A Case Study: Aligning Payment Reform and Population …1).pdf · 3/18/2016 A Case Study: Aligning...
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3/18/2016 A Case Study: Aligning Payment Reform and Population Health into One Joint Venture
Transcript of A Case Study: Aligning Payment Reform and Population …1).pdf · 3/18/2016 A Case Study: Aligning...
3/18/2016
A Case Study: Aligning Payment Reform and Population Health into One Joint Venture
Agenda
• Introduction
• Goals, Evolution, & Vision
•Alignment & Coordination
• Population Health Approach
• External Message & Next Steps
• Questions
Benevera Health
• Payer/provider partnership with unprecedented financial and clinical alignment
• New jointly-owned Population Health company
• Reduced costs, improved patient experience
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Agenda
• Introduction
• Goals, Evolution, & Vision
•Alignment & Coordination
• Population Health Approach
• External Message & Next Steps
• Questions
Value and goals of payer/provider collaboration
Population Health
Data Sharing/Analytics
Coordination/Quality
Better care, lower costIncentives/Costs
•More complete picture of the patient and patient populations
• Focus on patient populations using risk stratification
• Better delineation of duties (e.g. Care Management)
• Focus on Primary Care
• Identify and share best practices
• Align incentives to focus on value
•Move away from volume-based payments
• Share risk across all patients
Why a Joint Venture?
•The providers and payer in our joint venture have different motivations:
Provider Payer
Risk strategy: benefit from efficient care of patients, gain access to diversified revenue
Market Strategy: partner with providers in a strategy that can’t be duplicated
Insurance market: have a say in products, pricing, and strategy without up-front investment in creating a new insurance company
Provider value: learn from provider perspectives in their communities, value in provider commitment to insurance goals
Population Health: Develop a jointly invested population health approach that leverages the best of payer and provider models, efficiency, data, and technology
Our evolution
Phase IIPhase I Phase III
• Launch jointly owned insurance products
• Narrow network products, risk sharing
• Provider-driven Care Management Model
• Data Sharing
• Grow jointly owned products
• Design broader JV including more partners, products, and risk sharing
• Launch new JV and Population Health Company
• Value based Care
• Refine model
• Expansion
• Establish initial Joint Venture
• Set initial scope and terms
2013/2014 2015 2016+
Population Health
• To succeed in taking on financial accountability and aggressive joint financial targets , payer and providers make significant investments in technology and resources
• To deliver better quality care and reduce costs, payer and providers share data and integrate to create a richer picture of the patient
• Analytics with richer data allow for improved and more proactive identification and more accurate risk stratification
Financial/Clinical Accountability
• Partner Providers take on financial accountability and aggressive targets for their members as well as the rest of the insurance company’s members in the region
• Partner providers jointly agree to clinical measures and outcomes
• Payer and providers delineate duties more effectively and efficiently
• Providers have a say in insurance products, pricing, and market strategy
Key Components of our Joint Venture
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Agenda
• Introduction
• Goals, Evolution, & Vision
• Alignment & Coordination
• Population Health Approach
• External Message & Next Steps
• Questions
Long Term Value and Recognizing the “hockey stick”
10Time
Ret
urn
on
Inve
stm
en
t
Today
Similar strategies typically require a multi year investment before ROI+
Stage 1:
• Capital outlay
• Provider risk models
• Premium reductions
• Pop Health & utilization improvements
Stage 2:
• Continued premium advantage to grow market
• Population Health strategies capture greater share of patient services
Stage 3:
• Incentive pay-outs begin
• Increased membership fills excess capacity
• Additional capital outlay to move to broader population health infrastructure
Benevera
Status Quo
Risk Pool 2• Partner providers share
upside/downside financial profit/loss for patients attributed outside partner providers
• Provider share in the insurance business and risk
• Risk corridors apply
Risk Pool 1• Partner Providers take
upside/downside risk for attributed members with Harvard Pilgrim
• Discounts and risk corridors apply
• ~40% of Harvard Pilgrim members in NH are attributed to a provider partner
Financial and clinical alignment
95,000 Fully Insured members, 75,000 Self-Insured Members (Future)
• Providers have a voice in Harvard Pilgrim products, pricing and market strategy
• Providers agree to work together with the Benevera clinical committee to identify clinical and financial best practices for their sites
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Delineation of responsibilities
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JV
Provider
Payer
Medical Services
Population Health
Administrative and Insurance Services
Care Teams
IT Investments
Community insight
HMO PPO LPLimited
network plans
All Harvard Pilgrim Plans in
NH
Benevera Health benefits all HPHC plans & members in NH
•~95,000 fully-insured Harvard Pilgrim members in NH – effective January 1, 2016
- All products, broad and narrow networks
•~75,000 self-insured HPI and HPHC members in NH – effective early 2017
•Premiums on all products are 4% lower in 2016 because of Benevera Health 13
Agenda
• Introduction
• Goals, Evolution, & Vision
• Alignment & Coordination
• Population Health approach
• External Message & Next Steps
• Questions
Provider Driven Population Health Approach
Population health approach
• Leverage trust in providers and coordination of duties to improve patient engagement
• Utilize EMR and Claims data for more accurate and predictive models to improve outcomes and care
• Staff care teams including social workers and pharmacists to address a broad set of circumstances
Current Payer Care Management
Our Population Health Approach
• Insurer driven
-Outreach done by payer, by phone
-Focuses on financial indicators
• Utilizes Claims Data only
-Data lag limits some interventions
-Clinical information not used
• Identifies high risk and cost patients
-Focus on chronic and complex conditions
• Identifies broader set of patients
-Gaps in preventive care, vaccine reminders, screenings, pharmacy adherence
• Claims and EMR data
-Some data integrated real-time
-EMR data for improved interventions
• Provider-driven-Outreach done by nurses aligned with the PCP using phone, email, in-person
-Physician develops personalized care plan
HarvardPilgrim
Data
Partner Provider
Data
• All services paid by Harvard Pilgrim
• Usually received 30-60 days after services
• All services with partner providers, regardless of payer
• Usually received within hours/days
• More complete view of the patient, real-time, actionable analytics, improved outcomes
• Enables proactive engagement of more patients, identifying issues earlier
• Reduced duplication of tests and services
Working together leads to improved outcomes
MoreComplete Picture of
the Patient
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Embedded and Geographically-based care teams
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• Embedded in practices when possible, Geographic proximity when not
• Co-visits and home visits possible, as appropriate
• Heavy use of Social workers with BH background
Agenda
• Introduction
• Goals, Evolution, & Vision
• Alignment & Coordination
• Population Health approach
• External Message & Next Steps
• Questions
Benevera external message
Benevera Health helps provide healthier health care by:
•Transforming the delivery of health care to create a better patient experience at lower cost – Premiums 4% lower in 2016!
•Helping contain costs over the long-term and improving care experiences
•Being available to everyone covered by a New Hampshire based Harvard Pilgrim Heath Plan.
•Empowering members and caregivers to make appropriate, informed choices about providers and treatments
•Benevera Health is a complement to health plans, providers and hospitals that leverages data-driven insights, advanced health management techniques, proactive intervention and professional guidance to give clients a sustainable option that is needed today.
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Next Steps
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• Continue to implement: refine model, technology, and staffing
• Expand partnership: include more aligned hospital systems in our region; expand to different regions
• Innovate: leverage the partnership to deliver care in ways not typically supported by a fee-for-service environment, share technologies, try new payment models
• Offer Additional Products/Services: bring learnings from processes, tools, and technologies to other payers and providers
Agenda
• Introduction
• Goals, Evolution, & Vision
• Alignment & Coordination
• Population Health approach
• External Message & Next Steps
• Questions
