Is the Era of the Traditional Health Insurer Dead?
Becker’s Hospital Review
Annual Meeting
Last updat ed: Eric Dahlberg 4/6/16
Is the Era of the Traditional Insurer Dead?
“There's a big difference between mostly dead and
all dead. Mostly dead is slightly alive.”
What does a “Traditional Health Insurer” do?
Traditional Health Insurer
Collect premiums.
Adjudicate and pay claims.
Contract with providers.
Set and administer benefits and cost-sharing.
Take on and manage risk.
Transition to “value” accelerating Movement away from FFS underway
Target percentage of Medicare FFS
payments linked to quality and alternative payment models
4
2016
All Medicare FFS
85%
30%
2018
All Medicare FFS
90%
50%
All Medicare FFS
FFS linked to quality
Alternative payment models
Sources: Medicare: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html Commercial: http://www.hcttf.org/
Medicare leading the charge…
… with commercial market following suit.
Pledge of the
Health Care Transformation Task Force
75% Portion of business to be in
“Value” arrangements by 2020
• Includes some of the nation’s largest
payers and health systems.
• Pledge focuses on implementation of “Triple Aim”(better health, better
care and lower costs).
Changing payer mix More Medicaid patients may impact performance
5
More providers seeing more
Medicaid patients1
13%
of providers accepted
Medicaid patients for the
first time in 2014
But 2016 Medicaid payers’ performance
lagging2
Sources: 1. athenaResearch / 2. 2016 PayerView analysis
94.8%
93.2%
96.6%
88.7%
Blues Commercial Medicare Medicaid
FPR by Payer Type, 2016
Changing players Payers consolidating, adding technology capabilities
6 Sources: (top graphic) The Wall Street Journal, http://www.wsj.com/articles/anthem-agrees-to-buy-cigna-for-48-billion-1437732331 (Bottom graphics): Oliv er Wyman, http://issuu.com/oliverwymangroup/docs/oliver_wyman_ahip_vertical_integrat
• And back to the future –
payers and providers are
dipping their toes in the
waters of narrowed
networks and vertical consolidation
• Lots of industry thinking on
what’s fueling ongoing
merger and consolidation
activity: pursuit of
economies of scale, market share, risk mitigation as
population health takes off?
1. Source: Kaiser/HRET Survey of Employer Sponsored Health Benefits, 2006-2015 2. Source: AHIP 2015 Census of Health Savings Account (HSA) - High Deductible Health Plans (HDHP)
More cost sharing Rising deductibles in employer-sponsored plans fueling HSA growth
19.7M
Americans enrolled in
HSA/HDHP’s
up 146% since 2009
$1,318
Average employee deductible
up 60% since 2009
Deductibles steadily rising…1
… and HAS/HDHP enrollment skyrocketing1
8
Retail and urgent care clinics
Marketplace reacting Consumers prioritizing access & convenience
Telehealth
The organization makes every effort to honor its commitments
6 5
6 4
5 6
5 4
4 9
4 7
4 4
This organization is accurate & honest in representing itself & its intentions
6 4
6 2
5 6
5 4
5 1
4 9
4 2
N A T I O N A L H E A L T H S Y S T E M E X E C U T I V E P E R S P E C T I V E
62.7 /100
59 /100
54.8 /100
51.3 /100
46.9 /100
40.5 /100
NOT SO MUCH
Do health systems trust health plans?
This organization balances its interests with ours & doesn’t routinely take advantage of us
5 9
5 2
5 1
4 5
4 4
4 2
3 5
2015 PAYOR TRUST
INDEX
SM
NOT SO MUCH
Do physicians trust health plans? 58.6
/100
60.5 /100
58.2 /100
56.5 /100
57.6 /100
57.1 /100
2015 PAYOR TRUST
INDEX
SM
N A T I O N A L P H Y S I C I A N P E R S P E C T I V E
Which of the three statements best describes the six largest national health insurance companies (Cigna, United, Aetna,
Anthem, Humana, and state BlueCross plans)?
When it comes to ethical behaviors, health plan employees rate their competitors worse than Wall Street firms rate theirs.
N A T I O N A L H E A L T H P L A N E M P L O Y E E P E R S P E C T I V E
75.1%
Health Plan Employees Payor Trust Index
FEEL SOME COMPETITORS HAVE ENGAGED IN UNETHICAL BEHAVIOR
57%
TRUST THEIR EMPLOYER, BUT FEEL THE INDUSTRY HASN’T CHANGED FOR THE BETTER IN THE PAST FIVE YEARS
65%
2015 PAYOR TRUST
INDEX
SM
PayerView 2016 Full results coming May 10th
12
Blues Commercial payers
Medicaid payers Medicare payers
• At the forefront of transition to value.
• Strong performers across the
board again this year.
• Best practices, refined processes yield strong results.
• Top scores on key metrics like
Days in Accounts Receivable, Denial Rate.
• Despite unique challenges, these payers score best on
Provider Collection Burden.
• But - continued expansion may strain future performance.
• Standardized claims adjudication systems and rules
drive top performance on First-
Pass Resolution Rate, ERA Transparency.
How to respond? How do payers and providers respond to these changes and
challenges?
Payer
Priorities
Provider
Priorities
In this evolving healthcare marketplace, collaboration
is essential for success.
Payers and providers can effectively tackle today’s challenges by working with one another and with partners to:
Transition to “value”: Plug in to clinical data sharing and report ing capabilit ies to manage risk.
Changing payer mix: Work with industry partners to develop effective administrat ive processes.
Market consolidation: Strive to smooth transit ions to the new platforms and technologies that consolidation activity may spur.
More cost-sharing: Improve transactions to provide accurate eligibility, patient liability, pre-determination, and coverage information at ToS.
Focus on access/convenience: Joint ly develop the processes and systems necessary to support new models of care delivery like telehealth and beyond.
To learn more about harnessing the power of athenahealth’s network to drive insights and tackle the
challenges of today’s evolving healthcare marketplace, visit: ATHENAHEALTH.COM/PAYERVIEW
Questions