Wednesday, April 23, 2014

Obamacare Observations From the Marketplace

Robert Laszewski

Posted 4/22/14 On Health Care Policy and Marketplace Review

A few observations from my travels and conversations in the marketplace:

About half of the enrollments are coming from people who were previously insured and half are not. When I try to gauge this, I go to carriers who had high market share before Obamacare and have maintained that through the first open enrollment. Some carriers have said only a small percentage of their enrollments had coverage before but health plans only would know who they insured before. By sticking to the high market share carriers who have maintained a stable market share and knowing how many of their customers are repeat buyers, it's possible to get a better sense for the overall market. Other conventional polls have suggested the repeat buyers are closer to two-thirds of the exchange enrollees.

The number of those in the key 18-34 demographic group improved only slightly during the last month of open enrollment so the average age is still high. The actuaries I talk to think this issue of average age is made to be far more important than it should be. It is better to have a young group than an old group. But remember, the youngest people pay one-third of the premium that older people pay. The real issue is are we getting a large enough group to get the proper cross section of healthy and sick?

The bigger concern continues to be the relatively small number of previously uninsured people who have signed up compared to the size of the eligible group.

The recent report released by Express Scripts reporting on very costly pharmacy claim experience from January and February enrollees is far more concerning than the average age.

About 15% to 20% of new enrollees are not completing their first month's enrollment by not paying their premium, according to my marketplace discussions.

I note that the California exchange just reported their non-pay number was 13%. That makes sense to me because California did not have the information technology difficulties the feds did––many of the non-pays were caused by system related problems like duplicate enrollments and "834" transactions that weren't able to be processed. California also appears to have a population more amenable to the new health law and therefore more likely to pay than the national average.

On the other hand, the Georgia insurance commissioner reported that only about half of those who enrolled had paid their premiums by March 31––although any enrollments between March 15th and April 15th have until April 30th to pay.

If California and Georgia can tell us the number of people who have completed their enrollment and paid for their coverage, why can't the Obama administration? As I wrote on this blog recently, the carriers all have this data and can make it available to the administration in a matter of a few days––or even hours.

The back-end of, that reconciles enrollment between the feds and the health plans, is still not fully built and won't be for months to come. The feds and the carriers are still talking about how parts of the reconciliation system will work.

While the Obama administration could easily poll all of the carriers to be able to report a more accurate enrollment, I don't expect them to report the real enrollment numbers until after these last systems are built––and that could easily be months away.

When the back-end is finally built and tested, we will have the mother of all accounting reconciliations trying to clean up months of workarounds and patches. It may well be that the back-end of won't be fully built until close to the first anniversary of the launch of Obamacare.

The administration would be doing themselves a favor to report the actual enrollment sooner rather than later. Every month, an individual health insurance block loses 2% to 3% of its members. Generally, the "change of life" adds about offset the deletes. But in this case, while people can buy coverage if they have a qualifying event, the general market cannot buy coverage until the next open enrollment period. The upshot is that this first Obamacare block is likely to lose lots of people on a net basis as the people who simply let their coverage lapse can't be offset by those who later simply become interested in being insured before the next enrollment. The longer the administration waits to give us a solid enrollment number the farther they are going to be from eight million.

There is a lot of dissatisfaction being communicated from consumers to insurance company call centers and their agents about the new health insurance plans, particularly compared to the plans people are used to. Many people likely signed up because having insurance is the right and responsible thing to do––especially if their plan was canceled. Many who had insurance before could now get a subsidy and sometimes a better plan for their out-of-pocket premium. Many also feared the fine. Some have health problems and they can finally get insurance. But it would appear we shouldn't confuse someone wanting to buy an Obamacare policy with an average Silver Plan deductible of $2,600, and the likelihood of a narrow network, with the person necessarily being pleased with the product.

There is a concern that the administration sees the recent flurry in enrollment as evidence Obamacare is working and therefore the plan offerings do not have to be improved. Without more attractive offerings there is concern that the currently poor penetration into the eligible market will not improve.

What will the 2015 rate increases be? 9.9% There will be some variation in rate actions because the Obamacare enrollment outcome varies considerably among states. Also, some carriers' rates turned out to be too high and others too low when compared to their competitors which will likely lead to some compression in the local markets as these outliers get closer to typical rates. This could produce a few significant increases or decreases for 2015.

But generally, I really do expect a lot of rate increases just below 10%. The carriers do not have, and will not have, claim data worth much by the time the 2015 rates are due between May 27 and June 27. All of the people who signed up in the last half of March, for example, have an effective date for coverage of May 1––we won't know anything about their claims costs.

Health plans will have very little claim data on the new enrollees when they must complete their pricing analysis. Any rate increase of more than 10% is subject to regulatory review under federal guidelines. Ironically, if regulators challenge a carrier's rate increase, no matter how concerned the health plan is with the enrollment demographics, the carrier will have very little hard claim data with which to defend the action.

Health insurers are also protected from most underwriting losses in 2015 because of the $20 billion reinsurance scheme. Simply, the carriers are worried about the Obamacare risk pool, they have no hard data to credibly project or defend a challenge from a regulator, and 9.9% is the most they can generally get unchallenged.

Will any health plans exit the Obamacare exchange markets in 2015? No. The program is so immature at this point that no one's original strategic calculus over Obamacare has changed. Health plans do not expect Obamacare to be repealed. They expect it to evolve. The current or future Obamacare represents all of the individual and small group health insurance market in the U.S. You can't be in this substantial market without going along for this ride.

That their losses are minimized through 2016 by the $20 billion Obamacare reinsurance scheme is no small issue in their calculations.

Many health plans are a lot more concerned about their Medicare Advantage payment rates than their Obamacare results right now.

When will we finally have a good handle on Obamacare's claims experience?Years. In a year we will have some pretty good data on the 2014 enrollments. But, then we will have just had the 2015 open-enrollment and there will be questions about the impact these new people will have on the overall program. In addition, the 2015 open-enrollment will again have millions of relatively healthier cancelled policyholders signing up for Obamacare because their one year extensions will be running out (don't count on a lot of carriers extending these policies further).

Really, we won't have a good handle on Obamacare's costs until the program's enrollment stabilizes so that the group's final composition can be accurately measured, and we then get at least a year of claim data from that point.

Also, at the end of 2016 "the training wheels will come off" as the $20 billion reinsurance scheme ends.

It seems that every time there is a snippet of news––an insurance company is entering the market for 2015 so that means it's working, or an insurance commissioner reports lots of people aren't paying their premium so it's not working––people try to make something of it.

This is going to take years to play out.

The politics of Obamacare will likely be more volatile than the health plans' near term rate actions.

Robert Laszewski is an Annapolis, MD-based health care analyst and former health plan executive. He writes at Health Care Policy and Marketplace Review.

Tuesday, April 15, 2014

Virginia Should Take the Obamacare Medicaid Expansion Money and So Should All Republican States

The article below, written by Bob Laszewski, originally appeared in The Health Care Blog and Health Care Policy and Marketplace Review on 4/14/2014.

By Bob Laszewski

In a September 2012 post on this blog, I said that Republican governors should be expanding their Medicaid programs under Obamacare. I argued that Republicans have long called for state block grants and the flexibility to run their own Medicaid programs in what are the state "laboratories of democracy."

I made the point that, given the then recent Supreme Court decision enabling states to opt out of the expansion, the Obama administration would be hard pressed to deny any reasonable proposal from Republican governors. If Republicans really believed in state responsibility and flexibility for how they run their Medicaid programs, this was the opportunity to prove it. (See: The Medicaid Controversy––The Republican Governors Should Put Up or Shut Up)

Since then, a few Republican governors have taken that tack and the Obama administration has been very cooperative and flexible.

This is a good place to recognize outgoing HHS Secretary Sebelius for her leadership by being willing to work with state Republicans in order to get millions of people covered who wouldn't be getting coverage otherwise.

Good faith Republican Medicaid proposals have led to good faith responses from Sebelius' Department of Health and Human Services (HHS) and a few done deals and other deals still in the works.

Many Republicans have said that Medicaid is not sustainable and that the feds could well cut the new Obamacare funding in future years. Sebelius responded by giving these governors an out if funding were to be cut.

Of course Medicaid is unsustainable, that's why the states should be given the autonomy to run their own plans and deal with these challenges in any number of different ways the country can learn from.

Arkansas, a conservative state led by a Democratic governor and a very conservative Republican legislature, was one of the first states to secure a Medicaid waiver from the Obama administration. The Republican legislature just renewed that program.

But in a recent Forbes article, that expansion came under sharp criticism:

"Any Governor or legislator still considering a "Private Option" style ObamaCare Medicaid expansion in their state should take an extra-long look, as the Razorback state's version is turning out to be hugely     expensive. While the "Private Option" plans are required to look almost exactly the same as Old Medicaid from an enrollee's perspective, the plan does have one big difference from a straight "traditional" ObamaCare expansion: state taxpayers are on the hook for all cost overruns. The trend of enrollment in the first few months project a cost overrun of tens of millions of dollars for 2014 alone, with potential overruns growing larger in the future."

Sounds like a Medicaid block grant success story to me!

Seriously. Yes, Arkansas apparently has some serious problems that need to be fixed. But isn't that what Medicaid block grants are all about––decentralized experimentation, trial, error, and adjustment?

So, what do we know about Medicaid in Arkansas:
  1. Arkansas has its own experiment trying to figure out how to deliver better low-income care at a better cost.
  2. Because of it, 100,000 people are being covered that wouldn't have been covered without the state and the feds doing a deal.
  3. Arkansas got more flexibility and the governor and legislature, not bureaucrats in Washington, DC, are responsible for making it work.
  4. Looks like Arkansas is not off to a sterling start.
  5. So, Arkansas needs to adjust.
  6. And, Arkansas will adjust because they have to.
Nobody said giving the states autonomy would lead to easy successes.

And, let me be clear, I don't know if the private option scheme Arkansas is following is the right course. But, that is what experimentation is about. Other states can and probably should try other things.

I can't figure out what's the matter with all of these reluctant conservatives on the subject of Medicaid expansion. As many as 5 million people don't have health insurance coverage because of their refusal to expand Medicaid––on their own terms.

Republicans want Medicaid block grants but when the Obama administration effectively goes along with the concept by approving a number of special deals the other Republican governors don't make the Obama administration a good faith offer of their own.

And, when a state like Arkansas arguably stumbles out of the gate, they declare state Medicaid autonomy a failure.

Right now, the new Democratic governor of Virginia is in the middle of a big battle with his conservative Republican legislature. He's basically telling his legislature he wants to go to Washington and get a deal to expand Medicaid on Virginia's terms.

But the Republicans are saying, "No."

I know that being anti-Obamacare is a potent election-year issue for Republicans. But every time they get a block grant concession from the Obama administration Republicans could argue they know how to fix America's broken health care system with practical "common sense" and state-based Republican ideas. Why shouldn't this be a winning political strategy for them?

What are they afraid of; the blue states will end up covering more people for less money than red states doing it their way?

So much for 50 state laboratories.

This from the same party that thinks selling insurance across state lines, association health plans, and high risk pools are good common sense ideas.

Wednesday, April 9, 2014

Employers Challenged by Employee Engagement, Outcomes-based Health Incentives, and Price Transparency According to New Texas Business Group on Health Survey

Texas employers say their biggest challenges in 2014 include engaging and empowering employees to make better health and health care decisions, evaluating health exchanges, and dealing with the lack of health care price transparency.

A recent survey of 73 large- and mid-size Texas employers by the Texas Business Group on Health, an employer-sponsored health care coalition, revealed five primary concerns regarding health benefits:
  • More than half mentioned the challenge of creating outcomes-based wellness incentives, meaning they would like to reward measurable health improvements rather than participation in wellness activities.
  • About 42 percent said they wanted to improve employee engagement in their health and well-being.
  • The same percentage identified lack of health care price transparency.
  • Forty percent said evaluating the impact and opportunities afforded by private exchanges in the insurance marketplace created by the Affordable Care Act.
  • About 38 percent named focused employee education on personal health and becoming well-informed health care consumers.
"Given the size and growth of the Texas economy, the challenges facing our employers most likely reflect the concerns of all U.S. businesses," said Marianne Fazen, chief executive officer of the Texas Business Group on Health and the Dallas-Fort Worth Business Group on Health. "This should be a wake-up call to the health services industry to focus on what's most important to employers to help them continue to sponsor health benefits to their employees."

A report on the survey can be found at here.

A New Day for Transparency: CMS Releases Medicare Physician Data Files

Brian Klepper
After decades of secrecy, the Centers for Medicare and Medicaid Services (CMS) has released files on charges and paid amounts to 880,000 medical providers who received $77.4 billion in 2012.

It is likely that these are aggregate data, lacking the individual claim detail that would help purchasers identify which providers consistently deliver the highest quality care at the lowest episodic cost. But CMS' release indicates that they no longer believe that physicians have a right to privacy when it comes to public expenditures for their services, which could mean that, in the future, more granularity will be forthcoming.

This is potentially a hugely disruptive health care innovation. Commercial health plans consider claims data proprietary and have jealously protected it. Having an alternative, credibly sized data source in the Medicare provider file will allow purchasers to conduct comparative analyses to determine high and low performers. In turn, this new level of value transparency will translate to market pressure on the medical community to demonstrate efficacy.

Here's a USA Today article on the release, and here's the page where you can download the files.

Friday, April 4, 2014

New "Business Pulse" from the CDC Foundation

Check out the latest edition of Business Pulse, a quarterly feature that offers businesses useful resources from the Centers for Disease Control and Prevention. Explore benefits associated with CDC's work to protect Americans - including businesses and their workforces - from chronic threats that impact health and productivity to major health emergencies. You can access the current edition of Business Health - along with all past editions - online. 

Thursday, April 3, 2014

Two Wins on Transparency and Payment Levels

Brian Klepper

Going forward on the NBCH blog, I will try to post often and in depth on issues related to health and benefits. We'll also consider non-promotional, thoughtful contributions from regional coalition staff and employer members.

Two important items are in today's news that merit your attention. First is Medicare's announcement of its intention to release its Physician Claims data set. Presumably, analysis of these records will permit a better understanding of physician performance and value, critical for patients and purchasers. Public information on performance should encourage more physicians to be more aware of their practice patterns, creating new market pressures for excellence that have been lacking in health care for decades. I have already asked our team to inquire about how to obtain that set.

Also, yesterday the US Senate approved a bill that calls for identifying overvalued procedures in the Medicare fee schedule. After 22 years of an opaque and corrosive relationship between Medicare and the AMA's Relative Value Scale Update Committee (RUC), this is a heartening and unexpected move. The question now will be whether the House affirms. Certainly, we can expect the entire health care industry, except for primary care, to lobby against House approval. Because this change has momentous economic ramifications that are squarely in the public interest (as well as those of purchasers), we should each consider contacting our Congressional representatives to advocate for them to do the right thing.

Here's an article I have first published on the Health Affairs Blog a little more than a year ago that explains why and how RUC came to be such a powerfully negative influence on health care.

The RUC, Health Care Finance’s Star Chamber, Remains Untouchable
Brian Klepper
Posted 2/1/13 on The Health Affairs Blog

On January 7, 2013, a federal appeals court rejected six Georgia primary care physicians’ (PCPs) challenge to the Centers for Medicare and Medicaid Services’ (CMS) 20-year, sole-source relationship with the secretive, specialist-dominated federal advisory committee that determines the relative value of medical services. The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is, in the court’s view, not subject to the public interest rules that govern other federal advisory groups. Like the district court ruling before it, the decision dismissed the plaintiffs’ claims out of hand and on procedural grounds, with almost no discussion of content or merit.

Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care finance, a star-chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.

The RUC exerts its influence by rolling up the collective interests of the nation’s most powerful medical specialty societies and, indirectly, the drug and device firms that support and benefit from their activity. The RUC uses questionable “methodologies,” closed to public scrutiny, to value medical services. CMS has historically accepted nearly 90 percent of the RUC’s recommendations without further due diligence. In a damning October 2010 Wall Street Journal expose, former CMS Administrator Tom Scully described the RUC’s processes as “indefensible.”

The RUC’s distortion of America’s health care market, ramping up both care and cost, cannot be overstated. It has consistently over-valued specialty services and undervalued primary care services. Ophthalmologists performing cataract procedures are now paid 12.5 times the hourly rate of PCPs involved in a moderately complex office visit, arguably a more complicated activity.

At the same time, the erosion in primary care reimbursement has reduced office visit durations and undermined primary care’s moderating influence over specialty care. These dynamics are almost certainly responsible for the doubling of specialty referrals over the past decade.

The RUC’s excessive valuations of certain procedures — e.g., cardiac stenting, colonoscopies, back surgeries — have created lucrative incentives for over-utilization. 2008 OECD health data showed that, for every inpatient percutaneous transluminal coronary angioplasty (PTCA) performed on patients in the United Kingdom, New Zealand or Switzerland, we do more than four in the US. Then there are data showing a clinically inexplicable 15-fold increase in complex spinal fusions between 2002 and 2007, with adjusted mean hospital charges of $81,000.

All health care interests except primary care win under this arrangement. Everyone else loses. Unnecessary care puts patients at physical risk. Purchasers — taxpayers, employers and individuals — pay twice the cost of care in other developed countries, an economic burden that now threatens to pull the US economy off a cliff. And the role of PCPs gets short shrift.
The Legal Objection To The RUC
The core of the Augusta physicians’ legal challenge was that the RUC is a “de facto Federal Advisory Committee,” and therefore subject to the stringent accountability requirements of the Federal Advisory Committee Act (FACA). This law ensures that federal bodies have panel compositions that are numerically representative of their constituencies, that their proceedings are open, and that methodologies are scientifically credible. In other words, FACA ensures that advisory practices are aligned with the public interest.

The RUC adheres to none of these and is an object lesson in how special interests can be insinuated into and capture regulatory processes, displacing the public interest. For example, when the legal challenge was first filed, only 3 of 29 RUC panelists (10 percent) represented primary care, even though some 30 percent of US physicians practice primary care. RUC meetings are closed to the public, unless an invitation is extended by the Chair, and admission is tied to the guest signing a nondisclosure agreement. Determination of a procedure’s value has been based on as few as 30 survey responses by physicians who know that their reimbursement will be linked to how they have answered the questions.

The Effects Of The RUC’s Influence
There are also several cascade effects. One is our crisis-level shortage of PCPs. All but the most idealistic medical students are steered away from primary care and into the specialties by relative low reimbursement. A PCP can expect to earn $3.5 million less over a 30-year career than a typical specialist. When the comparison is against high-earning physicians, like orthopedic surgeons, the difference is $10 million. Just as our boomer population reaches its years of highest health care use and cost, we’ll have a devastating primary care shortage, which in turn will propel traditional primary care cases into far more expensive and often unnecessary specialty care.

And, as lead plaintiff Paul Fischer MD has noted, the policies promoted by the RUC have degraded many areas of specialty medicine, narrowing care patterns as specialists “practice to the codes” that are most lucrative, and straining the collegiality that, until recent years, characterized most medical care.

One difficulty in challenging the RUC is that, to lay observers, it can appear to be a technical issue, accessible only to people who get down in the weeds. But it is foundational, defining the relative value of care services, which in turn drives pricing, profitability and care patterns.

That said, there are true experts who grasp the gravity of the problem. Among the most compelling are four former Administrators of CMS — Gail Wilensky, Bruce Vladeck, Tom Scully and Mark McClellen — who came together in a remarkable round table discussion last March in front of the Senate Finance Committee, co-chaired by Orrin Hatch and Max Baucus, unanimously agreeing that the RUC has been a colossal error and must be replaced (See the video here.) As Dr. Vladeck commented:

I’m hopeful that some combination of the need to address overall deficit reduction strategies more generally and a different kind of political climate in the relatively near future will create the opportunity for people to say, “We made a mistake in 1997. We created a formula that produces irrational and counterintuitive results, and we’re just going to abolish it and start all over again in terms of some kind of cap on Part B payments. It’s the only way we’re going to get out of this morass.”
A Laudable Effort By Six Primary Care Physicians
America’s health care community should also acknowledge the tremendous effort mounted by the six Augusta, GA PCPs: Robert Clark, Becca Talley, Paul Fischer, Edwin Scott, Rob Suykerbuyk and Les Pollard. These physicians financed the legal challenge out of their own pockets and did so for no other reason than they were convinced of the huge wrong CMS’ relationship with the RUC perpetrates on the American people and on primary care. They are great American citizens who, unlike their primary care societies, took a stand on behalf of the public interest, literally putting their money where their mouths are and paying the price of admission to the legal system.

American health care has many problems that contribute to uneven quality and egregious cost, but CMS’ longstanding relationship with the highly conflicted and unaccountable RUC is among the most outrageous and damaging. Now, with legal remedies exhausted, the avenues of redress are limited.

As Dr. Vladeck noted, perhaps America’s looming fiscal crisis, driven primarily by its health care costs, can compel Executive or Congressional action on the RUC. Only if the CMS Administrator changes her agency’s reliance on the RUC in its current form, presumably with pressure from the White House, Congress and the HHS Secretary, can this problem be resolved. Doing so would be a huge step toward regaining our fiscal balance, not just in health care but for the nation as a whole.

Opportunity Knocks - April 2014

National Infant Immunization Week
April 26-May 3, 2014

This year marks the 20th anniversary of National Infant Immunization Week (NIIW). Since 1994 NIIW has raised awareness about the benefits of scheduled immunizations for children aged 2 years and younger against vaccine‐preventable diseases (VPDs).[1] NIIW is a national platform taking place this year from April 26 to May 3 and is designed to:
  • Enhance awareness around the dangers of VPDs and the importance of childhood immunizations
  • Step up efforts to protect children against VPDs through immunizations
  • Encourage better communication between parents and health care professionals
  • Remind parents and caregivers they need to make and keep needed immunization appointments for their children
The Centers for Disease Control and Prevention (CDC) recommends 14 vaccines be administered to children by the age of 2 years.[2] An easy‐to‐read infant immunization schedule is available for download from the CDC website. For employees who are parents of young children, the CDC also offers a host of educational materials and tools to help make the immunization process easier for parents and children. For parents who are uncertain and question the need to vaccinate their children, it is particularly recommended to direct them to this website for more information.

Overall, undervaccination due to missed or delayed immunizations is a distinct trend in the United States.[3,4] Studies have shown that 1 in 3 children are undervaccinated during the first 2 years of life,[3] and that undervaccinated children have more emergency department visits and hospital admissions than appropriately vaccinated children.[4] Therefore, the need to emphasize the importance of pediatric well visits and adherence to vaccination schedules is vital during NIIW, especially given the good possibility that many appointments were cancelled during the series of snowstorms affecting much of the nation this past winter.

In the weeks preceding NIIW (April 26–May 3), it is key that local communities take steps to ensure that children are protected against common VPDs and that parents are well informed.

• Employer coalitions are encouraged to advance the goals of NIIW and begin educating employer members about childhood vaccinations through:
– Reposting this newsletter onto their website
– Downloading NIIW promotional resources and circulating to employer members
– Sending educational materials to employer members to encourage support for immunizing the children of their employees

• Employers can similarly do their part by:
– Generating awareness of NIIW among employees using available promotional resources
- Educating their employees about needed childhood vaccinations and recommended immunization schedules
– Encouraging their employees to schedule and keep well‐child visits to help make sure that children receive immunizations
– Helping employees to better understand pneumococcal vaccines and to assess their children’s risk for pneumococcal infection

Childhood immunizations are an important need that can be easily overlooked. NIIW is an excellent opportunity to stress the importance of childhood immunizations and to encourage all applicable employees to schedule well visits for their children to protect them against diseases that can affect their childhoods.

1. NIIW (National Infant Immunization Week). Centers for Disease Control and Prevention website. Updated December 17, 2013. Accessed March 7, 2014.
2. 2014 recommended immunizations for children from birth through 6 years old. Centers for Disease Control and Prevention website. Published January 30, 2014. Accessed March 7, 2014.
3. Luman ET, Barker LE, Shaw KM, McCauley MM, Buehler JM, Pickering LK. Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed. JAMA. 2005;293(10):1204‐1211.
4. Glanz JM, Newcomer SR, Narwaney KJ, et al. A population‐‐‐based cohort study of undervaccination in 8 managed care organizations across the United States. JAMA Pediatr. 2013;167(3):274‐‐‐281.

*Please note that publication in an Opportunity Knocks Newsletter is not meant to be construed as an endorsement of any company, product, or service by NBCH.

To find out how your company can submit an opportunity for Opportunity Knocks contact Ellen Thomson.

Monday, March 31, 2014

American Health Strategy Project Businesses Lead the Way in Worksite Health Promotion

Employers share efforts to adopt value-based health benefit strategies

Washington – March 31, 2014 – Improving health while reducing costs was a key focus for the employers who participated in the American Health Strategy Project (AHSP) according to a new report released this week by the National Business Coalition on Health (NBCH), Partnership for Prevention, and Pfizer Inc. AHSP is a national pilot launched in 2010 by NBCH in cooperation with Pfizer, with five business health coalitions selected to work with employers to improve the health of their employees and families, promote wellness and prevention, unlock the full value of health benefits, and manage health care costs.

The business health coalitions that participated in AHSP: Dallas-Fort Worth Business Group on Health, Midwest Business Group on Health in Chicago, Oregon Coalition of Health Care Purchasers, Pittsburgh Business Group on Health and the Virginia Business Coalition on Health.

The new report produced by Partnership for Prevention, “Creating a Corporate Health Strategy: The American Health Strategy Project Early Adopter Experience,” tells the story of four of these coalitions and their participating employers.

“Health programs developed with a solid understanding of an employer population’s data and clinical evidence will be more likely to improve the health of their workforce,” said Marcia Wright, PharmD, Senior Director, Pfizer. “We’ve found this often to be the case in this national project.”

The strategies implemented by many of the businesses included: promoting healthy lifestyles to employees; offering incentives for activities like health risk assessments; providing coverage for evidence-based preventive screenings; designing benefits based on data; and making environmental changes to promote health.

"Through the AHSP pilots, employers recognized the value of tailoring benefits to the health risks of their employee population and became savvier decision makers as they were more strategically-invested," said Sara Hanlon, Vice President, NBCH. "Businesses nationwide can benefit from these pilots by adopting similar models to make better, more informed benefit decisions for their workforce."

The American Health Strategies Project is grounded in quality improvement processes, incorporating evidence based disease support from Pfizer's Medical Outcomes Specialists and a suite of tools to support employers in improving the health of their population.

“Employers with strong health management teams and access to real data can help foster healthier, more productive employees and may achieve higher value for their health care spend,” said Elissa Myers, President and CEO, Partnership for Prevention. “We’re sharing these success stories in the hopes that other purchasers can learn from these tested strategies.”

About the National Business Coalition on Health

The National Business Coalition on Health is a national, non-profit, membership organization of purchaser-led business and health coalitions, representing over 7,000 employers and 25 million employees and their dependents across the United States. NBCH and its members are dedicated to value-based purchasing of health care services through the collective action of public and private purchasers.

About Partnership for Prevention

Partnership for Prevention is a national organization that advances policies and practices for evidence-based prevention. Since its inception, Partnership for Prevention’s Leading by Exampleinitiative has served as a forum for peer-to-peer communications targeted to employers of all sizes, emphasizing the value of health promotion and healthy worksite cultures. Business leaders are spotlighted and share their new and successful approaches to worksite health and productivity.

About Pfizer Inc.

At Pfizer, we apply science and our global resources to bring therapies to people that extend and significantly improve their lives. We strive to set the standard for quality, safety and value in the discovery, development and manufacture of health care products. Our global portfolio includes medicines and vaccines as well as many of the world's best-known consumer health care products. Every day, Pfizer colleagues work across developed and emerging markets to advance wellness, prevention, treatments and cures that challenge the most feared diseases of our time. Consistent with our responsibility as one of the world's premier innovative biopharmaceutical companies, we collaborate with health care providers, governments and local communities to support and expand access to reliable, affordable health care around the world. For more than 150 years, Pfizer has worked to make a difference for all who rely on us. To learn more, please visit us at

# # #

Media Contacts:
Cary Conway
National Business Coalition on Health

Victoria Davis

Comments from American Health Strategy Project Participants

The statements below may be used with attribution in connection with today’s announcement of the final American Health Strategy Project report.

Dallas-Fort Worth Business Group on Health (
“We’re pleased to share the impressive results achieved by the seven pace-setting DFWBGH employers who participated in the Texas Health Strategy Project. The structured, data-driven approach to benefits design, coupled with group learning, information sharing and collaboration, created an environment of innovation, idea generation and mutual accountability which resulted in creative new solutions or enhancements to existing programs to address employees’ health needs.”
Marianne Fazen, PhD, Executive Director, Dallas-Fort Worth Business Group on Health

Midwest Business Group on Health (
“As a result of the Midwest Health Strategy Project, MBGH employers learned how to access and better use actionable data in order to make more informed decisions regarding the health of their employees and develop key benefit design decisions using innovative value-based approaches. The project was also successful in supporting the employers to develop a more business-focused, integrated health management strategy by focusing on key guiding principles that fostered their individual company's overall health and well-being.”
Margaret Rehayem, Senior Director of Strategic Initiatives & Communications, Midwest Business Group on Health

Oregon Coalition of Health Care Purchasers (
“Working with our purchaser members on the Oregon Health Strategy Project allowed us to show members how their health plan data tells a story about their population’s health. The aggregate data brought to light key areas for improving health cost trend. Coupled with actionable solutions, members continue to realize value from this effort.”
Jill Freeman, Member Support & Engagement Specialist

Pittsburgh Business Group on Health (
“The value individually and collectively to the Pittsburgh Business Group on Health employer participants is demonstrated in the number of employers that moved into “Best In Class” in the four core principles over the course of the project. In addition, many of the employers continue to use the AHSP as a template for other additional value-based health initiatives.”
Diane C. McClune BSN, MBA, Director of Operations, Pittsburgh Business Group on Health

Virginia Business Coalition on Health (
“Challenged to achieve optimum value for every dollar spent on health care, Virginia Health Strategy Project employers were open to address population and organizational strategies that addressed the ever growing rates of obesity, diabetes, and cardiovascular disease.”
Eileen Ciccotelli, MPM, Vice President, Virginia Business Coalition on Health

Thursday, March 27, 2014

New NBCH Tool Helps Employers Assess Quality of their Pharmacy Benefit Management Programs

Resource developed to raise awareness of PBM quality initiatives and change
the purchaser conversation from “price” to “value”

WASHINGTON – March 27, 2014 – To provide employers with the decision support information needed to manage their pharmaceutical benefits management vendors and programs, the National Business Coalition on Health (NBCH) launched the 2014 NBCH PBM (Pharmacy Benefits Management) Quality Assessment. Almost 30 business health coalitions of employer purchasers from across the U.S. have signed on to date to participate in the program led by the non-profit NBCH.

“Comparing health plan-integrated PBMs with carve-out PBMs is always difficult,” said James Downing, Director, Global Benefits at McCormick & Co., Inc. “This tool can provide an objective apples-to-apples analysis.”

In developing this purchaser decision tool, NBCH surveyed coalitions where 90 percent of respondents indicated they were being asked by employer members for information to help them better manage their PBM programs and vendor selections. The query also found key issues of concern to employers include:
  • Increases in pharmacy costs as a percentage of their overall benefits spend.
  • Consultants and brokers may be influenced by commissions and purchasing collaboratives.
  • Desire to move beyond price-only considerations and into value in making PBM decisions.
  • Number of new PBMs entering the industry has created the need to objectively judge their credibility.
  • Difficulty in comparing “carve-in” PBMs integrated into the health plans, and “carve-out” PBMs specializing in PBM services.
“Our employer members have asked about the comparative value provided by PBMs,” said John Miller, executive director, Mid-Atlantic Business Group on Health and member of NBCH Board of Governors. “They want to move beyond a pure price discussion and prior to the development of this tool, there wasn’t a resource to look to for objective information on PBM clinical and population health services.”

A variety of PBMs have signed on to participate in the RFI to date, including: Cigna Pharmacy Management, EnvisionRxOptions, OptumRx, and ProCareRx.

Based on the analysis and data from eValue8™, NBCH developed and tested this new PBM Quality Assessment Tool to meet its members’ needs. eValue8 is a comprehensive evidence-based online tool used by coalitions and employers for more than 10 years to objectively measure and compare health plan vendors about how they manage critical processes that control costs and improve health and health care, including PBM services.

Scored by a small team of trained consultants, eValue8 questions are developed and updated by experts based on recommendations and specifications from organizations like the National Quality Forum, PQA, and academic institutions. The PBM Assessment is drawn from the evidence-based PBM measures of eValue8, with minimal additional questions suggested by our PBM experts.

“In an era of health care reform, new PBM models, and complex consulting relationships, employers desire more relevant and unbiased PBM procurement processes”, said Kathi Fairman, vice president at The Pharmacy Benefit Management Institute. “The PBM Quality Assessment Tool will provide employers a more comprehensive evaluation of their PBM options, going beyond the traditional price discounts and allowing for innovative models to emerge.”

Next steps
Responses from participating PBM vendors are due May 16 and scoring will end in June with reports and results being released to participating coalitions and their employer members in July.

About eValue8
eValue8 was created by business coalitions and employers like Marriott and General Motors to measure and evaluate health plan performance. eValue8 asks health vendors probing questions about how they manage critical processes that control costs, reduce and eliminate waste, ensure patient safety, close gaps in care and improve health and health care.

County Health Rankings Webinar

Have you heard of the County Health Rankings & Roadmaps program but would like to learn a bit more about the program? Join the County Health Rankings team for this webinar which will provide a comprehensive overview of the program.

On this webinar they will discuss:
• Why we rank and why rankings are useful;
• The County Health Rankings model and measures;
• The 4 components of the County Health Roadmaps project; and
• How to use the Rankings & Roadmaps to ignite action in your community.

This webinar includes a tour of the County Health Rankings & Roadmaps website as well an introduction to new features in 2014.

This webinar will be Tuesday, April 1st from 3-4 pm Eastern Daylight Time, 2-3 pm Central Time, 1-2 pm Mountain Time, 12 Noon - 1 pm Pacific Time, 11 am - 12 Noon for Alaska, and 10 - 11 am for Hawaii.

You can register here.

Wednesday, March 26, 2014

5th Annual County Health Rankings Released

The Robert Wood Johnson Foundation and the University of Wisconsin's Population Health Institute have released the fifth annual County Health Rankings. An easy-to-use snapshot, the Rankings reveal the overall health of nearly every county in the nation. It allows each state to see how people from one county to another compare on a range of factors from housing to transportation to community safety and offers ways to take action to promote lifelong health and ensure that every community is a healthy place to live, learn, work, and play. Learn more at 

Tuesday, March 25, 2014

New Report Card on State Price Transparency Laws, Regulations, and Websites Released

Forty-five states received a failing grade, only two received a B (Maine and Massachusetts), and no states earned an A, according to the second annual Report Card on State Price Transparency Laws developed by Catalyst for Payment Reform (CPR) and Health Care Incentives Improvement Institute (HCI3). The Report Card offers policymakers, consumer advocates, and other health care stakeholders a comprehensive state-by-state resource on consumer access to price information for health services. The grades are lower than in 2013 as this year’s Report Card no longer graded states only on the laws they have adopted to promote price transparency, but also on states’ price transparency regulations, price transparency websites (to the extent they exist), and all payer claims databases – the ideal source of data for these websites because they contain more accurate, complete price information. States that relied on all-payer claims databases as the source of price information for consumers received higher grades, as did states with adequate, fully operational, consumer friendly websites (mandated by law).

Some states have robust price transparency laws and regulations on the books, requiring them to create a publicly available website – but often the public can’t readily access price information because the website is poorly designed, or inadequately functioning. As an example, New Hampshire – a state that received an A in last year’s Report Card – received an F this year, because its website is inoperative and may remain so for an extended period.

To get a high score, a state needed to have both the “spirit of the law” – public access to a fully functioning website, and the “letter of the law” – robust legislation and regulations on the books ensuring the price information would remain accessible.

You can view the full report card here.

Wednesday, March 19, 2014

New Resources from Consumer Reports Health and Choosing Wisely

Consumer Reports Health and Choosing Wisely have recently released a number of new resources as well as highlighted partner content. Check out the list below.

From Health Affairs Blog: The Arkansas Payment Reform Laboratory

The Health Affairs Blog has launched a series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. Check out the first post in the series - written by part of the team evaluating the Arkansas model, the Arkansas Payment Improvement Initiative.

Tuesday, March 18, 2014

'SHOP' Health Insurance Marketplaces Providing Small Businesses with Choice of Insurers, Plans

Read more below about a new Issue Brief from The Commonwealth Fund.

The Affordable Care Act seeks to help small employers offer coverage by reforming the small-group market and establishing Small Business Health Options Program (SHOP) marketplaces. Seventeen states and the District of Columbia chose to operate their own SHOP marketplaces in 2014, with the federal government operating the SHOP marketplace in 33 states. This brief examines state decisions to enhance the value of SHOP marketplaces for small employers and finds that most have set predictable participation and eligibility requirements and will offer a competitive choice of insurers and plans. States also are seeking to facilitate small employers’ shopping experience through online tools and access to personalized assistance. While not all SHOP marketplaces are yet functioning as intended, their establishment offers an opportunity to identify successful strategies for improving the affordability and accessibility of coverage for small employers.

Access the full Issue Brief here.