Diane
Lovell


Oregon
AFSCME
Council
75
May
11,
2011
AGENDA
ÿSemi‐Final
Plan
Designs
ÿMedical
and
Dental
Renewals
ÿPreference‐Sensitive/Evidence‐Based
Changes
Under
Consideration
ÿRetiree
Options

5/16/11 2
The
Scenarios
ÿ Scenario
A
ÿ PY
2012
and
PY
2013
funding
PEPM
is
based
on
5%
increases
over
2011
re‐projected
costs
of
$1,214.05
PEPM
with
the
April
1,
2011
changes
and
March
2011
data.

ÿ Scenario
B
ÿ PY
2012
and
PY
2013
funding
PEPM
is
based
on
0%
increases
over
2011
re‐projected
costs
of
$1,214.05
PEPM
with
the
April
1,
2011
changes
and
March
2011
data

ÿ Scenario
C
ÿ 2012
to
2013
funding
PEPM
is
based
on
0%
increase
from
proposed
Governor’s
Budget
of
$1,149.04
PEPM

5/16/11 3
 Plan
Design
Changes:
These
plan
design
changes
(made
to
the
Providence
Statewide
and
Choice
plans)
will
achieve
a
zero
dollar
deficit
at
the
end
of
year
2013
to
the
midpoint
of
the
recommended
low
and
middle
RBC,
with
all
plan
design
changes
occurring
in
2012.

Scenario Scenario Scenario

A B C
Add
more
procedures
to
the
Additional‐cost
Tier
(being
considered
by
OEBB) $5,000,000 $5,000,000 $5,000,000
Out‐of‐pocket
Max:

$1,500,
(Scenario
B
&
C
$2,000
OOP) $6,200,000 $10,800,000 $10,800,000

$50/month
Spouse
or
Domestic
Partner
Surcharge $12,000,000 $12,000,000 $12,
000,000

Health
Engagement
Model $0 $0 $0
Deductible:
$250
In‐network,
$500
Out‐of‐network
(4
office
visits
not
subject)
(Scenario $12,900,000 $12,
900,
000 $27,
600,
000
C
Deductible:
$500
In‐network,
$1,000
Out‐of‐network)

Tobacco
Surcharge
for
Employees
and
Spouses
$25/month $2,400,000 $2,400,000 $2,
400,000

Rate
Retirees
Separately
Going
Forward
(1.9M
savings
starting
in
2013) $0 $0

Office
Visit
Co‐Insurance:

20%
PCP,
35%
Specialist $5,600,000 $5,600,000

Rx
Tiers:
$0
Value
$10
Generic,
$30
Brand,
$100
Specialty
Mail
Order:

2.5
x
Retail,
no
tiers $10,300,000 $10,300,000 $10,300,000
exceptions,
$50
Rx
Deductible
for
all
Value
drugs

Reduce
Chronic
Care
Coinsurance
(Asthma,
Hypertension,
Diabetes,
COPD,
CHF, ($2,800,000) ($2,800,000) (2,
800,
000)

Cholesterol)*
Additional
Funding $43,000,000 $67,000,000

Subtotal
Estimated
Savings $46,000,000 $99,000,000 $137,900,000

$1,000
out‐of‐pocket
max
for
Rx ($1,000,000) ($1,000,000) ($1,000,000)

Pharmacy
tier
exceptions ($2,140,000) ($2,140,000) ($2,140,000)

Strategies
to
Enhance
Enrollment
in
Choice
and
Kaiser N/A N/A

Weight
Watchers
for
Dependents* TBD TBD TBD

Optional
Savings ($3,140,000) ($3,140,000) (3,140,000)

5/16/11 4
Two‐Year
Plan
Design
Changes
ÿThe
changes
made
in
each
of
the
scenarios
are
intended
to
be
the
only
changes
made
during
the
biennium.
ÿThis
will
hold
true
unless
utilization,
cost
of
care
or
numerous
high‐expense
claims
drive
costs
above
the
predicted
9.7%
trend.

5/16/11 5
2012
Medical
and
Dental
Renewals
ÿKaiser
Medical
–
8.6%
ÿ Implement
Sleep
Study
and
Imaging

co‐insurance
previously
implemented
for
our
Providence
Plans
ÿProvidence
Choice
(4.4%)

and
Providence
Statewide
Plan
(4%)
ÿ Plan
design
changes
explained
on
previous
slide
ÿODS
(.2%)
ÿ No
Plan
Changes
ÿKaiser

(3.1%)
ÿ No
reductions,
new
PreventaMax
Benefit
added
at
no
additional
cost
ÿWillamette
Dental
(0%)
ÿ Implement
a
$5
co‐pay
ÿ Orthodontia
co‐pay
increases
from
$1,200
to
$1,500
ÿ Increase
applies
to
patients
that
have
not
been
banded
at
time
of
implementation

5/16/11 6
Preference‐Sensitive
Conditions
ÿ Trying
to
find
$5M
in
savings
through
evidence‐based
medicine
and
preference‐sensitive
conditions

ÿ Evidence‐based
medicine
(EBM)
or
evidence‐based
practice
(EBP)
aims
to
apply
the
best
available
evidence
gained
from
the
scientific
method
to
clinical
decision
making.[1]
It
seeks
to
assess
the
strength
of
evidence
of
the
risks
and
benefits
of
treatments
(including
lack
of
treatment)
and
diagnostic
tests.[2]
Evidence
quality
can
range
from
meta‐analyses
and
systematic
reviews
of
double‐
blind,
placebo‐controlled
clinical
trials
at
the
top
end,
down
to
conventional
wisdom
at
the
bottom.
ÿ Preference‐Sensitive
Conditions
are
those
for
which
two
or
more
valid
treatment
choices
are
available
for
most
patients.
Chronic
back
pain,
early‐stage
breast
cancer,
early
stage
prostate
cancer,
and
benign
prostatic
hypertrophy
are
considered
preference‐sensitive
conditions.
Treatment
choices
for
these
conditions
should
be
made
by
well‐informed
patients
who
base
their
decisions
on
the
best
available
evidence
as
well
as
their
personal
values
and
preferences
ÿ PEBB
is
reviewing
a
list
of
28
conditions
where
there
is
little
evidence
demonstrating
that
the
treatment
improves
health
or
for
which
there
are
two
or
more
valid
treatments.

A
PEBB
subcommittee
will
review
this
information
and
make
a
recommendation
to
the
full
Board.

The
list
is
a
compilation
of
treatments
under
review
by
the
Oregon
Employees
Benefits
Board
(OEBB),
on
tiers
three
or
four
of
the
Oregon
Health
Authority’s
essential
benefits
model
and
either
not
covered
or
low
on
the
list
of
effective
treatments
as
determined
by
the
Oregon
Health
Services
Commission.
ÿ If
we
are
unable
to
find
$5M
in
savings,
we
will
have
to
make
other
additional
cuts
to
Scenario
A
to
make
up
the
difference.

5/16/11 7
Retiree
Options
ÿPEBB
has
not
made
any
decisions
to
change
Retiree
inclusion
in
PEBB
Plans
ÿ2,101
retirees
comprise
4.1%
of
the
PEBB
plan.

This
number
has
declined
each
of
the
last
four
years.
ÿRetirees
do
have
other
options
for
healthcare
ÿPERS
ÿ COBRA
ÿ OMIP
ÿ Individual
Market
ÿ Oregon’s
Health
Exchange
in
2014
ÿPERS
plans
are
valued
between
93%
and
97%
of
PEBB
full
time
plans
based
on
existing
plan
design
features.

When
PEBB
implements
changes
in
2012
this
gap
will
narrow
even
more.

5/16/11 8
Next
Steps
ÿMay
17
Board
Meeting
Agenda:

ÿReview
Preference‐Sensitive
Subcommittee
work
ÿ
Review
fees,
consultant
commissions
and
provider
tax
ÿ
Approve
2012
Plan
Year
composite
rates
ÿ
Approve
HEM
plan
design
and
framework

5/16/11 9