Maine’s Value-Based
Insurance Design -101
Nancy R. Morris
Communication & 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.
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Not All Services Are Created Equal
Effective care
Supply-sensitive
care
12%
63%
25%
Preferencesensitive
care
The Dartmouth Institute for Health Policy and Clinical Practice (Wennberg, Weinstein, Fisher, et al.)
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
CEO Summit Recommendation
Message from
clinicians to
employers
Develop and offer
a benefit plan that
supports evidencebased care and
allows us to move
to outcomes based
performance
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
The Cost of Health Care
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
1
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Using EMR’s To Aid in
Communication
Clearing the Path to High
ROI Service Use
Slow Down and Review
Options
Stop and Look at the
Evidence Before
Proceeding
Goal: Reduce Unnecessary Services $265 Billion IOM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Green Services
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Yellow Services- SDM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Red Services
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
2
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Assuring High Quality Delivery
PCMH’s are the hub. When necessary they refer to:
High
Effective
&
Inefficient
Effective
& Efficient
Quality
Ineffective
&
Inefficient
Ineffective
& Efficient
Low
High
Costs
Low
Goal: Reduce high prices and inefficiently delivered services $155 Billion IOM
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
3
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
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
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
4
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
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
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
MHMC VBID Plan Design
5
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
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
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Current Health Plan Rating Display
• Working to
standardize VBID
benefits
• Working to
standardize
provider value
ratings
• Working to
standardize
administrative
requirements
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
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
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
State & Federal
Others
•
•
•
•
•
Aetna
Cigna
Anthem
Harvard Pilgrim Health Plan
Maine Community Health
Options
• Medical Mutual
• Geisinger
• MaineCare
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
State & Federal
•
•
•
•
•
Cross Agency
Holden Agency
USI
Aliant
Acadia Benefits
Others
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
State & Federal
Others
• HealthReach
• Maine Optometric
Association
• MaineHealth
• Maine General
• OMC Wellness
• St. Mary’s
• Spurwink
• MidCoast Health
• InterMed
• Maine Osteopathic
Association
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
State & Federal
Others
• Centers for Medicare
& Medicaid Innovation
• Maine State Employee
Health and Benefits
Office
• Maine CDC
• Veteran’s
Administration
• MEABT
• Maine BOI
• DHHS
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
•
•
•
•
•
•
State & Federal
•
•
Others
•
•
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
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
Community Effort
Health Plans/Payers
Brokers
Providers/Associates
State & Federal
Others
Continued
• Robert Wood Johnson
Foundation-NJ
• Oregon State-OR
• Internal MHMC staff
• Neel Shah, Costs of CareMA
• Integrated Health
Association-CA
• Pacific Business Group on
Health-CA
• AARP
Maine Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org
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 Health Management Coalition | Maine Health Management Coalition-Foundation
11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org