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Investing in Maternal and Child Health: Strategies for Employers


The Maternal and Child Health Plan Benefit Model: evidence-informed benefit design. Effective strategies for ... Limited in pediatrics and obstetrics ... – PowerPoint PPT presentation

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Title: Investing in Maternal and Child Health: Strategies for Employers

Investing in Maternal and Child Health
Strategies for Employers
  • National Business Group on Health
  • December 11, 2007

Overview Learning Objectives
  • Understand how to use Investing in Maternal and
    Child Health An Employers Toolkit
  • The business case for MCH
  • The Maternal and Child Health Plan Benefit Model
    evidence-informed benefit design
  • Effective strategies for communication,
    education, engagement
  • Investing in maternal and child health
  • What does investing mean?
  • Why is it important?
  • How can it be done?

  • Kathryn Phillips Campbell, Manager Center for
    Prevention and Health Services
  • Scott Rothermel, Consultant NBGH
  • Rebecca Main, Marriott International Maternal
    and Family Health Benefits Advisory Board

Sources 1. PricewaterhouseCoopers LLP. Actuarial
analysis of the National Business Group on
Healths Maternal and Child Health Plan Benefit
Model. Atlanta, GA PricewaterhouseCoopers LLP
August 2007 2. Shellenback K. Child Care and
Parent Productivity Making the Business Case.
Ithaca, NY Cornell Department of City and
Regional Planning 2004.
Business Case
  • 1 out of every 5 large employers spend on
    health care is for MCH services1
  • Pregnancy is a leading cause of short- and
    long-term disability and turnover for most
  • Childrens health problems are a leading cause of
    employee absence and productivity loss
  • Absences cost employers 3 billion per year2
  • 26 of the time, employees calling in sick are
    providing care to a family member

Business Case
  • Improved MCH health is associated with
  • Lower healthcare costs
  • Increased productivity
  • Improved retention
  • A healthier future workforce

Business Case Children
  • Important, but often overlooked population
  • 43 of NBGH employers provide dependent coverage
    through age 25, pending school status1
  • 33 of all beneficiaries are under the age of 252
  • 14.7 of claims costs are for children
  • 8.6 of employees provide care to a child with a
    special health care need3
  • In 2003, childrens costs totaled 67 billion in
    the U.S.4

Sources 1. National Business Group on Health.
Maternal and Child Health Benefits Survey.
Washington, DC National Business Group on
Health January 2006 2. PricewaterhouseCoopers
LLP. Actuarial analysis of the National Business
Group on Healths Maternal and Child Health Plan
Benefit Model. Atlanta, GA PricewaterhouseCoopers
LLP August 2007 3. Perrin J, Kuhthau K, Fluet
C. Children with Special Needs and the Workplace
A Guide for Employers. Boston, MA Center for
Child and Adolescent Health Policy at the
MassGeneral Hospital for Children 2004 4.
Chevarley FM. Utilization and Expenditures for
Children with Special Health Care Needs. Research
Findings No. 24. Rockville, MD Agency for
Healthcare Research and Quality 2006.
Business Case Healthy Pregnancy
  • In any given year, 5 of female employees will
    experience a pregnancy1
  • Pregnancy and childbirth account for 25 of all
    hospitalizations in the United States2
  • Complications of pregnancy are costly in the
    short- and long-term
  • Each year employers spend 9 billion on claims
    related to prematurity and low birthweight2
  • 10 of babies covered by employer-sponsored
    health plans are born with a prematurity
  • Other complications preeclampsia, multiple
    births, 40 more C-sections today than in 19973

Sources 1. March of Dimes, 2007 2. National
Committee for Quality Assurance. The State of
Health Care Quality 2005 Industry Trends and
Analysis. Available at http//
OHCQ_2005.pdf. Accessed on June 7, 2007 3. CDC.
National Vital Statistics Report, Vol 52, No 10.
Large Employer Specific Cost Data
  • Actuarial analysis
  • Medstat database
  • PricewaterhouseCoopers proprietary cost models
  • 120,000 beneficiaries
  • Cost data from 2004

Childrens cost and service-use profiles are
different than those of adults
Investing in Maternal and Child Health
7-part resource guide on plan design, education,
and communication
  • Business case
  • Maternal and Child Health Plan Benefit Model
  • Healthcare strategy
  • Employer education and case studies
  • Beneficiary education and communication tips
  • Materials for employees on MCH topics
  • Tools, metrics, crosswalks

Maternal and Child Health Plan Benefit Model
  • Plan design specific to the needs of children,
    adolescents, and childbearing women
  • Comprehensive/unified plan (includes mental
    health, dental, vision, and prescription drug
    coverage recommendations)
  • Reduces administrative cost burden allows for
    clinical integration
  • Evidence-informed
  • Affordable (employee) sustainable (employer)
  • Centered on prevention and early intervention
  • Designed by NBGH advisory board
  • Benefit managers medical directors professional
    association delegates experts in pediatrics,
    family medicine, occupational medicine health
    plans healthcare consultants
  • Reviewed by 30 external experts

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Evidence-Informed Benefits
  • Evidence-based strong scientific evidence of
    effectiveness (e.g., USPSTF recommendations)
  • Limited in pediatrics and obstetrics
  • Recommended guidance based on the best available
    information about a condition, disease or health
    service (e.g., expert opinion, consensus, panel

Maternal and Child Health Plan Benefit Model
  • HMO and PPO plan designs
  • 34 recommended benefits
  • 5 categories
  • I. Preventive Services
  • II. Physician / Practitioner Services
  • III. Facility-Based Care
  • IV. Therapeutic Services / Ancillary Services
  • V. Laboratory, Diagnostic, Assessment, and
    Testing Services

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Innovative Benefits
  • Preventive care
  • Preconception care
  • Postpartum care lactation support
  • Early intervention services for mental health /
    substance abuse
  • Preventive dental care
  • E-visits telephonic visits, group care, care by
    a healthcare team
  • DME Medical foods, cochlear implants, donor
    breast milk, breast pumps

Administrative Changes
  • Medically necessary care is
  • Prescribed by a physician or other qualified
    healthcare provider.
  • Required to prevent, diagnose, or treat an
    illness, injury, or disease or its symptoms help
    maintain, improve, or restore the individuals
    health or functional capacity prevent
    deterioration of the individuals condition or
    remedy developmental delays or disabilities.
  • Generally agreed to be of clinical value.
  • Clinically consistent with the patients
    diagnosis and/or symptoms.
  • Appropriate in terms of type, scope, frequency,
    duration, intensity, and delivered in a setting
    that is appropriate to the needs of the patient.

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Cost-Sharing Recommendations
  • Zero cost preventive care

Cost-Sharing Recommendations
  • Recommended total participant cost (premium, OOP
    total) excludes prescription drugs
  • Individual (1) 2,370 total (1,500 maximum
    copayment/coinsurance, plus 870 premium).
  • Individual plus one dependent (2) 5,420 total
    (3,000 maximum copayment/coinsurance, plus
    1,740 premium).
  • Family (3) 5,420 total (3,000 maximum
    copayment/coinsurance, plus 2,420 premium).

Cost-Sharing Balance
  • Growth in healthcare premiums has consistently
    outpaced both inflation and growth in workers
    earnings for the past 20 years.1
  • Between 2000 and 2005, the cost of buying
    coverage for an employee increased 61 (273)
    for single coverage and 60 (971) for family
  • Family out-of-pocket costs for medical care are
    also on the rise.
  • In 2003, 18.2 of families with
    employer-sponsored health coverage spent 10 or
    more of their annual income on medical expenses -
    a 28 increase over 8 years.1

Sources 1. Henry J. Kaiser Family Foundation.
Health Care Costs A Primer. Key Information
Health Care Costs and Their Impact. Menlo Park,
CA Henry J. Kaiser Family Foundation August
2007 2. Sommers JP. Offer Rates, Take-up Rates,
Premiums, and Employee Contributions for
Employer-Sponsored Health Insurance in the
Private Sector for the 10 Largest Metropolitan
Areas, 2005. Statistical Brief 178. Rockville,
MD Agency for Healthcare Research and Quality
July 2007.
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Actuarial Analysis
  • Background
  • Summary
  • Plan benefit strategies
  • Employee feedback
  • Actuarial models
  • Process
  • Examples
  • Early Intervention Services for Mental Health /
    Substance Abuse
  • Preventive Preconception Care

Actuarial Analysis - Background
  • Benefit managers have limited strategies if they
    expect to stay within their budgets
  • Adjust benefit coverage levels / care management
    models for medical services
  • Adjust employee cost-sharing formulas
  • Reduce demand for medical services by
    incorporating coverage for preventive services
    part of a value-based purchasing strategy

Actuarial Analysis - Background
  • Employer feedback
  • Benefit coverage levels implemented majority of
    financial management strategies
  • Employee cost-sharing maximized, and in some
    cases exceeded, cost-shifting burden to employees
  • Prevention strategy experimented with some
    services, but lack economic / financial models to
    implement comprehensive prevention strategies

Actuarial Analysis - Background
  • Actuarial models
  • Primary application for evaluating the cost
    impact of benefit coverage levels and
    cost-sharing strategies
  • Secondary application considers prevention as a
    cost offset
  • If cost is avoided then resources can be used
    elsewhere in the organization

Actuarial Analysis - Process
  • Identified two plan types
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Incorporate prevention strategy and related
    project values
  • Results need to be financially competitive with
    existing employer strategies

Actuarial Analysis - Process
Actuarial Analysis - Process
  • Develop and benchmark HMO and PPO models
  • Populated benchmark models with national data
    sets from Medstat and PwC
  • Peer-reviewed literature used to fill-in gaps

Actuarial Analysis - Process
  • Estimate cost-impact of MCH Plan Design
  • Historical utilization rates / patterns
  • Managed care models for medical and mental health
  • Population demographics
  • Cost-sharing model
  • Provider reimbursement levels

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Actuarial Analysis ExampleEarly Intervention
Services for Mental Health / Substance Abuse
Actuarial Analysis ExampleEarly Intervention
Services for Mental Health / Substance Abuse
  • Benchmark model
  • Insufficient experience data available to support
    the benchmark model
  • Benefit estimated to cost employers
  • 4.83 (HMO) and 5.85 (PPO)
  • Overall plan impact
  • Increase plan costs by 1.7 and 1.9,
  • Cost offset
  • Probably cost-saving

Cost-Impact Summary
  • Adopting all of the recommended benefits would
    cost the average employer, with a market-average
    plan design, an additional 6 for a HMO or 10
    for a PPO
  • Most large employers already provide some of the
    recommended benefits
  • Cost-impact assessments provided on a per benefit
    level and per category
  • Adopting all preventive services for a HMO plan
    would cost 3.8 / 10.99 PMPM
  • Adopting the recommended well-child care benefit
    would cost 0.1/ 0.37 PMPM

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Balanced Scorecard Analysis Tools
  • Balanced Scorecard
  • Value Proposition
  • Perspectives
  • Key Performance Indicators
  • Strategy Maps
  • Side-by-Side Analysis Tool

Balanced Scorecard and Analysis Tools
  • Balanced Scorecard Value Proposition
  • Develop a maternal and child health strategy
  • Evaluate existing health benefits
  • Implement and track the MCH Plan Benefit Model
  • Design and evaluate additional MCH and work/life

Balanced Scorecard and Analysis Tools
  • Perspectives and Key Performance Indicators
  • Financial
  • KPI 0 net increase in plan costs 1 year after
    adopting up to three MCH Plan Benefit Model
    preventive services.
  • Customer
  • KPI X increase (from baseline) in number of
    participants / attendance rate in pregnancy
    education program.
  • Operations
  • KPI X decrease (from baseline) in number of
    children who have an ER admission related to
    asthma symptoms.
  • Learning and Growth
  • KPI X increase (from baseline) in the number
    of home health visits post-delivery.

Side-by-Side Analysis Tool
  • Summary
  • Benchmarking and analysis resource
  • Directions for use
  • Gather plan benefit documentation (i.e., summary
    plan description, administrative contract)
  • Insert relevant plan information
  • Summarize key differences
  • Analyze variance
  • Consider plan modifications

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Education and Engagement
  • Research and experience show that plan changes
    arent enough to improve health
  • Communication fact sheets
  • Open enrollment opportunities
  • Low health literacy challenges
  • Employee education resources
  • Preconception, prenatal, and postpartum care
  • Child health
  • Adolescent health

Marriott International
  • Rebecca Main

For Additional Information, Contact
  • Kathryn Phillips Campbell phillips_at_businessgrouph
  • 206-708-1610
  • Georgette Flood
  • 202-585-1837

PDF copies of all materials available
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