The Analytics of Health Insurance CO-OPs


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Join Health Catalyst and two leading innovators who are focused on the analytics necessary to make CO-OPs work. We promise, this will be in engaging presentation discussing the following:

1. Characteristics of CO-OPs including expected participantion and services provided.
2. The analytics necessary to drive the CO-OP business forward.
3. A comparison between the services provided by CO-OPs and traditional health plans.
4. The clinical and financial analytics of a typical CO-OP.

What impact will CO-OPs have on the insurance markets, what analytics are necessary, and how their success could impact payments for health system services? Will they be able to materially reduce healthcare costs? How will consumers embrace the insurance options they provide?

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  • A Consumer Operated and Oriented Health Plan (CO-OP)
    Gives members a voice in the CO-OP’s operations
    What is covered under benefit plans
    Members sit on the board
    No profits – if revenues exceed costs, the surplus will be reinvested to directly benefit members
    Lower premiums, expanded benefits and quality improvements 

    Insurance Designed to Make Members Sustainably Healthy
    Incentives for preventive care: Until now, health insurance has only helped people who are sick or hurt. We think health insurance should also be there to help people stay healthy. That’s why we reward you for taking simple, healthy actions (like getting a yearly checkup) with more benefits and lower costs.
    Creates a shared sense of responsibility among members to advance their own health and the health of the CO-OP.
    Partnerships with primary care providers to improve quality and reduce costs.
  • Difference between FFM (Federally-facilitated marketplace) and HIX (Health Insurance Exchange)… latter is state-based
  • The percentage of Coloradans without health insurance in 2013 was 14.3%, or approx. 741,000 Coloradans (one in seven residents).

    Nearly one in five Coloradans has public health insurance.

    Douglas County (HSR 3) the lowest uninsured: 5.4%

    NW corner the highest: 24.8%

    Connect for Health Colorado enrollment: ~70k (through Jan-14)

    Colorado HealthOP has a bit above 10% market share.
  • National Commission on Community Health Services
    1962-1967 – 21 community health studies, over 1,000 community and health leaders
    Chaired by Marion Folsom
    Published their findings in 1966
    12 Recommendations

    Supported the emergence of Community Health Centers
    Called for the formation of the specialty of Family Medicine
    Promoted aspirations for environmental health, clean water, and air quality
    Called for the need for comprehensive reproductive health care

    Then in the 1970-80’s got pretty much demolished by political whim and for-profit healthcare
  • Communities of Solution: The Folsom Report Revisited

    The Community as a Learning System for Health
    National Committee on Vital and Health Statistics

    13 Grand Challenges

    Foster the ongoing development of integrated comprehensive care practices (Patient-Centered Medical Homes)
    Provide every individual in the United States the opportunity to form a partnership with a personal physician and a team of health professionals
    Create a health workforce to serve the needs of US communities, including community health workers.
    Integrate health services
    Create a national network of community partnerships that engage and activate the citizenry to self-define local, regional, and statewide Communities of Solution

    Communities of Solution

    Link primary care and public health
    Public health can be the usual public health agency
    Or the myriad other community organizations that are interested in health
    Local community members help catalyze the collaboration between public health groups and primary care providers
    Yes, behavioral health is in there too.
    Local data drives local change
    Place based data is essential

    Can this really exist?
  • Bill lives near Downtown Denver in a small apartment. He grew up in the San Luis Valley and moved to Denver after high school.
    He has been a truck driver, carpenter, a cabby. Now he is disabled, unable to work. He’s about 60 years old.

    Bill is a hot-spot
  • 7 hospitalizations in past year
    Acute MI last year.
    Heart Failure x 3
    Pneumonia landed him in the hospital for a week last winter.
    Diabetes II x2
    Non healing foot ulcer
    9 additional ER Visits in past year.
    Chest pain x 2
    Leg swelling x4
    Cough x 1
    Diabetes x 2 - hyperglycemia
  • Bill was identified by the local emergency room as a super-utilizer, a Hot-Spot.
    He was enrolled in an aggressive healthcare follow-up plan funded by the city and a local foundation.
    Bill got better.
    Bill lost 30 pounds
    He sees his family doctor every 2-3 weeks
    He checks his blood sugar and his A1c dropped from 12 to 8
    He saw a counselor in his primary care office for 4 months and his depression is much better
    He takes his medications. And eats a regular diet.

    His utilization dropped, and the costs of his care plummeted.
  • Bill is not that uncommon. In Campden or Philadelphia, Fresno or Denver. There are a number of hot-spots that have a lot of medical problems and end up in the ER and hospital.

    Super-utilizers,, cost the healthcare system millions and billions of dollars each year. Just a small fraction of the patients account for > 50% of our healthcare costs.
  • There is a poorly maintained park a few blocks away. A couple of nearby churches have shelters for homeless men and families. There is a medical clinic a couple bus stops away. Bill lives in a part of town that has been called “blighted”From the periphery of Denver's urban core through outlying historic residential neighborhoods, the ten-block Welton Street corridor once thrived as a vibrant and high profile urban tapestry of jazz, entertainment, and vital services within the greater Five Points area. These sixty years later, a third of the corridor is blighted, developed primarily as surface parking, and the rest sees comparatively sparse pedestrian activity nightlife..
  • But urban blight is not the only place where healthcare has disintegrated. There are suburbs and gated communities where people live in isolation, lacking integrated primary care and behavioral health, poor collaboration between public health and medical providers, schools, and community organizations.Location can matter, but money is not the only predictor.
  • Today, identifying individual patients with high utilization of health care is relatively easy given the vast improvements in health information technology, But, is the super-utilizer the real problem? Do they have some medical defect or general disregard for their community? Are hot spots are enemy? Or is the problem really “cold spots,” communities in which the social determinants of health, support, and access to primary care have broken down?
  • The Usual SuspectsProvidersClinicsHospitalsPublic healthAnd the unusual suspects Schools Churches Business Clubs Community groups Patients Others
  • “Other” plans have data structures built upon other, older/legacy, data structures. Layer upon layer of (unnecessary) complexity.Different formats, inconsistent rules, unverifiable analytics…
  • CO-OPs present an “open road” from both a data and analytics approach perspective.There is a clean slate from which to construct, develop, and partner in determining the best health for our members.Room to grow, share, collaborate – together. Providers, patients… communities.
  • “Other” plans can throw the term “Big Data” around as if it can/will solve everything.They approach population health as just a Big Data problem, and that this will allow them to…
  • … thread the needle of the issue at hand.More volume, velocity, variety.They think of variety as different formatted data… not different insights.
  • Wide Data – sourcing data on patients from multiple and disparate sources.Not just those immediately thought of in health care.
  • Data must have meaning – for the patient, for the provider, for those who care… for the communities.This will have lasting impacts. Allows for ongoing needs assessment, evaluation, and program development. Continuous quality improvement.Promote continuum of care.Focus on “always” events and not “never” events.
  • The Analytics of Health Insurance CO-OPs

    1. 1. © 2013 Health Catalyst © 2013 Health Catalyst February 12, 2014 The Analytics of Healthcare CO-OPs
    2. 2. © 2013 Health Catalyst What is a CO-OP?  Consumer Oriented and Operated Plans – Commercial, non-profit health plan licensed by its state(s) – (501(c)29 designation) ... tax exempt – Must be a “start-up” healthcare entity – 51% of Board must be consumers of the plan and may not have been in management after 7/17/2009 – Must be consumer governed with > 51% of members being individuals & small groups – May direct market and/or offer through Exchanges
    3. 3. © 2013 Health Catalyst What is a CO-OP?  CO-OP main features Annual profits can only be spent to: 1. Lower future Premiums 2. Improve the quality of care delivered to members 3. Repay Loans awarded by the Federal Government 4. Accumulate sufficient reserves to provide for growth & financial stability
    4. 4. © 2013 Health Catalyst CO-OP Financial Model  Funding – Start-up Loans (CMS/Federal Government) Repaid through CMS within five (5) years of each withdrawal Fixed interest rate at 1% below benchmark 5 year treasury rate with significant late payment penalties – Subsidy Loans Provided incrementally as milestones are met Repaid with interest through CMS within fifteen (15) years from the date of each disbursement Fixed interest rate at 2% below the benchmark treasury rate with significant late payment penalties
    5. 5. © 2013 Health Catalyst Benefit Plan Design - EHB Required to comply with specific state’s EHB Essential Health Benefit must consist of: Minimum standard of coverage for benefit design – Reasonable out-of-pocket spending limits – Cannot include any annual or lifetime maximum caps Limits cannot be placed on coverage to invoke adverse selection Limits are placed on the number of plan choices for decision- making Insurers must offer full range of benefit plan designs
    7. 7. KENTUCKY STATE SPECIFIC PARAMETERS  640,000 uninsured Kentuckians  34% of those with incomes at or below 138% of Federal Poverty were uninsured.  34% of Kentuckians who earn up to 200% of FPL were currently uninsured as well.  20% of Kentuckians were covered by some form of public insurance
    8. 8. THIS IS KENTUCKY ,TOO  Ranks 45th in overall health status by America’s Health Rankings (2013)  Ranks 49th in overall health status by Gallup Healthways Well-Being Index (2012)  #1 for highest smoking rate in the U.S.  #1 for preventable hospitalizations  #1 for cancer deaths  #6 for premature deaths  #6 for obese adults (1.1 million)  #7 for cardiovascular deaths  #9 for diabetes
    9. 9. 2014 ENROLLMENT RESULTS  Offered all plan levels in the state(individual)  Platinum  Gold  Silver  Bronze  Catastrophic  Open network which we continue to build  In-house medical management  State based exchange  Results: Approximately 24,000 lives to date
    10. 10. ESSENTIAL HEALTH BENEFITS Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services, and Chronic disease management Pediatric services, including oral and vision care.-
    11. 11. MEMBER EDUCATION  These members have been forced to navigate the social and medical systems alone due to their lack of insurance and often fail to receive many of the services they need.  KYHC Clinical Care staff will seek to educate our membership on the services available to them through our benefit designs.
    12. 12. INFORMATION COLLECTION  Use of Health Risk Assessments  Member interviews  Member outreach  Medical/Pharmacy claim review
    13. 13. CARE COORDINATION • Engage patients with chronic illnesses while hospitalized • Follow patients intensively post-discharge • Teach/coach patients about medications, self-care, and symptom recognition and management • Remind and encourage patients to keep follow-up physician appointments
    14. 14. PLAN ANALYTICS  Initial Pharmacy data will provide the first insight into membership  Concurrent review of hospital stays will also provide information  HRAs though self reported may also shed some light on membership  As medical claims are processed they can also provide valuable information
    15. 15. 2015 GOALS  Received approval of federal loan for expansion intoWest Virginia for 2015  Already working on rates for plans for 2015 in Kentucky and Initial plan forWestVirginia  Maintain member centric approach for medical management and partner with our PBM for analysis of trends in KY and preparation initial formulary forWest Virginia expansion.
    16. 16. Colorado HealthOP A Health Insurance Cooperative That Is Turning Health Insurance Upside Down 7/25/2014 16
    17. 17. Colorado HealthOP Overview ● Created through funds from the Affordable Care Act and with the partnership of the Rocky Mountain Farmers Union ● We are a new, non-profit health insurance co-op ● Our board will include members who buy our insurance and will help to make decisions about how we spend our funds ● Commitment to community health through ongoing partnerships and campaigns 7/25/2014 17
    18. 18. Colorado HealthOP Mission & Vision 7/25/2014 18 ● Mission To improve the health of individuals and communities through trusted partnerships with members, employers, and providers. ● Vision To be a catalyst for the transformation of the health and vitality of Colorado communities.
    19. 19. Insurance Designed to Make Members Sustainably Healthy 7/25/2014 19 ● Preventive care and healthy action incentives ● Shared responsibility ● Primary care provider partnerships Insurance is supposed to help when people get sick or injured; we think insurance should also be there to help people stay healthy.
    20. 20. (the Marketplace) 7/25/2014 20 ● Colorado HealthOP is one of the options on the marketplace ● The marketplace was created through the ACA ● Works like a airline booking website – you can compare plans and rates ● Metal tiers help to distinguish each plan and its benefits (bronze, silver, gold)
    21. 21. This Is Colorado 7/25/2014 21 ● Overall Rank of 8th by America’s Health Rankings (2013) ● Overall Rank of 2nd by Gallup Healthways Well- Being Index (2012) ● Lowest prevalence of obesity in the U.S.
    22. 22. This Is Also Colorado 7/25/2014 22
    23. 23. And So Is This 7/25/2014 23
    24. 24. Health Is A Community Affair 7/25/2014 24
    25. 25. Community of Solution 7/25/2014 25 ● Problem Sheds ● What is the problem? ● Where is it? ● Who does it impact? ● Asset Sheds ● Local identification of health problems ● Local data ● Local solutions
    26. 26. “… and he stoppeth one of three…” 7/25/2014 26 I would like you to meet Bill…
    27. 27. 7/25/2014 27
    28. 28. 7/25/2014 28
    29. 29. 7/25/2014 29
    30. 30. 7/25/2014 30
    31. 31. 7/25/2014 31
    32. 32. 7/25/2014 32 no health?” Cold –
    33. 33. 7/25/2014 33
    34. 34. 7/25/2014 34 How do we get there? Where?
    35. 35. 7/25/2014 35 Song of the Open Road…
    36. 36. 7/25/2014 36 Big Data … or Dark Matter?
    37. 37. 7/25/2014 37
    38. 38. 7/25/2014 38 Wide Data is part of the solution…
    39. 39. 7/25/2014 39 Meaningful Data is …
    40. 40. 7/25/2014 40 Bridge to Data ● Claims ● HRA ● Biometrics ● EMRs ● MEPS ● BRFSS ● CHAS ● CO APCD
    41. 41. David Napoli Director of Performance Improvement & Strategic Analytics Twitter: @Biff_Bruise 7/25/2014 41
    42. 42. © 2013 Health Catalyst Questions and Answers Additional Information • See us at HIMSS 2014 booth #6076 • Call 801.708.6800 to request a meeting • Listen to two clients speak: ‒ “Improving Outcomes with an Innovative Approach to Population Health Analytics” » Stanford Hospital & Clinics » Yohan Vetteth, Pravene Nath, MD » Date/Time: Thursday, 2/27, 12 PM » Location: Room 304A, Session #229 ‒ “Blending Clinical and Financial Data to Drive the Value Equation” » Texas Children’s Hospital » Charles Macias, MD » Date/Time: Wednesday, 2/26, 1 PM » Location: Room 304A, Session #191 • Follow us on Twitter: @HealthCatalyst • Explore our site: 42