the analytics of health insurance co-ops
DESCRIPTION
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?TRANSCRIPT
© 2013 Health Catalystwww.healthcatalyst.com
© 2013 Health Catalystwww.healthcatalyst.com
February 12, 2014
The Analytics of Healthcare CO-OPs
© 2013 Health Catalystwww.healthcatalyst.com
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
© 2013 Health Catalystwww.healthcatalyst.com
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
© 2013 Health Catalystwww.healthcatalyst.com
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
© 2013 Health Catalystwww.healthcatalyst.com
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
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
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
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
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.-
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.
INFORMATION COLLECTION
Use of Health Risk Assessments
Member interviews
Member outreach
Medical/Pharmacy claim review
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
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
2015 GOALS
Received approval of federal loan for expansion into West Virginia for 2015
Already working on rates for plans for 2015 in Kentucky and Initial plan for West Virginia
Maintain member centric approach for medical management and partner with our PBM for analysis of trends in KY and preparation initial formulary for West Virginia expansion.
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Colorado HealthOP
A Health Insurance Cooperative That Is Turning Health Insurance Upside Down
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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
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Colorado HealthOP Mission & Vision
●MissionTo improve the health of individuals and communities through trusted partnerships with members, employers, and providers.
●VisionTo be a catalyst for the transformation of the health and vitality of Colorado communities.
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Insurance Designed to Make Members Sustainably Healthy
●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.
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(the Marketplace)
●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)
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This Is Colorado
●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.
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This Is Also Colorado
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And So Is This
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Health Is A Community Affair
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Community of Solution
●Problem Sheds●What is the problem?●Where is it?●Who does it impact?
●Asset Sheds●Local identification of
health problems●Local data●Local solutions
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“… and he stoppeth one of three…”
I would like you to meet Bill…
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no health?”
Cold –
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How do we get there? Where?
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Song of the Open Road…
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Big Data … or Dark Matter?
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Wide Data is part of the solution…
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Meaningful Data is …
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Bridge to Data
● Claims● HRA● Biometrics● EMRs● MEPS● BRFSS● CHAS● CO APCD
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David NapoliDirector of Performance Improvement & Strategic Analytics
Twitter: @Biff_Bruise
© 2013 Health Catalystwww.healthcatalyst.com
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: www.healthcatalyst.com
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