As you saw in our numbers, we didnt actually see an increase in volume over the time and then in there three procedures, i think weve seen a little bit of increase in colin os ko pi, but that isnt necessarily a bad thing. For a screening like that, its probably a good thing. Yes, maam. My name is lisa summers. Im with Century Health care institute. My question is given cprs work on Maternity Care payment reform. Certainly, o b care is not entirely elective once youre pregnant, you have to deliver, but women certainly have months to shop for prenatal care and Delivery Services and we know theres huge variation in cost and quality and its a very High Frequency in occurrence. 4 million births per year. And if you have thoughts about whether or not the lessons weve learned from the global payment in Maternity Care informs this discussion at all. We work with some very progressive employers. They sort of selfselect to be that way. I dont know that Maternity Care will be Maternity Care services will be at that is probably down the road in terms of reference pricing. I think Maternity Care is much better suited for payment methodology because you have so many parts of the, you do have time to look around and shop, but you also have many providers in that system and then once youre in the facility delivering, there are other variables that could come into play, so im not sure well see Maternity Care be a Reference Priceable. It may be, but i think its more prominent for different kinds of payment reform like bundled or blended payment. The one comment i would make is that youre right, there is wide variation. We havent looked at bundled or pricing, c section rates in hospitals, which in california, 22 to 50 , and the appearance or the fact that there is now a decreasing a fair number of women who were induced in the 37th week or just shortly after, between 37 and 39 weeks, which is now looked at as a non actually a contraindication if there were no other indications. 39 plus. And the rate of these nonmedicate and enormously because a large number of those infants end up in the neo natal intensive care unit. Reducing c sections and with reducing premature induction of labor where its not indicated and admissions to the icu, so it can have a big impact on total cost. This is actually an area the private can learn because we have several state medicaids and we just did a, just ran a case study on south carolinas outcome birth initiatives where its not a reference pricing program, baugh nonplace of employment policy. Commercial private sector could learn a lot to reduce those csection rates and the early elective inductions, which are a major cost driver. International academy of social insurance. So, in addition to Consumer Education, are there a new set of challenges for implementing reference pricing for orthopedic and other health Care Services versus implementing it for pharmaceuticals and then quickly, my second question or in bringing down the quality. I think reference pricing is still so new its hard to say it hasnt worked right. Were all kind of in that version one kind of initiative where were just trying certain things. Were trying Different Things and what other employers are doing. I think its a little early still to tell where its not working. In krogers results, weve seen poisetive results on the cost side. The things on the pharmacy side or medical side where its not working yet. But were certainly watching things like Interest Rates on the pharmacy side because like you said before, we dont want people to forgo medication when they need it. Butting right now, we havent seen anything thats not working yet. At home or abroad, i think at home, it is abroad where reference pricing on drugs has been quite common. I havent read anything that would indicate there was a decrease in or that it didnt decrease costs and that it also decreased quality, which we want to improve quality. I dont know if anyone on the panel can answer that question. There are different challenges for implementing different types of reference pricing programs so its obl when youre implementing a program for hip and knee replacement, which is far more complex than lab tests or imaging, there are lots of variables in there. The Consumer Education piece has to be tailored. I think a lot of it, its around medical literacy and being able to articulate something in an easy to understand why. Whether it is your lab or a knee, hip replacement, but its highly dependent on the type of service. I think the other thing, its easier to know or ask about the cost of a Prescription Drug than to know about a cost of a medical service, so when youre going to the counter in a pharmacy, you can ask for different costs at level to even know where to go to get so the people can make better choices. Couple of times in the last few minutes, weve talked about an elective versus nonelective Health Expenditures and we have a specific question asking if we have some sense of what share of Health Care Spending is elective as oppose d to trying to negotiate while youre in the ambulance on the way to the emergency room. I dont know the proportion of spending. I dont either. For such a large increase of spending, particularly in medicare, does that count as if youre taking a preventive drug or going through some sort of service to keep you from worsening in your diabetes that that would not necessarily could you apply that reference pricing to those kinds of things as well . Its any script in that those four categories of drugs. The medical side with the hightech imaging, we dont do target pricing for children although were finding whats happening with our associates and their family members who are over the age of 18, theyre starting to ask questions when their children need an imaging service, so thats good. We dont really call it elective. Its not an emergency david, do you have something to add on to that . Several people are interested in reimbursement domestic tourism. Medical tourism, yes. Let me read them off. If somebody had to travel to a distant hospital, expenses paid before travel, what kind of expensions are covered . Such as wages for extra time off, child care, post procedure follow up visits. Expenses for traveling companion. I think we may have heard a little bit about that. Thats all on one care for follow up care for family after procedures preferred provider whos located far away from the patients home. And finally, reimborsment for traveling expenses is good, but what about for conditions where travel is difficult and painful. Where people who dont have a companion to travel with them. What are the conditions under which youre requiring people to pay for travel impacting the able thety and ability to get to the high quality care . Would you like to expand on your descriptions. Sure. And to use one of the facilities and they dont have one in their community. We have a group of professionals, thats what they do. They help to coordinate the flights, the hotels, the meals, the companion traveling with them. All of that is taken care of so its not taken out of the pocket of the associate. So its billed as a claim. So all of that is taken care of for them. If someone cant travel, we have accommodations for that. So, it isnt intended to be such a stiff penalty just because they cant travel, so we try that first and if theyre willing to do that and if they can do that, trying to get them to another centers of excellence, a tooer two. I would say one of the challenges we was the post operative care, so moving someone back from the centers of excellence facility and getting them back into their local provider. For that care, so its taken a lot of coordinate between the the surgeon and local provider community. I think we got it all figured out, thats really where the challenge is. Its not getting them to the facility. The challenge is getting them back into the local provider community, but its working and it seems to be something that david. Anthem has a Concierge Service which provides all the travel arrangements, the if they have a condition that doesnt allow them, they would get a medical exception, which wouldnt force them to use the facility, so they could use something in the community if it was too far. And in california luckily, we have enough facilities that only happens in a very small number of facilities in Northern California where we have this kind of issue. This question goes in the other direction, in the examples provides today, we see large insurers pushing for procedures do you have any thoug thoughts on how this might work with just one or two providers and a small insurer network. Is that what you find yourself addressing when you have somebody in eureka . Right. So i mean thats the challenge, right, of having enough regi regionally located facilities and then having to have that travel companion. So, in terms of if theres only one facility, meeting or not meeting. Difficult to look at variation in a region like that. If you have only one or two providers, you can provide a procedure in a geographic area. Really only one or two providers. This type of pricing doesnt necessarily have the same impact for those providers, and it wont have the same kind. If you think about it, then you can end up in some kind of antitrust issues where if you have two providers, another price. We get into a whole other area of complicated issues. So its not likely these will occur there. We have only a few minutes left and we ask you to not only spend those listening, but filling out the evaluation form if you would. We have another california centered question here. How about a market heavily penetrated by hmos, and the question wonders how the reference based prices for anthems ppo compared with the prices in california hmos. The prices that they pay. Well, the the hmo in california in general, its decreasing gradually and the ppo is increasing, but theres still a large number of hmo members. In most cases, as far as anthem goes, the hospital pricing is a contract between anthem and the hospital. So, the professional component is where the with the exception of about 15 of our network, which is a full risk of a global setting with a contract with the hospitals, so the answer in short is that the hmo is currently not part of this initiative. And the prices paid at those institutions are the prices that t the. And this is a thinks its related. It might not be. Why cant reference pricing be part of the Carrier Network contracting negotiations, discounting up to the Reference Price. With was that a reasonable question in this context . Im a physician at heart. In the negotiation rather than the negotiated price agreed upon by both parties. I guess thats right. As you establish a network thats willing to meet that price, can you leverage that from those outside that range and negotiate that as part of your new contract. Im not going to venture too far into that other than to emphasize the fact there was that pressure on the nonconfirming institutions with the initiative to actually bring the prices down, which happened without it being a direct goal, so it may well be that it could be effective. From affairs perspective, its where we want it to go, right . So, we want to be able to bring the cost down of all of those services in a particular category. So, hopefully, target pricing or reference based pricing is eventually going to lead us there. Its just one of the initiatives trying to get us more aligned in a community. I think its really important to understand that reference pricing is is ultimately a benefit strategy. Its not a payment strategy. So, while you are capping the payment, you could still pay for it on bundled payment or fee or service or in other methods, so reference pricing is a benefit design, so while you know, cal pers, i dont want to speak for david here, but implemented reference pricing without having to renegotiate contracts and anthem didnt. Price of 30,000,n hospitals moved cordingly. And then surely, i would benefit price. And hospitals moved accordinglye and surely in subsequent a contracting cycles, that becomeh parts of the conversation, you dont have to implement b referenceec pricing through a contract negotiation, although once its etoccurred, it probab does become a part of it. Right now, im with taft we hartley fund. Anyone who has a good 60 relationship with a carrier like anthem, they say, well give you a guaranteed discount of 60 , but its based on the usual and customary, what im suggesting is we would have a lot more be manpower if our carriers werenf just negotiating on my behalf or krogers behalf, on their book p of business and telling some of these facilities, we will take a 60 discount but up to a a Reference Price as opposed to the usual and customary, which is more supply driven. Somethin and so its a really kind of oud of the box way to think, but its something i think that everyone in the room could till benefit from, if they have, youg know, stronger negotiations, while we still have a chance before Network Negotiations go t away, because everyone in the country is going to have stion insurance. And a hospital wont take a discount any more. Thats a very improved some formulation of your question from mine. Ea the point i would make is that i that this whole area y of pricing has been changed as d result of the the shroud is being lifted. The bereave yous discussions that occurred on discount or abt design target price were ced discussions around the argument about percentages off. Now the discussion is different and those high priced an institutions for my own personal experience in california are aware of the fact that their df prices are now out there, and at can be seen by the public and st it is a different discussion, te the extent that the end point ae youve described, i cant speakn to that. But i believe the nature of the discussion has changed, because of the fact that when the target prices are put out by these institutions they could be e recognized as way out of range of averages and reasonableness. I think its a positive. And by the way, one of the best illustrations of the impacs on the nonparticipating hospitals is in the chart. Our and weve heard some discussion of this before, but Jamie Robinson. And we have our friends to thank for the readable one page chart. The hospitals that were not. Participating in the calpers experiment. Bob . Bob grist, with all the discretion that the pairs have e in setting reference pricing that youve disclosed in this p panel. And with the tendency of employers to cost shift in terms of employees, usually in greater deductibles or co payments. What are the protections for consumers from reference pricinn which sets a standard price and expects the consumer to pay anything over that reference he price . It seems like a very dangerous a precedent even ifti its in they interest of the pair in the cint shortot run. You havent given any indicatiok paat this isn a way of reducing total health care costs, we dont know if the hospital is going to follow the procedure with regard to other pairs or whether theyre going to shift u thoset costs on to other procedures and im not sure how comfortable we should feel aboul this particular short term strategy to help pairs reduce e certain costs. The pan tellself is telling one story and we dont have on the Panel Providers or consumers whs have been discriminated against because their unique needs did t not fill the you know, you ce sort of assumed that quality remains the same, but in fact that may not be the case, in most health care situations. I think its about being an informed patient and its hey h completely voluntary to choose e where they get care. We dont tell them they have toy choose. The choice is theirs. They have an opportunity to be informed before they obtain a ct scan or mri or get a particular prescription. And to make a thchoice. R as to whether or not they wanted to stay under the target price e or they want to. Ers the choice is abocompletely the. Its about us and helping them be informed consumers of health care. So they know whether or not ahd theyre going to be paying more, if they chose to do so. Its a very good question, it would say to the issues of patient protection, there is the protection that if the member stays within the defined y reference paced network, their share is fixed as to whatever o benefit structure they have wit. Their employer. The only time they would be ens. Subject to additional costs is if they went outside the network. T i dont think its necessarily y bad in that sense. And the quality issue is relevant, t when youre talking about quality in general, there are ac few hundred organizations out de there when it am coulds to lot specific quality issues within these detailed procedures, theres a lot of quality metrict that need to hopefully will come out of registries, what we have at the moment is not completely adequate. Av orgaerms of the overall success, i would just say that there arer a number of initiatives that have been put out there, and there are various organizationso that describe various oment ha initiatives. Very many of them have fail ed and this is one of the few that at the moment has had success. The success is well documented by any partial third party with the Health Economists at uc sucs berkeley. I think theres some validity to this study. Ins to i think its a success story. Whether it can be replicated that remains to be seen its a successful initiative. Im biassed, of course, but i think it has done something to push the knowledge and the practice of Health Care Delivery along. Go t ahead, david. Calpers is extremely sensitive, given who we represent. In fact in the Jamie Robinson article includes an analysis of the out of pocket to the pairs. I didnt include it. O we did see the out of pocket went down to our members to oure members. And in general, if you think t about somethinerg like in th case, the deductible plays a big role in terms of how the out of pocket hits you. Knowthing with the colonoscopies, the cataracts, b the co insurance still plays a t roll othere, and so the lower costs are going to benefit you out of pocket. In terms of total costs, that t was also included, looking at out of pocket plus the net pay and the loud costs, that went down dramatically as well. Think for the hips and knees, that mab have been due to the deductible
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