Risk Contracting: What to Know About Stop Loss Insurance KATHRYN A BOWEN, EXECUTIVE VICE-PRESIDENT OCTOBER 27, 2016

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1 Risk Contracting: What to Know About Stop Loss Insurance KATHRYN A BOWEN, EXECUTIVE VICE-PRESIDENT OCTOBER 27, 2016

2 Provider Stop Loss Insurance Premiums Program Structure Losses within Retention What are we talking about today? Risk Assumption Program Structure Contractual Liability Uninsurable/ Uninsured Losses Losses Within Retention Uninsurable/Uninsured Losses Coverage Gaps Coverage Gaps Contractual Liability Insurance Premiums Questions 2

3 Provider Sponsored Plans Medicare Programs Commercial Arrangements State Medicaid Programs US Healthcare is moving to Value Value Shift gives rise to new and re-emerging risk bearing models Move to Value Based Arrangements New Organizational Models Estimated patient revenue through value based arrangements ($ billions in 2015) Provider Sponsored Health Plans (PHPs) Accountable Care Organizations (ACO s) Increased alignment between payment and provision to form virtual or real integrated delivery networks. 7% of all Covered Lives (~20.6 M lives) under Provider Owned Plans. 95 existing Provider Owned Plans. 110 Plans with Potential Provider Ownership. Growing number of models of payment and care delivery that seek to tie provider reimbursements to quality. 838 ACOs in the US - an increase of over 900% since % of ACO lives are in Shared Savings (upside only). 21% of ACO lives are capitated. 11% of ACO lives are Shared Savings with Risk (upside/ downside). 3

4 Level of financial risk Risk Contracting Shifting Risk & Accountability to Providers Shared Risk (ACO s) Capitation Fee-for-Service Pay-for-performance Shared-savings models Bundled Payments Episodic bundling Shared Savings Pay for Performance Fee-for- Service Shared Risk (ACO s) Capitation Degree of Provider Integration and Responsibility 4

5 Risk Assumption Signed. Sealed. Delivered.it s Yours Contract is executed Analyzed Assessed Avoided Minimized Eliminated Unacceptable risk. The biggest risk is not taking any risk In a world that is changing really quickly, the only strategy that is guaranteed to fail is not taking risks. Mark Zuckerberg Level of Acceptable Risk Assumption in Contract Full Risk Partial Risk Shared Risk Upside Risk Downside Risk 5

6 Risk Transfer Evaluating & Minimizing the Total Cost of Risk you have Assumed Evaluate the acceptable contractual risk to determine whether you will. Assume the Risk Transfer some or all of the Risk Captive Alternative Risk Method Provider Stop Loss Insurance It was never the intent for you to become an insurance company, yet 6

7 Provider Excess Defined Minimizing losses & mitigating claims Provider Stop Loss is a stop loss product that helps healthcare organizations manage the financial risk assumed for the cost of providing medical services. Provider Stop Loss provides financial stability for unpredictable, catastrophic claims that can materially impact a healthcare organizations financials NICU claims Transplants High Dollar Accidents or Illnesses Care for the chronically ill (Diabetic, CHF, COPD) Chemotherapy, high cost injectables or specialty drugs Other catastrophic events 7

8 1980 State of the Marketplace History and Today s Evolving Provider Stop Loss Landscape No Provider Stop Loss Market Stop Loss As Part of Capitation Contract Pricing Part of Cap Rate Premium is possible source of profit for HMOs Number of Private insurers offering stop loss declined $ M in premium in private marketplace Premium Savings Data Readily Available Reduction in Number Risk Assumption Contracts Private insurers offering stop loss $50-100M in premium in private marketplace Premium Savings Paper Medium No analytics High Loss Ratios Increase in number of private insurers offering stop loss Varying models of Risk Assumption $ M in premium in private marketplace Competition Analytics Underwriting Discipline 8

9 Risk Evaluation You are unique. Your solution must be too. Program Structure Insurance Premiums Losses within Retention Total Cost of Risk Contractual Liability Uninsurable/ Uninsured Losses Coverage Gaps The right solution is one that is tailored to you. 9

10 Tailored Program Actionable investigation to drive informed decisions Who are your members? Strength of the MCO market in which you operate? Contracts you have in place? Facilities in your area for reinsurance frequent flyers? Is Care Management Delegated? LESS CONTROL Is Claims Payment Delegated? MORE Risk Transfer Arrangements? CONTROL Available Data on Population? 10

11 Data & Analytics Unleashing the power of your data for policy mechanics Aggregating and Analyzing Data through source systems throughout the enterprise Determining which measures are applicable to reinsurance frequent flyers Reviewing Historical results to predict the future Leveraging information to determine the amount of risk you wish to Transfer vs. Hold. Statistical information on Facilities/Providers/Pharmaceuticals/Population Retention Evaluation Frequent Flyers MORE CONTROL 11

12 Program Structure Understanding your options across the control continuum Specific stop loss is a stop loss product that provides protection against a high claim on any one individual. Financial protection occurs on claims by single individuals who exceed a dollar limit (retention) chosen by the insured. Aggregate provides a ceiling on the total dollars that an insured will pay during a policy period. The insurer reimburses the insured after the end of the year on claims above a pre-determined amount LESS e.g. Historical Claims at $6,500,000. Reimburse above 110% or $7,150,000 CONTROL MORE CONTROL 12

13 Program Structure Delivering the protection in the areas that you have risk Hospital Risk Professional Risk Global (both Hospital & professional risk) - Retail Rx 13

14 Basic Policy Mechanics Who is Covered and at What Level of Risk Assumption? Annual Contract Specifies Covered Membership Categories Retention 14

15 Basic Policy Mechanics What is Covered by the Policy? Defines Covered Plans Plan 15

16 Basic Policy Mechanics Defining Limits of Risk Assumption Eligible Expense Basis Annual Maximums Per Member Coinsurance 16

17 Claim Valuation The Definition of how you will be paid when you have a claim Determines how claims will accumulate to the retention Determines how you will be reimbursed after the claim exceeds the retention Is not always What you pay Is determined by the Data you remit for Claims Payment 17

18 Claim Valuation Policy is based on the Lesser of Terminology Covered Services are Defined Listed by Risk Type (Hospital/Professional) Listed by Population Type (Commercial/Medicare/MediCal) Listed by Type of Service (Inpatient/Outpatient/Pharmacy) Listed by Provider of Service (Par/Non-Par/Contracted) The Lesser Of 18

19 Participating Providers In House Services vs. Referrals Who? Are you actually paid? What does your data say? Do you want coverage for participating providers? Plan vs. Private Network 19

20 Contracted Providers Minimizing losses & mitigating claims Provide Copies of Contracts to Insurer Remember to Update them when changes occur 20

21 Non-Contracted Providers Minimizing losses & mitigating claims Average Daily Maximum or Amount Paid 21

22 Pharmaceuticals Coping with the ever-changing complexion of risk According to CDC 54 New Drug & Biologic Approvals in 2015 One - half Specialty Pharmacy Developing New & Expensive Medicines Diabetes Renal Disease Multiple Sclerosis Coronary Disease Oncology Frequent Flyer Diagnoses usually have an element of pharmaceuticals 22

23 Pharmaceuticals Coping with the ever-changing complexion of risk Quote says Pharm/Inject/Clotting Factors/ Excluded Elsewhere? Percent of Amount Billed? Contracted Providers? Annual Maximum? Definition of Pharmacy Not usually in quote Administered by a physician May Exclude Retail Prescription Drugs May Exclude Blood and Blood Products May Exclude Agents for the treatment of clotting disorders and growth hormones May Not have a definition of Specialty Drugs 23

24 Losses Within Your Deductible Minimizing losses & mitigating claims Manage losses for assumed risk through Utilization Review Population Health Contracting Insurance Value Added Services - Transplant Networks - Bill Review - Pharmacy Consulting - Case Management for Catastrophic Claims - Top tier Primary and Supplemental PPO Networks - Specialty Pharmacy and Network Management 24

25 Uninsurable/Uninsured Losses Some risks cannot be transferred via insurance products Provider Stop Loss provides financial stability for unpredictable, catastrophic claims that can materially impact a healthcare organizations financials Unpredictable = Unknown Known Excluded Lasers/Higher Retentions Exclusions or Maximums on Specific Treatments/Pharmaceuticals 25

26 Coverage Gaps It s easy to buy coverage. It s more difficult to buy great coverage. Re-rate Provisions based on estimated members Material Change Provisions Appeals Deadlines Notice Requirements Transplant List Requirements Exclusions Disclosures Definitions (e.g. Ambulance) 26

27 Contractual Liability Hidden risk transfers & unknown assumption of liability Plan/Contract Requirements? Must Carry Stop Loss? Level of Stop Loss Required? AM Best Rating or Financial Size of Insurer Required? State Requirements? Federal Requirements? CMA MA PIP - for plans that carry Substantial Financial Risk Panel Size Single Combined Deductible Separate Institutional Deductible Separate Professional Deductible 1-1,000 $6,000 $10,000 $3,000 1,001-5,000 $30,000 $40,000 $10,000 5,001-8,000 $40,000 $60,000 $15,000 8,001 10,000 $75,000 $100,000 $20,000 10,001-25,000 $150,000 $200,000 $25,000 >25,000 None None None 27

28 Insurance Premiums In the beginning there is price. In the end there is cost. Pricing is per member per month Pricing is by population type Creative payment options Aggregating Specific Corridor Premium Refund Mechanisms Goal is achieving the lowest NET cost for the risk you are wanting to transfer 28

29 Know your Total Cost of Risk You are unique. Your solution must be too. Program Structure Insurance Premiums Total Cost of Risk Losses within Retention Perform a Risk Evaluation + Use your Analytics = Appropriate Level of Risk Assumption Contractual Liability Uninsurable/ Uninsured Losses Coverage Gaps The right solution is one that is tailored to you. 29

30 Questions? Provider Stop Loss Reinsurance HMO Reinsurance ACO Reinsurance PPO Reinsurance Exchange Reinsurance 30

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