SEOW Attachment 1 December 4, 2018 - Oregon Documents/Attachment… · Moda Value-Based Purchasing/Benefit Design (SEOW Attachment 2) BethAnne Darby, Kraig Anderson, ... Tom Syltebo

SEOW Attachment 1 December 4, 2018

Page 1 of 3

Oregon Educators Benefit Board Strategies on Evidence and Outcomes Workgroup

November 6, 2018 Meeting Synopsis

The Strategies on Evidence and Outcomes Workgroup (SEOW) of the Oregon Educators Benefit Board held a meeting on November 6, 2018 at the Oregon Health Licensing Office. Attendees: Workgroup Members: Tom Syltebo, SEOW Chair Geoff Brown Robert Young Cheri Maas-Anderson Ron Gallinat Staff/Consultant: Glenn Baly, OEBB Ali Hassoun, PEBB/OEBB Jenny Marks, Willis Towers Watson Steve Carlson, Willis Towers Watson Carriers/Other Representatives: BethAnne Darby, Moda Health Kraig Anderson, Moda Health Dr. Jim Rickards, Moda Health Carly Rodriquez, Moda Health Bill Dwyer, Moda Health Erica Hedberg, Moda Health 1. October 2018 SEOW Meeting Synopsis (SEOW Attachment 1) SEOW approved the October 2018 meeting synopsis without any changes. 2. Moda Value-Based Purchasing/Benefit Design (SEOW Attachment 2) BethAnne Darby, Kraig Anderson, Dr. Jim Rickards, Carly Rodriquez and Bill Dwyer provided a review of Moda’s value-based purchasing and benefit design efforts, including:


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• Value Based Benefit Design Initiatives (annual wellness visits, chronic condition office visits, home infusions with preferred provider, Qwest Labs and Additional Cost Tier).

• Major Joint Replacement Reference Pricing • Pharmacy Management: Site of Care • OPDP/Northwest Prescription Drug Consortium • PCPCH Program • Synergy/Summit • Moda-OHSU Virtual Visits • C3 Program • Next Steps SEOW Action/Information Request Tom Syltebo asked that a more detailed review be done on the Additional Cost Tier, including looking at individual procedures, cost point for assigning copays, other elements. Tom Syltebo asked that a more detailed review be done on the Reference Pricing program, including adding more procedures. Tom Syltebo and Glenn Baly asked for regular reports from OHA on the PCPCH program including next steps. Tom Sytebo asked that a more detailed review of Centers of Excellence be conducted Tom Syltebo asked the carriers to determine how OEBB can assist them with the CPC+ program. 3. Value-Based Purchasing – Market Scan (SEOW Attachment 3) Jenny Marks reviewed value-based purchasing initiatives in the market, including

• Definition of value-based purchasing • Types of value-based purchasing • Market prevalence • Measuring value-based purchasing • OEBB accomplishments and opportunities • Next steps

SEOW Action/Information Request


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Tom Syltebo wants to review quality outcome comparison between Synergy/Summit and PPO plans in early 2019. Tom Sytebo asked for further research on public entities use of memo of understandings to address outliers in outcomes/quality/cost. No public comment.

willistowerswatson.com

Utilization and Claim ReviewOEBB Opportunity Analysis

December 04, 2018

SEOW Attachment 2

© 2018 Willis Towers Watson. All rights reserved.

Presentation to SEOW


OEBB Medical and Pharmacy Opportunity Analysis Agenda

Project objectives Scope/process Overview of findings Claimant examples

Carrier next steps Carrier report back

2© 2018 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.

Willis Towers Watson has prepared this material for OEBB’s 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 material should not be disclosed or distributed to any third party other than as agreed with you in writing. Willis Towers Watson does not assume any responsibility, or accept any duty of care or liability to any third party who may obtain a copy of this material and any reliance placed by such party on it is entirely at their own risk.

http://natct.internal.towerswatson.com/clients/612555/OEBB2018HB/Documents/Opportunity%20Analysis%20Slides%20-%20Medical%20and%20Pharmacy%204%2011%202018.pptx

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Project Objectives

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Project Objectives

Each year, Willis Towers Watson delivers an annual report overview of cost, claims and utilization of medical and pharmacy services by OEBB members. As a follow-up to this review, SEOW directed Willis Towers Watson, Moda and Kaiser to take a deeper look at the top conditions identified in the report.

Willis Towers Watson also incorporated findings from the Avoidable Claims and Conditions study conducted in 2017

The areas for additional review included: Cancer Arthritis Cardiovascular care Mental health Diabetes Additionally, we reviewed the claims data for general patterns of care related to hospital

readmissions, multiple ER visits, Pharmacy adherence, multiple pharmacy prescribers and other red flags

The project was a collaborative effort between Willis Towers Watson, Moda and Kaiser to identify areas of opportunity for improved care processes and to encourage efficient and value-based care (lower cost, higher quality/better outcomes)

4© 2018 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.http://natct.internal.towerswatson.com/clients/612555/OEBB2018HB/Documents/Opportunity%20Analysis%20Slides%20-%20Medical%20and%20Pharmacy%204%2011%202018.pptx


Project Objectives (Continued)

Willis Towers Watson reviewed claims costs and utilization patterns of OEBB members within the Moda and Kaiser data for general utilization patterns with particular focus on the five major condition areas below:


Assessment Metrics Common to All Conditions

Assessment Measures Specific to the Condition

Cancer care Appropriate hospital admissions or readmissions

Medication adherence and opiate use

Review for unnecessary or frequent use of emergency room and advanced radiology

Indications of poor coordination of care and notifications

Site of service (less costly) Chemotherapy/oncology

management

Arthritis: osteoarthritis (OA) and rheumatoid arthritis (RA) and musculoskeletal (MSK)

Pharmacy management (effective UM edits, site of care/channel management)

Mental health Screening, prevention and red flags (depression, ER and opiates)

Cardiovascular care Heart/valve procedures Preventable adverse events

Diabetes Medication adherence and associated ER/admits



Background: Finding Evidence of Efficient and Value-Based CareLinking data, outcomes and costs

6

MED — Morphine Equivalent DoseMPR — Medication Possession Ratio

Claims: Inefficient care

Claims: Poor pharmacy adherence or

utilizationmanagement

Claims & Electronic Medical Record:

-Variation in cost/outcomes-Engagement with PCPCH

-Population health

Policies:-Target specific providers

-Develop programs to drive better efficiencies

Benefit: Steer with value-

based plan design

Payments: Based on better

value

Easier

Moderate

Harder

Level of Effort

Step 2: Benchmarks defining inefficient care — examples(diagnoses, venue, provider)

Step 1: Finding the gaps Step 3: Closing gaps with right solutions

(member and provider solutions)



Evidence of Efficient and Value-Based Care


Step 1: Finding the gaps

Step 2:Benchmarks defining inefficient or sub-optimal care

Easier (Medical claims) Claim review for utilization red flags

>5 ER visits/year >3 admissions/year >3 advance radiology/year 30 day readmits (all cause)

Moderate(Rx claims)

Pharmacy claim review for medication adherence, poly-pharmacy and poly-prescribers

>15 medication PMPY >10 prescribers PMPY <80% MPR (by Rx class and member)

Site of Rx for OA/RA/chemo >100 MED (opiate) Generic fill rate >90%

Harder(Electronic medical record and clinical data)

Variation of Cost/Quality/Outcomes by provider

Member engagement with PCPCH Effectiveness of case management

and coaching

NQF (HEDIS Metrics #) Cardiac stents (NCDR stds.)(proof of trial of Rx and

EST) Depression remission (171) and Rx (105) Cancer therapy (breast/GI timely chemo (559)) Gene mutation testing (GI (1859/60) and breast

(1857/8))


Step 3: Develop programs, policies, benefit design or payment model reforms based on specific outcomes


Scope of Review



Scope of Experience Review

© 2018 Willis Towers Watson. All rights reserved. Proprietary and Confidential. For Willis Towers Watson and Willis Towers Watson client use only.9

Detailed medical paid claims data from OEBB’s data warehouse (Truven) Data was provided for OEBB’s population and their dependents Approximately three years of incurred claims data

The reporting periods by carriers are as follows:

All cost figures, unless noted, are allowed charges (before plan deductible and coinsurance)

Medical — What Claims Did We Review?

Kaiser ModaIncurred July 1, 2014 to June 30, 2015, paid through

September 30, 2017*Incurred October 1, 2014 to September 30, 2015, paid through

December 31, 2017*Incurred July 1, 2015 to June 30, 2016, paid through

September 30, 2017Incurred October 1, 2015 to September 30, 2016, paid through

December 31, 2017Incurred July 1, 2016 to June 30, 2017, paid through

September 30, 2017Incurred October 1, 2016 to September 30, 2017, paid through

December 31, 2017*2014 data not complete





Focused on specific services for high-cost claimants, safety issues and inefficiencies Multiple inpatient admissions and/or preventable 30-day readmissions Use of emergency room (ER) services Use of radiology services:

CT scans MRI scans PET scans Low value radiology services Breast imaging

High-cost claimants (HCCs) are defined as a member with $50,000 or more total allowed medical costs in a particular 12-month period

High utilizers are defined as a member using a particular service greater than or equal to the thresholds noted below during a 12-month period Three or more Inpatient admissions and readmissions Five or more ER visits Three or more advanced radiology services

Medical — What Were We Looking For?





Methodology Willis Towers Watson reviewed paid pharmacy claims data between January 1, 2017 through

December 31, 2017 for OEBB Claims data was obtained directly from Moda and Kaiser using a standardized request for

information containing fields required to capture pharmacy care performance

The objective of the analysis was to identify critical gaps in pharmacy care for high-cost claimants with an excess of $5,000 in pharmacy spend over the time period.

The analysis focused on the following four clinical metrics:

Adherence to medications used to treat high blood pressure, high cholesterol, diabetes, depression, antipsychotics and asthma/COPD and specialty drugs used to treat multiple sclerosis and rheumatoid arthritis

Opioid utilization Multiple unique prescribers per member (poly-prescribers) Unique prescriptions per member (poly-prescriptions)

Pharmacy — What Were We Looking For?



Medical and PharmacySummary of Findings



Overview of Initial Findings:


Medical

Area of Focus What We Looked For What We Learned

Cancer

Preventable admits and readmits Preventable conditions (sepsis) Venues of service (same service

at lower costs)

No patterns of cancer readmission or sepsis typical in other carrier program reviews

Some excessive use of CT/MRI/PET in cancers in both plans

Cardiovascular Adverse events by locations, provider and services

No excessive ER or admissions noted in cardiovascular

Arthritis 30-day readmit for joint and

spine surgery Rx adherence in DMART Rx

No excessive ER or admissions noted in osteoarthritis (i.e., major joint replacement and spine surgery) or rheumatoid arthritis

Diabetes Poor adherence leading to preventable ER and admits

No excessive ER or admissions noted in for members with diabetes

Mental Health

30-day readmits without office follow up

Poor adherence to Rx MH and SA related ER over use

Several members had excessive ER with migraine and substance abuse diagnosis


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14

Area ofReview What We Looked For What We Learned (Moda and Kaiser)

High-cost claimants

Opiate usage Morphine usage Preventable ER visits Preventable

admissions or re-admissions

Little to no opiate overuse issues and excessive ER visits Morphine Equivalent Dose (MED) (>90 MED 3 – 6 months) % population Moda – 0.1%; Kaiser – 0% # members Moda – 34; Kaiser – 0

>5 ER visits per year highly correlated serial admissions (>3/year) and 30-day readmissions in the OEBB population Little evidence of excessive use of ER and admissions in

cancer, cardiovascular, arthritis (MSK) and DM Salem and OHSU were more likely to have >5 ER and >3

admissions Preventable readmissions and 30-day admissions have a

significant potential savings and quality improvement

Overview of Initial Findings:Medical (Continued)



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Overview of Initial Findings:Pharmacy — Medication Adherence

Area of Focus What we Looked For What we Learned

Cancer No gaps in therapy during oral chemotherapy treatment.

Oral cancer Rx adherence (avg. MPR) (Moda – 97%; Kaiser – data not available)

Cardiovascular

Mean possession ratio (MPR) ≥ 80%

Surrogate marker for medication adherence

High cholesterol Rx adherence (avg. MPR) (Moda – 84%; Kaiser – 79%)

High blood pressure Rx adherence (avg. MPR) (Moda – 83%; Kaiser – 77%)

Diabetes Diabetes Rx adherence (avg. MPR) Moda – 75%; Kaiser – 71%)

Mental health

Antidepressants Rx adherence (avg. MPR) (Moda – 50%; Kaiser – 54%)

Antipsychotic Rx adherence (avg. MPR) (Moda – 79%; Kaiser – 74%)

Rheumatoid Arthritis (RA)

Specialty RA medication adherence (average MPR) Moda – 77%; Kaiser – 54% Adherence stat was based on a defined list of

specialty medications commonly used to treat RA



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Area of Review What We Learned

Poly-pharmacy/Poly-prescriber

Poly-prescriber (>10 unique prescribers) Moda:182 unique members with greater than ten unique

prescribers

Poly-pharmacy (15 different medications) Kaiser: 71 unique members taking between 11 – 25 prescriptions Moda: 36 unique members taking ≥ 30 prescriptions

Site of Care (Offering home infusion instead of in-office infusions where appropriate)

Potential opportunity for high-cost specialty medications used to treat auto-immune disorders such as Rheumatoid Arthritis, Crohn’s and Ulcerative Colitis

Example (Moda) Remicaide:Avg. allowed/home infusion: $2,795Avg. allowed/office infusion : $6,558# home infusions in 2017: 7# office infusions in 2017: 57

Overview of Initial Findings:Pharmacy — Poly-prescriber and Poly-pharmacy



High-Cost Claimants and/or Inefficient Care: Member Examples


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2016 2017Oct Nov Dec 2017 Feb Mar Apr May Jun Jul Aug Sep

ER Crohn's disease

Oct 17

Office Crohn's disease

Oct 24

ER Nail disorders

Oct 25


Oct 31


Nov 1

ER Calculus of kidney and ureter

Nov 16

ER Abdominal and pelvic pain

Nov 18

ER Crohn's disease

Nov 24


Dec 9

ER Other disorders of eye and adnexa

Dec 26

Office Dorsalgia

Dec 29

ER UNKNOWN

Jan 3

Jan 4

Office Pain, not elsewhere classified

Jan 9


Jan 12

Inpatient Hospital Crohn's disease

Jan 14

Inpatient Hospital Other sepsis

Jan 28

ER Phlebitis and thrombophlebitis

Feb 6


Feb 15

Office Scoliosis

Feb 16

ER Nausea and vomiting

Feb 17

Office Scoliosis

Mar 17

Office Dorsalgia

Mar 24

ER Crohn's disease

Mar 29

Apr 9

ER Other diseases of digestive system

Apr 10

Apr 11

Office Spondylosis

Apr 14

ER Psychotropic drugs, not elsewhere classified

Apr 16

Urgent Care Facility Asthma

Apr 17

Office Conjunctivitis

Apr 18

May 5

Office Other anxiety disorders

Jun 2


Jun 3

Office Abdominal and pelvic pain

Jun 15

ER Pediculosis and phthiriasis

Jul 25

Jul 29

ER Crohn's disease

Jul 31

Office Bipolar disorder

Aug 15

ER UNKNOWN

Aug 20

ER UNKNOWN

Aug 21

Urgent Care Facility UNKNOWN

Aug 23


Aug 26

ER UNKNOWN

Sep 3


Sep 9

Sep 20


Sep 22


Sep 27

Oct 1 - Oct 2 OOS1 Crohn's disease

Oct 18 - Oct 19 OOS1 Crohn's disease

Nov 6 - Nov 10 OOS1 Abdominal and pelvic painJan 28 - Jan 29OOS1 Other sepsis

Feb 7 - Feb 8OOS1 Phlebitis and thrombophlebitisMay 28 - Jun 2OOS2 Crohn's disease

Sep 1 - Sep 9OOS3 Alcohol related disorders

Service Type 2016 CountER 39Inpatient hospital 7Office 32Urgent care facility 9Grand total 89

Hospitalizations

Example: OEBB Member (Moda)

Office or ER VisitHospitalizations

OOS = Out of state (number for each hospital)



2017Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep2016 2017

ER VisitOct 10

ER VisitNov 4

ER VisitNov 14

Doctor VisitNov 17

ER VisitDec 4

ER VisitDec 5

Doctor VisitDec 15

Doctor VisitDec 29

Doctor VisitDec 31

Doctor VisitJan 6

ER VisitJan 8

Doctor VisitJan 28

Doctor VisitFeb 10

Doctor VisitFeb 13

Doctor VisitMar 5

Doctor VisitMar 13

Doctor VisitMar 20

ER VisitMar 30

ER VisitMar 31

ER VisitApr 2

ER VisitApr 3

Doctor VisitApr 4

Doctor VisitApr 7

Doctor VisitApr 14

ER VisitApr 24

Doctor VisitApr 26

Doctor VisitMay 1

Doctor VisitMay 10

ER VisitMay 30

ER VisitJun 8

Doctor VisitJun 29

ER VisitAug 15

ER VisitAug 21

Doctor VisitAug 22

Doctor VisitAug 23

ER VisitSep 12

ER VisitSep 13

ER VisitSep 24Doctor VisitSep 25

Diagnoses Dorsalgia/apondylosis/LPB Open wound hand/soft tissue

disorders Opioid related disorders Unknown Abnormal involuntary movements Idiopathic neuropathy/enthesopathies Transient cerebral ischemic Cellulitis and acute lymphangitis Unspecified disorder Burn lower limb Cutaneous abscess Hordeolum Epididymitis Persons encountering health services Reaction to severe stress

Example: OEBB Member (Moda)18 ER visits, 40 Unique Prescribers, 27 Unique Medications



Venue of Service Visit Count Emergency room — hospital 44Federally qualified health center 3Office 14Urgent care facility 6Total 67


2017Jul Aug Sep Oct Nov Dec 2017 Feb Mar Apr May Jun

Doctor VisitJul 7

Doctor VisitJul 21

Doctor VisitNov 26

ER VisitFeb 26

Doctor VisitMar 20

ER VisitMar 21

Doctor VisitMar 24

Doctor VisitMay 12

Doctor VisitMay 23

Doctor VisitJun 15

Feb 26Hospital Complications of transplanted organs and tissue

Mar 5

Mar 5Hospital Complications of transplanted organs and tissue

Mar 8

Mar 13Hospital Complications of transplanted organs and tissue

Mar 16

Diagnoses Abdominal and pelvic pain Encounter for screening for malignant

neoplasms Transplanted organ and tissue status Elevated blood glucose level Drug or chemical induced diabetes

mellitus Unknown Acute bronchitis

Example: OEBB Member (Kaiser)Rx Profile: Non Compliant with Meal Time and Basal Insulin, Sporadic Fill History of Testing Supplies, 20 Unique Medications




2016 2017Oct Nov Dec 2017 Feb Mar Apr May Jun Jul Aug Sep

Doctor VisitOct 17

Doctor VisitOct 24

ER VisitNov 1

Doctor VisitNov 8

Doctor VisitNov 22

ER VisitDec 7

Doctor VisitDec 13

Doctor VisitDec 14

Doctor VisitDec 22

ER VisitDec 28

ER VisitDec 30

ER VisitJan 6

ER VisitJan 7

ER VisitJan 8

Doctor VisitJan 12

Doctor VisitJan 16

Doctor VisitJan 23

Doctor VisitFeb 20

ER VisitFeb 22

ER VisitMar 6

Doctor VisitMar 27

Doctor VisitMar 30

ER VisitApr 10

ER VisitApr 13

Doctor VisitApr 25

Doctor VisitMay 17

Doctor VisitMay 24

ER VisitMay 30

ER VisitMay 31

Doctor VisitJun 22

ER VisitJun 27

ER VisitJul 7

Doctor VisitJul 18

Doctor VisitJul 19

Doctor VisitJul 24

ER VisitJul 30

Doctor VisitAug 2

ER VisitAug 3

ER VisitAug 16

Doctor VisitAug 16

Doctor VisitSep 20

ER VisitSep 25

ER VisitSep 28

Diagnoses Abdominal and pelvic pain Ulcerative colitis Pain in throat and chest Other joint disorder, not elsewhere

classified Asthma Unknown GI and abdomen Acute pharyngitis Shoulder lesions Abnormal results of function studies Candidiasis Nausea and vomiting

Example: OEBB Member (Moda)Rx profile: Overall Med Compliance 30.7%, 6 Unique Prescribers for Vicodin, 20 Unique Medications




Carrier Review



Carrier Review of Findings


On April 12, 2018, Willis Towers Watson reviewed the preliminary findings with OEBB staff, Moda and Kaiser

Moda and Kaiser were asked to review the top “red-flag” members and report back:

Did the member have a Patient Centered Primary Care Home?

Were the members engaged with a health coach or in a PCPCH care plan?

Moda and Kaiser were each provided with a specific list of areas to review for general utilization or care pattern improvements

In September, Willis Towers Watson, Moda, Kaiser and OEBB staff met to review carrier findings and research


Next Steps


Kaiser

Areas of Additional Research for Kaiser Review members with high readmissions — opportunities to address transition of care/reduce

readmissions Review members with higher ER utilization — opportunity to address outlining support/education

and assessment of social needs Cancer care — review opportunity to address lower cost medications — infused to oral, high

admissions, care management, reduce readmissions Pharmacy — MS related — review opportunities for medication cost reduction Coding: review large claimant inpatient diagnoses for “Never Events” and investigate correct coding

of location of service in data feeds to Truven Claim coding for “encounter of aftercare” and “unknown” diagnosis — identify opportunities to

capture more specific diagnosis Review members with poly-prescriber/poly-pharmacy (red-flag members)



Next Steps


Moda

Areas of Additional Research for Moda Review high ER utilizers for all hospitals and identify avoidable vs. unavoidable — review

PCPCH/C3 attribution of these members Review medication adherence for members with diabetes and rheumatoid arthritis Review members with poly-prescriber/poly-pharmacy (red-flag members); identify potential process

improvement or PCP communication opportunities Claim coding for “encounter of aftercare” and “unknown” diagnosis- identify opportunities to capture

more specific diagnosis (lower order Z codes) Review large claimant inpatient diagnoses for “Never Events” Review opportunities for site of care program related to chemotherapy Arthritis: cost review of biosimilar substitution and compo therapies for rheumatoid arthritis and

utilization of low dose alternatives



Carrier Report Back



Carrier Response


Kaiser

Area of Review Kaiser Response

Very high-cost claimant (>$250k) opportunities

Claimants tend to need care at contracted hospitals Transplant process is well coordinated and subject to multiple reviews Case managers assigned to all transplant cases OEBB’s number of very high cost claimants is lower than Kaiser book of

business

Cancer care opportunities

Kaiser had very few cancer patients with admissions for sepsis Medication optimization Rituxan biosimilar coming soon 12 – 16 hour infusion rooms Expanding cancer navigation programs

ER utilizationopportunities

OEBB ER utilization within Kaiser is low Mental health issues common among highest ER utilizers. Mental

health support could be better integrated into case management programs.

Proactive chart review by teams for all members with high ER use may discover additional opportunities



Carrier Response


Kaiser

Area of Review Kaiser Response

High readmissionopportunities

Improve transition of care experience Home visits Social needs assessments TBC enrollment

Uncontrolled diabetes in admissions and readmissions are reliable triggers for case management follow-up

Medical coding opportunities

Providers do appropriately code claims for the Kaiser system — but they are looking at improvements needed in their data feed process for sending to the data warehouse

Poly-prescriber/poly-pharmacy programs

Poly-prescriber — not an issue in the Kaiser system Polypharmacy — develop process to alert care providers and care

management team of issues as they arise

High-cost Rx coding opportunities

Kaiser currently does not have coded diagnosis of primary condition information for high-cost medicines when medicine/pharmacy is the highest claim category

Opportunity is to provide supplemental data or algorithms to complete the data picture



Carrier Response


Moda

Area of Review Moda Response

High-cost claimant opportunities

Of the 19 HCC that Moda was asked to review, five were participating in the C3 program. Moda determined to reach out to the additional 14 in an effort to engage them in the program.

ER utilizationopportunities

18.7% of Moda ER visits identified as not avoidable or mental health 15% identified as avoidable 19.5% identified as being PCP treatable Moda is in the process of implementing the Premanage (EDIE) program

to support managing ER utilization for the OEBB population Moda recently added a virtual visit option which may help to further

reduce ER visits

Poly-prescriber/poly-pharmacy programs

Medication Therapy Management (MTM) program designed to assist patients are those with multiple chronic conditions or multiple medications (has not yet been implemented for commercial clients)

Moda's specialty pharmacy partner, Ardon Health supports comprehensive disease specific patient management/clinical programs that include MTM evaluations with every fill of a specialty medication

Medication Use Evaluation (MUE) program evaluates medication-use patterns of members with the goal of improving patient health outcomes



Carrier Response


Moda

Area of Review Moda ResponseClaim coding for “encounter of aftercare” and “unknown” diagnosis

Effective October 1, 2017 Moda will return claims to the provider that are not billed out to the highest level of specificity

Chemotherapy site of care program

Chemotherapy agents are a topic for discussion and consideration in the next phase of the site of care program

Arthritis: review of biosimilar substitution and compo therapies for rheumatoid arthritis and utilization of low dose DMARD and MTX

Self-administered biosimilar used to manage RA have been approved by the FDA, but none of these products are currently available on the market

At the point that they become commercially available, Moda will ensure our utilization management strategies encourage the use of the most clinically appropriate and cost-effective medications

Moda is conducting a retrospective Medication Use Evaluation (MUE) initiative for all lines of business Outreach via mailings to members with a RA diagnosis, who do not

have a prescription for a disease-modifying antirheumatic drug (DMARD). Mailings will also go out to the providers of the members who were identified.



Carrier Response


Moda

Area of Review Moda ResponseReview medication adherence for members with diabetes and rheumatoid arthritis

The majority of the OEBB population are adherent to their therapy

Review large claimant inpatient diagnoses for Never Events

Moda clinical editing identifies potential hospital acquired conditions andNever Events

Nurse auditors review the itemized bill to determine which charges to deny and then they route the claim to the inpatient processing role with instructions of services to be denied and what ex code to use


OEBB WELLNESS PROGRAM 2019-20 Program Recommendations

December 4, 2018SEOW Attachment 3

Glenn BalyPolicy/Program Development Coordinator

Jenny MarksWillis Towers Watson

Agenda

• OEBB Wellness Program Subgroup Work• Wellness Program/Benefits Review• Program/Benefit Recommendations • Next Steps

2

Executive Summary Background:

• In 2017, OEBB established a subgroup to formally review its current health risk-based well-being offerings to determine overall strategy, baseline metrics, communication opportunities, vendor / market review, member awareness and interests and identify gaps or duplicative offerings.

Milestones of the review:

• Creation of well-being program Mission statement, goals and strategies • Identification of stakeholders• Establishment of collaborative workgroups including OEBB Board and staff members, OEA

Choice Trust, Kaiser, and Moda and Willis Towers Watson representatives.• Comprehensive review of all vendors, program offerings, communications, participation

and outcomes. Reported at October 2018 SEOW Meeting • Review of incentive program options

• Vendor communications audit • Focus groups with members at the statewide annual Oregon School Employee Wellness

Conference as well as fielded an employee interest survey

3

Executive SummaryVendor Review Key Findings

Participation and engagement• Overall participation is low• Completion/engagement rates for programs is low• Lack of uniformity among vendors in definitions of participation, engagement,

eligibility and outcomes • OEBB members primarily use Kaiser and Moda wellness offerings for chronic

condition education and management • Highest interest / awareness among members is with Weight Watchers and

Healthy Futures

Vendors and programs

OEBB’s current wellness vendor partners have top tier resources, tools and tracking mechanisms

There are duplicative efforts from vendors to address various health risks:• Diabetes prevention — Weight Watchers and Virtual Lifestyle Management

(VLM), VLM (StayWell has a buy-up option) • Chronic conditions — Kaiser, Moda, Canary Health’s Better Choices Better

Health (BCBH)

4

Vendor Review and RecommendationsWeight Watchers

• Program Modalities – At-work Meetings, Local Community Meetings and Weight Watchers Online

• Weight Watchers has committed to enhancing their own communications and marketing and is expanding its brand to provide more wellness services with weight management still a core function

• Weight Watchers received recognition as a CDC-certified diabetes prevention program.

• A single portal is being developed to improve member enrollment, renewal and participation.

• Developing the ability to track OEBB/PEBB participants and provide participation, engagement and outcome data (BMI).

• Developing population based and per participant pricing options

Recommendation

• Recommend the Board maintain Weight Watchers in the 2019-20 renewal negotiations with specific pricing option determined by the Board.

5

6

• Health Team Healthy U is a 12-week team-based worksite program that addresses multiple health conditions/risks

• HTHU has three program options (HTHU 1.0, HTHU 2.0 and HTHU 3.0) and is available through offline and online participation

• HTHU’s company, Provata Health, was acquired by StayWell (parent company Merck Rx.)

• Staywell has agreed to phase out offline participation due the lack of verification and work with OEBB to enhance verifiable outcome data.

• Staywell is developing multiple pricing options (per participant, PEPM, etc.)

• Staywell offers a number of additional programs/services separate from the HTHU Program for an additional cost, including:• Customizable Incentives Point Bank/Rewards Software• Telephone/Virtual Coaching• Biometric Screening• Weight Management Program• Language Translations• Staywell Dashboard Enhancements• Critical Learning Modules/programs (Financial wellness, DPP, pain management, professional development,

pregnancy)• Custom Challenges• Tobacco cessation

Recommendations:• Recommend that the Board maintain the current Healthy Team Healthy U benefit (minus offsite participation)

for 2019-20 with specific pricing options determine by the Board• Evaluate additional Staywell capabilities for cost and duplication with current OEBB services for the 2020-21

plan year.

Vendor Review and RecommendationsHealthy Team Healthy U

7

Better Choices Better Health• A six-week, online program that helps those with chronic conditions develop self-

management skills through action planning, experience sharing and mutual support. • BCBH supplements, but does not replace, chronic disease management services

obtained through members health plans.

Virtual Lifestyle Management• 12-month online diabetes prevention program that promotes healthy habits for

increasing activity and losing weight.• Weight Watchers is also a CDC-certified diabetes prevention program and Kaiser offers a

diabetes prevention program.

Recommendations:• Recommend that the Board maintain the current BCBH benefit for 2019-20• Recommend that the Board maintain with VLM benefit with the addition of a digital

scale to collect verifiable data.• Evaluate the effectiveness of BCBH and VLM against other similar OEBB programs.

Vendor Review and RecommendationsCanary Health

8

Next Steps

• Present the wellness program/benefit recommendations with pricing at the January 2019 Board Meeting.

• Continue implementation of OEBB Wellness Plan strategies.