Applying Actuarial Knowledge to Navigate Carrier-Provider Contracting

Transcription

1 Applying Actuarial Knowledge to Navigate Carrier-Provider Contracting Monday, February 24, 2014 Presented by: Adam Singleton, FSA, MAAA

2 Provider Payment & Health System Reform Seminar February 24, 2014 Applying Actuarial Knowledge to Navigate Carrier-Provider Contracting Presented by: Adam R. Singleton, FSA, MAAA United Health Actuarial Services, Inc. Although I love to talk, let s have a quick reminder of a few things we would like very much to avoid talking about. Let s not talk about prices. Let s not talk about specific use. Keep discussions general to avoid confidentiality breaches. Remember that I m here to help actuaries help carriers and providers work with each other to improve our health care system! 2 2 1

3 Do you remember the old SOA motto? 3 3 The work of science is to substitute facts for appearances and demonstrations for impressions. John Ruskin 4 4 2

4 Navigating Provider-Carrier Negotiations Out of all my actuarial roles, I found the most opportunity to live the old SOA motto while serving as an actuarial and analytical advisor for a large managed care organization s provider contracting division. Today I will share some of my observations and thoughts about how actuaries can help both carriers and providers as they evaluate and negotiate payment terms in today s environment. The majority of my experiences occurred while supporting negotiations and network development in a fee-for-service environment on behalf of a carrier; a significant amount of that activity involved narrow networks pre- and post- ACA, as well as many situations with capitated or provider risk-share aspects. The context of our discussion will mostly be from a Commercial / Exchange perspective, although much of what I cover would, at least partially, apply to managed Medicare or Medicaid networks. Additionally, there will be a bias toward a carrier perspective, but provider perspectives are equally important. 5 5 Navigating Provider-Carrier Negotiations Today s topics include: Internal and External negotiations Help negotiate what to negotiate. Adversarial vs. Partnership situations Try to collaborate rather than negotiate. Technical Support that actuaries can offer Looking under the hood of the car can get it moving in the right direction. The Softer Skills There are benefits to having an actuary at the negotiation table. Case Study: A real-life, anonymous example Several layers of actuarial support helped move a deal forward

5 Navigating Provider-Carrier Negotiations Presenter s Background Adam is a health care actuary with 18+ years of experience working with Blues, A&H, Life insurance, and managed care organizations. He recently joined United Health Actuarial Services, Inc. (UHAS) as a Consulting Actuary, where he provides a variety of actuarial services, with a focus on provider payment and network development topics. Since 2003, Adam has been heavily involved in work related to the evaluation, development, negotiation, marketing, and pricing of Commercial provider networks. Prior to joining UHAS, Adam worked directly for the Vice President of Provider Contracting for a large multi-state managed care organization, where he built and led a specialized analytics team that focused on competitive benchmarking, claims data mining, provider reimbursement analysis, health care market analysis, network strategy and development, and pricing for Group and Individual insurance. Adam has evaluated provider networks in over 100 CBSA s throughout the U.S. and has supported negotiations and provided consultative services for dozens of narrow networks throughout the U.S. 7 7 Internal and External Negotiations Let s talk about the types of people involved in provider negotiations Managed Care Negotiators Financial Leaders Executive Leaders Sales Leaders a carrier dynamic Analytics Teams Other provider partners All participants are important contributors Opinion Alert: Actuaries tend to under-value the abilities of these contributors That said, actuaries still bring tremendous value to the negotiation Other than perhaps the Executive Leaders, actuaries can bring the broadest, most credible perspective to the table 8 8 4

6 Internal Internal and External Negotiations The pre-negotiation stage is critical Having the facts about the performance of a contract is important. Internal stakeholder incentives are not always aligned. Good analysis mitigates the impact that politics have on the strategy. Particularly in more local negotiations, anecdote can disrupt the process. At the negotiation table, the provider has their set of facts as well; the more misaligned the facts, the less likely a negotiation will succeed. 9 9 Internal Internal and External Negotiations Are the analytics sound? Even with good teams, analytical mistakes can lead negotiations astray. How much of the strategic discussion is anecdotal vs. accurate data analysis? What kind of analysis? Is there enough data to reflect the average service and severity mix? If not, were adjustments made or other data introduced? Are calculations done correctly? Are what if / trade-off scenarios being modeled correctly? Actuaries can ensure that there are sound analytical approaches and oversight

7 Internal Internal and External Negotiations Actuarial models during the pre-negotiation stage What is the value of the existing contract? What kind of increase/decrease should be proposed? Is the price the carrier pays reasonable relative to other payers? Is this provider high cost, low cost, etc. relative to similar providers? What is the impact of the provider contract on premiums? Internal and External Negotiations Internal Why are solid analytics so important at this stage? Besides the obvious, bad analytics can de-rail carrier-provider relationships. Negotiations are emotional; while people might not like the facts, if they trust them they will typically be willing to address them. Both parties want to maximize savings or revenue. Negotiations are very difficult if both parties truly believe different sets of facts Ignorance ultimately yields increased costs; it is not a viable option. We ve considered the cost side of the equation as quality measures are integrated into contracts, analytical needs increase will there be more agreements or disagreements? Let s agree on letting the actuaries get the measurements right!!!

8 External Internal and External Negotiations Typically some exchange of proposals occurs first Both parties will evaluate proposals. When facts are straight and incentives align things are wonderful! When they don t, the actuary can often help with re-alignment. Actuaries can supply data and or make presentations. Sometimes the actuary needs to be directly involved in discussions and meetings with the negotiators External Internal and External Negotiations What do we bring to the negotiation table? Market premium perspectives tolerance for premium rate increases, and, the degree of competition. Accurate assessments of the contract price: relative to other payers, and, relative to other similar providers. (Yes, it is possible to make these comparisons, if we have any doubters)

9 Internal and External Negotiations External What do we bring to the negotiation table? An increased perception of objectivity about the negotiation. Accurate savings analysis and market premium needs for alternative networks. Credence and support to statements and assertions previously made by the Managed Care negotiator. Explanations for complex topics related to data quality, analysis, credibility, calculations, price sensitivity, & population risk (esp. ACA). Actuaries can eliminate a lot of noise from the negotiation by making some of the unknown variables known reducing the level of fear & distrust Adversarial vs. Partnership Most negotiations are Adversarial Incentives are often misaligned Let s start with fee-for-service reimbursement. Degree of carrier and provider competition has a big impact. Dollars and egos are big too! Fear of the unknown is a big contributor Actuaries can help mitigate this problem with solid data & analysis. Assumption of bad intentions Relationships and trust are incredibly important. How are we going to transform the payment system under these conditions? Actuaries can increase the degree of trust at the negotiation table We bring sincerity with our approach. We are good at presenting just the facts. Our opinions are perceived to be driven by sound, logical deduction of the facts and economic principles Does these look like trust worthy actuaries?

10 How about these? Adversarial vs. Partnership Even when representing one side of the table we can help move carriers & providers towards partnerships. Respect the value of listening and understanding all perspectives. Don t put limitations on what you think you can learn or accomplish with respect to the facts, but be careful. Incorporate and consider all information that is communicated in the negotiations. Diligence in your analytics is critical not all things are as they appear; a healthy skepticism will serve you well, so long as you can keep an open-mind too! Remember the SOA Mission Statement The SOA, through research and education, advances actuarial knowledge and improves decision making to benefit society. We enhance the ability of actuaries to be trusted financial and business advisors on problems involving uncertain future events. We provide and ensure the integrity and relevance of our credentials

11 Measuring Contract Value Cost increases Actuarial Technical Support Are tools appropriate? Fee-schedule analysis, hospital contract analysis, etc. Understand the nuance not all approaches work well for all services. Is there enough data to measure the change in payment? How much variability exists with respect to service severity? What about variability by type of patient population? What is the cost of services relative to other similar providers? Cost Indexing providers is important to understand your options. It was critical in a fee-for-service environment and even more important for tiered or narrow networks and attributed networks, such as an ACO. How good is the contract cost relative to other payers? Competitive benchmarking is very important. Like it or not cost usually heavily outweighs the perception of quality Actuarial Technical Support Assessing Population Risk Health/Financial Risk Population health risk is very important when payments are tied to population health, quality indicators, or sharing risk. Actuaries help explain the impact of changes in underwriting rules, marketing and selling dynamics (e.g., on-exchange vs. off-exchange). Providers and carriers need to understand regulations regarding access to certain services, network adequacy, frequency of out-of-network events, etc. Health risks can be segregated into tranches and managed differently. Remember the 3R s and Risk Adjustment too! While not as important with fee-for-service contracts, assessing population risk is still valuable. Providers are often concerned about bad debt / un-collectables Actuaries can help move a negotiation forward with demonstrations of the impact member cost share levels can have on overall reimbursement. Models can help explain trade-offs; show the big picture, beyond a narrow path

12 Assessing Market Competition Actuarial Technical Support Often myths prevail with respect to market competition. Different players can compete differently: Different players may set prices different from their cost structure (intentionally and unintentionally). Carriers might not be competing on an apples-to-apples basis in terms of geographic scope, benefit design, or underwriting. Maybe someone else has a strong political connection. That said, cost-of-care is still critical Assessing Market Competition Actuarial Technical Support Organizations often don t have the time or take the time to research what is really happening in a market; anecdotes can cause havoc. Actuaries can advance negotiations and partnerships with data, evidence, insights, and deductions about competitive dynamics. Providers don t always understand the regulatory environment. No one has the magic to just come up with this on their own. A disciplined process for intelligence gathering and evaluation is critical

13 Actuarial Technical Support Projecting Costs & Allocating Payments Equitably As provider risk-sharing or other payment approaches such as bundles of care become more prevalent the issue of how to pay the participating providers becomes much more important. You think carrier-provider negotiations can become contentious imagine a hospital, a surgeon, an anesthesiologist, and an attending physician all trying to determine who adds the most value and who should get what share of the bundle. Hmmm Actuarial Technical Support Of course our goal as actuaries and patients would be that it would look more like this:

14 Actuarial Technical Support Projecting Costs & Allocating Payments Equitably Traditional cost and utilization models are good, but someone will probably need to determine how to allocate episodic costs equitably. What about shared risk pools? What about provider reinsurance? Has anyone encountered providers arguing about an attribution model? I haven t yet, but when payment is contingent on an algorithm that decides who your patients are. Negotiations will stall or political leverage will prevail without the ability for carriers and providers to understand the complexity of these sorts of arrangements. Negotiators need transparent, clear, well-trusted facts, data, and models from actuaries The Softer Skills Other benefits of having an actuary at the negotiation table We ve discussed credibility, market knowledge, diligence, etc. Negotiations are tense. The managed care negotiators and other leaders often do a good job of maintaining civility (but not always); however, there is often a degree of uneasiness. Actuaries bring a new face and new perspective. Typically, a few actuarial jokes are made or other remarks are made about your stereo-typed quirkiness or introverted nature (or love of Star Trek). Take these things in stride they help lighten the mood in the room and put people at ease with you. You bring a realness to the negotiation. Everyone in the negotiation knows it is about money (mostly), but you can help remind them why they need to be reasonable and agree carriers and providers are both looking out for the patient s interest too! Just in different ways. Lastly, remember that the people negotiating are smart and are experts in their area of practice. Learn from them and trust their lead in the negotiation. Let them coach you on what or what not to say, who your audience will be, and always make yourself approachable to both sides of the negotiation table

15 Well maybe not too approachable! And never forget

16 Case Study The case study will be made available at the seminar