Many members have asked for more background as to why PEBB chose to adopt HEM, as well as details of the program. Here is a summary of HEM and PEBB’s reasons for its adoption:
Over more than the last decade, medical inflation rates in Oregon (including those faced by PEBB) have been 10% or higher, each year, while regular inflation has been running in the 1 – 3% range. These increases are unsustainable and jeopardize members’ health care. PEBB has been working to manage the gap between these two trends with contracting efficiencies and plan design changes to emphasize evidence-based practices, and has generally achieved annual rate increases below the 10% but still above the 5% range. PEBB has pressed and are pressing its carriers and third-party administrators to promote value-based practices by providers (doctors, hospitals, drug companies, etc) so that patients and PEBB do not fall victim to the problems inherent in a fee-for-service system, in which unnecessary, or unnecessarily expensive, care is prescribed simply to generate profits for those same providers. In past years, union delegates have ensured that PEBB contribute to solving the healthcare funding problem by spending down its reserves, but there is no more cushion left in the reserves to keep that option open.
The Health Engagement Model is another approach to the same problem we’ve been facing for the last 15 years or so: How do we bring the increases in health care costs into line with our (slower) increases in our ability to pay for them? Everyone recognizes that there are many reasons for health care cost increases, and we have been trying our hardest to focus on those that are coming in at us from the outside: on providers, insurance companies (which is one major reason for going to self-insurance), on the lack of health care coordination.
But, at some point, health care consumers must be willing to take a look at what we can do ourselves in addition to continuing to search for more of the above solutions to the increasing costs. The HEM attempts to do that:
- It assumes everyone can take basic steps to try to stay or get healthier, but it does not penalize people for not being able to get healthier, as long as they’re taking the steps.
- Patients’ health information confidentiality is assured and continued: PEBB itself would not get access to confidential patient information (unless authorized by a patient in pursuit of an appeal); only those people who already have access to patient claim information (doctors offices, insurers, care management personnel, etc) would continue to be the ones to have that access.
- PEBB’s plan will allow people to choose not to sign up with the Health Engagement Model and instead go into a basic plan with the same plan design, but they would pay a surcharge as an alternative contribution to dealing with the rising costs of health care.
- The only expectation in HEM is that people follow through on their commitment to take a health assessment online and then take steps as recommended to deal with health risks – nobody is held accountable for succeeding in dealing with a health condition, just for taking the steps and trying. The same applies to chronic conditions: everyone will be expected to engage in just the steps appropriate for whichever chronic condition the patient has, as determined by their doctor, not to necessarily reverse their condition. (ie If we’re trying, we’re complying.)
- PEBB recognizes that some people are already healthy and getting more “engaged” in their health care won’t make them any healthier, and conversely that some people may not be healthy and are already fully engaged in the appropriate steps to deal with their health issues. The Health Engagement Model is not about changing what anyone is doing who is already engaged, but is about getting more people engaged, and there are other examples of plans similar to this being implemented with good success in other states and with other employers.
HEM, while imperfect, is an attempt to address the challenge before us all. PEBB is – we all are – in an environment of shrinking budgets and unsustainable medical cost increases and PEBB is doing its best to continue to offer high quality and affordable health care coverage even under these adverse conditions.