Massachusetts Fall Medical Director Meeting

Harvard Pilgrim

November 5, 2020 / WebEx / 12:00-1:30 PM

1 / © Harvard Pilgrim Health Care 2 / © Harvard Pilgrim Health Care General Updates

3 / © Harvard Pilgrim Health Care HMS/Ariadne Labs Grant: Home-Based Palliative Care

Patricia Toro, MD, MPH November 5, 2020

• Background: Home-based palliative care (HPC) reduces suffering; Many patients who qualify for HPC don’t receive it. • Problem: There is no published tool or process for a payor to identify patients at a population-level who could benefit from HPC. • Goal: To identify provider-friendly information (content, format, frequency, timing, and other attributes) and processes that will identify patients who could benefit from HPC.

• We seek your collaboration to create a tool and process to help identify appropriate patients for HPC.

Internal Use 5Only / © Harvard Pilgrim Health Care Invitation to Medical Directors

We invite you and your group to collaborate with us:

• Respond to an email from Dr. Toro and the research team connecting us to one or more key clinician and staff contact persons in your practice. • Contact person(s) will be invited for a 30-minute interview in December/January about provider- and practice-desired population-level information about members and suitable processes to help providers and practice staff identify patients who could benefit from HPC. • Later in 2021, an invitation will follow for contact person(s) to provide feedback on a prototype tool and process.

Internal Use 6Only / © Harvard Pilgrim Health Care Please reach out with any suggestions/recommendations:

[email protected] [email protected]

Thank you!

Helen Connaughton

8 / © Harvard Pilgrim Health Care COVID-19 Administrative policies

Telehealth Authorization in MA Pharmacy Credentialing • Audio only option • Lifting PA requirements • Early refills • Expedited Cred for acute care settings • Updated code set • Extensions • Provisional Cred • Hold concurrent review • Cost share change on • New drug monitoring • Fast track enrollment 10/1 for Commercial • Quantity limits • Medicare no cost • Pedi flu vaccine (3 + yrs) share through 12/31/20

Covid-19 Testing & Treatment Covering testing and treatment in full without member cost-sharing (copayments, deductible, and coinsurance)

Pay for Performance Extended QAP Program components through summer

Stay up-to-date with our COVID-19 informational page at harvardpilgrim.org/provider

9 / © Harvard Pilgrim Health Care Quality Program Updates

Janis Pochini

10 / © Harvard Pilgrim Health Care HPHC Quality Grant Year 2021

• Keeping the new 2020 format Kick Off • Accepted LOIs are invited to apply 2021-2022 • 18-month grant cycle for more meaningful measures • October start for longer concept development phase • New Covid-19 category in suggested topics • Kick off this month

Important Dates

11 / © Harvard Pilgrim Health Care QAP Components and Changes

Domain Changes from Prior Year Rewards for Excellence • One of two fixed measure lists dependent on LCU (R4E) membership size and measure denominator. No menu option offered due to measure changes and ↓denominators related to ↓ membership • Two domains: Health Outcomes and Clinical Processes. • Payment per measure Patient Experience • Mass required to submit same patient experience data as (PES) ME, NH,CT (Mass formerly measure on MHQP results) • Alternative measure for practice response to COVID 19 Health Equity • Expanded topic of social determinants intervention • Expanded topic suggestions for clinical interventions & require description of interventions & outcomes Infrastructure Support • 3 initiatives required (instead of 2): Unplanned hospital readmissions no change ED utilization - request that groups submit interventions &outcome measures Behavioral Health Integration into the Practice Provide description of integration and extent of practices participating • Change in Infrastructure PMPM

12 / © Harvard Pilgrim Health Care 2021 QAP Deliverables

QAP II Category 2020 Due Date 2021 Due Date

Rewards for Patient Safety & Prevention N/A N/A Excellence Clinical Processes N/A N/A

Health Outcomes Post by 4/1/21 Post by 4/1/22 BH Integration N/A N/A Pt Exp Survey Survey 12/31/20 12/31/21

Health Equity Plan Due  6/30/20 Plan 6/30/21  1/29/21 Final 1/31/22 Infrastructure Medical Director (10%) Attend 2 Meetings (10%) Attend 2 Meetings (10%) Support Business Plan (90%) Business Plan (90%) Initial 3/31/21  Initial 4/30/20 Final Report 1/31/22  Final Report 1/29/21

Upcoming Dates Next Steps • Medical Director Meeting on 11/5/20 • Patient Experience Survey due 12/31/20 • Health Equity Plan due 1/29/21 • Infrastructure Support Final Report due 1/29/21 13 / © Harvard Pilgrim Health Care Political and Policy Update

Kevin Rasch

14 / © Harvard Pilgrim Health Care ELECTIONS HAVE CONSEQUENCES DIRECTION OF HEALTH CARE POLICY ?

November 5, 2020

Kevin J. Rasch - Vice President, Government Affairs and Programs

 Rhode Island . Governor Raimondo was not on ballot . No meaningful change in leadership or composition of legislature

 Massachusetts . Governor Baker was not on ballot . No meaningful change in leadership or composition of legislature

 Connecticut . Governor Lamont was not on ballot . No meaningful change in leadership or composition of legislature

16 / © Harvard Pilgrim Health Care ELECTION RESULTS – NEW ENGLAND STATES

 Maine

. Governor Mills was not on ballot

. No meaningful change in composition of legislature; Speaker of House lost bid for U.S. Senate against Senator Collins

. Senator Collins is the last New England Republican in either chamber of the U.S. Congress (1 of only 4 Republicans in New England to hold statewide office)

 Vermont

. Governor Scott won reelection

. No meaningful change in leadership or composition of legislature

 New Hampshire

. Governor Sununu won reelection

. Significant change in leadership and direction of legislature in conjunction with unified Republican control of state government.

17 / © Harvard Pilgrim Health Care ELECTION RESULTS – FEDERAL OFFICES WHAT WE KNOW NOW*  Presidential Race

. Electoral College Count (as of Nov 5th at 11:00 a.m.)

• Biden / Harris – 253 (needs 17 more to win) • Trump / Pence – 214 (needs 56 more to win)

 Control of U.S. Senate – Republicans Still Control

. Democrats – 48 seats (net gain of 1)

. Republicans – 48 seats (net loss of 1)

 Control of U.S. House of Representatives – Democrats Still Control

. Democrats – 205 seats (net loss of 5)

. Republicans – 190 seats (net gain of 6)

* Per Washington Post or New York Times or AP tracking

18 / © Harvard Pilgrim Health Care ELECTION RESULTS – FEDERAL OFFICES WHAT WE DON’T KNOW NOW*

 Presidential Race

. Open States and Electoral College Count

. Alaska – 3 Electoral College Votes . Arizona – 11 Electoral College Votes . Georgia – 16 Electoral College Votes . Nevada – 6 Electoral College Votes . North Carolina – 15 Electoral College Votes . Pennsylvania – 20 Electoral College Votes

 Five Undecided U.S. Senate Races . Alaska – Sullivan vs. Gross . Georgia – Perdue vs. Ossoff – Potential for January runoff remains . Georgia (Special) – Loeffler vs. Warnock – January runoff to occur . Michigan – Peters vs. James . North Carolina – Tillis vs. Cunningham

 U.S. House of Representatives . 40 races still undecided . Likely will not change control of the U.S. House of Representatives

* Per Washington Post or New York Times or AP tracking 19 / © Harvard Pilgrim Health Care o ELECTION RESULTS – FEDERAL OFFICES WHAT WE DON’T KNOW NOW

KEY DATES AND PROCESS

 Bush vs. Gore (2000) – decided by U.S. Supreme Court 34 days after election day

 Litigation or recounts (GA, MI, PA and WI) potentially being pursed in a number of states may impact: . Presidential Race . Senate Races . U.S. House Races

 Secretaries of States must certify votes in respective states

 December 14, 2020 is date of Electoral College vote

 January 20, 2021 is Inauguration Day

20 / © Harvard Pilgrim Health Care ELECTION RESULTS – FEDERAL OFFICES HOW TO FOLLOW DEVELOPMENTS

 Rely on trusted news sources with transparent policies of journalistic ethics:

. Associated Press – apnews.com . Axios – axios.com . Boston Globe – bostonglobe.com . FiveThirtyEight – fivethirtyeight.com . Real Clear Politics - realclearpolitics.com . New York Times – nytimes.com . Washington Post – washingtonpost.com . Wall Street Journal – wsj.com . Politico – politico.com

 Approach news and information from opinion programs or social media platforms with caution and with critical thinking and analysis

 Remember polls and opinions (unless judicial opinions) don’t matter right now – it is all about the number of votes and the geographic dispersion of votes

21 / © Harvard Pilgrim Health Care ELECTIONS HAVE CONSEQUENCES

Knowing who is charge allows us to speculate on:

. How federal government will respond to U.S. Supreme Court Decision in Texas vs. United States

. Further rounds of COVID related economic stimulus and support

. Funding of government healthcare programs (Medicare and Medicaid)

. Federal health care reform in the nature of Medicare For All

22 / © Harvard Pilgrim Health Care HEALTHCARE POSITIONS

23 / © Harvard Pilgrim Health Care HEALTH CARE POLITICAL REALITIES

 During campaign details on health care plan were slim and represented visions, rather than concrete expectations of what we will see happen

 Healthcare became a bigger political issue late in the campaign

 Congressional election results limit ability to pass and implement major healthcare reform

 Major reform building on the ACA is realistically only possible with Democratic control of both chambers of Congress

 Supreme Court case is also a significant factor and the court’s decision will determine first priorities of whoever is in charge

 Influence from Medicare For All proponents remains and will reappear

24 / © Harvard EarliestPilgrim Health legislativeCare actions are likely not until Fall of 2021 ELECTION CONSEQUENCES

Texas v United States

 The Supreme Court to review the constitutionality of the Affordable Care Act (ACA) on November 10th in California v. Texas (known as Texas v. U.S. in the lower courts).

 Last year, a federal appeals court panel ruled that the ACA’s individual mandate is unconstitutional, since Congress has set the individual mandate tax penalty to zero.

 The case was brought by several Republican state attorneys general who argue that the rest of the ACA is not severable from the mandate and should therefore be invalidated.

 The Trump administration now argues that nearly all the ACA should be found invalid . Trump Administration previously argued that only the ACA’s pre-existing condition protections should be overturned.

 Pending a final decision on the case, the Trump administration has continued to enforce the ACA, but has also undermined.

25 / © Harvard Pilgrim Health Care ELECTION CONSEQUENCES

Texas v United States (cont’d)

 The ACA’s reforms affect nearly every American in some way. If the ACA is struck down, these provisions could be eliminated:

. protections for people with pre-existing conditions;

. premium subsidies for low- and modest-income people;

. expansion of Medicaid eligibility for low-income adults;

. required coverage of preventive services with no cost-sharing in private insurance, Medicare, and for those enrolled in the Medicaid expansion; and

. variety of tax increases to finance these changes.

 Uninsured Americans decreased by net 18 million from 2010 to 2019 after the ACA went into effect.

 Repeal of the ACA would play out differently from state to state. (50 million people had a declinable health condition in 2018, including over a third of the population in West Virginia, Arkansas and Mississippi)

 2016 Presidential Campaign – promised to repeal the ACA and “come up with a great health plan”

 Upon election / inauguration – claimed he had a “wonderful plan” and would be “putting it in fairly soon”

 2017 – “there’s a great plan, and this will be great healthcare” and it is “evolving”

 2017 – House Republicans passed an ACA repeal bill; however Senate failed to pass. Trump called repeal “mean” at one point / supported repeal at one point

 2018 – Executive order to increase “short term” insurance policies ; which do not cover preexisting conditions 27 / © Harvard Pilgrim Health Care TRUMP HEALTH CARE POSITIONS – KNOWABLE?

 2018 – Executive order to increase association health plans

 2018 – Promised plans to come out “over the next four weeks”

 2019 – “when the plan comes out”; “it’s much better than Obamacare”

 2019 – “already have the concept of the plan”; announcing that in about two months – maybe less”

 August 2020 – said he was considering an executive order extending preexisting conditions – already covered by the ACA

 August and September 2020 – issued executive orders focused on pharmaceutical costs; the orders require executive branch rulemaking

 September 2020 – “we’re going to be doing a health care plan very strongly”

 September 2020 – issued executive orders focused on “protecting” preexisting conditions should the ACA be repealed

 September 2020 – pledged to send $200 discount cards to 33 million older Americans to offset the cost of prescription drugs. Cost is in excess of $6.6B; legality and process is questionable

 September 2020 : “Obamacare is no longer Obamacare, as we worked on it and managed it very well,” “What we have now is a much better plan. It is no longer Obamacare because we got rid of the worse part of it — the individual mandate.”

 September 2020: “Obamacare will be replaced with a MUCH better, and FAR cheaper, alternative if it is terminated in the Supreme Court. Would be a big WIN for the USA!”

 November 10th, 2020 – oral arguments at the US Supreme Court on a case to

30 / © Harvard Pilgrim Healthinvalidate Care the ACA; invalidation backed by Trump Administration and DOJ BIDEN HEALTH CARE POSITIONS

BUILD ON AFFORDABLE CARE ACT

Program  Create a new Medicare-like government insurance public option plan to be sold on the ACA markets Eligibility  Approx. 2 million currently in the Medicaid expansion gap, in states not providing, would be automatically enrolled, for free  Available to the 150 million people who get insurance from their job  Undocumented individuals can buy in but not eligible for subsidies  Estimated 97% of Americans would have health insurance

Benefits  Protect pre-existing conditions  Prescription drugs: Medicare price negotiation, consumers may purchase internationally

Financial Assistance  Enhanced tax credits, tied to more generous insurance  Eligibility for government assistance would be available to anybody.  Total cost-sharing ceiling at 8.5% of income on insurance premiums.  Reinstates individual mandate

32 / © Harvard Pilgrim Health Care CONCLUSION  Will know soon who will be in charge in 2021 (Senate could be in January)

 End of the second week of November gives some direction on how the Supreme Court views current law surrounding the ACA

 Mid to late 2021 –

 Supreme Court ruling

 Depending on who is charge we will possibly see:

 Reaction to Supreme Court in Texas vs. United States

 Executive orders

 Legislative activity

 Possible regulatory changes coming (new or repeal of new or existing rules)

 State legislatures could look to shore up state law in advance of possible Supreme Court decision

Due back by COB tomorrow!