February 1, 2008  

Unanswered Questions

Was there an individual mandate to buy insurance? Was there employer pay or play?
No, Maine 's 2003 Dirigo Health Act did not include either an individual mandate, or an employer pay-or-play requirement. A Blue Ribbon Commission established by Governor John Baldacci, recommended that they be considered: "Regarding employer and individual mandates, the Commission endorses the concept of an employer mandate along with a mandate for individuals with income over 400% FPL, and recommends that the Governor move forward to explore the parameters of how such mandates would work, including, but not limited to such issues as: what is considered credible coverage; what would be a reasonable payment for businesses who elect not to purchase coverage; and how the individual mandate would be enforced (10-5-1). While the Governor included these proposals in his 2007 Dirigo reform package, Maine lawmakers rejected them.
- Debra Lipson and Jim Verdier of Mathematica

What participation rate is necessary to determine impact upon cost containment and overall uninsured numbers?
In order for a program to have a measurable impact on cost containment and the overall uninsured numbers in a state, the program must enroll a significant number of people who 1) did not have health insurance coverage before enrollment and/or 2) were imposing costs on the system before enrollment because their health care costs were being paid for by the private sector (hospital bad debt or charity care) or by taxpayers (Medicaid).  Whether these impacts are large enough to be measurable depends on their size relative to the baseline number of uninsured residents and on whether the available measurement tools (surveys of the uninsured, estimates of bad debt and charity care) are good enough to pick up those impacts.  In Maine, the DirigoHealth program enrolled only a small percentage of the uninsured residents of the state, and the available surveys of the uninsured in Maine did not have sample sizes that were large enough to permit reliable estimates of the impact of this relatively small enrollment on either the number of uninsured or on overall health care costs.
- Debra Lipson and Jim Verdier of Mathematica

But we should add the Superintendent found savings from this and gave the total number over the 3 yrs.
- Trish Riley and Karynlee Harrington of the State of Maine

What marketing strategies have proven to be successful?
The most successful marketing strategies the Agency has launched to date include several TV, Radio and Print campaigns where the focus was on brand awareness with an emphasis on the value proposition for small business. Survey results indicate that 51% of our Small Business and 64% of our individual members learned about DirigoChoice through the media. Additionally, In collaboration with the Agency's Carrier we also launched a direct mail campaign targeting over 30,000 small businesses statewide. The response rate was over 30%. The key to a successful launch is to have the internal infrastructure in place to provide the consultative support that is needed when potential members call looking for more information. It is also critical to have a solid relationship with a preferred network of insurance producers who understand the program and are committed to a consultative approach versus the more traditional transactional technique.
- Trish Riley and Karynlee Harrington of the State of Maine

Dirigo is intended to address cost, quality and access of health care on the cost side. However, it seems that limiting insurer profits and voluntary caps on hospital profits were the major strategies to lower costs. Are there other strategies that could be employed to substantially lower health care costs in Maine, given that Maine costs are some of the highest in the country?
The Mathematica study concluded that the cost containment strategies enacted by the 2003 Dirigo Health Act were not strong enough to produce as much cost savings as policymakers expected. This is borne out by the aggregate measurable cost savings estimates (on which the Savings Offset Payment insurer assessments are based), as approved by the Insurance Commissioner for the last three years, at levels substantially less than Dirigo Health Board estimates (see slide in Cyberseminar with the figures). The 2007 legislature, however, requested a study of the major cost drivers in Maine to inform future cost containment strategies. That report is due to the legislature in March 2008.
- Debra Lipson and Jim Verdier of Mathematica

Trish: can you talk more about the cost containment strategies used in Maine?
Dirigo Health reform was designed as a 3 tiered approach and sought to reduce costs by increasing Medicaid reimbursement to providers and covering un and under insured thereby lowering cost shift; imposed voluntary targets on hospitals with which they have complied and produced ---in savings and launched initiatives that will reduce costs overtime:

• ME Quality Forum- will reduce costly variation in care and provided funds to help start healthInfo Net, a new RHIO
• Strengthened CON, adding public health criteria in the state health plan and established a capital investment fund to limit how many CONs can be afforded in a given year
• Established rate regulation in the small groupmarket-insurers must meet MLR of 78 on a three year rolling average. The third year just ended and 6.7 M is being returned to policyholders
• Required new transparency in how insurers and hospitals report costs
• Requires hospitals and providers to post prices of most common procedures
• Established a new public health infrastructure to address chronic illness and streamlined funds to be more strategic in local funding

- Trish Riley and Karynlee Harrington of the State of Maine

Has the plan identified improved clinical outcomes for the Dirigo participants?
Probably too soon to tell, and they didn't have pre-post data (other than whatever the Muskie survey collected on early enrollees) to be able to address whether clinical outcomes have improved for DirigoChoice enrollees. Does Karynlee or Trish have some data from Anthem based on HEDIS measures for this group?
- Debra Lipson and Jim Verdier of Mathematica

Anthem does not provide HEDIS measures by Group. Anthem did provide the Agency with Care Management reports which identified the number of members in their care/disease management programs along with a summary of the various interventions. Unfortunately we were just getting to a point where Anthem was more comfortable with conducting some of the analysis the Agency requested when were changed Carriers.
- Trish Riley and Karynlee Harrington of the State of Maine

Is the Dirigo plan considered credible under HIPAA? Can the plans balance bill?
Yes, DirigoChoice is considered credible coverage under HIPAA. DirigoChoice is a PPO product and as such has an in-network and out-of-network level of coverage. When members follow the in-network guidelines balance billing can not occur. However, balance billing may occur when members access out of network services.
- Trish Riley and Karynlee Harrington of the State of Maine

Early in the presentations you mentioned a challenge related to integrating the small group and individual markets. Can you elaborate on that challenge? Has there been any spillover effect on these markets?
Mathematica addressed this question in the full report - see pp. 52-53.
www.mathematica-mpr.com/publications/pdfs/Dirigofinalrpt.pdf
- Debra Lipson and Jim Verdier of Mathematica

What are the qualifications for residency in the State of Maine?
The term Resident means a person who is legally domiciled in the State of Maine and has been for at least the last 60 days. (Note: Resident may temporarily be out of state in college or on a temp job assignment, but continue to have a legal Maine address and file Maine taxes they are still a resident of the State of Maine )
- Trish Riley and Karynlee Harrington of the State of Maine

Can you provide more detail on the source of the CMS data on state healthcare costs? We've done a study showing inter-state differences in service utilization and cost following fractures. The CMS data would be helpful to put our discussion in context.
cms.hhs.gov/NationalHealthExpendData/
05_NationalHealthAccountsStateHealthAccounts.asp#TopOfPage
then download: State of Residence, 1991-2004