Session 75 OF, Advantages & Challenges for Provider Led Health Plans. Moderator: LuCretia Leola Hydell, ASA, MAAA

Transcription

1 Session 75 OF, Advantages & Challenges for Provider Led Health Plans Moderator: LuCretia Leola Hydell, ASA, MAAA Presenters: Jerry Clark, MD, FACP Josh Martin Mark Rishell SOA Antitrust Disclaimer SOA Presentation Disclaimer

2 Advantages and Challenges of Provider Owned Health Plans October 25, 2016

3 Agenda Speaker Introductions Lucretia Hydell Premier Health: The Journey from Volume to Volume + Value Dr. Jerry Clark Premier Health Value Story Josh Martin Why Start a Provider Sponsored Health Plan? Mark Rishell Prepared Q & A Audience Q & A 2

4 Our Speakers Today Jerry Clark, MD, FACP President & Chief Medical Officer at Premier Health Group Josh Martin President of Premier Health Plan Market President at Evolent Health Mark Rishell Senior Vice President of Strategic Client Finance at Evolent Health 3

5 Agenda Speaker Introductions Lucretia Hydell Premier Health: The Journey from Volume to Volume + Value Dr. Jerry Clark Premier Health Value Story Josh Martin Why Start a Provider Sponsored Health Plan? Mark Rishell Prepared Q & A Audience Q & A 4

6 Premier Health: The Journey from Volume to Volume + Value Dr. Jerry Clark Advantages and Challenges of Provider Owned Health Plans October 25,

7 Premier Health: At A Glance 100+ locations in 25 communities Located in Dayton, OH: 1.5M+ population 4 Hospitals >14,000 employees $1.8B in annual revenue Locally governed Not-for-profit 400+ employed physicians 6

8 Premier s Vision for Population Health Premier Health can drive substantial community health improvement with the potential to enhance annual financial performance at scale by $10M + by 2020 on 150K + lives through the execution of a multi-year Population Health Strategy 7

9 Premier has Launched a Comprehensive Multi- Year Population Health Strategy to Achieve the Vision beginning ,000+ employees and dependents Full replacement plan in 2014 State-of-the-art wellness program Exploring risk-based partnerships in Medicare, Medicaid, and Commercial Employee Health Payer Partnerships Medicare Advantage Individual market on- and offexchange in 2015 Consider Small group off-on exchange Large group, self-insured in 2015 Commercial MA HMO and D-SNP products in

10 But it Has Limits We Project ~3-7% of Dayton Population Will be Covered by Premier Health Plan Covered Lives (in Thousands) +0% p.a. 1,700 1,710 Medicare Commercial Medicaid Uninsured Premier Health Plan 9

11 Our Goal: The Quadruple Aim Population Management 1. Improving Patient Health Per Capita Cost Physician Engagement Physician Engagement Experience of Care 4. Supporting Physicians and aligning compensation for success 3. Delivering Highest Value Care 2. Offering Superior Care 10

12 Differing Processes Lead to Confusion and Cost Within the Physician Practice Payer 1 Payer 2??? Payer 3 Payer 4 Payer 5 Process Key Risk Adjustment Care Management Success Metrics 11

13 Payer Partnership Network Creates Streamlined Processes for Physician Payer 1 Payer Partnership Network Payer 2 Optimized Process Payer 3 Payer 4 Integrated Technology Solution Physician Payer 5 Multi-disciplinary Care Team Payer 6 Quality Bonuses Process Key Risk Adjustment Care Management Success Metrics 12

14 If We re Successful, We Get to Determine Our Future Build capabilities using both Health Plan and Payer Partnerships As capabilities mature, we have improved strategic position with payers Long-term, we provide multiple sustainable options to the community for accessing our advanced care model 13

15 What Makes Premier Health Plan Different? 1 Physician engagement and leadership 2 Technology integration 3 Local, personalized clinical programs 14

16 Data Integrated for a Patient-Centric Stratification Approach Clinical rules engine, predictive models and clinical judgment are used to identify patients for care advising PRIMARY DATA PATIENT PROFILE Administrative Data Med / Rx claims Eligibility Lab values Biometric screenings Clinical Data Provider files Consumer data EHR integration ADT feeds Utilization Trends Health Status Gaps in Care Medications Medical Costs Chronic Conditions Engagement Biometrics / Labs Demographics Health risk assessments Patient activation Survey Data Patient experience Physician referral Risk Scores Clinical Rules Engine 15

17 Unlocking Success: Creating a Team-Based Approach Primary Care Practice PCPs Medical Assistants Care Advisor Patient & Family Specialist Nurse Practitioners Patient & Family Physician Assistants Behavioral Specialists Social Workers Nurses Dieticians Pharmacist 16

18 Meeting Members Where They Are Health is dynamic. Premier Health s population health platform is flexible and responsive to individuals changing care needs. 17

19 Accountable Care Organization Clinical Integration Payor and Employer Partnerships Population Health Management Building blocks of integrated care Health Homes (PCMH) Primary Care Physicians Continuum of Care Physician Hospital Alignment EHR and HIE Specialty Care Physicians Physician Hospital Organization (PHO) Leadership and Culture Measurement 18

20 Agenda Speaker Introductions Lucretia Hydell Premier Health: The Journey from Volume to Volume + Value Dr. Jerry Clark Premier Health Value Story Josh Martin Why Start a Provider Sponsored Health Plan? Mark Rishell Prepared Q & A Audience Q & A 19 19

21 The Premier Health Value Story Josh Martin Advantages and Challenges of Provider Owned Health Plans October 25,

22 Premier Health in 2013: Health Care Reform Creates New Threat and Opportunity Market Overview Dayton, OH; 1.7M person DMA 2 System and 2 carrier dominated market Major growth in Medicaid and individual markets expected as ACA takes effect 4 hospitals 50%+ market share Strong reputation with consumers Controls 42% of commercial & MA fully insured market Looking to move into lower price arrangements Key Players 7 hospitals 45% market share Have one narrow network exchange product with Anthem Limited activity in the Value space 30% of commercial & MA fully insured market share Situation in 2013 Leadership knows population health infrastructure critical to maintaining market leader position FFS success creates a disadvantage in an increasingly cost driven market CEO sets an aggressive vision of shifting a significant portion of revenue to value based care by 2018 Launching a Health Plan Provides Platform to Achieve Goals

23 Premier Health s Value Business Strategy Today Strategy Overview In 2014, Premier launched its own Health Plan & began partnering with other national payers in value-based payment arrangements through its PHO, Premier Health Group. Premier s Value-based strategy is an extension of Premier s mission of improving the health of the community it serves. In 2016, Premier Health Plan currently covers 34,000 lives across Medicare Advantage, ASO, and Commercial lines of business. Premier Health Group (the PHO) manages 3,300 additional lives in a value-based arrangement with a large national payer. The strategy diversifies Premier s revenue source away from a solely fee-for-service base in a world that is moving towards value-based payment. Additional benefits include: Increased in-system utilization of Premier providers via the Plan s narrow network Aligning independent physicians more closely with Premier. Essential Requirements for Success Scale Cost and Pricing Plan MD Network Clinical Improvement Program Infrastructure & Change Management

24 Premier s go-to-market roadmap began with managing its own Employee Plan Initial development Blueprint and infrastructure build Premier employees Continued expansion Starting with an Employee Plan helped Premier build core capabilities for faster success in new product lines Medicare Commercial Expand market share and capabilities

25 The Employee Plan served as a proving ground for tools and capabilities. Premier (with Evolent s support) took over management of its self-insured Employee Health Plan in 2014 as a way to test its Health Plan and Pop Health capabilities and to iron out any kinks. Details on the Population: 18,000 employees and dependents. Financial Performance: Currently on track for 3 consecutive years of beating targets. Clinical Performance: Significant decreases in Ambulatory Care Sensitive (ACS) admissions and overall utilization metrics. Ambulatory Care Sensitive Admissions ( ) Annualized Change ACS Admissions Rate (as % of total admits) 12.7% 8.5% 7.9% % Ambulatory care sensitive (ACS) admissions are defined as admissions where appropriate ambulatory care may prevent or reduce the need for admission to the hospital. ACS condition definition logic is based on Agency for Healthcare Research and Quality Prevention Quality Indicators and Evolent s Proprietary Prospective Risk Score System logic.

26 Why pursue Medicare Advantage? MA provides a large medical expense PMPM to impact with clinical programs. Demographic trends driving growth in Medicare Advantage Affiliate transfer pricing issues not a concern (unlike Commercial lines of business) Ease of scaling MA due to an even playing field from a unit cost perspective Ability to leverage non-profit status and STARs advantage to create a meaningful delta on premium and benefits

27 Critical areas in Medicare Advantage Plan implementation Heavy Compliance Focus due to CMS oversight Network Build: ensuring Medicare GeoAccess requirements are met. Risk-Adjustment: the impact of accurate coding on revenue is significant. Medicare Advantage Stars program requires a robust infrastructure to support Quality improvement and reporting.

28 Lessons learned after Year 1 of MA operations Aggressive Benefit Positioning in Year 1 yields significant membership growth Investing in growth through the income statement. Not every market is dependent on brokers for MA, but if yours is, don t fight it. Market share will suffer. Engaging Physicians in RAF and Quality Performance is critical. Assisting with incentives and enabling capabilities Compliance, Compliance, Compliance

29 Premier s MA Plan has exceeded growth expectations and is tracking in line with financial targets. Evolent Blueprint Projection vs. Actual Premier Health Plan Life Growth in MA >350% over initial projections 2,000 7,600 >150% over initial projections 20,000 7,000 5,000 9,300 Projected Actual Projected Actual By the end of 2016, Premier achieved 10% market share in a 9-county service area From a financial standpoint, Premier s Year 1 MA experience was within 1% of its MLR target

30 Agenda Speaker Introductions Lucretia Hydell Premier Health: The Journey from Volume to Volume + Value Dr. Jerry Clark Premier Health Value Story Josh Martin Why Start a Provider Sponsored Health Plan? Mark Rishell Prepared Q & A Audience Q & A 29

31 Why Start a Provider Sponsored Health Plan? Mark Rishell Advantages and Challenges of Provider Owned Health Plans October 25,

32 Why Start a Provider Sponsored Health Plan (PSHP): To exert more control over where and how premium dollars are spent Move from FFS to value based care Capture a higher percentage of services provided to the PSHP members Creates a more competitive market for health plans

33 Control over Premium: Increases in premium are not likely to keep up with medical inflation The premium pie is shrinking a smaller percentage of healthcare expenditures go to hospitals and physicians as pharmacy, specialty drugs and other categories of spending increase. Government programs, in particular Medicare and Medicaid, are growing as a percentage of the total covered population. Annual spending increases for these programs are often less than medical inflation, and in some cases less than the growth in the CPI. MCO s pay a smaller percentage of premiums to providers than PSHP s. MCO s are effective at moving services out of hospital settings and into lower cost free-standing facilities.

34 Considerations for Starting a PSHP: Market share and density of population High cost vs. low cost provider Long-term strategic decision ( years) Sufficient capital to fund start-up costs and early year losses

35 Keys to Success: Don t manage as a division of a hospital separate company with its own board and management team Managing a PSHP takes a different skill set than managing a health system hire an experienced health plan management team Long-term investment be prepared for early year losses

36 Agenda Speaker Introductions Lucretia Hydell Premier Health: The Journey from Volume to Volume + Value Dr. Jerry Clark Premier Health Value Story Josh Martin Why Start a Provider Sponsored Health Plan? Mark Rishell Prepared Q & A Audience Q & A 35

37 Agenda Speaker Introductions Lucretia Hydell Premier Health: The Journey from Volume to Volume + Value Dr. Jerry Clark Premier Health Value Story Josh Martin Why Start a Provider Sponsored Health Plan? Mark Rishell Prepared Q & A Audience Q & A 36

38 Advantages and Challenges of Provider Owned Health Plans October 25, 2016