SOA Annual Symposium Shanghai. November 5-6, Shanghai, China. Session 4b: Health Insurance Market in China. Jesse Song

Transcription

1 SOA Annual Symposium Shanghai November 5-6, 2012 Shanghai, China Session b: Health Insurance Market in China Jesse Song

2 Jesse Song, FSA, MAAA Agenda China health insurance market overview US health insurance practice sharing Market development calls for actuaries expertise 1

3 China healthcare spending overview RMB billion China Healthcare Expenditure by Source of Funding 1,800 1,600 1,00 1,200 1, % CAGR ( ) others out of pocket Commercial insurance Public % 50% Healthcare spending is low but is growing rapidly Over 0% of the healthcare expenditure is currently paid by individual Individual spending on healthcare continue to rise faster than GDP growth and inflation. Only % is financed through supplemental insurance 1% Rank by Per Capita Cost Country Total Health Expenditure % Per Capita % of GDP 50% 1 United States $7, % 5 Switzerland $6, % 10 Canada $,5 9.8% 116 China $16.% Sources: WHO, WPMI analysis USD Billion USD Billion Despite growing share in total life market, health insurance market remains small Life Insurance Premiums 25% CAGR (2007 to 2011) Health & Accident Insurance Premiums % CAGR ( ) % 2010 Distribution of Total Life Premium 5% 2% 10% Health ADD Term Life Other Life 2010 Term Life, Health and ADD Premium Individual vs. Group 15% 85% Individual Group 1% 2% 2010 Distribution of Term Life, Health and ADD Premium 1% 56% 2010 Health and ADD Premium Individual vs. Group 68% Term Life Health ADD Individual Group Sources: CIRC, Insurance Yearbooks 2

4 China Healthcare Ecosystem 1. Government basic program (three pools) + employers supplemental plans + Individual plans 2. Providers dominated by public sector hospitals; lack of industry standards around hospital/ physician practices; inconsistent quality of care. Majority FFS payment; some total payment reform. Reimbursement for supplement plan; cashless services for highend plans only 5. Lack of data standard Public Payer Government/Social Security Private Payer Commercial Insurance People Personal Healthcare Needs: Information Access and service delivery Management Payments and Risk Protection Payer Healthcare Ecosystem Provider Public Sector Providers Hospitals/Community Health Centers Private Sector Providers 5 Healthcare reform remains a top government and societal priority in China Healthcare Reform Goals Three year, US$125 billion reform plan launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by Expanding coverage to insure more than 90% of the population 2. Establishing a national essential medicines system to meet everyone's basic needs. Improving the primary care delivery system. Making public health services available and equal for all 5. Reforming public hospitals and the healthcare delivery system 6

5 Group Health Insurance Group health insurance a prevalent employee benefit in China Coverage for Accidental Risk and Additional Ancillary Benefits Critical Illness Hospital Allowance Travel Insurance Accidental insurance Long Term Disability Life insurance Commercial Group Insurance Enhanced Health Coverage High end medical Middle end medical BMI supplemental Tiered offerings, benefits from low to high w/ choice of: osupplemental or unlinked w/ BMI ohealth provider access omaternity, preventative care, emergency, dental and vision oco insurance, maximum pay out ohealth management Mandatory social security benefits Social Medical Insurance Basic Coverage Basic Medical Insurance (BMI) for urban employees BMI Hospital List BMI Drug Catalogue BMI Diagnosis and Treatment Catalogue BMI Coverage: OP & IP w/ coinsurance 7 Multi-tiered supplemental plans 2 1 Worldwide coverage Annual limit 10 million RMB Comprehensive (preventive, dental, etc.) Cover non BMI, foreign clinics/vip with coinsurance Deductible Annual limit 1 million RMB Cover non BMI, foreign clinics/vip with coinsurance Deductible Annual limit 50,000+ RMB Cover non BMI and VIP access with co insurance Deductible Annual limit 20,000 RMB Non BMI expense excluded 8

6 Gaps in product and service offerings What s Available A variety of commodity type insurance products Health products that are riders to a life insurance policy Lack of information about healthcare and health conditions A hospital experience that is intimidating and confusing What s Needed Products and services that are needs based Stand alone health insurance that are relevant for an individuals unique circumstances A trusted source for general and condition specific health information including tools and programs Help with navigating specific healthcare needs Products that provide asset protection Healthcare management assistance 9 Challenges in development of a robust health insurance market in China 1 Government policysupport 2 Consumer awareness Provider collaboration Industry expertise development 10 5

7 Agenda China health insurance market overview US health insurance practice sharing Market development calls for actuaries expertise 11 Health insurance companies can play an important role in the financing and delivery of health care Employer Design products and services that align with business need Support member education Understand and influence medical cost trends Reduce administrative cost Government Program Manage government program Integrate and coordinate with government program Control costs and ensure appropriate utilization of health care services Commercial Insurance Individual Understand member needs and deliver focused products and services Provide information about prevention and care Opportunity to improve access and health quality Provider Determine where care is delivered through development of provider networks Opportunities for improving health outcome Control costs through negotiation with providers and ensure use of appropriate evidence based services 12 6

8 Product innovation evolves to balance the costs and needs of its customers Health Plan Enrollment for Covered Workers by Plan Type NHE Percent Growth Over Prior Year % 7 7.5% 1 5.1% 2 5.8% 2 6.% % 2 8.6% % % % % % 6.7% % 0% 10% 20% 0% 0% 50% 60% 70% 80% 90% 100% Source: Kaiser Family Foundation Indemnity HMO PPO POS CDHP 1 Targeted programs and policies developed for both providers and members Clinical Data Lab, PHR, HRA, Carved out services Insurance Company Administrative Data Claims, eligibility, demographics PROVIDER COMPONENT CONSUMER COMPONENT Quality Improvement Tools Pay for Performance Network Centers of Excellence Quality/ Safety Tools Cost and Outcomes Tools Decision making Tools Source: WellPoint 1 7

9 Extensive data leveraged to analyze and manage costs US Best Practices Leveraging Data Clinical and Evidence based d administrative data medicine Identification and Stratification % of Members 50% 20% 25% % 1% Well Members Prevention and Education Low Risk Members Optimize Resources in Acute Episodes of Care, Population Care Moderate Risk Members Disease Management and Education, Risk Avoidance High Risk, Multiple Diseases Episodic Care Mgmt, Clinical Guidelines, High Risk Disease Mgmt Complex and Intensive Care Total Care Integration 10% 10% 25% 0% 25% % of Health Care Costs Source: WellPoint 15 Integrated Health Care Model: Better Health Lower Costs Higher Member Satisfaction Source: WellPoint 16 8

10 Agenda China health insurance market overview US health insurance practice sharing Market development calls for actuaries expertise 17 Health insurers shall develop a diverse set of capabilities Claims Administration Customer Service Support Functions Membership and Billing Medical Care Management Quality Insurance Company Training Product Development Data Analytics Procedures Ancillary Products Payment for Services Provider Network 18 9

11 Practical steps for market transition need actuaries contribution Market Practice Homogeneous plan and gaps in protection Restrictive practices and individual underwriting Products Underwriting Best Practice Innovative plan design; enhanced catastrophic t coverage Professional group underwriting approach and the pooling principle of insurance Bundling of risk and medical benefits; lack of transparency Low data quality and lack of comprehensive analytics Pricing System and Data Analytics Disciplined and transparent pricing methodology and practice High quality data transformed to meaningful information to help employers understand utilization, cost and health risk 19 Evolving product offerings can strengthen catastrophic insurance coverage Case study: An employee is diagnosed with leukemia in Feb Medical expenses out of BMI scope not covered He will most likely be excluded from the group life andad&dcoverage in 201 No long term disability coverage Product considerations: High dollar claimant reimbursement v.s. critical illness Appropriateness of extending coverage for expenses out of BMI scope Long term disability Case management 20 10

12 Use data analytics to understand health care cost and deliver value Collect Enrich Member data (demographic, claims medical, claims Rx) Provider data (diagnosis, procedures, admission, discharge) Other (physical check up, HRA) Integrated and aggregate analytics Unit cost Trend Pricing Utilizations High cost Reserving Incidence rate Chronic disease Data not there Deliver Solid pricing and reserving Continuous innovation on product design Value (care management) 21 Summary There are significant opportunities to develop a 1 robust, sustainableprivate healthinsurancemarket for China, despite the existing challenges 2 Best practices in other countries need to be localized to make it work for China Actuaries shall be part of the industry collaborations to develop sustainable solutions 22 11