DISTRIBUTION PLATFORM OPTIMIZATION: TURNING AN ACCOUNTABLE CARE ORGANIZATION (ACO) INTO A HEALTH PLAN

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1 CLIENT BRIEFING MARCH 2016 DISTRIBUTION PLATFORM OPTIMIZATION: TURNING AN ACCOUNTABLE CARE ORGANIZATION (ACO) INTO A HEALTH PLAN Best practices for achieving distribution platform optimization, increasing provider collaboration and access to quality care, and embracing the value based model. AUTHORS Yvonne Villante Mark Bethune THE CURRENT LANDSCAPE While participation in ACOs are voluntary, the US healthcare system has witnessed a spike in ACO interest and adoption. Since 2011, at least 744 organizations have become ACOs or entered into value based relationships, but only a few have created value-based insurance products and benefits. Currently there are 477 ACOs across 4 different models. 21 have been approved for the Next Generation cohort beginning in January Next Generation participants, starting in 2017, can choose capitated payment, meaning Medicare would pay the ACOs a per-member, per-month lump sum, and providers would then be responsible for any care that patients need.

2 Serving as a powerful differentiator amongst other local healthcare systems, this opportunity holds key competitive advantages their current markets, as well as those related to participation of state and federally facilitated marketplaces. In fact, 67% of the US population is estimated to reside in primary care service areas, according to industry experts. Health systems formed by groups of doctors, hospitals, and other health care providers, come together to provide coordinated high quality care to their Medicare patients and strive to eliminate care duplication. Projected to serve 17% of the 7.92 million assigned beneficiaries living in the United States and its territories, the opportunities related to establishing and marketing value-based insurance products are significant and include: 1. Competitive Pricing - ACO specific products may charge premiums that are 5 12% percent below the average market offerings. 2. Distribution Channeling The ability to enter into new lines of business and distribution, including state and federally facilitated marketplace participation. 3. Strengthen Stakeholder Ties Whether it be the local community, providers & staff, or other stakeholders, new market opportunities are paving the way for increased consumer loyalty. The traditional fee-for-service payment system further strengthens the provider and ACO relationship, driving accountability to patient treatment and care. 4. Big Data Analytics Serving as the supplier of health insurance products, ACOs gain access to member-level analytics. 5. Cost Containment - In 2014, the third year of the Medicare ACO program, 97 ACOs qualified for shared savings payments of more than $422 million. 6. Profitability - Provider-owned plans profitability has typically been higher in comparison to other health plans. On average, provider-owned plans earned about 3.2% higher profit margin in 2013, and positioned well above 3% since 2010, according to A.M. Best Co. 7. Reductions in Uncompensated Care - Reduction in uncompensated care and improved delivery are among the benefits for provider-led health plans. As a result of their strong relationships with providers and competitive payment levels, provider-led health plans avoid some of the challenges that conventional insurers have to face. PROVIDER-LED HEALTH PLANS ARE OPERATING IN MOST STATES Many health systems are taking a cautious approach to entering the insurance business, while others have embraced the prospect. The provider-sponsored health plan model present in approximately 40 states - has achieved success through attaining state insurance licensure or, alternatively, partnering with healthcare payers. Prior to the establishment of public exchanges, provider-sponsored 1

3 insurance companies achieved a 3.2 percent average profit margin in 2013, comparative to the insurance industry as a whole, according to A.M. Best Company. 107 health systems offer health plans in at least one market, covering over 18 million lives or nearly 8% of all insured Americans. HOW TO TURN AN ACO INTO A HEALTH PLAN WITH DISTRIBUTION PLATFORM OPTIMIZATION To launch an optimized value-based health plan, ACOs will undergo several phases including research, planning, and product development. To achieve an optimized distribution platform, we recommend healthcare organizations review a five step approach. This review includes an analysis on timing, a readiness assessment, strategy / structure determination and planning, examination of operations including current and requires capabilities, as well as short and long-term oversight requirements. 2

4 Timing Offering a health plan often requires the establishment of new organizational competencies, capital funding to meet Risk-Based Capital requirements (RBC), resources, and risk management without compromising providing quality care, provider coordination, and patient engagement. Even though the majority of health systems are performing well, determining the right time to pursue this can be challenging. Wondering whether your organization is ready to pursue this distribution platform and ultimately reduce costs while placing your patients and members in the center of your focus? Begin with a road map for the next three to five years, outlining strategies for rolling out a product based on customer type (for example: exchange, individual, small group, etc.), incentivizing provider evolution, and expanding into second-priority markets. Once there is a strategy in place, take a look at the current industry landscape, and notice the trend. With the rise of health insurance exchanges, industry experts agree that the number of provider-led health plans is increasing, and the number of participating provider-led insurance products sold on the health insurance marketplaces, continues to grow. Conduct a Readiness Assessment Running a profitable and successful health plan organization may be a new concept for many providers and ACOs. Whether they are developing their infrastructure, IT, management, stakeholder relations, member relations, or oversight; the responsibilities ahead are plentiful and may include: - Coordination & alignment of physicians and treatment - Data analytics & predictive modeling - Provider network design - Plan management - Member outreach 3

5 Many health systems sustain strong population health expertise, which will come into play when developing an internal managed care skillset. Offering an example of baseline competencies, the following are essential requirements for an ACO to create and bring to market insurance products: - Coordination & alignment of physicians and treatment - Data analytics & predictive modeling - Provider network design - Plan management - Member outreach - Oversight and compliance with regulatory bodies including the canters of Medicare and Medicaid Services (CMS) Beyond the responsibilities related to this venture, organizations should understand how to operationally establish and offer value-based insurance products and benefits. The most probable options include building in house, buying or licensing a solution, or partnering with an established health insurer. Let s examine the pros and cons of each option: Market Approaches SOLUTION THINGS TO CONSIDER DEVELOP CAPABILITY INTERNALLY Likely takes months Start-up costs including capital requirements Accepts full risk Regulatory requirements can be challenging Must build health plan sales & marketing, actuarial and pricing SOFTHEON (PARTNER WITH INDUSTRY LEADING EXPERTS) Leverage the expertise of the most experienced and accomplished professionals in this space Gain access to industry leading technology, processes and systems Enjoy a quick, seamless implementation process, completed within any budget. PARTNER WITH AN INSURER Leverage existing infrastructure and licenses Existing insurance business, expertise, and membership Financially less attractive organizational conflicts relating to management, product design, pricing, etc. 4

6 Strategy & Structure Health insurance exchanges. Through examination of these provider led plans, we found that 75 health systems and providers participated on the ACA for the 2015 plan year. Another 63 sold cobranded plans through partnership with an insurance company. Aligning with ACA goals, the statebased and federally-facilitated insurance marketplaces have produced a platform that in essence, levels the playing field for all insurance carriers. Examined by total medical membership, the top 10 include: Provider-Sponsored Health Plan Total Enrollment (2014) % From Public Exchanges (2014) Kaiser Foundation Health Plan, Inc. 7,588, % AmeriHealth Caritas Family of Companies 1,879,528 NA Healthfirst 1,005, % HealthPartners, Inc. 908, % UPMC Health Plan, Inc. 865, % SelectHealth 729, % Health Alliance Plan of Michigan 686, % Priority Health 587, % Kaiser Foundation Health Plan of Colorado, Inc. 573, % Group Health Cooperative 549,500 * Operations Source: AIS s Directory of Health Plans: 2015, published by AIS. Organizations should have a dedicated operations team that provide various levels of support throughout the lifetime of the engagement, including design, development, implementation, and post go live support. The Organization should have a dedicated call center to support agency business and operations, which is then augmented by the product management and development resources. Operations agents should work specifically with customer issues while product managers work on simplifying processes within the product suite. Development resources work with product managers to automate known functions in the product suite, as well as build out new functionality. 5

7 CONCLUSION As Value Based Care continues to gain momentum in the shape shifting Healthcare Industry, it is important that ACOs streamline operations and create transparency among its stakeholders. It is also critical to stay within compliance of CMS guidance, which requires an administrative system that is flexible and quickly adaptable to ongoing regulations. With consumers and employers looking to trim coverage costs while ensuring high-quality care, public and private insurance exchanges might be an ideal vehicle for insurance plans that include an ACO. Only a handful of ACO plans, however, are being marketed on either type of exchange. Softheon is a one stop shop for ACOs; enabling them to maximize the opportunities present in today s marketplace. Softheon provides solutions for enrollment, HIX integration (both state and federal), direct enrollment, premium billing, edge server, and CSR reconciliation. By removing these headaches, Softheon allows ACOs to focus on doing what they do best; taking care of patients. 6

8 About Softheon Empowering the nation's first state health benefit exchange since 2008, Softheon's vision and strategic direction address healthcare payer, provider, and government agencies' goal of meeting Affordable Care Act (ACA) milestones. Softheon provides HIX Integration, Direct Enrollment, Premium Billing, and Edge Server solutions for insurance carriers of all sizes participating in Federal and State Health Insurance Exchange (HIX) Marketplaces. Softheon's Marketplace Connector Cloud (MC2) has been trusted by health plans, in all 50 states, as an accelerated federal, state, and private exchange integration platform. Softheon MC2 is a Software-as-a-Service (SaaS) solution where insurers pay a one-time activation and ongoing PMPM fees for exchange members only, while eliminating most, if not all, risks associated with ACA enrollment compliance and other mandates. (800) info@softheon.com. 7

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