Premium Rate Components Incurred Claims for Rating Period Trend / Health Care Inflation Reinsurance (Unexpected / Catastrophic Claims) Reserves –IBNR –Pending / Unpaid Claims
Premium Rate Components Capitation – Fixed flat amount paid to physicians in exchange for specific services / Typical of HMO Plans Credibility Factor – Percentage load applied for groups under 1,000 members Demographic Factor – Percentage adjustment for group specific demographics
Premium Rate Components Premium Tax – 2% state tax applicable to fully insured plans Administrative Costs –Claims Administration –Customer Service –Marketing Materials / EOCs, etc –Utilization Review / Case Management –Vendor Profit –Broker Commission
Premium Components Trend Credibility Factor Reinsurance Capitation Reserves Demographic Factor Administrative Costs Premium Tax Incurred Claims Premium Components you can and cannot control for future cost impact…..
Major Conditions - Historical Overview Diabetes Asthma CAD Depression
Percent of Members Compared to Percent of Cost by Condition Members Compared to Costs 21% of SMC Kaiser members have at least 1 chronic condition. This represents 54% of the total San Mateo County Kaiser cost.
Care for Diabetes Checklist Support and co-manage high risk diabetes patients with care/case managers. Assure patients with diabetes have their cholesterol monitored because they are at risk for heart disease. Assure patients receive regular eye exams to delay or prevent loss of vision. Provide opportunities for plan participants to learn about diabetes in health education classes Assure patients are taught self-management skills to care for the condition.
Care for Depression Checklist Consider providing a program through a diagnosis either by their primary care physician or behavioral health specialist. Because primary care physicians are often the first point of contact and in a position to spot symptoms, consider developing several tools, such as pocket reference guides and clinician education programs, to assist in diagnosis. Track medication use to ensure that patients are maintaining treatment plans. Work with network clinicians to provide training in rapid cycle change methodology to support providers in testing innovative ways of caring for patients with depression as a co-morbidity Provide publications to help patients understand depression and its treatment options.
Cardiovascular Disease Checklist Assure patients enter a care program based on their use of certain medications or clinic or hospital visits for heart disease? Assure patients are on medications for lowering cholesterol and reducing heart rate and blood pressure. Provide lifestyle coaching about exercise, weight control, and smoking cessation.
Asthma Checklist Assure patients enter a care program based on an office, ER, or hospital visit, which results in an asthma diagnosis or their use of asthma-specific medications. Minimize patients relying on rescue medications. Provide self-management plans to teach patients to control their asthma, enabling them to be more productive and have a better quality of life. Modify lifestyle to obtain weight loss for moderately obese members and smoking cessation.
Disease Management – Conclusion Identify early at-risk patient through network provider tools. Streamline electronic sharing of best practices among network provider physicians nationwide. Provide culturally appropriate materials in multiple languages make services accessible to diverse populations. The approach to treating patients with multiple chronic conditions should be built into the integrated care. Increased work productivity leads to better health outcomes, leading to fewer sick days and greater productivity. Working together in a collaborative effort is the best way to leverage the provider(s), employees, retirees, and employer resources to improve the health of employees / retirees.
In Closing………. Claims can be reduced by: Disease Management for Chronic Conditions Early Identification of At-Risk Members Value Based Plan Designs Focus on Prevention Member Education/Member Awareness Lifestyle Modification Support More Efficient use of Services Improved Member Health Long term savings can best be achieved through a reduction in claims.