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What’s Now and What’s Next hfma 05.15.14. Trends in the Industry Narrow Networks Are All the Rage Health System Strategies How to Successfully Deploy.

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Presentation on theme: "What’s Now and What’s Next hfma 05.15.14. Trends in the Industry Narrow Networks Are All the Rage Health System Strategies How to Successfully Deploy."— Presentation transcript:

1 What’s Now and What’s Next hfma

2 Trends in the Industry Narrow Networks Are All the Rage Health System Strategies How to Successfully Deploy the Right Strategy Here’s What We’re Going to Cover Today

3 Payors have been shedding risk for a decade, shifting their books of business from 70-80% fully insured to 70-80% self-insured, putting all the risk on the employer (to pay for care) and on the hospital (to collect larger and larger financial responsibility from patients). They capitalized on the “consumer-directed health care” trend and dramatically increased the financial risk carried by their members. Risk What Are Health Plans Doing? Utilization IP, physician visits, and Rx usage are all down. Elective surgeries are way down. ER visits are up. Premiums Premium increases continue to outpace medical inflation (and have for more than 20 straight years). Profit is the single most profitable period in the history of the managed care industry. Stock prices have surged, and now the ACA is requiring millions of new customers to purchase their products. Networks Narrow and getting narrower by the day.

4 What’s Happening Across the Nation? Exchanges Exchanges are open for business. Network participation is a major strategic issue for providers. Consumer marketing and brand strategies are suddenly critical. The world is suddenly upside down on a number of fronts. ? WALL STREET JOURNAL Young Avoid New Health Plans Early Buyers of Coverage Are Older Than Expected, Raising Expense Concerns In Kentucky, nearly 40% of 4,631 enrollees in private health plans are over age 55, while 24%, including children, fall under age 34. A much higher portion of young people signed up for Medicaid plans. WellPoint Inc., the largest insurer offering plans in Connecticut, said most of its enrollees in that state were between 55 and 64 in a recent call with investors. The insurer said it predicted an initial wave of enrollees might be older, but that it would increase efforts to woo younger members.

5 1. Payors becoming providers - limited but important 2. Payors demanding cuts - how do you tackle new problems with fewer resources? 3. Health systems launching their own health plans 4. Taking risk 5. Direct contracting with employers 6. Narrow networks 7. Pushback on physician rates, non-hospital sites, implants and stop loss 8. Major league payor/provider conflict Trends in the Industry

6 Insurers across the nation are watching Highmark, which became the first — and so far only — insurer to take a major step into the hospital business when it purchased seven medical centers this year. “Every insurer and Blue Cross plan in the country is taking a close look” at what's happening in Pittsburgh, said Ted Schwab, partner at the health and life sciences practice of Oliver Wyman, a New York-based management consulting firm. “If this one is successful, you're going to see activity at an unprecedented level,” he said. Hospitals and health insurers are increasingly jittery about maintaining revenue and profit as customers and the government demand that the health care system rein in costs and improve quality. Insurers across the nation are watching Highmark, which became the first — and so far only — insurer to take a major step into the hospital business when it purchased seven medical centers this year. “Every insurer and Blue Cross plan in the country is taking a close look” at what's happening in Pittsburgh, said Ted Schwab, partner at the health and life sciences practice of Oliver Wyman, a New York-based management consulting firm. “If this one is successful, you're going to see activity at an unprecedented level,” he said. Hospitals and health insurers are increasingly jittery about maintaining revenue and profit as customers and the government demand that the health care system rein in costs and improve quality. 1. Payors Becoming Providers

7 Highmark and West Allegheny Health System (WPAHS) Aims to offset UPMC’s alleged dominance in Pittsburgh market; announced during public and hostile negotiations with UPMC. Highmark assumes the mantle of hero – supposedly ensuring competition in the market by saving WPAHS and maintaining choice (other than UPMC). Deal would put Highmark back in the driver’s seat, playing a larger role in care delivery and quality. WPAHS later said deal was off the table, but Highmark blocked them from pursuing other buyers, while pressuring the system to declare bankruptcy. Settled with bondholders for $.85 on the dollar. Other Highmark initiatives: - In January, announced plans to build 10 ASCs in western Pennsylvania. - Acquiring Jefferson Regional Medical Center and Saint Vincent Health System. - Creating regional physicians network, recruiting 200+ physicians in past year; largest acquisition was Premier Medical Associates, Pennsylvania’s largest independent physician practice. 1. Payors Becoming Providers

8 Macro Payor Trends: Vertical Integration October 2012 AIS Report on BCBS Plans N.C Blues Plan Invests in Urgent Care to Cut ER Costs “...the catalyst for the deal with FastMed came following a review of data regarding ER visits by members...Non-emergency ER visits represent about 14% of all ER claims paid by the insurer, and a 5% shift away from ER use to urgent care clinics could reduce medical spending by $8 million annually. November 20, 2012 Pittsburgh BusinessTimes Highmark-WPAHS talks get underway “The acquisition must be approved by the state Insurance Department, which would also open the doors to an additional $200 million infusion for WPAHS from Highmark. Highmark has already committed $200 million to WPAHS as part of its effort to create a $1 billion medical network to compete with the University of Pittsburgh Medical Center.” January 17, 2013January 17, 2013 CNBC New Cigna Medical Group Health Center Opens “The treatment center is designed to provide cutting-edge health care to Cigna customers through easy access to primary care physicians...” June 09, 2011June 09, 2011 Los Angeles Times WellPoint to buy CareMore Health Group for about $800 million “The deal is part of an effort by WellPoint to boost its presence in the senior care market. CareMore, based in Cerritos, has 26 clinics in California, Nevada and Arizona that specialize in caring for people on Medicare.” July 2011 Managed Care Magazine Humana Steps Back To Seize the Future “When Humana recently purchased Concentra, a company that, among other things, operates 300 stand-alone clinics, the plan entered familiar terrain. Before becoming primarily a health insurance company in 1993, Humana was the nation’s largest for-profit hospital company.” September 1, 2011 WALL STREET JOURNAL UnitedHealth Buys California Group of 2,300 Doctors “UnitedHealth Group Inc. will acquire the operations of a major southern California physician group, in the latest example of how lines are blurring between insurance companies and health-care providers..” 1. Payors Becoming Providers

9 2. Payors Demanding Cuts - Demands for rate cuts increasingly common from Blues and United - Price leaders in each market particularly at risk - Lower volumes, government cuts create huge price pressures - Population health, wellness strategies require resources for investment - not starvation diet

10 New provider-owned health plans. “Hospitals from Colorado to Virginia are exploring similar strategies spurred by rising costs and incentives in the health reform law. An estimated 20 percent of networks market an insurance product, including MedStar Health, serving the Washington-Baltimore region with Georgetown University Hospital and eight other facilities. Another 20 percent are exploring doing so, according to a survey of 100 hospital leaders conducted last year by the Advisory Board. Driving the change is the transition from FFS payment schemes, which pay for each doctor’s visit, appendectomy or CT scan separately, to one that pays providers a lump sum per person per year. This will shift more of the financial risk of medical care from insurers to providers. Once hospital systems are paid this way, “they’re sort of halfway toward being an insurance company,” said Chas Rhoads, chief research officer for the Advisory Board. “The more hospitals take on risk and manage the care, the more they look like insurance companies. And ultimately you have to ask: why do we even need an insurance company sitting between a health system and an employer?” 3. Health Systems Launching Their Own Plans

11 New provider-owned health plans. 3. Health Systems Launching Their Own Plans

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13 13 Forming or joining payors’ narrow networks was the most common strategy currently in place. Population health strategies for employers and other groups were said to be in preparation or in place by over half of respondents. Q: Different strategies that many health systems have begun to implement are listed below. Please indicate the stage, if any, that appropriately describes where your hospital/health system stands in implementing the following strategies or programs. Health System Strategies by Stage in Hospital or Health System Implementation Strategy N/A: Do not have in place and no plans to in future STAGE 1: Talking about it, but not doing anything yet STAGE 2: Planning and preparing to implement STAGE 3: Currently have in the works Don't know/ Unsure Total Participating in a capitation or other global risk program/initiative 27%25%13%29%7%100% Population health for employers and other groups 12%24%25%31%8%100% Starting your own health plan or joining an existing provider-owned health plan 38%20%7%26%8%100% Forming or joining one or more payors' narrow networks 17% 13%47%5%100% 3. Health Systems Launching Their Own Plans

14 Risk Now, the payors are finishing their “hat trick” of shedding risk in their new contract approaches. - All the latest trends in payor/provider contracting point to providers taking on more risk for the care they provide. - Providers are facing lower payments for fee-for-service care, quality-based payments that may be complex or even impossible to manage or measure. - We face tiering and restricted networks that will drive up deductible and co-payment collection problems even more. The contracts for participation in Exchange networks are likely to shift even more risk onto providers. 4. Taking Risk

15 Trust toward Payors (Behavioral Reliability) This organization makes every effort to honor its commitments 15 The average of all payor scores is 56.9 (on a 100-point scale). Cigna and Blue Cross / Blue Shield performed best with scores of 66.4 and 65.9 respectively. United Healthcare performed worst with a score nearly 14 points (24%) below the average. Q. For each health plan below, indicate your level of agreement with this statement: This organization makes every effort to honor its commitments. *Trust Index Score values are calculated on a scale from 0 for "Strongly disagree" to 100 for "Strongly agree" wherein "Neither" is valued at 50 and "Don't know" responses are excluded from the analysis.

16 Trust toward Payors (Honesty) This organization is accurate and honest in representing itself and its intentions 16 The average of all payor scores is Cigna and Blue Cross / Blue Shield performed best with scores of 65.9 and 62 respectively. United Healthcare performed worst with a score 13 points (23%) below the average. Q. For each health plan below, indicate your level of agreement with this statement: This organization is accurate and honest in representing itself and its intentions. *Trust Index Score values are calculated on a scale from 0 for "Strongly disagree" to 100 for "Strongly agree" wherein "Neither" is valued at 50 and "Don't know" responses are excluded from the analysis.

17 Trust toward Payors (Fairness) This organization balances its interests with ours and doesn't routinely take advantage of us. 17 The average of all payor scores is 47; all scores were lower in this measure, suggesting a disconnect between the interests of payors and providers. Cigna and Coventry performed best with scores of 57 and 52.6 respectively. United Healthcare again performed worst with a score nearly 11 points (23%) below the average. Q. For each health plan below, indicate your level of agreement with this statement: This organization balances its interests with ours and doesn't routinely take advantage of us. *Trust Index Score values are calculated on a scale from 0 for "Strongly disagree" to 100 for "Strongly agree" wherein "Neither" is valued at 50 and "Don't know" responses are excluded from the analysis.

18 Trust toward Payors Combined Trust Measures 18 The average of all combined payor scores is Cigna, Blue Cross / Blue Shield, Coventry and Aetna were all above average. WellPoint / Anthem, Humana, BlueCard, and United Healthcare were all below average. † Composite Trust Index Score values are calculated as an equally-weighted mean of all three individual Trust measures.

19 Consumer Trust toward Payors Combined Trust Measures 19 66% of respondents believed Blue Cross / Blue Shield to be the health plan most trusted by consumers; only 6% believed the plan to be the least trusted. 47% believed United Healthcare to be the health plan least trusted by consumers; only 6% believed the plan to be most trusted. Q. Thinking about the consumers and patients you serve, who do you think they regard as the MOST trustworthy health plan? Q. Thinking about the consumers and patients you serve, who do you think they regard as the LEAST trustworthy health plan?

20 Please indicate what stage (if any) your hospital/health system is at in terms of implementing the following strategies/programs Don’t know Stage 3: Currently have in the works Stage 2: Planning and preparing to implement Stage 1: Talking about it, but not doing anything yet Do not have in place and no plans to in future 5. Direct Contracting

21 6. Narrow Networks Networks Narrow and getting narrower by the day. Exchange networks started the trend, but challenge is much bigger.

22 6. Narrow Networks Networks Narrow and getting narrower by the day. Exchange networks started the trend, but challenge is much bigger. How do you protect (and grow) market share? How much will you discount to participate in a payor’s exchange network? What are your competitors’ likely strategies? How does your organization become “must have” for employers and consumers alike? How do you establish relevance with consumers, and preference? How do you protect (and grow) market share? How much will you discount to participate in a payor’s exchange network? What are your competitors’ likely strategies? How does your organization become “must have” for employers and consumers alike? How do you establish relevance with consumers, and preference?

23 “...but if there’s no agreement on which hospitals and doctors deserve the best or worst ratings, then how, asked Dr. Bechta, can the insurers claim that these plans are driving patients to the lowest-cost, best-quality providers?” 6. Narrow Networks

24 Thousands of employers … across the country are slashing expensive doctors and hospitals from their insurance rosters in a move to hold down rising healthcare costs — a trend that is gaining favor with corporate bosses, if not the rank and file. The availability of doctors varies by each narrow network. Woodland Hills-based Health Net, one of the first to promote the strategy in California, features 47,000 doctors in its full HMO network but just 7,000 physicians in its Silver plan. That network — available in 10 counties, including Los Angeles, Orange, San Bernardino and Riverside — can save businesses as much as 14% on insurance premiums, a spokesman said. An even smaller network, Bronze, has 1,600 doctors in (three LA counties), and can shave as much as 24% off insurance bills.

25 “What businesses say they want - and what insurers are promising - are networks made up of fewer but higher quality physicians. Whereas tiered networks offer incentives to patients who see “preferred” or “high performing” physicians, or charge higher co- pays for visits to lower-tier doctors, narrow networks don’t pay for care for anyone other than those physicians deemed cost-efficient and high quality. By definition, a network can’t be narrow without leaving some doctors out. Where networks are supposedly quality based, it’s unclear that all insurers are offering physicians a chance to understand why they’re included or excluded, or disclosing the measures by which the network is selected.” 6. Narrow Networks

26 “As the health care overhaul moves ahead, the nation’s health insurers are scrambling to reinvent themselves, hoping to boost their image and entice millions of Americans to enroll, some for the first time. Blue Shield of California has opened centers inside Lucky Supermarkets in San Francisco. Blues plans in Florida, Pennsylvania and three other states have also opened store- front sales centers. Customers going to H&R Block this tax season will be asked if they want to learn about health insurance options, part of a partnership with Blue Cross Blue Shield expected to expand to as many as 42 states by next spring.” 6. Narrow Networks

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29 7. Pushback on Key Revenue Items Physician employment and rates Non-hospital sites (OP, lab, Dx imaging) Addition of new hospitals or entry into new markets Implants, high cost drugs, and stop loss thresholds Facility fees

30 Sources: Nooga,com, Pittsburgh Business Times, Public Broadcasting Atlanta, Beckers Hospital Review, Durham-Middlefield Patch, The Post and Courier How much rates will rise through Dec. 31, 2014, has become the latest point of disagreement between health insurer Highmark Inc. and the University of Pittsburgh Medical Center 8. Major League Payor/Provider Conflict

31 Health System Strategies

32 ACO Strategy In 2012, about one-third of providers had an ACO strategy in place or were making preparations. This year, over half of providers have an ACO strategy in place or nearly in place. Please indicate what stage (if any) your hospital/health system is at in terms of implementing the following strategies/programs Stage 1: Talking about it, but not doing anything yet Stage 2: Planning and preparing to implement Stage 3: Currently have in the works Do not have in place and no plans to in future Don’t know 9% 2013 Do not have in place and no plans to in future Stage 2: Planning and preparing to implement Stage 3: Currently have in the works Stage 1: Talking about it, but not doing anything yet Internal Wellness or Population Health Strategy Please indicate what stage (if any) your hospital/health system is at in terms of implementing the following strategies/programs.

33 Clinical Integration Strategy +11% Please indicate what stage (if any) your hospital/health system is at in terms of implementing the following strategies/programs. Don’t know Stage 1: Talking about it, but not doing anything yet Stage 2: Planning and preparing to implement Stage 3: Currently have in the works Do not have in place and no plans to in future % Direct Contracting with Employers Please indicate what stage (if any) your hospital/health system is at in terms of implementing the following strategies/programs Don’t know Stage 3: Currently have in the works Stage 2: Planning and preparing to implement Stage 1: Talking about it, but not doing anything yet Do not have in place and no plans to in future

34 34 Forming or joining payors’ narrow networks was the most common strategy currently in place. Population health strategies for employers and other groups were said to be in preparation or in place by over half of respondents. Q: Different strategies that many health systems have begun to implement are listed below. Please indicate the stage, if any, that appropriately describes where your hospital/health system stands in implementing the following strategies or programs. Health System Strategies by Stage in Hospital or Health System Implementation Strategy N/A: Do not have in place and no plans to in future STAGE 1: Talking about it, but not doing anything yet STAGE 2: Planning and preparing to implement STAGE 3: Currently have in the works Don't know/ Unsure Total Participating in a capitation or other global risk program/initiative 27%25%13%29%7%100% Population health for employers and other groups 12%24%25%31%8%100% Starting your own health plan or joining an existing provider-owned health plan 38%20%7%26%8%100% Forming or joining one or more payors' narrow networks 17% 13%47%5%100% 3. Health Systems Launching Their Own Plans

35 employer engagement is not occ med

36 “Must Have” Hospitals 36 Most respondents indicated their hospital or health system was a “must have,” whether for all services (52%) or only certain services (22%). Q: As you think about the reputation of your hospital or health system, which of the following best describes your hospital, in the eyes of the major payors you work with?

37 The future for health systems revolves around employers. How? - Health systems launch their own health plans - Pursue direct contracting strategies - Launch new population health and wellness programs - Begin to engage employers in conversation, understand their issues and concerns, and explain how their needs will be met in the future. Wild card is the employer response to private and state insurance exchange options. - If providers fail to price their services properly and demand commercial market rates, the exchanges will incentivize employer “dumping” - Research estimates that between 15% and 40% of small to midsize employers will stop providing employer-sponsored coverage. Providers could experience the largest “reverse cost shift” in history, the greatest shift of high-margin commercial business into lower-margin exchange business. Critical Audience: Employers On the other hand, what happens if you’re out of network?

38 Tighter Managed Care Restrictions Consumer-Driven Health Plans (High- Deductible Plan w/ HSA) Higher Employee Cost Sharing Disease Management Programs Critical Audience: Employers

39 “This year, grocery giant Kroger Co. has flown nearly two dozen workers to Hoag Orthopedic Institute in Irvine and several other hospitals across the U.S. for hip, knee or spinal fusion surgeries in an effort to save money and improve care. Starting in January, Wal-Mart will offer employees and dependents heart, spine, and transplant surgeries at no cost at six major health systems across the nation, with free travel and lodging. It’s all part of a growing movement by employers fed up with wildly different price tag for routine operations. In response, businesses are showering workers with generous incentives - including waiving deductibles and handing out $2,500 bonuses - to steer them to these top- performing providers offering bargain prices. At Kroger, employees may pay 10% out of pocket if they choose one of the company’s 19 select hospitals, compared to 25% to 50% out of pocket for other nearby medical centers.” Critical Audience: Employers

40 Several employer groups across the country are calling on health plans and healthcare providers to make healthcare pricing more readily available to their employees and consumers by Catalyst for Payment Reform - a not-for- profit organization of large employers and health care buyers that includes 3M, Delta Airlines, Dow Chemical, the Walt Disney Co., and Xerox Corp. - is directing the effort. Critical Audience: Employers

41 How to Successfully Deploy the Right Strategy

42 clarity

43 Roadblocks in Achieving Better Payment Terms 43 Nearly 2 of every 3 respondents (65%) felt they need better benchmark data to achieve better payment terms with payors. A majority (51%) believed improved public perception would eliminate roadblocks as well. Q: Which of these roadblocks would you face, if any, when pushing for better payment terms with your largest payors? Select ALL that apply.

44 resolve

45 strategy

46 story

47 discipline

48 The Meek Submit, The Bold Survive More hospitals are engaging employers than ever before. - The “city on the hill” strategy. - Direct contracting with large employers. - Narrow network products with 2nd and 3rd tier payors. - Wellness and disease management programs. - Medical homes, ACOs, risk strategies. Population health is the future - the question is what (exactly), when each switch get flipped, and how margins are protected. Hospitals are helping drive exchange enrollment, and trying to figure out their consumer marketing strategies. Bigger health systems are expanding margins and increasing leverage. Deals abound, affiliations are everywhere, and scale is everyone’s goal.


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