Milliman Healthcare Services

Transcription

1 Milliman Healthcare Services

2 Milliman Introduction About Milliman Milliman is the leader in providing actuarial consulting services to the health industry. We also develop and maintain sophisticated healthcare tools and products that are industry standards. Known for our technical acuity and comprehensive knowledge of the industries we serve, Milliman offers intelligent, independent analysis to help clients manage their healthcare portfolios costeffectively without compromising quality of care. Our expertise derives from the diverse backgrounds of our consultants, who include actuaries, health economists, clinicians, and information technology specialists. The challenges faced by individual healthcare systems are unique, and yet often have similar characteristics: steeply increasing cost trends, structural inefficiencies, and misaligned incentives for stakeholders. At Milliman, we provide integrated actuarial and clinical input to meet these challenges. We provide practical solutions for our clients based upon the best available global information while responding to the local healthcare delivery environment. MILLIMAN S SERVICES INCLUDE: Actuarial benchmarking and forecasting models Product pricing and development Contract analysis Development and evaluation of medical management programmes Evaluation of hospital/clinic efficiency Return on investment models for disease management and wellness/screening programmes Mergers and acquisitions Outsourcing of medical management and bill audit review

3 Milliman Health Cost Guidelines Milliman Health Cost Guidelines Milliman s Health Cost Guidelines TM (HCGs TM ) provide benchmark utilisation and average costs for a wide range of healthcare services. They can be used in the private and public sector as benchmarks to evaluate past experience, design and price benefits and alternative options for new or existing products, and project future health care costs. Milliman has more than 40 years of experience in developing HCGs and currently has HCGs in the United States, United Kingdom, Hong Kong, Chile, Mexico, South Africa and Brazil. All our HCGs combine data from multiple sources with our unique actuarial insights and are used extensively by Milliman consultants in many types of client projects. The Milliman US HCGs are an industry standard and are licensed by more than 90 health insurers. Included in the HCGs The Milliman HCGs include a set of rating guidelines and models, including suggestions for underwriting adjustments, geographical adjustments, trend factors, benefit limit factors and copay factors. They also incorporate age/sex factors for different categories of medical services and claims probability distributions to help assess the impact of excesses/deductibles. The Benefits Milliman actuaries use the HCGs because: They provide a consistent starting point for pricing a variety of health insurance plan designs with alternative benefit choices Our rating models allow the user to determine utilisation and claims costs using a rigorous methodology that is flexible enough to account for the individual quirks of different benefits plans It is possible to determine under and over-utilisation relative to a peer group market average

4 Milliman Disease Management Programmes Calculating the Return on Investment for Disease Management Programmes Chronic Disease Management (CDM) programmes aim to provide better quality of care to patients with chronic diseases, while reducing the cost of health services by increasing the efficiency and effectiveness of care delivery. How Milliman can Help Many payers invest in CDM programmes because they perceive them to have successful outcomes in other healthcare economies. Milliman can help assess whether a CDM programme is likely to meet your clinical and financial goals in your unique environment. Whether you are thinking of starting a CDM programme or already have one underway, our models can determine how you can get the best outcomes for the money invested in a CDM programme. Measuring the Return on Investment (ROI) from CDM programmes requires a mix of clinical knowledge, actuarial, economics and statistical techniques, and financial acumen. Milliman consultants have considerable experience in designing evaluations and building complex models to estimate ROI for most types of programmes and wellness/screening initiatives. Benefits of ROI Models ROI Models can be used at the planning stage to prioritise investment decisions and choose between different types of programmes, based on projected benefits and costs. The model will assist in creating a programme that maximises return. By developing and using a ROI Model, financial and clinical goals can be set for the programme to be evaluated against, which will ensure continuous improvement of the programme and clear demonstration of outcomes. Post-implementation, a ROI Model can: Help assess the outcomes of a CDM programme Demonstrate financial and clinical benefits and costs over an appropriate time horizon Assist with contract negotiations between external vendors of programmes and payers, including developing outcomes metrics and key performance indicators

5 Milliman Medical Management Controlling Costs with Medical Management The right medical management can help contain increasing healthcare costs and ensure that each patient receives the most appropriate care for his or her circumstances. There are many different ways to design and implement medical management techniques. We can help you identify the programmes that are likely to be the most cost-effective and give the best quality outcomes in your environment. MEDICAL MANAGEMENT PROGRAMMES All patients want reassurance that they are receiving quality care in a timely manner in the best possible environment. Historically, payers have limited their role to paying the bill for treatment, taking little responsibility for the quality of care provided. However, with increasing utilisation of healthcare services and expensive advances in medical technology, payers are starting to look for ways to ensure that patients get appropriate evidence-based best practice care. This is not necessarily always the most expensive care, but the care which that best suits the patient s circumstances. Some medical management techniques are purely focussed on quality, while others are solely aimed at cost reduction. Some of the common techniques include utilisation or demand-management programmes, contracting and network management, and benefit design changes. Yet, many of these initiatives are unsophisticated and give poor value for money. The most effective programmes are part of a co-ordinated and comprehensive medical management strategy that strives primarily to improve quality, with reduced costs emerging as a natural benefit. HOW MILLIMAN CAN HELP Milliman ensures that you get the most out of your medical management activity by reviewing your current medical management programmes and benchmarking these against best practice globally. We provide strategic advice that balances the interests of all stakeholders and allows you to focus efforts on areas with the best outcomes. We have intimate knowledge of the critical success factors that can transform your medical management into a world-class programme. Milliman Screening Services gives you access to low-cost offshore clinical expertise to perform the administrative tasks that support case management and bill audit processes.

6 Milliman Healthcare Provision Increasing the Efficiency of Healthcare Provision How can you tell whether you are providing healthcare for your constituents or employees in the most efficient and cost-effective way? How can you maximise the quality that your patients receive while minimising the cost? Many hospitals and clinics believe there is an evitable trade-off between quality and cost. Milliman believes it is possible to achieve cost reductions by focussing on quality of care. Successful Healthcare Providers To be financially successful, while achieving high quality outcomes, healthcare providers must balance the needs of patients and payers. Most payers are encouraging customers to use increasingly restrictive networks and for hospitals to be successful they must be able to compete on both quality and price. To reduce costs while maintaining quality is challenging, and healthcare providers will need to: Reduce variations in practice patterns between hospitals and doctors and understand the process bottlenecks that contribute to inefficiencies and costs. By adhering to evidencebased best practice protocols, hospitals can work with their medical staff to implement patterns of delivery that ensure better clinical outcomes while reducing costs Encourage doctors to take more financial responsibility by aligning their incentives more closely with other stakeholders Understand the financial implications of contracts to make sure the risks and rewards have the correct balance for the organisation and are appropriately designed Model the demand for health services to make sure the right services are performed with the right staff at the right time How Milliman can Help Milliman has worked with healthcare providers all over the world to benchmark their performance, help them understand their financial risks, and implement programmes for change. We can provide and implement best practice protocols to increase the quality and efficiency or your clinical care. We create financial models to assist in planning, negotiating with payers and investment decisions. Milliman can help you achieve financial success alongside high quality care.

7 Milliman Evidence-Based Medicine Quantifying the Impact of Evidence-Based Medicine Milliman s actuarial benchmarks have helped healthcare systems understand the gap between current experience and what is possible for more than 50 years. By using benchmarks from health economies that deliver best practice care with optimal infrastructure, we can show you where to invest in improving the delivery of care to your population by allowing you to understand your strengths and weaknesses. Whether you are a healthcare insurer, payer or hospital, you can use actuarial benchmarking as part of a process to prioritise initiatives to increase quality and efficiency. The actuarial benchmarks developed by Milliman provide an absolute standard of what is possible in terms of goal hospital admission rates and lengths of stay for a specific population at a specific period in time, rather than a comparison against other healthcare economies with different demographics and sub-optimal efficiency. How Milliman Develops Actuarial Benchmarks We use data from the most efficient healthcare systems throughout the United States to develop rates of hospital admissions, bed-days and average lengths of stay for a standard population based on the evidence of how optimal care can be delivered. We adjust these rates using our proprietary actuarial demographic factors and calculate expected numbers of admissions and beddays for your specific population. For some health systems, it may also be necessary to adjust the data for different benefit limitations. Finally, we apply trends to our benchmarks to ensure that they are a true comparison to your most recent data. By comparing your data to the actuarial benchmarks, we can determine: Clinical specialties associated with the highest potentially avoidable admissions Age groups that have the highest excess lengths of stay Clinical specialties with the greatest opportunities for efficiency savings Benefits of Benchmarking your Experience Benefits include: Quantifying the financial impact of adhering to evidencebased guidelines Understanding and prioritising the needs of different sub-populations to reduce inequalities in clinical outcomes Estimating the cost-benefit of better delivery infrastructure Helping create a business case for investment in medical and disease management programmes

8 Milliman Medical Management Support Milliman Case and Medical Management Support Milliman s expertise and technical know-how can provide the solutions you need to increase efficiencies and deliver cost savings from Medical Management functions. Milliman Screening Services (MSS) gives health insurers and payers access to low-cost offshore clinical expertise to perform the administrative tasks that support case management and bill audit processes. The evaluation and analysis of clinical information is timeconsuming and costly. Approximately 70% to 90% of case management activities and workload consist of administrative functions that can be performed in an offshore environment. Health insurers can realise administrative cost savings of 40% to 50% by outsourcing tasks currently carried out by on-site clinical staff, such as data entry, screening and documentation of medical necessity for review. The MSS outsourcing system allows health insurers to improve turnaround time, gain efficiency and reduce administrative costs while still staying in direct contact with care providers and maintaining control over final care determinations. Leveraging well-qualified and knowledgeable physicians, nurses, occupational therapists and information technology specialists, the MSS system combines focused care management innovation and delivery experience with global operational capabilities. Account management and customer service is provided through your local Milliman office. The result is a solution that makes case and medical management costeffective and efficient.

9 Milliman Healthcare Services