seow attachment 1 january 8, 2019
TRANSCRIPT
SEOW Attachment 1 January 8, 2019
Page 1 of 4
Oregon Educators Benefit Board
Strategies on Evidence and Outcomes Workgroup
December 4, 2018
Meeting Synopsis
The Strategies on Evidence and Outcomes Workgroup (SEOW) of the Oregon Educators Benefit
Board held a meeting on December 4, 2018 at the Oregon Health Licensing Office.
Attendees:
Workgroup Members:
Tom Syltebo, SEOW Chair
Geoff Brown
Robert Young
Ron Gallinat
Staff/Consultant:
Glenn Baly, OEBB
Ali Hassoun, PEBB/OEBB
Jenny Marks, Willis Towers Watson
Steve Carlson, Willis Towers Watson
Dr. Jeff Thompson, Willis Towers Watson
Brad Lawson, Willis Towers Watson
Carriers/Other Representatives:
Kraig Anderson, Moda Health
Dr. Jim Rickards, Moda Health
Erica Hedberg, Moda Health
Dr. Keith Bachman, Kaiser Permanente
1. November 2018 SEOW Meeting Synopsis (SEOW Attachment 1)
SEOW approved the November 2018 meeting synopsis without any changes.
2. OEBB Coordinated Care Model: Focusing on Primary Care (SEOW Handout A)
Dr. Jim Rickards & Kraig Anderson reviewed Moda’s proposal to redesign the current
Summit/Synergy Plans for the 2019-20 Plan Year, including:
• Summit/Synergy background and need for redesign
• Redesign Concept
SEOW Attachment 1 January 8, 2019
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o Merge Synergy/Summit and Connexus Plans
o C-3 like benefits enrollment
o Incentivize through member benefits not price
o Align incentives between member, provider, and payer
SEOW Action/Information Request
Geoff Brown sad OEBB needs to develop a communications plan to explain the benefits of
Summit/Synergy and the medical home model (PCPCH)
Tom Sytebo said SEOW should look at cost / quality relationship in July 2019 Tom Syltebo asked that Moda provide an expanded presentation on development and
implementation of quality and performance metrics that are part of the Data Collaboration in
Summit/Synergy, including:
• Where is Moda going with the Collaborative (goals)?
• What metrics are being considered as part of the move from a claims/payment based model to quality/performance based model?
• Which clinics / providers are involved in the data sharing now and how is the arena of participating providers being expanded?
• Type of data collected, including health risk and outcome data. Deidentified quality
report.
• What is the state of data sharing between Urgent Care Centers and Moda? What are the
plans to expand data sharing between/among Urgent Care Centers and Moda?
• What are Moda’s plans for expanded data sharing in their market outside of OEBB?
Geoff Brown asked that a price variation comparison report be provided major joint surgery
under reference pricing and Summit/Synergy.
Tom Syltebo asked for more detailed review of the total cost of care model and CCM 2.0.
Tom Sytebo said that premium impact data needs to be provided for CCM 2.0 and would like
to review and discuss what happens to existing renewal guarantees
Ron Gallinat asked what implementation challenges Moda foresees for CCM 2.0
Robert Young asked if CCM 2.0 would cause navigation challenges for members.
Tom Syltebo asked what changes need to occur with the current model to incorporate the
External Forces (below) if OEBB decides to stay with the current model
SEOW Attachment 1 January 8, 2019
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• SB 1067 - 200% of Medicare
• SB 934 - Medical Primary Care spend requirements
• HB 2009 - Patient Centered Primary Care Homes
• CPC+ Program
• CCO 2.0
3. Utilization and Claim Review: OEBB Opportunity Analysis (SEOW Attachment 2)
Jenny Marks and Dr. Jeff Thompson reviewed the opportunity analysis related to a review of
OEBB claims and utilization, including
• Project objectives
• Scope/Process
• Overview of Findings (claimant examples)
• Carrier next steps
• Carrier report back
SEOW Action/Information Request
SEOW would like additional information re: Ardon Health and Medical Use Evaluation
programs
Tom Syltebo highlighted 3 things from Kaiser to work on /follow up:
• Addressing mental health/compliance with depression medications
• Infusion Rooms
• Proactive chart review by teams for members with high ER utilization
And three 3 things for Moda to work on/follow up:
• Addressing HCC through engagement of members in C3
• Case Management for members with multiple ER visits
• Review potential for Site of Care program for cancer treatment
Tom Syltebo asked what the HbA1c performance measures wants for Kaiser Moda.
4. OEBB Wellness Program – 2019-20 Program Recommendations (SEOW Attachment #3)
Glenn Baly and Jenny Marks reviewed the 2019-20 recommendations for OEBB wellness
programs, including:
SEOW Attachment 1 January 8, 2019
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• Overview of Wellness Subgroup Work
• Program/Vendor Review Key Findings
• Weight Watchers Recommendations
• Healthy Team Healthy U Recommendations
• Better Choices Better Health/Virtual Lifestyle Management Recommendations
• Next Steps
SEOW Action/Information Request
SEOW will decide on the wellness program recommendations at the January 8 meeting when
pricing options are provided.
4. New Business (12/4 Board Meeting Request)
• Benefit Change Request – Infertility Benefits
Areas to Consider:
• Types of Infertility Benefits (What’s covered and What isn’t)
• Market prevalence/utilization of infertility benefits
• Number of affected people (level of fertility issues)
• Costs and Premium Impacts
• Any other concerns
No public comment.
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OEBB Wellness ProgramProposed Carrier/Vendor Renewal Costs
January 8, 2019
SEOW Attachment 2
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Agenda
Summary of current and projected program costs
Proposed vendor renewals — detailed
Better Choices Better Health
Diabetes Prevention/Virtual Lifestyle Management
Healthy Team Healthy U
Weight Watchers
Recommendations
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This report was prepared for your sole and exclusive use and on the basis agreed with you. It was not prepared for use by any other party and
may not address their needs, concerns or objectives. This report should not be disclosed or distributed to any third party other than as agreed with
you in writing. We do not assume any responsibility, or accept any duty of care or liability to any third party who may obtain a copy of this report
and any reliance placed by such party on it is entirely at their own risk .
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Summary of Current Costs
Program Participants
Costs
2018 – 2019 (Projected)2019 – 2020
(Projected)
Canary Health:
Better Choices Better Health 442 $82,000 $98,000
Canary Health:
Virtual Lifestyle Management572 $130,000 $161,000
Healthy Team Healthy U 7,527 $749,000 $749,000
Weight Watchers 8,935 $1,848,000 $1,250,000
Moda Health Coaching 472 $1,860,000 $1,860,000
Moda Weight Management Included above $580,000 $580,000
Moda Tobacco Cessation 36 $471,000 $471,000
Kaiser Health Coaching 1,390 $251,000 $251,000
Total $5,971,000 $5,420,000
3
2018 – 2019 projected costs are based on participation numbers achieved during the 2017 – 2018 plan year
2019 – 2020 projected costs are based on participation assumptions from the 2017 – 2018 plan year
Actual participation levels for each year may yield higher or lower costs
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Proposed Vendor Renewals
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Canary Health
Better Choices Better Health
5
Current offering: chronic condition management peer group support
Access to BCBH application
Small group support system with trained peer moderators
Living a Health Life with Chronic Conditions book/e-book
Weekly lessons and action planning tools
Engagement rate in 2017 – 2018:
Initial enrollment: 442
Completed program: 63
Current and proposed cost structure:
MilestoneCurrent
Cost/milestone
Renewal
Cost/milestone
Initial enrollment in the
program$160 $195
Completion of the six-week
program$175 $195
Projected annual cost $82,000 $98,000
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Canary Health
Virtual Lifestyle Management
6
Current offering: diabetes prevention program
Access to VLM application including lessons, weight tracking and group chat
Online coaching support
Activity monitoring and tracking tools
Digital scale with feeds to online tracking tool
Engagement rate in 2017 – 2018:
Initial enrollment/orientation: 423
4 lessons completed: 174
8 lessons completed: 108
16 lessons completed: 55
Current cost structure:
$255/initial enrollment
$65/completion of each 4,8 and 16 lesson milestones
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Canary Health
Virtual Lifestyle Management (Continued)
7
Canary Health proposed two options for renewal cost structure
Lesson completed approach (similar to current arrangement)
Time based and weight loss milestones
Lesson completed Time and Weight Loss
Initial enrollment/
orientation$195
Initial enrollment/
orientation$195
4 lessons completed $195 Active 1 month $195
8 lessons completed $195 Active 2 – 3 months $195
16 lessons completed $195 5% weight loss $195
Annual projected cost $148,000 $161,000
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Healthy Team Health U
Renewal Current Offerings
8
HTHU 1.0, HTHU 2.0 and HTHU 3.0 – 12-week lifestyle behavior change
programs
Supporting Products/Services
Activity/Blood Pressure Monitor
Web Platform/Mobile App
Health Risk Assessment
Guided Meditation App Subscription
Advanced Activity Tracking
Online Coaching
Exercise video series, healthy recipes, digital health games
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Healthy Team Healthy U
Renewal Proposal
Participants EnrolledCurrent and Renewal Cost
Structure (PPPY)
Up to 10,000 $84.00
10,001 – 14,999 $81.48
15,000 – 19,999 $79.04
20,000 – 24,999 $76.66
25,000 – 29,999 $74.36
9
Number of Participants
2017 – 2018Projected Annual Cost
7,527 $749,000
Additional costs include activity and blood pressure monitors
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Weight Watchers
10
Current offering:
Workplace workshops + digital (13 week voucher)
Community workshops + digital (13 week voucher)
Digital only (three-month subscription)
Initial 13-week program is provided at no charge to the member; subsequent 13-week programs
are available at no charge if the member can demonstrate participation in at least 10 of the 13
weeks
Current cost structure
13-Week Cost
Workplace workshops + digital $163.10 (12.55/week)
Community workshops + digital $125.80 ($9.68/week)
Digital only $57.75 ($4.44/week)
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Weight Watchers (Continued)
11
Weight Watchers proposed two alternate pricing structures renewal consideration
Fixed fee of $1,250,000/year for a two-year period with a performance guarantee
Per participant per month structure
Fixed Fee Per Participant Per Month
Workplace workshops + digital
$1,250,000
$44.95 ($10.37/week)
Community workshops + digital $44.95 ($10.37/week)
Digital only $19.95 ($4.60/week)
Projected annual cost $1,250,000 $3,900,000
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Recommendations
OEBB staff and consultants recommend accepting the following renewals:
Canary Health’s BCBH renewal as proposed
Canary Health’s VLM proposal for engagement time/weight loss achieved
Renewal of Staywell’s Healthy Team Healthy U program (no change)
Weight Watcher’s fixed fee renewal proposal
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H E A LT H W E A LT H C A R E E R
JANUARY 8, 2019
Robert Valdez, CEBS, FLMI
Principal
P E B B D R A F T R O A D M A P
SEOW Attachment 3
1Copyright © 2019 Mercer (US) Inc. All rights reserved.
P E B B ’ S R O A D M A P V S . O H A’ S C C O 2 . 0
O H A R O A D M A P
2021
• 20% VBP target
2022
• 35% VBP target
2023
• 50% VBP target
2024
• 60% VBP target
2025
• 70% VBP target
• Mercer recommends PEBB consider more aggressive Value-Based-Payment targets:
‒ 2021-2024: Category 2C, transitioning to Category 3
‒ By 2025: Category 3B (APMs with Shared Savings and Downside Risk)
‒ ACO/CCO will be required to have a minimum Category 4 payment model after six years of
development/implementation
2020
• 20% VBP target
2021
• 35% VBP target
2022
• 50% VBP target
2023
• 60% VBP target
2024
• 70% VBP target
• OHA’s CCO payments to providers must be in the form of a VBP and fall within LAN Category 2C (Pay for
Performance) or higher
P E B B D R A F T R O A D M A P
2Copyright © 2019 Mercer (US) Inc. All rights reserved.
P E B B ’ S R O A D M A P V S . O H A’ S C C O 2 . 0
F I N A N C I A L R O A D M A P
Source: APM Framework, HCP-LAN,2017
3Copyright © 2019 Mercer (US) Inc. All rights reserved.
OEBB Data Roadmap
SEOW Meeting
SEOW Attachment 4
January 8, 2019
© 2019 Willis Towers Watson. All rights reserved.
Agenda
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Overview/review of return on investment and value of investment
OEBB data sources
How to measure success
High-level data plan strategy
Vendor-partner data and measurement opportunities
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What do we mean by ROI and VOI?
3
Return on Investment (ROI) measures only medical claims cost savings, while Value on
Investment (VOI) also captures broader impacts of wellbeing programs
ROI VOI
Typically refers to financial benefits divided by program
costs
Claims cost savings targets are typically:
Inpatient admissions and stays
Emergency room visits
Laboratory and imaging tests
Large claims
Pharmacy utilization
Sometimes, ROI calculation includes other easily
monetized savings such as:
Workforce disability
Work absence when available
ROI answers the question — “Did we get cost
savings greater than our wellbeing investment?”
Incorporates a broader range of benefits beyond medical
claims cost reduction alone, that may include:
Population health metrics
Health risks
Biometric measures
Activity, fitness levels
Program participation
Stress, resilience measures
Employee productivity metrics
Absenteeism, lost days from work
Presenteeism
WC, STD, LTD
Other business benefits
Organizational culture of health
Reputation, “employer of choice”
Talent recruitment, retention
Workforce morale
Business competitiveness
Company performance, stock price
VOI answers the question — “What is the total value
we got from our wellbeing investment?”
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Full Costs
From Poor Health 30%
70%
Medical Care and
Pharmaceutical Costs
Health-Related
Productivity Costs
Absenteeism Short-term disability
Long-term disability
Presenteeism Overtime
Turnover
Temporary staffing
Administrative costs
Replacement training
Off-site travel for care
Customer dissatisfaction
Variable product quality
ROI is an incomplete measure of potential wellbeing benefits
Conventional ROI analyses only address the tip of this iceberg
4
Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152
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Which programs are appropriate for ROI evaluation and which are
appropriate for VOI evaluation?
5
Type of Program Target PopulationImpact on Medical
Claims
Appropriate
Evaluation Method
Wellbeing programs aimed at
improving physical, emotional,
financial and social health
The entire population Little or no impact on
short-term medical
claims costs
VOI
Medical management programs
aimed to better coordinate care of
those with serious illness
High-risk portion of
covered population
Should lower short-term
medical claims costs
ROI
All employer-sponsored programs bring unmeasured additional value to
employers to the extent they are valued by members
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OEBB data sources — 2018
6
Kaiser and Moda:
Medical claims and spend
Rx claims and spend
Risk level by chronic condition
Engagement/participation condition management
Outreach condition management
Canary Health:
Annual report — Better Choices Better Health
Annual report — Virtual Lifestyle Management
Weight Watchers:
Annual reporting:
Communication and outreach
Engagement and participation
Outcomes
Modality
Research report with Kaiser
HTHU — StayWell:
Annual report:
Communication
Engagement and completion by program
Self-reported outcomes
Data Warehouse:
Truven warehouse — WTW and carriers
Additional:
BSSE survey
HERO report (Kaiser)
WTW data request spreadsheet to vendors
Program awareness survey
OEA Choice Trust — data on entity activity
Stress and resiliency vendor (Kaiser) (Future)
OEBB website click rate and type (Potential)
Communication outreach and type
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How to measure success
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Sample list
Increase in participation in all programs — from prior year
Increase in completion rates in all programs — from prior year
Increase in entity engagement — from prior year
Verified data indicating reduction of risk factors, i.e., lower blood pressure, increase in HDL
Verified weight loss
Participant vs. non-participant and/or cohort analysis year-over-year: vendor-partner, carrier, data warehouse
Risk migration (low, moderate, high)
Improved overall health risk score
Increase in preventive exams/primary care engagement
Closure of gaps in care for specific conditions
Rx analysis, i.e. individual’s reduction in medication (Metformin)
Employee satisfaction
• Overall
• Specific programs
• Current program offerings
Increased use of OEBB wellbeing communication resources, i.e., website
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Data plan overview
8
2019 – 2020 2020 – 2021 2022 – 2023
Engagement & Data Alignment
Identify participation for each
program and offering
Establish benchmarks and
participation goals
Establish cadence of reporting
Measure current year against past
years, benchmarks and goals
Review data against success
metrics established with vendor-
partners
Completion rate
Participation
Identify areas for cohort analysis
Diabetes participants
WW participants
Work with OEA Choice Trust and
Moda’s Wellbeing Consultants to
establish entity participation and
goals
Measurement & Analytics
Continue participation and
engagement measurement
Establish specific program analytic
projects for each vendor-partner
specific to VOI, ROI, participant
vs. non-participant, medical, Rx
claims, etc.
Cohort risk reduction
Verified weight loss
Conduct cost/benefit analysis and
areas of opportunity
Identify opportunities for
measurement within the Truven
data warehouse
Create dashboards for quarterly
and annual review
Ongoing Review & Analysis
Continue prior year’s projects
Enhance measurement scope to
include additional data elements:
(for example)
EAP utilization
Financial programs
Entity engagement
Add, enhance or remove vendor-
partners based on data and
impact
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Weight Watchers (WW)
9
Metrics:
Eligible population
Registered for program
Number of sessions/weeks attended
Completion of program
Average reported weight (self-reported or verified)
Average percent of weight loss
Additional program outcomes
Targeted outreach to members
Opportunities:
Engagement and completion metrics by modality and location
Cohort year-over-year reporting
Work with carriers or WTW’s measurement team to assist with ROI analysis (similar to Kaiser and WW report)
Need WW-provided benchmarks for above metrics
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Wellbeing vendor — HTHU (StayWell)
10
Metrics:
Eligible population
Employees with registrations
Participation in various program offerings
Completion of various programs started
Self-reported outcomes (pre/post)
Satisfaction
Opportunities:
Verified data, i.e., physician forms, biometrics, digital scale, digital blood pressure, etc.
Aggregate data by location
Cohort data — year over year
Integration with Kaiser and Moda for participant/non-participant analysis
Current data and metrics are suitable for VOI. Verified data integrated with medical claims, etc. could produce ROI
analytics (participant vs. non-participant, program-specific impact analysis, etc.)
Decisions regarding OEBB’s relationship with StayWell will impact metrics and analysis
Decisions regarding incentives and marketing of HTHU with impact metrics and analysis
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Metrics BCBH:
Clinically eligible population — Kaiser and Moda
Members signed up
Members started a workshop
Members attended 4 of 6 week “Completion”
Members completing all 6 weeks
Satisfaction
Member outreach
Opportunities:
Verified biometrics
Cohort year-over-year reporting
Aggregate risk migration of identified members, i.e. Low risk in year 1 to moderate risk in year 2
More meaningful metrics around claims and spend — participant vs. non-participant (Canary, carrier, data warehouse)
Work with WTW’s measurement team to assist with ROI analysis (currently receiving claims data from both Kaiser and
Moda)
Identify ways to track member’s participation in online condition management programs for analysis
Need Canary Health provided benchmarks for above metrics
Metrics VLM:
Eligible population — Kaiser and Moda
Members signed up
Members enrolled
Members completed lessons 4, 9 and or 16
Member average weight, BMI and weight loss
% of members that lost at least 5%
Satisfaction
Member outreach
Chronic condition — Canary Health
11
Better Choices Better Health (BCBH) and Virtual Lifestyle Management (VLM)
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Chronic condition — Kaiser and Moda
12
Metrics:
Eligible population — medical plan participants with diagnosis of diabetes, asthma, COPD, HF or CAD
Stratification of member risk by condition — low, moderate or high
Confirm only moderate or high-risk members are targeted for condition management programs
Participation in condition management programs ← engagement Completion of condition management programs started
Management of condition, i.e., A1c (HEDIS measures)
Rx and medical claims for analysis (participant vs. non-participant, closure of gaps in care, etc.)
Targeted outreach to members
Opportunities:
100% outreach to moderate and high-risk members
Cohort year-over-year reporting — compliance and Rx dosage and adherence
Aggregate risk migration of identified members, i.e., low risk in year 1 to moderate risk in year 2
Work with WTW’s measurement team to assist with ROI analysis (currently receiving claims data from both Kaiser and
Moda)
Identify ways to track member participation in online condition management programs for analysis
Need Kaiser- and Moda-provided benchmarks for above metrics
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Sample Dashboard Example
Appendix
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VLM, 5%
Canary, 6%
W.W. , 47%
HTHU, 26%
Chronic Condition - Kaiser ,
8%
Virtual Lifestyle Management (DPP Program):
• 16 week core program, followed by eight monthly maintenance lessons
Moda Condition Management:• Engagement in Moda’s chronic
condition management program –moderate and high risk members –was 18%
18%
Healthy Team Healthy U (HTHU):• A clinically validated workplace wellness
program proven to impact behaviors, improve employee health, and deliver outcomes
Blood Pressure:Percentage of subscribers with a recorded blood pressure ≥ 140/90
Smoking:Percentage of subscribers who have indicated they are smokers
Depression:Percentage of subscribers with recorded diagnosis of depression
Weight (BMI):Percentage of subscribers with a recorded BMI ≥ 30
Diabetes:Percentage of subscribers with a recorded diagnosis of diabetes
High Cholesterol:Percentage of subscribers with recorded high cholesterol
Wellness Program Costs:
Health & Lifestyle Risk - Kaiser Annual Wellness Report 2016
Financial
Benchmark: 9% (Kaiser) Benchmark: 6% (Kaiser)Benchmark: 43% (Kaiser)
Benchmark: 35% (Kaiser)
2019 Engagement
7%
SAMPLE - OEBB Wellness Program Dashboard- 2019
Canary Health (Chronic Conditions):• Targeted outreach to Moda members with
COPD, Depression, Diabetes, Hyperlipidemia, Hypertension, or Rheumatoid Arthritis (Kaiser members may opt in)
1.5%
SAMPLE - Program Participation 2018 – 2019
2018 2019 % Change
Chronic Condition
Kaiser
Chronic Condition
Moda
Weight Watchers
HTHU
Canary Health
Virtual Lifestyle
Mgmt
Weight Watchers:• 13 week sessions in the
workplace, local community meeting, or online
• Participants can attend 4 – 5 sessions per year, but must attend 10 – 13 meetings to enroll in the next session
9%
43% 8% 6%
Benchmark: 14% (Kaiser) Benchmark: 8% (Kaiser)
8%7%36%
Results
Low physical activity 72%
Nutrition risk 99%Weight management risk 69%Quality of health – Good/Better 52%Quality of life – Good/Better 68%
Note: Shaded areas denote benchmark value.
Kaiser Total Health Assessment:
6%
Program Costs and % of Total 2015 – 2016
Weight Watchers HTHUChronic
Condition Moda
Chronic Condition
Kaiser
CanaryHealth VLM Total
ProgramCosts
$XXX,XX $YYY,YY $ZZ,ZZZ $AA,AAA $BB,BBB $CC,CCC $XYZ,ABC
Annual Wellness Costs - % ofMedical / Rx premiums:
$2,366,112(Total Wellness Program Cost)
$648,546,743(Total Medical & Rx
Premium)
0.4% of Total Premium)
Individual Program % of Total :
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Fertility/Infertility Benefit Coverage
OEBB
January 8, 2019
SEOW Attachment 5
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Agenda
Background
Current OEBB plan provisions for infertility
What are other employers offering?
Specialty vendors landscape
Coverage options and examples
Appendix
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http://natct.internal.towerswatson.com/clients/612555/OEBB2019HB/Documents/Infertility_Benefit_Overview.pptx
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Background
Infertility is a relatively common issue in the
U.S.
11% of women have impaired ability to get pregnant
or carry a baby to term
9.4% of men aged 15 – 44 have some form of
infertility*
Coverage of the diagnosis and conventional treatment of
infertility is relatively common among employer health
plans; however, coverage of higher-cost Assisted
Reproductive Technology (ART) procedures such as In-
Vitro Fertilization (IVF) is still evolving
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*Infertility and Impaired Fecundity in the United States, 1982 – 2010: Data From the National Survey of Family Growth, Number 67, August 14, 2013
Assisted Reproductive Technology (ART)
ART-conceived infants contribute to the prevalence of
low birthweight and preterm deliveries and the
percentage of twin ART-conceived infants remains
persistently high1
Women with multiple pregnancies have higher
systemic and localized comorbidities compared with
women with single birth pregnancies2
Pregnancies with delivery of twins
cost ~5X as much as single birth
Pregnancies with delivery of triplets or
more cost nearly 20X as much2
Multiple birth rate varies by 100% across U.S. employers
Evidence-based practices and genetic
screening technology can reduce multiple births,
high-risk pregnancies, complications — and costs
Average adjusted total all-cause health care cost2
$21,458 per delivery with single birth
$104,831 with twins
$407,199 with triplets or more
Twins and triplets or more were more likely to have
stayed in a neonatal intensive care unit than were
singletons2
1Assisted Reproductive Technology Surveillance — United States, 2014, CDC, February 10, 2017; 2Healthcare expenses associated with multiple vs singleton pregnancies in the
United States, AJOG, December 2013; 3Births, Methods of Delivery, CDC, 2015
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OEBB’s Current Infertility Coverage
OEBB’s contracts with Moda and Kaiser both currently exclude any coverage related to
infertility (office visits, diagnosis and/or treatment of infertility, artificial insemination)
The PEBB program currently provides limited coverage (50% coinsurance) for infertility:
Infertility defined as the inability to become pregnant or the inability to carry a pregnancy to term
as evidence by three consecutive, spontaneous miscarriages. PEBB Plans cover limited infertility
services including:
– Office visits, diagnostic tests and medical and surgical procedures to treat infertility
– Limited coverage for artificial insemination
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Willis Towers Watson 2017 Maternity, Family and Fertility Pulse Survey
HighlightsIn 2017, Willis Towers Watson conducted a survey of nearly 500 employers around their maternity, family and fertility
benefits, including their plans for the future.
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Sample: Companies with at least 100 employees and offers fertility benefits
Source: 2017 Willis Towers Watson Maternity, Family, Fertility Pulse Survey.
Does your organization include any of the following limits on
the coverage of fertility services?
58%
34%
23%
16%
11%
Lifetime limit medical/surgery
(Median limit: $15,000)
Lifetime limit pharmacy
(Median limit: $10,000)
Other limits
Limit the number of cycles
(Median limit: 3.0 cycles)
No limits
15%
5%
5%
3%
83%
Eggs for medical indications only
(as part of cancer treatment/IVF)
None of the above
Other
Sperm
Eggs for delayed pregnancy at
woman's discretion
Does your organization offer coverage for cryopreservation
for any of the following?
of firms covered fertility
services as part of their
medical benefit plan, with an
additional 10% of firms
expecting to do so by 2019
of firms planned to
enhance their benefit plan
design offering for fertility
services in 2018
of firms covering fertility services
do so for same-sex members
regardless of their underlying
fertility, with an additional 16%
planning to do so by 2019
55% 65%17%
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Willis Towers Watson 2017 Maternity, Family and Fertility Pulse Survey
Continued
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Integrated Family Assistance is Evolving as a Leading Edge Benefit Design
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Maternity,
Infertility
and Family
Assistance-
Related Benefits
Supporting Working Parents
Family Planning Maternal Care
Centers of excellence;
custom networks
Digital health engagement
Family and fertility solution
Infertility treatment
Plan design
Surrogacy and adoption benefits
Behavioral health program
Communication approach
Cost and quality transparency
Health plan maternity care
and management programs
Member education
Pharmacy management
Childcare resources
Data analytics, warehouses
and benchmarking
Employee assistance programs
Flexible work arrangements
Parental leave programs
Leading edge employers tend to focus on a holistic approach to family friendly benefits
approach — supported by a variety of specialty vendors
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Marketplace Solutions
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Source: CBINSIGHTS Research Briefs, The Femtech Market Map, January 26, 2017
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Infertility: Evidence-Based Coverage Approach Recommendations
No benefit Unmanaged benefitBest practice:
Evidence-based benefit
Coverage All coverage is paid out-of-pocketCoverage provided with few or no
limits
Coverage provided at Centers of
Excellence (COEs) with eSET,
where appropriate, subject to
benefit limits, where allowed
Patient
Education
Patients have little information
about the highest quality infertility
center
Patients have little information
about the highest quality infertility
center
Patients steered to infertility case
management resources and COEs
Evidence-
based
medicine
Patients seeking success with a
single cycle are more likely to have
multiple embryos transferred
Patients might continue treatment
cycles when there is low likelihood
of pregnancy, raising costs and
delaying consideration of adoption
or other alternatives
Patients utilize:
COEs
Mandatory elective single embryo
transfer (eSET), where
appropriate
Multiple
gestationsHigher rate of multiple gestation Higher rate of multiple gestation Lower rate of multiple gestation
Costs
Low infertility treatment costs as
patients are very cost sensitive
Potentially higher downstream
NICU costs
High infertility treatment costs as
patients demand expensive
treatment
Potentially higher downstream
NICU costs
Moderate infertility treatment
costs
Potentially lower downstream
NICU costs
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Potential Coverage Options — Examples
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Description Limited Benefit Full Benefit
Level I
Diagnosis and surgical treatment of
the underlying cause of infertility (i.e.,
counseling, testing and treatment of
infertility)
Sterilization reversal
Covered at applicable
deductible/coinsurance level
Covered at applicable
deductible/coinsurance level
Level II Ovulation induction
Intrauterine insemination
50% coverage up to $15,000
lifetime maximum per
member
Covered at applicable
deducible/coinsurance level
up to $15,000 lifetime
maximum per member
Level III
Advanced reproductive services:
In-vitro Fertilization (IVF)
Zygote Intra-Fallopian Transfer (ZIFT)
Gamete Intra-Fallopian Transfer
(GIFT)
Pre-Implantation Genetic Diagnosis
(PGD)
Cryopreserved embryo transfers
Intracytoplasmic Sperm Injection
(ICSI); or ovum microsurgery
Not covered
Covered at applicable
deducible/ coinsurance
level. Separate/Additional
$15,000 lifetime maximum
per member.
RxSeparate Lifetime maximum
of $10,000 per member
Separate Lifetime maximum
of $10,000 per member
OtherUse of COE, warrantees/performance guarantees
Limits on number cycles, age limits
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Appendix
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Infertility Coverage Under PEBB Plans
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Moda:
Infertility — covered at 50%
Infertility is defined as the inability to become pregnant or the inability to carry a pregnancy to term as evidence by
three consecutive, spontaneous miscarriages. The Plan covers infertility services including:
Diagnostic testing and related office visits to determine the cause of infertility
Examination, related laboratory testing and medical and surgical procedures to treat infertility
Artificial insemination, limited to a lifetime maximum of six cycles and sperm wash
Acquisition cost for semen
Infertility — covered at 50%
We cover treatment of involuntary infertility and artificial insemination, subject to utilization review using criteria
developed by Medical Group.
Infertility services include diagnostic imaging and laboratory tests, limited to tests to rule out sexually transmitted
diseases, hormone level tests, semen analysis and diagnostic laparoscopy or hysteroscopy. This benefit
includes diagnosis of both male and female infertility, however Services are covered only for the person who is
the member
Exclusions include the cost of donor semen, donor eggs, services related to procurement storage, oral and
injectable drugs used for the treatment of infertility, services related to conception by artificial means and
services to reverse voluntary, surgically induced infertility.
http://natct.internal.towerswatson.com/clients/612555/OEBB2019HB/Documents/Infertility_Benefit_Overview.pptx
From PEBB’s handbook
Kaiser:
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Compliance Issues Around Infertility Coverage
13
The ACA did not mandate expanded infertility coverage, but 19 states include some form
of infertility treatment as part of their state benchmark plan
13 states mandate infertility coverage and nine require IVF coverage1
Mandates vary widely and include various limitations and exclusions
1Listing reflects mandates as of 04/27/2018 from the National Conference of State Legislatures2Mandates that insurers must offer coverage to group policy holders; employers have discretion as to whether to offer to members as a coverage option
Infertility and IVF mandate Infertility mandate only IVF mandate only
Connecticut
Hawaii
Illinois
Maryland
Massachusetts
New Jersey
Rhode Island
California2
Louisiana
Montana — HMOs only
New York
Ohio — HMOs only
West Virginia — HMOs only
Arkansas
Texas2
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Wide Variation Among States, Even When IVF Coverage is Mandated:
14
State Applies to:Examples of Allowed
Limitations/Exclusions
Waiting Period for IVF
Coverage*
Arkansas Individual/group health plans
that provide maternity benefits
Lifetime maximum of $15,000
(equivalent to average cost of single
IVF cycle)
Two years of unexplained
fertility
Hawaii
Individual/group health plans,
hospital contracts, medical
service plans providing
pregnancy-related benefits
Coverage not required for first-line
less expensive treatments
One time only benefit
At least a five year history
of infertility using other
infertility treatments
Maryland
Individual and group plans
delivered in-state that provide
pregnancy-related benefits,
HMO’s in some cases
$100,000 lifetime benefit cap
Limit of three attempts/live birth
Two years of attempts with
less costly covered
treatments
Texas
Group health insurance policy
and HMO offering pregnancy-
related benefits
Only mandate to offer not cover
Excludes coverage for first-line less
expensive treatments
At least five year history of
infertility
*Waiting period may be waived in some cases if proof of specified underlying medical condition.
Sources: American Society for Reproductive Medicine (ASRM), http://www.asrm.org/insurance.aspx
Notes
Often allow exemptions for self-insured employers, HMO’s and in some cases government and religious organizations
Many only require coverage for the policyholder or policyholder’s spouse and include conditions requiring that the patient
or policyholder’s eggs be fertilized by the spouse’s sperm, which may exclude unmarried and same-sex couples
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