Health Plans and Population Health Management
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Transcript of Health Plans and Population Health Management
© 2012 Health Fitness Corporation
1© 2011 Health Fitness Corporation 1© 2012 Health Fitness Corporation 1
A Partnership Checklist for Population HealthJune 14, 2012
Join the conversation on Twitter at #healthweb
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Today’s Discussion
1. The health plan landscape
2. Why population health management?
3. Health Plan Top 10 Checklist
4. Q&A
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The Health Plan LandscapeHow is the market respondingto regulation?
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Changing landscape, health plan evolution
Regulatory Drivers Market Response
ACA--Increasing the number of insured consumers B-to-C shift in insurance marketing
Medical Loss RatioDesign quality improvement activities that can be measured and verified.
Accountable Care Organizations Collaborate as conveners, participants, value-based payers
Comprehensive Primary Care Multi-purchaser initiative for com-prehensive, accountable care
Health Insurance Exchanges (HIX) Design consumer-focused plans
Mergers and acquisitions High level of activity in both horizontal and vertical directions
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Changing landscape, health plan evolution
Regulatory Drivers Market Response
ACA: Increasing the number of insured consumers
• Consumer-centric products and services
• Low-or-no cost preventive care services
• Wellness services—health risk assessments, biometric screening, health coaching, reimbursement for smoking cessation, chronic care management
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Changing landscape, health plan evolution
Regulatory Drivers Drivers—Affordable Care Act Market Response
Medical Loss Ratio • Measured and verified• Can include:
- Population health/wellness- Care management- Case management- Chronic care management
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Changing landscape, health plan evolution
Regulatory Drivers Market Response
Accountable Care Organizations
Collaborate as conveners, participants, value-based payers• CMS Pioneer ACOs• Medicare Shared
Savings Program• Commercial ACOs
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Changing landscape, health plan evolution
Regulatory Drivers Market Response
Comprehensive Primary Care Multi-purchaser initiative for comprehensive, accountable primary care
Apr 2012CMS released selected markets
May 2012Health plan payersapply to participate
Aug 2012Practicesannounced
Sep 2012Project launch
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Changing landscape, health plan evolution
Regulatory Drivers—Affordable Care Act Market Response
Health Insurance Exchanges (HIX)
$1B
Design consumer-focused plans• Supreme Court ruling in ACA
(June 2012)• Est. 26M to 67M to enroll (Rand)• Customer mix:
- High risk only? - Employees of small/medium
size companies with lean policies
- Large employer groups• Bronze, Silver, Gold and
Platinum plans
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Federal HIX Establishment Grants
Source: Healthcare.gov fact sheet
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Regulatory Drivers—Affordable Care Act
Market Response
Mergers and acquisitions High level of activity in both directions--horizontal & vertical
Changing landscape, health plan evolution
Hospital Hospital
Health Plan Hospital Practice
Health Plan
Hospitals
Practices
Data/ AnalyticsPHM
Hospital Practice
Hospital Practice
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Why Population Health Management?
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Why engage in a population health management strategy?• Decades-long record with large employers as demand-
side strategy to reduce claims costs• Right side of the MLR equation• Health risk data gathered BEFORE claims filed• Retain traditional customers (large/medium employers)• Attract new customers (new consumer marketplace)
R
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Consumer Trust
Core Business
Experience Readiness
Health plan-based PHM vs. partnership
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The Health Plan Top 10 Checklist
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10Single source
On-site program delivery
Proven experience
People
Recognition
Stable, scalable
Customized, flexible
Accountability
Outcomes & science-based
Technology & data
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
For comprehensive, integrated health management programming
• Centralized accountability—one contract, one management structure, one bill
• Simplicity in integrating data to measure performance
• Optimum program delivery—no finger-pointing• Member experience--One phone number, one portal,
warm transfers
Single source
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
On-site program delivery capabilities
• Choose a vendor who can bring services to the doorstep of multiple, diverse employer-clients of your plan
• On-site screenings bring more to the employer-client bottom line—better participation, less time away from the job
• Company-owned screeners vs. rent-a-nurse• On-site health improvement classes• On-site program administration
On-site program delivery
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EXPERIENCE• Scale• Complex client needs• Implementation
Proven experience and expertise
• Consultative partnership resources• Ability to gauge health trends across different
employer-client types—manufacturing, service, high-tech, public employee, etc.
• What engagement activities really work in different settings? Focus groups, data mining resources
Experience & expertise
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
Technology is a good tool, but people turn the key on engagement
Layers of support: • Customer service• Program development experts• Implementation experts• Behavioral science experts• Outcomes experts• Data and technology experts• Occupational health, health advising, health risk
assessment, medical oversight, etc.
Experience & expertise
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EXPERIENCE• Scale• Complex client n• eeds• Implementation
ENGAGEMENT• Intrinsic behavior change
Recognition and references
• PHM partner name recognition• Client testimonials• Third-party recognition for PHM excellence
• Award-winning clients
Innovations in Prevention Award
Recognition & references
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
Stable, scalable and national in scope
• Proven track record and financial stability• Ability to provide services in multiple locations at
the same time—geographic and resource reach• Ready to grow as you grow
Stable & scalable
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
Customized, flexible, consultative approach
• Comprehensive, integrated program• Modular approach to fit with plan’s own programs• Customizable templates– Incentives– Service options—Coaching? Occupational health?
Wellness classes? Screenings?– Program needs and preferences—telephonic,
on-site, web-based, all of the above– Portal platform
• Complete customization and client branding• Expert adviceCustomized & flexible
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
Pricing and performance—accountability
• Pricing—based on utilization of services• Performance—outcomes based measurement• Measurement, verification of participation and
outcomes essential in more transparent environment (ACOs, HIX)
Accountability
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
Outcomes methodology and science-based approach
Look for REAL gains, not what-ifs• Lower claims costs• Change in risk factors from high to low• Can your partner demonstrate the value of the
program with clear, unambiguous data?
Outcomes-, science-based
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ROI Claims Analysis MethodologyMeasurement
Pre-Program Year Program YearMeasurement
Post-Program Year
Participants Baseline
Characteristics
Participants - Measure
Difference in Claims Spend
Participants Receive Services
Matching
Process
Reference Baseline
Characteristics
Reference - Measure
Difference in Claims Spend
Compare
T1 to T2
Outcomes-, science-based
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EXPERIENCE• Scale• Complex client needs• Implementation
PERSONALIZATION• Client customization • Unique client needs • Participant experience
ENGAGEMENT• Intrinsic behavior change
Technology and data capabilities
• Data sharing needed for accountability in reform efforts—ACOs, PCMHs, HIX
• Data transfer• Integrating data from disparate sources• Engagement factor• eHealth portal with your branding• Personalized consumer environment
Technology & data
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Question & Answer SessionGLENN LEARYVice President, Business Development HealthFitnesswww.HealthFitness.com