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2013-1247-Minutes for Meeting November 25,2013 Recorded 12/5/2013COUNTY NANCYUBLANKENSHIP,F000NTY CLERKOS Q 20IN20 COMMISSIONERS' JOURNAL 12/05/2013 11:04:09 AM I I I III II VIII ~ I III~II III Do not remove this page from original document. Deschutes County Clerk Certificate Page Deschutes County Board of Commissioners 1300 NW Wall St., Suite 200, Bend, OR 97701-1960 (541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org MINUTES OF WORK SESSION DESCHUTES COUNTY BOARD OF COMMISSIONERS MONDAY, NOVEMBER 25, 2013 Present were Commissioners Alan Unger, Tammy Baney and Anthony DeBone. Also present were Tom Anderson, County Administrator; and, for a portion of the meeting, Scott Johnson, Health Services; Chris Doty and George Kolb, Road Department; Mike Berry, Surveyor; David Inbody, Administration; Ronda Connor, Personnel; Teresa Rozic and Susan Ross, Property & Facilities; Nick Lelack of Community Development; by conference phone, Laurie Craghead, County Counsel; and media representative Elon Glucklich of The Bulletin; and one other citizen. Chair Unger opened the meeting at 1: 30 p.m. 1. Update on Discussion regarding Lechner Estates. Commissioner DeBone said some citizens have approached him regarding this situation. Mike Berry explained that the area of concern is at the corner of Burgess and Dorrance Meadow, about two miles from La Pine. It is officially the Dustan neighborhood. It does not include Lechner Acres. (At this time, he did a PowerPoint presentation with handouts) Mr. Berry gave the history of the area. Lots were created through deeds and not through an official subdivision. The landowners thought they bought 1.25-acre tracts in a certain configuration. Some of the lot lines are off by about half. This issue began in the late 1940's. The roads, which were used for logging, don't go east-west as was thought, but were the basis for the development. An unlicensed logger put in posts and the property lines were not configured as they should have been. An aerial photo from 1951 shows the roads in relation to the lots. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 1 of 11 Mr. Berry explained "Aliquot Parts", referring to quarters and sections. This is different from metes and bounds which details a point of beginning and how it goes from there. The Assessor's map from 1961 shows not all lots had been sold. In 1991, the Surveyor's Office was given a sales map by Pearl Lechner. In 1961, Pearl Lechner created another subdivision. She realized there was a problem with the original development in 1963 .and hired a surveyor to try to correct the problem. They knew what was being sold was not accurate, so required a metes & bounds description on further sales. Problems started coming up in 1971 when property owners became aware the lot lines were not right. More were noted in 1984. The County sold tax lot 100 in 1989, but rescinded the sale when there were problems noted. It had been foreclosed in 1973 due to lack of tax payments. There was a question as to whether the parcel actually existed. Surveyor Jeff Kern established where the monument corners are. In 1990 or 1991, maps were made of where the existing features are. Nothing happened after that. Pearl Lechner was interviewed in 1991 by the County Surveyor; she admitted the lots were not located correctly per the section lines. She had a survey done years prior. There was a discussion about the discrepancy with `someone in authority' and did not think it could be corrected. She never intended to create a gap between the lots. He felt that tax lot 100 did not exist. Title companies and land surveyors have to comply with the metes and bounds descriptions. In 2007 and 2008, residents tried to Bancroft funds to make these adjustments. Creating a new subdivision could not be done because of zoning, public input, costs and legal issues. It is also complex because each person living there as well as their lenders and others would have to be a party to this. In 2008, there was a work session with the Board on this issue, which included many of the property owners. They talked about lot line adjustments and the cost. Dave Kanner (former County Administrator) said at the time that this is not the County's problem. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 2 of I I A lot line adjustment would be very complicated, with deeds going to four or five parties per property. Some have fixed their lines north and south, but otherwise it is very difficult. David Inbody created an FAQ document sent to property owners with information and possible avenues to follow. The County by law has to record deeds as presented. In 2009, departments discussed this to try to come up with solutions. Considered were waiving fees for text amendments to allow larger tax lot adjustments. There was a discussion regarding a better aerial photo at a cost of up to $10,000, which was authorized by the Board. Money is an issue for the residents, and the County cannot force them to comply. Also, the Burgess/Huntington subdivision has the same problem (surveyed by this original unlicensed surveyor many years ago as well). This property is now within the City of La Pine. The maps were completed in July 2010. The County made a Code change for lot line adjustments to remove the barrier to making this kind of change. Many record verifications were done, and seventeen of the owners submitted an application. Commissioner DeBone asked if any roads bisect properties. Mr. Berry indicated some do. They have talked about deeding all to title or escrow companies to sort it out, but they would have to have a lot of project managers involved if this happened. Some say there are as many as 2,500 lots or more possibly involved. If there were a Court order, landowners and lenders would have to comply. The Court probably would not give specific instructions on how to solve the problem areas. The County may not be indemnified against claims, and funding would be needed for the initial work. Laurie Craghead said this was a privately created problem and there should be no County liability from any past actions. In the future if the County had a surveyor do this work, the sense is there would be liability at that time. The County paid for the aerial survey, offered to only charge for one lot line adjustment fee for each property, and the Clerk would record one document with all of the changes. The owners would have to bear some costs, including having someone else write up the legal descriptions. It is possible too much County involvement would set precedence. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 3 of 11 Commissioner DeBone noted that it would probably take a Court order to get the process moving. Mr. Berry said that he talked to an attorney who stated that the Court is the final say, and no one could opt out. They don't want it to be expensive for the property owners, and he doubts that any of them have gotten counsel to find out more for themselves. Mr. Anderson said that money is needed as well as consensus. When government steps in, there can be some mistrust and a difference of opinion. Some residents there tried to champion this project but couldn't get there. Other costs are involved besides County fees. Commissioner Baney noted that the community would have to bring itself together, either voluntarily or by Court order. The money might be available, but the residents have to see the need and agree on what to do. Chair Unger added that otherwise, there is no clear path, and he does not want to create liability for the County if there can be no consensus. Commissioner DeBone said they would need to review this occasionally until someone wants to push it forward. He will contact Ken Mulenex who was involved previously. Someday someone there will feel this needs to be fixed. Commissioner Baney reiterated that the community has to coordinate and then ask the County for help. The County can't just make this change on its own. It has to be a coordinated effort. Mr. Berry suggested that perhaps they could find a legislator who will help them craft some kind of local improvement district to make it more feasible. Commissioner Baney noted that it would still have to be one voice from the community. Mr. Anderson said there was a somewhat similar situation in the north County, but all of the 8 or 10 property owners agreed to a lot line adjustment at the same time. The key was consensus. 2. Discussion of 2014 Health Risk Assessment Incentive Program. David Inbody said they try to start the year with a review of the previous year's program, and go forward. The Board was clear they don't want employees to consider this an entitlement. He has met with departments and Medcor. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 4 of I 1 The idea is to keep costs flat and raise the bar on expectations. The HRS includes a questionnaire, measuring biometrics and doing a fasting blood draw. The second year they added an incentive for participation, and got 200 more people that way. They encouraged a follow-up visit with the provider. Last year the follow-up became a requirement. This was for the employee and spouse, and 265 spouses participated, bringing the total to 799. Some concepts for this year include, instead of an incentive in one lump sum, to spread it out. This has been an issue in the past; for instance, new employees had to wait a whole year. They also wonder what to do with single people on the plan. They can get only one month's premium holiday. A proposal is tiering how premiums are provided: married couple; and single employee or an employee whose spouse doesn't participate. There is an opportunity for those who participate to have an ongoing discount. There are lots of reasons for getting an HRA. A large amount of costs come from a small number of people. This could help reduce the number of high risk people. Ronda Connor said that DOC staff can advise of the validity of the follow-up. Intervention is a discussion of serious issues. Studies show a discussion can be just as helpful as trying to force someone into change. Education is the key. Tiny lifestyle modifications can make a huge difference. They cannot look at short-term numbers for chronic issues; they need to look at five or ten years. It is evidence-based, but there is much more to it than that. It is not a lot to ask someone to take the next step if they have two or more from the risk category. Mr. Inbody said that after the HRA is completed, if there are two health risk issues, they are requested to meet with a provider or the wellness manager to identify a plan for change, and follow up quarterly. Clinic staff has recommended this. Otherwise, some people just go through the motions. They should not be rewarded for continuing the same bad behavior. Going through the process has had an impact. Those who participate spend significantly less than others, every year. They spend less and participate more in prevention. These numbers are significantly above the national average. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 5 of 11 There are fewer visits to the ER and urgent care. Some went up because they were diagnosed when they hadn't been previously. This was picked up early enough to treat the condition, so has a long-term impact on the plan. Last year each person who took the HRA spent an average of $1,000 less on the plan, a net savings of about $750,000. Danielle Fegley said that her department will analyze the easiest way to administer the incentive. It all has to be entered manually at this time. Mr. Inbody said the first piece would be distributing the incentive through the year. The second piece would be to tier and delineate how to handle single/married and spouse incentive. The third piece is requiring an employee with two health risks to develop a plan with the DOC or Medcor. Chair Unger said this should be voluntary, for those people who want to take advantage of the savings. Mr. Connor stated that EBAC recommended a monthly option and an incentive for the spouse. It is not an entitlement, and focuses on more than the money. She is not keen on reducing the premium for single persons. Mr. Inbody said that the bigger issue is delineation between single/married regarding the incentive. This creates a disparity for the single person. For instance, it could be $90 for a single who does not participate, $98 for a married person, $82 if the employee and spouse both participate. It would be contingent on the premium rates for next year, which have not yet been established. Ms. Fegley noted that the composite rate benefits all the same. There are complaints because single people have to pay for those with families. There needs to be some kind of differentiation. Philosophically, it was felt that if the employee with a spouse does not participate, the employee should not get this and neither should the spouse. Commissioner Baney feels there should be a difference, and that those with families should pay more. They need to make a slow entry into this. Chair Unger said they are all covered lives, so the ones who participate should benefit, employee or not. Commissioner DeBone stated that some in EBAC have fought against a tier structure, and it has been the culture for many years. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 6 of 11 Chair Unger said that there is a subset of people who won't get involved. He wants to keep it simple for Personnel and the plan. Mr. Inbody noted that if they don't participate, they spend $1,000 more a year than others. Maybe they should contribute more into the plan. Commissioner DeBone said that some point there will be diminishing returns. They can incentivize only so far. Chair Unger added that they should offer encouragement, not an entitlement. Commissioner Baney asked where they hope to be. This is percentage based, and costs will go up per union agreements. Ms. Connor said they would like to get to a point where they can see where they will be in five years. There are two sets of people; those who support the wellness plan and those that don't care. Higher costs may make them want to pay more attention. She would like to see tiered rates relating to family size as well. Mr. Anderson added that since they are focusing on cots, he is a fan of tiered rates also. This is only fair. He does not want them to lose sight of the savings piece. There is a magnitude of savings with an HRA. The more this is done, the better the linkage. There is a direct link in investing in an HRA and savings. In terms of today, for fiscal year 2014-15, they need philosophical direction from the Board. Mr. Inbody said that they don't have to set the rates now. They can lay out the comparative rates by category, not the premium per se. Ms. Hegley added that in the past, the discount was associated with the premium cost. The rates are not yet established. Instead of an amount equal to the premium, they could go with an amount per month, perhaps $10 per month. They can spread this out over a year if there are no problems with administering it that way. They could require follow-up if there are two or more health risks. Commissioner Baney and Chair Unger support this. Commissioner DeBone does not. Mr. Inbody noted that then he costs the plan more. There was a segment of people who did follow up but only to get the incentive. Others should not have to pay for someone else's additional costs. Mr. Inbody asked about the single/married offset. Commissioner DeBone said that in reality, this seems to be sacred at EBAC. But, if you have a family, of course, there are more costs to the plan and someone has to pay it. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 7 of 11 Commissioner Baney noted that this does not adjust the rate for a family, just the discount. Mr. Inbody stated that they could bring it back to EBAC. It is clear that if you have a spouse or family, you are spending more. Are they justified in having other employees cover this? A single employee can get a one-month premium holiday. If married, they get double. It is better to change what is being charged at the beginning. Commissioner Baney said she supports this, but wants EBAC's opinion clarified. 3. Other Items. Scott Johnson discussed a Central Oregon Health Council grant application to target tobacco cessation for clients at the annex. It would include nicotine replacement therapy, and contracting with someone to try to engage clients in this regard. There would be no additional staff required. DEBONE: Move approval of the grant application. BANEY: Second. VOTE: DEBONE: Yes. BANEY:: Yes. UNGER: Chair votes yes. Commissioner DeBone said there was a request from a citizen who lives off State Recreation Road for the County to put reflectors along the sides of the road. Chris Doty stated that they are called roadside reflector delineators. Not a lot of County roads have them. They examined this area and felt that nighttime driving might be compromised due to terrain. They are proceeding with the reflectors. This is the first time they have done this outside of new construction. They will test it as a pilot program to see how the hold up, and then evaluate other areas. It cost $2,000 for the product and about $4,000 to install them. It involved two days of work. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 8 of I I Commissioner DeBone said the citizen would like to see the County do a press release on this. Mr. Doty replied that it is a pilot program, and they don't want to get 100 requests for this. Mr. Doty asked the Board to sign PILT letters. At NACo, they approached the federal delegation to reauthorize PILT, and to offer assistance if needed from here. Commissioner DeBone said that secure rural schools funding can come and go at any time. He asked why they are calling this a reauthorization. Mr. Doty stated that is what they call it there. It is subject to annual approval through the Department of the Interior. The goal is to reauthorize it but also work on a long-term formula so there can be consistency. BANEY: Move signature of the PILT letters. DEBONE: Second. VOTE: BANEY: Yes. DEBONE: Yes. UNGER: Chair votes yes. Commissioner Unger said that the Salvation Army told him they need a place in Redmond to collect food and gifts and package them up. They wanted to know about using the Design Center. Susan Ross stated that they offered them space before on Wall Street. The Design Center is not appropriate. It is a shell, unfinished with no heat or air conditioning, no outlets and no lights. She suggested that perhaps Evergreen School would be better. Chair Unger noted that there is the Opportunity Center behind Wal-Mart as well. But most groups want to charge for the use. Ms. Ross said she would talk to those at the Fair & Expo to see if they have something that can be used short- term. Mr. Anderson said he is working on a updated needs and requirements list for departments in Redmond. He will have a report later; but with one exception, there does not seem to be a dire need for new County space there. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 9 of 1 I Mr. Anderson said COIC wants to know if the membership from the County will remain the same as last year, with Chair Unger as representative and Commissioner DeBone as alternate. Also, citizen appointees Chris Bellusci and John McLeod wish to be reappointed. BANEY: Move they continue with the current COIC appointments. DEBONE: Second. VOTE: BANEY: DEBONE UNGER: Yes. Yes. Chair votes yes.. Mr. Anderson asked about the Board signing a support letter on forest collaborative efforts with OED funds. Chair Unger added that they are asking for $50,000 for each National Forest for outreach, media presentations and staff support. BANEY: Move signature of the National Forest support letter. DEBONE: Second. VOTE: BANEY: Yes. DEBONE: Yes. UNGER: Chair votes yes. Mr. Anderson asked about the letter requested by the City of Redmond for COACT support of Redmond Airport. BANEY: Move signature of the COACT support letter. DEBONE: Second. VOTE: BANEY: Yes. DEBONE: Yes. UNGER: Chair votes yes. In regard to the Board Chair and Vice Chair for 2014, so the staff can advise departments on the new signature block, it was decided that Commissioner Baney will be Chair and Commissioner DeBone Vice Chair. This will be formalized at the first meeting in January 2014. Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 10 of 11 Mr. Anderson said that the people putting together Honor Flight have asked for $3,000 to get six veterans to Washington, DC. Three would be from Redmond and three from Bend. Chair Unger suggested that they challenge the City of Redmond, and perhaps each Commissioner could request match funds from various groups, such as Rotary. The group needs to know as soon as possible to make arrangements. Mr. Anderson suggested these funds come from general fund, as it should not become a regular request from discretionary grant funds. They will need a letter to go forward, and this should be put on a business meeting agenda for mid-December. Mr. Anderson said that Eastern Oregon Counties Association has asked for $15,000 from Deschutes County, as a membership fee. The Board discussed this request and decided that $7,500 is appropriate at this time. Commissioner Baney cautioned that they don't want to see AOC fractured east and west. This needs to be monitored. Mr. Anderson suggested that perhaps they could be a sub-group of AOC and not a separate organization. Chair Unger would like to review their by-laws before committing further. Being no further items discussed, the meeting adjourned at 4:00, at which time the Board went into executive session. DATED this Zlq- Day of . _ 2013 for the Deschutes County Board of Commissioners. Alan Unger, Chair Tammy Baney, Vice hair ATTEST: (5~~ Anthony DeBone, Commissioner Recording Secretary Minutes of Board of Commissioners' Work Session Monday, November 25, 2013 Page 11 of 11 Deschutes County Board of Commissioners 1300 NW Wall St., Suite 200, Bend, OR 97701-1960 (541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org WORK SESSION AGENDA DESCHUTES COUNTY BOARD OF COMMISSIONERS 1:30 P.M., MONDAY, NOVEMBER 25, 2013 1. Update on Discussion regarding Lechner Estates - Chris Doty 2. Discussion of 2014 Health Risk Assessment Incentive Program -David Inbody 3. Other Items PLEASE NOTE: At any time during this meeting, an executive session could be called to address issues relating to ORS 192.660(2) (e), real property negotiations; ORS 192.660(2) (h), litigation; ORS 192.660(2)(d), labor negotiations; or ORS 192.660(2) (b), personnel issues. Meeting dates, times and discussion items are subject to change. All meetings are conducted in the Board of Commissioners' meeting rooms at 1300 NW Wall St., Bend, unless otherwise indicated. If you have questions regarding a meeting, please call 388-6572. Deschutes County encourages persons with disabilities to participate in all programs and activities. This event/location is accessible to people with disabilities. If you need accommodations to make participation possible, please call (541) 388-6571, or send an e-mail to bonnie.bakernae,deschutes.org. 4 ~ xl IS I C O a~ 0 G 4- p' I II ' I V-Z) I r~ ivil z, I I I I I I ~I ~ I ~I' I I ' 4 I ' ~ II I I I ~ ~ I .C ' Iq~ ~ ~,I I n z ~ ~I ~ I ' II q I I I I I' ~ ~I' II ~ ro ~a of v la Dustan Neighborhood - Brief Timeline 1947 & 1948 - Bert and Pearl Lechner buy the west half of Section 4, approximately 320 acres. 1950 - Lechners hire unlicensed surveyor/timber cruiser to lay out roads and small tracts. Surveyor sets thin walled pipes at corners, but apparently does not correctly perform work (east - west roads are 4° off cardinal directions). 1951- Lechners start to deed off tracts. The legal descriptions are "aliquot part" descriptions which do not match the pipes set by surveyor or the roads built by Lechners. 1963 - Pearl Lechner realizes a problem exists and has licensed surveyor stake a tier of correction lots just south of Lechner Lane. 1971-1990s - Private surveyors begin reporting in their survey narratives that deed vs. occupation problems exist in the neighborhood. 1989 - County sells tax lot 221004CO00100 at auction. It is discovered that problem exists with deed vs. occupation with this and surrounding tracts and BOCC votes to rescind sale. 1990 - BOCC directs County surveyor to set any of the section's surrounding PLSS corners. This work is completed in early 1991. 1991- County Surveyor Jeff Kern interviews Pearl Lechner about history of these lands 1991- SOCC directs County Surveyor to have neighborhood mapped via an aerial photo contract. Maps are prepared. No further action by county. 2007-2008 - Dave Bancroft and Ken Mulenex organize 40+ landowners to approach County to discuss problem. 2008 - Dave Inbody is made public contact for this problem. Creates FAQ document which is mailed to landowners. 2009 - October - Admin, Legal, CDD, Property Management and Surveyor research and discuss steps the land owners would need to take to resolve problems. 2009- 11/23/2009 a meeting is held with county staff and eight landowners to discuss options. Board commits to have general fund pay for aerial mapping flight to help interested parties determine solutions to problems. 2010 - County makes code change to allow Property Line Adjustments in these situations. Performs lot of record verifications (17 of 41 lots not verified). 2010 - 8/18/2010 - BOCC Work Session. Aerial photos presented to Bancroft and Mulenex. 2013 -11/25/2013 -8000 Work Session to review background. U:\22-10-04 Dustan Rd Neighborhood\5urvey Background Reports\Dustan Road Neighborhood - brief timeline for BOCC 2013_1125.doc Page 1 of 1 11/25/2013 mjb TO: BOARD OF COMMISSIONERS FROM: DAVE INBODY & RONDA CONNOR SUBJECT: HEALTH RISK ASSESSMENTS DATE: 11/22/2013 CC: TOM ANDERSON, ERIK KROPP Background Deschutes County first offered health risk assessments (HRAs) to employees and dependents in January 2011. It was offered to anyone on the health plan over the age of 18. A total of 377 people received HRAs in 2011. The health risk assessment included the following: • Online Questionnaire -a series of questions regarding a variety of health-related topics • Biometrics - Height, weight and blood pressure was measured for each participant • Fasting Blood Work - cholesterol, triglycerides and glucose levels were tested in 2012, HRAs were again offered. Employees were encouraged to make an appointment to review their results with a provider at the Deschutes Onsite Clinic (DOC). In addition, employees were given a one-month health insurance premium holiday ($65 value) for taking an HRA. This had a significant impact on participation among employee. Spouse and dependent participation was about the same as 2011. The total number of participants was 582 The incentive for getting a one-month health insurance premium holiday was extended in 2013 to include not only employees, but also spouses. Since the premium had increased to $90 per month, the incentive was increased to $90 as well. In order to qualify for the incentive, an employee needed to not only complete the online questionnaire, biometrics and blood work, but a follow up visit with a health care provider to discuss the results was also required. The additional incentive for spouses resulted in a significant increase in spouse participation. Employee participation was about the same. Another change was a more concerted effort to get patients into the Deschutes Onsite Clinic (DOC) for their blood work. In the previous two years, large events were scheduled at work locations through which the vast majority of blood draws were completed. Although there were a few events in 2013, the majority of blood draws occurred at the DOC. 11RA Participation by Year and Participant Type Year Emptoyees Spouses Dependents 18-26 , Total 2011 Participants 320 48 9 377 % Participating__ 31% 7%, 5% 20% 2012 Participants 536 40 6 582 % Participating 52% 7°/, 3%, 30% 2013 Participants 532 265 2 799 % Participating 52%, 37% 1% 38% 2014 Health Risk Assessment For 2014, like 2013, it is recommended that the HRA include completion of an online questionnaire, biometrics, blood draw and follow up visit with a provider. In addition, it is recommended that anyone whose results indicate at least two risk factors be required to meet with either a provider or the wellness coordinator to develop a plan for addressing those risk factors in order to receive the incentive. This is intended to address identified risk factors, which typically lead to high health plan costs if not managed. Last year, the deadline to complete the blood draw was March 31, the deadline for the follow up visit was June 30 and the incentives were disbursed in August and September. It is suggested that instead of a one-month premium holiday, a monthly premium discount be provided. The discount will begin in August and continue for the next 12 months. For those with two or more health risks, they will be required to check in with a provider or the wellness coordinator on a quarterly basis to review their health plan in order to continue receiving the incentive. Each employee premium for the 2015 plan year (August 2014-July 2015) will be based on the following: Employee Type HIRA Participation Premium Rate* l Employee Participates $74 per month Single Emp oyee Employee Does Not Participate $82 per month Employee & Spouse Participates $74 per month Married Employee Employee Participates, Spouse Does Not Participate $82 per month Neither Employee or Spouse Participates $90 per month *All rates are based on current plan rates. These rates could be altered for plan year 2015. Why do Health Risk Assessments Matter? The reason for providing HRAs is to encourage participants to pursue a pro-active, preventive approach to health care. The participant is provided a snapshot of their health condition, highlighting any risk factors identified. Early detection and management of potential risk factors can prevent the onset of a chronic condition. Additionally, providing an annual opportunity for employees to meet with a health care provider to discuss their health condition will enable participants to better understand their health. For Deschutes County, a healthier population results in lower health benefits costs. 1. HRAs Save Claims Cost by Detect Conditions Early In the last 12 months, 60% of health benefits expenses were as a result of 284 (10% of covered lives). Many high-value claims are for behavioral-driven conditions. For example, among the 100 members with the highest claims cost in the health benefits plan in the last 12 months, 19% were diagnosed with heart disease (vs. 4% among all covered lives in plan) and 13% were diagnosed with diabetes (vs. 4% in plan). The cost is significantly reduced if these conditions are detected early or avoided completely through preventive treatment. The risk for both of these conditions can be tracked through the testing provided as part of the health risk assessment, such as blood pressure, cholesterol, triglycerides and glucose. 2 ®ocuMent Rsproduves Poorly (Archived) Number of Covered Lives by Claims Cost Total Group Cost by Claims Cost Category Category 2. HRA Participation Leads to Cost Savings People who participate in the HRAS process spend less in the following year than those who do not participate. The greater the level of participation, the lower the claims cost. $s,5oo Claims Cost by.HRA Participation Level $8,000 $7,500 $7,004 a~~S ,w yo12HRP y~P o~a a~ Q $6,500 ~00 2012" ^ $6,000 z0,2$ ZD HRAs Z3 Rt ti $5,500 ~011MRa $5,000 Year 0 Year 1 Year 2 Year 3 3 3. HRA Participants Increases Health-Conscious Behavior HRA participant are more likely to take preventive steps toward detecting and treating chronic conditions. Here are a few examples Preventive Actions Plan HRA National: At least one office visit 88.6% 95.1% 78.2% Mammogram (Women 40+) 48.1% 52.8% 33.4% At least one dental visit 73.6% 86.9% 63.5% Conversely, those who do not participate in the HRA process are more likely to pursue more emergency-driven, higher cost actions. ER Visits per Member per Year Urgent Care Visits per Member per Year 0.18 ate 0.14 "C •r 0 3 i 0.12 11 SG 0.10 US M n.rfx 6.20 0.15 05 n.n 00 o.uu Yeaf4l Yea; 42 YearC Year 44 Yea'H1 Y-42 Y-#3 Yearu4 At Least one I tM Annul Han Did Not Participate $ --At least one HM •-HRA 2011, 2012 & 2013 • Did Not Part it.ipale - • : --Fewer ER by HRA Participants Fewer Urgent Care Visits by HRA Participants Diabetes Cases per Member Heart Disease Cases per Member 0.14 1.11 JAL ¢ (1 In 11.14 ..m...... ......•..m.........., Q I? 0.10 0.06 0 IN 0 0, o.IA n.W O.Ot nm D.00 51 Y- 41 Yvn 92 Yea, e3 Yeal44 vt.~I V,a, kl Yie, ,ti v, a~eA At I,-.1 ,,,x•1IRA _I IRA 7011)01?e,1015 Il„1N„1 e.,,ll~~l"I' -----wl trd;tunr HRA HIIA 1011, 1011&1113 - 014 Nol PanNipate More cases of diabetes and heart disease among HRA participants, but........ 4 7 2014 Health Risk Assessment Expense and Cost Avoidance Analysis The total expense to the County for this incentive will vary based on participation. Last year, there were 799 participants at a,cost of $71,910 for incentives. If this level of participation is repeated in 2014, the expense for incentives would total $76,704. The expense for 100% participation by all employees and spouses eligible would be $167,616. There are also 349 dependents over 18 years old on the plan who may also participate in the HRA, but they are not eligible for an incentive. Additional expenses associated with the HRA process include $15 per participant for the blood work ($11,985). An additional phlebotomist would be contracted to assist with the blood draws. The County would pay $22.64 per hour for the phlebotomist. It is estimated 200 hours will be required at a cost of $4,528. Other miscellaneous expenses such as marketing and those expenses associated with the online questionnaire are estimated at about $500. On average, HRA participants spent $1,062 less in the health benefits plan in the 12 months following the HRA than those who did not participate. Those who participated in the HRA all three years spent an average of $1,485 less in the 12 months following the HRA than those who did not participate. Assuming the trend will continue, and the same number of HRA participants in 2014, the HRA process will result in $848,305 in cost avoidance to the health benefits plan. _Expenses 2613 k f 79 T 2014 000 "RAs) (1 2014 (all ible)" li 9 ( , g e Blood Draws $11,768 $11,985 $15,000 $31,425 Additional Staff $6,835 $4,528 $5,660 $11,873 Incentive Expense $71,910 $76,704 $96,000 $167,616 $500 Other Expenses $179 $500 $500 _ .TotaL-` t ; ,$90,692 $ 44~ 7 :$117,160`° _ $271,414 Cost Avoidance** $848,538 $848,538 $1,062,000 $2,224,890 t?lari 5avin s, . ; $46 $7544if LNet 44,84Q $9 $,2,023,476 _ _ . *All eligible participants include 1,746 employees and spouses and 349 dependents over 18 years old. The dependents are not included in the incentive expense. **Cost avoidance is based on the average savings per participant for three year period multiplied by number of participants. As part of the HRA incentive, it is recommended that a premium offset be afforded those employees who are unmarried. This offset is in the amount of $96 per year. The total expense associated with this offset is $29,184. r Hypertension: Benefits of NonPharmacologic Therapy Hypertension remains one of the most important multipliers for cardiovascular and renal risk. A blood pressure of greater than 140/90 has been associated with 69% of first myocardial infarctions, 74% of cases of coronary heart disease, 77% of first strokes and 91 % of cases of congestive heart failure. According to a meta-analysis published in the Lancet in 2002, there was a doubling of mortality for every 20 mmHg increase in systolic blood pressure for strokes and ischemic heart disease. This risk was independent of age. Current recommendations for patients who are considered high risk: existing cardiovascular disease, prior stroke or transient ischemic attack, evidence of target organ damage, should have a goal blood pressure of <130/80 mm Hg. Lowering a patient's blood pressure by 20 mmHg can reduce the cardiovascular and stroke mortality by 50% over the next 12 years. A reduction in systolic blood pressure of 5 mm Hg has been associated in observational studies with reductions of 14 percent in mortality caused by stroke, 9 percent in mortality caused by heart disease, and 7 percent in all-cause mortality. In addition, a weight loss of 10 lb (4.5 kg), a realistic goal for most individuals who are overweight, can reduce or prevent hypertension. Nonpharmacologic therapy is most likely to reduce systolic blood pressure by about 10-12 mm Hg and diastolic blood pressure by no more than 4-7 mm Hg. Modifications include reducing dietary sodium to less than 2.4 g per day; increasing exercise to at least 30 minutes per day, four days per week; limiting alcohol consumption to two drinks or less per day for men and one drink or less per day for women; following the Dietary Approaches to Stop Hypertension eating plan (high in fruits, vegetables, potassium, calcium, and magnesium; low in fat and salt); and achieving a weight loss goal of 10 lb (4.5 kg) or more. A 20 lb weight loss can be equated to the benefit of a single drug in lowering blood pressure, which is a reduction in systolic blood pressure of 5 to 20 mm Hg. As far as alcohol is concerned, heavy daily or binge drinking has been associated with sustained increases in blood pressure. Using a therapeutic guideline to reduce alcohol intake can lead to a reduction in alcohol, which in turn can lead to a reduction of blood pressure by about 20/10 mm Hg. As part of a comprehensive lifestyle program, men should have no more than two alcoholic drinks per day and women no more than one per day. The recommended sodium intake is less than 100 mEq per L per day for all patients with hypertension or prehypertension. Aerobic exercise has positive effects on blood pressure whether or not a person has hypertension, producing average reductions of 4 mm Hg in systolic blood pressure and 3 mm Hg in diastolic blood pressure. Recommendations: As weight loss does not follow a set formula. Patients need to have good resources to verify the appropriate diet and exercise interventions are appropriate. In general, a 20 pound weight loss in a person who is at least 30 pounds overweight will take four to six months. Therefore, a plan of action should be put into place to get feedback overtime which will promote the possibility of success. Likely follow up every 4-8 weeks is reasonable. During these follow up sessions, reminders of low sodium diets and appropriate alcohol intake can be given. Exercise logs should also be reviewed at that time. Patients should continue to receive reinforcement for good choices and actions, as long as documentation verifies the attempt. Time line for expected outcome on nonpharmacologic treatment should be 4-6 months. References Chobarian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7 Report. JAMA; 289: 2560-2572. Thom T, Haase N, Rosamond W, et al. Heart Disease and Stroke Statistics - 2006 Update: a report from the American Heart Association Statistics Subcommittee. Circulation. 2006; 113: e85-e 151. Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002; 360:1903-1913. Wexler R, MD, MPH, and Aukerman G, MD. Ohio State University College of Medicine, Columbus, Ohio. Nonpharmacologic Strategies for Managing Hypertension. Am Fam Physician. 2006 Jun 1;73(11):1953-1956. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med. 2001;344:3-10. Whelton PK, Appel LJ, Espeland MA, Applegate WB, Ettinger WH Jr, Kostis JB, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of non-pharmacologic interventions in the elderly (TONE) [published correction appears in JAMA 1998;279:1954].JAMA. 1998;279:839-46. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension. 2000;35:544-9. How to Fix Cholesterol without medicines If there is too much cholesterol in the blood, some of the excess can become trapped in artery walls. Over time, this builds up and is called plaque. The plaque can narrow vessels and make them less flexible, a condition called atherosclerosis or "hardening of the arteries." This process can happen to blood vessels anywhere in the body, including those of the heart, which are called the coronary arteries. If the coronary arteries become partly blocked by plaque, then the blood may not be able to bring enough oxygen and nutrients to the heart muscle. This can cause chest pain, or angina. Some cholesterol-rich plaques are unstable-they have a thin covering and can burst, releasing cholesterol and fat into the bloodstream. The release can cause a blood clot to form over the plaque, blocking blood flow through the artery-and causing a heart attack. The body makes all the cholesterol it needs. Cholesterol circulates in the bloodstream but cannot travel by itself. As with oil and water, cholesterol (which is fatty) and blood (which is watery) do not mix. So cholesterol travels in packages called lipoproteins, which have fat (lipid) inside and protein outside. Two main kinds of lipoproteins carry cholesterol in the blood: ■ Low density lipoprotein, or LDL, which also is called the "bad" cholesterol because it carries cholesterol to tissues, including the arteries. Most of the cholesterol in the blood is the LDL form. The higher the level of LDL cholesterol in the blood, the greater your risk for heart disease. ■ High density lipoprotein, or HDL, which also is called the "good" cholesterol because it takes cholesterol from tissues to the liver, which removes it from the body. A. low level of HDL cholesterol increases your risk for heart disease. Risk factors you can't change Age-45 or older for men; 55 or older for women Family history of early heart disease-father or brother diagnosed before age 55, or mother or sister diagnosed before age 65 Risk factors you can change • Smoking • High blood pressure • High blood cholesterol • Overweight/obesity • Physical inactivity • Diabetes Once you know your heart disease risk category, you can find your LDL goal level. if you have you are in category LDL goal Heart disease, diabetes, or a I I-ligh R.i.sk. Less than 100 mg/dL risk score more than 20% 2 or more risk factors and risk II-Next Highest Risk Less than 130 mg/dL score 10-20% 2 or more risk factors and risk III-Moderate Risk Less than 130 mg/dL score less than 10% 0 or I risk factor IV-Low-to- Moderate Risk Less than 160 mg/dL, The Framingham tables are based on data from the landmark Framingham Heart Study, a long-term study of the people in Framingham, MA, and their offspring. It gives a risk score, or chance of having a. heart attack in the next 10 years. There are applications available for smart phones that consumers and providers can use to determine the risk. 'The points are determined based on age, total cholesterol, HDL, smoking and systolic blood pressure. The intensity of your treatment will be tied to the degree of your heart disease risk. But whatever your degree of risk, you'LI need to follow the TLC Program. This section gives you the steps to follow. The program uses a step-by-step approach to help make it easier for you to adopt the changes (see Box 8 on page 17). For instance, during the first 3 months of treatment, your main aim will be to lower your LDL cholesterol to its goal level through diet and physical activity. You will take in only enough calories to maintain a healthy weight, or achieve it if you're overweight. Change LDL Reduction Saturated fat Decrease to less than 7% of calories 8-10% Dietary cholesterol Decrease to less than 200 mg/day 3-5% Weight Lose 10 pounds if overweight 5-8% Soluble fiber Add 5-10 grams/day 3-5% Plant sterols/stanols Add 2 grams/day 5-1.5% Total 20-30%* * Notice that this amount of LDL reduction from H.C compares well with many of the cholesterol-lowering drugs. Recommendations: A typical path to success would be: First Doctor Visit-Start Lifestyle Changes Reduce saturated fat, trans fat, and cholesterol. Increase physical activity moderately. • If overweight, reduce calories increase fiber-rich foods to help reduce calorie intake. Disecusions with the wellness coordinator can help with appropriate diet and exercise interventions -Allow 6 weeks- Second Doctor Visit heck LDL and, If Needed, Add More Dietary Approaches o Reinforce reduction of saturated fat, trans fat, and cholesterol. Add plant stanols/sterols. Increase soluble fiber. A I low 6 weeks- Third Doctor Visit-Check LDL and, If Needed, Add Drug Therapy • Start drug; therapy for LDL lowering, if needed. 0 Focus on treatment of metabolic syndrome (abdominal obesity, elevated triglycerides, elevated blood pressures, abnormal glucose, and low HDL)reinforce weight management and physical activity. -Every 4 to 6 months- Keep Checking Progress to ensure success! U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Heart, Lung, and Blood Institute NIH Publication No. 06-5235 December 2005. Lowering your Cholesterol with therapeutic Lifestyle Changes.