One Year Out: Providers Experiences with Public Health Insurance Exchanges

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1 Health Policy One Year Out: Providers Experiences with Public Health Insurance Exchanges July 28, 2014

2 Road Map Introduction to Advisory Board Provider Experiences with and Reactions to Exchanges in Year One 3 Strategy 2015: Stay the Course

3 3 The Advisory Board Company in Brief 3,600 + Hospitals and health care organizations in our membership 2,200 + Health care professionals employed 1,500 + Hospitals using our performance technologies RESEARCH AND INSIGHTS PERFORMANCE TECHNOLOGIES CONSULTING AND MANAGEMENT TALENT DEVELOPMENT Memberships Offering Strategic Guidance and Actionable Insights National Peer Collaboratives Powered by Web-Based Analytic Platforms Seasoned, Hands-On Support and Practice Management Services Partnering to Drive Workforce Impact and Engagement Dedicated to the most pressing issues and concerns in health care 300+ industry experts on call 200+ customizable forecasting and decision-support tools Leading provider: Over 50% of inpatient admissions in the United States flow through our technology platforms Over 1.5 million user sessions annually Key challenges addressed: physician performance, population health, revenue cycle, referral growth, surgical profitability, and supply/ service cost 2,500+ years of operator experience in hospital and physician practices Principal terrains: hospitalphysician alignment/practice management, transition to valuebased care, revenue cycle optimization, hospital margin improvement Range of engagements from strategy/diagnostic to best practice installation to interim management to fully managed services Impacted the achievement of 76,000+ executives, physicians, clinical leaders, and managers 17,000+ outcomes-driven workshops tailored to partners specific needs Survey Solutions Customized strategies for improving employee and physician engagement National health care-specific benchmarking database of 480,000 respondents 165,000 + health care leaders served globally $500 + million in realized value per year 1,300 + engagements completed 6,200 + employee-led improvement projects 3

4 4 Exchanges Take Off, Even With Major Hurdles Providers Expect Continued Outreach Will Find an Untapped Demand Public Exchange Enrollment in Qualified Health Plans M 8.0M Key Challenges for Enrollment Outreach Difficulties with Healthcare.gov Technological difficulties with the enrollment platform required time intensive work arounds, providers expect HIX numbers are smaller due to attrition 2.2M 2.1M Demand outstripped supply Providers already had significant demand for assistance without targeted outreach October to December January to February March Total Return on enrollment efforts unclear Providers reaching out with limited resources and unsure whether efforts will impact volume, payments 1) Numbers do not add precisely due to rounding. Source: HHS, Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period, May 1, 2014; Cheney K and Haberkorn J, Obama: 8 Million Enrolled Under ACA, Politico, April 17, 2014, available at: ACA Private QHP Spreadsheet, ACASignups.Net, July 22, 2014, available at: Advisory Board analysis and research.

5 5 Mission Trumps Finances in Enrollment Efforts External Resources Key to Developing an Outreach Program External Resources for Exchange Outreach and Education Insurance agents and brokers Financially incented by their commission to enroll new patients on insurance products Navigator grant recipients Organizations recieving federal funding to educate and enroll patients on the exchanges Community organizations Established venues to reach a large audience, likely interested in options in the community Key Points on Providers Enrollment Outreach Efforts Effectively connecting with uninsured populations often requires cultural sensitivity (e.g., education, translators) Need to make the process/support convenient for enrollees and be willing to persevere despite complexities Providers have mixed perspectives on the legality of using claims data to focus outreach efforts on uninsured populations Effective enrollment initiatives can be repurposed for other similar efforts Health plans Insurers have clear stake in enrollment results, willing to contribute resources Source: Advisory Board analysis and research.

6 6 Provider-Led Plans See Exchanges as Opportunity Dichotomous Experiences for Providers Contracting With Exchange Plans Providers View Exchange As Possible Point of Entry Expect to reduce marketing expenses given an online presence next to competitors Believe consumers will trust plans run by providers more when given side-by-side choice 75% 18% 28% States where four or fewer insurers have greater than 5% share in individual market Percentage of hospitals currently operating insurance products Percentage of hospitals intending to launch plan within five years Providers Experiences Contracting with Exchange Plans Two types of experiences emerging as providers contract with exchange plans 1 2 Comprehensive Negotiations: Providers including rate discussions for exchange coverage as part of broader negotiation with insurers; rates for services provided under exchange plans essentially the same as rates for services provided under other plans Separate Negotiations: Providers negotiating rates for exchange-covered services separately from other negotiations; rates often lower than rates for traditional private payer coverage Source: Washington Post, Is this the end of health insurers? Jul 5, 2013, available at: North Bay Business Journal, May 23, 3013, State Exchange to Offer Five Health Plans in Region, available at: Kaiser Family Foundation, How Competitive Are State Insurance Markets? October 2011, available at Advisory Board interviews and analysis.

7 Health Plans Squeezing Provider Payment Rates to Lower Premiums 7 7 Some Providers Rejecting Lower Rates, Worried about Future Leverage Harper Medical Group % below commercial rates Anticipated Provider Reimbursement Rates for Exchange Plans Johnson Health System 1 Rates well below commercial rates Desmond Medical Center 1 20% below commercial rates Tenet Healthcare Up to 10% below commercial rates Catholic Health Initiatives Modest discounts from commercial rates WellPoint Inc. Between Medicare and Medicaid rates Ramos Health 1 10% above Medicare rates Span Health System 1 10% below commercial rates Meriwether Hospital 1 5% below commercial rates A Troublesome Precedent? We ve only signed one contract for an exchange plan, at a rate close to Medicare. We can do it for a small book of business if we get new volumes. But I m very afraid of the conversation for our next commercial contract negotiation if we can take those rates on this contract, I know the payer will want it for others. Vice President for Managed Care Rivera Health System ) The Pseudonym. Advisory Board Company advisory.com Source: Advisory Board interviews and analysis.

8 8 Trends in Exchange Plans Track Broader Market Narrow Networks, Beneficiary Cost Sharing Not Unique to Exchange Plans Parallel Market Trends on the Exchanges Increased Beneficiary Cost-Sharing Providers expect patients (especially those opting into Bronze plans) to be responsible for more expenses via high-deductible health plans and increased cost sharing Selective Networks Forming Health plans launched on the exchanges will likely continue to create and sustain high-value and selective networks of care Shift to Risk-Based Contracts Payers have increased interest in value-based arrangements, especially for plans on the exchange or for higherrisk populations Increased Interest in Provider-Led Plans Exchanges present a point of entry for providers looking to launch a health insurance product Source: Advisory Board analysis and research.

9 9 Strategy for 2015: Stay the Course Providers Continue a Wait and See Approach as Questions Loom Questions on Role of Exchanges in Coming Years Plan Loyalty/Turnover What percentage of exchange enrollees will remain in the same exchange plan from year to year? How much churn will there be between Medicaid, the exchanges, and other insurance products? Volume and Case Mix Considerations Will increased coverage lead to significant shifts in demand for particular or all services? How will providers need to adjust capacity in response? Uncompensated or Undercompensated Care To what extent will uncompensated (charity) care be reduced? Will exchange enrollees be able to pay their premiums and beneficiary-portion of care costs? Source: Advisory Board analysis and research.

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