UNIVERSAL ACCESS TO CARE WORK GROUP 2018 1 LPRO : L EGISLATIVE P - - PowerPoint PPT Presentation

UNIVERSAL ACCESS TO CARE WORK GROUP 2018

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

August 23, 2018

1

AGENDA

Welcome, Opening Remarks ………………………………………………………………………………..8:00—8:10am

• Representative Salinas, Chair, Work Group

Path to Universal Coverage in California – A Comprehensive Report …………………………8:10-—9:15 am

• Andrew Bindman, MD, University of California San Francisco

DCBS Marketplace Advisory Committee………….…………………………………………………….9:15—9:45am

• Dan Field, Chair, Marketplace Advisory Committee
• Chiqui Flowers, Administrator, Health Insurance Marketplace

America’s Health Insurance Plans: Medicaid Buy-in………………………………………………..9:45—10:15am

• Elise Brown, AHIP
• Sunshine Moore, AHIP

Medicaid Buy-in: Oregon Policy Goals and Design Considerations…………………………….10:15—11:00am

• Tim Sweeney, OHA

Zachary Goldman, OHA

• Jesse O’Brien, DCBS

Oliver Droppers, LPRO Work Group Discussion: Medicaid Buy

• in …………………………………………………………….11:00—11:45am
• Representative Salinas, Chair

Public Comment………………………………………………………………………………………………11:45—12:00pm

• Representative Salinas, Chair

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

2

Today’s Objectives

• Learn about California’s path to universal coverage including identified strategies for improving

their health care system

• Learn about Oregon’s Marketplace Advisory Committee
• Committee’s policy priorities in 2018
• Consider Medicaid buy-in option in Oregon; preliminary design considerations
• Identify and confirm potential policy goals
• Identify initial design considerations
• Discuss next steps –September
• For September, the goals are to:

1. Review potential straw models for a Medicaid buy-in in Oregon based on preferred policy goals identified today 2. Consider advantages and disadvantages 3. Identify feasibility considerations (e.g., 1332 waiver, risk pools, on/off exchange, potential changes in APTC)

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

3

The Marketplace Advisory Committee

5

• Established in ORS 741.004
• Created to advise DCBS regarding:
• The assessment paid by insurance

companies

• Outreach strategies for reaching

minority and low-income communities

• Solicitation of customer feedback
• The affordability of health benefit plans
• ffered through the exchange.

The Marketplace advisory committee

6

• New committee workgroup on market

stability for consumers

• Their initial work identified indicators of

market stability: affordability, choice, accessibility

• Affordability is first area of focus
• Rising premiums, out-of-pocket

maximums

• People who qualify for subsidies

protected from premium increases

The Marketplace advisory committee

7

• A second workgroup is reviewing options

for eligibility and enrollment platforms

• Group respects public’s and leaders’

sensitivity around this topic

• Costs to use HealthCare.gov have gone up
• HealthCare.gov fee structure ensures

costs will continue to rise

• Landscape of technology options has

changed

• Different technology may permit more

flexibility

The Marketplace advisory committee

MEDICAID BUY-IN: OREGON CONSIDERATIONS

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

8

Abou

• ut A

AHIP IP

America’s Health Insurance Plans (AHIP) is the national association whose members provide coverage for health care and related services to millions of Americans every day. Through these offerings, we improve and protect the health and financial security of consumers, families, businesses, communities and the nation. We are committed to market-based solutions and public-private partnerships that improve affordability, value, access and well-being for consumers. Accident & Health Business Markets represented by AHIP in the United States:

• Major Medical
• Medicaid
• Medicare Advantage
• Medicare Supplemental Insurance

(Medigap)

• Supplemental Health
• Long-Term Care
• Disability Income Insurance
• Dental
• Vision

I. Level Setting – Coverage in Context II. Key Questions 1. Why and For Whom? 2. What is it and how does it work? 3. Market impact and affordability?

• III. Alternatives

1. Increase enrollment, improve the risk mix 2. Lower costs for consumers 3. Lower costs for everyone

Considerations for Medicaid Buy-In

10

• I. Level Setting – Coverage in Context

11

Point in time uninsured = 6.2% but… Long-term uninsured = 3.3% …more than 80% of uninsured people qualified for either OHP or financial assistance. There are currently about 243,000 uninsured people in

• Oregon. If 80% of these people gained health

insurance coverage, about 34,000 Oregonians would remain uninsured

Top reason for long- term uninsured = cost

I. Level Setting – Coverage in Context II. Key Questions 1. Why and For Whom? 2. What is it and how does it work? 3. Market impact and affordability?

• III. Alternatives

1. Increase enrollment, improve the risk mix 2. Lower costs for consumers 3. Lower costs for everyone

• II. Key Questions

12

• 1. Increase Enrollment/Improve the Risk Mix
• Marketing and outreach for those already eligible
• Promote continuous coverage
• Promote health and wellness/social determinants of health
• Protect non-medical, consumer-oriented benefits and services
• III. Alternatives

13

• 2. Lower costs for consumers
• State-based premium assistance programs
• State-based reinsurance (i.e. 1332 waiver)
• Tax Changes (i.e. Tax-deductible premiums, HSA flexibility)
• III. Alternatives

14

• 3. Lower costs for everyone
• Promote lower list prices, transparency, competition, and value

in prescription drug pricing

• Protect consumers from surprise out-of-network bills
• Curb inappropriate steering/third-party payments
• Support efforts to address over/under/misuse of goods and

services – maximize health care dollars

• Support efforts to target fraud, waste, and abuse
• Expand telehealth, wellness programs, and other innovative

approaches

• Eliminate taxes/fees that harm consumers and increase

premiums

• III. Alternatives

15

16

Where Does Your Health Care Dollar Go?

• 3. Lower costs for everyone
• Promote lower list prices, transparency, competition, and value

in prescription drug pricing

• Protect consumers from surprise out-of-network bills
• Curb inappropriate steering/third-party payments
• Support efforts to address over/under/misuse of goods and

services – maximize health care dollars

• Support efforts to target fraud, waste, and abuse
• Expand telehealth, wellness programs, and other innovative

approaches

• Eliminate taxes/fees that harm consumers and increase

premiums

• III. Alternatives

17

Market Instability Adds to Premiums

18

EMPLOYER MARKET

Short Ter erm Pl m Plan ans

INDIVIDUAL MARKET

No Ind ndividual M Mand ndate +9 to 1 10% Risk C Corr rridors rs +$12 +$12.3 b 3 billion CSRs +20 +20 to 25% 25% AHPs +2. +2.7 7 - 4% 4% St State Ma Manda dates HIT +3% +3% Medical Trends/Drugs +5.7 - 6.5% Exchange U User Fees

Source: https://www.ahip.org/2019-premiums-individual-market/

/ahip @ahipcoverage AHIP ahip.org

Questions? Thank you!

smoore@ahip.org | 916.996.2376

Appendix

5 Factors Impacting Premiums

21

Source: https://www.ahip.org/5-factors-that-impact-your-health-insurance-premium/

• Promote generic competition (CREATES Act).
• Develop a robust and competitive market for

biosimilars and interchangeables.

• Expand the leverage and tools plans have to

negotiate lower drug costs (e.g., flexibility to better manage formularies).

• Increase transparency in how drug

companies set prices.

• Develop an infrastructure for independent

reporting of value.

Lowering Drug List Prices

22

“Reducing list prices is the fundamental goal of our policy solutions for prescription drugs” - AHIP

https://www.ahip.org/wp-content/uploads/2018/07/AHIP-Part-D-Rebates-20180716.pdf

Premium Impacts 2013-2015

23 Majority of premium increase is attributable to the change in Health Status (“Morbidity”).

Source: “Stabilizing the Individual Insurance Market”, Oliver Wyman, August 23, 2017; Accessed at http://health.oliverwyman.com/c

• ntent/dam/oliver-

wyman/blog/hls/featured- images/August2017/_Stabilizin g_the_Individual_Health_Insur ance_Market.pdf

High Cost Drugs: Is It the R&D?

Source: Vox, “9 of 10 top drugmakers spend more on marketing than research”, February 27, 2015, http://www.vox.com/2015/2/11/8018691/big-pharma-research-advertising

A Broken and Distorted Market

25

Government-granted monopolies via patent system and market exclusivity provisions in federal law

Market Dysfunction

(via problematic marketing, legal, and regulatory practices)

HIGH PRICES HIGHER COSTS

Product-hopping

Artificially prolonging drug patents to avoid competition from generics, resulting in fewer treatment options and sky-high costs for consumers

Biosimilar Blocking

Delaying or blocking a less costly biosimilar version of a drug

Pay-to-Delay

Paying generic drugmakers to keep lower- cost competition out of the market

Acquisitions of Drug Rights

Buying specific drug rights deemed undervalued to subsequently increase prices

Orphan Drug Status Abuses

Drugs that are approved as “Orphan Disease Drugs” but subsequently used for common use

What’s Driving Prices? Patent Dynamics and Other Pricing Strategies

• 2. What problems are the work group

being task to solve in Oregon?

• Policy pathway to universal coverage
• Better care, more people, less money
• Access issues (rural/urban, income disparities)
• Affordability
• Address unmet health care needs
• Address cost drivers; administrative burden, system

complexity, & financial accountability

27

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

* Information from the April 19th workgroup meeting

Member Observations - July

What questions do you have about designing a Medicaid buy-in program in Oregon?

• Potential role of a Medicaid buy-in option as a “public option” coverage

program in Oregon?

• Level of behavioral health benefits in a Medicaid buy-in option

compared to existing coverage in Marketplace offerings

• Different financial reserve requirements among CCOs and Marketplace

carriers

• Creation of a new entity to operate a Medicaid buy-in option
• Potential role for rate-setting in a Medicaid buy-in option
• Utilization and access to primary care services
• Existing funding sources for coverage in Oregon (public & private)
• Potential impact to state’s budget

LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

28

Place Your Logo Here - Align Center

Medicaid Buy-In Discussion

August 23, 2018 Universal Access to Healthcare Workgroup

Place Your Logo Here - Align Center

30

Disclaimer

The following presentation outlines some important considerations for the Universal Access to Health Care Work Group and does not reflect any recommendations from the Oregon Health Authority or the Department of Consumer and Business Services.

Place Your Logo Here - Align Center

31

Introduction

The term “Medicaid buy-in” can mean many different things and can be

• perationalized in multiple ways

Today’s discussion will focus on 1. Useful data points for reference 2. Some of the high-level goals that Work Group members could adopt as priorities

Place Your Logo Here - Align Center

32

Comparing Medicaid and Commercial Coverage is Inherently Difficult

Benefit Differences:

• Long-standing differences in target populations lead to differing

benefits, structure, and delivery systems

• ACA expansion has increased connectedness; differences remain

Actuarial Value comparisons:

• Marketplace AV calculations are a function of enrollee out-of-pocket

costs; Medicaid enrollees pay little to no out-of-pocket costs Payment rate differences:

• Comparing Medicaid to commercial rates is difficult due to lack of

consistent data on commercial payment schedules

• More data is available to compare Medicaid to Medicare rates

Place Your Logo Here - Align Center

33

Notable Differences in Services Covered by OHP & Benchmark Plan

Differences in Covered Services Benchmark Plan Oregon Health Plan

Acupuncture/Chiropractic/Massage therapy

No Yes, for certain conditions

Naturopathic care

No Yes

Non-emergency medical transport

No Yes

Vision care

No Yes, excluding adults

Dental (all ages)*

No Yes

Hearing aids

No Yes

Home based habilitative services

No Yes

Early periodic screening, diagnostic, and treatment (EPSDT)

No Yes

Targeted case management

No Yes

Private duty nursing services

No Yes

Intermediate care services

No Yes

Extended services for pregnant women

No Yes

Personal care services

No Yes

Place Your Logo Here - Align Center

34

CCO Professional Services Reimbursement Rates vs. Medicare

70% 80% 90% 100% 110% A B C D E F G H I J K L M N 2016 Professional Svcs vs. Medicare Medicare

Source: 2018 CCO Rate Development Actuarial Certification

Place Your Logo Here - Align Center

35

Useful Data Points for this Discussion

The 2015 Physicians Workforce Survey results show that the majority (87.9%) of responding physicians in Oregon are accepting new Medicaid patients. https://www.oregon.gov/oha/HPA/ANALYTICS/Documents/2015Physi cianWorkforceFactSheet.pdf

Place Your Logo Here - Align Center

36

Current map of CCOs

Place Your Logo Here - Align Center

37

Healthcare.gov plans, 2019

https://dfr.oregon.gov/healthrates/Documents/2019-fnl-prpsd-rates.pdf

Place Your Logo Here - Align Center

38

Individual market (off-Exchange), 2019

https://dfr.oregon.gov/healthrates/Documents/2019-fnl-prpsd-rates.pdf

Place Your Logo Here - Align Center

39

Details of Desired Policy Goals Will Help Identify Structure of Medicaid Buy-in

High-Level Goal: Expand Health Coverage in Oregon What are the Work Group Priorities to get there:

• Reduce monthly premiums
• Reduce out-of-pocket costs
• Enhance benefits or value for given premium
• Additional consumer choice

Place Your Logo Here - Align Center

40

Details of Desired Policy Goals Will Help Identify Structure of Medicaid Buy-in

High-Level Goal: Stabilize / strengthen individual market What are the Work Group Priorities to get there:

• Carrier of last resort
• More plans on the marketplace
• Increased plan offerings
• Other regulatory approaches (e.g. individual mandate, additional

reinsurance programs, etc.)

Place Your Logo Here - Align Center

41

Details of Desired Policy Goals Will Help Identify Structure of Medicaid Buy-in

High-Level Goal: Spread Oregon’s Health Care Transformation What are the Work Group Priorities to get there:

• CCO-type plans on the marketplace (individual market)
• CCO-like financial incentives on the marketplace (individual market)

Place Your Logo Here - Align Center

42

Details of Desired Policy Goals Will Help Identify Structure of Medicaid Buy-in

High-Level Goal: Streamline transitions for consumers between Medicaid & private coverage What are the Work Group Priorities to get there:

• CCOs offering plans on the marketplace (individual market)
• CCOs offering plans to small group market

Place Your Logo Here - Align Center

43

Other important issues for later discussions

• Federal waiver considerations
• Role of CCOs
• Impact on commercial market
• Impact on providers, hospitals, clinics
• State costs or savings
• Trade-offs between potential goals

Medicaid Buy-in Design Considerations

1. What is the overall policy goal? Is it to increase coverage? Improve affordability? Increase competition by creating another marketplace option? Leverage delivery system reform through Oregon’s Medicaid program? 2. How many individuals would gain new coverage of shift existing coverage? What is the target population? What’s the income level? Exclude individuals eligible for employer-based coverage? 3. Would the buy-in program be administered as an extension of the ACA Medicaid program (low-income individuals and families), or as a stand alone program? Managed care or fee-for-service? 4. What benefits would be covered? OHP benefits or 10 essential health benefits? Long-term services, adult dental benefits, non-emergency transportation LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

44

Medicaid Buy-in Design Considerations

5. What is the appropriate level of out-of-pocket costs? How would cost sharing be structured: co-pays, premiums, deductibles? Similar to Marketplace, Medicaid, in between, other? 6. How would premiums be setting and corresponding premium assistance determined? Would premiums be set by the state (similar to Medicaid), or would rates be developed by carriers in the marketplace? Would certain populations pay not premiums? 7. Provider reimbursement? Medicaid level, commercial, or in between (e.g., Medicare fee-for-service)? Potential cost savings to the program based differences between market coverage and the buy-in program? 8. What federal dollars would be available? How much federal funding would be available, if any, and what percentage of program costs can federal spending support? LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

45

Next Steps - September

The goals are to:

• 1. Review potential straw models for a Medicaid buy-in in Oregon based on

preferred policy goals identified today

• 2. Consider advantages and disadvantages
• 3. Identify feasibility considerations (e.g., 1332 waiver, risk pools, on/off

exchange, market stabilization, carrier participation, potential changes in APTC) Learn about Project Access Now – Affordability Coverage Programs (e.g. premium assistance) LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE

46