Top 10 Issues for Health Plans - Strategic & Operational Priorities

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1 Top 10 Issues for Health Plans - Strategic & Operational Priorities Thomas Carleton, Sr. Director, Health IT & Analytics Mosaic Health Solutions (BCBS NC) Nancy Wise, SVP, Strategic & Regulatory Consulting HTMS, an Emdeon Company PRESENTER LOGOS HERE 1

2 HCEG organizes forums for health plan executives to exchange ideas, develop valuable peer relationships, explore innovation, and navigate tactical and strategic issues in healthcare. Information Technology Dialogue & Networking Experience & Insight Operational Innovation Develop forums (webinars, whitepapers, conferences) for the enhancement of information technology and operations in healthcare Educate executives on clinical and administrative trends, new and emerging technologies, and other innovations to assist in achieving cost containment, effective service, and high quality healthcare Create an environment for the open exchange of information and insight among health plan executives Provide feedback on the trends and technology needed to ensure products and services meet present and future healthcare needs 2

3 2016 HCEG Top Ten 1. The Consumer Experience: omnichannel business, mhealth, HIX, social media and telehealth. 2. Payment reform: ACOs, P4P, value-based care and value-based reimbursement 3. Population health: managing total health, including social and environmental determinants 4. Provider/Plan integration: combining functions of care delivery and financing in a single organization. 5. Transparency: triple aim price, quality and service measures to support customer decisions 6. Retail health care: established consumer companies disrupt traditional care providers (TIED) 7. Pharmacy: cost, compliance, convenience & specialty health (TIED) 8. Big data and advanced analytics: identifying patterns, opportunities in vastly detailed data sets 9. Cybersecurity: protecting the privacy and security of customer information 10.Genomics: customizing prevention and treatment to individual DNA 3

4 htms core service areas Strategic Analysis Operational Excellence Systems Assessment Selection & Procurement Implementation & Upgrade Strategic Staffing content expertise Core Systems/Optimization Public Program Expertise Medicare, Medicaid, MCOs Consumer Centric Healthcare HIX, Quote-to-Card, Member Portals Payer - Provider Alignment ACO, HIE, Care Management, ICD-10 Emerging Products & Capabilities 4

5 about the Industry Pulse goal Offer insight into strategic and operational priorities for payers during the retail transformation in the industry distribution participation Distribute to payers around the country through: HTMS / Emdeon HCEG The Health Plan Alliance The National Association of State Health Cooperatives (NASHCO) Health plan executives Industry leaders (n>100) The information and materials provided and referred to herein are not intended to constitute legal, regulatory, accounting, medical or financial advice and do not create an attorney-client or other fiduciary relationship between Emdeon/HTMS or its representatives and any third party. Additionally, Emdeon /HTMS does not guaranty the accuracy of the information contained herein. The interpretations, extrapolations, views and opinions of each individual presenter are not necessarily the views of Emdeon/HTMS. Emdeon/HTMS disclaims any and all liability for any reliance you may place on the information contained herein. 5

6 Health plan and industry leaders weighed in 1% Government entity by role by organization type 4% 7% Provider President/CEO 8% 10% Vendor Consultant to health care industry Vice President Director Manager 70% Third party administrator Health plan Specialist/Analyst Other (please specify) 0% 10% 20% 30% 40% 50% % of Participants % of Participants 6

7 what we ll be sharing Assessment of what the data says, and some of our interpretation of what it might indicate across the following topic areas: Perspectives on the ACA Consumer priorities and engagement Risk management Operational Impacts Some thoughts on what this might mean moving forward Quotes from respondents are peppered throughout the document to make the survey results come forward in the voices of health plan participants. New data! Input from the group on lingering questions 7

8 Weighing in on the impact of the ACA 8

9 Overall, How has the ACA affected your company s financial performance? Continued financial pressures from government programs 40% 35% 30% 25% 20% 15% 10% 5% 0% 4% Much Worse 32% Worse 38% About the Same 22% Better Survey was administered prior to the availability of risk corridor results 4% Much Better Participants identified financial challenges ahead See ongoing political challenges and uncertainty with respect to core components of the ACA Lack of knowledge on financial performance with HIX members until 2 years after pricing Financial drain of unsettled Exchange regulations/ 3Rs Challenging reimbursement environment from governments 9

10 This is notably different from last year About the Same Worse Much Worse How have regulatory changes to the Individual Market affected your org s risk pools? 14% 24% 59% Much Better Better Much Worse 60% of respondents reported that their risk pool in the individual market remained the same. Another 28% saw it decline significantly. Better 2% Worse Much Better 1% 0% 10% 20% 30% 40% 50% 60% About the Same 10

11 Participants felt consumers were somewhat better off as a result of the ACA 60% 50% Overall, how do you think the ACA has impacted consumers? 53% Helping families find coverage for their children 40% 30% 20% 10% 0% 7% Much better off Somewhat better off 21% Minimal impact 11% Somewhat worse off 8% Much worse off More patient interaction We want to increase efforts on member engagement and improve member satisfaction 11

12 How do we engage consumers? 12

13 Which of the following do you believe consumers most want from their health insurance coverage? Something they can afford Lower care costs Access to their provider of choice Support on navigating the health care system Coordinating care across providers 38% 27% 71% 86% Easy to understand benefits and consolidated billing Lower Premiums Support to stay well Other 18% 9% Shoppable real prices & quality ratings 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Participants could select up to 3 choices 13

14 Payers may want to consider alternative models Payer as a partner in health Preventive maintenance Care coordination Condition management Health education (health tips) Payer as a partner in health finance Transparency into cost / quality Support in choosing the best: Treatment option Care setting Provider Help with managing health care investment dollars Minimizing unexpected costs 14

15 Technology is finally embracing the healthcare industry via its many facets of services Which of the following tools and services does your organization use in order to engage more with consumers? Health risk assessments 66% Smart monitors for certain condition monitoring and ongoing management Patient portals Member incentives Proactive outreach Social media Cost estimator tools Mobile health applications 35% 40% 50% 64% 61% 66% Surely, from mobile technology to information, consumers will be more informed about their conditions, preventive measures and cure. The interaction between consumers and physicians will be richer. Provider and condition price Other None 6% 5% 31% Members on board of directors 0% 10% 20% 30% 40% 50% 60% 70% Participants could select all that apply 15

16 Which forms of retail distribution have your plan adopted? Broker channels Understanding how to be a retail driven organization and how to make the transition to that model 52% By 2020, which distribution channel do you expect to overall be most productive for health plans? Public HIX Private HIX None Storefront 20% 25% 32% 52% Public Exchange Multi-Payer Private Direct Sales (web-based) Broker 12% 12% 36% 33% Other 10% Single-Payer Private 7% 0% 10% 20% 30% 40% 50% 60% Participants expect exchanges to be the dominate form of distribution by 2020 Storefront 1% 0% 10% 20% 30% 40% 16

17 How do we manage risk? 17

18 Which of the following methods does your organization currently use to manage member risk? Improved data analytics on ACA members and subsequent targeting for care management and risk adjustment reporting Disease / condition management 86% Increased provider risk sharing 51% 52% of participants identified risk management as a critically important operational priority (up 17% since 2013). Alternative reimbursement methods Member segmentation Accountable Care Organizations Other 6% 41% 35% 49% 0% 20% 40% 60% 80% 18

19 Which data sources are the most important for managing your population's risk? There is an opportunity for using more non-traditional data to improve consumer engagement: social, broader community, 3rd party nonmedical data Internal member and claims records Provider data and claims Risk adjustment vendor data warehouse Government data sources 20% 46% 74% 79% Today, a majority of participants do not incorporate data sources beyond claims and risk adjustment data, but some may be looking to expand that in the future. Socioeconomic data Consumer financial data Other 7% 4% 17% Expanding risk management to include social determinants of health 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 19

20 How do we prioritize operations? 20

21 The opportunity for differentiation will be in customer service and member engagement C r i t i c a l Customer service Data analytics Privacy & security Membership retention Customer service Membership retention Membership growth Regulatory compliance Data analytics Member retention Customer service Regulatory Compliance Membership Growth Provider Networking & Contracting Member retention Member growth Customer service Member retention Automation & performance optimization Member growth Member retention Regulatory/ mandate compliance Health care reform compliance I m p o r t a n t Vendor Relationships Brand & Marketing Product benefit design Provider Networking & contracting Product benefit design Payment integrity Brand, marketing, communications Private HIX Public HIX Risk Mgmt Payment Integrity Claims accuracy and recovery Risk management Product benefit design Regulatory/mandate compliance Customer service Claims accuracy & recovery Product design Automation & process optimization Product design L o w e r p r i o r i t y Payment integrity Risk mgmt. Privacy & security Brand, marketing, & communications Product benefit design Privacy & security New sales channels Privacy and security Risk mgmt. Customer Service Risk Mgmt. Claims accuracy and recovery 21

22 Improvement in technology and operational infrastructure to help enable access to data for analytics and proactive member interventions Branding & marketing Several critically important operational issues have steadily increased in priority since 2013 Automation & performance optimization Data analytics Customer service 0% 10% 20% 30% 40% 50% 60% 70% 80% 22

23 What key pain points has your plan encountered during HIX administration? Lack of knowledge on financial performance with HIX members until 2 years after pricing Enrollment 68% Technology limitations 61% Financial reconciliation 59% Premium billing 55% Financial drain of unsettled Exchange regulations/ 3Rs Risk management Product development Compliance EDI Marketing / Sales reach 21% 29% 34% 50% 45% Provider contracting 18% Other 5% 0% 10% 20% 30% 40% 50% 60% 70% 23

24 Continued controlled growth Remaining consistent since 2013, participants see the most growth potential in Medicare, Medicaid, and Exchange lines of business Medicare 82.5% 7.5% 10.0% Medicaid 76.3% 6.6% 17.1% Individual (public HIX) 68.3% 13.4% 18.3% Self-insured 66.2% 10.8% 23.0% Small group 56.6% 27.6% 15.8% Individual (off public HIX) 59.7% 18.2% 22.1% Large group 50.6% 18.2% 31.2% Ancillary and specialty health 47.4% 5.3% 47.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Grow Shrink No Change 24

25 Challenges 25

26 Thus far, lots have been accomplished! But there is so much more that can be done. Pricing Membership very price dependent Irrational pricing in all market segments Price correction in the individual market Compliance Compliance requirements on exchange products Compliance and the shifting regulatory/statutory sands Financials Additional capital to fund growth Committing the resources and capital necessary to launch alternative payment models and total cost of care management efforts with providers Infrastructure Challenges around new operating platform and ensuring end to end seamless integration Stabilizing the system and processes Creating new solutions and updating the current solutions to competitive standards 26

27 Opportunities 27

28 It's an innovative climate currently for my organization Growth Care Coordination Considering geographic expansion as a new opportunity Expansion to other lines of business Continued growth in the individual market Merger potential Alignment with health systems wanting to partner with health plans Higher degree of integration with provider system to manage costs and risk Advancement of alternative payment models promoting payerprovider collaboration and joint performance improvement Consumerization Technology Investing in CRM, contact center, to be more responsive to individuals The opportunity for differentiation will be in customer service and member engagement. We want to increase efforts on member engagement and improve member satisfaction Implementation of new technology for analytics and reporting as well as care management Improvement in technology & operational infrastructure to help enable access to data for analytics and proactive member interventions Continuing to leveraging technology and data to better manage internal costs and claims trend and enhance the member experience 28

29 One more thought Remaining relevant in an increasingly competitive provider landscape Our state has significant competition Large payer consolidation Increased competition Government regulations and consolidation of the provider community 29 29

30 Why do you work in healthcare? To give to other people and make a difference 60% 50% 40% Enjoy the challenge we face in the future 30% 20% I love what I do 10% 0% To help fix the health care system To tackle satisfying problems For job stability/security To change to world Other The change is constant Participants could select up to three 30 30

31 Buzz Origin Destination Consumer trend hype curve Consumer trend reality curve 31

32 What we re seeing Interest in competitive intelligence Intentional product and portfolio design Operational assessment / efficiency Compliance as a part of strategy and operations Unsticking: Providers, networks, communications, administration, etc

33 QUESTIONS? DISCUSSION

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