“New Plan for Improving Health
Benefits, and Your Bottom
Line”
How Can Population Health
Management Drive Both
Agenda
Navigating the Affordable Care Act
2. State of Health Today
1.
a)
b)
c)
The Cost Curve
Cost and Quality Drivers
Shifts in Health
Changing the Approach
4. Opportunities
3.
3
Cost Drivers
- New Benefits
• Unlimited Lifetime
• Mental Health Parity
• Guaranteed Issue
• Dependent Coverage
• Limited
Underwriting
32%+
4
Cost Drivers
Cost = Price + Volume + Population
5
Healthcare Costs Business
• Annual healthcare cost per capita in the State of
Indiana have increased 76% from 1999 to 2009
• Nationally, Business Health Premiums have more
than doubled in the last 10 years
 138% growth compared to workers’ earnings
at 42% and inflation of 31%
• Cost expected to rise 7% in 2013
• 2013 total per active employee health care cost
estimate $11,507 (employer share $8,911)
• Pent up Demand Building
Increases in Health Insurance Premiums
Compared with Other Indicators, 1999–2010
Health Insurance Premiums
Workers’ Contribution to Premiums
Workers’ Earnings
Overall Inflation
180%
160%
140%
159%
138%
120%
100%
80%
60%
42%
40%
20%
31%
0%
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Data: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999–2010. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation
(April to April), 1999–2010; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999–2010 (April to April).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
2010
Chronic Diseases
45% of the population has at
least one chronic disease
• #1 cause of death & disability
•
• Accounts for 75 cents of every $1.00 of healthcare
expense
• Responsible for 7 of 10 deaths in the U.S.
• 26 million Americans have diabetes including 7
million who do not know it
Obesity Related Stats
69% Percent of adults are overweight
• 36% Percent of adults are classified as Obese
• $147 Billion annual cost
• For every 100 employees, Obese workers have:
•
•
•
184 lost workdays (14 lost workdays for normal-weight)
12 Worker’s Comp claims (5.8 workers comp claims for
normal-weight)
NOTE: Obesity-related conditions include heart disease,
stroke, type 2 diabetes and certain types of cancer,
some of the leading causes of preventable death.
Unhealthy Population
Obesity (BMI ≥30 kg/m2)
1994
No Data
<14.0%
2010
2000
14.0-17.9%
18.0-21.9%
22.0-25.9%
>26.0%
Diabetes
1994
No Data
2010
2000
<4.5%
4.5-5.9
%
6.0-7.4 %
7.5-8.9 %
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
>9.0%
Diabetes Epidemic
25
Percentage with Diabetes
Number with Diabetes
Percentage with Diabetes
7
6
20
5
15
4
10
3
2
5
1
0
0
1958
62
66
70
74
78
82
86
90
94
98
02
06
Number with Diabetes (Millions)
8
10
Year
• 10-fold increase in children with Type 2 diabetes in last five years.
• If trend continues 43% of US adults will have diabetes by 2050
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
The Definition of Wellness
“The quality or state of being in
good health especially as an
actively sought goal”
Types of Wellness Programs
Active•Only
63%
of Employers with 3199 employees and 92%
of employers with 200+
employees offer a
Wellnesswellness program
Participatory
• 50+% stated
in a recent
survey they did not know
Health their program’s return on
Contingent/
investment
Outcomes Based
Typically fewer than 20 percent of eligible employees
participate in wellness interventions.
The Other End: ONLY Manage High Cost
SHIFT over one year
Unknown
Risk?
Low Risk
PMPY
Moderate
PMPY
$5,580
18%
$3,040
High Risk
PMPY
$13,248
36% were High Risk
8% were new members
The Standard Approach
Targeted
Population Health
Management
Changing the Approach
Population Health
Management Process
Identify
Engage
Measure
• Care Gaps
• Risk Analysis
• Financial Analysis
• Education
• One-on-one Coaching
• Care Coordination
• ROI
• Cost Avoidance
• Savings
Targeting the Right Members
% of Members
5%
Poly Chronic
At Risk/Singular
Procedure
Minor Health
Issues
20%
75%
% of Costs
10%
Poly Chronic
25%
At Risk/Singular
Procedure
65%
Minor Health
Issues
Narrowing the Field
Sources: 2010 World Economic Forum and AON Hewitt 2012 Health Care Survey
Data Analytics: Identify
E
m
p
l
o
y
e
r
Employee
Medical
Claims
Spouse
Pharmacy
Claims
Dependents
LAB and Biometric
Data
APH Risk
Navigator
Historical Cost
PMPM
Utilization
Data Repository
Trending
Risk Analysis
Lag Schedule
IBNR Projections
Care Gap
Analysis
Identify
 High and Moderate Risk Members are identified
through a multi-point Risk Analysis covering a wide
range of medical and pharmacy based triggers and
benchmarks, including:
Utilization Patterns
 Historical Medical and Pharmacy Spend
 Diagnostic Indicators (Hypertension, Diabetes, …)
 Care Gap Analysis
 Medication Adherence
 Behavior Patterns
 …And More

Engage
 Identify current resources
 TPA Care Management
 Disease Management Programs
 Wellness Programs
ROI
Example: A large employer with 15,000 members had 2 members under
management with their TPA care management team.
Conclusion: There’s room for improvement
Engage
•
Look to your community
Occupational Health Clinics
• On-site Coaching
• Local Hospital Resources
•
•
•
•
•
•
•
Blood pressure screenings
Diabetes education and support groups
Cancer support groups
Fitness classes
Etc…
Primary Care Physicians
22
Measure Your Outcomes
Targeted Members
The right intervention
How to Measure Outcomes
•
What do you need?
Measure
Type of
Intervention
Targeted
Members
Data
Analytics
Opportunity
Client Initiative Outcomes
•
Health Plan with 1,000 EEs
•
•
•
135 Members were targeted
for intervention and sent to
TPAs Care Management team
for management
85 Members enrolled in the
program
The 85 collectively reduced
their PMPM by 29%
(~$500,000) over a 9 month
period
•
Health Plan with 5,000 EEs
•
•
•
•
Targeted members
inappropriately using the
Emergency Room
Education letters were sent
out to each member
Inappropriate ER Utilization
decreased by 36%
The Plan saved ~$150,000
Opportunity
Client Initiative Outcomes
•
Health Plan with 250 EEs
•
•
•
•
•
50 Members were targeted for
intervention through an onsite
Nurse Navigator Program
PMPM was reduced by 8%
IP utilization was decreased by
29%
Preventive screening
compliance increased
cumulatively by 32%
Diabetes and Cholesterol Gaps
in care were reduced by 41% in
a 12 month period
•
Health Plan with 2,000 EEs
•
•
•
•
•
Engaged Occupational Health
Clinic for Nurse Navigator
Program
173 Participants lowered their
PMPM by 11% ($179,897)
Overall Risk Scores decreased
21%
Predicted cost over 12 months
decreased by 22%
Over a 24 month period the
plan saved ~$375,000
Client A
Medical PMPM vs. National Trend
$248.96
$230.52
$250
$213.44
$218.69
$200
$197.63
$204.87
$201.02
2009
2010
2011
$150
$100
$50
$0
2012
By implementing targeted programs to address high risk
areas within the population ABC Company’s PMPM
Medical costs have stayed below the 8% national trend
since 2009.
$
2010
1,430,450 $
2011
5,432,543 $
2012
6,022,687 $
Total
12,855,681
Client B
Case Study – Client B Results
Medical and Rx Cost (PMPM) vs. National Trend
$600
$509.20
$469.86
$500
$433.58
$400.12
$400
$314.54
$300
$369.26
$340.79
$55
$317
$56
$260
$261
$366
$338
$52
$324
$60
$298
$64
$321
$84
$71
$200
$100
$286
$264
2008
Client B Rx
2009
2010
2011
Expected PMPM based on National Average
$234
$250
$282
$0
2006
2007
Client B Med
2012
– While maintaining stable benefits and National Trend calculated at 8% for medical and
10% for prescription drugs, Client B’s health plan strategy has contributed to the
following savings
Total savings compared to National Trend
2007
$1,364,612
2008
$1,819,997
2009
$4,253,257
2010
$7,678,247
2011
$8,499,478
2012
$8,216,422
Total
$31,832,013
Client C
Medical & RX Per Member Per Month Cost vs. National Trend
$500.00
$467.65
$436.36
$450.00
$405.29
$400.00
$373.58
$344.39
$350.00
$315.05
$288.22
$300.00
$263.69
$250.00
$62.50
$40.00
$38.88
$41.70
$49.86
$49.75
$200.00
$50.35
$53.70
$150.00
$100.00
Client C is an employer with
~344 employees. They
implemented an onsite
nurse coaching program, and
excellent coordination
between stakeholders
$223.69
$216.51
$245.42
$268.90
$252.60
$203.59
$169.78
$155.17
2012-2013
May - Jul
2013
$50.00
$0.00
2006-2007
2007-2008
2008-2009
Medical Per Member Per Month Costs
2009-2010
2010-2011
2011-2012
Pharmacy Per Member Per Month Costs
National Trend
‘07-’08
‘08-’09
‘09-’10
‘10-’11
’11-’12
‘12-’13
May – Jul ’13:
$301,332
$585,997
$353,760
$572,452
$892,161
$1,769,164
$531,525.94
Cumulative Savings:
$5,006,391
The Bottom Line
Quest for Stabilization
An equilibrium in the market’s Medical Economics can only be achieved by
constantly managing the variability in health price (cost), volume (use), and
having a thorough understanding of the population being managed.
Price
Volume
Population
“If I had nine hours to cut down a
tree, I would spend six hours
sharpening my axe.”
-- Abraham Lincoln
31
Resources
• CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
• Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of Overweight
and Obesity in the United States, 1999-2004. JAMA 2006;295:1549-1555.
• RAND Health http://www.dol.gov/ebsa/pdf/workplacewellnessmarketreview2012.pdf
• Centers for Disease Control and Prevention, Chronic Disease Overview. 2010. As of July
15, 2012
• Advanced Plan for Health National Database
• RAND Health_Employer Self-Insurance Decisions and the Implications of the Patient Protection
and Affordable Care Act as Modified by the Health Care and Education Reconciliation Act of
2010 (ACA)
• Kaiser Family Foundation, Employer Health Benefits 2012 Annual Survey, available at
http://ehbs.kff.org