ARTICLE PULL-OUT. Commercial Carriers. Table 1-1: Texas Commercial Enrollment Trend. Texas

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1 12 HEALTH PLAN ANALYSIS ARTICLE PULL-OUT Content from HealthLeaders-InterStudy s Texas Health Plan Analysis, Summer 2012: August 24, 2012 Commercial Carriers BY BILL MELILLE Table 1-1: Texas Commercial Enrollment Trend Company January 2012 January 2011 Change % Change BCBS Texas 3,933,118 3,866,946 66, % UnitedHealthcare 2,366,660 2,253, , % Aetna 2,235,120 2,400,256 (165,136) (6.9%) Cigna 1,091, , , % Humana 446, ,100 51, % BCBS Illinois 267, ,983 (7,592) (2.8%) CareFirst BCBS 234, ,215 (15,564) (6.2%) Scott & White Health 134, ,646 (9,468) (6.6%) FirstCare Health 74,424 96,264 (21,840) (22.7%) Assurant Health 68,709 64,581 4, % Source: HealthLeaders-InterStudy Texas Overall commercial enrollment in Texas increased between January 2011 and January 2012, indicating the potential for continued organic growth of managed care organizations. While employers and employees continue to gravitate to the wide provider network options of PPO plan designs, the economic reality of higher premiums has spurred some movement toward plans that offer a higher degree of utilization control, such as point-of-service plans, and lower cost options such as consumer-directed health plans. Among MCOs that could capitalize on employer interest in controlling costs is Cigna Healthcare, which continues to develop its accountable care model.»» Enrollment: The Texas commercial market picked up between January 2011 and January 2012, adding 210,224 members, up to11,948,059 commercial members. Growth in PPO and POS products, which increased in enrollment by 3 percent and 7 percent, respectively, more than offset a 130,000-member decline in statewide HMO enrollment (HealthLeaders-InterStudy). Nearly all of the POS enrollment growth in Texas came through Cigna HealthCare and UnitedHealthcare plans. The increase in POS plan enrollment could signify that employers and employees are becoming more willing to forego the flexibility of PPO plans in favor of lower costs through tighter utilization control, including prescription drug benefit utilization. Copyright 2012 HealthLeaders-InterStudy Texas Article Pull-Out All Rights Reserved 1

2 Texas employer groups lean strongly toward self-funded arrangements. More than two-thirds of commercial plan members (nearly 7.9 million) are enrolled in self-funded plans. The self-funded segment of the market added nearly 200,000 lives from January 2011 to January 2012 while the fully insured segment added nearly 25,000 members, up to 4,069,922 members (HealthLeaders-InterStudy). The stability of the fully insured market indicates that plans dropping HMO coverage are switching to fully insured POS and PPO plans rather than dropping coverage altogether. Growth in self-insured enrollment is consistent with Texas trends. In a state where the healthcare reform law is highly unpopular, increase self-insured migration could indicate more employers want to avoid the law s impact. Between January 2011 and January 2012, Cigna HealthCare showed the largest enrollment gains, growing by 132,152 commercial members, up to 1,091,520 members. The MCO s POS plan enrollment increased nearly 15 percent, up to 895,853 members and PPO enrollment increased 9 percent, up to 166,702 members. Cigna has been the most active carrier in the state in terms of accountable care program development and offers a narrow-network plan with Kelsey-Seybold Clinic in the Houston area. Development of such plans could further boost Cigna s enrollment as employers in the market look for strategies to control benefit expense. With new accountable care initiatives in Dallas-Fort Worth and Houston, look for Cigna to sustain its growth using those ACO capabilities to appeal to employers. Blue Cross and Blue Shield of Texas, the state s largest MCO, posted solid gains from January 2011 to January 2012, adding 66,172 commercial members, up to 3,933,118 (HealthLeaders-InterStudy). In September 2012, the Texas Blue plan will lose the self-funded Open Access contract for the Employee Retirement System of Texas, which covers state and university employees. UnitedHealth will take over the contract. The ERS loss will wipe out most of the Texas Blue s POS membership, but its strength remains in its PPO plan offerings. The Blue plan s PPO enrollment increased nearly 7 percent, up from 3.25 million to 3.45 million members between January 2011 and January BCBS of Texas PPO enrollment is evenly split between fully and self-insured enrollment (1.71 million fully insured members and 1.74 million self-insured members, respectively). HMO enrollment for the Blue plan decreased nearly 66 percent, down to 34,248 members as of January UnitedHealthcare gained 112,718 commercial members, a 5 percent increase between January 2011 and January 2012, up to 2,366,660 members. The health plan s growth came solely through its POS plans, which account for 92 percent of its commercial enrollment. POS enrollment for UnitedHealthcare increased 6 percent, up 118,026 members to 2,179,082 enrollees. That gain was offset by a slight decrease in PPO enrollment and indemnity plan enrollment. In the individual market, UnitedHealth subsidiary Golden Rule also added 1,300 lives, up to 61,887 in January 2012 (HealthLeaders-InterStudy). Commercial enrollment for Aetna declined nearly 7 percent between January 2011 and January 2012, down to 2,235,120 enrollees. Losses in PPO enrollment a 154,512 member decrease drove the MCO s decline in overall enrollment, although it also experienced a 12,773-member decline in HMO enrollment. Humana s enrollment grew by 51,700 members, or 13.1 percent, giving it 446,800 commercial members. While its HMO products lost about 2,100 members, PPO and POS plans had solid growth. PPO enrollment grew from 220,200 to 246,300, an 11.9 percent increase, and POS products grew from 138,800 to 166,500 lives (HealthLeaders-InterStudy). Scott &White Health Plan s efforts to diversify its product lineup blunted some of its HMO losses. Commercial enrollment for the integrated health plan decreased by 9,469 members between January 2011 and January 2012, down to 134,178 members. HMO enrollment for the MCO decreased 27 percent, down to 103,731 members. Scott & White enrolled 4,159 members in its POS plans, a relatively new product for the MCO. Rate increases have forced many small employers to look elsewhere for coverage. Several municipal and county governments in Central Texas have chosen different carriers because of HMO expense. This trend Copyright 2012 HealthLeaders-InterStudy Texas Article Pull-Out All Rights Reserved 2

3 has led Scott & White to introduce alternatives to its HMO plans. With Texans generally preferring plans with more provider choices, the fully insured HMO will likely continue its slow decline. Self-insured PPO enrollment grew slightly to 26,067. Scott & White Healthcare s employees account for nearly all of its selfinsured PPO membership. FirstCare fared worse, posting another steep enrollment decline. Commercial enrollment declined nearly 23 percent between January 2011 and January 2012 (HealthLeaders-InterStudy). From HMO products, FirstCare lost 12 percent, or 9,834 lives, giving it 60,173. FirstCare has seen its government business reduced significantly in the past three years, ending its participation in the ERS HMO program after not meeting the HMO rate benchmark and exiting some regions of the Federal Employee Health Benefits Program. FirstCare still participates in TRS-ActiveCare, a regional HMO for Texas school employees. Like Scott &White, FirstCare has moved to diversify its enrollment. Both Scott & White and FirstCare received Medicaid Rural Service Areas contracts effective March 2012, which should generate new revenue and decrease their reliance on commercial products.»» Narrow networks: Employer interest in narrow network plans is on the rise as groups look to slow the growth of healthcare benefit expense. Cigna offers its KelseyCare Powered by Cigna, a narrow plan built around Houston s Kelsey- Seybold Clinic. Blue Cross and Blue Shield of Texas has developed an exclusive provider organization (EPO) plan, in which members must use its preferred network or face the full cost of care, and Aetna has developed a tiered hospital network that allows members to receive additional discounts for choosing high-performing facilities. All the carriers are looking at a more efficient network to drive people to the best providers, says James Watt, CEO of Employee Benefit Solutions, a Houston-based consulting firm. Although employer interest in narrow-network plans is growing, the dynamics of the Texas employer sector present challenges to the growth of such designs. For instance, companies in the energy sector (one of the largest employer segments in the state) often have large blocks of employees in smaller metropolitan areas such as Midland and Odessa. For those companies, the need to provide a broad network can override cost considerations. We think that all insurers that are delivering network solutions to clients in urban areas, where you ve got excess capacity, that s where you will see the narrowing [of networks]. In the suburbs, you won t see significant narrowing, Watt says. For groups with urban and rural workforces, dual option plans will remain popular. With a dual option plan, employers can offer a narrow-network alongside the broader network. The city of House operates under such a model, with the Kelsey-Seybold narrow network design as its most affordable option»» CDHP: Consumer-directed health plan enrollment continues to gain traction in Texas. Between January 2011 and January 2012, Texas carriers added 171,015 CDHP members, a 19 percent increase, up to 1,074,513 members. Given the state s response to the U.S. Supreme Court ruling on healthcare reform the state does not plan to broaden Medicaid eligibility market forces will continue to work in favor of CDHPs. As the cost of indigent care is passed on indirectly to commercial insurers, employers are likely to see steady increases in premiums. Those [uninsured] people will still be utilizing services. There will be pressure on the health care companies to get compensated through the private sector for what they are not getting through the public sector, says John Currie, principal and vice president of Employee Benefit Solutions. For BCBS of Texas, CDHP enrollment accounts for nearly 11 percent of its commercial enrollment as of January Between January 2011 and January 2012, CDHP enrollment increased by 20 percent, or 70,124 members, to reach 413,636 (HealthLeaders-InterStudy). CDHP for UnitedHealth increased by 82,978 members, or 26 percent, up to 399,607 members as of January CDHP accounts for about 17 percent of the MCO s commercial enrollment. Copyright 2012 HealthLeaders-InterStudy Texas Article Pull-Out All Rights Reserved 3

4 Cigna saw a smaller CDHP increase, adding 12,208 members, a 9.2 percent increase, to enroll 145,473 CDHP members as of January 2012 (HealthLeaders-InterStudy).»» Cost control: Although some skeptics call the accountable care movement a rehash of the 1990s HMO boom, which was never popular in Texas, momentum for implementing ACO programs is building in the larger metropolitan areas of the state. Advocates of ACO programs note that a key difference between the HMO movement and the push for accountable care is the proliferation of patient information, claims data and population registries that physicians and patients lacked 20 years ago. Cigna has added a Houston-based Collaborative Accountable Care (CAC) in partnership with St. Luke s Health System Clinically Integrated Providers and Renaissance Physicians Organization. The partnership is specific to Cigna members and if its shows good results, it could lead employers with a high percentage of employees using those providers to switch to Cigna. It will include 500 providers affiliated with St. Luke s and 1,642 from Renaissance. Registered nurses serving as care coordinators will review Cigna claims data to identify members who do not refill maintenance medications, members due for preventive screenings and those with a higher risk of being re-hospitalized. The Houston ACO could serve up to 44,000 Cigna members. Cigna members who later become patients of participating physicians will be automatically enrolled into the accountable care initiative. The development of the Houston CAC fits with Cigna s national pattern of creating new accountable care initiatives with technologically advanced physician practices. Nationally, Cigna expects to have 100 CACs in operation by Cigna began its first Texas partnership with the Medical Clinic of North Texas (MCNT) in Early results showed improved results for chronically ill members who receive services through MCNT. One of the challenges with such programs is to move beyond improved possession ratios (when and how patients fill a prescription) to improved treatment and compliance (patients taking the medication as prescribed), says Larry Levy, M.D., medical director for Lockton Dunning Benefits in Dallas. New technology and improved outreach by the ACO or the PBM could help identify problems earlier and keep members compliant and optimally treated. Drugs and drug utilization are important issues. Convenient outreach and timely data in a low cost, efficient manner will improve the health plan results, Levy says. You really need to know if someone is getting and taking the medication and how it is working. Cigna also has established a foundation for many more ACOs through its new national provider agreement with Tenet Healthcare. Through that agreement, ACOs and other clinically integrated organizations started by Tenet will use Cigna s accountable care model. The focus of the initiative will be high-risk Cigna members, primarily those with chronic illnesses (Tenet press release, July 24, 2012). With 12 Texas hospitals located primarily in the El Paso, Houston and Dallas regions, Cigna s accountable care initiatives could rapidly become the state s most prominent coordinated care model. Physicians affiliated with Tenet facilities can be included in Cigna s CAC model, its medical home initiatives, bundled payment arrangements, and pay-forperformance incentives. Cigna also partners with Kelsey-Seybold Clinic on a branded narrow-network product offered in the Houston area, KelseyCare Powered by Cigna. Kelsey-Seybold operates a capitated model and considers itself an ACO. Organizations like Kelsey-Seybold are ahead of the game. We are seeing more of those types of entities coming to life, Watt says. Memorial Hermann Health System also operates an ACO in the Houston area. Even with the continued development of ACOs, employers have been slower to embrace accountable care. However, if insurers can demonstrate cost savings and better health results, then products tied to such coordinated care initiatives could prove to be popular choices. Health plans typically partner early with technologically savvy practices, a strategy that reduces their investment, and frequently Texas insurers are willing to aid practices with onsite clinical coordination and PCMH certifications, Levy says. For instance, smaller medical groups may need additional staff to handle the increased level of responsibility in PCMH certification and may require larger virtual groups to support. You need to have EMR technology in groups that do not have it, Levy says. Copyright 2012 HealthLeaders-InterStudy Texas Article Pull-Out All Rights Reserved 4

5 More employers are also moving beyond rewards for completing health risk assessments and tying benefits to outcomes, says Mike Barbour, a partner in Mercer s Houston office. The trend is less toward rewarding people and more toward making it mandatory. For example: if you have a chronic condition linked to these behaviors and you do not manage them, you might have no out-of-pocket limit. The concept of trading value for value is more the theme of the day, says Barbour.»» alue-based strategies: Some self-funded employers are pursuing arrangements with providers and third-party administrators that would allow them to offer PCMHs to their employees, Levy says. Those new contracting arrangements could be effective in Texas due to the high number of independent providers and self-funded groups that design their own benefits. Table 1-2: Fully ersus Self-Insured Enrollment Breakdown For Texas (Largest Plans) Company Fully Insured Self-Insured % FI Ratio % SI Ratio BCBS Texas 1,729,065 2,204, % 56.0% UnitedHealthcare 602,707 1,763, % 74.5% Aetna 435,626 1,799, % 80.5% Cigna HealthCare 150, , % 86.2% Source: HealthLeaders-InterStudy, as of January 2012 In the Dallas-Fort Worth area, the North Texas Employer Collaborative, which includes the Dallas-Fort Worth Business Group on Health and more than 30 self-insured employers, plans to implement a quality and pricing initiative with area hospitals and medical practices. The collaborative, which does not include health plan involvement other than to provide claims-based costs of care for participating employers, will initially focus on value-based reference pricing for primary care, musculoskeletal surgeries (knee and hip replacements), and cardiac stents. To reduce variability between facilities, employers seek the high-quality, low-cost care by direct contracting with centers of value for these specific procedures, says Marianne Fazen, Ph.D., executive director of the Dallas-Fort Worth Business Group on Health. Although providers have been hesitant to join, the region s self-insured employers have the patient numbers to drive change and convince providers, Fazen says. It has to be a group initiative or there is no impact. You need the volume of self-insured employers who can make those decisions, she says. The program is an extension of the business group on health s work identifying high-quality diabetic care providers in the region. That initiative did not include provider pricing, but focused on steering members toward high-quality providers. To effectively manage chronic illnesses, employers need to be aggressive with such initiatives. If you have patients with complex chronic conditions, the odds of them randomly selecting a physician capable of optimally treating them is relatively low. If you have a physician group that is good at treating complex chronic conditions, you can pay them more, give the employee more incentive, and save money in the process Barbour says. Another Dallas-Fort Worth quality initiative, the North Texas Accountable Healthcare Partnership, will launch in January Under the program, participating employers, health plans and providers would split any savings at the end of the plan year. Some physicians groups can already move information through the partnership s health information exchange and once the larger providers are involved, the partnership will begin building databases to track population health. Because most Dallas-Fort Worth employers already signed their health insurance contracts for 2013, the partnership has not signed on any employer members yet. Because of health system and provider interest, it is likely these employers will be among the first to test the partnership s capabilities. Once they participate, other employers will have greater enticement to join, Fazen suggests. Copyright 2012 HealthLeaders-InterStudy Texas Article Pull-Out All Rights Reserved 5

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