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/
Payer Analytics In A Shifting Healthcare Landscape - June Presentation To Chicago Technology For Value-Based Healthcare
1. PAYER ANALYTICS IN A SHIFTING
HEALTHCARE LANDSCAPE
Technology for Value Based
Care Meetup
June 19, 2018
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. 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. 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. 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. 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. 6
KEY TRENDS IN THE
PAYER MARKETSPACE
Value Based Care Meetup – June 19, 2018
Payer Analytics in a Shifting
Healthcare Landscape
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. 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. 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. 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. 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. 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. 13
WHERE PAYER ANALYTICS
ARE HEADING
Value Based Care Meetup – June 19, 2018
Payer Analytics in a Shifting
Healthcare Landscape
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
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