lisa pettigrew - csc - transforming phi for health outcomes with analytics

1DELIVERING INNOVATION TOGETHER 14TH Annual Australian Health Insurance Summit 2015

Industry Transformation, Disruption & Competitive Trends

§ Private Health Payers / Insurers around the world are challenged by pressures to reduce costs, improve coordination and health outcomes, evolve towards member / patient-centric models

§ Health insurers are facing competitive challenges from new players disrupting the incumbent market status quo from all quarters

§ A major competitive challenge these new players pose is the effective gathering, sharing, and use of data

§ Building analytics competencies helps Health Insurers create actionable insights, improve outcomes, and reduce time to value

“The global healthcare

analytics market, estimated at

$4billion in 2013, is expected to reach $21billion by 2020, growing at a CAGR of

25.2% from 2013 to 2020”,

Markets & Markets 2013


Limitations of Traditional Insurance

Model§ Limits on premium increases

§ Decreasing profits§ Regulatory scrutiny§ New market entrants§ Rapid development of new, lower cost therapies

§ How to evaluate new non traditional models of care?

Rise of Provider-Payer Convergence

§ Provider-payer contracts, joint ventures

§ Bundled & performance payments, gradual decline of fee for service models

§ Provider-payer mergers and acquisitions

§ New retail health entrants

Expectations of the Activist Health Consumer

§ Increasing consumer engagement

§ Consumers making data-based decisions

§ New patient-generated data

§ “Retailization” and “consumerization” of the engaged experience

§ Social & digital

No longer should the consumer go to the health system;; the health system now comes to the consumer

The key to the new healthcare experience is data analytics to target the right response and support to the right member in the right way

Shifts in the competitive landscape

CSC Proprietary and Confidential 3July 28, 2015

Source: McKesson Market Pulse Survey, 2014

2% 5% 7%6%8%

10%8%12%

14%10%

14%18%

17%

18%

19%

56%42%

32%

Today in 2 years in 5 years

Projected Mix of Payment Models Among Payers

Fee For Service

Pay for Performance

Capitation

Episode of Care /Bundled Payments

Global Payments

Other, e.g., shared savings

Shifting Reimbursement Models: From Fee-for-Service to Pay-for-Performance

• Gradual projected reduction in Fee for Service and gradual move to Pay For Performance

• US Medicare payment reform leading the way


More than 90 new health companies have been created since 2010. PwC Health Research Institute Analysis, 2015

Is Change Really Happening? New Market EntrantsVenture capital funding for health care technology firms has increased 176% this year, with the majority of funding allocated to data analytics companiesRock Health, 2015 (San Francisco–based healthcare seed funding firm)

The global population health management market was valued at $12.8 billion in 2013. It is expected to grow at a CAGR of 26% from 2013 to 2018 to reach $40.6 billion by 2018Markets & Markets 2013


“One of the fastest-growing startups in Silicon Valley history”

The New York Times

“Obamacare Startup Oscar Health Hits A $1.5 BillionValuation”

Forbes

Example Disruptors

“In the fast changing world, CVS’ strategy is to be a one-stop-shop for healthcare”

The New York Times

6

Source: IDC, Best Practices: Payer Analytics for a Post-Reform Market, April 2015

Where are payers investing in analytics?


Unleashing the value of Advanced Data Analytics for Health Insurers

Advances in computing technology and the explosion of new digital data sources are expanding the industry beyond traditional actuarial science

PHI is catching up to other industries in the adoption of predictive and optimization business models

Investments in analytics and ‘digital’ are not simply IT projects – today PHIs are shifting their attention to people and management processes

§ Turning big data into "actionable data“ for health consumers – remote patient monitoring (biometrics) provides new real-time data and insights for prediction

§ Optimizing care for member populations– through creating a comprehensive view of complex usage, needs, and outcomes trend at all possible levels of operation

§ Creating personalized medicine –advanced analytics are vital to gain value from population health, clinical and digital data for individuals

§ Lowering healthcare costs - analytics can help provide transparency on healthcare costs, as well as help patients make smart decisions on their healthcare


Systems of Record Data

Genomic & Genetic Data

Patient Generated Data

The Three Major Data Forms for Future Healthcare Data

So what data are we talking about?..........


………and what we can do with this data?

Systems of Record DataData stored in EMRs, Policy Admin systems and other enterprise / dept systems. Basic analytics unlocks important predictions for demand planning and disease patterns.

Genomic & Genetic DataHuman DNA data, once sequenced and readily available has potential to personalize medicine & therapy and to understand, manage and prevent disease.

Patient Generated DataBiometric & qualitative data captured directly by a patient into a device (IoT) or a system eg., telehealth monitors, biometric devices, wearables, & patient record tools.

The Three Major Data Forms for

Future Healthcare Data

Member Acquisition & Retention

• Campaign Management & Targeting

• Social & Digital Engagement • Life Events & Health Profiling• Wider Eco-Systems / Upsell

Underwriting Efficiency

• Are claims consistent with population propensity

• Predictive Analysis• Patterns of Claims

Claims Efficiency• Are claims consistent with population propensity?

• Unnecessary Treatments• Patterns of Overtreatment• Inflated Claims• Patterns of Claims / Leakage• Loss adjustment expenses

Provider Management

• Differences in Provider outcomes

• Different Treatments Pathway by providers

• Incentives & behaviours

Wellness, Prevention &

Population Health• How to target preventative schemes (“personas”)

• Predictive Analysis• Biometric & social data

Fraud Management & Prediction

Rising improper paymentsFraud prediction Risk assessments & Real-time Risk Assessment of TransactionsProductive Investigations

10

Example - Patient (Member) Care Coordination Centres

“I’ll have an ounce of prevention”

“Will I still be able to not exercise?”

The Reluctant Health Consumer

The Activist Health Consumer

Member | Patient | Consumer• Changing competitive landscape and perception of health insurance• Rise of the informed health consumer • Tailor products & services to capture right mix of members• New digital models and health management tools• Proactively become healthcare leader

The Health Insurer of the

Future

11

Example - Patient (Member) Care Coordination Centres

• Changing how outcomes are measured

• Changing the care pathways

• Respecting patients expertise

• Changing the ‘commissioning’ of care

• Changing the location of care

• Managing the “system” and the other determinants of healthcare and the costs of healthcare

• Serving population of ~250,000 in northern England• Coordinating care with outcomes• Pooled funding of health and social care


Example - Empowering Consumers: What Do They Want? And how does analytics help?

Provider-Payer Convergence

§ Provider-payer contracts, joint ventures

§ Provider-payer mergers and acquisitions

Source: AoNHewitt Consumer Satisfaction Survey, 2015

Five Ways to Empower Consumers

1. Be Transparent

2. Create a hyper relevant experience for me

3. Make it clear and simple

4. Don’t forget about me after enrollment

5. Guide me to the right next steps


Conclusions

§ Industry Transformation & Disruption is happening

§ Investments in data analytics are necessary for the future

§ New member engagement models require data strategies

§ There are 3 major forms of healthcare data

§ The health insurers of the future are investing in advanced analytics and big data

§ New models of population health management are converging traditional models of providers and payers

§ Consumers need a “navigator” for the complex health system

Thank You

Lisa [email protected]

+1 703 626 3976

+61 418 489 521

@lisapettigrew

DELIVERING INNOVATION TOGETHER