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
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Agenda
• Introduction
• Goals, Evolution, & Vision
•Alignment & Coordination
• Population Health Approach
• External Message & Next Steps
• Questions
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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
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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
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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
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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+
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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
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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
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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
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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
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Agenda
• Introduction
• Goals, Evolution, & Vision
• Alignment & Coordination
• Population Health approach
• External Message & Next Steps
• Questions
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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
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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
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Agenda
• Introduction
• Goals, Evolution, & Vision
• Alignment & Coordination
• Population Health approach
• External Message & Next Steps
• Questions
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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
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Agenda
• Introduction
• Goals, Evolution, & Vision
• Alignment & Coordination
• Population Health approach
• External Message & Next Steps
• Questions