UPMC Health Plan. April 11, 2018

Transcription

1 UPMC Health Plan April 11,

2 Agenda 1. Overview of UPMC 2. Major Medicare Policy Items 3. Community HealthChoices 2

3 UPMC s Mission UPMC s mission is to serve our community by providing outstanding patient care and to shape tomorrow s health system through clinical and technological innovation, research, and education. 3

4 UPMC: Our Commitment UPMC started building an integrated delivery and financing system over 20 years ago to position for the new paradigm. Our strategy allows us to focus on what matters most: Improving the health the communities Implementing cost-effective solutions Providing service excellence Leveraging our unique structure to partner with all stakeholders: community providers, patients, members, employers... 4

5 UPMC Today $17 billion integrated global health enterprise with 85,000 Employees Ranked #10 Best Hospitals U.S. News & World Report More than 30 hospitals with more than 6,000 licensed beds More than 600 doctors' offices and outpatient sites More than 5,700 affiliated physicians, including 3,800 employed by UPMC 23 senior communities, assisting over 2,900 residents on a daily basis Affiliated University of Pittsburgh ranked #5 in NIH funding 3rd largest GME program (1,360 residents) 4.6 million outpatient visits 5

6 UPMC Commitment to the Community Total Economic Impact of $30 Billion as every dollar directly spent by UPMC creates more than twice as much impact. Provides more than $960 million in community services contributions in Fiscal Year 2016, or more than 15 percent of net patient revenue. UPMC is Pennsylvania s largest nongovernmental employer and supports more than one in five hospital jobs. UPMC committed more than $100 million in support for minority and women-owned businesses. 6

7 UPMC: Global Academic Integrated Delivery and Finance System 85,000 employees & $17 B Revenue Insurance Services Health Services Division UPMC Enterprises UPMC International Services 3.4 M Members Top ranked Quality 4.5 Star Medicare Service Excellence: Stevie Award Winner 30+ hospitals 500 outpatient locations 310,000 IP admissions 4.2 outpatients visits 3,800 employed physicians 5,700 total physicians 20+ countries Hospitals: Italy Established partnerships in: Italy, Ireland, China, Columbia, Kazakhstan 1

8 UPMC Insurance Services: A Diverse Product Portfolio 2 nd Largest in Nation Provider Led 3 rd Largest Insurer Operating in PA Over 3.4 M Members Annual Revenues $7 B (run rate) 10,000+ Employer Groups Fastest Growing Medicaid and CHIP Plan Top tier Medicaid plan in PA 4 Star Medicare Dual Special Needs Plan 10 th Largest SNP Nationally Top 10 Nationally in Medicaid Quality Highest Ranked Provider Satisfaction (PA) J.D. Power Certified Call Center National Business Group on Health Platinum Winner 2012 Global Call Center of the Year Awardee (ICMI) 8

9 UPMC Insurance Services Division Priorities Launching and expanding Community Health Choices (CHC) Improving health outcomes and quality metrics for SMI (goals of SMI population health management) Substance Use Disorder Addressing the Social Determinants of Health Aligning CHC and D-SNP clinically and financially D-SNP enrollment 9

10 UPMC: Membership All Products Total PA Members January 2018 = 1,281,180 Change From Jan 2017 = 68,589 Updated: 1/15/2018 UPMC-Owned Facilities 10

11 UPMC for You Service Area 11

12 UPMC for Life, Inc. Medicare Membership + Service Area Total PA Members January 2018 = 174,738* Change From Jan 2017 = 10,946 *25,255 total D- SNP Members as of 2/15/2018 Updated: 1/15/2018 UPMC-Owned Facilities 12

13 UPMC for Life Medicare Advantage HMO Service Area HMO Expansion Tioga Lycoming Clinton Union Snyder Sullivan Current 2017 Service Area Fulton PerryDauphinLebanon Bucks Cumberland Montgomery Chester Delaware 2018 Expansion Counties 13

14 Fulton Chester Delaware UPMC for Life Medicare Advantage PPO Service Area PPO Expansion Current 2017 Service Area Fulton Lehigh PerryDauphin Berks Lebanon Cumberland Lancaster Adams York 2018 Expansion Counties 14

15 UPMC for Life, Inc. Medicare Advantage Special Needs Plan (SNP) WPA 28 Counties UPMC Enrollment: 22,928 UPMC Market share: 42% Current 2017 Service Area 2018 Expansion Counties Reflects Jun, 2017 CMS enrollment data. 15

16 Medicare Policy Issues 1. Bipartisan Budget Act of Health Related Supplemental Benefits 16

17 Bipartisan Budget Act of 2018 Highlights Permanently reauthorizes Medicare Advantage (MA) Special Needs Plans (SNPs) Two-year extension of funding for outreach and education activities for Medicare beneficiaries. Allows MA plans to offer a wider array of targeted supplemental benefits to chronically ill enrollees beginning in Makes coverage of speech generating devices under durable medical equipment permanent under the Medicare program (removing the 2018 sunset under current law). 17

18 Bipartisan Budget Act of 2018 Highlights Accelerates the closure of the Part D program coverage gap, known as the "donut hole" by decreasing beneficiary contribution to 25% in Increases drug manufacturer discount from 50% to 70% under Part D. Increases Medicare reimbursement for home health agency providers by 1.5 percent in Increases Medicare reimbursement for skilled nursing facility (SNF) providers by 2.4 percent in FY19. 18

19 Health Related Supplemental Benefits Recent CMS Guidance will allow MA plans to include additional services that increase health and improve quality of life, including coverage of non-skilled in-home supports and other assistive devices. Expansion of the definition of primarily health related. The new definition will allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization. Under this reinterpretation, CMS will allow supplemental benefits if they are used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization. 19

20 Community HealthChoices UPMC Health Plan

21 PA Medicaid Expenditures by Population Older adults and people with disabilities account for 29% of the PA Medicaid Enrollment and 62% of spending Community HealthChoices includes a large proportion of this population and spending Major drivers of cost are reliance on nursing facilities and poorly coordinated care Figures do not include Medicare spending for the same population According to the MLTSS Association, LTSS duals are 6% of the total Medicaid population accounting for 43% of spending 21 Source: Governor s Executive Budget As of 12/6/2017

22 MLTSS by State Active MLTSS Program in 2014 Active MLTSS Program in 2015 Currently Implementing MLTSS ( ) 22 Capitated Duals Demo (MLTSS for duals in demo) States to Watch for Potential MLTSS Activity

23 Current LOB Primary Acute LTSS Three Domains of Service Primary care is the first line of support for health and wellness Includes routine check-ups and preventative services Focused mainly on physical health Acute care for catastrophic events Acute care may also become necessary when the support systems in one of the other two domains fail or break down Includes emergency room visits, inpatient, and skilled nursing facility Long-term services and supports (LTSS) help older adults and people with disabilities accomplish everyday tasks that many of us take for granted bathing, dressing, fixing meals, and managing a home Services can be delivered: at home (HCBS), in an adult day, nursing facility (NF), and, newly to Pennsylvania, assisted living 23

24 5 Different Programs Become 1 HCBS Aging: Frail older adults or living with disabilities (over age 60) $21,700 per year CommCare: People living with traumatic brain injury $76,300 per year OBRA: People with physical and developmental disabilities $61,000 per year Independence: Severe physical disability resulting in multiple functional limitations $39,200 per year Attendant Care: Physical disability lasting more than a year, able to self-direct $24,000 per year The Waivers serve a very diverse population Over half of participants are in the Aging Waiver Under 60 programs serve a range of physical disabilities with varying levels of independence Examples include people who are: Relatively independent wheelchair users (Attendant Care) Ventilator dependent (Independence) Living with HIV/AIDS (Independence) Living with Brain Injury (CommCare) Intellectually and physically disabled but not in services before age 21 (OBRA) Each is a stand-alone program today with slightly different services and utilization 24

25 CHC Goals Rebalance the long term care systems Provide services in the least restrictive setting Keep Pennsylvanians aging in place Transition those who are able out of nursing facilities and back into the community Improve coordination across Medicare, Medicaid, and LTSS Care for duals, especially those receiving LTSS, is highly fragmented All CHC-MCOs are required to have an aligned D-SNP in the zones in which they operate 95% of Pennsylvanians say they would rather age in their home or community than in a nursing facility, but only 41% of the waiver-eligible population currently does so 25

26 Community HealthChoices Program CHC includes revenue to support: Medicaid Medicare (not included) LTSS Healthcare Home and Community- Based Services Medicaid Secondary D-SNP (not included) Nursing Facility Medicaid Primary Participants will need to voluntarily elect D-SNP coverage Mandatory enrollment for eligible participants 26

27 Community HealthChoices Program CHC includes : Health Care Medicaid Secondary Coverage for duals who may or may not be in our D-SNP Medicaid Primary Coverage for people living in nursing facilities or on Home and Community Based Services (HCBS) Waivers without Medicare Long-Term Services and Supports (LTSS) Ongoing support of custodial nursing home residents Nursing home eligible older adults and people with disabilities who receive home and community-based services (HCBS) D-SNP revenue will grow rapidly as auto-assigned Medicaid CHC members elect to have coverage Each zone will have a Continuity of Care Period All LTSS providers currently serving participants will be contracted for 6 months Critical window for performance evaluation of new provider partners 27

28 347k Pennsylvanians Included Non-LTSS Duals Age < ,291 Age >= ,151 Nursing Home Age < 60 5,692 Age >= 60 49,858 HCBS Age < 60 22,498 Age >= 60 37,950 HCBS: Home and Community Based Services Southwest Southeast Lehigh/Cap Northeast Northwest Total Community Dual 58,254 73,131 45,793 35,014 19, ,442 Nursing Facility 12,320 15,861 12,413 9,933 5,023 55,550 HCBS 10,391 33,940 6,459 5,352 4,306 60,448 28

29 22,711 49, , , , Circle size represents total LTSS sub-population by zone

30 $7 Billion State Procurement Includes nursing home, traditional Medicaid, and Medicaid secondary coverage it does not include the D-SNP financial impact HCBS include services not offered by Health Plans through our traditional network Examples of new services: Personal Care, Adult Daycare, Nursing Home Services, Job Coaching, Non-Medical Transportation, Pest Eradication, Vehicle and Home Modification 30

31 Selected Bidders DHS selected three plans to join them in integrating care and rebalancing 31

32 Same Zones as HealthChoices

33 General Program Status CHC implementation is staggered Southwest: January 1, 2018 Southeast: January 1, 2019 Rest of State: January 1, 2020 Southwest plan enrollment ended on December 28 Approximately 50% of participants made an active choice; remaining participants were auto-assigned Participants can make plan changes monthly 33

34 Questions?