Transcript Making Health Care Consumerism Work

A Roadmap
for
Making Healthcare
Consumerism Work
A Pre-Conference Session on how to
structure your next healthcare
consumerism strategic planning
session
Pre-conference BONUS: A Priimer
on Government & Private
Exchanges, and ACOs.
Ronald Bachman, FSA, MAAA
President & CEO
Healthcare Visions, Inc.
Chairman, IHC Editorial Advisory Board
and League of Leaders
[email protected]
404-697-7376
Table of Contents
Page #
2
3
4
5
8
11
14
18
20
40
Topic
.
Agenda
Scope of Work
Background Info
Task #1 – Setting Principles for Change
Task #2 – Vision Statement Development
Task #3 – Identification of Acceptable Stategies
Change Formula
Actuarial Issues
Consumerism
Task #4 – Personal Care Accounts
65
78
93
102
111
Task #5 – Wellness, Prevention, & Early Intervention
Task #6 – Disease Management
Task #7 – Decision Support Tools
Task #8 – Incentives & Rewards
Task #9 – Viewing Consumerism by Generations
145
154
158
161
164
Task #10 – Create Consumerism Plans
Task #11 – Setting Time Frame for Implementation
Integrated Health Management
Potential Savings from Healthcare Consumerism
Actual Industry Experience Results
170
171
Task #12 (summary) – Potential Savings
Consumer-driven Healthcare Surveys of Growth
1
A 1.5 Day Agenda to Develop a
Healthcare Consumerism Strategy
Day#
1 Morning
1 Afternoon
2
Goal
Agenda, Scope of Work, Background, (T1-3),
Change Formula, Actuarial Issues, Consumerism,
Building Blocks (T4), Building Blocks (T5)
Building Blocks T(6-8), Multi-generational Issues (T9),
Create Plans(T10), Time Frame for Implementation(T11)
Review Decisions from Tasks 1-11, Financials Task 12,
Final Input to Roadmap
Tasks To Be Completed During 1.5 Day “Extreme” Consumerism
1.
2.
3.
4.
5.
6.
Principles
Consumerism Vision Statement
Strategies
Personal Care Accounts
Wellness
Disease Management
7. Decision Support Tools
8. Incentives & Rewards
9. Viewing by Generations
10. Create Consumerism Plans
11. Time Frames
12. Financial Analysis
2
Scope of Work for Developing
the Roadmap and Beyond
Design
Perform
Benefits
Diagnostic
Financial
and
and
& Actuarial
Contrib.
Readiness
Analysis
Strategy
Assessment
(set
(The Road
metrics)
Map)
•Evaluate current
plans
Develop
and
Evaluate,
Implement
Monitor
Select,
Education,
and
Implement
Comm.,
Evaluate
Vendors
Training,
etc.
•Communication
Strategy
•Web-based
Training,
education
•Periodic
reevaluation of
baseline metrics
•Interview
•Consumer
•Services
stakeholders
scorecards
•Performance
•Identify Basic
•Model options •Transition
•Survey, measure
•Print, video,
Principles for Change
strategy
•Accountability other media uses success,
•Evaluate cost
acceptance
•Create Consumer
•
Internal
vs.
impact and
•Optional
•Reliability
Vision Stmt
Coverages
External Services •Vendor/supplier
revise
audits
•Select Strategies
•Carve-out Programs
•Develop
•Reassess &
•Support services
measures of
modify as
•Develop Obj. &
success
•Health vs. Healthcare
appropriate
scope, set timeframe
•Debit/Credit Cards
•Incentive Programs
•Match HR/business plan
•Develop
•Est. Rel. Value
baseline costs of Components
•HDHP & Accts
•Co.& Ee
contrib. level
•Wellness & DM
•Vendors
•Technology
3
Background & Issues

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





Current Benefits,
Design Issues,
Service Issues,
General Concerns,
Anti-selection
Reasons for Change,
Interests in Consumerism,
Driving Forces for Change,
Perceptions of Employee Satisfaction, Dissatisfaction
Other Problems and Positives with Current Plans
4
Task #1 – Setting Principles for Change
Important…Not
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Important
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1.
2.
3.
4.
5.
Have the Right Vision & Vision Stmt
Have a 3-5 Year Roadmap/Strategic Plan
Consider Other Related Corporate Initiatives
Create plan as part of Employer of Choice
Consider other HR metrics impacted by Healthcare
6.
7.
8.
9.
10.
Provide Information on Rx Costs & Alternatives
Provide Information on Dr. & Medical Service Costs
Provide Information on Hospital Costs
Provide Information on the Quality of Dr. Care
Provide Information on the Quality of Hospital Care
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Focus on Discretionary Costs (Rx and OV)
Focus on High Cost Claims & Claimants
Focus on Wellness and Preventive Care
Focus on an Individual Behavior Changes
Focus on Group Behavior Changes
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Task # 1 – Setting Principles for Change
16. Use Incentives and Compliance Rewards
17. Increase Costsharing to Change Behaviors
18. Increase Employee Contributions to Offset Costs
19. Focus on Overall Plan Cost Reduction
20. Set the Right Measurements for Monitoring Progress
Important…Not Important
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21. Build Broad Employee Agreement for Change
22. Minimize Change from Current Plans
23. Make Choices and Plan Options available
24. Improve Access to Care
25. Maintain Existing Network of Providers
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26. Provide
27. Provide
28. Provide
29. Provide
30. Provide
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31. Alternative to cutting benefits or initiating contributions 1
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$ for post-65 retirement healthcare
$ for pre-65 retirement healthcare
$ for non-plan medical
$ for terminated ee’s healthcare
$ for non-healthcare expenses
6
Task #2 – Sample Vision Statement
Positioning to Balance Cost, Quality, and Access
Sample Vision Statement: Create health and healthcare program
options valued by employees that adapt effectively to
environmental trends that increase the quality of services,
improve access to care, and lower costs.
Uncertain,
Clinically Oriented
Supply Driven
Controls
Third
Party
Reimbursement
Quality
Access
Cost
Consumer
Valued Quality
Demand Driven
Controls
Consumer
Involvement &
Transparency
7
Task #2 – Create a Consumerism Vision Statement
Sample Vision Statements:
1.
Providing high performing highly educated employees and their families
with the security of comprehensive health and healthcare coverage that
meets their diverse needs and rewards their personal involvement and
responsibility as wise users of services to optimize their individual health
status and functionality.
2. Affect employee behavior change towards healthier lifestyles and greater
consumerism through the use of rewards and incentives.
3. Make employees better consumers of healthcare services by providing
them with the necessary health education, decision support tools and
useful information including provider cost and quality data.
4. Encourage greater employee awareness and involvement in healthcare
and financial decision making, as a building block towards a defined
contribution strategy for healthcare in the future.
8
Task #2 - Key Words / Phrases for Consumerism
Vision Statement for Addition to Guiding Principles
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
9
Task #3 - Identification of Acceptable Strategies
High Priority...Low Priority
1.Create Transparency – support “employee’s right to
know,” minimize distortions of third-party reimbursement
system, create transparency in costs, provide education/
training on healthcare costs, use decision support programs.
1
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2.Create Personal Involvement – establish greater
financial involvement through HDHPs, HRAs or HSAs,
reward good behavior, offer valued options, provide long
term incentives, provide immediate feedback.
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3. Be Bold and Creative - Shift from supply-side controls
to demand-side control designs. Be an early adopter/fast
follower, consider out-of-the box ideas.
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4. Focus on High Cost “Pareto” Population - Provide
financial protection to families in need due to high
unexpected medical costs and/or chronic conditions
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Task #3 - Identification of Acceptable Strategies
Continued
Important…Not Important
5. Focus on Saving Lives and Improving Health –
Focus on improving the health of the entire population
regardless of plan design selected. Implement prevention
& wellness for long term savings and DM for
immediate impact.
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programs that change behaviors towards acceptance and
compliance with wellness and early intervention, including
pre-natal, non-smoking, diet, exercise, and safety
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6. Focus on Preventive Care – Create incentive
7. Minimize Impact of Cost Shifting – Use consumerism
as an alternative to increased cost shifting or higher
contributions.
8. Implement Optional Consumerism – Provide new
programs and plan options on a voluntary basis.
11
Task #3 - Identification of Acceptable Strategies
Continued
High Priority…Low Priority
9. Implement Change on a Multi-Year Program –
Establish a consumer-centric program with a predetermined multi-year introduction of options and
use of accumulated HRAs and/or options.
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10. Focus on Information Sharing Only– Provide ees
with decision support systems and information sources w/o
accounts or incentives to reward behavioural change.
11. Use Packaged Programs – use full integration of plan
design, information, disease management, and decision
support systems from single vendor.
12. Use Existing Vendors – develop consumerist programs
through current vendor relationships only.
13. Use “Best of Class” Programs – use selected vendors that
May overlay core benefit designs as long as integration is
Non-disruptive and transparent to members
1
12
The Formula for Making Change Happen
Set by Mgmt’s
Direction
IHC Workbook
Implementation
Results
Desire for
Change
+
Vision /
Roadmap
+
Process for
Change
=
POSITIVE
CHANGE
Desire for
Change
+
Vision /
Roadmap
+
Process for
Change
=
Put on Back
Burner
Desire for
Change
+
Vision /
Roadmap
+
Process for
Change
=
Expensive
False Starts
Desire for
Change
+
Vision /
Roadmap
+
Process for
Change
=
Frustration
13
Stages of Change
Requirements &
Stages of Change
NO CHANGE
Without Desire – “Back Burner”
Without Vision – False Starts
Without Process – Frustration
- - - - - - - Alignment - - - - - - -
C
H
A
N
G
E
Threshold
No
Gather Info
C
H
A
N
G
E
Pros & Cons
Awareness
Desire for
Change
Comfort Level
Cautious Doing
CHANGE
CHANGE
Threshhold
Gather Info
Pros & Cons
Awareness
+ Vision + Process = Change
Requirements for Change
14
Preliminary Actuarial Work & Issues
1. Data Collection and Population Profiling
2. Distribution of claims (low-medium-high-catastrophic claims)
3. Types and Analysis of Chronic & Persistent Conditions
4. Review of Industry Data on Consumerism
5. Use of Actuarial Pricing Model
6. Behavioral Modification Recognition
7. Cost Impact of Strategies and Plan Designs Selected
15
Purpose of Actuarial Work
Perform the actuarial and financial analysis to determine the
impact of options available under a Consumerism Plan.
Determine Potential:
Plan designs
Saving Account Options / HRA, HSA, & Account Credits
Combinations and interactions of “Building Blocks”
Costsharing structure
Contribution strategies
Participation
16
Supply Controls or Demand Controls
Plan Sponsors and Members have two basic choices to control
costs:
1. Traditional Managed Care & HMOs - The “supply of care” is limited
by a third party who controls the access to medical services (e.g.
utilization reviews, medical necessity, gatekeepers, formularies,
scheduling, types of services allowed), or
2. Healthcare Consumerism - The member controls their “demand for
care” because of a direct and significant financial involvement in
the cost of care, rewards for compliance, and the information to
make wise health and healthcare value driven decisions.
17
Supply Controls Are Failing
High Healthcare Costs Climbing Higher
Patients have lost control of their own
healthcare, and are not truly engaged in
the process of managing their health
Patients are frustrated with managed care
“rules” and the impact on time and
productivity
“Every
System is
perfectly
designed for
the results
achieved.”
Patients don’t understand healthcare costs
– costs are not transparent
18
Mega Trends
Leading to Demand Control
1.
Personal Responsibility
2.
Self-Help, Self-Care
3.
Individual Ownership
4.
Portability
5.
Transparency (the Right to Know)
6.
Consumerism (Empowerment)
19
Healthcare Consumerism - Defined
Healthcare Consumerism is about transforming an
employer’s health benefit plan into one that puts economic
purchasing power—and decision-making—in the hands of
participants.
It’s about supplying the information and decision support
tools they need, along with financial incentives, rewards, and
other benefits that encourage personal involvement in
altering health and healthcare purchasing behaviors.
“The job of a leader is to create the possible” –
Condi Rice
20
Consumerism – Saving Lives & Saving Money
The Moral Imperative
for Consumerism:
Increasing the Quality of Care,
Better Health,
and Improving Lives
The Economic Imperative
for Consumerism:
Saving Money
(Lower Product Prices and More Jobs)
21
Objectives Of Consumerism

Change participant health and healthcare purchasing behaviors

Narrow market cost and quality variations using patient decisions
• Increase transparency of healthcare costs to plan participants
• Give plan participants more control over and “shared responsibility” for
managing own healthcare and related costs
• Supply participants with the tools to act as better informed healthcare
consumers

Reduce costs for “discretionary care” through informed purchasing &
incentives

Reduce long term costs with added incentives for “good health”

Reduce costs of Chronic Conditions through improved compliance with
treatments and disease management programs

Reduce Acute Care costs with incentive hospital tiering based upon cost
and quality
22
Basic Requirements for
Successful Healthcare Consumerism

Must work for the sickest members, as well as the
healthy

Must work for those not wanting to get involved in
decision-making, as well as those that do
23
The Core of Consumerism
The Unifying Theme
for a
Health and Healthcare Strategy is:
Behavioral Change
“Implement only if it supports
behavioral change consistent with
the strategy”
24
Healthcare Consumerism
Roles & Responsibilities / Implications
Employers





Facilitators of change
Provide increased information and decision making tools
Improved employee morale with choice and access
Link to productivity, absenteeism, disability, turnover, etc.
Consumerism can improve costs/budgeting (current & future)
Payers (Self-Insured Employers)




Focus on high cost case mgmt/disease mgmt/population mgmt
Will become responsible for more communications, training,
education direct to consumers
Value added services may change, including transactions and
asset management
Diminished role of managed care for routine care
25
Healthcare Consumerism
Roles & Responsibilities / Implications
Employees




Increased responsibility for own health & healthcare
Involved in own treatment and medical necessity decisions
Improved access to care
Involved in financial costs of health & healthcare (P4C)
Providers



More direct involvement with patients and treatment
Service and quality will be determined by consumers
Pricing will become more flexible and visible (P4P)
Overall implications


Roles will change for all players
The picture change quickly - your strategy must prepare you for
rapid market changes
26
Consumerism Choices Involve
Options for Behavioral Change
Consumerism Choices:
Wellness
Preventive care
Early Intervention
Lifestyle Options (diet, exercise, smoking, safety)
Self-help, self care (Health literacy)
Discretionary Expenses (e.g. OV, ER, Rx)
Value purchasing (e.g. DXL, o/p vs. in/p, online)
Participation in Disease Management Programs
Compliance with Evidence Based Medical
Treatment Plans
27
Consumer Driven Healthcare
Traditional PPO Alignments
Building
Blocks
Personal
Care Accts
Employer
Plan Member
(Consumer)
Account
Options
Create
Savings
Health
Worksite
Management Wellness
Healthy
Lifestyle
Disease
Access to
Management Specialists
Treatment
Compliance
Decision
Support
Incentives
Communication Education
Financier
CDHC Focus Facilitator,
Coordinator
TPAs/
Insurer
Admin.
Accounts
Providers
N/A
Benefit Prevention,
Designs Primary Care
EBM &
Protocols
Standards
of Care
Decision
Tools
Medical
Counsel
Pay for
Compliance
Admin. Negotiated
Pymts. Rates / P4P
Empowered,
Responsible
Enabler
Care
Manager
FOCUS on Behavior
Change of Members
28
Healthcare Consumerism
IDS / ACO Alignments
Building
Blocks
Employer
Plan Member
(Patient)
Provider
TPAs/
Insurer
Personal Care
Accounts
Acct.
Options
Create
Savings
N/A
Administer
Accts.
Health
Management
Worksite
Support
Healthy
Lifestyle
Prevention,
Primary Care
Benefit
Designs
Disease
Management
Access to
Specialists
Treatment
Compliance
Standards of
Care
EBM &
Protocols
Communication
Education
Information
Therapy
Tools
Pay for
Risk
Pay for
Compliance
Pay for
Performance
Pay for
Administration
Accountable
Plans
Acct’ble
Acct’ble
Health
Care
FOCUS on Patient Provider Relationship
Acct’ble
Administration
Decision
Support
Incentives
Healthcare
Consumerism
29
Consumerism – Much Broader than
HDHP & Consumer-Driven Healthcare
Consumerism is
A Strategy
******************
It’s about moving from a “benefit”
to an “accumulating asset. It’s
about increasing one’s human
capital”
30
Evolution of Healthcare Consumerism
Focus
Impact
Choices
First
Generation
High Deductible
Plans with HRAs or
HSAs, Decision
Support Tools
Discretionary Expenses:
Rx, ER, OV, D-X-L
Initial Level and Type of
Accounts with CDHC / HDHP
Designs, Information and
Decision Support Services
Second
Generation
Behavior Change
Through Rewards &
Incentives
Chronic and Persistent
Conditions, Pre-natal,
Preventive Care
Covered Benefits, Type and
Level of Matching Funds and
P4C / P4P Incentives for
Prevention, Wellness, and
Disease Management
Programs
Third
Generation
Health and
Performance,
workplace health &
safety
Organizational Health,
Turnover, Absenteeism,
Productivity, Disability,
and Presenteeism
Group rewards, Importance
and Impact on non-health
Corporate metrics
Fourth
Generation
Personalized Health
and Lifestyle Needs
Personalized Health and
Performance Outcomes,
Genetic Predispositions
Lifecycle Needs, Culturally
Sensitive DM, Holistic Care,
Information Therapy
31
The Evolution
of Healthcare Consumerism
Future Generations of Healthcare Consumerism
Traditional
Plans
Traditional
Plans
with
Consumer
Information
1st Generation nd
2 Generation 3rd Generation 4th Generation
Consumerism
Consumerism Consumerism Consumerism
/CDHC
Focus on
Discretionary
Spending
Focus on
Behavior
Changes
Integrated
Health &
Performance
Personalized
Health &
Healthcare
Behavioral Change and Cost Management Potential
Low Impact
---- ---- ---- ---- ---- ---- ---- ---- ----
High Impact
32
The Promises of Consumerism
Major Building Blocks
of Consumerism
Personal Care
Accounts
Wellness/Prevention
The Promise of Demand Control & Savings
The Promise of Wellness
Early Intervention
Disease and Case
Management
Information
Decision Support
Incentives &
Rewards
The Promise of Health
The Promise of Transparency
The Promise of Shared Savings
It is the creative
development,
efficient delivery,
efficacy, and
successful
integration of these
elements that will
prove the success or
failure of
consumerism.
33
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling, push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy,
incentives to access
work data
social networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
34
Longevity
Personal
Accounts
Health Mgmt
Wellness/Prevention
Condition
Management
Information
Decision Support
Incentives &
Rewards
35
Creating Healthcare Consumerism Plans

Understand Basic Consumerism Plan Designs

Including Consumerism in All Plan Options
Building Blocks
1. Understanding HRAs/HSAs to Create Personal Care Accts as a Basis
for Health “Asset Accumulation”
2. Include Wellness Programs that Encourage Healthy Habits
3. Include Disease Management Programs that Encourage Compliance
4. Include Decision Support Tools for All Plans
5. Include Incentives/Disincentives to Change Behavior
36
Basic Plan Design Options
& Healthcare Consumerism
Traditional
Health Plans
Personal Accounts
Most Healthcare
Consumerism Plan Designs
Typical
CDHP
Wellness/Prevention
Early Intervention
HMO
&
PPO
&
PPO
&
FSAs
FSAs
FSAs
with
Disease Management
Case Management
Information
Decision Support
Incentives &
Rewards
HRAs? HRAs?
HRAs
Must Meet HSA /
HDHP Legal
Definition
HDHP
PPO
&
HDHP
PPO
&
Ltd
FSAs
&
HSAs
Ltd
FSAs
&
HSAs
&
Ltd
HRAs
37
Potential Use of PCAs to Support
Consumerism Plan Designs
Traditional
Health Plans
Personal Accounts
HMO
PPO
Most Healthcare
Consumerism Plan Designs
Typical
CDHP
Wellness/Prevention
Early Intervention
Disease and Case
Management
Information
Decision Support
Incentives & Rewards
Minimum
Co-Payment
Designs
PPO
Health
Incentive
Accounts?
Initial
$500$1000
HRA
with
Incentive
HRAs
Must Meet HSA / HDHP
Legal Definition
HDHP
PPO
HDHP
PPO
High Ded & Co-Insurance
Designs
Initial Er HSA
Contribution
Initial Er HSA
Contribution
With
HRA
Match
&
Incentive
HRAs &
HSAs
38
PPO/HRA and PPO/HSA
High Deductible Health Plans
Four components that work together to improve quality, outcomes,
and lower cost.
Preventive 100%
Coverage
Health Accounts
(HRAs or HSAs)
Health Tools
and Resources
HRA – ER provided $s
Health
Account (HRA/HSA)
Deductible Gap
Personalized
Health
Care
3.
Web- and HSA - ER and/or EE
PhoneProvided $s
Based
Tools
HRA/HSA –
Individual & Group
Reward $s
PPO
“Benefit dollars” to
pay for healthcare
expenses.
1.
Additional
Health Coverage
beyond the HRA/
HSA.
2.
Wellness, Condition care
Programs, Information and
Decision Support Tools and
Resources.
Incentives
and Rewards
4.
39
Task #4 - Personal Care Accounts
The Promise of Demand Control & Savings
HSAs, HRAs, FSAs
“Of the 5 building blocks, the greatest among
them is the Personal Care Account”
40
HSAs and HRAs - Two Very Different Accounts
to Support Consumerism

HSA (2003 MMA)
- A law, with specific requirements and benefit design
requirements.
- Most TAX ADVANTAGED vehicle ever created

HRAs (6/26/2002)
- A regulatory creation based upon an IRS ruling
- Most FLEXIBLE vehicle ever created
41
Health Savings Accounts – Advantage Employees
 Tax-free savings vehicles for medical
expenses, no use-it-or-lose-it rule
 Effective January 1, 2004
 Eligibility: must be covered under high
deductible health plan (HDHP)
 Portable
42
Health Savings Accounts
Individual accounts
 To permit saving for qualified medical and retiree
health expenses on a tax-free basis
 Must be offered in conjunction with a legally defined
HDHP - “High Deductible Health Plan”
Portable
 An HSA is owned by the individual, similar to IRAs,
and transfers if the employee changes jobs
 Held in a trust or custodial account; trustees – banks,
insurance companies, approved non-bank trustees
43
Health Savings Accounts: Contributions

Contribution limits determined monthly based on
status, eligibility, HDHP coverage as of first day of
month (offset by other HSA contributions)

2013 Monthly limit – 1/12th of lesser of deductible or
$3,250 (self-only), $6,450 (family), indexed

Catch-up contributions, to $1,000 annually in 2013
44
HSAs – Real Dollars, Portable, Vested
 Can be used or taken in cash at anytime, even when no
longer eligible to make contributions
 Tax-free if used to pay for qualified medical expenses (IRC
Section 213(d))
 For other purposes, subject to income tax and 20% penalty
- 20% penalty waived in case of death or disability
- 20% penalty waived for distributions after age 65 or older
 HSA can be transferred tax-free to spouse on death;
otherwise taxable to estate or beneficiary
 Transfers upon divorce, nontaxable, becomes spouse’s HSA
45
2014 HSA Eligible HDHP
High Deductible Health Plan – By Law

Self-only: a deductible of at least $1,250; maximum HSA is $3,300; no
more than $6,350 maximum out-of pocket expenses (incl. Ded.)

Family coverage: a deductible of at least $2,500; maximum HSA is
$6,550; no more than $12,700 on out-of pocket expenses (incl. Ded.)

2014 Age 55 and over catch up amount of $1,000

Preventive services are not subject to the deductible

OK for out of network costs to exceed maximum out-of pocket limits
THE ABOVE 2014 AMOUNTS ARE SUBJECT TO
ANNUAL INDEXING
46
HRAs- Advantage Employers
National Accounts, Er Controlled Rules
 Employer does not fund and has cash flow value
 Employer can determine rules for HRA usage; they are
subject to forfeiture; they are not portable, but can be
subject to vesting
 HRAs are more flexible in plan design, can tailor scope of
reimbursements, are less costly for employer
 Employer decides if HRA can used for (1) medical plan
expenses not otherwise reimbursed, (2) non-plan QME
213(d), and/or (3) insurance premiums
47
Important Differences between Use of HRAs
and HSAs for Supporting Behavioral Change
Personal
Care
Accounts
Health
Reimbursement
Arrangements
Health Savings
Accounts
Generation 1
Initial
Account Only
1. Any Amount
2. Notional Acct
3. Employer
Determined
4. Employer Only
Contributions
Generation 2
Generation 3
Activity &
Indiv. & Group Corporate
Compliance Rewards
Metric Rewards
1. Flexible Activity &
Compliance Rewards
2. Employer Determined
3. Can not be cashed out
4. Must be used for
healthcare
Generation 4
Specialized Accts,
Matching HRAs,
Expanded QME
1. Flexible Indiv & Group
1. Specialized Notional
Rewards
Accts,
2. Employer Determined
2. Can terminate by
3. Can not be cashed out
employer rules
4. Must be used for healthcare 3. Potential IRS Expanded
QME
1. Amounts Set by law 1 Must give Cash Option 1. All participants must
2. Real Dollars in Acct 2. Awards must be same
receive same amount or
3. Er or Ee Contrib
$ amt or same % of
same % of deductible
4. Contributions up to
deductible
2. Difficult to use for Group
plan deductible of 3. HSA can be used (with
Incentives
$1250-3250 Single
20% penalty) for non$2500-6450 Family
healthcare expenses
5. Non-substantiation
1. 100% Vested &
Portable
2. Can use matching
HRAs,
3. Potential IRS
Expanded QME
48
HRAs – Best for Larger Groups?
HSAs – Best for Individuals and Small Groups?
Current State
Combination
Accounts
Employerbased
healthcare
Special
Purpose
Accounts
Incentive
Matching
HRAs
Employerbased
Healthcare
with Individual
Accountability
Employerbased
Defined
Contribution
Developments
HSAs
Individual-based
Healthcare
Er-Based with HSA
Contributions
FSAs
Employerbased
Healthcare
Traditional (Ltd
Carry-over)
Special
Purpose NonPlan
49
Are HSAs the right vehicle for large
employer groups?
Yes, If………..
Or
No, Because…….
Need to Understand the Consumer
Movement, Federal Health Policies, &
the Market Transformation
that is Underway
50
Are HSAs the Wave of the Future?
Which Direction will Legislation Take?
Yes, if….




… we recognize the HSA legislation and regulations as a good start and another
building block for consumerism and behavioral change.
…Er’s and Ee’s recognize current limitation and optimize available uses
…there is additional legislation/regulation to support large Er interests in providing
HSAs (use for healthcare only, Rx coverage problem, combination accounts).
…there is legislative support for the common use of FSAs for targeted needs,
HSAs as true “Health Savings Accounts” and HRAs as true “Health
Reimbursement Arrangements.
No, because….




… they were not legislated/regulated with large employers in mind.
… of a desire to promote individual insurance over individual ownership (under
employer and individual policies)
… they are just a tool to cost shift to employees, they can not reward behavior
change
… they are only desirable to the young, healthy, and wealthy
51
Summary - PCA Comparisons
52
Summary - PCA Comparisons (cont)
53
The Fundamental Federal Policy Question
Will Legislation/Regulation Use HSAs to
… mainly promote portable Individual & Small Group
Insurance,
OR
… expand Personal Care Account ownership through in
both an employer-based and individual-based
healthcare system thru HSAs, HRAs, and FSAs.
54
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy.
incentives to access
work data
Social networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
55
Task #4 - Discussion on Type(s) and
Use of Personal Care Accounts
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
56
Task #5 - Wellness, Prevention, and Early
Intervention
The Promise of Wellness
57
Wellness - Defined
Wellness is a proactive organized program providing
lifestyle and medical/clinical assistance to employees
and their family members in maintaining good health.
Wellness programs encourage voluntary behavior
changes and support compliance with proven
approaches to maintain health, reduce health risks
and enhance their individual productivity.
58
Wellness – The Need
For every 100 members:










23-30% smoke (70% want to quit, 35% try each year)
29% have high blood pressure
30% have cardiovascular disease
80% do not exercise regularly
55% or more are overweight or obese
30% are prone to low back pain (many linked to obesity)
6-9% have diabetes
10% are depressed
35% are under significant stress
50% do not wear their seat belts
59
Wellness – The Desire for Change
For every 100 members:
47% are trying to improve their diet
 37% plan to undergo some health screening
 30% state they exercise regularly
 Only 23% are aware of the health promotion and
wellness programs offered by their employer sponsored
health plans
 76% of employers with over 11,000 employees offer
health management programs

60
Wellness - How Does It Impact Employees and
Family Members?
Well
At-Risk / Acute Condition
e.g., Inactivity, High Stress,
Overweight, High Blood
Pressure, Smoking
e.g., Low Risk, Good
Nutrition, Active
Lifestyle
No Claims
% Ee
15%
Generally
Healthy
O/P (Low)
48%
14%
Prevention
%$
0%
In/P
(High)
Maternity
3%
3%
Wellness – Lifestyle
12%
15%
12%
5%
Minimize Acute Episodes
% Ee
63%
20%
Maximize Recoveries
% $
12%
32%
Early Intervention
Chronically-Ill
Catastrophic
e.g., Diabetes, Musculoskeletal,
Heart Disease, Asthma, MH/SA
e.g., Cancer, Rare
Diseases,
Head Trauma
O/P (Low)
12%
In/P (High)
In/P (High)
4%
1%
Wellness - Lifestyle
21%
20%
15%
Minimize Complications
17%
Maximize Stabilization
56%
Wellness - Clinical
Wellness - Clinical
Traditional Wellness Programs
61
Wellness – Examples for Employer
Sponsored Programs
Common Programs




Health Risk Appraisals
Weight Management
Fitness/exercise/health clubs
Smoking cessation
Employer Support
Communication and awareness (newsletters, health fair, posters)
 Screening (health awareness profiles, blood pressure check, blood
tests, body fat analysis)
 Education (seminars/classes, self help kits, group discussions, lunch
and learn)
 Behavioral Change (on-site fitness center, flu shots, lunchtime walks,
yoga classes)

62
Wellness – Working within Consumerism
Traditional Plans
 Cover selected wellness in benefit plan at 100%
 Supplement with non-plan wellness and work-site programs
 Other: same * as below PPO/HRA incentives
PPO/HRA
 Include Employer defined wellness/prevention benefits at 100%
*
*
*
Include HRA Incentive for Health Risk Appraisal (Wellness Assessment)
Include HRA Incentives for personal wellness activities
Include HRA Incentives for work-site wellness participation
PPO/HSA
 Include IRS defined Preventive Care benefits at 100%
 Benefits contingent upon HSA contribution? Wellness Appraisal
 Other: same * as above with PPO/HRA incentives
63
Consumerism - Programs and Services
Prescription Drugs Information
Evidence Based Medicine
 Medical Care Guidelines
 Health Library
Disease Management
 Condition Specific Assessment
Tools
 Chronic & Persistent Wellness
 Voluntary Participation
 Voluntary & Incentive Based
 Mandatory Participation
 Mandatory & Incentive Based
Stress Management
 Assessment Tools
 Self Help Tools
Depression Screening
Preventive Care – Lifestyle
Early Prevention
Wellness
 Online News
Safety




Lifestyle
Pre-Natal
Nutrition
Well Baby Care
Fitness
Personal Health Management
New Mom Programs
Preventive Care – Clinical
Medical Services Support
 Immunizations
Self Care Management Information
 Hypertension Screening
 FAQ, Preparation for In/P
 Cholesterol Testing
On-Line Health Risk Assessment
End of Life Care
 Mammograms
 Pap Smears
 Personal and Family Tracking
Provider Cost/Quality
 Blood Pressure Checks
Incentives
 Colorectal Cancer Testing
Health & Performance
 Population Management
 Diabetes Testing
Regional Centers of Excellence
 Case Management
 Osteoporosis Testing
 Cost & Quality Management
 Chlamydia Tests
64
Wellness & Preventive Care for HSAs
Preventive care includes, but is not limited to, the following:
Periodic health evaluations, including tests and diagnostic
procedures ordered in connection with routine examinations,
such as annual physicals.
 Routine prenatal and well-child care.
 Child and adult immunizations.
 Tobacco cessation programs.
 Obesity weight- loss programs.
 Screening services

However, preventive care does not generally include any service or
benefit intended to treat an existing illness, injury, or condition.
65
HSA Safe Harbor
Preventive Care Screening Services
Cancer Screening
Breast Cancer (e.g., Mammogram)
Cervical Cancer (e.g., Pap Smear)
Colorectal Cancer
Prostate Cancer (e.g., PSA Test)
Skin Cancer
Oral Cancer
Ovarian Cancer
Testicular Cancer
Thyroid Cancer
Infectious Disease Screening
• Bacteriuria
• Chlamydial Infection
• Gonorrhea
• Hepatitis B Virus Infection
• Hepatitis C
• Human Immunodeficiency Virus
(HIV)
• Syphilis
• Tuberculosis Infection
Heart and Vascular Diseases Screening
Abdominal Aortic Aneurysm
Carotid Artery Stenosis
Coronary Heart Disease
Hemoglobinopathies
Hypertension
Lipid Disorders
Mental Health/Subst. Abuse Screening
• Dementia
• Depression
• Drug Abuse
• Problem Drinking
• Suicide Risk
• Family Violence
66
Quest Diagnostic Report
•A Quest Diagnostic report showed 60% of employees who
participate in wellness programs report that the incentive is a
deciding factor in their choice to participate.
•Incentives have been so successful in increasing participation
that approximately two-thirds of the employers who invest in
employee wellness use an incentive to drive employee
participation.
•Bio-metrics (e.g. blood pressure, cholesterol, body mass
index, waist size, and A1(c)) are popular as measuring
standards for improved outcomes.
67
Wellness – Planning
Will the wellness program be for employees only, or employees
and dependents?

Will you purchase from vendor, internally developed, or a
combination

Consider in conjunction with plan covered wellness benefits
(immunizations, mammograms, screening, EAP, physical exams, prenatal care, well child care, etc.)

Consider in conjunction with worksite programs (safety,
ergonomics, work-life programs, etc.)


Incentives/rewards provided for compliance
68
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info
mgmt, info with
info, integrated health
and services,
incentives to access
work data
information therapy
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
69
Task #5 - Discussion on Type(s) and
Use of Wellness and Prevention
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
70
Task #6 - Disease Management Programs
The Promise of Health
The “Holy Grail” of Cost and Quality
Improvements
71
Disease or Condition Management –
the Holy Grail of Potential Savings
Primary cost drivers are chronic disease and serious acute
conditions.
80%
of
costs
Driven by
20% of
claimants
For a typical employer, 15-30% of costs are
driven by controllable health risks
50%
of
costs
Have a
behavioral
root cause
(CDC 1999)
72
Disease Management Potential
Focus on Hi-Volume / Hi-Cost Users
Cost Curve
% Members
% Costs
1%
-> 20%
15%
-> 68%
50%
-> 95%
EBRI -Stakeholders in Consumer-Driven
Health Care
73
Disease Management - Defined
Disease Management is an proactive organized program
providing lifestyle and medical/clinical assistance to employees
and their family members with chronic and persistent conditions.
Disease Management programs encourage voluntary behavior
changes and support compliance with proven medical practices
which stabilize conditions, reduce health risks and enhance their
individual productivity.
74
Disease Management – The Need
60+% of an employer’s total medical costs come from chronic and persistent
diseases such as, diabetes, asthma, congestive heart failure, back pain, and
depression.

45% of Americans live with at least one chronic disease. 14% live with two or
more chronic diseases.

76% of hospitalizations, 72% of physician visits, and 88% of Rx is due to
chronic conditions

The average cost of health care for a diabetic is $13,200/yr compared to
$2,600/yr for a non-diabetic.


61 million Americans live with cardiovascular disease

50% of chronic disease deaths are traced to cardiovascular disease.

Coronary artery disease is a leading cause of premature permanent disability.

Obesity is becoming the #1 preventable cause of death
75
Today’s Health Care Environment and Trends
Determinants of Health
60%
50%
40%
30%
20%
10%
0%
Determinants
Access to
Care
Genetics
Environment
Behavior
10%
20%
20%
50%
Source: IFTF, Centers or Disease Control and Prevention
76
Disease Management – The Desire for Change
Very Little under Traditional System:
50% do not follow recommended standards of care
 33% will high blood pressure do not know
 33% of diabetics do not know it
 Patient’s lack of knowledge and information
 Patients without financial incentives to change health and healthcare
behaviors
 Distortions of current 3rd party reimbursement medical financing
system.
 Plans pay for treatments not prevention or compliance
 Physicians without incentives to take time and effort to deal
effectively with chronic conditions

77
Disease Management –
Elements for a Successful Program
There are four elements of a successful disease
management:
1. A delivery system of health care professionals and organizations
closely coordinating to provide medical care and support the patient’s
compliance throughout the course of a disease.
2. A process that monitors the compliance and describes outcomebased care guidelines for targeted patients.
3. A process for continuous improvement that measures clinical
behavior, refines treatment standards, and improves the quality of
care provided.
4. Incentive awards that support the disease management medical
and clinical care services
78
20 Priority Areas
per the Institute of Medicine
1. Asthma, supporting and treating
those with chronic conditions.
2. Care coordination for patients with
multiple chronic conditions.
3. Children with special health and care
needs, particularly those with chronic
conditions.
4. Diabetes, which can lead to high
blood pressure, heart disease,
blindness and other complications.
5. End-of-life care for people with
advanced organ failures, concentrating
on reducing symptoms.
6. Frailty - preventing accidents,
treating bedsores and improving
advanced care.
7. High blood pressure - left untreated
it can lead to heart attack, stroke and
kidney failure.
8. Immunization.
9. Evidence-based cancer screening,
which can reduce death rates for many
cancers, including colorectal and
cervical.
10. Ischemic heart disease, also known
as coronary heart disease. Efforts
should focus on prevention.
79
20 Priority Areas
per the Institute of Medicine
11. Major depression, which currently
has a much lower treatment rate that
other major diseases.
16. Pregnancy and childbirth,
especially improving the quality of
prenatal care.
12. Medication management to
prevent errors.
17. Self-management and health
literacy, using public and private
organizations to increase the level of
health education.
13. Noscomal infections. These are
infections acquired in the hospital
and kill an estimated 90,000
Americans annually.
14. Obesity, which is blamed for as
many as 300,000 deaths annually in
the United States.
18. Severe and persistent mental
illness; improving mental health care
in the public sector, including state
hospitals and community centers.
19. Stroke, the third highest cause of
death in America.
15. Pain control in advanced cancer.
20. Tobacco-dependence treatment for
adults.
80
Disease Mgmt - How Does It Impact
Employees and Family Members?
Well
At-Risk / Acute Condition
% Ee
15%
Generally
Healthy
O/P (Low)
O/P (Low)
48%
14%
Prevention
%$
0%
In/P
(High)
Maternity
3%
3%
Wellness – Lifestyle
12%
15%
12%
5%
Minimize Acute Episodes
% Ee
63%
20%
Maximize Recoveries
% $
12%
Catastrophic
e.g., Diabetes, Musculoskeletal,
Heart Disease, Asthma, MH/SA
e.g., Low Risk, Good
Nutrition, Active
Lifestyle
No Claims
Chronically-Ill
e.g., Inactivity, High Stress,
Overweight, High Blood
Pressure, Smoking
32%
12%
e.g., Cancer, Rare
Diseases,
Head Trauma
In/P (High)
4%
In/P (High)
1%
Wellness - Lifestyle
21%
20%
15%
Minimize Complications
17%
Maximize Stabilization
56%
Early Intervention
Wellness - Clinical
Wellness - Clinical
Disease Management Program
81
Disease Management Programs
Designed and Financially Aligned for Success
Program Type:
DM vendor pricing
method
Percentage of chronic
diseased
participating in
program
Return on investment
of disease
management
programs
Passive
Phone and mail
out- reach, no
incentives
Assertive
Incentives (i.e.,
waiving Rx copays)
Aggressive
Incentives (i.e,
waiving Rx copays,
premium
differential
Per employee
per month, all
employees
Low PEPM on all ees
plus hourly or per
case rate on
participants only (rate
varies based on
participant risk
status)
Low PEPM on all
ees plus hourly or
per case rate on
participants only
(rate varies based
on participant risk
status)
10%
50%
75%
0 - .5
1.5 - 2
1.5 - 3
82
Disease Management Program Planning

Identify key populations

Focus on Compliance

Manage expectations

Respect privacy
Follow Best practices (EBM, Outcomes
Based Medicine)

Integrate demand management, disease
management and utilization management


Give patients their own data
Align Incentives for patients, providers,
and Employer

83
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy,
incentives to access
work data
social networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
84
Task #6 - Discussion on Type(s) and
Use of Disease Management Programs
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
85
Task #7 - Decision Support Tools
The Promise of Transparency
&
The “Right to Know”
86
Healthcare Consumerism –
Already Active Consumers
Consumers Search Internet
for Medical Content
Consumers Ask Physicians
for Genetic Testing
Consumers Work with Providers
on Personalized Health Plans
Consumers Monitor and Track
Their Own Medical Status Regularly
Consumers and Providers Coordinate Care and
Understanding through Integrated Clinical and
Information Therapies
87
Decision Support Tools
Survey of Attitudes
Patient decision making preferences
“INFORMED”
PARENTAL
17.1%
INTERMEDIATE SHARED
DECISION MAKING
45%
11%
PATIENT AS DECISIONMAKER
22.5%
4.8%
Employer Role:
Recognize the “consumer-preference spectrum”
Provide consumer-focused decision support tools for:
Choice of Health Plan
Choice of Provider
Choice of Treatment
Current and Future Financial Considerations
88
Decision Support Tools for Consumerism
Basic Design Information
Provider Selection Support
HRA Fund Accounting
Physician Quality Comparison
Underlying PPO Plan Design
Physician Cost Comparison
Disease and/or Medical Management
Hospital Quality Comparison
HSA Fund Accounting
Hospital Cost Comparison
Debit/Credit Card
Personal Benefit Support
Plan Comparison Cost Estimator
Account Balance
On-line Claim Inquiry
SPD
Care Support
On-line Provider Directory
Provider Scheduling
On-line Rx Comparisons
On-line Patient Decision Support
24/7 Nurse Line
Personal Health Management
Health Risk Appraisal
Health & Wellness Information
Targeted Health Content
Medical Record, History
Health Coach
89
Decision Support Tools
Employer Considerations
• Employee Readiness
 Sophistication and orientation
 Internet competency and access
• Due Diligence
 Accuracy




Usability
Independence
Stability
Integration issues
• Targeted Clinical Support:
 Value-based Evidence Based Medicine
 Personalized Chronic Care Management Tools
 Consumer-Focused Stress Management
90
PwC Study
A PricewaterhouseCoopers study found that nearly a third
(32%) of consumers has used some form of social media for
healthcare purposes.
The self-absorbed “Me” generation is giving way to sharing
communities on Facebook, Picassa, Linked-In, Plaxo, and
YouTube.
91
Consumerism – a new force
Consumerism
can be a force to address
quality and cost variations
in a given market
92
Decision Support
Tools for Cost & Quality Information
 Lower LOS
 Lower Cost
 Episodes of Care
Variation in Cost & Quality
Hospitals – CABG*
Align Strategy
with the “Value
Purchasing”
 Awareness
 Pay for
Performance
 Tiered
Networks
 Regional
Centers of
Excellence
Cost
Efficiency
Quality
 Fewer Adverse Affects
 Lower Complication Rates
 Lower Mortality
* Healthshare/SelectQualityCare weighted averages
93
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy,
incentives to access
work data
social networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
94
Task #7 - Discussion on Type(s) and
Use of Decision Support Tools
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
95
Task #8 - Incentives, Rewards,
The Promise of Shared Savings
Pay for Compliance
&
Pay for Performance
“Two sides of the same coin”
96
Consumerism Incentives – Participation Based
Incentives must be participation and activity-based rather than
outcomes-based. HIPAA laws prevent rewards based on health
standards. The law allows incentive designs if the following
requirements are met:

Limit the reward to a specified amount (not to exceed between 20% of the
cost of employee-only coverage; PPACA allows up to 30% in 2014).

Be reasonably designed to promote health or prevent disease.
Be available to all similarly situated individuals. There must be a feasible
alternative for those that cannot reach the health standard because of a medical
condition.

Inform employees that individual accommodations and alternatives are
available.

97
Wellness Incentives – Outcomes Based
While HIPAA generally prohibits plans from differentiating benefits or premiums
based on health status, employers can still design and implement wellness
programs with financial incentives. Only a "bona fide wellness program" can
provide a reward based on a health standard or health outcome (i.e., a low
cholesterol level). To be a "bona fide wellness program," the law specifies that the
program must meet four requirements:
1. Limit the reward to a specified amount (not to exceed between 20% of the cost
of coverage; 30% under PPACA in 2014).
2. Be reasonably designed to promote health or prevent disease.
3. Be available to all similarly situated individuals. There must be a feasible
alternative for those that cannot reach the health standard because of a medical
condition.
4. Inform employees that individual accommodations and alternatives are
available.
- National Business Group on Health
98
Wellness Incentives – Participation Based
All wellness programs that are based on
participation rather than outcomes are permitted.
For example, financial incentives or premium
discounts for participating in a health fair, joining a
health club, or attending smoking cessation
program, regardless of the health outcomes or
results, are allowed.
- National Business Group on Health
99
Rewards & Incentives for Smoking Cessation
The NGBH conducted a Quick Survey on "Smoking Cessation
Incentives/Disincentives." The results from 26 respondents showed:
69% of the respondents offered discounts on annual health care
premiums/contributions for non-smokers, and 15% offered another
type of benefit enhancement.

Similarly, 45% of the respondents offered premium discounts for
employees that participated in smoking cessation/wellness
programs.

57% included smoking cessation as part of a broader wellness
initiative/incentives at the worksite.

- National Business Group on Health
100
Incentive Awards - Three Very Different
Personal Care Accounts
1.
Flexible Spending Accounts (FSAs) – Traditional
Group Plans with Use-it-or-Lose-it
2.
Health Reimbursements Arrangements (HRAs) –
Employers’ choice for cash flow flexible incentive
based medical plan benefit designs (best suited for
self-insured groups)
3.
Health Savings Accounts (HSAs) – Employees’
choice for funded portable triple tax advantaged with
“High Deductible Health Plans” (best suited for
individuals and small groups)
4.
Combination Accounts – creative but confusing
101
The Evolution of
Encouraging Personal Responsibility
Plan Design
Education
Incentives & Rewards
Participation
Engagement
Compliance
Outcomes
Health Status
102
102
NBGH Study
The National Business Group on Health and Fidelity Investments survey:






* 73% of Employers used incentives in 2011 in their health improvement
programs.
* The average incentive value was $460 (2010:$430 and 2009: $260).
* Incentives used by employers include cash, gift cards and contributions
to health savings accounts (HSA).
* A small but growing percentage of employers link eligibility for enrollment
in their health care plans to participation in health improvement programs.
* 7% of employers in 2011 required completion of a health risk assessment
for employees to be eligible for health care plan coverage, and
* 10% will link completion of an HRA to plan eligibility in 2012.
The survey is based on the responses of 139 employers, ranging in size from
1,000 employees to 100,000 employees.
103
Using Information & Incentives
To Address Wellness & Disease Management
Behavioral Changes
Low Users
No
Claims
% Mem
%
Dollars
15%
Medium
Users
Generally
Healthy
48%
High
Users
Acute Episodic Conditions
O/P, Low In/P, High
Maternity
14%
3%
Wellness - Lifestyle
Prevention
0%
12%
15%
12%
3%
5%
Minimize
% Mem
%
Dollars
63%
12%
Maximize
Very High
Users
Chronic & ersistent
.
Conditions .
O/P, Low In/P,High
12%
Catastrophic
4%
Wellness - Lifestyle
21%
20%
1%
15%
Minimize
32%
17%
Maximize
Early Intervention
32%
Wellness -56%
Clinical
Wellness - Clinical
104
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy,
incentives to access
work data
social networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
105
Task #8 - Discussion on Type(s) and
Use of Incentives & Rewards
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
106
Task #9 – Viewing Healthcare Consumerism by
Generations
Review of
Plan Design Concepts
by
Generation
107
1st Generation Healthcare Consumerism
Focus on Plan Design and implementation of HRAs
and/or HSAs and basic decision support tools.
Impact: Discretionary Expenses
Choices: Level and Type of Accounts with Plan
Designs, information and Decision Support
Services
108
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy.
incentives to access
work data
Social Networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
109
Rand Study
A recent Rand study found that when people shifted into
health insurance plans with deductibles of at least $1,000
per person, their health spending dropped an average of
14 %.
Health care spending also was lower among families
enrolled in high-deductible plans that had HSAs.
Account based plans are a good start, but if the goal is to
change member behaviors and to engage them to make
better informed health and healthcare decisions more than
a new plan design is needed.
110
2nd Generation Healthcare Consumerism
Focus on Behavior Changes. How to use plan design
to effectively change health and healthcare purchasing
behaviors with individual and group incentives/rewards.
Impact: Chronic & Persistent Conditions, Pre-Natal,
Wellness & Preventive care.
Choices: Covered Benefits, Type and Level of
Matching Funds and Incentives for Prevention,
Wellness, and Disease Management Programs
111
2nd Generation Healthcare Consumerism
with Focus on Behavioral Changes
Healthcare Consumerism models require a shift in
responsibility from the employer to the employee in the
purchase and use of health and healthcare. Communication,
information, and education along with the reward system drives
this change.
Passive
Users of
Health Care
Services
Educated,
Engaged, and
Empowered
Health Care
Consumers
Basic
Benefit Consumerism
Access to
Health Care Education
Behavior
Information &
Information
Support Decision Support
112
2nd Generation Behavioral Change a Key
Determinant of Health
Today’s Health Care Environment and Trends
Determinants of Health
60%
50%
40%
30%
20%
10%
0%
Determinants
Access to
Care
Genetics
Environment
Behavior
10%
20%
20%
50%
Source: IFTF, Centers or Disease Control and Prevention
113
Healthcare Consumerism
Drives New Behaviors from All Participants
Employee
Passive Participant
Active & Empowered
Patient/Consumer, P4C
Employer
Primary Purchaser
Plan Facilitator Financial
Contributor
Barrier
Enabler / Education
& Information
Contracted Supplier
Clinical and Service
Standards, Care
Manager, P4P
Health Plan
Provider
114
Consumer Behavioral Changes
1.
Focus on Preventive Care
2. Live Healthy & Safely
3. Use Nurse Line for Common Issues
4. Treatment Compliance for Chronic Persistent Problems
5. Consider Health and Healthcare Issues Together
6. Use Lower Cost / Higher Quality Alternatives
115
Consumer Behavioral Changes
7. Choose Rx Substitutions
8. Talk to Doctors as Informed Consumers
9. Be Compliance with Disease Mgmt Treatment Plans
10. Learn About Diagnosis/Condition
11. Act Like a Consumer - Demand Value and Service
12. Consider Plan as an Accumulated Asset rather than
a Time Limited Benefit
116
2nd Generation
Programs to Change Behaviors
Well
e.g., Low Risk, Good
Nutrition, Active
Lifestyle
At Risk / Acute Condition
Chronic
Conditions
e.g., Inactivity, High Stress,
e.g., Diabetes,
Overweight, High Blood Pressure,
Depression, Heart
Lacerations, Infections
Acute Conditions
Disease, Asthma,
e.g., Infections, Respiratory, Lacerations
MS/SA
Catastrophic
Conditions
e.g., Cancer,
Hepatitis C, Head
Trauma
Health
Promotion
Health Management
Chronic Disease
Management
Website
Wellness Appraisal
Patient Identification
and enrollment
Navigational Support
Address Comorbid
Conditions
Patient Advocacy
Healthy Lifestyle
Promotion
Targeted Behavior
Modification
Physical Activity
Campaign
Practice Guidelines
Care Coordination
High Cost Case
Management
Care Coordination
Address Comorbid
Conditions
Integrated Services, Communications, Measurement and Evaluation
117
2nd Generation Consumerism – Improving Health
and Lowering Costs with Behavioral Changes
Low Users
No
Claims
% Mem
%
Dollars
11%
0%
Generally
Healthy
29%
2%
% Mem
40%
%
Dollars
2%
Medium
Users
High
Users
Acute Episodic
.
Conditions
.
O/P, Low In/P, High Maternity
Chronic & Persistent
.
Conditions
.
O/P, Low
In/P, High
17%
9%
Evidence
Based
11% Medicine
17%
4%
PreNatal
care
3%
18%
Very High
Users
11%
Evidence
Based
18%
Medicine 35%
Catastrophic
1%
Safety
14%
Programs,
Regional
Disease
Discretionary
Management30% Centers of
Expenses
30%
Excellence
Stress Management / Health & Performance
31%
67%
Sample Impact Areas: Rx
Rx
Rx
Rx
Rx
Rx
Rx
Office Visits Office Visits Hosp Admits Hosp Admits OfficeVisits Hosp Admits Hosp Admits
DXL
DXL, ER
ER
ER
Specialists Specialists High Tech
118
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy,
incentives to access
work data
social networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
119
3rd Generation Healthcare Consumerism
Focus on Health & Performance. How healthcare
consumerism plan design and behavior change affects
work performance and the corporate bottom line.
Impact: Manageable Costs - Organizational health,
turnover, absenteeism, productivity, disability, and
presenteeism
120
What are “Manageable Employment Costs”?
Five components of “Manageable Employment Costs”:
1.
Health care: the dollars spent on health care whether self-insured or insured.
2.
Turnover: the direct hiring costs, temporary replacement costs, learning curve
costs, and lost productivity costs.
3.
Presenteeism: the time an employee is at work and assumed to be
productive, but is not productive.
4.
Disability: the direct costs associated with workers’ compensation and nonoccupational disability.
5.
Unscheduled Manageable Absence: the cost of absence that could be
positively influenced with proactive intervention.
121
3rd Generation
Health & Performance Strategy
Health & Performance is a benefits strategy that is
designed to balance the rising costs of health care
while optimizing employee health & performance
through targeted, strategic, and value-added
interventions.
Targeted, Strategic, Value-added Interventions
Better Health
Employee
Performance
122
3rd Generation –
Incentives and Rewards
Optimizing Individual and Organizational
Health & Performance
3rd Generation “Account Based” Benefits and Incentives Platform
•
•Holistic Health & Productivity Focus
• Culture of Health & Wellbeing
• Seamless Population Management
• Shared Responsibility/Accountability
• Organizational Alignment & Support
• Data Driven Process Excellence
123
3rd Generation
Health & Performance ROI
Health & Performance ROI will be measured by:





Reduced unscheduled sick days
Reduced paid time off
Fewer disability claims, more and faster recoveries
Reduced turnover
Improved survey results on teaming, creativity, staff moral
Resulting in:




More productive employees
More effective employees
Increased teaming, creativity, moral, workplace conflicts
Better bottom line results
124
3rd Generation
Creating the Health & Performance ROI
Keep in mind:
This is a multi-year strategy that results in cumulative
savings over time
ROI estimates are based on static number of members
• expect more to enroll each year which will increase
savings
Estimates assume the same benefit levels
• changes to the plan design could increase the ROI in
the shorter term
125
Example of 3rd Generation Concept
Consumerism Stress Management
Consumerism Stress Management is a process improvement
methodology designed to quickly improve bottom line saving
and progresses into a business strategy that optimizes a
company’s human capital an innovation efforts.
Consumerism Stress Management emphasizes employee
participation, the inclusion of corporate and operational
performance metrics, and the power of the Internet to
achieve savings by quantifying and positively influencing
stress-related “Manageable Employment Costs”.
126
3rd Generation – Stress Management and
Corporate Impact
Research suggests that stress has been directly
attributed to:
21.5% of total health care costs
40% of the primary reasons that employees leave a
company
50% of presenteeism is a function of stress
33% of all disability and workers’ compensation costs
50% of the primary reasons that employees take
unscheduled absence days
127
Related / Imbedded Health Costs From Stress
Source of Demand
And Pressure
Major Body Systems
Affected by Stress
Job
Family
Personal
Social
Financial
Environment
Muscular System
Digestive System
Cardiovascular
Emotional
Endocrine, Immune
Cognitive
128
3rd Generation Stress Management
The Corporate Costs of Mental Illness
Medical
Intensity
Low
Cost
Medium
Cost
High
Cost
Catastrophic
Type of
Condition
Frustration
Anxiety
Low Stress
Minor Depression
Moderate Stress
Depression
Anger
Attention Deficit
PostTraumatic Stress
High Stress
Major Depression
Schizophrenia
Bipolar Disorder
Obsessive Compulsive
Panic Disorder
Anorexia-Bulimia
Violence
Suicide
Direct MH
Costs
LOW
MEDIUM
HIGH
HIGH
Co-Morbid
Conditions
Indirect Corporate
Costs
Tobacco Use
Sleeplessness
Colds/Flu
Blood Pressure
Moderate–HIGH
Increased Errors
Presenteeism
Loss of Teaming
Hypertension
Musculoskeletal
Digestive
Gastrointestinal
Moderate-HIGH
Unsch Absences
Poor Morale
Relation Conflicts
Lost Productivity
Cardiovascular
Cancer
Diabetes
Asthma
Back Pain
Alcoholism
HIGH-VERY HIGH
Low Productivity
Divorce
Turnover
Early Retirement
Worker’s Comp
Disability
Accidents
Burns
VERY HIGH
Death
129
Work Violence
Disaster Recovery
129
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info &
mgmt, info with
info, integrated health services, info therapy.
incentives to access
work data
Social Networking
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
130
4th Generation Healthcare Consumerism
Focus on Lifestyle, Lifecycle, and Personal Health
needs. How healthcare consumerism plan design and
behavior change affects personal health and healthcare
based on lifestyle and personalized needs.
Impact: Lifecycle needs, Personal health, genetic
pre-dispositions, predictive modeling, healthy
habits, and wellness.
131
4th generation –
Individual Ownership and Portability
1.
Ownership, security, and portability of the PCA.
2.
Access to accounts post-employment.
3.
Vesting will be important to employees to secure
the value of the accounts.
4.
Compared to HSAs, employees may ultimately
expect “notional interest” on HRAs.
5.
Demand for more immediate use of the funds for
non-plan QMEs and use of HRAs for paying health
premiums.
132
4th generation –
Individual Ownership and Portability (cont.)
6.
Added HRA credits from unused vacation or
sick leave.
7.
PCA will need to accommodate personal
lifestyle expenses items such as, alternative
medicines and acupuncture.
8.
Ability to use debit/credit cards to cover
internet purchases and cyber-office visits.
9.
The IRS will have pressure to expand the
definition of QME to cosmetic surgery and
other personal care services.
133
4th Generation –
Personalized Health and Healthcare

Based on genomics, predictive modeling, and push technology.

Preventive care will include both lifestyle and clinical factors.

Treatments will include culturally sensitive care and guidance
Cyber-health Aides - decision support systems and wireless
connections that link each person to a personalized health and
healthcare cyber-support system (e.g. diabetes phone).

Personalized Internet Search engines based upon individual
profile health and healthcare needs. Cyber-support systems built
to profile activity and anticipate areas of interest
(e.g. TIVO/Travelocity)

Connected to services through monitors that will provide real
time feedback on health status, lifestyle, and health concerns.
(e.g. Health Buddy)

134
4th generation –
Decision Support tools and Individual needs
“Arrive in time” information and services at critical moments for care.
“Information therapy” is the active use of patient oriented information
with clinical evidence based medicine. Information needs to be
embedded into the process of clinical care—as information therapy.
Potential areas for Information Therapy:
Prostate surgery
Back surgery
ACL surgery
Coronary artery bypass surgery
Medication for depression
End-of-life care
Prescription of beta-blockers following heart attacks
Early-stage breast cancer testing
Colon cancer screenings
Immunizations and eye test reminders for diabetics
135
Nondiscrimination Rules
Health plans may not discriminate against similarly situated
individuals on the basis of a health status-related factor with
respect to 1) eligibility for the plan, or 2) premiums for the plan.
Health plans may not charge an individual a higher premium than
applies to similarly situated individuals because of health statusrelated factors.
However, health plans are allowed to make enrollment in the plan,
or receipt of particular benefits, contingent on regular completion
of health awareness or promotion activities that do not require
individuals to satisfy a particular health standard. Moreover,
employers are allowed to provide any kind of financial incentive
to plan enrollees who provide documentation of completion of
such activities.
136
Individuals & Health Status Factors
Health status-related factors include diagnosis of
overweight, obesity, results of cholesterol tests and a
history of overweight or eating disorders. They are
defined in a variety of ways, as follows:
• Health status
• Medical condition (including both physical and mental
illnesses)
• Claims experience
• Receipt of health care
• Medical history
• Genetic information
• Evidence of insurability
• Disability
137
The
Consumerism
Grid
Personal Accounts
Wellness/Prevention
Early Intervention
Disease Management
1st Generation
Consumerism
Focus on
Discretionary
Spending
Initial
Account Only
2nd Generation
Consumerism
3rd Generation
Consumerism
Focus on
Behavior
Changes
Integrated
Health &
Performance
Activity &
Compliance
Rewards
100% Basic
Web-based behavior Worksite wellness,
Preventive Care
change support
safety, stress & error
programs
reduction
Decision Support
Incentives &
Rewards
Personalized
Health &
Healthcare
Specialized Accts,
Matching HRAs,
Expanded QME
Genomics, predictive
modeling push
technology
Information, Compliance Awards, Population Mgmt, IHM, Wireless cyber –
disease specific
Integrated Back-to- support, cultural DM,
health coach
allowances
Information
Indiv. & Group
Corporate Metric
Rewards
4th Generation
Consumerism
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Work
Holistic care
Personal health
Health & performance Arrive in time info
mgmt, info with
info, integrated health
and services,
incentives to access
work data
information therapy
Personal development
Health Incentive
Non-health corporate
plan incentives,
Accounts, activity metric driven incentives
health status related
based incentives
138
Task #9 - Additional Considerations for
Building Blocks of Healthcare Consumerism
PCAs ______________________________________________________________
____________________________________________________________________
____________________________________________________________________
Wellness____________________________________________________________
____________________________________________________________________
____________________________________________________________________
Disease Management _________________________________________________
____________________________________________________________________
____________________________________________________________________
Decision Support ____________________________________________________
____________________________________________________________________
____________________________________________________________________
Incentives _________________________________________________________
____________________________________________________________________
____________________________________________________________________
139
Task #10 – Create/Design Basic Framework o
Consumerism Options
Design: Deductibles, Copays, Coinsurance, Max OOP,
Fund Balances, Wellness, Disease Mgmt, Incentives,
Carve-outs, etc.

Traditional PPO Plan

PPO with HRA

PPO with HSA

Other
140
Potential Anti-Selection
from Consumerism on an Optional Basis
Introduction of Consumerism on an optional basis will limit the cost
reduction. In particular, with HDHP’s fewer members will be
impacted and are those selecting HDHP’s are likely to have an
existing favorable health status (anti-selection). Companies and
members can benefit most by introducing consumerism with both a
HDHP option and consumerism features for current plans.
Example - Selection in An Option Environment
OPTION # 1
OPTION # 2
% Members
Participating
Clms/Part.Mbr. Vs
Clms/All Mbrs.
Remaining
Members
Clms/Part.Mbr. Vs
Clms/All Mbrs.
10%
75%
90%
103%
30%
85%
70%
106%
50%
100%
50%
100%
141
Design a PPO Plan
Traditional PPO
Desirable
PPO
Preventive
Preventive
Deductible
Deductible
20% Coins to
a Maximum
OOP
PPO 80%
Coverage
In-Network
100% Coverage
20% Coins to
a Maximum
OOP
What would you Include?
PPO 80%
Coverage
In-Network
100% Coverage
How large of a Deductible?
In-Network Coins?
In-Network Max OOP?
OON Coins?
OON Max OOP?
Other:
Carve-out Vision, Dental?
142
Design a High Deductible PPO/HRA Option
PPO / HRA
Preventive
Sample
PPO / HRA
Preventive
HRA
Deductible Gap ($500-1000)
Deductible Gap
20% Coins to
a Maximum
OOP $2-5,000
100% Coverage
__% Coins to
a Maximum
OOP of $_______
How Much in Initial HRA?
How Large of a
Deductible Gap?
HRA ($500-$1000)
PPO 80%
Coverage
PPO 80%
In Network
Coverage
In-Network
What would you Include?
Any Coinsurance?
PPO __%
Coverage In
Network OOP
of $______
100% Coverage
In-Network Coins?
In-Network Max OOP?
OON Coins?
OON Max OOP?
Other:
Carve-out or Incl.?: Rx, MH & SA,
Vision, Dental
HRA Incentives?
Wellness, DM. Other?
143
Design a High Deductible PPO/HSA Option
PPO / HSA
Preventive
Sample
PPO / HSA
How Much in Initial HSA?
Preventive
HSA=($1000=2600)
What would you Include?
Any Coinsurance?
HSA = _____
In-Network Coins?
In-Network Max OOP?
OON Coins?
OON Max OOP?
20% Coins to
a Maximum
OOP $5000 (incl
deductible)
PPO 80%
Coverage
In Network
100% Coverage
___% Coins to
a Maximum
OOP _______
PPO __%
Coverage
In Network
100% Coverage
Other:
Carve-out or Incl.?: Rx, MH & SA,
Vision, Dental
HSA Incentives?
HRA Incentive?
Wellness, DM. Other?
144
A Unified Theory of Plan Design
All Medical Plans can be view as catastrophic plans with first dollar
benefits funded by:
1. Post-tax self pay – Pure high deductible
2. Insurance – traditional HMO, EPO, POS, PPO, or Indemnity
3. Health Reimbursement Arrangements (HRAs) - HRA with
Deductible Gap
4. Health Savings Accounts (HSAs) – Legally defined
High Deductible Health Plan (HDHP)
5. Flexible Spending Accounts (FSAs)
6. Combinations of the above
145
PPO Plans Differ Mainly in the Way
Initial Dollars are financed
Traditional PPO
Insurance Funding
of Early Expenses
Preventive
PPO with
HRA Funding of
Early Expenses
Preventive
Deductible
PPO with
HSA Funding of
Early Expenses
Preventive
HRA
HSA
Deductible Gap
20% Coins to
a Maximum OOP
PPO 80%
Coverage
100% Coverage
20% Coins to
a Maximum OOP
PPO 80%
Coverage
100% Coverage
20% Coins to
a Maximum OOP
PPO 80%
Coverage
100% Coverage
Similar Catastrophic Protection
146
Sample Consumerism PPO Plan Designs
Traditional PPO
Insurance Funding
of Early Expenses
Preventive
100% coverage
Deductible $500
20% Coins to
a Maximum
OOP of $5,500
PPO with
Er HRA Funding of
Early Expenses
Preventive
100% coverage
Er HRA $1000
Deductible Gap
PPO 80%
Coverage
100% Coverage
20% Coins to
a Maximum
OOP of $5,000
PPO with
Voluntary Ee HSA Funding of
Early Expenses and Er HRA Match
Preventive
100% coverage
Voluntary Ee Funded
HSA up to $1250
$1,000
PPO 80%
Coverage
100% Coverage
$1250 HRA Er
Match to HSA to
cover part of:
PPO 80%
Coverage
20% Coins to
a Maximum
OOP of $4,800
100% Coverage
Max OOP = $6000
Max OOP = $6000
Max Ee Cost = $6000+Prem
Max Ee Cost = $6000+
Lower Prem
Max OOP = $6000
Min OOP = $4800 w/ HRA Match
Max Ee Cost = OOP+
+HSA+Lowest Premium
Incentive HRAs from
Initial “$0” Balance
Incentive HRAs from
Initial $1000 Balance
Incentive HRAs for
CY Co-Insurance Only
147
Task #10 – Create/Design Basic Framework of
Healthcare Consumerism Options
PPO
PPO/HRA
PPO/HSA
Other
Preventive Care Benefits
Front-end Deductible
Beginning Account Balance
Deductible Gap
PPO Coinsurance – In/Net
PPO Coins Max OOP-InNet
PPO OON Coinsurance
PPO OON Coins Max OOP
Carve-out Programs: Rx,
Vision, Dental
Incentives - DM
Incentives - Preventive Care
Matching Er HRA to Ee HSA
Other Decision Support Tools
148
Task #11 –
Implementation Planning & Time Frames
The Challenges and
A framework for Implementation
149
Employer Challenges in Developing a
Healthcare Consumerism Strategy
Lower Costs,
Increased Employee Satisfaction,
Quality/Value Driven Healthcare,
Improved Access to Care
Enterprise-wide Impact of Health & Healthcare
Collaboration
Standardize IT Platforms
Focus on High Cost / High Volume Users
Building the
Future Employer
Benefits Program
Pay-for-Performance
Consumerism
Healthcare Consumerism
Demand-Driven Healthcare
150
Communication Milestones
Accept Health Plan as
an Accumulating
Asset Rather than a
Short Term Benefit
Acceptance
I accept the
changes
Practical
Application
What does it
mean to me?
Education
Awareness
How does it work?
What is it?
Employee Decision-Making Cycle
151
Time Frame for
Implementation of
Consumerism (may
be Dependent Upon
Vendor Capabilities)
Personal Care
Accounts
Wellness/Prevention
Early Intervention
Disease and Case
Management
Information
Decision Support
Incentives &
Rewards
Yr__- __
Yr__-__
Yr__-__
Yr__-__
1st Generation
Consumerism
2nd Generation 3rd Generation
Consumerism Consumerism
Focus on
Discretionary
Spending
Focus on
Behavior
Changes
Initial
Account Only
100% Basic
Preventive
Care
Information,
health coach
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Activity &
Compliance
Rewards
Integrated
Health &
Performance
Personalized
Health &
Healthcare
Indiv. & Group Specialized Accts,
Corporate Metric Matching HRAs,
Rewards
Expanded QME
Worksite wellness,
Web-based
behavior change safety, stress &
error reduction
support
programs
Compliance
Awards, disease
specific
allowances
Personal health
mgmt, info with
incentives to
access
Health Incentive
Accts, activity
based incentives
4th Generation
Consumerism
Genomics,
predictive
modeling push
technology
Integrated Hlth
Wireless cyber –
Mgmt, Population support, cultural
Mgmt, Integrated DM, Holistic care
Back-to-Work
Health &
performance info,
integrated health
work data
Non-health
corporate metric
driven incentives
Arrive in time
info& services, info
therapy, Social
Networking
Personal dev. plan
incentives, health
status related
152
Integrated Health
Management
1st Generation
Consumerism
2nd Generation
Consumerism
A Logical Stake in
the Ground ?
Focus on
Discretionary
Spending
Focus on
Behavior
Changes
Personal Care
Accounts
Wellness / Prevention
Early Intervention
Disease Mgmt &
Case Management
Information &
Decision Support
Tools
Incentives &
Rewards
Initial
Account Only
100% Basic
Preventive
Care
Information,
health coach
Passive Info
Discretionary
Expenses
Cash, tickets,
Trinkets
Activity &
Compliance
Rewards
Web-based
behavior change
support
programs
Compliance
Awards, disease
specific
allowances
Personal health
mgmt, info with
incentives to
access
Zero balance
acct, activity
based incentives
3rd Generation
Consumerism
Integrated
Health &
Performance
4th Generation
Consumerism
Personalized
Health &
Healthcare
Indiv. & Group Specialized Accts,
Corporate Metric Matching HRAs,
Rewards
Expanded QME
Worksite wellness,
safety, stress &
error reduction
Genomics,
predictive
modeling push
technology
Integrated Hlth
Wireless cyber –
Mgmt, Population support, cultural
Mgmt, Integrated DM, Holistic care
Back-to-Work
Health &
Arrive in time
performance info, info & services,
integrated health
info therapy,
work data
social networking
Non-health
Personal dev. plan
corporate metric incentives, health
driven incentives
status related
153
Revealing the 5th Generation
A New Developing
Generation of Healthcare
Consumerism
154
Longevity
Personal
Accounts
Health Mgmt
Wellness/Preventio
n
Condition
Management
Information
Decision Support
Incentives &
Rewards
155
PwC Study
A PricewaterhouseCoopers study found that nearly a third
(32%) of consumers has used some form of social media for
healthcare purposes.
The self-absorbed “Me” generation is giving way to sharing
communities on Facebook, Picassa, Linked-In, Plaxo, and
YouTube.
156
5th Generation Healthcare
Consumerism
1.
2.
3.
4.
From Personalized (self) to Community (others)
From Health to Productive Longevity
From Self-help to helping Others
From Being Served to Sharing
5.
6.
7.
8.
From Taking to Giving
From Secular to Spiritual
From Monetary to Emotional
From Head (logic) to Heart
157
5th Generation Consumerism
Longevity Basics
1.
2.
3.
4.
5.
Move Naturally – Be Active Without Thinking About It
Painlessly Cut Calories by 20%
Avoid Meat & Processed Foods
Drink Red Wine in Moderation
Take Time to See the Big Picture
6.
7.
8.
9.
Take Time to Relieve Stress
Participate in a Spiritual Community
Make Family a Priority
Surround with Others who Share Values
Adapted from Blue Zone by Peter Buettner
158
Integrated Health Management Program
Implementation Option for Multiple Generations
General Manager
Personal Care Accts.
FSAs, HRAs, HSAs
Integrated Absence Mgmt
Acute Case Mgmt
Disease Mgmt Programs
The secret is
cooperation and
synergy between
components supporting
the corporate strategies
Demand Management
Prevention
Wellness
Utilization and Case Management
Communication
Education
NETWORK A / TPA A
NETWORK B / TPA B
159
Potential Savings & Actual Industry Results
from Early Generation Implementations
More than just Theory and Promises
“To achieve transformation to a future model
of healthcare consumerism, all participants
must advance in a consistent way to the
future model.”
160
The Value Proposition

5-8% Savings over 5 years with 2% lower trends
 Low Range of Savings
5% x 5 years + 2% x 5 years = 35%
 High Range of Savings
8% x 5 years + 2% x 5 years = 50%

20-35% lower Rx costs
Low Range: 20% x 20% = 4%
High Range: 35% x 20% = 7%
161
Potential Savings from
Full Implementation of Consumerism
Achievement of savings and improved outcomes is dependent upon both
the Type and Effectiveness of the programs implemented.
Gross* Savings as % of Total Plan Costs
(Programs Applicable to All Members)
Traditional plans
Effective
Programs
Implemented
Consumerism Plans
Passive
1st Generation
2nd Generation
3rd Gen & Future
Basic
2%
3%
7%
10%
Expanded
3-4%
5-8%
12-15.0%
20.0+%
Complete
4%
7%
17%
25%
Comprehensive
(Future)
5%
10%
20%
30%
*Excludes Carry-over HRAs/HSAs and any added
Administrative Costs of Specialized Programs
162
Healthcare Consumerism
Experience Results
163
American Academy of Actuaries
2009 Non-partisan CDH Consumerism Studies
1st Year Savings: The total savings generated could be as much as 12 percent
to 20 percent in the first year.
•
–
2+ Year Savings: At least two of the studies indicate trend rates lower than
traditional PPO plans by approximately 3 percent to 5 percent.
•
–
•
All studies showed a drop in costs in the first year of a CDH plan from -4
percent to -15 percent. A control population of traditional plans experienced
increases of +8 percent to +9 percent.
If these lower trends can be further validated, it will represent a substantial
cost-reduction strategy for employers and employees.
Cost Shifting: The studies indicated that while the possibility for employer
cost-shifting exists with CDH plans, (as it does with traditional plans) most
employers are not doing so, and might even be reducing employee costsharing under certain circumstances.
164
164
2011 Rand Study of CDHCs
The largest-ever assessment of high-deductible health plans finds that
while such plans significantly cut health spending, they also
prompt patients to cut back on preventive health care, according to a
2011 RAND Corporation study.
Studying more than 800,000 families from across the United States,
researchers found that when people shifted into health
insurance plans with high deductibles, their health spending dropped
an average of 14 percent when compared to families in health
plans with lower deductibles.
Health care spending also was lower among families enrolled in highdeductible plans that had moderate health savings accounts
sponsored by employers.
165
Experience Results
• Aetna reported in 2011 that employers who switched to accountbased health plans as their only plan option had saved $21.8
million per 10,000 members over the past five years.
• Cigna published a 2012 study concluding that employers can
save an average of $9,700 per employee over five years by
switching to account-based health plans.
• According to Towers Watson and the NBGH, companies that
successfully move their employees into account-based health
plans can achieve significant savings on their health benefit costs.
For example, companies with at least half of their workers
enrolled in an account-based health plan report that their peremployee costs are over $1,000 lower than companies without an
account-based health plan.
166
Task #12 (Summary) - Medical Plan Costs and
Potential Consumerism Savings Worksheet
Well
At-Risk
e.g., Low Risk, Good
Nutrition, Active
Lifestyle
Chronically-Ill
e.g., Inactivity, High Stress,
Overweight, High Blood
Pressure, Smoking
e.g., Diabetes,
Musculoskeletal, Heart
Disease
O/P (Low)
No Claims
Generally
Healthy
O/P (Low)
In/P (High)
Maternity
Distribution of Med
Costs
___%
___%
___%
___%
___%
___%
___%
___%
Avg $ Cost (000’s)
$0
$____
$____
$____
$____
$______
$_____
$______
Est. CDHC
Savings Pct.
0%
15%
12.5%
8%
5%
15%
20%
8%
$ CDHC Savings
(000’s)
$0
$____
$____
$____
$_____
$______
$______
$______
Incremental HRA
Costs
$____
$____
$____
$____
$_____
$______
$______
$______
Amount
In/P (High)
Catas-trophic
e.g., Cancer,
Rare Diseases
In/P (High)
Pct.
Est. CDHC Savings
$_______
_____%
Incremental HRA Costs
$_______
_____%
Net Annual Savings
$_______
_____%
167
Government
Exchanges
Ronald E. Bachman
Chairman
IHC Editorial Advisory Board
President & CEO
Healthcare Visions, Inc.
404-697-7376
[email protected]
168
Gov’t (Public) Health
Information Exchanges
(GHIEs)
&
Gov’t (Public) Health Insurance
Marketplaces
(GHIXs)
169
Government Health
Information Exchanges (GHIEs)
Typically transmit healthcare-related data among:
facilities, health information organizations, and
agencies according to state or federal standards.
The purpose of these Exchanges is to improve healthcare
delivery, information gathering, and transparency.
These Exchanges are an integral component of the health
information technology infrastructure under development
in the United States.
170
PPACA Health Insurance Exchanges
(Overview)
The Patient Protection & Affordable Care Act (PPACA) established government
(public) health insurance exchanges.
Who: Government Health Insurance Exchanges are for:
1. individual purchasers of health insurance, and
2. small groups (small group exchanges are defined by states and can
be up to 50 employees or 100 employees).
When: Effective January 1, 2014
1. American Health Benefit Exchange (AHBE for individuals), and
2. Small Business Option Program (SHOP for groups).
The word “Exchange” can be confusing. PPACA defines gov’t health insurance
exchanges (both federal and state-based). However, “Exchange” can refer to a
“Health Information Exchange” (HIE), a “Health Insurance Exchange” (HIX).
Because of the confusion “Marketplace” has generally replaced the original use
for Insurance Exchanges. There are both government (public) and private forms
of Information Exchanges and Insurance Exchanges (Marketplaces).
171
Employer Mandate for Large Group Employers
(50 or more)
Employer Shared Responsibility Payments
A penalty of $2,000 times the number of full-time employees
minus 30 employees if the employer does not offer qualified
health insurance coverage and at least one employee
receives a tax credit for the purchase of insurance through
an Exchange.
If the employer offers qualified health insurance coverage
but at least one employee declines the insurance coverage,
and gets a tax credit subsidy to buy insurance through an
Exchange, then the annual penalty is the lesser of (a) the
penalty for the employer mandate, or (b) $3,000 times the
number of full-time employees who received a tax credit to
buy insurance through the Exchange.
172
172
Employer & Individual Mandate
(Fewer than 50 employees)
Employers with fewer than 50 employees are exempt from
the employer mandate to provide insurance.
Small Employers can provide a tax advantaged “Defined
Contribution” through a state allowed Health
Reimbursement Arrangement.
Individuals are mandated to buy insurance (can purchase
from public or private exchanges or directly from insurers).
If individuals don’t buy health insurance the minimum tax
is $95 per person in 2014 and going to $695 in 2016 (up
to 3-times for a family indexed for inflation in subsequent
years). The maximum penalty is 2.5 percent of taxable
income.
173
Government Health Insurance Exchange
Marketplaces (GHIXs)
GHIXs are the entities for PPACA mandated private
insurance, mandated coverage, provide premium subsidies,
control plan designs, set premium levels (or require approval of
rate increases), shift funds among carriers through risk
adjusters, and establish state or nationwide insurance
mandates.
Subsidies may be available to individuals purchasing
insurance thru GHIXs. Small employers may also be eligible
for a tax credit to offset the costs of group insurance.
Used to identify individuals eligible for gov’t programs such
as Medicaid, High Risk Pool coverage, and Children’s Health
Insurance Plans.
174
PPACA Exchanges Defined (GHIXs)
A central provision of PPACA requires the establishment of
exchanges in each state—online marketplaces through
which eligible individuals and small business employers can
compare and select health insurance coverage from
participating health plans.
Begin enrollment by October 1, 2013, with coverage to
commence January 1, 2014.
States have some flexibility with respect to exchanges by
choosing to establish and operate an exchange themselves
(i.e., state-based), or by ceding this authority to Health &
Human Services (HHS) – (i.e. federally facilitated).
175
Governance Models
of State-based GHIXs
States may run one statewide exchange, regional exchanges
within the state, or participate in a multi-state exchange.
Can be governed by a state agency (new or existing), a
quasi-governmental agency, or a non-profit entity.
GHIX Models
Active purchaser: Exchange uses the market leverage of
enrollees to evaluate plan bids and selectively offer plans,
and/or negotiate to restrict cost growth of plan offerings.
The Massachusetts Health Connector is an example of an
active purchaser.
176
Governance of State-based GHIXs
(Continued)
Market Facilitator or Open Marketplace: Exchange relies
solely on qualified health plans meeting minimum
standards for entrance into the exchange, and allows
market forces to set plan premiums.
The Utah Health Exchange is based on the market
facilitator model.
177
GHIX Partnerships
State Plan Management: Plan management functions include the
collection and analysis of plan information, plan monitoring and oversight,
and data collection and analysis. Health & Human Service (HHS) will
coordinate with the state regarding plan oversight, including consumer
complaints and issues with enrollment reconciliation.
State Consumer Assistance: A state would oversee in-person consumer
assistance, manage direct assistance helping people sign up for
insurance, and conduct outreach. HHS would be responsible for other
consumer assistance functions including call center operations, managing
the consumer website, and written correspondence with consumers to
support eligibility and enrollment.
Both Plan Management & Consumer Assistance: If electing this
option, states would perform both these functions.
178
GHIX Implementation
48 States and D.C. were eligible to establish GHIXs. HHS
provided grants of $1 M to each state for research and
planning to determine how Exchanges could be operated
and governed.
Add’l funds were provided to develop state-based GHIXs.
Exchanges under the PPACA are government agencies or
non-profit organizations where private health insurance
policies are offered to individuals and small groups with
PPACA eligibility and coverage mandates, including
premium subsidies for low income individuals.
179
GHIX Implementation
GHIXs with fully insured individual plans will be available in
2014.
Fully service SHOP GHIXs with multiple insurer options have
been delayed until 2015. Single insurer option may be
available 2014.
States needed to show progress in establishing GHIXs by
January 1, 2013 or a federal Exchange may be implemented
in those states.
Until 2016, states can set Exchange eligibility at 50 or 100
employees.
In 2017, states may include employers with more than 100
employees.
180
181
Federal Poverty Level (FPL) Charts
48 Contiguous States and DC
For family units of more than 8 members, add $4,020 per person
Family Size
1
100%
11,490
Percent of FPL (2013)
133%
150%
200%
300%
15,282 17,235 22,980 34,470
2
15,510
20,628
23,265
31,020
46,530
62,040
3
19,530
25,975
29,295
39,060
58,590
78,120
4
23,550
31,322
35,325
47,100
70,650
94,200
5
27,570
36,668
41,355
55,140
82,710 110,280
6
31,590
42,015
47,385
63,180
94,770 126,360
7
35,610
47,361
53,415
71,220 106,830 142,440
8
39,630
52,708
59,445
79,260 118,890 158,520
400%
45,960
182
Essential Benefits
PPACA defines required essential benefits as ten broad
categories of coverage:
(1) Ambulatory Services,
(2) Emergency Services,
(3) Hospitalization,
(4) maternity and Newborn Care,
(5) Mental Health and Substance Abuse Services,
(6) Prescription Drugs,
(7) Rehabilitative Services,
(8) laboratory Services,
(9) Preventive and Wellness and Chronic Disease management
Services, & (10) Pediatric, including oral and vision care.
183
Essential Benefits by State
(State selected Reference Plan)
New HHS guidelines have proposed the adoption of a statebased “benchmark” approach. Rather than HHS defining
essential benefits for all, each state can choose a “reference”
plan from the following:
The largest plan by enrollment for any of the three largest
small group insurance products in the state;
• Any of the largest three state employee benefit plans;
• Any of the largest three national Federal Employee Health
Benefits Program plans; or
• The largest commercial HMO plan in the state.
•
184
Essential Benefits Default Plan
If a state does not choose a reference plan, HHS will use the
largest plan by enrollment in the small group market. The
chosen benchmark must satisfy coverage requirements in all
ten essential benefit categories.
A health plan will be required to offer benefits that are
“substantially equal” to the state reference plan. Plans can
adjust benefits, including both the specific services covered
and any quantitative limits, provided all ten categories of the
essential benefits are covered.
The variations by state could produce problems for selffunded plans operating in multiple states, as every state
could have different mandates for essential benefits.
185
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
EHB
Benchmark Plan Name
Plan Type
United
States
26
Recom’ed
25 Default
2 State Ee plan
21 CHIP
3 CHIP
Incl’d
45 Small grp plan 29 FEDVIP 42 FEDVIP 48
3
FEHBP
4 Commerc’l HMO 1 Incl’d
6 Incl’d
30 Yes
21 No
Alabama
Default
Small group plan
FEDVIP
FEDVIP
Included
Yes
Alaska
Default
Small group plan
FEDVIP
FEDVIP
FEHBP
Yes
Arizona
Recom’ed
State employee
plan
FEDVIP
FEDVIP
Included
No
Arkansas
Recom’ed
Small group plan
CHIP
FEDVIP
FEHBP
No
California
Recom’ed
Small group plan
CHIP
FEDVIP
Included Yes
Colorado
Recom’ed
Small group plan
CHIP
Included
Included No
Conn
Recom’ed
Commercial HMO
CHIP
FEDVIP
Included
NA
BCBS of AL320 Plan, PPO
BCBS of AKAlaska
Heritage
Select Envoy,
PPO
State of Az
Self-Insure
(Admin by
United), EPO
HMO
Partners
Open Access
POS
Kaiser- Sm
Grp, HMO
KaiserDed/CO HMO
1200D
ConnectiCare,
HMO
Pediatric
Dental
Pediatric
Vision
Mental
Health
Includes
Habilitative
Services
Location
No
186
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Location
EHB
Benchmark Plan Name
Plan Type
Pediatric Pediatric Mental
Dental
Vision
Health
Recom’d
Highmark (BCBS of
DE)- Simply Blue,
EPO
District of
Columbia
Recom’d
Group Hospitalization
and Medical Services Small group
FEDVIP
(CareFirst BCBS)plan
BluePreferred, PPO
Florida
Default
Georgia
Default
Hawaii
Recom’d
Delaware
BCBS of FLBlueOptions, PPO
BCBS of GA- HMO
Urgent Care 60 Copay
Hawaii Medical
Service Association
(BCBS)- Preferred
Provider Plan 2010,
PPO
Small group
CHIP
plan
Small group
FEDVIP
plan
Small group
FEDVIP
plan
Small group
CHIP
plan
Includes
Habilitative
Services
FEDVIP
Included No
FEDVIP
Included Yes
FEDVIP
Included No
FEDVIP
Included Yes
FEDVIP
Included No
187
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Location
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Includes
Habilitative
Services
EHB
Benchmark
Plan Name
Plan
Type
Pediatric
Dental
Pediatric
Vision
Mental
Health
Default
Blue Cross of IDPreferred Blue,
PPO
Small
group
plan
FEDVIP
FEDVIP
Included Yes
Recom’d
BCBS of ILBlueAdvantage
Entrepreneur, PPO
Small
group
plan
CHIP
FEDVIP
Included No
Default
Anthem (BCBS)Blue Access, PPO
Small
group
plan
FEDVIP
FEDVIP
Included Yes
Default
Wellmark (BCBS)- Small
Alliance Select,
group
PPO
plan
FEDVIP
FEDVIP
Included Yes
Default
BCBS of KSComprehensive
Major Medical,
PPO
Small
group
plan
CHIP
CHIP
Included No
Recom’d
Anthem (BCBS),
PPO
Small
group
plan
CHIP
CHIP
Included Yes
188
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Includes
Habilitative
Services
EHB
Benchmark
Plan Name
Plan Type
Pediatric Pediatric
Dental
Vision
Mental
Health
Default
BCBS of LAGroupCare, PPO
Small
group
plan
FEDVIP FEDVIP
Included Yes
Maine
Default
Anthem (BCBS of Small
ME), Blue Choice, group
PPO
plan
FEDVIP Included
Included Yes
Maryland
Recommen
ded
CareFirst (BCBS)HMO HSA Open
Access
Small
group
plan
CHIP
FEDVIP
FEHBP
Mass.
Recommen
ded
BCBS of MAHMO Blue
Small
group
plan
CHIP
Included
Included Yes
Michigan
Recommen
ded
Priority Health,
HMO
Commerci
CHIP
al HMO
FEDVIP
Included No
Default
Health PartnersSmall Group
Product, PPO
Small
group
plan
FEDVIP FEDVIP
Included Yes
Location
Louisiana
Minnesota
Yes
189
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Location
EHB
Benchmark
Plan Name
Pediatric
Plan Type Pediatric
Dental
Vision
Mental
Health
Includes
Habilitative
Services
Mississippi
Recom’d
BCBS- Network
Blue, PPO
Small grp
plan
Missouri
CHIP
FEDVIP
Incl’d
Yes
Default
Healthy Alliance
Small grp
(BCBS)- Blue
plan
Access Choice PPO
FEDVIP
FEDVIP
Incl’d
Yes
Montana
Default
BCBS of MT- Blue
Dimensions, PPO
Small grp
plan
FEDVIP
FEDVIP
Incl’d
Yes
Nebraska
Default
BCBS of NE- Blue
Pride PPO
Small grp
plan
FEDVIP
FEDVIP
Incl’d
Yes
Recom’d
Health Plan of
Nevada UHC- POS
C-XV-500-HCR
Small grp
plan
CHIP
FEDVIP
Incl’d
No
Recom’d
Anthem (BCBS)Matthew Thornton
Blue, HMO
Small grp
plan
FEDVIP
FEDVIP
Incl’d
Yes
Nevada
New
Hampshire
190
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Location
EHB
Benchmark
Plan Name
Plan Type
Pediatric
Dental
Pediatric
Vision
Mental
Health
Includes
Habilitative
Services
New Jersey
Default
Horizon (BCBS)HMO Access
Small grp
plan
FEDVIP
FEDVIP
Incl’d
Yes
New
Mexico
Recom’d
Lovelace- Classic,
PPO
Small grp
plan
CHIP
Included
Incl’d
Yes
New York
Recom’d
Oxford, EPO
Small grp
plan
CHIP
Included
Incl’d
Yes
North
Carolina
Recom’d1
BCBS of NC- Blue Small
FEDVIP
Options, PPO
group plan
FEDVIP
Incl’d
No
North
Dakota
Recom’d
Sanford Health,
HMO
CHIP
CHIP
Incl’d
No
Default
Community
Insurance
Small grp
Company (Anthem
plan
BCBS)- Blue
Access, PPO
FEDVIP
FEDVIP
Incl’d
Yes
Ohio
Comm’l
HMO
191
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Location
Oklahoma
Oregon
EHB
Benchmark
Plan Name
Plan
Type
Pediatric
Dental
Pediatric
Vision
Mental
Health
Includes
Habilitative
Services
Default
BCBS of OKBlueOptions, PPO
Small
group
plan
FEDVIP
FEDVIP
Include
d
Yes
Recommen
ded
PacificSourcePreferred
CoDeduct Value,
PPO
Small
group
plan
CHIP
FEDVIP
Include
d
No
FEDVIP
FEDVIP
Include
d
No
Pennsylvania
Default
Aetna, POS
Small
group
plan
Rhode Island
Recommen
ded
BCBS of RIVantage Blue PPO
Small
group
plan
FEDVIP
FEDVIP
Include
d
No
Default
BCBS of SCBusiness Blue
Complete, PPO
Small
group
plan
FEDVIP
FEDVIP
Include
d
No
South
Carolina
192
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Location
EHB
Benchmark Plan Name
Includes
Habilitative
Services
Pediatric
Dental
Pediatric
Vision
Mental
Health
Small group
FEDVIP
plan
FEDVIP
Included Yes
Plan Type
South
Dakota
Recom’d
Wellmark
(BCBS)- Blue
Select, PPO
Tennessee
Default
BCBS of TN,
PPO
Small group
FEDVIP
plan
FEDVIP
Included Yes
Texas
Default
BCBS of TXSmall group
FEDVIP
BestChoice, PPO plan
FEDVIP
Included Yes
Recom’d
Utah Basic Plus
State Employee
Plan, HMO
State
employee
plan
Included
Included Yes
Recom’d
The Vermont
Health Plan
(BCBS of VT) BlueCare, HMO
Commercial
CHIP
HMO
FEDVIP
Included No
Utah
Vermont
Included
193
Essential Health Benefit (EHB)
Benchmark Plans, as of January 3, 2013
Location
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
EHB
Benchmark
Plan Name
Plan
Type
Pediatric
Dental
Pediatric
Vision
Mental
Health
Includes
Habilitative
Services
Recom’d
Anthem (BCBS)KeyCare, PPO
Small
group
plan
CHIP
FEDVIP
Incl’d
Yes
Recom’d
Blue ShieldRegence Innova,
PPO
Small
group
plan
CHIP
FEDVIP
Incl’d
Yes
Default
Highmark (BCBS
of WV)- Super
Blue Plus 2000,
PPO
Small
group
plan
FEDVIP
FEDVIP
Incl’d
No
Default
United- Choice
Plus, POS
Small
group
plan
FEDVIP
FEDVIP
Incl’d
No
Default
BCBS of WYBlue Choice
Business, PPO
Small
group
plan
FEDVIP
FEDVIP
Incl’d
No
194
Private Exchanges
& ACOs
Ronald E. Bachman
Chairman
IHC Editorial Advisory Board
President & CEO
Healthcare Visions, Inc.
404-697-7376
[email protected]
195
195
Private Health Information Exchanges
(PHIE)
Typically web-based portals providing consumer
health and health care information.
These Exchanges provide individuals and company health
plans with medical and clinical education, treatment
options, care costs, provider quality metrics, repositories
for personal medical records, and much more.
Others may provide medical information and online clinical
care.
Examples: WebMD, MDLiveCare
196
Comparison of
Public & Private Insurance Exchanges
Public Exchange
Private Exchange
Sponsor
Gov’l Entity – either state or
fed’l government (the default
if no state-based exchange)
Private Company
Product/Service
Offerings
PPACA qualified medical
benefits: Medical, Dental,
Vision through multiple
carriers
Medical, Dental, Vision and
other products: Life insurance,
disability, supplemental
products (e.g. cancer, legal,
HO, Auto) through a single or
multiple carriers
Target Market
Individuals and Small
Groups up to 50 or 100 Ees
(varies by state)
Small & Large Groups: Active
employees and retirees of
companies plus dependents
Financing
Individual, small employer,
federal gov’t with subsidies
up to 400% of FPL
Consumer and employer
Mercer’s Private Exchange Pulse Survey, 2013
197
Private Health Exchanges (PHIXs)
When: Some local exchanges have been
operating for many years.
New regional and national private exchanges
may start operating in 2013 and 2014.
PPACA increased awareness and the need for
a new health insurance purchasing system.
In addition, some of the private exchange
developers hope to get a share of the PPACA
government exchange business.
198
Private Health Insurance Marketplaces
(PHIXs)
What: Typically are web-based portals focusing on
consumer guidance and information for the private
purchase of health insurance.
These Exchanges serve as marketing and lead generation
sites for brokers/agents.
Individual and group product descriptions, premium
estimates, and purchases can be made online or by follow
up with an agent.
Private sites may also provide information and guidance for
those eligible for government insurance options (Medicaid,
CHIP, or Social Security Disability).
199
Employer Mandate for Large Group Employers
(50 or more)
If the employer does not offer qualified health insurance
coverage and at least one employee receives a tax credit
for the purchase of insurance through an Exchange the
penalty is $2,000 times the number of full-time employees
minus 30 employees .
If the employer offers qualified health insurance coverage but
at least one employee declines the insurance coverage,
and gets a tax credit subsidy to buy insurance through an
Exchange, then the annual penalty is the lesser of (a) the
penalty for the employer mandate, or (b) $3,000 times the
number of full-time employees who received a tax credit to
buy insurance through the Exchange.
200
Employer & Individual Mandate
(Fewer than 50 employees)
Employers with fewer than 50 employees are exempt from
the employer mandate to provide insurance.
Small Employers can provide a tax advantaged “Defined
Contribution” through a state allowed HRA.
Employees are mandated to buy insurance (can purchase
from public or private exchanges or directly from insurers).
If employee doesn’t buy health insurance the minimum tax
is $95 per person in 2014 and going to $695 in 2016 (up to
3-times for a family indexed for inflation in subsequent
years). The maximum penalty is 2.5 percent of taxable
income.
201
Types of PHIXs
by Sponsor
Business group PHIXs: developed from existing employer
associations. Typically will ensure portability for ees, but only
when the ee moves between participating ers and health
plans.
Insurer-sponsored PHIXs: developed for insured
policyholder, making it easy to move current small es into an
exchange and allow individual ees a wider choice of health
plan design. The portability (the ability of a consumer to keep
the same coverage as they move between jobs) is available
to individuals moving companies covered by the same
insurer.
202
Types of PHIXs (continued)
by Sponsor
Independent companies: developed with various
sponsorships, existing relationships, and business models.
These companies include existing information technology
vendors, consultants/brokers, and entrepreneurs.
These players seek to meet the needs of existing health
industry customers, employer groups, and broker clients.
They see the opportunity to expand on existing services
and technology to create new businesses in a growing
market.
203
Types of PHIXs by
Carrier Offering
Single-carrier Exchanges: These exchanges are
promoted by a single payor. They target employers that
wish to maintain some role in choosing both the
insurance carrier and plan design
Multi-carrier Exchanges: Promoted by brokers or benefits
consultants to provide a broad range of payor and plan
design options. Multi-carrier exchanges typically list
individual products on a menu of offerings.
204
205
205
Potential for PHIXs
•
The mid- and large-group markets that will not be involved in
the state-based federal PPACA exchanges.
Er costs: fixed and controllable using HRAs (Defined
Contributions).
•
•
Ees: will be able to choose their plan design.
Coverage will eventually be portable, so employees can keep
the same coverage as they change or lose jobs.
•
Unlike individual coverage today, the Ee contributions may be
made tax free through using a Sec. 125 payroll deduction.
•
Two-income families may be able to use contributions from
different Ers to purchase a single plan for the whole family.
•
206
Value of PHIXs
Employers
Employees
Cost
Reduced Cost &/or
Defined Contribution
Cost Efficient,
Convenient
Purchasing
Convenience
Simplified
Administration
Comprehensive
Coverage
Choice
Empowered
Employees
Personalized
Coverage,
Supplemental
Products
Mercer’s Private Exchange Pulse Survey, 2013
207
PHIX and Voluntary Products
% Employers offering Supplemental Products
Accident Insurance
43%
Cancer / Critical Illness Policies 38%
Auto / Homeowners Insurance
3%
% Employees wanting to Increase Some Benefits
and Decrease Others
Group Size
1-499
35%
500-999
45%
1000-4999
42%
5000 or more
39%
Mercer’s Private Exchange Pulse Survey, 2013
208
208
Types of PHIX by
Business Model
The Group Model: there may be as many as 20 different
health plans for an employee to choose from but they’re
all in a group platform and they are generally from just one
carrier.
Individual Model: Individual insurance policies. Especially
good for smaller groups that have not been offering group
insurance and can’t meet the minimum participation of
funding requirements of the group model.
209
Business Model Concerns for Carriers
• Margin compression: Greater choice of health plans may
reduce overall payor margins. Multi-carrier exchanges may
commoditize products and lead to higher transaction fees
(e.g. individual commissions)
• Administrative burden: Employees will need more
support to select their plans. Payors and PHIXs will need to
integrate products, member and billing data (i.e. increased
administrative costs and complexity).
• Disintermediation: The exchange administrator may
control the sales and marketing process, diluting a payor’s
contact with the customer and thus its ability to manage the
relationship.
210
HRAs for Small Employers &
Limited Use by Large Employers
U.S. Department of Labor ruled that HRAs are group health
plans and therefore cannot have annual limits.
HRAs can be used by small employers (under 50 Ees) to
assist funding of health insurance since they have no
mandate.
The DOL guidance means that a large employer would be
subject to substantial penalties if they use stand alone
HRAs for funding Ee purchses of QHPs.
Any size Er can use HRAs for retirees or for the purchase of
Supplemental products such as dental or vision.
211
Defined Contribution & Functions of Private Exchanges
212
212
Projected Growth of Private Exchanges:
Mercer
Mercer: The % of US employers considering offering a
private exchange for active and/or retired employees has
tripled in the past year to 56%.
Mercer said that 10 major insurance carriers—including
Aetna, Cigna, Humana, UnitedHealthcare and a number
of Blue Cross and Blue Shield plans—have signed on to
the firm’s private exchange for 2014 enrollment.
Mercer’s exchange will be available to employers with at
least 100 employees
213
Projected Growth of Private Exchanges:
Aon
Aon Hewitt said all of the new clients have at least
5,000 employees and represent a range of industries.
With the additional clients, Aon Hewitt said 330,000
employees will be receiving coverage through its
exchange.
In total, Aon Hewitt anticipates more than 600,000 U.S.
employees and their families will be covered under
plans in the Aon Hewitt Corporate Health Exchange in
2014.
214
Self-Insured Plans
PPACA creates significant mandate differences and cost implications
between fully insured and self-insured plans. Self-insured employer
plans are explicitly exempted from some PPACA requirements. SelfInsured Plans are NOT:
•
Required to provide minimum essential benefits (required to meet the costsharing limits, benefit levels, and “minimum essential coverage” but are not required
to provide the “minimum essential benefits”).
•
•
•
•
•
•
Required to participate in a risk-adjustment system,
Subject to single risk pool standards,
Subject to 3-1 age pricing compression and other rating mandates,
Subject to medical loss ratio (MLR) mandates,
Subject to review of premium increases, and
Subject to the annual insurance fee that starts in 2014 for fully insured
plans.
215
Self-Insured Plans
The existing benefits of self-insured are retained. They are
NOT:
Subject to state premium taxes,
Subject to state coverage mandates, and
Subject to insurance reserve requirements.
Under PPACA, employers will retain the choice of fully insured
and self-insured arrangements. However, fully insured plans will
mostly be offered through health exchanges because federal
employee premium subsidies (up to 400% of the federal poverty
level) will only be available through exchanges. The size of
groups eligible for participation in an exchange may vary by state
and can increase over time based on PPACA requirements.
216
Self-Insured Plans
Because PPACA exempts self-insured plans from some
costly requirements, it may be financially beneficial for an
employer (regardless of size) to consider self-insurance.
As PPACA is implemented, self-insuring may become a
better value than fully insured plans for small firms with good
historical experience and a good risk profile.
In 2009, self-insured plans were offered to 13.5% of plans
with fewer than 100 employees, 25.7% of Plans with 100499 employees, and 82.1% of plans with more than 500
employees (Agency for Healthcare Research and Quality),
217
217
Self-Insured Plans
Cost competitive reinsurance arrangements are available.
High claims risks can be mitigated with specific and
aggregate stop-loss coverage.
Courts have consistently upheld ERISA federal exemptions
from state insurance laws and the use of reinsurance for
small groups, even as states have tried to restrict them. It is
uncertain at this time if federal laws or regulations will change
to prohibit this gambit.
Under PPACA, if the health of self-insured groups
deteriorates they can then join an exchange. In the exchange,
their experience is spread over the entire exchange pool as
part of a single risk pool.
218
Index of PHIXs
(A-B)
Alegeus WealthCare Marketplace
Aon Hewitt Corporate Health Exchange
Array Health Private Health Exchange
Assurex Global Marketplace Platform
Benefitfocus HR InTouch Marketplace Edition
BeneFit Marketplace™ from Empowered Benefits
BenefitMall Individual Exchange
Bloom Private Exchange Platform for Employers
Bloom Private Exchange Platform for Health Plans
219
Index of PHIXs
(H-M)
hCentive WebInsure Private Exchange
Health Partners America Insurance Exchange
Horizon Select (Horizon BCBS of New Jersey)
InsureXSolutions Private Exchange
Lawley Marketplace from Lawley Benefits Group
Liazon Bright Choices Exchange
Mercer Marketplace
MyCieloChoice (Individual Exchange)
MyPlanSource
220
220
Index of PHIXs
(C-E)
Capital BlueCross MyCoverage Selector™
CHOICE Adminstrators Exchange Solutions
Cielostar Private Exchange Solution
ConnectedHealth Smart Choices Exchange
ConnectedHealth Consumer Marketplace
ConnectedHealth Smart Choices Platform™
Digital Benefits Marketplace
ExtendRetiree
221
Index of PHIXs
(P-W)
PeopLease Benefits Marketplace
RightOpt, a Private Health Insurance Exchange
Solstice Marketplace
Towers Watson OneExchange
Virtus Benefits Private Marketplace
Willis Advantage
222
Accountable Care Organizations
(ACOs)
1.
An accountable care organization is a group of payers,
physicians, hospitals and other healthcare providers that
voluntarily collaborate to provide efficient, high-quality
and coordinated care to an assigned population of
patients.
2.
If providers reduce costs and/or improve specified
quality metrics in a certain timeframe, they are able to
receive financial rewards from or share in the savings
with Medicare or a commercial payer.
3.
ACO arrangements can also involve risk, in which the
provider would have to pay back a portion or all of the
costs that exceeded the payer's established benchmark.
223
Accountable Care Organizations
(ACOs)
7. As of August 2013, 488 healthcare entities are practicing
accountable care, according to a Leavitt Partners report.
8. Medicare ACOs now represent 52 percent of all ACOs,
as there are 253 organizations contracting with CMS for
accountable care, according to the August 2013 Leavitt
Partners report.
9. Unlike a health maintenance organization, beneficiaries
do not join ACOs — their providers do. Patients are notified
of their providers' participation in a commercial or Medicare
ACO. Patients can decline having their protected health
information shared within the ACO, or choose to receive
care from another physician if they do not wish to
participate.
224
Accountable Care Organizations
(ACOs)
4. The goals of ACOs are known as "the triple aim.“
 (1) improving the experience of care,
 (2) improving the health of populations and
 (3) reducing per capita costs of healthcare.
5. Physician groups are the largest leaders of ACOs,
although hospital systems are a close second, according
to a 2013 Leavitt Partners report.
6. As of February 2013, ACOs covered 37 million to 43
million Medicare and commercial patients, according to an
Oliver Wyman report.
225
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to Know.“)
Abington (Pa.) Health.
Adventist Health-Portland (Ore.).
Advocare Walgreens Well Network (Marlton, N.J.).
Advocate Health Care (Oakbrook, Ill.).
Alexian Brothers Accountable Care Organization (Arlington
Heights, Ill.).
Allina Health (Minneapolis).
Arizona Connected Care (Tucson).
Atlantic Accountable Care Organization (Morristown, N.J.)..
Atrius Health (Newton, Mass).
Aurora Accountable Care Organization (Milwaukee).
226
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to Know.“)
Banner Health Network (Phoenix).
Baptist Health System (San Antonio).
Barnabas Health ACO-North (West Orange, N.J.).
BayCare Health System (Clearwater, Fla.).
Baylor Quality Alliance (Dallas).
Beacon Health (Brewer, Maine).
Bellin-Thedacare Healthcare Partners (Green Bay, Wis.)..
Beth Israel Deaconess Care Organization (Westwood, Mass
Billings (Mont.) Clinic.
BJC HealthCare ACO (St. Louis).
Brown & Toland Physicians (San Francisco).
227
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to Know.“)
Cape Cod Health Network ACO (Hyannis, Mass.).
Carolinas HealthCare System (Charlotte, N.C.).
Cedars-Sinai Accountable Care (Beverly Hills, Calif.).
Chicago Health System ACO.
Children's Hospital of Philadelphia.
Cleveland Clinic Florida (Weston).
Cornerstone Health Care (High Point, N.C.).
Crystal Run Healthcare ACO (Middletown, N.Y.).
Dartmouth-Hitchcock (Lebanon, N.H.).
Dean Clinic and St. Mary's Hospital ACO (Madison).
Diagnostic Clinic Walgreens Well Network (Tampa Bay, Fla.).
Dignity Health (San Francisco).
228
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to Know.“)
Essentia Health (Duluth, Minn.).
Everett (Wash.) Clinic.
Fairview Health Systems (Minneapolis).
Franciscan Alliance (Mishawaka, Ind.).
Genesys Physician Hospital Organization (Flint, Mich.)
Greater Baltimore Health Alliance (Towson, Md)
Hackensack (N.J.) Alliance ACO..
Health4 (Columbus).
HealthCare Partners California ACO (Torrance, Calif.).
HealthCare Partners of Nevada (Las Vegas).
HealthPartners (Bloomington, Minn.).
Health Management Associates (Naples, Fla.).
229
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to Know.“)
Heartland Health (St. Joseph, Mo.).
Heritage California ACO (Northridge).
Hoag Memorial Hospital Presbyterian (Newport Beach, Calif.).
Holy Cross Hospital (Fort Lauderdale, Fla.).
Hunterdon Healthcare Partners (Flemington, N.J.).
Indiana University Health (Indianapolis).
John Muir Health (Walnut Creek, Calif.).
JSA Medical Group (Saint Petersburg, Fla.).
Kelsey-Seybold Clinic (Houston).
KentuckyOne Health Partners (Louisville, Ky.).
Key Physicians (Chapel Hill, N.C.).
230
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to Know.“)
Lahey Clinical Performance ACO (Beverly, Mass.).
MaineHealth Accountable Care Organization (Portland).
Memorial Hermann Health System (Houston).
Mercy Health Select (Cincinnati).
Methodist Le Bonheur Healthcare (Memphis, Tenn.).
Methodist Patient-Centered ACO (Dallas).
Michigan Pioneer ACO (Detroit).
MissionPoint Health Partners (Nashville, Tenn.).
Moffitt Cancer Center (Tampa, Fla.).
Monarch Healthcare (Irvine, Calif.).
Montefiore ACO (New York City).
Mount Auburn Cambridge Independent Practice Association
(Brighton, Mass.).
231
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to
Know.“)
NCH Healthcare System (Naples, Fla.).
Northwest Ohio ACO (Toledo).
Novant Health (Winston-Salem, N.C.).
Ochsner Accountable Care Network (New Orleans).
OneCare Vermont (Colchester, Vt.).
Optimus Healthcare Partners (Summit, N.J.).
Orlando (Fla.) Health.
OSF Healthcare System (Peoria, Ill.).
Park Nicollet Health Services (St. Louis Park, Minn.).
Partners HealthCare (Boston). Penn Medicine (Phila.)
Physician Health Partners (Denver).
Physician Organization of Michigan ACO (Ann Arbor).
232
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to
Know.“)
Plus (Fort Worth and Arlington, Texas).
PrimeCare Medical Network (Ontario, Calif.).
ProHealth Physicians (Farmington, Conn.).
ProMedica (Toledo).
Providence Health & Services, Southern California (S.F.)
Renaissance Health Network (Wayne, Pa.).
Scott & White Healthcare Walgreens Well Network (Temple,
Texas).
Seton Health Alliance (Austin, Texas).
Sharp HealthCare (San Diego).
St. Luke's Clinic Coordinated Care (Boise, Idaho).
Steward Promise (Boston).
233
Index of ACOs
(Becker's Hospital Review: "100 Accountable Care Organizations to
Know.“)
Texas Health Resources (Arlington).
Triad HealthCare Network (Greensboro, N.C.).
UCLA Health ACO (Los Angeles).
UnityPoint Health (Des Moines, Iowa).
University of Michigan Health System (Ann Arbor).
VirtuaCare ACO (Marlton, N.J.).
Wellmont Integrated Network (Kingsport, Tenn.).
Wilmington (N.C.) Health.
234
Exchange InfoCast Website
www.theihcc-hcv.com
235