Thursday, March 17, 2011

#WHCHPI Health Plan Innovation Conference kicks off, Keynote by Martin Graf of LEK

Today I will be blogging from the World Health Care Congress Health Plan Innovation Conference. Today (March 17th) the conference kicks off.
This is the third annual conference and the organizer is Bridget Kotelly.

The program can be found here:
8:00 am -
8:15 am
Molly Goins-Cox
Head, Member Experience
Aetna, Inc. 

 View Biography

Mohan Nair
Chief Innovation Officer
The Regence Group 

 View Biography

Themes: Hyper Connectivity and Consumer Engagement.

Mohan: The winners will be those that master the unknown "unknowns."

Keep your core identity. Don't lose your way as you navigate the expected crises.

Keynote Address: 

The New Quality Equation in Health Care – ACOs, Medicare STAR Ratings, Exchange Implementation – What Does it all Mean?
A ‘beyond the basic’ evaluation of the impacts of reform mandates on various sectors of the health plan marketplace. Understand key impacts and evaluate where there is opportunity (and necessity) to innovate in order to stay in business and to profit in the new health care economy.
  • Accountable Care Organizations (ACOs) – Where does the plan fit in?
  • Medicare Advantage – Innovations necessary to survive
Martin Graf
Vice President
L.E.K. Consulting 

 View Biography

A mile wide and a foot deep....

The evolving health care landscape
Accountable Care Organizations
Medicare Star Ratings
Health Insurance Exchanges
Wiring Health Care (EMR/EHRs)


- a lot still playing out.
- wiring health care
- Government spending

Macro Trends:
- Aging population
- Growth of un/under insured
- Skill shortages in health care

Economics of Health care:

- Pay for performance
- cost impact of new technology
- consumer centric models
- retail healthcare
- increased consumer cost share
- spending on health care

Change is driven by Pain or Opportunity. Often the latter - Overwhelming Pain.

Accountable Care Organizations (ACOs) are a response to cost growth, aging population and variations between cost and quality.

Medicare Star Ratings are a response to Medicare Advantage costs
Medicare Advantage members not having better health
Plan accountability

Health Insurance Exchanges:
spur competition, increase access

interoperability and cost efficiency


ACOs are a government intervention. Driving integration and consolidation.

Post reform we expect to see Group Insurance decline as employers pay penalties and push employees in to individual exchanges.
Medicare will expand through "Boomers" but reimbursement rates will drop.
Commercial business shrinks. Individual business grows through purchases on insurance exchanges.  Bad debt drops as more people are covered.

Post reform. We can expect Individual business to be lower margin than existing commercial business.

Health Plan Opportunities with ACOs:

- Administrators for ACOs
- Incentive and Risk Alignment
- Extend wiring for interoperability
- Care models to manage care transitions
- Develop measures to assure that ACOs achieve quality affordable care
- Change perception to consumer embraces coordinated care - wellness incentives, social media etc.

ACO Pilots:
- Humana, Cigna, Blue Shield of CA, UHG, Aetna

Health Plan Opportunities:
- Risk Manager for ACOs
- Turn-key ACO Enabler
- Become the ACO (vertical integration)
- ACO competitor/alternative in the marketplace. (Kaiser, Geisinger and BCBS)

Medicare Star Ratings:
majority of Medicare Advantage Plans don't meet the 4 Star level.

Managing Chronic conditions is not done well by most MA Plans. Expect to see emphasis placed on these under performing areas by CMS.

Managing Chronic conditions needs a drill down to the provider level. [Ed: that speaks to better evidence based processes]

Innovation opportunities:
- Organizational innovations
- Network innovations
- Provider Engagement innovations

we could see networks streamlined as poor performing providers are dropped from the network.
[Ed: how does this play out with the expected scarcity of medical professionals]

Health Insurance Exchanges:

By 2014 19M people expected to buy through Exchanges
$4-5B in IT costs on top of cost of covering these lives.

What to expect:
- More enrollment at lower profitability
- Elimination of Risk Selection (no pre-existing conditions)
- Commoditization of Plan Offerings (Product and Prices and affordable coverage options)

Current Distribution costs: Individual (10-15%), Small Group (5-7%), midsized (1-3%) of premiums.

Need to reduce distribution costs but widen distribution channels: Public and private exchanges. Navigators, Aggregators.

Financial functions become critical. Complex transactions, reconciliation, distribution and flow of funds.

Brand differentiation will happen outside the exchange. 

Plans need to identify the right customers, target them and engage them to manage health costs.

Think about Health Score used for target marketing. 

Wiring Health Care:

- ARRA/HITECH stimulus has been a big kick starter in this area.
- Trend towards single sourced solutions
- Shift towards ambulatory care away from hospitals.
- Reimbursement changes (reductions)
- HIT Vendor consolidation
- Hospital and Provider Consolidation
- Pay For Performance
- ICD10 implementation

Innovation Opportunities:
- Care Delivery Management (Telehealth, Mobile, Medication Administration - eMAR)
- EMR/EHR And Clinical Data Management (Enterprise EMR/EHR, Clinical Data Warehousing, Clinical Decision Support)
- Claims and Revenue Cycle Management (Revenue Cycle Management - spend analysis - workforce management, Asset Management - RFID)

Health Information Exchanges:

- Data aggregation
- Break down silos.

80/20 rule applies (Medco experience in North Carolina in managing Diabetes) 80% of diabetes patients seen by 20% of providers.

$1.6B to be spent by 2015.

- Spread benefits - drive quality based payments tied to HIE use.
- Better care at lower cost - better decision making
- Enable new models - longitudinal records lead to better choreography of care.
- Growing interest in HIE  (Aetna bought Medicity, United bought Axoloti)

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