Create happiness if u can t find it

Transcription

1 Create happiness if u can t find it

2 NUTS AND BOLTS OF PREDICTIVE ANALYTICS Why Should We Care and Impact to Your Spend

3 UNDERWRITING During the Dark Ages CAVEMAN Health care op,ons: live or die 3

4 Medical Underwri,ng A process used by insurance companies to try to figure out your health status when you apply for health insurance coverage to determine whether to offer you coverage, at what price, and with what exclusions or limits. 4

5 Factors and Conditions We consider the following condi,ons and factors when evalua,ng each proposed insured. As you review this list, remember that it s just a quick reference and does not include everything that could affect our final underwri,ng decision. Also, some rated classifica,ons may qualify for the Placement Improvement Program, depending on the product, so please contact your underwriter for more details. Preferred Plus/Preferred Risk Guidelines (For all products except Na,onwide YourLife Single Premium UL) Ages: Nontobacco Preferred Plus Nontobacco Preferred Tobacco Preferred NicoCne/tobacco use Minimum specified amount No use within past 5 years $100,000 ($125,000 Na,onwide YourLife Term II; $250,000 Na,onwide YourLife 20- pay, WL 100 and YourLife SUL II) No use within past 12 months Use within past 12 months $100,000 ($125,000 Na,onwide YourLife Term; $250,000 YourLife SUL II) Minimum age Maximum age Blood Pressure Readings Depends on product (see specific product specifica,ons) Up to and including age 70, depending on product Not to exceed 140/80 age <55 Not to exceed 145/90 age <55 Not to exceed 140/90 age >55 Not to exceed 150/90 age >55 No Treatment Treated blood pressure acceptable if well controlled for at least one year Treated cholesterol acceptable Treated cholesterol acceptable < 210 and <4.5 < 230 and <6.5 < 260 and <5.0 < 220 and <4.0 < 240 and <6.0 < 270 and <4.5 < 230 and <3.5 < 250 and <5.5 Blood Pressure Treatment Total cholesterol and HDL raco Moving violacons DUI/DWI Drug/alcohol abuse Family history Felony conviccon AviaCon/avocaCon/foreign travel No more than 1 in the past 3 years No more than 2 in the past 3 years No DUI/DWI convic,on in the past 5 years No history of abuse No history of abuse within 10 years No death due to cardiovascular disease or cancer in either parent or sibling prior to age 60 No history of felony convic,on No ra,ng for avia,on, hazardous avoca,on risk or foreign travel/residence risks Civil exclusion can be used, if available ins state the applica,on was signed, with possible considera,on for Preferred and Preferred Plus if rest of case qualifies Any avia,on (excluding commercial pilots) or hazardous avoca,on risk is not eligible for Preferred Plus Personal History No history of coronary artery disease, diabetes, stroke or cancer (except basal cell- skin) 5

6 Life Underwriting Build Chart (For all products except Na,onwide YourLife Single Premium UL) Height Preferred Preferred Standard Table B Plus or Beger or less 198 or less 205 or less 211 or less 218 or less 225 or less 232 or less 239 or less 246 or less 253 or less 261 or less 268 or less 276 or less 284 or less 292 or less 300 or less 308 or less 316 or less 324 or less 332 or less 341 or less 349 or less Table C Table D Table E Table F Table H Table J Table L Decline

7 CEO of General Electric: Jeff Immelt So, Industrial Companies are in the informa,on business whether they want to be or not. We want to treat analy,cs like it is as core to the company over the next 20 years as material science has been over the last 50 years. 7

8 Big Data The ability to take large sums of data from mul,ple sources and provide useful informa,on in decision support strategy development and predict events in the future. 8

9 Poindexter Process Medical Claims Pharmacy Claims Analysis Action Steps Lab Biometrics Poindexter Opportunity IntervenCon HRA EMR Tracking Results 9

10 DescripCve AnalyCcs What happened? Why did it happen? Challenges Past PracCce/Performance Mines Historical Data/Success/Failure Process of UnderwriCng 10

11 PredicCve AnalyCcs Historical Performance/AcCons Add RaCos/Algorithms/Big Data Sets Probable Future Outcome Likelihood of a SituaCon Occurring 11

12 PrescripCve AnalyCcs Big Data AnCcipates What Will Happen When It Will Happen Why It Will Happen MiCgate Future Risk Prescribing Decision, OpCons, Outcomes DiagnosCc Analysis 12

13 DescripCve AnalyCcs PredicCve AnalyCcs Historical Data Big Data What Happened Why Did It Happen Probable Future Outcome Mi,gate Future Risk Change Outcome PrescripCve AnalyCcs ArCficial Intelligence 13

14 40% of the $3 Trillion healthcare spend each year could have been avoided. 14

15 Predictive Process Iden,fy the Individual Predict the U,liza,on Poten,al/Risk Factor Predict the Cost Interven,on 15

16 Predictive Risk Analysis/ Process System Disrup,on Transforma,on Behavioral Manipula,on Pa,ent to Consumer Revolu,on 16

17 MODEL INCLUDES Age Sex Loca,on Diagnosis Procedure Socioeconomic Considera,on Cost Event Type (inpa,ent, outpa,ent, emergency) Drug Iden,ty Dosage Lab Time Period 17

18 MulC- AdapCve Regression Spline 18

19 f(x)= i=1 k c i B i (x) y = α + c1 ( x τ1 )+ + c2 (τ1 x)+ + c3 ( x τ1 )+ ( z τ 2 )+ + e y α c (x τ ) c (τ x) c (x τ ) (z τ 19

20 20

21 PREDICTIVE ANALYTICS Spend ReducCon through Targeted IntervenCon 21

22 BREAK THE CYCLE Generally Healthy At Risk/LocaCon/Socioeconomic/Hereditary Chronic/Limited Management Polychronic/MulCple Disease States Behavioral in Nature Severe Behavioral End of Life 22

23 PopulaCon Health/PredicCve Risk AnalyCcs/ DisrupCon/IntervenCon/Will! Drive Consumer Revolu,on Change the Model from Episodic Care to Management of an Individual or Popula,on Behavioral Applica,on will Yield Physician Movement from Treatment Silos to Broad Landscapes of Management Fee- for- Service will be Replaced 23

24 Provider PaCent Centered Management Predic,ve Risk Popula,on Health Consumer- Driven Health Predic,ve Risk Engagement Employer/Buyer Benefit Structure Consumer Engagement Value- Based Provider Engagement 24

25 Empowered Employers with PredicCve AnalyCcs Impacts Overall Spend Impact to EBITDA Healthy Workforce/Lower Absenteeism/ Higher Produc,vity Manage and Jus,fy Reinsurance Premiums/Projec,on (Laser Impact) 25

26 We should all try to think outside the box. Advanced Plan for Health Overview 26 26

27 One of Poindexter s Clients Medical & Rx PMPM vs. National Trend Medical PMPM Costs Pharmacy PMPM Costs National Trend *National Trend (Expected) based on 8% annual medical cost trend and 10% annual prescription drug cost trend. $ $40.00 $ $ $38.88 $49.75 $ $62.50 $ $41.70 $ $49.86 $ $ $50.35 $59.03 $ $ $ $ $ $ $ $ May-Jan (2014) While maintaining stable benefits, the APH health plan strategy has contributed to the savings of: $5,950,606 27

28 One of Poindexter s Clients Impact of Poindexter s Intervention Before After Trend #"Participants Age/Gender"Mix Medical0Utilization Pharmacy0Utilization Before After Trend Total"Medical"Claims"Paid $762,916" $589,906" D22.68% Total"Pharmacy"Claims"Paid $314,161" $357,176" 13.69% Per"Employee"Per"Month"(PEPM) $469.49" $361.02" D23.10% $0D % 78.03% 5.96% Per"Member"Per"Month"(PMPM) $417.81" $321.47" D23.06% $10.01D % 12.06% D18.11% Avg."claims/member D15.96% $25.01D % 7.09% D17.89% %"of"claimants"to"members D2.76% $50.01"+ 2.08% 2.57% 23.59% Avg."Claim"Cost $276.02" $253.94" D8.00% Per"Employee"Per"Month"(PEPM) $193.33" $218.59" 13.07% Claims D15.96% Per"Member"Per"Month"(PMPM) $172.05" $194.65" 13.13% E"&"M"visits D11.70% #"Claimants % Preventive"Office"Visits % #"Scripts 3, , % Procedures D14.25% Average"Scripts"per"Claimant % Hospital"admits D51.72% Average"Scripts"per"Member % Hospital"days D51.88% Average"Script"Cost $87.75" $97.30" 10.87% ALOS/hospital"visit D0.31% Generic"%"of"Dollars 46.94% 49.29% 5.00% ER"visits D30.91% Generic"%"of"Scripts 73.03% 76.52% 4.79% Urgent"Care"Visits % 90"Day"Supply"%"of"Dollars 7.88% 7.65% D2.98% %"Paid"InDNetwork"(Total) 99.77% 99.96% 0.19% 90"Day"Supply"%"of"Scripts 5.03% 5.45% 8.46% 28

29 Another One of Poindexter s Clients Impact of Poindexter s Intervention Before After Trend #"of"participants Age/Gender"Mix Medical"and"Pharmacy"Combined Per"Member"Per"Month"(PMPM) $2,681.74" $1,781.11" I33.32% Total"Savings Total"Claims"Paid $3,153,727.82" $2,094,581.09" I33.58% $1,059, #"Claimants % #"Claims 7, , I29.49% Avg."claims/member I29.49% %"of"claimants"to"members % % % Medical0Utilization Pharmacy0Utilization Total"Medical"Claims"Paid $2,531,764.38" $1,471,748.18" I41.87% Total"Pharmacy"Claims"Paid $621,963.44" $622,832.91" 0.14% Per"Member"Per"Month"(PMPM) $2,152.86" $1,251.49" I41.63% Per"Member"Per"Month"(PMPM) $528.88" $529.62" 0.54% Avg."claims/member I32.89% #"Claimants I1.22% Avg."Claim"Cost $669.42" $579.89" I13.38% #"Scripts 3, , I26.07% E"&"M"visits/1000"members I26.91% Average"Scripts"per"Claimant I25.16% Preventive"Office"Visits/1000"Members % Average"Script"Cost $165.11" $223.64" 35.45% Procedures/1000"members I24.65% Generic"%"of"Dollars 37.71% 37.66% I0.12% Hospital"admits/1000"members I65.15% Generic"%"of"Scripts 72.53% 72.09% I0.61% Hospital"days/1000"members I58.22% 90"Day"Supply"%"of"Dollars 7.56% 6.83% I9.73% ALOS/hospital"visit % 90"Day"Supply"%"of"Scripts 4.99% 4.20% I15.86% ER"visits/1000"members I26.98% Urgent"Care"Visits/ % 29