Rating Providers on Quality and Efficiency Continues

In its eighth year, the GIC’s Clinical Performance Improvement (CPI) Initiative improves provider transparency, quality, and efficient use of resources.  The program aggregates over 126 million de-identified book of business claims from the six GIC health plan carriers to make quality and efficiency comparisons among physicians.  The GIC and our health plans use these results to tier providers.  Members pay the lowest copay for the highest performing quality and/or cost efficient doctors:

***Tier 1 (excellent)

  **Tier 2 (good)

    *Tier 3 (standard)

Throughout the year, the GIC and our plans worked with the provider community to improve communication and understanding of the initiative.  We also went out to bid for a consultant to assist with the aggregation, management, and quantitative analysis of the data.  A new two-year contract was awarded to Mercer, who will maintain the current methodology on a short-term basis, an important consideration in light of the GIC’s directive to move to integrated ways of paying for care.  The CPI consultant will be re-procured in a year to allow time for the new payment models to take shape.

Mental Health Carrier Change

Not only were the health plan contracts ending June 30, 2013, but the mental health carve-out vendor contract with United Behavioral Health was also ending.  The carve-out vendor administers mental health, substance abuse and Employee Assistance Program benefits to members covered under all of the UniCare health plans and Tufts Health Plan Navigator and Spirit, for a total of 255,000 employee, retiree, and family member lives.  The first phase of the procurement sought to determine whether or not these benefits should be carved back into the health plans or separately procured and continued as a carve-out arrangement.  After careful analysis, we determined that the best approach for keeping the health plans focused on IRBO work and for program continuity was to conduct a separate mental health carve-out procurement.

In keeping with the direction of integrated care, the mental health carve-out procurement sought to integrate benefits with the health plans and prescription drug carriers, administer plan designs, and provide top quality customer service.  After a comprehensive process, the Commission awarded a contract to Beacon Health Strategies, with a value of approximately $45 million per year, and an effective date of July 1, 2013.  A Boston-based company, Beacon has provided mental health benefits for GIC members covered under Fallon Community Health Plan and Neighborhood Health Plan for a number of years.  Beacon is an innovator in coordination with health plan benefits, and will work closely with staff at UniCare and Tufts to better coordinate care for those with chronic medical conditions who frequently suffer under- or undiagnosed mental health conditions along with their medical conditions.

Employee Assistance Program Helps Those Affected by Marathon Bombings

The GIC provides state agencies and participating municipalities with free Employee Assistance Program (EAP) benefits for managers and supervisors as part of its mental health carve-out.  Agency and municipal staff can contact the EAP for help with stress management, personality conflicts, and help in dealing with challenging behavior.  Critical incident debriefings are also provided for client cases or staff murder, domestic violence, and unexpected deaths.

Many state agencies were directly or indirectly affected by the April 2013 Boston Marathon bombings, and EAP services were invaluable to those from seven agencies who helped with the aftermath or knew some of those involved, killed or injured.  The GIC’s EAP Coordinator has provided assistance to agencies across the Commonwealth for over 20 years under two different vendors and was recently hired by the new mental health carrier, Beacon.

Defense of Marriage Act Overturned

The GIC has provided coverage of same sex spouses since 2004, when Massachusetts legalized same sex marriages.  However, because the federal government did not recognize same sex marriage, insureds covering a same-sex spouse were subject to federal income tax on the value of the benefit provided to their same-sex spouse.  At the end of June, the U.S. Supreme Court overturned these adverse tax implications.  In advance of the ruling, the GIC worked with the Comptroller and the Attorney General’s Office to coordinate the implementation of this change.  Through these efforts, communications about the implication of the overturn relating to GIC benefits were immediately distributed, and the GIC, state agencies and municipalities were ready to implement members’ corresponding health plan and Health Care Spending Account elections.

New Regulations Implemented

The GIC undertook a nine-month project to implement new regulations necessitated by federal health care reform, municipal reform, and transportation agency consolidation.  The proposed regulations garnered wide interest and input, particularly from participating municipalities and their union members.  The first draft was discussed by the Commission in the fall, and was followed by a public hearing and public comments over the winter.  The Commission adopted the final regulations in April and they were promulgated by the Secretary of the Commonwealth on May 10, 2013. 

The new regulations unified the municipal regulations, which had been broken into two separate regulations reflecting the initial 2007 municipal health reform law (M.G.L. c. 32B, §19) and the newer 2011 law (M.G.L. c. 32B, §21-23). Where there are differences between the two laws, these are outlined within the single municipal regulations section.  Eligibility for local elected officials and teachers during the summer months, new penalties for late notice of employee terminations, a three-year lockout provision for municipalities that withdraw from the GIC, and claims data access with privacy provisions were included.  In keeping with federal and state health care reform, the definition of Primary Care Providers and dependents were changed, and orphan coverage was expanded up to age 26, to match our expanded dependent coverage.  The remainder of the changes clarified GIC operational procedures and policies.

This information provided by the Group Insurance Commission .