Medical Services Board Discussion Kim Bimestefer, Executive Director - - PowerPoint PPT Presentation

Medical Services Board Discussion

Kim Bimestefer, Executive Director

April 12, 2019

• Building Personal Care and Home Care Work Force to support growing

Seniors and Individuals with Disabilities populations – Workforce Development Workstream including Training, tracking workforce against needs, $20M budget action for 2019-20

• CIVHC Foundational S

upport: $4M funding including $2.5M in this budget, which funds the APCD. Advisory Board refocus. Employer Data.

• Funded three more Medicaid Fraud Inspectors. Renewed focus on this.
• Improved Member Service Technology (but not enough). Provider service

support is solid (< 60 sec AS A)

• Primary Care Providers Incentive Model support

2

Some HCPF Budget Requests

2017 Colorado Health Access S urvey 3

Focus: Getting Colorado Covered

S

• urces:

Colorado insurance coverage percent ages are f rom t he Colorado Healt h Access S urvey, S ept ember 2017. ***Nat ional insurance coverage percent ages are f rom U.S . Census Bureau Current Populat ion Report , Healt h Insurance Coverage in t he Unit ed S t at es: 2017, issued S ept ember 2018.

**National Uninsured: 8.8%

In Process Work

• CHAS

S urvey Insights

• Other hired consultants to help

define the uninsured drivers

• Public Option work (bill 1004)

• Lt. Governor’s New Cabinet:

Lower healthcare costs to save people money on healthcare

4

Focus: Healthcare Affordability

5

Medicaid consumes

33%

S tate’s Total Budget (25%

• f General

Fund)

Colorado Private S ector (Consumers and Employers)1

$65,718 2016 median income $20,940 2016 average cost of private insurance

1 Source: Income data from Colorado DOLA LMI Gateway, US Census Median Household Income

• 2. CO Department of Health Care Policy and Financing

Health Care is

32%

• f median household

income

Some Initial Affordability Pathways

• 1. Constrain prices, especially hospital and prescription drugs.
• 2. Champion alternative payment models.
• 3. Align and strengthen data infrastructure.
• 4. Improve our population health.
• 5. Maximize innovation.

6

Solution: Drive more Consistency in Hospital Price and Quality. Drive the community to the higher quality, lower cost locations

(sometimes called Centers of Excellence).

Each bubble reflect s hospit al volume for a non- emergent procedure. The posit ion of the bubble reflect s cost / qualit y met rics at t hat hospit al. Such chart s are being produced for a number of procedures t o help ident ify Cent ers of Excellence.

7

Centers of Excellence Alternate Payment Methodology, Policy Discussion, in Collaboration with the AG’s Office

8

Other Hospital Affordability Solutions

Efficiency

• Out of Network

contracting and reimbursement

Aligned Quality, Incentives

• Value based payments to hospitals

to reward appropriate referrals that improve cost, quality

• Hospital Transformation Program

Accountability

• Hospital Transparency
• Community Health Needs

Assessment transparency and Community Boards engagement

8

Medicaid generates about $1B in Rx claim costs (before rebates) Over the last six (6) fiscal years, 2012/13 through 2017/18:

Generic Rx costs down 8%

• r 1.3%

/ year Brand name Rx up 30% , or 5% / year SRx up 171% , or 28.5% / year Total Rx spend is up 51% , or 8.5% a year

Of this total 51% Rx trend,

more than 75% is due to Specialty Drugs.

9

Medicaid Rx Cost Trends

$0.00 $10.00 $20.00 $30.00 $40.00 $50.00 $60.00 $70.00 FY1213 FY1314 FY1415 FY1516 FY1617 FY1718

Pharmacy Average PMPM

S PECIALTY AVERAGE PMPM NON SPECIALTY AVERAGE PMPM GENERIC AVERAGE PMPM OVERALL AVERAGE PMPM

10

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 FY1213 FY1314 FY1415 FY1516 FY1617 FY1718

NON SPECIALTY DRUG SPECIALTY DRUG

1.25%

• f CO Medicaid

prescriptions (specialty drugs) are so expensive, they are consuming > 40%

• f Medicaid’s

Rx resources (before rebates). This is in line with national and commercial carrier trends.

Impact of Specialty Drugs on Medicaid spend

Specialty Drug Impact

11

Specialty Drugs: we’re at the beginning

42

new drugs launched in 2017.

75% were specialty drugs

$12 billion spent on new drugs in 2017.

80% was spent on specialty drugs

specialty drugs dominate FDA approval pipeline.

S

• urce: IQVIA Medicine Use and S

pending in t he US , 2017.

12

The US General Accounting Office found that 315 different drugs experienced 351 “ extraordinary price increases” at least a doubling in price year- to-year.

Drug Price Increases are a Problem, Too

13

Drug companies spend about $40B a year MORE

• n marketing and

administrative expenses than on research and the development of new drugs

No, The High Cost is NOT Due to Research

Physician Prescribing Shared Tool

• Assists prescribing based on cost and quality efficacy of prescription vs. DTC ads or

manufacturer incentives to influence specific Rx use.

• Loads payer/ carrier formularies, reimbursements, copay structures, and PAR rules
• Will also host carrier/ payer programs by patient so prescriber can inform patient about

health improvement programs (functional medicine).

• Department Request to Negotiate to be released May/ June 2019 (needs CMS

approval). Prometheus – potentially avoidable costs and quality tool, rolling out now Tele Health / Tele Medicine– rural & front range opportunities

• Key opportunity to address the Disability Community, Behavioral Health, access in rural

communities, S pecialty care access

• Awaiting the roadmap from University

14

Innovations and Shared System Solutions

12+ Teams Actively Strategizing and Implementing Cost Control and Quality Improvement Solutions:

• Hospital Costs, Claim S

ystem, Rx, PACE / S eniors, Fraud-Waste-Abuse, FQHC/ PCP, etc. Medicaid Cost Control Bill SB18-266 passed unanimously, signed into law May 2018. Now in implement at ion!

• Innovations that Improve Quality Outcomes and Costs:
• Prometheus – RAEs have been t rained, Hospit als/ PCMH/ FQHCs – in t raining
• Physician Rx Prescriber Tool – Q4 t arget cont ract
• Medicaid Catch-up with Colorado’s Commercial Carriers
• Hospital Review – March 2019 Implement ed
• Modernize Medicaid Claim Edits - t hroughout lat er 2019
• New HCPF Cost Control & Quality Improvement Office
• HCPF Medicaid Quality analytics and reporting
• HCPF Care Support and Cost Control analytics and programs
• Affordability Roadmap for Coloradans

15

Implementation of 18-266 Medicaid Cost Management

35 Health Care bills in process. S

• me of the more interesting:
• Exchange Reinsurance bill
• Public Plan
• Out of Network bill
• Transparency bill – Hospital (signed int o law)
• Transparency bill - Pharma
• Drug Importation bill
• Investments in Primary Care
• Lots of Behavioral Health bills
• More t o come!

16

Key Healthcare Legislation