Yours, Mine, Ours: Provider-Payer Convergence & the Future of Analytics

Transcription

1 Session #23 Yours, Mine, Ours: Provider-Payer Convergence & the Future of Analytics John Moore President & Founder Chilmark Research

2 Objectives & Take-Aways Why Value-based Care & Need for Convergence What Does Convergence Look Like Analytics The Foundational Platform Getting There Looking Ahead

3 Chilmark Research: Our Purpose, Our Values Purpose: Help Organizations Adopt, Deploy and Use IT to Improve the Patient Experience Values: Provide the Highest Quality, Objective Research Be Pragmatic Foster Intellectual Curiosity Contribute to the Social Good

4 Observations Move to Value-Based Care (VBC) Accelerating Providers ill-prepared to assume risk and shift to a quality driven business model Early Experiments with At-Risk Arrangements Inconclusive ACOs struggle to invest in requisite organizational, process and technology strategies Provider/Payer Relationships Increasing Multiple financial and clinical models prevail, no clear winners Emerging Provider/Payer Market Requires New Business & Technology Strategies

5 Commercials/Employers Driving ACO Growth By 2020: - Employer Supported ACOs will Double to Nearly 50% - 75% of Aetna s Spend will be in VBC Contracts Contracts Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q Total Commercial Medicare Medicaid SOURCE: Leavitt Partners Center for Accountable Care Intelligence

6 Providers Are Missing VBC Goals SOURCE: McKesson Corporation 2016 Journey to Value: The State of Value Based Reimbursement in 2016

7 Payvider Strategy Is Collapsing Payvider Success is Exceedingly Rare Successes are Outliers 37 Payviders Established Since 2010* Only 11% are Profitable Folded 16% Profitable 11% Casualties Abound Mercy Health, OH Northwell, NY Profitable Losing $$$ Folded Losing $$$ 73% *SOURCE: Analysis of Integrated Delivery Systems and New Provider-Sponsored Health Plans, June 2017, RWJF

8 Three Points of Failure Region-Specific Not Scalable - ~250K members typically needed Not Competitive with National Plans - Large, multi-state employers Requisite Skills Actuarial, Risk Modeling, Contracts Culture Animosity Between Administrators & Clinical Health Plan Success Not Always Aligned with Provider Success

9 Overlap, Misalignment and Gaps Persist

10 Several Paths to Convergence Examples: Humana/Concentra Anthem/CareMore Optum/Monarch Health Payer Acquired Physician Organizations Provider Sponsored or Owned Health Plans Examples: Kaiser Detroit Medical Center Geisinger Memorial Hermann UPMC Potential for the over 400 IDNs in the US Examples: Anthem/Aurora Aetna/Innova Health Bright Health/Centura Joint Ventures Employer Sponsored Plans and Services Examples: Iora WeCare

11 Poll Question #1 Which of the following is the most likely route to convergence for your organization? a) Payer-acquired physician organization b) Joint venture c) Provider-sponsored or -owned health plan d) Direct contract; employer-sponsored plans and services e) Unsure or not applicable

12 Growth Is in Co-Branded Relationships SOURCE: Hospital Networks: Perspective from Three Years of Exchanges, 2016,McKinsey Center for U.S. Health System Reform

13 Objective: Provide a Health Service Respond to Rising Consumerism CDHP = Greater Out of Pocket Expense - Digital Health/Engagement - Higher Quality, Better Value Differentiate in Their Market Be All-in-One Service - Employers, Consumers, etc. Deliver Highest Value

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15 Silos Defeat Move to Consumer Centric Model

16 Biz, Ops, Tech, Data Synchronicity Required $ Strategy & Objectives Clinical, Operational & Financial Objectives, KPIs, Metrics for Success Enabling Processes Care Coordination & Mgmt, Eligibility, Prior Auth, Risk Mgmt, Engagement Processes Applications Data Governance Common, Shared Data Platform Applications Registries, Risk Analysis, Clinical Guidelines, Reports, Actionable Guidelines Data Governance Access, SSO, HIPAA, Consent Mgmt Data Platform Shared Data Platform, Single Source of Truth

17 Convergence Demands Data Transparency Data Transparency FFS P4P ACO JV Transactional Strategic

18 Convergence DOA without Data Provider Clinical Payer Claims Labs Processes PBM Financial Applications Data Governance Financial Common, Shared Data Platform

19 Single Version of Truth Drives Strategy Common Shared Data Platform Enables Ability to Optimize Prior Auth Facilitate Care & Utilization Management Deliver Deeper Insights to Point of Care - Care gaps, med lists (and fills), visits, evidence-based care pathways, visits, etc. Deeper Consumer/Patient Engagement - Longitudinal record Reduce Redundancies

20 The Chasm FFS Remains Primary Source of Revenue Value-based Care Revenue Under 10% Parallels to Retail Online ~10% of Retail Sales - Amazon Purchase of Whole Foods VBC & Requires Restructuring, Resources, Executive Commitment Cultural Realignment FFS

21 Poll Question #2 What percentage of your organization s revenue comes from a value-based contract? 1) Less than 10% 2) 10-25% 3) 26-40% 4) Greater than 40% 5) Unsure or not applicable

22 Trust?!

23 Creating a Data Platform Strategy for Convergence Technology NOT a Limiting Factor 2012 Only 20% of Leading Vendors Supported both Claims and Clinical Today All Leading Vendors Support Claims and Clinical Not an IT Project, Not an Analytics Project Assemble Strategic, Multi-disciplinary Team - All Stakeholders Reach Consensus on Core Data Elements Types & Sources Timeliness Quality Purpose Access

24 Top Challenge: Governance Its Policy, People, Privacy, Security & Trust All Soft Issues Requires Diplomatic Leadership Strength Resolve Humor Respect

25 Meeting Partner(s) Where They Are Convergence Not for Everyone Market Dynamics Matter - Parity Critical Align Incentives To Shared Economic Outcomes Clinical Transformation - Short-term Hit => Long-term Gain Clear Metrics to Drive Continuous Improvement Performance, KPIs, Clinical, Process - Common Shared Data Platform

26 Looking Ahead Customer Centricity Key Differentiator Comprehensive & Complete Health Service - Know Me, Care for Me, Serve Me, Show Me Best Practices Non-Existent Fragmentation Reigns - Localization Paramount Soft Issues Define Success Inclusive Respect Trust

27 Takeaways/Recommendations Get Internal House in Order Governance, Quality, Sources Understand Tolerance for Risk - Ready to Invest for Long-term? Pay Attention to Early Innovators Model Structure - JV, Shared Risk, Bundles & Post-acute - Incentives, Alignment, Success Sustained Executive Leadership True Commitment from All Parties?

28 Closing Thoughts Migration to VBC will Accelerate Few, Truly Ready Today Consumer Centricity Core to Success Engage, Understand, Serve Success Contingent on Comprehensive Data VBC Necessitates a Data-Driven Enterprise

29 We are only as good as the information we have delivered at the point of decision. - Dr. David Blumenthal Former Director ONC

30 Thank You