merely value beneficiaries

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

2007 Benefit Program Attributes

  • Two plans replaced the former plan:

    • The Health ImprovementPlan (HIP)—better, “sculpted” benefits if covered adults followed a Personal Health Improvement Prescription (PHIP)

    • The StandardPlan-lesser benefits and higher costs for adults who do not wish to follow a PHIP and make a real effort to improve their health

  • Health Care Counselors replaced previous utilization review and case management

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

2007 Benefit Program Attributes (cont’d)

  • A new pharmacy benefit manager was named, and greater emphasis placed on the clinical appropriateness of prescribed medications

  • Existing PPO networks and TPA retained

  • A new and improved Council 31 Pathways to Health web site that:

    • Connects participants to their PHIPs, personal health information and members of their health team

    • Helps participants learn how to become knowledgeable and effective contributors to their health

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

Why Join the Health Improvement Plan? Financial Incentives!

  • PPO Deductibles: $200 HIP/$400 Standard Plan

  • Coinsurance: 90%/80% HIP; 80%/70% Standard Plan

  • Annual OOP Limits: $1,250 HIP; $2,500 Standard Plan

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

Why Join the Health Improvement Plan? Financial Incentives! (cont’d)

  • Double above for family; double again for non-PPO providers

  • Lifetime Limits: $2 million HIP; $1 million Standard Plan

  • Contributions (for the first time!):

    • HIP: 0.5% of salary for a spouse

    • STANDARD: 1.0% of salary for employee; 2.0% for a spouse = 3% of salary!

    • Each adult makes their OWN SELECTION, they don’t have to be in the same plan.

    • Children are automatically in the HIP

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

The Change “Navigator”- the PHIP

  • A CONFIDENTIAL health competency development schedule for each adult based on merged health risk assessment, wellness screening, and claims data

  • It may require the use of specialized services at various stages of diagnosis and treatment based on personal health factors

  • Compliance will be tracked and noncompliance will result inineligibility for the Health Improvement Plan and transfer to the Standard Plan

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

Examples of the PHIP’s Targeted Actions and Competencies

  • Participate in CONFIDENTIAL health risk assessments and wellness screenings

  • Designate a primary care physician and learn how to communicate more effectively with him/her

  • Become care cost and benefits savvy by understanding what constitutes the “right” care and learning how to make care and cost trade-offs

  • Learn to stay healthy; reduce risks of illness, disease, injury, and premature death; improve capabilities, quality of life

  • Adopt appropriate early detection practices

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

Examples of the PHIP’s Targeted Actions and Competencies (Cont’d)

  • Effective use of information technology

  • Self treat health problems appropriately

  • Help prevent medical errors

  • Help coordinate their own care

  • Work with the health care counselor

  • Actively participate in treatment plans and comply fully with them

  • Access end-of-life resources

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

Five Months In, What Have We Learned?

  • Lots of administrative glitches caused by introducing new program elements, integrating new service providers and tying adult participants to their own plans.

  • Aligning a Value Based Benefit philosophy with conventional stop loss carrier utilization review requirements is not easy

  • Building the “right” website takes time, and getting participants to use it in meeting their PHIP requirements and making better health improvement and care choices is a new frontier

  • Participants are forgiving, and most importantly “get” what we’re trying to do

AFSCME Council 31


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Paying For Quality Health Care Benefits With Actions, Not Cash

QUESTIONS?

NEED TO KNOW MORE? CHECK OUT THE HPN DISPLAY

AFSCME Council 31


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