Session 111PD, International Health Insurance Innovation. Moderator/Presenter: Presenters: John Rogers, ASA, MAAA Jane Wang

Transcription

1 Session 111PD, International Health Insurance Innovation Moderator/Presenter: Presenters: John Rogers, ASA, MAAA Jane Wang SOA Antitrust Disclaimer SOA Presentation Disclaimer

2 Clover is a whole new kind of Medicare. John Henrik Rogers, MS, ASA, MAAA Society of Actuaries, Health Section Austin, Texas June 23 25, 2018 Carmen Clover member

3 We re not just using technology to pay out claims. We re building a learning machine, and we re using it for health. By operating at the nexus of care and cost, we think we can fix how care is given and for how much. Vivek Garipalli Clover founder 2

4 Clover currently operates in 18 counties across four states: NJ, GA, PA, and TX members ,074 members ,274 members 2016 Since launching in 2013: We ve grown from 190 members in Hudson county, NJ to 30,000 members to over 18 counties across four states In 2017, we became the #2 insurer in the individual Medicare Advantage market in the New Jersey counties we serve 17,000 members ,000 members ,000+ members Bucks County, Pennsylvania Savannah, Georgia San Antonio, Texas 3

5 Clover currently operates in 18 counties across four states: NJ, GA, PA, and TX. Since launching in 2013: We ve grown from 190 members to 30,000+ members In 2017 we became the #2 insurer in the individual Medicare Advantage market in the New Jersey counties we serve. 4

6 70 Yrs Average age 17% Hospitalized in the past six months 29% Disabled 15% On Medicaid 25% With a behavioral health diagnosis 5

7 Care & Technology: Data Feedback Loops Technology Care 6

8 Care: Our clinicians can make time with your patients more meaningful. Annual nurse practitioner visit Clover members can receive an annual Clover Care Visit at no extra cost. Nurse practitioners can do routine checkups, work with physicians to carry out treatment plans, and help remove barriers to care. We can help patients lower medication costs, refill prescriptions, and schedule appointments. In % of our members took advantage of this service. Post-hospitalization visits When a Clover patient has been in the hospital, our team is here to help ensure continuity of care. We will proactively inform the patient s physician about hospital admissions, discharge dates, and discharge plans. We will also offer to meet with our members for an in-home visit, and report back to their doctor with important details. Member outreach Our team of social workers and field-outreach coordinators is committed to the health, wellbeing, and safety of Clover patients. Field-outreach coordinators help ensure members have access to the care they need. Licensed social workers provide counseling, behavioral health assessments, and access to a referral network of community and psychosocial resources. 7

9 Care: Encourage Care in the Most Appropriate Setting Pre-Acute Acute Clipart provided in free trial of conceptdraw.com Post-Acute Hospital / Inpatient Inpatient Rehab Acuity / Cost Prevention Specialist / Urgent Care / MHSA Emergency Department Observation Care Skilled Nursing Facility Long Term Care / Institutional Home Social Care Retail Pharmacy Primary Care Physician Often Chronic Home Health / Palliative/ Hospice Home Care Clinical Ops (Home Visits, Campaigns, Principium) Utilization Management Social Work / MHSA Provider Alignment Medicaid Covered Only

10 Our technology can help prevent serious health problems. Our proprietary software aggregates and integrates health data across every spectrum of the member s healthcare experience, from labs and UM requests to customer experience encounters and nurse and social worker home visits. Our system runs on a feedback loop. It gets smarter over time, so our clinical and experience teams always have the most up-to-date information on our members, allowing them to identify potential issues and intervene if needed. Member Profile Our internal member profile software helps our clinical and experience teams get a complete view of a member s background before Clover Care Visits and when members call in with issues or questions. 9

11 TECH: Our Tech Stack 10

12 TECH: Our Tech Stack 11

13 TECH: What is Decision Science? Actuarial Pricing, Reserving, and Finance Support The Original Data Scientist Business Analytics Executive Insights, Special Tasking, and Finance Support Risk Scores, UM, Stars, Care Management, Member-level Outcomes Machine Learning Automated, granular decisions Product Science Improving operations through data 12

14 John Henrik Rogers, MS, ASA, MAAA John is a Senior Actuary at Clover Health on the Business Analytics team. John works closely with data scientists and engineers to build insights into Clover s results through data readiness and analysis. Recent projects include consolidating and tracking CMS Stars measures using real-time data, analysis of Clover s Complex Care Management program, and analysis of Clover s Utilization Management program. From , John was an actuarial advisor for KPMG London. He was the technical lead to provide actuarial modelling and pro forma financial projections for a major international life insurer expanding into Europe and Southeast Asia. He also evaluated software options including liability modelling software, statistical software, and risk reporting platforms for KPMG s economic capital working group. From , John worked for Milliman. He performed detailed cost analysis to support policy decisions by California Health Benefits Board and carrier implementation of Affordable Care Act (ACA). He was the lead developer for Milliman s MyRxConsultant.com and developed software supporting the Milliman Atlas of Public Employer Health Plans. Prior his actuarial career, John served as the Executive Officer of USS Chinook and Patrol Coastal Crew INDIA. John received an honorable discharge from the United States Navy in 2011 and three Navy Achievement Medals. John is a daily user of SQL and Python. He has also used R, Prophet, SAS, Excel, ASP.NET, Java, C, C++, LISP, graph algorithms, Apache Tomcat, SMS, Django, and networking protocols (BGP, OSPF, RIP). Education: MS, Computer Science, Naval Postgraduate School BS, Mathematics, Massachusetts Institute of Technology 13

15 Thank you 14

16 Appendix 15

17 Affordable PPO plans for easy access to care TECH Data-driven technology that analyzes patient behavior and needs to identify interventions and reduce costs Physician + Patient CARE Care coordination by nurse practitioners, social workers, and our member experience team 16

18 Clover identifies risks early on in order to keep members healthier and prevents future expensive medical and hospital bills. This reduces overall costs a savings passed directly back to members. Forbes Magazine January

19 2013 Clover operates a Medicare Advantage plan for 190 members in Hudson County Clover grows its membership to 6,216, expands to five new counties, forms a clinical operations team and achieves a 3.5 star rating Clover grows its membership to 26,000+, expands to nine counties, reaches #1 market share in Hudson county, and makes plans for a major expansion to 3 new states Vivek and Kris Gale found Clover with the idea of using technology to improve patient outcomes Clover grows its membership to 1,800, opens an office in San Francisco to deepen our tech & data talent Clover grows its membership to 15,904, expands to nine counties. 18

20 VALUE: Our plans make every dollar go further. Benefits for patients The benefits of a PPO with the cost and ease of an HMO No/low copays for innetwork providers Prescription coverage Rich plan benefits Choices in doctors that directly benefit physicians We don t get in between doctors and their patients No/low cost barrier to initiating care No referrals No pre-authorizations for typical, in-office visits Less administrative burden Preventive services Rewards programs for managing wellness 19

21 Clover Health Co-founders Vivek Garipalli is a serial healthcare entrepreneur and turnaround expert focused on innovation to increase quality healthcare access and improving patient outcomes. In 2008, Vivek founded CarePoint Health, a fully integrated healthcare system in New Jersey. Through his role at CarePoint whose mission is to serve uninsured and underinsured patient populations Vivek experienced the misalignment of providers and insurance companies first-hand. Kris Gale is a recognized leader in building and scaling engineering teams and was part of the founding engineering team at Yammer. During his six years there as vice president of engineering, he helped grow Yammer s engineering organization from three people to over 200. Kris also spearheaded the platform s direction and ensured its ability to scale, culminating in its acquisition by Microsoft in

22 Management Team Pritam Baxi, CFO Varsha Rao, COO Wendy Richey, CCO Andrew Toy, CTO Prior to becoming Chief Financial Officer at Clover, Pritam led multiple teams at Sears Holdings, including finance, member experience and operations. Before that, he spent 15 years at Amazon managing the Worldwide Operations Finance function. Varsha joined as Chief Operating Officer from Airbnb where she oversaw operations, customer experience and safety in 15 countries as Head of Global Operations. She is also the co-founder and CEO of cosmetics company eve.com. Wendy is Clover s Chief Compliance Officer and boasts over 35 years of corporate compliance, government programs and operations experience in the healthcare industry. An experienced technology leader, Andrew spent several years at Google where he ran Machine Learning and Analytics for the G- suite team. Before that, he was CEO of Divide, which was acquired by Google in

23 CARE: Case Studies Application for financial assistance One of our social workers helped a member complete his Specified Low Income Medicare Beneficiary application. A social worker in a community center had started the process but the member, who is illiterate, was unable to finish on his own. The member s Social Security check increased by $134.00/month and he received a reimbursement of $ for the months he was eligible for SLMB. Milkshake for cancer patient A member came home from the hospital after cancer surgery. He said he felt nauseous after chemo and just wanted to drink something to settle his stomach. When the visiting nurse suggested he try Ensure, he said it was boring and tasted terrible. So she suggested he put fruit in it strawberries and bananas to make it like a milkshake and she even made one for him. Making sense of medications During a Clover Care Visit, a member admitted that he hadn t taken his medication in over a week and doesn't take it regularly. The visiting nurse spoke to him at length about the importance of being compliant with medication, gave him two pill boxes "day" and "night and called the pharmacy to refill three of his prescriptions. Intervention for alcoholism A member had a long history of readmits for psychiatric hospitalizations due to co-occurring alcohol and mental health issues. The team collaborated in working together with the member to ensure that he is receiving the necessary treatment. We were able to successfully refer the member to ICMS where he receives intensive community case management service. 22

24 L I V E. W O R K. P L A Y. Engagement Platform for Life Insurance Carriers

25 Optimity Helps Insurance Companies attract and retain policyholders with customized & branded mobile apps.

26 New Experience for this New Generation of Policyholders

27 Who we are & Why proactive health?

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29 Zhiren Lou ( ) Late-detection of cancer 6 months of intensive treatment 3 rounds of chemo but the best of reactive health just isn t enough.

30 Team Advisors Experience

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32 DEMENTIA Super Fit Average High Risk Optimity improves the health of the full population

33 Proactive Engagement Selling Engaging

34 Proactive Engagement Today s professionals want Mobile-first: check phones 48X a day Community: based on common interests Value-add: useful tips & insights Self-care: data exchange Gamified: progress & rewarding experiences

35 The Solutions

36 What do they get? A personalized pocket health coach Fun & Holistic Access healthy activities Sync 100+ wearables & health apps

37 Micro-activities Members can do daily activities personalized based on their goals and schedule

38 Easy as Interact daily Engage with useful content and health tips, interact within their affinity community. 1. Join Potential & current customers via your branded lifestyle companion 3. Earn Rewards Accumulate loyalty points for member perks, products & rewards.

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40 Engagement is about value you add to their lives, not how many ads they see.

41 Business Benefits

42 Insurtech Value Chain where Optimity adds value through engagement Marketing, Distribution, Sales Underwriting, Pricing Service & Customer Retention Claims Management LIVE. WORK. PLAY. LIVE. WORK. PLAY. Attract target customer segments Access member benefits & perks Pre-qualify leads for cross-sell and up-sell Support healthy behaviors Engage members in affinity communities Build loyalty and affinity with points and rewards Boost persistency

43 The old marketing and sales playbook is broken, Because the way people buy has changed. 94% skip TV ads 50% (over 200M) are on do-not-call lists 27% direct mail is never opened 63% ignore internet ads

44 Engagement Methodology ATTRACT PRIME DELIGHT REFERRAL CONVERT In-force, Group, Customers Engaged Members Rewarded Members Promoters Repeat Customers Seed with current Value-add healthy Loyalty points & Viral growth with A lifetime of customers experiences member benefits like audience cross-sell / up-sell Establish your unique brand Leverage Optimity content Introduce exclusive products Open community where Engage at the right times to of health and lifestyle libraries to support members and brag-worthy member perks members invite their peers, members developing life-stage, Build contacts Accumulate data to form to create affinity to your brand family and colleagues goals and needs Attract your target customer customer personas, segments Boost your NPS and increase Grow desired leads with Avoid price competition: segments to a community and pre-qualify leads persistency no additional cost or effort Service (instead of sell to) your captive loyal community

45 Personalized Offers We help carriers perform qualification and needs analysis with current in force population to expand the number of products they hold with the carrier. Are you looking to identify potentials needs to offer relevant insurance products at opportune times? Do you want to turn data into meaningful insights about your customers and move closer to personalized offers? Client Example (CA, 3M+ Life & Health Insurance Policyholders) Generate leads to cross-sell and up-sell relevant insurance products Perform needs analysis for current group population to offer additional insurance products (Life, Auto, Home) Create member segments using Health Risk Assessment, Wearable data, social and demographic information Experiment with member segments to personalize support and offers based on persona Support future underwriting with this dynamic data wallet (working with Reinsurers)

46 Play Demo: Admin

47 Health Benefits

48 Traditional Solutions Lack Sustained Usage Web Portals seasonal fad low adoption Fitness Apps Wearables User Engagement no follow-up Classroom Coaching

49 Our Dynamic Solution Delivers Better Engagement Centralized ML-enabled Opportunistic coaching User Engagement Connected apps & device (IoT) Sustainably engaging

50 Physician-driven preventive micro-actions DEMENTIA CANCER COPD DIABETES HEART DISEASE OBESITY DEPRESSION KIDNEY DISEASE Our Medical Advisors Eduardo Franco Professor of Oncology, Epidemiology & Biostatistics McGill University Editor in Chief, Journal of Preventive Medicine Eli Rosenberg Cardiologist St. Paul Hospital MBA, Ivey Mark Stone Primary Physician MBA, Rotman

51 User segmentation: Moving users into a healthier state Healthy & Unwell & Healthy & Building good habits Unwell & Doing nothing Improving engagement with health programs Trying to improve Seeking guidance & support Preventing regression Exhibiting poor habits Motivating habit change Educating on consequences Providing fresh, new challenges Keeping motivated Preventing catastrophe

52 Health state: Improvements Engaged Optimity users rated themselves at the beginning of a 90-day measured program. Data shows that the initial scores are diverse with a large standard deviation, and after 90-days on Optimity the shift in health outcomes is statistically significant. Average score Std. deviation Median: 5 8 Modes: 4 10

53 DEMENTIA Super Fit Average High Risk Optimity improves the health of the full population

54 Dynamic Health Assessments and Risk Scores

55 ROI Reduction in Claims analysis supported by Insurance Research Labs at

56 Referrals Renewals Reduced Risk More Sales Better Retention Higher Profits

57 Live. Work. Play. with Optimity Jane Wang CEO