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NEW JERSEY (UPDATE!): Plan Design Committee approves new option for SEHBP.

Voluntary pilot program to improve care, control costs.

The Design Committee voted 5-0 to move forward with a voluntary pilot program beginning this year.  No member will be required to participate, and no member who participates will give up any other benefits to do so. The Committee’s action comes several months after the State Health Benefits Program (SHBP), which covers public employees who do not work in schools, adopted a similar pilot program with overwhelming support from unions including AFCSME, CWA, AAUP-AFT, the State Troopers, the State PBA and FMBA.

Published on Monday, January 11, 2016

By New Jersey Education Association

NJEA Secretary-Treasurer Sean M. Spiller spoke in support of the DPCMH model at a Feb. 12 press conference. Source: http://www.njea.org/news/2016-01-10/long-awaited-primary-care-pilot-poised-for-approval

NJEA Secretary-Treasurer Sean M. Spiller spoke in support of the DPCMH model at a Feb. 12 press conference. Source: http://www.njea.org/news/2016-01-10/long-awaited-primary-care-pilot-poised-for-approval

January 11, 2016 – The School Employees’ Health Benefits Program (SEHBP) Plan Design Committee today approved a long-awaited pilot program to give some members the opportunity to utilize Direct Primary Care Medical Homes (DPCMH).  The pilot program grows out of an effort spearheaded by NJEA, in partnership with a coalition of other public sector unions, physicians and health care policy experts.  The effort also garnered legislative support, including an endorsement by Senate President Steve Sweeney.

NJEA and AFT initially began to explore the DPCMH concept as a way to enhance the quality of care offered to members while slowing the growth of premium costs.  The DPCMH model does both of those things through an innovative, patient-centered approach to care designed to prevent and treat chronic illness more effectively, thus reducing the overall cost to plan participants.

These changes will take effect as soon as reasonable, but no later than March 1, 2016.

The Design Committee voted 5-0 to move forward with a voluntary pilot program beginning this year.  No member will be required to participate, and no member who participates will give up any other benefits to do so. The Committee’s action comes several months after the State Health Benefits Program (SHBP), which covers public employees who do not work in schools, adopted a similar pilot program with overwhelming support from unions including AFCSME, CWA, AAUP-AFT, the State Troopers, the State PBA and FMBA.  Today’s SEHBP Plan Design Committee vote to approve the pilot program became possible after the State’s representatives on the committee backed away from demanding concessions that NJEA and AFT were unwilling to accept as a condition for participation.

NJEA President Wendell Steinhauer lauded the Committee’s action. “NJEA is committed to making sure our members have access to affordable, high-quality health care. This model shows great potential to help our members stay healthier while also saving them money.  It’s a win-win situation, and I’m proud of the work we’ve done to bring it this far.”

NJEA Vice President Marie Blistan highlighted the financial benefits to members.  “Our members already pay too much for healthcare, and those costs are rising. It’s our job to reverse that trend, and this approach gives us another tool to do that.”

NJEA Secretary-Treasurer Sean Spiller, who spoke in support of this approach last February at a Statehouse press conference, urged members to examine it carefully. “We know how much our members value their health benefits.  That’s why we took the time to carefully study and understand this plan, and that’s why we insisted on a pilot program to ensure that it works as intended.  We were clear that it has to be totally voluntary, and that it can only add benefits, not take anything away. The Committee heard that and met our requirements.”

DPC Consumer Guide cover_2015_KINDLENJEA’s coalition partners also hailed the vote.  AFT-NJ President Donna Chiera said, “School employees in New Jersey should have access to great healthcare.  This approach will provide another option for members who value a close relationship with their primary care physician and who want a doctor to know them well. The fact that this plan enhancement is predicted to help control costs as well makes it a real win for all members in the SEHBP.”

Mark Blum, Executive Director of America’s Agenda, a healthcare policy expert who has been working with the New Jersey unions for the past year, said, “The evidence is clear: better patient access to personalized, high quality care from family doctors who are personally responsible for delivering and coordinating that care results in better health outcomes and lower overall costs.  The Direct Primary Care Medical Home Program is designed to deliver exactly these results. Public employees and family members who enroll in the program are signing up for more than quick, convenient, access to primary care with no out-of-pocket costs, they are signing up for a much more personal, more satisfying health care experience.”

NJEA , AFT and the other unions will continue to participate in the creation of the pilot program and the monitoring of its implementation and success.

[MP3] Download and LISTEN ... “MD2B: BUILDING STRATEGIC ALLIANCES WITH EMPLOYERS” ... Source: (By The DPC Journal, Nov. 2015)

[MP3] Download and LISTEN … “MD2B: BUILDING STRATEGIC ALLIANCES WITH EMPLOYERS” … Source: (By The DPC Journal, Nov. 2015)

Plan Design Committee also tackles compound drug concerns

The Plan Design Committee also acted at the same meeting to address the over-prescription of certain compound medications, which have exploded in cost in recent years, adding to the premiums paid by NJEA members in the SEHBP.  In just one year, between September 2014 and September 2015, there was a 195.5% increase in usage from less than 2% of the total SEHBP enrollees. Costs have skyrocketed as a result.  Between January and September 2015, the cost of compound medications was over $54 million. During the months of June, July, and August 2015 alone, the spending was $24.2 million, which represents a significant growth each quarter.  Costs for individual medications in this category have risen from $100 on average per prescription in 2010, to over $4,000 on average per prescription in 2015.

The SEHBP premium rate increases for 2016 were determined in the summer of 2015.  Since then, the SEHBP has continued to see increased utilization of compound medications each quarter.  At this rate, even with the above-average increases in premium, the State presumably will not be able to intake enough in premiums in order to absorb the total prescription costs.  The SEHBP Commission and Plan Design Committees have received reports and recommendations from Express Scripts, the SEHBP prescription drug provider, on how to curb these costs.

The SEHBP Design Committee voted to adopt a resolution that makes the following changes regarding access to some compound medications in the prescription drug program:  

  1. Determines coverage of the compound medication by evaluation of every component in a compound against the plan design;
  2. Eliminates coverage for certain compound medications that have no clinical evidence of effectiveness;
  3. Establishes a list of compound-specific exclusion criteria.  This list would include certain ingredients that lack clinical evidence within compounds, products that are commercially available through alternative medications, traditionally considered over-the-counter medications, and products that have continuous and/or significant price increases.
  4. Rejects automatically any compound on the compound exclusion list or containing drugs not covered by the plan.
  5. Continues the allowance, approval, and dispensing of compounds that have clinical value.

It is important to note that certain compound medications will continue to be approved based on appropriate criteria.  The resolution states that these types of medications “are necessary when the medical needs of a patient cannot be met by an FDA-approved medication because of an allergy to a component of a medication or a patient needs a liquid form of a medication because of difficulty swallowing or for some other medically necessary reason.”  As a result, when a patient requires a compound medication, that medication will be approved.  Further, should an individual patient receive a denial of coverage for a compound medication, there is an appeal process to seek appropriate coverage.

These changes will take effect as soon as reasonable, but no later than March 1, 2016.

To learn more about how compound drugs with questionable medical value have begun to drive up the cost of prescription coverage, see this page.

SOURCE: http://njea.org/news/2016-01-11/plan-design-committee-approves-new-option-for-sehbp

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