Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the

Transcription

1 Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 Individual Results May Vary The Law of Large Numbers 2

3 TAC Self Funded Year over Year Trend Incurred Claims from November 2014 to October 2015 and paid through December 2015 Non Medicare Primary 3

4 TAC Pooled Year over Year Trend Incurred Claims from November 2014 to October 2015 and paid through December 2015 Non Medicare Primary Top 20 Accounts by Membership 4

5 What is Trend Rolling 12 Month Average Change in Costs (PMPM) 5

6 TAC Pooled Monthly Paid Claims PMPM TAC Pooled experience Claims incurred October 2013 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 6

7 TAC Pooled Rolling 12 Paid Claims PMPM TAC Pooled experience Claims incurred November 2012 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 7

8 TAC Pooled Rolling 12 Paid Claims PMPM Feb 14 Feb 15, trend of 5.4% TAC Pooled experience Claims incurred November 2012 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 8

9 TAC Pooled Rolling 12 Paid Claims PMPM Oct 14 Oct 15, trend of -0.8% TAC Pooled experience Claims incurred November 2012 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 9

10 TAC Actual Experience Period Ending October

11 Trend Tree TAC Pooled experience Claims incurred November 2013 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 11

12 Components of Change Excludes High Cost Claimants > $50,000 TAC Pooled % Impact $ Impact (In Thousands) Age/Gender 0.5% $577 Area 0.0% $19 Tier 0.3% $410 HCC (Greater than $50K) 3.0% $3,899 Inpatient Utilization (Days/1000) 0.3% $409 Unit Cost ($/Day) 0.5% $638 Inpatient Total 0.2% $229 Outpatient Utilization (Visits/1000) 0.3% $384 Unit Cost ($/Visit) 1.2% $1,562 Outpatient Total 1.5% $1,946 Professional Utilization (Services/1000) 0.5% $664 Unit Cost ($/Service) 0.8% $994 Professional Total 1.3% $1,657 Total 0.8% $1,034 TAC Pooled experience Claims incurred November 2013 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 12

13 Mountain Graph $100k 13

14 Trend by Service Category TAC Pooled experience Claims incurred November 2013 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 14

15 Trend by Cost Source - Outpatient TAC Pooled experience Claims incurred November 2013 through October 2015, paid through December 2015 Claim dollars on a paid basis Excludes Medicare Primary 15

16 What are the Primary Drivers of Trend? 16

17 What Are the Primary Drivers of Trend? Cost Shifting Medicare Medicaid Bad Debt Specialty Hospitals Hospital Revenue Centers Advances in Technology Radiology Specialty Rx Over testing Robotics Bio Pharmacy Biogenetics Legislative Mandates ACA Mandates Tort Legal Risk Litigation Lifetime Max Excise Tax Utilization Increases Age # of Services/ Visit Defensive Medicine Misaligned Incentives Economy Rush/Hush/ Crush Readmissions Never Events Provider Charges Charge Master Price / Cost Relationship Physicianowned ASCs Hospital Based Physicians Hospital Consolidation Revenue Optimization Labor shortage/ Nurses Incentives misaligned Fraud, Waste, Abuse False Representation Criminal Activity Aberrant Practice Patterns Inappropriate Treatment Unnecessary Services Duplicate Services Overutilization Misuse of Resources Overpayments Poor Lifestyle Choices Obesity HTN Diabetes 8/15/80 Complications Comorbidities 17

18 What Can we do to Control Trend? 18

19 What Levers Can We Pull to Impact Costs? Contracting Strategy Network Makeup Network Size HMO / POS / EPO ACOs Medical Homes Tiered Network Alternative Networks Onsite Clinics Navigation Bridges To Excellence Centers of Excellence Provider Selection DRG Contracting Case Rates Bundled Payments Global/Episodic Reference Based Pricing Hospital Stop Loss Levels Risk Sharing Formulary Makeup Prepayment Edits Rebundling Claims Audits Capitation Rx Rebates Pay for Performance Value Based Care Payment Models Plan Design Contribution Strategy Premium Credits CDHP Value Based Design Incentives / Disincentives Onboarding / Activation Concierge Service Transparency Tools Nurseline Decision Support Tools Member Responsibility Personalized Messaging Mobile Apps Consumerism & Education Fully Integrated Care Management Platform Predictive Modelling Data Mining Regression Modeling Hospital Quality Initiative Inpatient Profile Care Path Portal Risk Stratification Member ID SMS Text Messaging Technology & Analytics 19

20 What Levers Can We Pull to Impact Costs? Health Risk Assessments Needs Assessments Care Planning Fitness Discounts Wellness Consulting Onsite Wellness Coordinators Biometric Screenings Preventive Care Quality Initiatives Lifestyle Management HEDIS Outcomes Prior Authorizations Referral Authorizations Redirection High Tech Radiology Quality Initiatives Concurrent Review Care Coordination Discharge Planning Behavioral Health Step Therapy Specialty Rx Clinical Review Gap Closure Engagement Health Risk Improvement Low Back Pain Cardiac Clusters Pain Management Chronic Kidney Disease Managing Outcomes Longitudinal Care High Touch Models Medication Adherence Polypharmacy Complex / Catastrophic Case Management Episodic Case Management High-Dollar Claims Management Alerts Grand Rounds Community Partnerships ESRD/Medicare Specialty Carve Outs Oncology Program Palliative Care Program Wellness Prevention Counseling Utilization Management Condition Management Case Management 20

21 Specialty Drugs 21

22 Specialty Drugs Growing Piece of a Larger Pie 2018 est. $510B Traditional Specialty 22

23 Specialty Drugs Growing Piece of a Larger Pie Utilization 2018 est. $510B Traditional Specialty 23

24 Strategy & Best Practices Drug spend forecasted to be 30-40% of total health care spend by 2020 Pharmacy Benefit Strategy Clinical Management: Maximize Utilization Management Benefit Design: Copay Design Site of Care: Mandatory Specialty Pharmacy Medical Benefit Strategy Clinical Management: Specialty Pharmacy Review Unit Benefit Design: NDC Based Pricing and Automatic Redirect Site of Care: Infusion Network Strategy 24

25 Impact of Shock Events 25

26 Monthly PMPM Cost: 6% Trend $400 $380 $360 $340 $320 $300 $ Jan 12 Mar 12 May 12 Jul 12 Sep 12 Nov 12 Jan 13 Mar 13 May 13 Jul 13 Sep 13 Nov 13 Jan 14 Mar 14 May 14 Monthly PMPM Cost Jul 14 Sep 14 Nov 14 Jan 15 Mar 15 May 15 Jul 15 Sep 15 Nov 15 No Trend 6% Trend

27 Monthly PMPM: 6% Trend with one HCC 27

28 Rolling 12 Month Average PMPM Cost -2% +15% 28

29 Year over Year Trend 29

30 Seasonality 30

31 Claims Seasonality Showcase Paid to Allowed ratio of claims on top of the total claims 31

32 Claims Seasonality Showcase Influenza claims for You can see the clear peaks in each flu season 32

33 Leveraging 33

34 Benefit Leveraging 80 10% % 88 20% 13.3% 0% 0% Leveraging = 3.3% Leveraging = 10% 34

35 Questions & Discussion 35

36 Jumbo Claimants Data includes all BCBSTX ASO accounts with greater than 500 members and 24 months experience Thresholds trended at 7% annually Claim dollars on a paid basis Excludes Medicare Primary 36