Post on 31-Dec-2015
.…a health and consumer services company making people’s lives better
From Infomediary to Market Maker...
Sam Ho, M.D.Senior Vice President, Chief
Medical Officer
swh:2 .…a health and consumer services company making people’s lives better
Current EnvironmentEnvironment Ripe for Change
• Highest cost trends in 10 years
• Recession
• Rising unemployment / softer labor market
• Consumerism requires information & choice
• Science of performance measurement is improving
• Discount pricing possible & managed solutions
Cost sensitivity
• Benefit reduction & cost-sharing
• Consumer Healthcare Organization (CHO)
• QUALITY INDEX® profile
swh:3 .…a health and consumer services company making people’s lives better
PHS Quality Pedigree
Quality & Accountability
• hailed by purchasers, regulators, consumers, providers, CMS, NCQA, IOM, AHRQ
• NCQA – 21 Consecutive Excellent or Commendable MCO/MBHO Awards. 6 States with Excellent; PCCA = only statewide MCO @ Excellent
• Only MCO to Receive Paul Ellwood Award From FACCT for Efforts in Developing a Consumer-Driven Healthcare System.
• HEDIS - Exceeded Industry Average in 18 Quality-of-Care Measures Compared to California Health Plan Competitors
• Ranked #1 for Patient Satisfaction Among Network Model HMO’s in California - leading consumer magazine, October 2001
• AAHP’s 2001 National Exemplary Practice Award for Congestive Heart Failure Program (CHF) - Colorado
swh:4 .…a health and consumer services company making people’s lives better
• 2000 California HMO Performance Assessment Survey
PacifiCare = Ranked Best by 198 Physician Organizations – 200% Better Than 2nd Ranked HMO
PacifiCare = Ranked Best by 367 Hospitals – 31% Better Than 2nd Ranked HMO
PHS Quality Pedigree
Quality & Accountability
swh:5 .…a health and consumer services company making people’s lives better
Foundation for Change
2002 Measures
• 28 Commercial Indicators & 29 M+C Indicators – Staying Healthy– Appropriate Care– Patient Safety– Service & Satisfaction– Affordability
swh:6 .…a health and consumer services company making people’s lives better
• Effective consumer information tool
• Effective provider management tool
• Platform for product innovation– Tiered benefits– Tiered compensation
• Expanded metrics for 2001 to 2002: staying healthy, appropriate care, patient safety, affordability, service & satisfaction
• 2001 - QUALITY INDEX® profile for Women & enhanced core QUALITY INDEX® Profile
• 2002 - Introduce QUALITY INDEX® profiles of Hospitals & Physicians
• “Leapfrogging” Leapfrog & others– expanded measures, report cards, incentives, benefit plan design
swh:7 .…a health and consumer services company making people’s lives better
Hospital - Leading the Industry
• 87 measures– Medical, surgical, OB, peds– Risk-adjusted outcomes
• Leapfrog measures (9)
• Appropriate care
• Patient Safety
• Patient Satisfaction (Calif)
• Affordability
• 100 Top Hospitals - Solucient
• Aggregated score
• Other report cards = 4, 9, or 30 measures
swh:8 .…a health and consumer services company making people’s lives better
as Platform for New Products
• Value network based on costs and quality
• Lower premium vs. standard HMO or PPO
• Broad network still offered
• Incentives to choose better & cost-effective vs. just cheaper
• Educate consumers on cost + quality variation
• Tiered compensation and market share rewards best performing providers
swh:9 .…a health and consumer services company making people’s lives better
2003 “Value” Product - Quality and Cost as Drivers, w/Costs = Primary
Tiered/Narrow HMOHospitals
Qu
alit
y
Cost
Preferred
Non-Preferred
Tiered/Narrow HMOPhysicians
Qu
alit
yCost
Preferred
Non-Preferred
Coupled with QUALITY INDEX® Profile information to empower consumers
swh:10 .…a health and consumer services company making people’s lives better
PacifiCare Value vs. Kaiser
CurrentCalifornia MDs PMGs Hospitals Members
PacifiCare Value Plan 12,000 119 ~125 50%
Kaiser 6,000 30 30 100%
• “Narrow” Network = 2-4x Kaiser’s Network• Value Network + Benefit Changes = 10-20% Premium Savings
swh:11 .…a health and consumer services company making people’s lives better
• 10 measures (QIX subset)• Preventive health• Chronic diseases• Satisfaction
• Total system cost– PMG + Hospital + Rx
• 6 measures (starter set)• Leapfrog group measures• Satisfaction
PMG Quality
+
Hospital Quality
Costs+
2003 Integrated Value Equation
swh:12 .…a health and consumer services company making people’s lives better
• QUALITY INDEX®
• Consumer info
• Core
• Hospitals
• Physician
• Web link with directory
• Patent pending
• CQI
• Improved clinical outcomes
• Improved service outcomes
• NCQA
• HEDIS
• Provider Profile
• Market maker
• Tiered hospitals– HMO & PPO– Quality– Affordability– Choice
• Tiered MG’s– HMO– Quality– Affordability– Satisfaction– Choice
• Tiered MD’s– HMO & PPO– Quality– Affordability– Choice
+ AccountabilityQuality Product Leadership
“Caring is good… doing something is better