Session 99 PD, The Role of A Healthcare Provider Actuary. Moderator: Jay Hazelrigs, ASA, MAAA

Transcription

1 Session 99 PD, The Role of A Healthcare Provider Actuary Moderator: Jay Hazelrigs, ASA, MAAA Presenters: Kevin E. Dotson, FSA, MAAA David Allen Myers, ASA Daniel P. Santmyer, FSA, MAAA Timothy Willard Smith, ASA, MAAA, MS SOA Antitrust Disclaimer SOA Presentation Disclaimer

2 The Role of a Healthcare Provider Actuary Value Based Care Moderator: Jay Hazelrigs Presenters: Kevin Dotson, Dave Myer, Dan Santmyer and Tim Smith Session 99, Tuesday, June 13,

3 The Role of a Healthcare Provider Actuary - Value Based Care Discussion Items Housekeeping Anti-Trust Please see Society of Actuaries Antitrust Disclaimer Statement (in meeting app and on the SOA web site) Questions Please state your questions clearly in the microphones and speakers will do their best to repeat the question to everyone Introductory to Strategic Initiative Introductions Current Environment Providers New Capabilities Skills of the Provider Actuary 2

4 Introductory to Strategic Initiative 3

5 Introductory to Strategic Initiative SOA Health Section Council identified set of strategic initiatives Objectives First started in 2015 Closed subgroups Defined deliverable and end date All members contribute 2 are completed, 4 underway The Role of a Healthcare Provider Actuary Began last summer Health meeting first set of information White paper to be completed by beginning of 4 th quarter 2017 Workshop tomorrow at 8:30am, Sessions 114 & 129 4

6 Introductions 5

7 Kevin Dotson & Dan Santmyer Worked together previously at Anthem/WellPoint National accounts with a focus on national network efficiency and reimbursement strategy After leaving Anthem, continued to work together with Dan serving as a consultant to Kevin on network strategies. Dan also spent 3 years of service at a managed behavioral health company Upon leaving Anthem, Kevin moved to Optum where he has transitioned from a payer/employer consulting role into advising providers around value based care solutions Recently Dan rejoined Kevin at Optum where they focus on enabling providers to be successful in value based care 6

8 Tim Smith & Dave Myers Worked together at Highmark Health through the formation of the IDFS between Highmark and the Allegheny Health Network Dave previously worked for Geisinger, and now manages Highmark s Actuarial efforts around value-based care Tim previously worked for Coventry for 14 years, and now leads the Pittsburgh practice of Axene Health Partners All of the presenters love this Provider stuff way too much. 7

9 Current Environment 8

10 Overview ACO Growth Triple Aim Industry Pressures Commercial Medicare Medicaid Employer 9

11 ACO Growth Projections Leavitt Partners - Projected Growth of Accountable Care Organizations, December

12 Triple Aim* Smarter Spending Reducing per-capita costs of healthcare delivery Healthier People Better health for populations: such as poor nutrition, physical inactivity, and substance abuse Better Care For individuals safety, effectiveness, patient-centered, timeliness, efficiency and equity *Berwick s Triple Aim HealthAffairs 11

13 Industry Pressures - Commercial 12

14 Industry Pressures - Commercial 13

15 Industry Pressures - Commercial 14

16 Industry Pressures - Medicare MACRA/Quality Payment Program (QPP) purpose MACRA replaced the Sustainable Growth Rate methodology that pays Fee-for-Service (FFS) providers with a new payment system the Quality Payment Program. The mandatory Quality Payment Program rewards providers for the delivery of high-quality care delivered to Medicare beneficiaries and is part of CMS s commitment to transition the Medicare program from FFS to value-based payments. CMS estimates that in 2017 MACRA will impact over 50% of physicians. The Final Rule was open for public comment for 60 days, with comments due to CMS on December 13, CMS indicated that the Agency plans to implement the law in an iterative process, and new provisions will be introduced in the upcoming years. April 2015 Repeals April 2016 Oct 2016 Applies to Two new payment tracks: Takes effect MACRA AT A GLANCE Passed into law The Sustainable Growth Rate (SGR) Formula. Proposed rule released Final rule released Medicare FFS Physician Revenues only 1.Merit-Based Incentive Payment System (MIPS) 2.Advanced Alternative Payment Models (APMs) Beginning 2017; impacts revenues in 2019 (i.e. two year lag)

17 Industry Pressures Medicare MACRA Fee Schedule Impact MIPS vs. APM & On Medicare Fee Schedule (baseline) MIPS = Merit based Incentive System +0.5% each year No Change Max Adjustment (+/-) or 0.75% Advanced APM = Adv. Alternative Payment Model (QP) +5% bonus Excluded from MIPS MIPS positive adjustments have the potential for a 3X adjustment (i.e. +12% for 2019 up to +27% for 2022+). Intended to be budget neutral. For , exceptional performers (top 25th percentile) are eligible for additional payment from 0.5% grading up to 10% ($500M funding per year). 16

18 Industry Pressures - Medicare 17

19 Industry Pressures - Medicare How MACRA impacts Medicare physician reimbursement 18

20 MACRA Impact on Hospitals Physicians likely will be looking to hospital partners for help on meeting the stipulations of MACRA s various payment models. As physicians gain efficiencies to meet the MACRA requirements, this will trickle down to reducing admissions, which will increase pressure on hospitals to transform to a valuefocused care delivery model. Additional revenues at risk if physicians form partnerships with other Hospital systems What models can you bring to the table? Can you deliver on an Advanced APM model? Can you set up an MSO model to aggregate and execute on the reporting requirements in MIPS? Health Affairs (April 2017)*..cuts in Medicare payments to hospitals could be as high as $250 billion by 2030 because of how physicians respond to the incentives built into the payment models. These changes include incentives to reduce hospital spending and as a result will reduce the use of hospital care, because physicians will make decisions to avoid admissions and readmissions..suggests that hospital leaders change their business models to account for the reduced inpatient revenues. Some of those changes may mean reducing costs, increasing outpatient revenues and improving the health of patient populations.. 19

21 Industry Pressure Medicaid Massachusetts Medicaid Landscape Key goals of MassHealth restructuring are to create a sustainable system that rewards outcomes and value; and improve integration of physical and behavioral health MassHealth s transition to the future state will impact all stakeholders in Medicaid: MassHealth members will have options for participation Health systems will participate in the ACO program with three model options; Pilot (Dec 2016 Dec 2017) and Full ACO (beyond Dec 2017) MCOs will be engaged in the transformation to provide high-quality and timely data MCOs and ACOs will need to partner with community partners that will help members navigate the system of care with focus on behavioral health and LTSS Approval of 1115 waiver will fund these efforts based on achieving target goals 20

22 Industry Pressure Medicaid TennCare (Tennessee Medicaid) Landscape Health Care Innovation Initiative launched in February 2013 to change the way health care is paid Implemented episodes of care to reward providers for providing highquality and efficient care for acute medical and behavioral treatments and conditions. Done in waves. 75 episodes by Key components: Principal Accountable Provider (PAP), or quarterback: The PAP is the type of provider that has the best opportunity to influence the quality and cost of a type of episode. Fairness: The costs of an episode are risk-adjusted so that providers who deliver effective and efficient care to more complex patients are appropriately rewarded Performance measurement and transparency: The initiative will provide PAPs with significant data and information related to episodes of care for which they are accountable, to enable greater understanding of the drivers of performance

23 Industry Pressure Medicaid 22

24 Challenges Across Lines of Business Balancing multiple risk contracts is essential as providers move from FFS to value Cost containment When developing strategy to address cost, need to take holistic view of impact on broader organization Margin management Understanding internal cost structures. Trying to focus care to maximize profitability. Quality Organizations need to understand the financial implications of quality across contracts Network Must understand volume going outside ACO and the domestic network Coding accuracy Most risk contracts are adjusted for disease burden of patients managed 23

25 Additional Industry Pressures 24

26 Additional Industry Pressures 25

27 Additional Industry Pressures 26

28 Many Challenges Faced in Managing Post- Acute Care 27

29 Provider s New Capabilities 28

30 Providers Acquire Payer Capabilities Financial/Risk Management Population Health Management Network Strategy Shared Triple Aim Goals Smarter Spending Heathier People Better Care 29

31 Financial/Risk Management Similar Skills to Acquire Hiring Chief Analytics Officer to interact with Chief Information Officer, Chief Financial Officer and Chief Medical Officer Actionable and accurate data warehouse Setting of appropriate, fair and reasonable rates/capitation received/target budget benchmarks Financial modeling and scenario testing of value based contract components Forecasting targets and tracking progress towards targets Capital requirements Risk Adjustment Key Provider Considerations Providers consider care delivered as revenue where payers typically view care delivered as costs Availability of Data Commercial and Medicaid payer claims data not always made available to providers Outside of collaborative efforts led by provider alliances, payers, local governments, etc., internal clinical data sources have limited use for financial management 30

32 Population Health Management Similar Skills to Acquire Technology driven care management and coordination processes Quality metrics and outcomes Risk stratification and identification of patients needing intervention and health coaching Thorough diagnosis coding enabling risk stratification, care planning and appropriate valuation of morbidity/risk adjustment Key Provider Considerations Define and execute accountable culture within available resources Frequent and actionable reporting to Primary Care Physicians/Sub-Providers that support Triple Aim Meaningful feedback on provider performance Facilitate actions that need to be taken to meet overall quality/care and health strategy Available at point of service during patient visit 31

33 Network Strategy Similar Skills to Acquire Assess provider efficiency and quality Ensure providers (own system and referrals) administer appropriate care at reasonable rates producing high quality outcomes Negotiate reimbursement rates Distribution of shared risk bonus payments or losses with own system providers and/or referral providers Key Provider Considerations Impact of leakage outside of health system/preferred referral partners For Commercial and Medicaid populations, reimbursement to providers outside of health system and not directly contracted) is unavailable 32

34 Skills of the Provider Actuary 33

35 Skills of the Provider Actuary Financial Management Value-Based Reimbursement (VBR) design - Bias, anti-selection - Volatility VBR modeling - Actuarial values for a given design - Scenario testing, simulation - Risk/return analysis Asset liability management Reserves / RBC / cash flow analysis Risk appetite 34

36 Skills of the Provider Actuary Risk Appetite Payer vs Provider Across Provider Types Payer Hospital System Provider ACO/CIN Physician Group 35

37 Skills of the Provider Actuary Bias & Anti-Selection in Value-Based Arrangements 36

38 Skills of the Provider Actuary High Performance Network Identification of high quality and efficient providers Value of narrow networks (rate v volume) Acquisition / organization strategies Physician compensation 37

39 Skills of the Provider Actuary Physician compensation Finding a way to pay physicians to not do procedures Overheard from a physician in a true integrated delivery system This was a really bad month for us. Utilization was way up. 38

40 Skills of the Provider Actuary Acquisition / Organization Strategies Pay for Value vs Pay for Improvement Phased rollout for new participants Distribution of gains/losses across entities 39

41 Skills of the Provider Actuary Population Health Management Predictive analytics Trend / claim cost analytics Payer data knowledge ROI clinical program effectiveness 40

42 Skills of the Provider Actuary Predictive analytics Clinical Data Timely Scope of data elements Specificity Clinical Data Payer Data Integrated Data Payer Data Scope across continuum History/ stability 41

43 Skills of the Provider Actuary ROI of a Bundled-Payment Arrangement Initial Admit Readmit Sub-acute Savings at Best-in- Class Provider System Avg cost % Avg Cost (all bundles) % Avg Cost (all bundles) AVERAGE TOTAL COST Provider A Outpatient ASC $ 12,000 5% $ % $ 1,200 $ 13,700 Provider A Inpatient Hospital $ 20,000 8% $ % $ 1,600 $ 22,560 $ 8,860 Provider B Inpatient Hospital $ 30,000 12% $ 1,440 40% $ 4,000 $ 35,440 $ 21,740 42

44 Conclusion & Questions Traditional Actuarial skills Financial management is a great fit Modeling, scenario testing, etc. Non-traditional skills Network optimization and population health Easier transition for the actuary with a Med Econ bend Key point: Need to think about cost from the underlying provider cost perspective, and how to ultimately squeeze margins out of lower volume 43

45 Questions & Thank You Provide Your Feedback and Win! Complete your evaluation and be entered to win one of these three great prizes: One complimentary registration to the 2018 Health Meeting One complimentary room reservation in a standard room (max. 3 nights) at the Austin Hilton for the 2018 Health Meeting One complimentary registration to a Health Section sponsored webcast *See Official Rules