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TRANSCRIPT
Healthcare & Legislative Update
Gulf Coast ChapterFlorida Government Finance Officers Association
Anna Maria Studley – Director, Client DevelopmentSeptember 20, 2019
Question #1
Does the new Firefighter Cancer Legislation refer to an employer’s responsibilities
under …….A. Workers’ Compensation
B. Benefits
C. All of the Above
D. None of the Above
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Senate Bill 426
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Firefighter Cancer Benefit: Provides Benefits &
Compensation for Firefighters Diagnosed with Certain Cancers
Effective: July 1, 2019
Florida Firefighter Cancer Bill
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Created F.S.112.1816
(Bill text Introduction
Summary)
• Upon Receiving diagnosis of cancer if certain conditions met
• Requires ER make certain Disability Payments in event of total and permanent disability
• Death benefits to beneficiary if Firefighter dies as result of cancer OR cancer treatments
• Requires Division of Fire Marshall to adopt certain rules
• Amends S. 121.735 F.S. - Allocations for member line-of-duty death benefits; percentage amounts
Florida Firefighter Cancer Bill
• Firefighters; 21 Cancer Types
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Bladder Brain Breast Cervical
Colon EsophagealInvasiveSkin
Large Intestinal
LungMalignant melanoma
MesotheliomaMultiple Myeloma
Non-Hodgkin’s Lymphoma
Oral Cavity & Pharynx
Ovarian Prostate
Rectal Stomach Testicular Thyroid Cancers
Florida Firefighter Cancer Bill
•Definition:
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Florida Firefighter Cancer Bill
•Costs borne SOLELY by the EMPLOYER−Any applicable increases in funding or costs can
not be passed on to fire fighters
o Costs to provide the reimbursements & lump sum payments under Section 2 (health and lump sum)
▪ Taxable if not funded through pre tax process
o Disability retirement benefits under Paragraph 3(b)
o In the Line of Duty death benefits under Paragraph 4(b)
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Florida Firefighter Cancer Bill
•Medical & At Time of Diagnosis Lump Sum Eligibility:−At least 5 continuous years employment with
employer
−Non-tobacco use in preceding 5 years
−Not employed in another position in preceding 5 years proven to create higher risk of cancer
−Firefighter electing to continue coverage in the employer-sponsored health plan or trust
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Florida Firefighter Cancer Bill
• If eligible……Medical & At Time of Diagnosis Lump Sum Benefits− Timely reimbursement of out of pocket copays,
deductibles & coinsurance
o H.S.A.
o H.R.A.
− One-time lump sum payment of $25,000 upon diagnosis
o Benefit is taxable if firefighter is not taxed on value of premium paid by employer for coverage
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Florida Firefighter Cancer Bill
• If eligible……Medical & At Time of Diagnosis Lump Sum Benefits− Up to 10 years following termination of employment
Contingent upon:
o The firefighter is not subsequently employed as firefighter
o Continuation of coverage in the employer’s sponsored health plan or trust
•Administrative support & implementation − Attestations - testing
− Reimbursement claim form
− HRA plan document10
Florida Firefighter Cancer Bill
• Employer options for At Diagnosis Lump Sum Payment− Diagnosis 7/1/19 or after
− $25,000 one-time payout
− Taxation
− Self fund out of general funds
− HRA
− Purchase coverage paid by employer
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Florida Firefighter Cancer Bill
• Employer options for At Time of Diagnosis Lump Sum Payment− Purchase coverage paid by employer
o Florida League of Cities - 3 plan options
o VFIS
o Star & Shield
o Worksite benefits – evaluate any coverage gaps
▪ AFLAC – Fl Fire Cancer – Modified Critical Illness
▪ Colonial – Critical Illness
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Florida Firefighter Cancer Bill
•Disability & In the Line of Duty Death Benefit Eligibility − Not subject to 5-year employment requirement
− (a) when firefighter does, or
− (b) when firefighter does not participate in an employer sponsored retirement plan
•Disability Benefit− Provides for disability benefits due in the event of total &
permanent disabilities due to the cancer or circumstances from treatment of cancer
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Florida Firefighter Cancer Bill
• Employer Options for In the Line of Duty Death Benefit− $75,000
− Employer paid coverages
o Death Benefit only or Combined
o 21 Cancers or more
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Pharmacy – Key Challenges
•Managing Pharmacy Costs
•Lack of Transparency
•Complex Purchasing Structure & Pricing−Multiple stakeholders
−Rebates & discounts
o Percentage being received?
o Classification of medications eligible?
o What is Pharmacy Benefit Management (PBM) actually paying?
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US Pharmacy Distribution System
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Pharmacy Pricing
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WACWholesale Acquisition
Cost
MACMaximum Allowable
Cost
AWPAverage
Wholesale Pricing
Pharmacy Pricing
Wholesale Supply Chain
• Pharmaceutical manufacturers & Pharmacy Benefit Mangers have the most influence in setting Wholesale Acquisition Costs
• Increased consolidation in the market has increased availability of rebate dollars and discounts on generic, brand & specialty medications
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Pharmacy Pricing
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1975200 wholesalers
200050 wholesalers
Top 3 distributors= 90% of market
Supply Vs.
Demand
Pharmacy Pricing
If you have seen one price for a medication, you have seen one price!
• Pricing based on stakeholder negotiation power & leverage in the marketplace
• Pharmacies negotiate discounts & rebates:− Manufacturers – pay to play
−Wholesalers
− Pharmacy benefit managers (PBM) – to be included in carrier networks & prescription drug list (PDL) placement
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Manufacturer to Health Plan
Via Pharmacy Benefit Manager (PBM)
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Pharmacy Benefit Manager
Goal to Membership & Profitability
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Rebates
Discounts
Pharmacy Networks
Maximum Allowable Cost
Specialty
Mail-order
Pharmacy Clinic Programs
Claim Administration Fees
US Pharmacy Benefit Management Regulation
23sourceonhealthcare.org
PBM Legislation & Contracting
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Legislation
- Donut Hole
-Registration & Licensing
Rebates
- Percentage
- Drug Classes
Re-negotiation
- Hold Harmless
-Network Discounts
Transparency
Question #2
•Who was the latest company to be approved to purchase a major PBM in the amount of $54 Billion?
A. Aetna
B. Cigna
C. Florida Blue
D. Humana
E. United Healthcare
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Carrier Strategy – Pharmacy Focus
• Aetna & CVS
₋ Remove barriers to consumer access
o Make it simple
₋ Enhanced services in the local community
₋ Expand ‘Project Health’ preventative screening events to manage chronic conditions
₋ Cost reduction programs to improve medication adherence
o Timelier & more comprehensive reviews
o Expanded services & hours at MinuteClinic locations
o Florida Hubs - Tampa
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Carrier Strategy – Pharmacy Focus
• Cigna & Express Scripts
₋ Leverage Express Script’s technology
& clinical capabilities with specialist care support
₋ Advance Cigna’s goals to improve – multi year plan
o 2019/2020 - Affordability
o 2020 forward - Value-based care delivery
models & personalized customer engagement
₋ 2020 Planning
₋ Renewal - Cigna goal to be 4% lower than NAHU projections
₋ Pilot programs
₋ Oncology expanded via telemedicine
₋ Gene therapy specialty meds
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Carrier Strategy – Pharmacy Focus
• 2019 / 2020 Planning
₋ Transition to Express Scripts platform
o Cigna companies/members 10/1/19
o New business 1/1/20
o Renewals 2/1/2020
o No member impact
o One ID card
₋ Pilot programs
o Oncology expanded via telemedicine
o Gene therapy specialty meds
o ‘Your Care Anywhere’ - Overlap network - telemedicine
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Carrier Strategy – Pharmacy Focus
• Cigna & Express Scripts
₋ Enhance the ability to deliver:
o Improved total cost of care o Improved clinical outcomes focusing on the whole person
healtho Increased choice of benefit designs & solutions with
easier/simpler health care for Pharmacy
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Carrier Strategy – Pharmacy Focus
• Florida Blue & Prime Therapeutics
₋ Personalized medicine & diagnosis to
protect health and treat disease
₋ Manage costs through holistic care
₋ NetResults
₋ formulary w/ more excluded drugs to manage hyper – inflated cost of brands & generics
₋ Vertically integrated solutions & intervention
o Pharmacist case management & controlled substance predictive modeling
o Active management of high cost members
o Value based programs 30
Carrier Strategy – Pharmacy Focus
• Humana
₋ Own their own PBM
o Integrated solutions - data with pharmacy clinical management and medical/wellness alerts for proactive member engagement
₋ Partner with providers to manage health holistically
₋ Make it easier for members to engage in their health with clinical programs that intersect healthcare & lifestyle
₋ Enhancing & leveraging technology
₋ Clinical management model to address expansive specialty drug market
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Carrier Strategy – Pharmacy Focus
• United Healthcare & Optum Rx
₋ TCoC – Total Cost of Care - synchronized packages
o Highly managed formulary
o Required Rx clinical programs
o Personal Health Support (PHS)
o End to end advocacy model
o Preferred home delivery
o Exclusive specialty & benefit management
₋ Personalized alerts and interactions using data analytics
o Assured Living - Optum partnership with Best Buy Geek Squad
₋ PreCheck MyScript™
o Real-time alternative medications, patient cost by pharmacy, authorizations & clinical alerts
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Question #3
• Approximately what percentage of individuals in the United States with a diagnosable mental disorder seek treatment?
A. 32%
B. 56%
C. 70%
D. 87%
*National Alliance on Mental Illness - www.nami.org
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Mental Health Statistics
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• Low rate of engagement by members for treatment are costing employers approximately $1 trillion per year (2016 - $226 billion/year)
• 1 in 8 employers have data directly connecting mental health with overall health & performance
− Emotional well being of employee impacts:
o Absenteeism = 63%; Conflicts at work = 42%
o Harassment and bullying at work commonly reported and havesubstantial impact to employee’s mental health
− ROI 4:1 when investments are made to scale up treatment for common mental disorders
Mental Health Statistics
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• Suicide Trends – United States +24.2%
• In the US – 2017 Suicides:
− 10th leading cause of death in the United States
− 1.4 million attempted; 47,173 completed
− 90% of people who complete suicide show symptoms of mental health condition
Florida Legislation – Oct 1, 2018
• Senate Bill 376 & House Bill 227− Amended 112.1815
− Benefits for first responders
o Firefighters, paramedics, emergency medical technicians, and law enforcement officers, including volunteers.
− Certain circumstances, post traumatic stress disorder (PTSD) is an occupational disease
o As described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, published by the American Psychiatric Assoc.
− Employing agency of first responder, must provide educational training related to mental health awareness, prevention, mitigation & treatment
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Florida - CFO & Fire Marshall Patronis
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• Focus for First Responders - Critical Incidents: Mental health awareness, prevention, mitigation, and treatment
• Objectives:
− Review stressors associated with emergency services
− Discuss reactions, symptoms, and syndromes; select disorders related to critical incident stress
− Explore individual and organizational activities for both promoting and improving crew mental health
− Describe basic objectives and the intervention steps of Psychological First Aid
Federal Legislation
•Mental and behavioral health services are essential health benefits− Plans must cover:
o Behavioral health treatment, such as psychotherapy & counseling
o Mental and behavioral health inpatient services
o Substance use disorder treatment
o No pre-existing
o Individuals can not be denied for coverage at time of application
o Equitable level of benefits with medical services
▪ Testing values
▪ 100%38
Mental Health First Aid
• Mental Health challenges are more common than heart & lung disease and cancer, combined
• 1 in 5 Americans will experience a diagnosable mental disorder in any given year
• Recovery is possible!
• How To:
− Respond in a mental health emergency
− Offer support to someone in emotional distress
− Eliminate stigma preventing an individual from seeking treatment
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Spectrum of Interventions
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Well Becoming Unwell Unwell Recovering
Prevention
Early
Intervention
Treatment
Where Mental Health First Aid can help on the spectrum of mental health interventions
What to Watch For
• Captive Stoploss Options
• Telemedicine – Telepods
• Clinics
− Wrap networks
− Pharmacy integration – Corrections
• Dental –
− Alternate ways to design benefits & contract providers
− $10,000 maximum
• Amazon, Jimmy Buffet & JP Morgan Chase
− Pill Pack – Amazon Pharmacy41
Government Benchmarking
• CavU - 4 You
− Exclusive to public sector
− Free access to the site
− Individually choose who you consider a comparable entity
− Output report includes your specific data
− Interactive chat feature
− Additional customization capabilities
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Thank you!!!
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