Bending The Healthcare Trend

Transcription

1 Bending The Healthcare Trend Mark Rosenberg & Greg Alonzo May 2018 High Performance Employer Summit

2 Today s Discussion More than just cost-shifting What we are seeing Keys to successful cost containment Data (and analytics) drives decisions Bend The Trend 2

3 Destination Employer Critical Illness Medical Dental COBRA FSA, HSA & HRA Absence Management PBM Health Management Programs Wellness Programs 3

4 What We Are Seeing Health benefit costs continue to rise 10% Annual Increase In Medical Costs vs CPI 9.0% 9.0% 8.5% 8% 7.5% 6.5% 6.8% 6.2% 6.0% Trend is improving, but still significantly above general inflation 6% Wide variation in organizations actual experience 4% 3.2% 2% 1.6% 2.1% 1.5% 1.6% 1.3% 2.0% 0% 0.1% Medical Trend CPI Inflation 4

5 What We Are Doing Managing rising health benefit cost Historically Cost shifting to members using: Plan design changes Admin fee negotiations Increased cost sharing with employees Vendor changes may get some savings through better discounts Today Data Analytics to actually reduce cost: Identify true cost drivers Actually reduce (not shift) overall cost Identify actionable cost savings opportunities Implement near-term tactics and longerterm strategies Monitor and adjust 5

6 Understanding Cost Drivers Wide variation in the unit cost of treatment Knee Surgery (Chondrosplaty) (CPT 29881: Arthroscopy, knee, surgical; debridement/shaving of articular cartilage) $428 $1, x Endoscopy (CPT 43239: Esophagogastroduodenoscopy, flexible, transoral; biopsy, single or multiple) $213 $ x Lumbar Epidural (CPT 62311: Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast ) $134 $ x 6

7 Understanding Cost Drivers Chronic conditions are a key driver of cost Large Claims (Claims > $25,000) Chronic (Claims < $25,000) Over half the people with large claims have chronic conditions Healthy / Minor Acute 7

8 Keys To Successful Cost Containment Each company and benefit plan is unique Be proactive Understand your health benefit plan performance, and the underlying drivers of that performance Move to a plan design platform that will enable a range of cost-containment strategies and tactics Consumerism Shared decision-making Case- and condition- management Network and place-of-service management Take a total quality/continuous improvement approach to managing this process 8

9 Data (and analytics) drive decisions Data Integration Data Enhancement Analytics Reporting & Access Medical, Pharmacy, Eligibility and Wellness data Over 60 established carrier/tpa feeds Other specialized data Fully customizable Clean, standardize and normalize Incurred data completion Custom Benchmarks Clinical Risk Groups (CRG) Health Risk Index (HRI) Care Gap Index (CGI) Actuary-driven analytics subject-matter experts Deep analytics that identify true underlying drivers of cost and utilization Extensive analytic toolset developed over decades Predictive models embedded throughout Over 85 standard GBSInsider reports Standard and custom dashboards Standard and custom Excel analysis workbooks Consultant and client access 9

10 Understanding Cost Drivers Impact of having the right benchmark Cost PMPM 40 Custom Benchmarks Demographics (age, sex) AND Regional AND Plan design AND Industry Cost PMPM Actual National Actual Gallagher National 10 0 Medical 0 Surgical Maternity Medical Surgical Maternity Variance to: National Benchmark +39% +77% +22% Custom Benchmark 0% +27% -12% 10

11 Client Example HRI + Custom Benchmarks = Insight Should client continue to spend $80K/yr on wellness? Y1-12% $3M saved Y4-25% HRI for the group had gone from 12% below benchmark to 25% below benchmark after 4 years. The financial benefit of this health improvement was over $3 million per year. The so what : - Re-committed to wellness plan - New areas of wellness focus - Utilized the data in union negotiations 11

12 Long Term Short Term Savings Tactics Bend The Trend: Proven Cost Containment Administrative Errors (Medical) Administrative Errors (Pharmacy) Provider Misuse & Abuse Patient Misuse & Abuse Sub-Optimal Pricing Pharmacy Optimization Phantom Employees Ineligible Claims Duplicate Claims Plan Design Adherence Phantom Employees Ineligible Claims Day Supply Checks Plan Design Adherence NCCI Edits Generic Substitution Rates Visits per Patient Labs Ordered per Patient Opioid Scripts by Provider Dependent Eligibility Opioid Usage by Member High Utilizers of PCP & SCP High Utilizers of ER Network Utilization Out Of Net. Claims Large Claims Advanced Imaging Physical Therapy Specialty Drugs Generic Fill Rates Specialty Drugs Therapeutic Interchange Medication Therapy Management Tactics to Bend the Trend - Member Engagement and Consumerism - Value-Based Plan Design - Concierge Solutions - Second Opinion & Shared Decision-making - Continuous Pharmacy Management - Hospital Readmits - Unbundled Health Plans - Narrow Networks - Reference-Based Reimbursement - Population Health Management - Telehealth - Disease Management 12

13 Bend The Trend Client Example What a deep dive looks like Physical Therapy: Place of Service Potential Savings for Migration to Office/Free Physical Therapy - 1/1/ /31/2017 Standing Encounter Allowed Cost Per 100% Migration 80% Migration to 60% Migration to 40% Migration to 20% Migration to Place of Encounter Count Amount Encounter to Free Standing Free Standing Free Standing Free Standing Free Standing Hospital Outpatient 2,050 $521,437 $254 Office/Free Standing 220 $18,075 $82 Total 2,270 $539,512 $238 Additional Cost for Hospital OP Setting $172 $353,011 $282,409 $211,807 $141,204 $70,602 Chronic Conditions: Identifying Candidates For Disease Management Actual % of Non-Healthy Claimants Benchmark % of Non- Healthy Claimants Number of Cost per Ratio Actual Clinical Category Claimants Actual Claims Claimant to Benchmark TPN or Respirator Dependence 1 $124,718 $124, % 0.0% 3.05 Diabetes - Dominant or Moderate 307 $1,315,906 $4, % 2.5% 1.60 HIV 35 $963,771 $27, % 0.3% 1.43 Mental Illness or Substance Abuse - Dominant or Moderate 208 $1,717,123 $8, % 1.9% 1.43 Mental Illness or Substance Abuse - Minor 509 $872,371 $1, % 4.9% 1.35 Circulatory Disease - Dominant or Moderate 1654 $6,519,717 $3, % 16.3% 1.30 Diabetes with HTN or Other Chronic Disease 435 $2,718,343 $6, % 4.4% 1.26 Malignancies - Non-Metastatic 75 $1,025,511 $13, % 0.8% 1.14 History of Organ Transplant 4 $72,393 $18, % 0.0% 1.13 Two Other Chronic Diseases - Both Dominant 158 $7,676,861 $48, % 2.0% 1.02 Dialysis 7 $1,575,910 $225, % 0.1% 1.01 Musculoskeletal Disease - Minor 304 $1,436,482 $4, % 3.9% 1.00 Competing Other Single as Chronic a Destination Diseases Employer - Minor 1027 $2,983,142 $2, % 13.2%

14 Bend The Trend Client Example Potential Opportunity Summary Administrative Errors - Medical Administrative Errors - Pharmacy Patient Misuse and Abuse Site of Care Optimization Pharmacy Management Disease Monitoring Gross Annual Savings Estimate* Percent of Total Claims Comments Duplicate Claims $222, % 50% recovery estimate Ineligible Claimants $44, % Members with claims outside of membership eligibility Phantom Claims $207, % Claims for members not on the enrollment tables Potential savings assuming members are Medicare ESRD $767, % primary with 50% of their claims covered by Medicare Duplicate Claims $17, % Recovery estimate Ineligible Claimants $29, % Members with claims outside of membership eligibility Phantom Claims $0 0.00% Claims for members not on the enrollment tables Days Supply Greater than Design $35, % Potential deviation from plan design Dependent Eligibility $1,019, % Assumes 3% ineligible dependents Opiod Use $59, % Assumes savings of 50% of total medical related cost Advanced Imaging $1,015, % Estimated savings from 100% utilization of freestanding facilities Physical/Speech/Occupational Estimated savings from 100% utilization of freestanding facilities $432, % Therapy Increased Network Utilization $0 0.00% Savings from shift of Out of Network utilization 1% Increase in Generic Substitution $474, % Savings based on 2017 cost and utilization Medication Therapy Management $357, % Estimated savings based on Drug Treatement Problems (DTP) Asthma $218, % COPD $481, % Estimated savings from 50% of members shifting Diabetes $1,703, % one level in disease severity Heart Disease $818, % Hypertension $2,084, % *Savings cannot be added because of some double counting within categories. Savings are estimates only and are not guaranteed. Total Paid Claims: $83,932,205 14

15 Changing Health Benefit Platforms Traditional approaches are being challenged 15

16 Mark Rosenberg Area President, Healthcare Analytics Benefits & HR Consulting Greg Alonzo Area Chief Operating Officer, Healthcare Analytics Benefits & HR Consulting High Performance Employer Summit