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PAYER ANALYTICS IN A SHIFTING
HEALTHCARE LANDSCAPE
Technology for Value Based
Care Meetup
June 19, 2018
1
DISCUSSION TOPICS
Value Based Care Meetup – June 19, 2018
Payer Analytics in a Shifting
Healthcare Landscape
1) STATE OF...
2
WHAT IS ACA?
Payer Analytics in a Shifting
Healthcare Landscape
1) Individual Mandate - All citizens & legal residents a...
3
ACA BY THE NUMBERS
Payer Analytics in a Shifting
Healthcare Landscape
Source: Kaiser Health Spend Analyzer, based on U.S...
4
CURRENT STATUS OF ACA
Payer Analytics in a Shifting
Healthcare Landscape
1) Individual Mandate – repealed as part of the...
5
INSURER PARTICIPATION ON ACA EXCHANGES
Payer Analytics in a Shifting
Healthcare Landscape
Source: Henry Kaiser Foundatio...
6
KEY TRENDS IN THE
PAYER MARKETSPACE
Value Based Care Meetup – June 19, 2018
Payer Analytics in a Shifting
Healthcare Lan...
7
GROWTH OF GOVERNMENT SPONSORED HEALTHCARE
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – J...
8
HEALTHCARE INDUSTRY CONSOLIDATION
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19, ...
9
HEALTHCARE INDUSTRY CONSOLIDATION
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19, ...
10
HEALTHCARE CONSUMERISM
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19, 2018
Sourc...
11
HEALTHCARE CONSUMERISM
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19, 2018
Sourc...
12
INCREASED PRESSURE TO REDUCE COSTS
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19...
13
WHERE PAYER ANALYTICS
ARE HEADING
Value Based Care Meetup – June 19, 2018
Payer Analytics in a Shifting
Healthcare Land...
14
INTERNATIONAL INSTITUTE FOR ANALYTICS MATURITY
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meet...
15
ANALYTICS ROI MATURITY MODEL
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19, 2018...
16
HEALTHCARE PAYER ANALYTICS LANDSCAPE
Payer Analytics in a Shifting
Healthcare Landscape
MAINTAIN OR RETIREMONITOR
EXPER...
17
PAYER ANALYTICS NEXT 5-8 YEARS
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19, 20...
18
DATA MANAGEMENT & GOVERNANCE
Payer Analytics in a Shifting
Healthcare Landscape
Value Based Care Meetup – June 19, 2018...
19
QUESTION & ANSWER
Value Based Care Meetup – June 19, 2018
Payer Analytics in a Shifting
Healthcare Landscape
Strategy ∙ Execution ∙ Results
Phil Kelly
Managing Partner
Email: Phil.Kelly@ipowerconsult.com
Office: 630.219.0047
Mobile...
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Payer Analytics In A Shifting Healthcare Landscape - June Presentation To Chicago Technology For Value-Based Healthcare

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This is the June 2018 presentation to the Chicago Technology For Value-Based Healthcare https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/

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Payer Analytics In A Shifting Healthcare Landscape - June Presentation To Chicago Technology For Value-Based Healthcare

  1. 1. PAYER ANALYTICS IN A SHIFTING HEALTHCARE LANDSCAPE Technology for Value Based Care Meetup June 19, 2018
  2. 2. 1 DISCUSSION TOPICS Value Based Care Meetup – June 19, 2018 Payer Analytics in a Shifting Healthcare Landscape 1) STATE OF THE AFFORDABLE CARE ACT 2) KEY TRENDS IN THE PAYER MARKETSPACE 3) WHERE PAYER ANALYTICS ARE HEADING
  3. 3. 2 WHAT IS ACA? Payer Analytics in a Shifting Healthcare Landscape 1) Individual Mandate - All citizens & legal residents are required to have health insurance to avoid a tax penalty 2) Minimum Essential Health Benefits ▪ 10 essential health benefits that must be included in both individual and small group health insurance policies ▪ 4 standard cost sharing models; Bronze, Silver, Gold, and Platinum. ▪ Pre-existing condition exclusions and lifetime or annual dollar limits prohibited 3) Additional Market Regulations ▪ Guaranteed issue of all non-group health plans during open enrollment ▪ Premiums can only vary based on 4 factors; age, geography, family composition, and tobacco use 4) Co-Ops & Risk Corridors ▪ Consumer operated and oriented plans - designed to provide a non-profit option for Healthcare coverage ▪ Risk-corridor program was established to help offset insurer losses in the first three years of the insurance exchanges 5) Medicaid Expansion ▪ Medicaid eligibility expanded from 61% to 138% of the federal poverty level (FPL) ▪ Minimum essential health benefits for newly eligible adults & increased drug rebate percentage 6) New Taxes – projected at $20-$30B per year ▪ Medicare payroll tax on wages increase from 1.45% to 2.35%, ▪ Healthcare Payer taxes that peak at $14B annually ▪ Escalating taxes on pharmaceutical manufacturers (peak at $2.8B annually) ▪ New excise tax of 2.3% on the sale of medical devices ▪ Exclusion of over-the-counter drugs from HSA reimbursement Value Based Care Meetup – June 19, 2018
  4. 4. 3 ACA BY THE NUMBERS Payer Analytics in a Shifting Healthcare Landscape Source: Kaiser Health Spend Analyzer, based on U.S. Department of Health and Human Services (HHS) - National Health Expenditure Accounts (NHEA) Source: Gallup- Sharecare Well-Being Index 2017 Value Based Care Meetup – June 19, 2018
  5. 5. 4 CURRENT STATUS OF ACA Payer Analytics in a Shifting Healthcare Landscape 1) Individual Mandate – repealed as part of the 2018 Tax Reform Bill (H.R.1) starting in 2019 2) Minimum Essential Health Benefits – current administration is considering the approval of plans that don’t meet all standards 3) Additional Market Regulations – Unchanged but payers have begun to pull out of ACA markets 4) Co-Ops & Risk Corridors ▪ Only 4 of 23 Co-ops have remained financially viable ▪ $8B in risk-corridor payments went unpaid to payers – gov’t recently won on appeal 5) Medicaid Expansion - adopted by 34 states – additional spend of $8.5B 6) New Taxes - Repealed by the American Health Care Act (HR 1628) in 2017 ▪ Employer Mandate Tax ▪ Medicine Cabinet Tax ▪ Flexible Spending Account tax ▪ Chronic Care Tax ▪ HSA withdrawal tax ▪ Health insurance tax (deferred for 2017 & 2018) ▪ Medical device tax ▪ Tax on prescription medicine ▪ Tax on retiree prescription drug coverage Value Based Care Meetup – June 19, 2018
  6. 6. 5 INSURER PARTICIPATION ON ACA EXCHANGES Payer Analytics in a Shifting Healthcare Landscape Source: Henry Kaiser Foundation: Insurer Participation on ACA Marketplaces, 2014-2018 2014 2018 Value Based Care Meetup – June 19, 2018
  7. 7. 6 KEY TRENDS IN THE PAYER MARKETSPACE Value Based Care Meetup – June 19, 2018 Payer Analytics in a Shifting Healthcare Landscape
  8. 8. 7 GROWTH OF GOVERNMENT SPONSORED HEALTHCARE Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 Health Insurance Premiums & Enrollments Source: NAIC 2017 Health Insurance Industry Analysis Report Medicare/Medicaid has grown an average of 31% annually. It now represents 54% of all health insurance.
  9. 9. 8 HEALTHCARE INDUSTRY CONSOLIDATION Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 INTERMEDIARIES • Insurers • Pharmacy Benefit Mgrs. • ACOs PROVIDERS • Ambulatory • Acute • Post-Acute • Retail • Tele-Health HEALTH TECH • Analytics/HIE’s • Mobile • Wearables • Tele-heath tools • Blockchain PURCHASERS • Wholesalers • Mail Order • Purchasing Groups MANUFACTURERS • Drug • Device • Medical/Surgical PAYERS ▪ Government ▪ Employers ▪ Individuals Healthcare Value Chain UNC & Carolina Healthcare Ascension & Presence PinnacleHealth & UPMC Northshore & Advocate Dignity Health and Catholic Health Initiatives (CHI) 115 mergers in 2017 alone United Health & Optum Centene & Fedelis CVS and Aetna JP Morgan, Amazon, Berkshire Hathaway Optum & Surgical Care Affiliates Humana & Kindred Healthcare Wellcare and UNC Health Alliance Kaiser Permanente Henry Ford & Health Alliance Takeda Pharmaceutica & ARIAD Pharmaceuticals Generex Biotechnolog & Emmaus Life Sciences Ipsen & Oncology assets Celgene & Delinia McKesson & CoverMyMeds WNS & HealthHelp Significant PE activity
  10. 10. 9 HEALTHCARE INDUSTRY CONSOLIDATION Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 Source: West Monroe Partners – Reshaping Healthcare M&A
  11. 11. 10 HEALTHCARE CONSUMERISM Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 Source: Connecture-Mega-trends in Healthcare Consumerism: A 5-Year Study Source: McKinsey-2016 McKinsey Consumer Health Insights Survey
  12. 12. 11 HEALTHCARE CONSUMERISM Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 Source: Citius Tech: Future of Healthcare in the Consumerism World 2017
  13. 13. 12 INCREASED PRESSURE TO REDUCE COSTS Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 ▪ Risk Sharing ▪Risk Based Provider Contracts ▪Increased Deductibles ▪ Increased use of pre-authorization and case management ▪ Increased utilization of outpatient & tele-medicine ▪ Increased disease management for chronic conditions ▪ Increased fraud/waste/abuse efforts – especially Rx abuse
  14. 14. 13 WHERE PAYER ANALYTICS ARE HEADING Value Based Care Meetup – June 19, 2018 Payer Analytics in a Shifting Healthcare Landscape
  15. 15. 14 INTERNATIONAL INSTITUTE FOR ANALYTICS MATURITY Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 Stage 5 Analytics Competitor Stage 4 Analytics Companies Stage 3 Analytical Aspirations Stage 2 Localized Analytics Stage 1 Analytically Impaired Healthcare
  16. 16. 15 ANALYTICS ROI MATURITY MODEL Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 Change Mindset Goal: Implement data driven change ▪ Implements new business models, behaviors, and decision patterns ▪ Follow-through focus and results measurement ▪ High degree of repeatability Data Access Mindset Goal: Improve Access to Data ▪ Frequently an abundance of data but not the ‘right’ data ▪ Driven by tools and technology ▪ Analysts struggle to keep pace with decision-making Problem Mindset Goal: Solve a Specific Business Problem ▪ Improves outcomes for a narrow problem set ▪ Enterprise level analysis requires effort ▪ Frequently supported by analytic applications 10x Analytics © 2018 iPower Consulting, Inc.
  17. 17. 16 HEALTHCARE PAYER ANALYTICS LANDSCAPE Payer Analytics in a Shifting Healthcare Landscape MAINTAIN OR RETIREMONITOR EXPERIMENT / PILOT INVEST / EVOLVE USE CASE MATURITYLOW HIGH INCREMENTAL ROIOPPORTUNITY LOWHIGH Value Based Care Meetup – June 19, 2018 Provider Cost Benchmarking Actuarial / Rates Risk Based Provider Contracting Network Design Provider Performance Analysis Customer SatisfactionTreatment Adherence Plan Benefit Design Health Outcome Analysis Consumer Segmentation Competitive Benchmarking Clinical Interventions Member Analysis Population Health Fraud/Waste/ Abuse Sales Analytics Call Center Operations Employer Reporting
  18. 18. 17 PAYER ANALYTICS NEXT 5-8 YEARS Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 10x Analytics © 2018 iPower Consulting, Inc. Payers That Win Will: ▪ Create data assets across the healthcare value chain ▪ Integrate dispirit analytics into integrated use cases ▪ Begin incentivizing specific desired consumer behaviors ▪ Master risk sharing and contract pricing ▪ Integrate network design into their consumer offerings ▪ Think strategically data- analytic technology investments
  19. 19. 18 DATA MANAGEMENT & GOVERNANCE Payer Analytics in a Shifting Healthcare Landscape Value Based Care Meetup – June 19, 2018 Data Management Model Maturity Indicators • Builds data assets that generate value • Creates organization trust • Standardizes data definitions • Handles errors and data quality issues • Moves the needle on data quality • Secures & protects data assets © 2018 iPower Consulting, Inc. Data management and governance plays a critical role in creating data assets across industry segments and organizations.
  20. 20. 19 QUESTION & ANSWER Value Based Care Meetup – June 19, 2018 Payer Analytics in a Shifting Healthcare Landscape
  21. 21. Strategy ∙ Execution ∙ Results Phil Kelly Managing Partner Email: Phil.Kelly@ipowerconsult.com Office: 630.219.0047 Mobile: 630.721.7851 www.ipowerconsult.com Thank You!

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