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Digital Health Strategies:
What Matters to Payers?
Presented by
Susan Philip, MPP
Healthcare Management Consultant
January 20, 2016
This document is proprietary and is intended solely for the use and information of the client to whom it is addressed.
This document is intended solely for the party to whom it is addressed and is confidential
2
Confidential and Proprietary
Milliman, Inc.
Deep knowledge, independent analysis, and practical strategies
for the rapidly changing healthcare industry.
 Milliman is among the world's largest providers of actuarial and related products and
services. Founded in 1947, Milliman is an independent firm with offices in major cities
around the globe. We are independently owned and managed by our principals.
 Known for our technical and business acumen, we provide expert consultation on
both the financing and delivery of healthcare. Clients include most of the leading
health insurers, Blue Cross plans, and HMOs, as well as providers, employers and
sponsors, government policymakers, pharmaceutical companies, and foundations.
 Milliman consultants include actuaries, clinicians, and information-technology
specialists—offering a diversity of experience to help you cost-effectively manage
your organization without compromising quality of care.
www.Milliman.com
3
Confidential and Proprietary
Market Analysis
Analyze market environment, trends, competitors, and differentiators
Readiness Assessment
Assess readiness to enter into a market, develop a new product, change
product offerings
Accreditation Assessment
Assess ability to obtain accreditation or meet programmatic requirements,
e.g. NCQA, URAC, CMS programs, 5-Star Quality
Operational Assessment and Process Renovation
Evaluate processes and programs for compliance with best practices and
identification of opportunities for improvement
Implementation Support
Assist implementation efforts including project management support,
detailed project/work plans, training tools and programs
Administrative Benchmarking
Compare and benchmark administrative efficiency, staffing,
and costs using proprietary tools and data
Consulting services overview
4
Confidential and Proprietary
Payers 101
 Entities are called payers, health plans, health insurers, carriers, and
issuers
 Entities authorized to provide insurance within a state. Must
demonstrate that they can effectively manage risk for their members
 Health insurance is regulated at a state level with a few exceptions
 Payers offer different health insurance products for each business line
which vary by
– Costs (including premiums, cost-sharing, such as deductibles and coinsurance,
out-of-pocket maximums)
– Benefits (including those required by law and additional benefits)
– Network (in-network versus out-of-network providers)
– Terms and conditions (for example, medical necessity criteria typically applies)
5
Confidential and Proprietary
Key Drivers Examples of Market Effects
Policy and Regulatory
Changes Resulting from
the Affordable Care Act
 Insurance reform: Guaranteed issue, mandates, subsidies have increased those with
insurance
 Payment reform: Moving from volume based payments that have no link to quality or
outcomes to value-based payments that encourage evidence-based practices
 Delivery system reform: Moving to patient-centered, population-based care which is
more integrated with the community
Public and Private
Purchaser Demands
 Self-insured employers seeking ways to better manage healthcare costs associated
with chronic conditions
 State Medicaid agencies seeking ways to better coordinate care for Medicaid-
Medicare beneficiaries
 Medicare penalizes hospitals for avoidable readmissions
Consumer Demand  Demographics
 Ease of use and growing demand for digital devices and tools
Supply Side Changes  Provider consolidations– vertical and horizontal
 New provider entrants (e.g. retail care)
 Pharmaceutical, biotech, and medical device advancements
 Digital health innovations
Drivers of payers’ digital health investment strategy
6
Confidential and Proprietary
Key Drivers Examples of Payer Responses
Policy and Regulatory
Changes Resulting from
the Affordable Care Act
 Consolidation
 Market exit/entry: offer new business lines (e.g. health insurance exchanges);
 Develop new products using value-based insurance design
 Allow prospective members to comparison shop among products
Public and Private
Purchaser Demands
 Price transparency tools: allow members of self-insured plans to compare potential
out of pocket costs between providers
 Investment in analytics to inform business intelligence, strategy, and day-to-day
operations
 Investment in programs to address “high-risk” or “high-utilizers”
 Investment in care management tools for care managers and coordinators
 Consider piloting innovations for subset of population
Consumer Demand  Investing in consumer portals and other consumer-facing digital tools
 Investment in engagement tools/programs for those with chronic conditions
Supply Side Changes  Partnering with providers in share savings/risks arrangements (e.g. ACOs)
 Investment in health information exchange infrastructure
 Investments in decision support tools imbedded in the workflow (i.e. through EHR)
 Develop “narrow,” “high-value” networks
Payers’ responses are opportunities for innovation
7
Confidential and Proprietary
Company Type Functions/Examples
Population Health
Management
 Diabetes self-management tools and devices
 Medication adherence tools
 Wellness/patient engagement tools involving gamification
 Behavioural health assessment
 Post-discharge coordination and management tools
Administrative Efficiency  Referral management
 Solutions to improve data exchange from/to primary, speciality and tertiary providers
Healthcare Delivery  Telehealth
 Cognitive behavioural therapy tools
 Remote/ongoing monitoring
Analytics  Aggregate data across care continuum
 Quality of care reporting support
 Provider-level performance reporting
 Data visualization
Entrepreneurs are honing in on these opportunities
Provider Support  Imbedded tools in EHR
 Real-time, evidence-based decision support tools
Payment Model  Tools combining members’ coverage and negotiated prices to estimate comparative
out-of-pocket costs
 Healthcare services “groupers”
 End-to-end solutions for ACOs
8
Confidential and Proprietary
Checklist: Considerations for approaching payer
1
Clear value proposition:
 How does the solution save healthcare and/or administrative dollars?
 Other measures: quality of care, outcomes, efficiencies, patient satisfaction,
provider satisfaction
2
Target population clear:
 Medicare, Medicaid, Dual, commercial, self-insured
 Condition-specific, if applicable
3 Solution aligned with payers’ growth strategy
4 Solution aligned with payers’ payment and delivery transformation strategy
5 FDA review: If applicable, what is the status of the FDA approval?
6
Integration: Can the solution be integrated into existing systems/EHRs, if
applicable? Estimated cost of integration
7 Analytics: Does solution support ongoing analytics to measure impact of solution?
8 Key provider partners: Are they using the solution or willing to use the solution?
9 Pilot conducted and evaluated (more later)
10 Plans to scale solution with realistic cost projections
9
Confidential and Proprietary
November 20, 2015
This presentation has been prepared for informational purposes only. No portion may be provided to or relied upon by
any other party without Milliman’s prior written consent. Milliman does not intend to benefit or create a legal duty to any
third party recipient of its work.
The materials in this presentation represent the opinion of the authors and are not representative of the views of
Milliman, Inc.
These slides are for discussion purposes only. These slides should not be relied upon without benefit of the discussion
that accompanied them.
Susan Philip MPP
Healthcare Management
Consultant
susan.philip@milliman.com
650 California Street, 17th Floor
San Francisco, California 94108
USA
Tel +1 415 394 3788
Fax +1 415 403 1334
milliman.com

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Digital Health Strategies: What Matters to Payers?

  • 1. Digital Health Strategies: What Matters to Payers? Presented by Susan Philip, MPP Healthcare Management Consultant January 20, 2016 This document is proprietary and is intended solely for the use and information of the client to whom it is addressed. This document is intended solely for the party to whom it is addressed and is confidential
  • 2. 2 Confidential and Proprietary Milliman, Inc. Deep knowledge, independent analysis, and practical strategies for the rapidly changing healthcare industry.  Milliman is among the world's largest providers of actuarial and related products and services. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe. We are independently owned and managed by our principals.  Known for our technical and business acumen, we provide expert consultation on both the financing and delivery of healthcare. Clients include most of the leading health insurers, Blue Cross plans, and HMOs, as well as providers, employers and sponsors, government policymakers, pharmaceutical companies, and foundations.  Milliman consultants include actuaries, clinicians, and information-technology specialists—offering a diversity of experience to help you cost-effectively manage your organization without compromising quality of care. www.Milliman.com
  • 3. 3 Confidential and Proprietary Market Analysis Analyze market environment, trends, competitors, and differentiators Readiness Assessment Assess readiness to enter into a market, develop a new product, change product offerings Accreditation Assessment Assess ability to obtain accreditation or meet programmatic requirements, e.g. NCQA, URAC, CMS programs, 5-Star Quality Operational Assessment and Process Renovation Evaluate processes and programs for compliance with best practices and identification of opportunities for improvement Implementation Support Assist implementation efforts including project management support, detailed project/work plans, training tools and programs Administrative Benchmarking Compare and benchmark administrative efficiency, staffing, and costs using proprietary tools and data Consulting services overview
  • 4. 4 Confidential and Proprietary Payers 101  Entities are called payers, health plans, health insurers, carriers, and issuers  Entities authorized to provide insurance within a state. Must demonstrate that they can effectively manage risk for their members  Health insurance is regulated at a state level with a few exceptions  Payers offer different health insurance products for each business line which vary by – Costs (including premiums, cost-sharing, such as deductibles and coinsurance, out-of-pocket maximums) – Benefits (including those required by law and additional benefits) – Network (in-network versus out-of-network providers) – Terms and conditions (for example, medical necessity criteria typically applies)
  • 5. 5 Confidential and Proprietary Key Drivers Examples of Market Effects Policy and Regulatory Changes Resulting from the Affordable Care Act  Insurance reform: Guaranteed issue, mandates, subsidies have increased those with insurance  Payment reform: Moving from volume based payments that have no link to quality or outcomes to value-based payments that encourage evidence-based practices  Delivery system reform: Moving to patient-centered, population-based care which is more integrated with the community Public and Private Purchaser Demands  Self-insured employers seeking ways to better manage healthcare costs associated with chronic conditions  State Medicaid agencies seeking ways to better coordinate care for Medicaid- Medicare beneficiaries  Medicare penalizes hospitals for avoidable readmissions Consumer Demand  Demographics  Ease of use and growing demand for digital devices and tools Supply Side Changes  Provider consolidations– vertical and horizontal  New provider entrants (e.g. retail care)  Pharmaceutical, biotech, and medical device advancements  Digital health innovations Drivers of payers’ digital health investment strategy
  • 6. 6 Confidential and Proprietary Key Drivers Examples of Payer Responses Policy and Regulatory Changes Resulting from the Affordable Care Act  Consolidation  Market exit/entry: offer new business lines (e.g. health insurance exchanges);  Develop new products using value-based insurance design  Allow prospective members to comparison shop among products Public and Private Purchaser Demands  Price transparency tools: allow members of self-insured plans to compare potential out of pocket costs between providers  Investment in analytics to inform business intelligence, strategy, and day-to-day operations  Investment in programs to address “high-risk” or “high-utilizers”  Investment in care management tools for care managers and coordinators  Consider piloting innovations for subset of population Consumer Demand  Investing in consumer portals and other consumer-facing digital tools  Investment in engagement tools/programs for those with chronic conditions Supply Side Changes  Partnering with providers in share savings/risks arrangements (e.g. ACOs)  Investment in health information exchange infrastructure  Investments in decision support tools imbedded in the workflow (i.e. through EHR)  Develop “narrow,” “high-value” networks Payers’ responses are opportunities for innovation
  • 7. 7 Confidential and Proprietary Company Type Functions/Examples Population Health Management  Diabetes self-management tools and devices  Medication adherence tools  Wellness/patient engagement tools involving gamification  Behavioural health assessment  Post-discharge coordination and management tools Administrative Efficiency  Referral management  Solutions to improve data exchange from/to primary, speciality and tertiary providers Healthcare Delivery  Telehealth  Cognitive behavioural therapy tools  Remote/ongoing monitoring Analytics  Aggregate data across care continuum  Quality of care reporting support  Provider-level performance reporting  Data visualization Entrepreneurs are honing in on these opportunities Provider Support  Imbedded tools in EHR  Real-time, evidence-based decision support tools Payment Model  Tools combining members’ coverage and negotiated prices to estimate comparative out-of-pocket costs  Healthcare services “groupers”  End-to-end solutions for ACOs
  • 8. 8 Confidential and Proprietary Checklist: Considerations for approaching payer 1 Clear value proposition:  How does the solution save healthcare and/or administrative dollars?  Other measures: quality of care, outcomes, efficiencies, patient satisfaction, provider satisfaction 2 Target population clear:  Medicare, Medicaid, Dual, commercial, self-insured  Condition-specific, if applicable 3 Solution aligned with payers’ growth strategy 4 Solution aligned with payers’ payment and delivery transformation strategy 5 FDA review: If applicable, what is the status of the FDA approval? 6 Integration: Can the solution be integrated into existing systems/EHRs, if applicable? Estimated cost of integration 7 Analytics: Does solution support ongoing analytics to measure impact of solution? 8 Key provider partners: Are they using the solution or willing to use the solution? 9 Pilot conducted and evaluated (more later) 10 Plans to scale solution with realistic cost projections
  • 9. 9 Confidential and Proprietary November 20, 2015 This presentation has been prepared for informational purposes only. No portion may be provided to or relied upon by any other party without Milliman’s prior written consent. Milliman does not intend to benefit or create a legal duty to any third party recipient of its work. The materials in this presentation represent the opinion of the authors and are not representative of the views of Milliman, Inc. These slides are for discussion purposes only. These slides should not be relied upon without benefit of the discussion that accompanied them. Susan Philip MPP Healthcare Management Consultant susan.philip@milliman.com 650 California Street, 17th Floor San Francisco, California 94108 USA Tel +1 415 394 3788 Fax +1 415 403 1334 milliman.com