Providers Contracting Directly With Employers

Transcription

1 Providers Contracting Directly With Employers NOVEMBER 14,

2 The Current Model 2

3 Direct-to-Employer (DTE) Health Plan Aligned Incentives Gain Share Direct Relationship At The Table Integrated Data & Analytics PROVEN POP HEALTH Transparent - EVERYTHING Budget Targets Savings 3

4 The Market is Changing Employers are approaching Providers demanding Direct Contracting Strong desire to reduce healthcare costs by 10%+ Want more than discounts- Improved care and long term savings Focus on prevention, early detection and better outcomes Reinventing Healthcare 4

5 Direct-to-Employer (DTE) Health Plan DTE Strategy: 1. Directly contract with self-funded employer(s) for a FFS or a retroactive discount with an upside gain share 2. Medical Provider is the center of the relationship with the employer not an insurance carrier 3. Gain sharing arrangement 4. Financially incent members to use the sponsoring Medical Provider(s) and adhere to protocols intended to address gaps in care and to manage appropriate utilization 5

6 Direct-to-Employer (DTE) Health Plan There are 5 main reasons the DTE program is a strategically important: 1. Millions in NEW incremental net revenue 2. Control over YOUR OWN network 3. Employers directly connect with local medical providers without a middle man for better patient care and lower costs 4. Sponsoring Medical Provider has a low risk strategy and robust source of new fees and revenues 5. Increases the ability to achieve the Triple Aim increased satisfaction, better outcomes and reduced cost 6

7 Direct-to-Employer Medical Provider Our analysis reveals that you need less than a 1% market penetration to generate Millions in Net Incremental Revenue. 7

8 Direct-to-Employer Medical Provider You Pick the Name of the Health Plan You Determine the Fees Charged You Practice the Medicine You Receive the Profits You Make it Successful 8

9 Benefits for the Employer REDUCED MEDICAL SPEND THROUGH CARE CONTROL AT THE TABLE WITH THE MEDICAL PROVIDER INCENTIVIZED MEDICAL PARTNERS IMPROVED AND SUPERIOR ANALYTICS COMPETITIVE STOP-LOSS INCREASED FLEXIBILITY INCREASED CASH FLOW & STABILIZATION OF COST 9

10 The LEADING Independent Administrator Market Leading Direct Contracting Programs State-of-the-art Population Management Replacing current models with collaborative partnerships Delivery systems built so that Providers can prosper by reducing overall cost of care and improving the quality of care for members 10

11 DTE Model of Collaboration Stratify entire population by risk and compliance with standards of care Provide data necessary for medical staff to effect necessary treatment options Leverage Key Benefit administration Claims processing Customer service Sales/ Distribution Wrap networks Contract DIRECTLY with key local providers for optimal rates TRANSFORM HEALTHCARE as a recognized leader in your commercial market 11

12 DTE Model of Collaboration Key Benefit Health Plan Administration Acquire & Retain Customers Customer Service Population Management Transparent PBM Stop-Loss Employer/Broker Support Medical Provider Tier 1 Provider Network Population Management Medical Director oversight Local Provider Recruitment Network Management 12

13 DTE Financial Impact Positive financial impact: Medical Provider is the primary medical delivery system Restrict access to any other providers except in instances of emergency care or medically approved referrals to any other provider. New revenues from fees: Gain share distribution, AND Medical services not otherwise paid in major medical plans, AND Network Access Fees Year Membership DTE Net Revenue Incremental Net Revenue YEAR 1 3,500 $ 13,475,458 $ 7,951,051 YEAR 2 5,500 $ 21,175,440 $ 12,494,460 YEAR 3 12,500 $ 48,126,000 $ 28,396,500 13

14 DTE Financial Impact Medical Service Delivery Gross Medical Claim Revenues 3,500 Members Current Passive PPO DTE NET Direct-to-Employer Plan DTE NET Incremental Revenues In-Patient Hospital $ 7,083,462 $ 2,380,043 $ 5,277,179 $ 2,897,136 Out-Patient Hospital 4,871,915 1,636,964 3,629,577 1,992,613 Professional 2,818, ,851 2,099,417 1,152,566 Outpatient Surgical 443, , , ,500 Emergency Room 489, , , ,047 Home Heath 460, , , ,230 Laboratory 155,222 52, ,641 63,486 Other Unlisted Facility 58,471 19,646 43,561 23,915 Outpatient Dialysis 49,492 16,629 36,871 20,242 Mental/Sub. (In/Out) 9,430 3,168 7,025 3,857 Rehabilitation (In/Out) 2, ,929 1,059 Total Medical Revenues: $ 16,445,189 $ 5,524,407 $ 12,249,058 $ 6,724,651 Enhanced Revenues DTE Network Fees N/A , ,000 CDM Regimens of Care N/A , ,480 DTE Gain Share N/A , ,920 Total Net Revenues: $ 16,445,189 $ 5,534,407 $ 13,475,458 $ 7,951,051 PMPM:

15 True Population Management Analyzes all patient data for evidence-based treatment Stratify risk and identify Gaps in Care Proven models to change patient behavior Nurse coaches outreach to identified patients with chronic conditions and comorbidities Evaluates care and compares to current standards Proven to reduce overall costs by 11-17% 15

16 Every Member - Every Encounter Data Supported by Over 1.5 Million Members Under Management Encounter Data Regardless of Provider in your DTE Triage & Referral Mgt. 16

17 Every Member - Every Encounter Every Disease State Identified Every Member Defined by Chronic/Acute Conditions Regimen of Care Identified Provider Focused 17

18 Population Health Results $600 $500 $400 $300 $200 $100 $0 Midwest Multi-Specialty Physician Group 4,900+ Members PMPM Comparison 90% Completion Rate for CDM Regimens of Care $439 $421 $473 $411 $509 $ / / /2017 Actual PMPM Total Cost of Care AON Hewitt Trend Cumulative Savings $15.4 Million Trend: Trend is a forecast of per capita cost increases that takes into account various factors, including price inflation, utilization, government-mandated benefits, and new treatments, therapies, and technology. 18

19 Population Health Results $600 $500 $400 $300 $200 $100 $0 Midwest Acute Care Hospital 7,800+ Members 80% Completion CDM Regimens of Care PMPM Comparison $385 $411 $362 $327 $443 $ Actual PMPM Claims Costs AON Hewitt Trend $477 $180 Cumulative Savings $47 Million Trend: Trend is a forecast of per capita cost increases that takes into account various factors, including price inflation, utilization, government-mandated benefits, and new treatments, therapies, and technology. 19

20 DTE Program Description - Network Out of Network Wrap Network (Rented) Friends & Family (Contracted) YOUR Network YOUR NETWORK TIER 1 The Medical Providers Your Directly Control, or are Part of Your CIN/IPA/PHO/PO. Gain Share distribution!! Friends & Family Providers TIER 1 & 2 Medical Providers that are in your Catchment Area and are Complimentary to Your Medical Services TIER 1 benefit access through approved referrals from TIER 1 providers WRAP NETWORK TIER 1 & 2 Medical Services from Already Existing PPO Networks for Members that Travel, for Tertiary and Specialty Services You do not provide, and for Employees Residing Outside Your Direct Catchment Area - TIER 1 benefit access through approved referrals from TIER 1 providers OUT OF NETWORK Non Contracted Medical Providers 20

21 DTE Program Marketing & Sales KEY WORKS WITH YOU TO MANAGE & SELL: Branding & Messaging Direct & Brokerage Sales Distribution Brochures, Web Site, Media, etc. Implement with your Own Employee Benefit Plan 21

22 Proven Partner - Direct-to-Employer Market Key Family: 40 Years of a Proven Track Record 2.5 Million Lives Under Management DTE Integrated Reinsurance and Medical Stop-Loss Coverage Turn-key and customized Administrative Systems- Claims, Customer Service, Fulfillment, Compliance, Data Reporting, Referral Management Systems, Mobile Apps Customized Plan Designs with Provider Attribution and Referral Management Systems Comprehensive Data Analytics, including: Risk Stratification, Gaps In Care, Clinically Based Physician Profiling, Predictive Modeling Network Development and Wrap Networks One-sided Gain Share and Distribution of Gain Share Disbursements & Reporting 22

23 Proven Partner - Direct-to-Employer Market Key Family: Transparent PBM Low Cost Integrated Wellness Plans Mobile Apps Self-Service IT Apps Employee-Employer-Provider Lowest Cost Stop-Loss Insurance Rates Member Transparency Tools 23

24 A Partner You Can Trust Key Family Will NOT Compete Against You Our Objectives are Aligned Completely Transparent We have the size, scale, and sophistication of a commercial insurance carrier but without the inflexible and bureaucratic systems 24

25 FIRST STEPS - ASSESSMENT Determine if you are the right Candidate in the Right Market? We do a basic analysis of your viability as a narrow network in your primary catchment market and the ability to fill in the gaps in your services offered. We also do a preliminary analysis of the employer market to determine potential opportunities available. Once an agreement is signed, a full detailed analysis of all assumptions is begun. 25

26 PHASE 1 PROGRAM START-UP Oversite Assessments Goals The Blue Print Engagement Project teams are guided by experienced senior healthcare industry executives We determine your readiness to receive thousands of new health plan members Program goals are set and progress closely tracked We draft a comprehensive business plan to launch and grow the program Full engagement is achieved though high levels and communication and collaboration 26

27 PHASE 2 ON-GOING PROGRAM GROWTH Sales Marketing + Branding Program Monitoring Growth Strategies + Campaigns Account Management Sales Plan Implementation - Professional sales manage-ment - Agent and broker network - Prospect identification & targeting - Sales Goal Tracking Marketing Plan Implementation - Program branding - Employer campaigns - Employer events - Full integration with Medical Group Marketing Goal Achievement + Reporting - Goal publishing - KPI reporting - Employee satisfaction sampling - Employer satisfaction sampling Development & Implementation - Employer Advisory Panel - Broker/Agent Advisory Panel - Plan offering optimization - Eliminate friction in the sales channel Ongoing communication + stakeholder engagement: - Physician Leadership - Operations Leadership - Physicians - Office Administrators - Marketing - Compliance/ Insurance/ Risk/Legal 27

28 FOR MORE INFORMATION Jack Hill The Key Family - ACSG Phone: Jack.Hill@AccountableCareSG.com 28

29 Key Family Additional Material 29

30 The Organization The Key Family of Companies Key Benefit Administrators (KBA) American Health Data Institute (AHDI) Accountable Care Solutions Group (ACSG) Key Partners, Inc. (KP) RGI, LLC Founded in 1979 as a full-service group benefits administration firm specializing in self-funded medical plans. The Key Family has grown to become one of the country s largest independently-owned third party administrators, supporting a wide variety of group benefit plans. The Key Family services employer-sponsored plans, medical provider organizations, insurance carriers, and third-party payers throughout the US. With two major locations in Indianapolis, Indiana and Ft. Mill, South Carolina, Key Family has 800+ employees, 4,000+ corporate customers, and 2.2 million+ members under management. KBA is one of the nation s largest privately held third party administrators, providing various functions such as policy issue, billing and collection, customer service, claims management, benefit consulting, administration of employee plans, ancillary plan services and management support services. The largest and oldest population health database in the country. A pioneer in population health management enabling employers and medical providers to manage the cost and risk of health plan utilization in a way that optimizes benefits to the members. Proven to improve the health care status of the population. Consulting and project management services for medical providers desiring to deploy their own health plan strategy effectively creating collaborative community health solutions. Our partner in contracting and maintaining PPO networks, both locally and nationally, with over 85 provider networks under contract. The underwriting specialists for medical stop-loss and reinsurance placement. 30

31 Key Family Solutions & Value Proposition Solution Set Client Focus Key Family Differentiators Health System Value Direct-to-Employer Health System Sponsor Local Employers Experienced Population Management System Turn-Key Totally Customizable Integrated Stop-Loss Revenue Enhancement Surprisingly Low Cost of Entry Increased Incremental Income Gain Share with S/F Plans At the Table with Employers Speed to Market with KBA Risk/Reward Adjustability Self Funding Plan Administration Single Employer or Hospital System s Plan Experience with Employer Plans Hospital clients Can Increase Domestic Steerage Analytics Proven Results IT System Capabilities (e.g. reporting, referrals, plan management, etc.) Drive Domestic Steerage LEARN Population Health Manage Chronically Ill Evaluate Physician Practice Partners More Effectively Utilize Assets of System with Members AHDI Analytics & Nurse Coaching Health Systems Employers Providers in Episodic Care Proven Results in Reducing Secular Trend Easy Access with Targeted Analytical Information (EZView) Superior Analytical Framework across all Member Encounters Identifies and Helps Reduce Gaps in Care and Clinically-Based Physician Profiling 31