Caroline R. Piselli RN, DNP(c), MBA, FACHEPricewaterhouseCoopers Health Industries Advisory Director

Building Your Plan to Get from Here to There: Steps Required to Achieve a Blended Services Model

Source: PwC Health Research Institute

• National Trends / Role of Government• Payment Methodologies• Shifting Demographics• New Customers• Empowered Consumer• Care Anywhere, Anytime

Agenda

Source: PwC Health Research Institute

New Health Economy Transformation

TRANSFORMATION from a fee for service environment to population health aligned with risk is a current to future state process.Key critical success factors expand well beyond payment methodology design, actuarial computation and include some of the following:

1- INNOVATIVE Design2- Population Health- OUTCOMES focused3- Current to future state VISION driven4- RISK linked to OUTCOMES, not process5- Flexible & Adaptable to CONTINUAL IMPROVEMENT6- CONTINUAL COLLABORATION 6- Sense of URGENCY and ACCELERATION

Source: PwC Health Research Institute

How is your organization preparing?

How are your current and new competitors preparing?

What is the overall market impact in your area?

What is the impact of new entrants? Retail? Pharma? Consumers?

What lessons can be leveraged from early adopters?

Is Your Organization Prepared for the New Health Economy ?

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

ACA Implementation

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute 13

Some Published Examples to Follow

Source: PwC Health Research Institute

MD Statewide Experience: PPC Cost SavingsSource: Health Affairs December 2012

Source: Health Affairs, December 2012 31:12; doi: 10.1377/hlthaff.2012.0357

Source: PwC Health Research Institute

Potentially Preventable Events

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

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PDF picture

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Risk Adjustmen

t

Reinsurance

Risk Corridors

Balancing insurer risks in the reformed insurance market:

Incentivize health plans to participate

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Population Management ReadinessDevelop a network across a geography that delivers evidence-based

care to improve the quality, efficiency and coordination of health care services

Pop

ula

tion

Man

ag

em

en

t R

ead

iness

Build to Scale

Select Providers & Physicians

Contract for Outcomes

NE

W C

ost

& V

alu

e

Posi

tion

ing

Patient Experience

Operational Efficiency

Clinical Outcomes

Adverse Event Mitigation

Cost/ ROI

Leveraging:• Data• Transparency• Critical Mass• Long Term

Commitment• Consumer

Value

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Source: PwC Health Research Institute

Questions?

Caroline R. Piselli, RN, MBA, FACHEHealth Industries Advisory DirectorPricewaterhouseCoopers caroline.r.piselli@us.pwc.com

Source: PwC Health Research Institute