1. Cost Containment and State Health Care Reform NAIC Health Innovations Working Group March 29, 2008 Isabel Friedenzohn Deputy Director, State Coverage Initiatives

2. State Coverage Initiatives (SCI ) An Initiative of The Robert Wood Johnson Foundation Direct technical assistance to states –State specific help, research on state policy makers’ questions –Convening state officials –Web site: http://statecoverage.nethttp://statecoverage.net –Coverage Matrix –Publications Grant funding State Coverage Initiatives

3. Health Care Costs – The Dilemma Per person spending expected to increase from $7,026 (’06) to $13,101 (’07) Projections that national health care spending will reach $4.3 trillion by 2017 (20% GDP) Keehan, S., et al., ‘Health Spending Projections through 2017: The Baby-Boom Generation is Coming to Medicare,” Health Affairs Exclusive, February 26, 2008, W-145.

4. Percent of Median Family Income Required to Buy Family Health Insurance Source: Calculations by Len Nichols, using KFF and AHRQ premium data, CPS income data.

5. Labor Market Realities OccupationFamily premium/Median wage Physician 7.3% History professor15.8% Secretary 29.1% Carpenter24.2% Cook49.8%. Source: KFF premium and BLS wage data

6. Increases in Health Insurance Premiums Compared to Other Indicators, 1988-2007 Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2007; KPMG Survey of Employer- Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988, 1989, 1990; Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1988-2007; Bureau of Labor Statistics, Seasonally Adjusted Data rom the Current Employment Statistics Survey, 1988-2007 (April to April).

9. Root Problems Inappropriate and/or overutilization of medical care/ good new technologies Regional variation in services and spending Administrative inefficiency associated with payer/provider/patient interface Growing uninsured population Insufficient preventive services Patients’ lack of price sensitivity Incentive mis-alignment Under-application of current evidence base Too small an evidence base Poor lifestyle choices Nichols, L. “Financing Health Reform: Share Responsibility IS the American Way.”, Financing Health Care Reform in New Jersey Forum, March 18, 2008. HCFO Hot Topics on Health Care Costs.

10. Distribution of Health Spending Adults Ages 18-64, 2001 Source: Employee Benefit Research Institute estimates from the 2001 Medical Expenditure Panel Survey.

11. More than 80% of Health Care Spending on Behalf of People with Chronic Conditions Thorpe, Kenneth E, PhD. What Accounts for the High and Rising Costs of Health Care? Slides presented at the State Coverage Initiatives National Meeting, Washington, DC, February 23-24, 2006

12. Challenges of Cost-Containment One person’s cost is another’s income System savings are not necessarily payer’s or state’s Cost-shifts have multiple participants and time horizons Nichols, L. “Financing Health Reform: Share Responsibility IS the American Way.”, Financing Health Care Reform in New Jersey Forum, March 18, 2008.

13. Types of Possible Remedies (1) Purchasing to Improve Quality/Patient Safety –Pay for performance –Tiered networks –Strengthening primary care and care coordination (medical homes) –Improve Efficiency (i.e., appropriate care settings) Purchasing Strategies to Reduce Costs –Pooled purchasing, rebates, etc Promoting Health and Disease Prevention –Wellness Programs –Disease Management –Reducing Obesity/Tobacco Use –Positive incentives for Health Producing and Using Better Information –Information Technology Evidence-Based Medicine Commonwealth Foundation. Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending. 2008

14. Types of Possible Remedies (2) Consumer-Related Strategies  Changes to Consumer Cost Sharing  Consumer Education (Performance Guides, Cost Transparency)  Consumer-Directed Health Care Supply Controls  Ration Services, CON, professional supply, technology diffusion Price Controls  Public Program Payment Formulae (Medicaid/Medicare)  Use Buying Power of State (Medicaid/State Employees)

15. State Efforts: Councils focus on Cost and Quality MA – Health Care Quality and Cost Council WV – Interagency Health Council ME – Maine Hospital Cost Commission LA – Health Care Quality Forum MD – Maryland Health Quality and Cost Council OH - Office of Health Ohio CO - Center for Improving Value in Health Care OR – Oregon Quality Institute

16. State efforts: RI HEALTHpact “wellness health benefit plans” for small businesses (<50 employees) Benefit design encourages wellness programs Insurers (2) required to offer Premiums must be equal to more than 10% of average annual state wages. Tiered provider networks

17. CA reform proposal: Cost Containment –Requirement that employers establish Section 125 plans –Individuals also able to make pre-tax contributions to HSAs –Work with both providers and insurers to improve efficiency and reduce overall health care costs –Implement health information technology (stipulates goal of achieving 100 percent electronic health data exchange in the next 10 years) –Increases Medi-Cal reimbursement rates to reduce cost-shifting (‘hidden tax’ on private payers).

18. Prescription for Pennsylvania Prescription for Pennsylvania is a set of integrated practical strategies for improving the health care of all Pennsylvanians, making the health care system more efficient and containing its cost. Source: Presentation by Ann S. Torregrossa, Deputy Director & Director of Policy GOHCR. NGA meeting on Benefit Design.March 26, 2008

19. Pennsylvania Proposed Reforms: Prescription for Pennsylvania Rx for AffordabilityRx for AccessRx for Quality Cover All PennsylvaniansHealth Care WorkforceHospital-Acquired Infections Coverage for College Students and Young Adults Removing Practice BarriersQuality Outcomes Community Benefit Requirements Cost-Effective SitesPay for Performance Uniform Admission CriteriaCo-Occurring DisordersChronic Care Fair Billing and Collection Practices Governor may consider individual mandate if number of uninsured does not decline over next few years Health Disparities Capital ExpendituresChild Wellness Small Group Insurance Reform Adult Wellness Transparency of Cost and Quality Data Long Term Living End of Life and Palliative Care Source: Presentation by Ann S. Torregrossa, Deputy Director & Director of Policy GOHCR. Alliance for Health Reform Briefing, October 26, 2007

20. Pennsylvania: “Every day that passes without meaningful change increases the cost to our health care system.”

21. Lessons learned in state reform efforts Little success so far in addressing underlying cost of health care but a new focus on chronic care management holds potential Address access, systems improvement, cost containment simultaneously— concern about long-term sustainability of programs and improved population health State Coverage Initiatives