Health Plan Update

Mayor and Council PresentationBudget Workshop Meeting

August 16, 2018

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HEALTH CENTERS

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Carla Podgurecki, M.D.

Stephen Bojan,R.N., A.G.P.C.N.P.-B.C.

Wondwessen Kebede,R.N., F.N.P.-B.C.

Juliette Fumtim, M.D.

Sherrie Pierce, D.N.P., R.N., F.N.P.-C.

Health Center Providers

David L Reeve M.D.

Satellite Centers

Hoffman Family Practice Associates - Burleson, Texas

Family Medical Center Southwest - Fort Worth, Texas

Highlands Medical Group - Arlington, Texas

Cornerstone Family and Sports - Keller, Texas

Texas Health Family Care – Weatherford & Willow Park, Texas

Marina da Silva Pinto Coulter, M.D. Fiona Atitso, M.D.

Roger L. Tolar, M.D. Mary P. Van Hal, M.D.

Norma L. Escamilla, D.O. Brent E. Bunnell, D.O.

John G. Hoffman, M.D Destiny F. Smith, R.N., F.N.P.-C.

Patrick A. Conway, D.O Alfred T. Hulse, D.O.

Downtown FW Lakeworth Huguley

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12001 South Freeway, Suite 208 Burleson, TX 76028

600 South Main, Suite 3.60 Fort Worth, TX 76104

6048 Lake Worth Blvd. Fort Worth, TX 76135

Health Center Utilization Total visits January – July

Primary Health Centers: 5,232 Satellite Locations: 1,375 Total: 6,607

56% of available appointments at the health centers have been filled

99% of all specialist referrals went to premium providers

New diabetes program Program launched May 14th

Testosterone treatment program under development September rollout

Twenty-two (22) new procedures now available

5 Satellite LocationsConvenient locations all around North

Texas All locations available to employees,

retirees and their dependentsNot held to same metrics as dedicated

Health Centers, which are guaranteed to offer exclusive services to city employees.

In most cases they may not have same or next day appointments, but will still be 100% covered with no co-pay or co-insurance required for those on the Health Center plan.

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1. Cornerstone Family and Sports100 Bouland Road, Suite 170, Keller, TX 76248

2. Family Medical Center South West7001 Granbury Rd, Fort Worth

3. Hoffman Family Practice Associates PA2730 SW Wilshire Blvd, Burleson

4. Highlands Medical Group– Arlington 400 W. Arbrook Suite 240, Arlington, TX 76014

5. Texas Health Family Care – Willow Park101 Crown Point Blvd., Ste 200 Willow Park, TX 76087

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PHARMACY PLAN

Pharmacy Plan Performance

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$99.22Plan Paid PMPM

Local Government benchmark PMPM$105.64

85.8%Generic Dispensing Rate

Less than Local Government benchmark0.2%

17.2%

8.0% Greater than Local Government benchmark

35.4%Specialty Plan Paid Percent

6.0%

Member Share

Less than LocalGovernment benchmark

$115.13Average Plan Paid/Rx

$1.11 Greater than Local Government benchmark

14,657Average Eligible Member

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Current Health Plan PerformanceThrough June, 2018

ACTIVES + NON-MEDICARE RETIREES

Rx Claims

2/3rds of savings from increased generic usage

17% of savings from better pricing through consortium

Other – cost, formulary and shift in plan enrollment

Generic efficiency rate 99%• The other 1% paying cost

differential

$221.33

$230.96

$54

$104

$154

$204

$254

$304

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

May

-15

Jul-1

5

Sep-

15

Nov

-15

Jan-

16

Mar

-16

May

-16

Jul-1

6

Sep-

16

Nov

-16

Jan-

17

Mar

-17

May

-17

Jul-1

7

Sep-

17

Nov

-17

Jan-

18

Mar

-18

May

-18

Look-Back Rolling 12 Rx Claims Per Employee/Per Month

Actual

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OPIOID USE

1,316

14515 45

<90 90-179 180-240 >240

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Opioid Claims Utilizers

Defined as 3+ opioid scripts within 120 days period; MAT - Medication Assisted Therapy (e.g., buprenorphine, etc..); Overdose Rescue Therapy – opioid overdose reversal with Narcan (naloxone), etc. MED –Morphine Equivalent Dose is a relative potency of an opioid to standard of a morphine; Cumulative MED is daily MED or narcotic load across all active opioid prescriptions in a members profile within a 120 day period; 5JAMA. 2016 Apr 19;315(15):1624-45. 6MME – Morphine Milligram Equivalent represents a relative potency of an opioid to a morphine dose.

CDC Guidelines advise prescribers to manage pain with lowest effective dose and to avoid or carefully justify doses for chronic users >90mg MME/day

Utilizers by Cumulative MED4

Current CDC Guidelines5 urge doses of 90 MME6 or less in chronic opioid utilizers5

exceed 180 MED/day

2.8% higher than high utilizers Employer benchmark1.2% higher than Employer benchmark

25.6%1,521

4.9%3,694

Opioid Utilization Snapshot

are high utilizers1prescription claims filled for an opioid

45Using 3 or more

pharmacies

60

76Using 3 or more

prescribers

96Current

Employees Exceeding 90

MME/day

Poly Pharmacy Poly Prescriber

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Health Plan Measures to Help and Prevent Opioid Addiction

• 1st fill maximum of 50 morphine milligrams/day and seven day supply limits on short-acting opioids

• For chronic utilizers, a drug specific maximum of 90 morphine milligrams/day

• Require prior authorization and quantity limits on all long acting opioids

• Require quantity limits on all opioid-based cold and cough agents + prior authorization for kids

Prescription Fills

• Auto generated patient letter following a fill of an opioid addressing risks; safer alternatives proper disposal and storage

• Outreach to the provider regarding patient-specific opioid users – dangerous drug combinations, excessive early refills, prescriber/pharmacy shopping

• Intensive case management of highest risk utilizers

OptumRXCustomer

Engagement

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WELLNESS

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Broader support for diabetics• Free supplies at the Health Centers (strips, meters and lancets)• Free medications and equipment• More comprehensive educational support program through THR Health Centers• Specialist (Endocrinologist) availability through the Health Centers

Weight management • Two new, FREE programs – Naturally Slim and Real Appeal• Availability of pharmacological weight control agents• Continuation of surgical options

Slow the production and destruction of diseases

2018 - 2019 Wellness Focus

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Contact dedicated staff 24 hours a day to talk to licensed behavioral health professionals for emotional support. Up to six counseling sessions are provided per issue at no cost to participants (no copays or deductibles to worry about).Counselors can help with anxiety and depression, family and relationship issues, caregiving, time management, establishing a work-life balance, and more.

Sessions are available: Face to face On the phone Online through video, from the comfort of your own home (A webcam

and internet access are required)

EAP Program - Counseling & Relationship Support

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In addition to the three (3) baseline VIVERAE requirements (MHA, TOB, PSF), you must also complete at least one (1) Preventive Screening.

Don’t worry…this is not as difficult as you may think. In fact, you probably already do one or more of these preventive screenings now. And when you complete your MHA, and log the date(s) of these on the VIVERAE website, you automatically get the points.

PREVENTIVE CARE COMPLIANCEGENDER-SPECIFIC RECOMMENDATIONS

MALES

(Must complete any 1 of the following)

Dental ExamProstate Exam

Influenza Vaccine (“Flu Shot”)Skin Cancer Screening

Eye ExamPneumonia Vaccine (“Pneumococcal Vaccine”)

Shingles Vaccine (“Herpes Zoster”)Fecal Occult Blood Test (“Stool Test”)

Prostate Specific Antigen Test (“PSA Test”)Colonoscopy

Osteoporosis Screen (“Bone Density Test”)

FEMALES

(Must complete any 1 of the following)

Dental ExamWell Woman Exam

Influenza Vaccine (“Flu Shot”)Pap Test

Eye ExamSkin Cancer Screening

Pneumonia Vaccine (“Pneumococcal Vaccine”)Shingles Vaccine (“Herpes Zoster”)

MammogramFecal Occult Blood Test (“Stool Test”)

ColonoscopyOsteoporosis Screen (“Bone Density Test”)

VIVERAE Requirements – New for 2018

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Mobile Dentist Office: Monthly visits to city buildings Book appointments online Last week of June Expected to save employees

1-3 hours work time Free preventative services for

employees on both PPO dental plans

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MEDICAL PLAN

$923.82

$1,017.71

$500

$600

$700

$800

$900

$1,000

$1,100

Jul-1

4

Sep-

14

Nov

-14

Jan-

15

Mar

-15

May

-15

Jul-1

5

Sep-

15

Nov

-15

Jan-

16

Mar

-16

May

-16

Jul-1

6

Sep-

16

Nov

-16

Jan-

17

Mar

-17

May

-17

Jul-1

7

Sep-

17

Nov

-17

Jan-

18

Mar

-18

May

-18

Look- Back Rolling 12 Medical ClaimsPer Employee/Per Month

Actual

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Current Health Plan PerformanceThrough June, 2018

ACTIVES + NON-MEDICARE RETIREES

Medical Claims

Improved contract pricing with Texas Health Resources

Implemented Health Centers

Transitioned retirees over 65 to Medicare

Plan design changes

Shift in plan enrollment

Recent experience hasbeen down

Absent of aggressivecost control measures,

expect trend to increasein coming months.

6.5%

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Emergency Room Utilization and CostsData through June

Metrics 2017 YTD 2018 YTDVisits per 1000 209.87 172.29Average Paid per Visit $3,350.17 $3,197.06Total Plan Paid $4,368,613 $2,885,928

Overall cost and visits are down

Lower out-of-network

utilization$3,135,179

$2,365,659

$1,233,435

$520,269

$0 $500,000 $1,000,000 $1,500,000 $2,000,000 $2,500,000 $3,000,000

2017 YTD

2018 YTD

In Network vs. Out of Network ER Costs

Out of Network In Network

Other Coverage Exclusion

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Determined to pilot with retirees only

Back-tested• Last two years of claims• Revenue loss from retiree contributions versus claims• Approximate savings - $433,000 or 19.5 percent

• One year $360,000• Other year $73,000

Discussed active spouses and retirees/spouse under age 65

Plan Enrollment Changes

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• Overall from 18% to 37%• Actives increased 112%• Retirees increased 711%• Projected loss of revenue - $5.5 million

Consumer Choice Plan enrollment increased

(lower premium)

• Actives - increased 2%• Retirees – increased to 15% (previously zero)Waiving coverage

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Plan Changes/Premiumsfor 2019

23Consumer Choice Plan employee/retiree only will continue at $0 cost

Retiree premiums remain the same

Employee premiums will remain the same

No significant plan design benefit changesNo changes to deductibles, out-of-pocket maximums, co-pays, etc.

Changes to plans over the last two-years are working

No Changes to Medical Plan Design and Premiums

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Eliminating drug coupon credit toward individual

deductible and out of pocket maximum

Implementing Preferred Copay Card Acceptance Program

Increasing the number of drugs covered by prior authorization

ADDING no cost prescriptions on commonly prescribed

prescriptions in the Health Centers

Expanding exclusion list for “Me Too” and high cost generics

Instituting quantity limits on certain medications, including

opioids

Pharmacy Plan

Preferred Co-pay Card Acceptance Program

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Humira$44,000.00

Copaxone$59,000.00

Enbrel$60,000.00

Rebif$94,000.00

$- $10,000.00 $20,000.00 $30,000.00 $40,000.00 $50,000.00 $60,000.00 $70,000.00 $80,000.00 $90,000.00

$100,000.00

Rheumatoid Arthristis Multiple Sclerosis

Yearly Client Savings per Member: Preferred / Accepted vs. Non-Preferred / High Cost

Preferred / Accepted High Cost / Non-Preferred

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$16 $4 $2,319

“Me Too” Drug Exclusions

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Cost Projections

Group Health Projection FY 2018

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RevenueEmployer Contributions $83,637,325Employee/Retiree $27,083,706Pharmacy Rebates $4,096,000Interest Earned $125,334

Total $114,942,365Expenses

Claims $91,167,415Administration/Other Expense $5,842,018Stop Loss Premium $385,424Salary and Benefits $1,990,082General Operating Other $1,300,426Transfers $9,960Medicare Advantage Premium $9,493,725

Total $110,189,050Surplus/Deficit $4,753,315

Group Health FY2019 Forecast

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Assumptions

Medical and Pharmacy Claims trended at a combined rate of 7.8%

3% increase in City contribution

No increase in employee/retiree contribution

Medicare Advantage cost reduced by $41.83 per enrollee (Health Insurance Tax)

RevenueEmployer Contributions $87,866,411Employee/Retiree $27,037,664Pharmacy Rebates $4,776,631Interest Earned $120,000

Total $119,800,706Expenses

Claims $84,926,221Administration/Other Exp $4,993,167Stop Loss Premium $361,321Salary and Benefits $2,061,502General Operating Other $1,813,610Transfers $14,376Medicare Advantage Premium $8,594,755Transfer to Fire 440 $13,353,397

Total $116,118,349Surplus/Deficit $3,682,357

Issues/Concerns/Opportunities

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Impact of Fire Fighters leaving plan

No shows in Health Centers

Further leveraging the Health Centers