Join Health Catalyst and two leading innovators who are focused on the analytics necessary to make CO-OPs work. We promise, this will be in engaging presentation discussing the following:
1. Characteristics of CO-OPs including expected participantion and services provided.
2. The analytics necessary to drive the CO-OP business forward.
3. A comparison between the services provided by CO-OPs and traditional health plans.
4. The clinical and financial analytics of a typical CO-OP.
What impact will CO-OPs have on the insurance markets, what analytics are necessary, and how their success could impact payments for health system services? Will they be able to materially reduce healthcare costs? How will consumers embrace the insurance options they provide?
7. KENTUCKY STATE SPECIFIC PARAMETERS
640,000 uninsured Kentuckians
34% of those with incomes at or below 138% of Federal
Poverty were uninsured.
34% of Kentuckians who earn up to 200% of FPL were
currently uninsured as well.
20% of Kentuckians were covered by some form of
public insurance
8. THIS IS KENTUCKY ,TOO
Ranks 45th in overall health status by America’s Health Rankings (2013)
Ranks 49th in overall health status by Gallup Healthways Well-Being
Index (2012)
#1 for highest smoking rate in the U.S.
#1 for preventable hospitalizations
#1 for cancer deaths
#6 for premature deaths
#6 for obese adults (1.1 million)
#7 for cardiovascular deaths
#9 for diabetes
9. 2014 ENROLLMENT RESULTS
Offered all plan levels in the state(individual)
Platinum
Gold
Silver
Bronze
Catastrophic
Open network which we continue to build
In-house medical management
State based exchange
Results: Approximately 24,000 lives to date
10. ESSENTIAL HEALTH BENEFITS
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance abuse disorder services, including
behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services, and Chronic disease management
Pediatric services, including oral and vision care.-
11. MEMBER EDUCATION
These members have been forced to navigate the social
and medical systems alone due to their lack of insurance
and often fail to receive many of the services they need.
KYHC Clinical Care staff will seek to educate our
membership on the services available to them through
our benefit designs.
12. INFORMATION COLLECTION
Use of Health Risk Assessments
Member interviews
Member outreach
Medical/Pharmacy claim review
13. CARE COORDINATION
• Engage patients with chronic illnesses while hospitalized
• Follow patients intensively post-discharge
• Teach/coach patients about medications, self-care, and
symptom recognition and management
• Remind and encourage patients to keep follow-up physician
appointments
14. PLAN ANALYTICS
Initial Pharmacy data will provide the first insight into membership
Concurrent review of hospital stays will also provide information
HRAs though self reported may also shed some light on
membership
As medical claims are processed they can also provide valuable
information
15. 2015 GOALS
Received approval of federal loan for expansion intoWest
Virginia for 2015
Already working on rates for plans for 2015 in Kentucky and
Initial plan forWestVirginia
Maintain member centric approach for medical
management and partner with our PBM for analysis of
trends in KY and preparation initial formulary forWest
Virginia expansion.
16. Colorado HealthOP
A Health Insurance Cooperative That Is
Turning Health Insurance Upside Down
7/25/2014 16
17. Colorado HealthOP Overview
● Created through funds from the Affordable Care Act and
with the partnership of the Rocky Mountain Farmers
Union
● We are a new, non-profit health insurance co-op
● Our board will include members who buy our insurance
and will help to make decisions about how we spend our
funds
● Commitment to community health through ongoing
partnerships and campaigns
7/25/2014 17
18. Colorado HealthOP Mission & Vision
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● Mission
To improve the health of individuals and communities
through trusted partnerships with members, employers,
and providers.
● Vision
To be a catalyst for the transformation of the health and
vitality of Colorado communities.
19. Insurance Designed to Make Members
Sustainably Healthy
7/25/2014 19
● Preventive care and healthy action
incentives
● Shared responsibility
● Primary care provider partnerships
Insurance is supposed to help when people get sick or
injured; we think insurance should also be there to help
people stay healthy.
20. (the Marketplace)
7/25/2014 20
● Colorado HealthOP is one
of the options on the
marketplace
● The marketplace was
created through the ACA
● Works like a airline
booking website – you can
compare plans and rates
● Metal tiers help to
distinguish each plan and
its benefits (bronze, silver,
gold)
21. This Is Colorado
7/25/2014 21
● Overall Rank of 8th by America’s Health Rankings
(2013)
● Overall Rank of 2nd by Gallup Healthways Well-
Being Index (2012)
● Lowest prevalence of obesity in the U.S.
25. Community of Solution
7/25/2014 25
● Problem Sheds
● What is the problem?
● Where is it?
● Who does it impact?
● Asset Sheds
● Local identification of
health problems
● Local data
● Local solutions
26. “… and he stoppeth one of three…”
7/25/2014 26
I would like you
to meet Bill…
A Consumer Operated and Oriented Health Plan (CO-OP)
Gives members a voice in the CO-OP’s operations
What is covered under benefit plans
Members sit on the board
No profits – if revenues exceed costs, the surplus will be reinvested to directly benefit members
Lower premiums, expanded benefits and quality improvements
Insurance Designed to Make Members Sustainably Healthy
Incentives for preventive care: Until now, health insurance has only helped people who are sick or hurt. We think health insurance should also be there to help people stay healthy. That’s why we reward you for taking simple, healthy actions (like getting a yearly checkup) with more benefits and lower costs.
Creates a shared sense of responsibility among members to advance their own health and the health of the CO-OP.
Partnerships with primary care providers to improve quality and reduce costs.
Difference between FFM (Federally-facilitated marketplace) and HIX (Health Insurance Exchange)… latter is state-based
The percentage of Coloradans without health insurance in 2013 was 14.3%, or approx. 741,000 Coloradans (one in seven residents).
Nearly one in five Coloradans has public health insurance.
Douglas County (HSR 3) the lowest uninsured: 5.4%
NW corner the highest: 24.8%
Connect for Health Colorado enrollment: ~70k (through Jan-14)
Colorado HealthOP has a bit above 10% market share.
National Commission on Community Health Services
1962-1967 – 21 community health studies, over 1,000 community and health leaders
Chaired by Marion Folsom
Published their findings in 1966
12 Recommendations
Supported the emergence of Community Health Centers
Called for the formation of the specialty of Family Medicine
Promoted aspirations for environmental health, clean water, and air quality
Called for the need for comprehensive reproductive health care
Then in the 1970-80’s got pretty much demolished by political whim and for-profit healthcare
Communities of Solution: The Folsom Report Revisited
The Community as a Learning System for Health
National Committee on Vital and Health Statistics
13 Grand Challenges
Foster the ongoing development of integrated comprehensive care practices (Patient-Centered Medical Homes)
Provide every individual in the United States the opportunity to form a partnership with a personal physician and a team of health professionals
Create a health workforce to serve the needs of US communities, including community health workers.
Integrate health services
Create a national network of community partnerships that engage and activate the citizenry to self-define local, regional, and statewide Communities of Solution
Communities of Solution
Link primary care and public health
Public health can be the usual public health agency
Or the myriad other community organizations that are interested in health
Local community members help catalyze the collaboration between public health groups and primary care providers
Yes, behavioral health is in there too.
Local data drives local change
Place based data is essential
Can this really exist?
Bill lives near Downtown Denver in a small apartment. He grew up in the San Luis Valley and moved to Denver after high school.
He has been a truck driver, carpenter, a cabby. Now he is disabled, unable to work. He’s about 60 years old.
Bill is a hot-spot
7 hospitalizations in past year
Acute MI last year.
Heart Failure x 3
Pneumonia landed him in the hospital for a week last winter.
Diabetes II x2
Non healing foot ulcer
Hyperglycemia
9 additional ER Visits in past year.
Chest pain x 2
Leg swelling x4
Cough x 1
Diabetes x 2 - hyperglycemia
Bill was identified by the local emergency room as a super-utilizer, a Hot-Spot.
He was enrolled in an aggressive healthcare follow-up plan funded by the city and a local foundation.
Bill got better.
Bill lost 30 pounds
He sees his family doctor every 2-3 weeks
He checks his blood sugar and his A1c dropped from 12 to 8
He saw a counselor in his primary care office for 4 months and his depression is much better
He takes his medications. And eats a regular diet.
His utilization dropped, and the costs of his care plummeted.
Bill is not that uncommon. In Campden or Philadelphia, Fresno or Denver. There are a number of hot-spots that have a lot of medical problems and end up in the ER and hospital.
Super-utilizers,, cost the healthcare system millions and billions of dollars each year. Just a small fraction of the patients account for > 50% of our healthcare costs.
There is a poorly maintained park a few blocks away. A couple of nearby churches have shelters for homeless men and families. There is a medical clinic a couple bus stops away. Bill lives in a part of town that has been called “blighted”From the periphery of Denver's urban core through outlying historic residential neighborhoods, the ten-block Welton Street corridor once thrived as a vibrant and high profile urban tapestry of jazz, entertainment, and vital services within the greater Five Points area. These sixty years later, a third of the corridor is blighted, developed primarily as surface parking, and the rest sees comparatively sparse pedestrian activity nightlife..
But urban blight is not the only place where healthcare has disintegrated. There are suburbs and gated communities where people live in isolation, lacking integrated primary care and behavioral health, poor collaboration between public health and medical providers, schools, and community organizations.Location can matter, but money is not the only predictor.
Today, identifying individual patients with high utilization of health care is relatively easy given the vast improvements in health information technology, But, is the super-utilizer the real problem? Do they have some medical defect or general disregard for their community? Are hot spots are enemy? Or is the problem really “cold spots,” communities in which the social determinants of health, support, and access to primary care have broken down?
The Usual SuspectsProvidersClinicsHospitalsPublic healthAnd the unusual suspects Schools Churches Business Clubs Community groups Patients Others
“Other” plans have data structures built upon other, older/legacy, data structures. Layer upon layer of (unnecessary) complexity.Different formats, inconsistent rules, unverifiable analytics…
CO-OPs present an “open road” from both a data and analytics approach perspective.There is a clean slate from which to construct, develop, and partner in determining the best health for our members.Room to grow, share, collaborate – together. Providers, patients… communities.
“Other” plans can throw the term “Big Data” around as if it can/will solve everything.They approach population health as just a Big Data problem, and that this will allow them to…
… thread the needle of the issue at hand.More volume, velocity, variety.They think of variety as different formatted data… not different insights.
Wide Data – sourcing data on patients from multiple and disparate sources.Not just those immediately thought of in health care.
Data must have meaning – for the patient, for the provider, for those who care… for the communities.This will have lasting impacts. Allows for ongoing needs assessment, evaluation, and program development. Continuous quality improvement.Promote continuum of care.Focus on “always” events and not “never” events.