ROI: Exploding the MythsROI: Myths • ROI is the right way to look at DM • The ROI from DM is...

ROI: Exploding the Myths

Al Lewis

Disease Management Purchasing Consortium LLC

Wellesley, MA

www.DisMgmt.com

ROI: Myths

• ROI is the right way to look at DM

• The ROI from DM is below our “hurdle rate”

• “Even if DM vendors say they save money, it’s all smoke and mirrors.”

• “Even if we think they do, our CFO won’t believe us”

• “Even if (s)he does, there’s a budget freeze on.”

• “Even if we save money, the vendor saves more, which is unacceptable

• “Maybe we save money, but we lose control of our members.”

• “If the vendors can do it, we can do it cheaper--let’s build.”• “We don't have the data to know our ROI”

• “Our health plan is too small to get a decent return.”

ROI: Myths

Guaranteed Savings Proposals mean “real” bottom

line profit improvement

• ALL four of these are “myths” if you contract on a guaranteed-savings basis– If you do DM internally then ROI IS a big issue

– There isn’t a population-wide ROI, period, unless you are using a labor-saver like biometric monitoring or a CMS-type tool

– “Poster Child” for building programs, Aetna, just went over to the buy side

How Guaranteed Savings Deals Work

Historic Period

total $/mem

ber with disease

Guaranteed savings

Contract Period

Guaranteed Savings

“Baseline costs”

Vendor Fees

Remaining Claims

ESRD Example:Prevalence * cost * %savings

• Medicare--30,000 members, 81 with ESRD

• Group--150,000 members, 90 with ESRD

• ESRD expense: c $60,000/year

• Total spend: $10-million

• Savings @ 8% ($4800/ESRD member)

• = c. $0.8 MM in guaranteed savings

How Guaranteed Savings Works: ESRD example (How Guaranteed Savings Works: ESRD example (cont’dcont’d))

Historic Period

Total claim

s $/mem

ber with E

Mixture of claims, TPM vendor fees, other vendor fees, and profit if projections exceeded

Guaranteed savings

Contract Period

Claims paid last 12 months($10M)

Net Savings Guaranteed ($0.8 M)

Mixture of claims ($8-million) plus vendor fees ($1.2-million) to total $9.2-million

FAQ on GS

• TOTAL population of people with the disease

• ADJUSTED for changes in prevalence

• ADJUSTED for PMPM change and (for ESRD) ESRD-specific contractual changes (eg Dialysis)

• YOU STILL PAY FEES

• EXCLUDE internal costs, which are about 1% (100 basis points)

• If your vendor doesn’t offer guarantees but they have outcomes AND you want guarantees, get vendor to obtain fee reinsurance

Why ROI isn’t the right measure if you use guaranteed savings

• ESRD example: – Gross savings: $2-million in claims

– Vendor fees: $1.2-million

– Net return $0.8-million, or 67% or 1.67 to 1

Why ROI isn’t the right measure if you use guaranteed savings

• Stock Analogy: – Gross sales price $20 per share

– Your cost $12 per share

– Increase in stock price $8

– return = $20/$12, or 67%

Health Plan “Hurdle Rate”

0%10%20%30%40%50%60%70%80%90%

Required "Hurdle Rate"

Net Return(2:1 gross return)

THATMYTH

ESRD ROI of spending $1.2MM for a net return of $0.8MM

0%10%20%30%40%50%60%70%80%90%

vs. DM Program Net

Return

HURDLERTE

AverageDM Retun

Comparing 67% returns

• 67% in a year is a GREAT return for a stock…

• …but for DM it doesn’t clear the “hurdle rate” so it will be judged a lousy investment...

Wait a Sec

• This 67% net DM ROI is Guaranteed

• The stock return was not guaranteed

• Therefore DM is a much better investment and because it’s guaranteed...

• ...we should really be comparing it to...

…Treasury Bills

0%10%20%30%40%50%60%70%80%90%

vs. DM Program Return

(Treasury Bills)

WARNING WILL ROBINSON EXTREME DANGER

• Do not believe anyone who says that they get 4:1 or 5:1 or 20:1 or whatever in DM

• (30-second sales pitch coming)

ROI in DM

• At the Disease Management Purchasing Consortium we pride ourselves in how high LOW our ROIs are– 1.5:1 to 2:1 except in ESRD

• However, they are real

• and they are guaranteed

• …but here is a shocker ****************

ROI the wrong measure to use

• Return is received in the same year as spending (in some categories the same quarter)

• The only relevant “return” issues are the size of the guarantee and ensuring that the “time value” of cash flows and internal admin cost don’t significantly dent it

ROI the wrong measure to use

• Return is received in the same year as spending (in some categories the same quarter)

• The only relevant “return” issues are the size of the guarantee and ensuring that the “time value” of cash flows and internal admin cost don’t significantly dent it

Sidebar: Internal costs of outsourced DM

• Use a 1% (100 basis point) benchmark to be conservative– includes all “unallocated expense” (c. 50% of

total internal cost) as well as budgeted expense

– lower for ESRD, rare diseases, combined chronic diseases via a single vendor, larger health plans, subsequent years of first outsource, subsequent outsources

• Vastly higher for “built” programs

ROI: Myths

The Budget Freeze

• Two Solutions:– Get a program where payment comes at the end

(but those programs are rare and you do NOT save anywhere near as much money)

• May create problems with global capitation

– Put monthly fees through medical spending (assign provider number to vendor)

• Argument: Savings are in medical and are guaranteed, so it’s OK to put costs through medical

• Be sure to rewrite or not send EOBs

ROI: Myths

• “Maybe we save money by outsourcing, but we lose control of our members.”

Lose control of members???

• Absent DM, you can’t even find them let alone know how much they cost

• Outsourced (or PBM/pharma/device-assisted) DM = Information, information = control

• Outsourced (or PBM/pharma-assisted) DM = Information, information = control

• Is it easier to control a vendor or your own staff?

Note: Vendors don’t walk on Water either

ROI: Myths

Source of Disease Management

0102030405060708090

% of all programs

"Assemble"DM CompanyBuildPharma/PBM

Why is “Building” declining?

• Freezes on internal staff and admin costs– “Buys” are in medical cost, not admin costs

• It doesn’t work. Only a few built programs can say “We started out with a population costing us $X and reduced it to __% of $x”

• Better vendor value propositions

• Easier implementation for outsources

• Builds being supplanted by “assembles”

Myths of “Building”

• “It’s our core competency”

• No--it’s a highly specialized “custom shop” vs. an HMO throughput shop

• Buying is itself a core competency

Myths of “Building”

• “It’s our core competency”

• “Why should we pay someone to do what we can do ourselves?”

• No--it’s a highly specialized “custom shop” vs. an HMO throughput shop

• Buying is itself a core competency

• You can also deliver your own packages absolutely, positively overnight

ROI: Myths

“We don’t have the data to know our ROI”

• You can count– #MIs/angioplasties/CABGs/strokes last year vs.

# this year

– total admissions last year vs. this year (population management program)

– People with ESRD

ROI: Myths

% of medical losses “locked in” as savings by 14,000-member health plan in ONE contract

CHFCAD+Diab.+COPD

Do ALL major chronics togetherDon’t be afraid to spend the feesLock in an ironclad guarantee

ROI: Myth and Fact

• No CFO should doubt the powerful returns from outsourced/assembled DM (and population management) with guarantees

Getting CFOs on Board: The State Secret

• Consortium “batting average” for putting first programs in place WITH CFO/CEO in room during major meetings with vendors and with Consortium: 3 for 3= 1.000

• Consortium “batting average” for putting first programs in place with NO ACCESS to CFO/CEO: c. 25 for 60= .416

Getting CFOs on Board: The State Secret

• Consortium “batting average” for putting first programs in place WITH CFO/CEO in room during major meetings with vendors and with Consortium: 3 for 3= 1.000

• Consortium “batting average” for putting first programs in place with NO ACCESS to CFO/CEO: c. 25 for 60= .416

Solution is to get CFOs to the table early

Conclusion for health plans: It’s the Economics, Stupid

• Pick the right vendor

• Get a good LOW “ROI”

• Focus on total savings in PMPM, not ROI

• Measure it Right in the Contract

• Adhere to your own contractual requirements

ROI: Exploding the MythsROI: Myths • ROI is the right way to look at DM • The ROI from DM is...

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