Change Healthcare 2017 - Health Plan Alliance · AI / Machine Learning. Cloud. Mobility. Internet of Things. Genomics. Imaging. ... to innovate and solve your biggest challenges

PROPRIETARY & CONFIDENTIALPROPRIETARY & CONFIDENTIAL

CHANGE HEALTHCARE CONSULTING

2018

PROPRIETARY & CONFIDENTIAL 2

Change Healthcare

Section 1.0


Change is constant in healthcareDriving our vision and strategy

Increasing Consumerism

Rise of Value-Based Care

Emerging Technology

Increasing Regulation + Compliance

System Inefficiency

Growing Government

Influence

New entrants & competitors

Consolidation and Vertical Integration

Inspiring a Better Healthcare System

Reducing healthcare’s cost burden

Building a connected healthcare ecosystem

Focusing on your

outcomes


Transformation is essential today

Challenges Transformation

Reduce Cost

Enhance Experience

Improve Quality

Our shared goals in transforming our

healthcare systemHealth system fragmentation

Market/regulatory uncertainty

New capability requirements

Time and investment to build new capabilities

Change management to transform organization

200+ health services deals/ M&A per quarter (2016-2017)

34% of payer investment in consumerism capabilities

26% of payer investment in value-based care tools

75% plan to invest in AI —only 20% have the tech

Source: PwC, ORC Change Healthcare Research, Modern Healthcare

PROPRIETARY & CONFIDENTIAL© 2018 Change Healthcare LLC and/or its subsidiaries or affiliates. All Rights Reserved.


Industry transformation is acceleratingDriven by exponential technologies

Social

AI / Machine Learning

MobilityCloud

Internet of Things

Genomics

Imaging

The “Shark Fin” Model of Industry DisruptionExponential Technology Innovations

Source: Accenture


Innovation at the center of the healthcare ecosystem

2,100Payer Connections

1 in 5US Patient Records

$2 trillionHealthcare Claims

12 billionHealthcare Transactions

5,500Hospitals & Health Systems

800,000Physicians117,000

Dentists

600Laboratories

Intelligent Healthcare Platform


Innovation at the center of the healthcare ecosystem

Software & Analytics

Network Solutions

Technology Enabled Services

Comprehensive SolutionsData and ConnectivityUnique position at the center of the healthcare ecosystem

Unparalleled transaction volume

Serving payers, providers, labs, pharmacies, consumers, others

12B transactions

$2T in claims

5,500 hospitals

800,000 physicians

Technology Partnerships

In-the-workflow connectivity

Solutions powered by the Intelligent Healthcare Platform

Industry-leading partners to drive innovation in healthcare

2,100 payor conections


Measurable impact for our customers

TPA administrative cost savings in 18 months by electronifying payments

Average savings per 2M covered lives for health

plan customers

Source: Change Healthcare Internal statistics. Individual results may varyNote: Trademarks or service marks are property of the named entities.

$170MSavings delivered to

over 60 payer customersQuarterly savings per

provider through jointly-operated VBC company

with BCBSAZ

$3.2B $200K

92% of Top 25 Health Plans

$1,000 ClaimsXtenTMDual Enrollment

Advocate B2B Payments ACO PartnerTM


Collaboration to Accelerate Your Transformation

We are dedicated to collaborating with you to accelerate the journey toward improved lives and healthier communities through:

Delivering solutions that help reduce cost, enhance member experience, and improve quality outcomes

Building strategic relationships to innovate and solve your biggest challenges

Earning trust through our commitment to customer service

Creating customer communities to enhance feedback and customer interaction


Accelerating Transformation for Payers

ENGAGEMENT CLINICAL FINANCIAL

INTELLIGENT HEALTHCARE PLATFORM

• Our transparency platform helps >20M consumers shop for care

• Largest healthcare communications vendor—1.3B items printed annually

• Comprehensive solutions for health and financial engagement

• InterQual® is used by 3,400 hospitals

• 60 payers use our risk & quality tools

• Leading community program on social determinants of health

• Value-based care joint venture with BCBS-Arizona

• 92% of top 25 health plans use our payment accuracy solutions

• Connections to 800K+ providers through our healthcare networks

• Comprehensive payer outsourcing and advisory services

• First healthcare member of blockchain consortium Hyperledger• Connections to 800K+ providers and unparalleled transaction

volume


Our payer solutions

ENGAGEMENT CLINICAL FINANCIAL

• Eligibility & Enrollment

• Transparency & Provider Search

• Consumer Payments & Communications

• Member Outreach & Education

• Consulting

• Provider Network Optimization

• Value-Based Payments (HealthQxTM)

• Value-Based Care Enablement

• Decision Support (InterQual®)

• Quality Analytics

• Clinical Review

• Consulting

• Risk Adjustment Analytics

• Payment Accuracy

• Provider Payments

• Medical EDI Networks

• Dental EDI Networks

• Pharmacy Benefits & Third Party Administration

• Consulting


Collaborating across the industry

Note: Trademarks or service marks are property of the named entities.


Change Healthcare Consulting

Section 1.0


A dedicated team of experienced, diverse, passionate, and creative team members with a shared vision:

Who we are

ENABLING SMARTER HEALTHCARE


As healthcare consultants we are dedicated to making it simpler for payers and providers to engage with an evolving and complex healthcare system.

We enable our customers to:

Cut through complexity and make better decisions

Chart a clear path forward

“See around corners” to stay ahead of shifting market dynamics

Eliminate inefficiencies

Our focus


We work with plans to optimize key functions…

Develop Products

& Services

Manage Customers

and Products

Develop & Manage Providers

Manage and

Deliver Care

Administer Accounts

Engage Customers

Support and enable process improvementFinance & Accounting, Human Resources, IT, Performance Improvement,

Project Management, Legal, Audit, Training, Facilities


…across all their key departments• Org structure• Integration• Core system(s)• Customer service• Portals• Transparency

Organization • CMS audit table• Policies• Current processes• CMS audit readiness• FWA

Compliance• Processing transactions• Direct enrollment• Reconciliation• Member documents

Enrollment

• AR• APTC & premium

calculation• Payment options and

management• Grace periods

Billing • CSR pre-pay/ reconciliation

• Risk management• Premium proration• 820 and PPR

Finance• EDI inbound & outbound• Reconciliations• Other transactions

EDI

• Vendor portfolio• Performance mgmt and

delegation• Contract reviews

Vendor management• Plans & benefits• CSR admin• Integration with vendors• Extracts to EDGE

System configuration• ACA knowledge• Staff training plans• Documentation reviews• RACI reviews

Staffing and Training

• Network strategy• Adequacy• ECPs• Provider data

Provider network

• Member engagement• Quality and outcomes

reporting• Care gap closure

Risk and medical management• Market assessment• Product portfolio

development• Sales and channel

development

Product sales and marketing


Change Healthcare Consulting’s national footprint

CHC Client States


Active participation in industry groups• Health Care Executive Group

(HCEG)• Health Plan Alliance (HPA)• Association of Community

Affiliated Health Plans (ACAP)• Medicaid Health Plans of

America• National Association of

Medicaid Directors (NAMD)• America’s Health Insurance

Plans (AHIP)• Workgroup for Electronic Data

Interchange (WEDI)

• Texas Provider Sponsored Health Plan Consortium

• California Association of Physician Groups (CAPG)

• California Association of Health Plans (CAHP)

• Wisconsin Association of Health Plans

• Texas Association of Health Plans

• Resource Initiative & Society for Education (RISE)

• Over a dozen other state health plan associations


We work collaboratively with our clients to define new strategies and bring them to life, unlocking the opportunities created by change

Change Healthcare ConsultingThe areas we support

Consulting Focus Areas

Healthcare Consumerism

Value-based Healthcare

Population Health

Government Programs

Process & System

Modernization

Analytics & Insights

Security & Compliance


We help our clients navigate change by offering a full spectrum of consulting services that range from strategy to implementation to continuous improvement.

Change Healthcare ConsultingThe value we bring

We are a ‘roll up our sleeves’ kind of firm - working with you to innovate, solve problems, and improve performance by bringing the right expertise and knowledge to your organization

APPROACH • Thinking toward the future and grounded

in the current reality

• Leveraging broad industry experience that spans payers, providers, and consumers

• Combining innovative thinking with disciplined execution

VALUE PROPOSITION• We earn trust by keeping ethics and

integrity at the core of our practice• Our purpose and passion is to improve

healthcare• We champion innovation, bringing deep

industry knowledge & experience• We are agile and pursue excellence in

process and outcomes• Our approach is collaborative to ensure we

deliver transformative results


Our clients serve the healthcare industry, both public and private, representing payers, providers, consumers.

Prior to joining Change Healthcare Consulting, our consultants have worked in a variety of roles in the healthcare industry and are keenly aware of the constraints posed by limited resources, organizational obstacles, and competitive pressure.

When you work with us, you get more than an engagement defined by a set of deliverables – you get a real relationship with accessible, experienced healthcare experts who are invested in your success.

Change Healthcare Consulting is all about healthcare -- and only healthcare

• Business Strategist

• Enterprise Architect

• Program Director

• Project Manager

• Subject Matter Expert

• Process Engineer

• Business Analyst

• Technical Analyst

TRUSTED ADVISOR

THOUGHT LEADER


Focus Area Trends

Section 2.0


Healthcare consumerism

Market trends

• Increasing member cost share

• Emerging public and private exchange markets

• Growing member expectations

• New and evolving regulatory requirements

• Potential for government audits

Impacts• Need for stronger engagement and

transparency solutions

• Transform operations to create a true retail operating model and deliver the experience demanded by consumers

• Strengthen consumer analytics and marketing capabilities

• Increase focus on regulatory compliance and respond to regulations as they evolve

How we help our clientsMarket intelligence Product developmentStrategic planning

Member engagementConsumer experience optimization

System selection & implementation


Value-based healthcare

Market trends

• Increasing medical and pharmacy costs

• Increasing member cost share

• Desire to better align incentives

• Push for more cost and quality transparency

• New and evolving regulatory requirements

Impacts• Analytics needed to develop optimized

treatment guidelines• Modernized systems required to

handle/automate innovative reimbursement methodologies

• New / enhanced consumer engagement and transparency solutions essential to consumer satisfaction

• Better coordination needed between care team to improve patient experience and outcomes

How we help our clientsMarket assessment & planning Product developmentAdvanced analytics

Quality & price transparencyInnovative provider contracting Care model redesign


Population health

Market trends

• Unsustainable healthcare cost growth

• Increasing prevalence of chronic conditions

• Shift toward value-based payment and risk sharing models

• Growth of high cost treatments and specialty medications

• Digitization of healthcare information

Impacts• Shift toward proactive, targeted intervention

and ongoing patient engagement• Accessible analytics needed to drive

clinically-informed, data-supported decisions and create a 360 degree view of the patient/member

• Heightened focus on transparency, benchmarks, and integrated quality improvement

• Increased provider collaboration and innovative care delivery models

How we help our clientsCare model redesign NCQA accreditationQuality improvement

Health information exchangeClinical integration/interoperability

System selection & implementation


Government programs

Market trends

• Growing government sponsored markets

• Increasing importance of bonus and pay for quality programs

• Ongoing regulatory evolution

• Increasingly punitive audit environment

• Scarcity of resources / expertise in a complex, highly regulated market

Impacts• Increasing competition driven by

attractiveness of government sponsored markets

• Training and operational excellence become more critical to achieve quality scores for outcome based payments

• Audit vulnerabilities are unknown for many plans, creating a significant business risk; mock audits are needed to proactively identify gaps

How we help our clientsMarket Entry Program & system implementationOrganizational development

Compliance trainingMock audit & remediation Stars assessment & improvement


Process & systems modernization

Impacts• Increasing importance of smart build, buy,

and partner decisions, enabled through an understanding of the vendor landscape

• Need for skilled, experienced resources that have both the expertise and tools to implement complex projects on time and within budget

• Trusted partners are needed that work with you to innovate, solve problems, and improve performance - from start to finish

Market trends

• Historical business models and technologies that are not aligned with market needs

• Aging legacy systems and infrastructure

• Evolving regulatory requirements

• Vendor proliferation

• Resource constraints

• Complex, enterprise initiatives

How we help our clientsSystem assessment & optimization Program managementSystem selection & procurement

Enterprise application integrationBusiness & technical analysis Business process transformation

ImplementationsUpgrades Testing & role-based training


Analytics and insights

Impacts

• Organizations are overwhelmed and are not leveraging data as a strategic asset

• Ability to condense meaningful insights that enable decisive transformation is limited by both the quality of data and the native competencies of stakeholders

• Ability to tailor visualizations for stakeholder consumption is critical when transitioning from reporting to analytics

Market trends

• Explosive size and scale of healthcare data converging - clinical, activity/cost, behavioral, and pharmaceutical multivariate sources.

• Huge cost pressures in the context of reform, economic climate, and payment innovation

• Technology advances that facilitate information sharing

• Proliferation of quality measures for providers creates complexity and constraints

How we help our clientsData governance Data warehousingData curation and confidence

Custom visualizationsReport development Actionable insights


IT Risk & Security Services

Impacts

• The increase in ransomware and other cyber attacks is pushing healthcare organizations to rapidly improve lagging security infrastructure

• Preparation to prevent, manage, and mitigate IT security issues will be essential as security breaches will occur

• Data governance must become a core competency for healthcare IT leaders

Market trends

• As healthcare continues to digitize, the number of data breaches continues to rise and stakeholders must balance the increases in data with improvements in IT security

• Targeted and large-scale ransomware attacks have become a normal threat that healthcare organizations must manage

• The rise of connected devices and mobile devices through the Internet of Things creates new vulnerabilities requiring IT security innovation

How we help our clientsIT Security/Risk Evaluations PEN TestingAdvanced Threat Protection

IT Security ManagementVirtual CISO BCDR/Data Governance


Strategic Value

Section 3.0


• Broad Experience: We’ve provided strategic and operational guidance to CEO’s, CIO’s and COO’s in hundreds of health plans, giving us a broad context for health industry trends.

• Relevant Understanding: Our team brings vast experience having served in leadership positions in health organizations before becoming consultants. We too have navigated the challenges companies face with limited resources, competing priorities, market pressures, and complicated internal environments.

• Integrated Knowledge: Our Strategy and Analytics team is tightly integrated with both our organizations technology and operations experts, as well as our clients to provide a balanced perspective and a real world understanding of how strategic shifts impact all parts of an organization.

• Actionable Results: We are an action-oriented team who is driven to ensure that any analysis we produce is directly contextualized within an environment and relevant for immediate planning and execution.

• Customized Solutions: While we leverage our learning and have richly grounded frameworks to guide our efforts, we are not a template-driven organization. Our work is customized to specifically address an organization’s local marketplace and unique capabilities and challenges.

• Five-Star Talent: We are a talent-rich team, bringing you real people, real experience, and real results

Change Healthcare’s strategic value

Deep operational depth and industry experience makes us different from traditional strategy consulting houses…


Example engagements

Assisted a large multi-state Medicaid Plan in successfully applying and entering the D-SNP program (in 3 states) resulting in high star ratings when eligible for their first measurement.

BPO/TPA vendor implementation/replacement for a 315,000-member regional health plan (BPO services included enrollment processing, customer service, claims processing, premium billing, and fulfillment.

Health Insurance Exchange (HIX) planning engagement for a mid-western state where our team performed intensive research and analysis, including primary and secondary research, interviews with key stakeholders, data modeling, and program planning to provide requested data and planning related to the HIX.

Technical lead on the merger of four (4) regional health plans facilitating the consolidation of infrastructures and the migration to a common claims system.

Business process optimization for a 100,000 member California Plan for the purposes of extending the productive life of their legacy core administrative system.

System selection and procurement for a Coordinated Care Organization focused on dual-eligible (Medicaid/Medicare) beneficiaries.


Example engagements (cont.)

Core system selection and subsequent implementation support for a 1.9 million-member health plan (Internally developed system to Facets).

Care Management system procurement and implementation for 400,000-member Regional Health Plan in upstate New York offering Medicare, Medicaid, and commercial benefits via an integrated delivery system.

Network development for a start-up health plan in the Southwestern United States contracting with more than 1,200 physicians, agencies, and facilities over an 8 week period.

IT assessment and road mapping for a specialized healthcare organization that focuses on providing primary, specialty, hospital, and ancillary services to dual-eligible (Medicare/Medicaid) members throughout New England and New York.

Program director for a regional Health Information Exchange (HIE), whose goal was to optimize the workflow of primary care practices using information technology to positively impact the status of 50,000 diabetic patients in this region.

Supported large national BPO to identify opportunities for compliant Medicare process improvement and the implementation of best practices.


Example engagements (cont.)

Core system selection and implementation for a 90,000-member California-based regional health plan providing services to Medi-Cal, Healthy Families, AIM, and Healthy Parents members.

Medicare Mock Audit for large multi-state Medicare Advantage Plan

Care Management system procurement and implementation and strategic assistance in sourcing Case Management for 45,000-member integrated delivery system offering Medicaid and SNP in Southern Texas.

IT assessment and road mapping, core system selection and procurement, and subsequent business and technical support for a core system replacement for a 400,000-member health plan with Commercial, Individual, Medicaid, and Medicare lines of business.

Project/vendor management and configuration guidance to support new Care Management system for a mid-size IPA offering Medicaid and Medicare; also provided interim direction of the Care Management Department and development of medical policies for all lines of business.

As part of a Medicare Program Audit provided Universe Consulting services and advanced analytics to validate all Universes within 2-days resulting in a first pass acceptance by CMS


Soon to be divested by its hospital system parent corporation, this academic hospital and trauma center could no longer rely on IT security services from the corporate office. The organization needed an independent evaluation of IT vulnerabilities and a roadmap to protect itself from growing healthcare information security risks and other threats to its clinical and financial data systems.

Example engagements

Provided risk mitigation services for a regional New England health plan, including management of external investigations and audit, internal audit and monitoring reporting, and compliance infrastructure development. Further provided interim staffing for the vice president of compliance and the privacy officer.

A university hospital was divesting from a large healthcare system and required solutions that would protect and enable their organization to recover data. We provided them with an Enterprise Data Protection plan that included a hybrid cloud storage solution and Backup as a Service solution.

A not for profit hospital needed an independent evaluation of IT vulnerabilities and a roadmap to protect itself from IT security risks and other threats to its clinical and financial data systems


Q&A

Section 4.0


Thank you!

David V. GallegosSVP, Consulting Services

Change Healthcare [email protected]

Phone: 954.616.7862

Documents

Change Healthcare 2017 - Health Plan Alliance · AI / Machine Learning. Cloud. Mobility. Internet of Things. Genomics. Imaging. ... to innovate and solve your biggest challenges