Projection for Oops! 5/28/2013. Facts and Figures Aon 2012 Survey CHALLENGES AND OPPORTUNITIES TRENDS IN THE HEALTH BENEFIT PAYER MARKETPLACE

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1 Facts and Figures Aon 2012 Survey CHALLENGES AND OPPORTUNITIES TRENDS IN THE HEALTH BENEFIT PAYER MARKETPLACE The average health care cost per employee was $10,522, up from $10,034 in 2011 The employees' portion of the total health care premium was $2,204, up from $2,090 in 2011 Average employee out of pocket costs, such as co payments, co insurance and deductibles, were $2,200, up from $2,072 in 2011 Projection for 2013 For 2013, average health plan premium costs per employee are projected to jump to $11,188, of which average employee contributions to the health plan premium would be $2,385. In addition, average employee out of pocket costs (co pays, coinsurance and deductibles) would be $2,429. Oops! These folks will be moving into a really fully insured product for the first time, and so there may be a higher cost associated with getting into that market 1

2 Additional Cost Added Lack of Pre existing condition controls Enhanced benefit design Healthcare informatics cost until it is operational and culture changes Reform fees Limits on premium differentiation Health insurance will become relatively less expensive for people with chronic conditions and relatively more expensive for healthier people, Robert G. Cosway, Actuary at Milliman The Government s Bet Competition in Exchanges will lead to cost reduction Changes underway in Healthcare informatics and Medicare contracting will reduce the inefficiency in healthcare delivery Never Before Level of Focus Healthcare Reform never really addressed cost and may have exacerbated it 36 pages Steven Brill Increased the focus on billed cost Hall of Shame Mark ups Stents Billed at Over $20,000/Each Acquisition Cost is $3,000/Each 2

3 Hall of Shame Mark ups Hall of Shame Necessity Implant Billed Invoiced Infuse Bone Graft $44,880 $5,100 Nuvasive Cages $54,416.27/Each $5,625/Each Large 15CC $11,968 $1,360 DBX Mix 10CC $12,311 $1,399 Full term infant; Born with Severe Respiratory Distress; Diagnosed with congenital diaphragmatic hernia 91 Day Stay; $330,000 in Nitric Oxide Charges No Clinical Support of N.O. for this situation Hall of Shame Billing Error Financial Comparison Large Metro Area Charges & Costs for All DRGs $90,000 $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 Hospital Billed $4,035/Each for a customized IV mix; $205,785 Total When questioned admitted error; Should have been $135/Each or $6,885 $0 Charge Medicare Reimbursement Cost 3

4 Outpatient Facility Comparison Metro Area OP Charge & Cost for Colonoscopy Concerns with MD Billing $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 A balanced and well designed fee schedule, along with proper procedure mix, treatment protocols, and coding are thecornerstones of a successful andprofitable practice. Unfortunately, most doctors lose TENS OF THOUSANDS OF DOLLARS annually by not implementing and maintaining upto date fees, clinical procedure protocols, and using the latest insurance code set. Marketing Brochure for Physican Revenue Maximization Company Charge Cost Clinical Editing Impact is Enormous 245,000 Claims; $34.5 Million Paid Basic Code Bundling Already Applied Significant Issues Identified Via Retrospective Surveillance/Pre Payment 8,165 Questionable Claims (3.3%) $1,316,000 in Potential Savings (3.8%) Type of Issue # of Claims $ of Savings Inappropriate Use of Assistant Surgeon 6 $1,118 Excessive IP MD Visits Per Day 324 $23,414 Excessive MD Office Visits Per Day 1,243 $119,866 Repeat Procedures within 3 Days 12 $3,986 Mutually Exclusive Procedures 9 $2,763 Unbundled Pre op/post op Care 610 $72,794 NCCI Mutually Exclusive 189 $21,290 Not Typically Covered Services 12 $8,567 Disallowed Multiple Procedures 32 $26,412 Upcoding to New Patient Code 315 $37,526 Comparison of Tech/Prof vs. Max Allowable 123 $23,412 Missed Multiple Procedure Reductions 1,012 $149,891 Missed Bilateral Reductions 21 $8,342 Missed Assistant Surgeon Reductions 123 $62,312 Unbundled Separate Procedures 1,320 $345,321 Inappropriate Obstetrical Add ons 23 $2,147 Chemistry Lab Unbundled 413 $1,856 NCCI Composite Component 921 $194,138 Typically Experimental 54 $9,312 Potential Cosmetic 470 $65,872 Upcoded IP MD Visits 12 $7,312 Questionable Medical Protocol 921 $128,372 Total 8,165 $1,316,023 4

5 What Does Data Suggest? Charges are grossly inflated Confirms suspicion that discounted FFS is weakest contracting method Confirms that % savings are very misleading Medicare is too close to costs to be considered reasonable reimbursement What is a fair mark up on costs? Most facilities will make money at % of Medicare reimbursement PPOs are a Box of Contracts Recruit Credential Negotiate Contract Increasing Concern About PPOs Contract Value is Slipping Increases in Fee Schedules Introduction of Outlier Agreements Poor Focus on Ancillary Services (Rx and Implants) Lack of UCR Definition for Billing Little Control of MD on Referral Patterns Lack of Contracting of REAP Providers Increasing Provider Turnover Limited Quality Analysis So where is healthcare reform and continued rising cost of healthcare leading Plan Sponsors? 5

6 Defined Contribution Model Defined Contribution Model Cost Healthcare Reform Confusion/Risk Alternative Network Model Limited Network Model Cost certainty; Total compensation transparency; Uniformity of benefits in multi state environments; COBRA costs; Looming excise tax on high cost coverage (the so called Cadillac tax ) under PPACA Potential for reduced administrative costs; and Higher employee satisfaction. Private Health Exchange Not to be confused in any way with State and Federal Government Exchanges Run by private companies or not for profit entities Range ofbenefit plan offerings Employee cost sharing differences Network differences Wellness/prevention requirements Back to the Future Limited Networks Promoted in Healthcare Reform via Accountable Care Concept Vertical integration of responsibility within medical community Cost Quality Satisfaction 6

7 Why will ACOs Succeed Where Gatekeeper HMOs Failed? Recognition that healthcare is vertical vs. horizontal It is far more important to share information as the patient requires additional resources than to control access Huge momentum for Healthcare IT Promotion of Implementation of EMRs and Patient Health Records Connectivity efforts are massive Maturation of HIPAA Privacy has improved ability to share information Significantly enhanced patient self management tools Better agreement on practice standards/guidelines/ areas of quality improvement focus Increased Transparency Alternative Network Arrangements Shift away from calculating an allowable amount based on billed charges to one based on an accepted benchmark Reference Based Pricing 30 50% Cost Savings Develop Consumerism Balance Billing Access Issues Evolving to this Model Plan Document must be very clear with respect to reasonableness as the basis for provider charges In Network Networkallowable applied to OON Consider well contracted carve out provider networks Use reasonable standards in establishing the benchmark for paying providers Must supply patient advocacy The Paradigm is Shifting in Payer World Currently it is all about the transaction Claims, calls, authorizations, checks, etc. The new model is all about the patient Collectionofwide range ofdata Collection of wide range of data Identification of risk/gaps Tracking participation in programs Providing effective communication Facilitating self management/accountability Wringing PAC out of the system 7

8 Example of Patient Dashboard JAMA Study on Price Transparency Phone survey of two hospitals in each state including any in U.S. News Top Hospital Report Asked for price of hip replacement for 62 yo woman Results were not unexpected: Only 45% of the Top Hospitals could identify a cost; Cost ranged from $12,500 to $105,000 Only 10% of the remaining hospitals could identify a cost; Cost ranged from $11,100 to $112, Study by Thompson Reuters True Price Transparency Assume price and quality information was available for Top 300 surgical procedures $38 Billion in savings for employer sponsored plans Walmart has negotiated surgical Centers of Excellence networks Cleveland Clinic, Scott White, Geisinger 8

9 Transparency is Getting There State efforts: Maryland, Minnesota, New Hampshire, South Dakota, New Jersey Improving private efforts: Leapfrog Castlight Healthcare Blue Book ChangeHealthcare NewChocieHealth Still heavily influenced by Medicare data collection Q QUESTIONS?? Glenn S. McLellan, President McLellan Consulting Services Marysville, Ohio (860)