Over the past three issues of HealthLeaders magazine, I wrote a three-part series looking at the health plan of 2020. I examined possible payment models, benefit designs, and member relationships in 10 years.
I started writing the series when health reform looked iffy at best, but with or without health reform, insurers need to prepare for a very different world by 2020.
Healthcare costs and the employer-based health insurance market are not sustainable in the long run. Forcing members to shoulder more of the costs isn't going to work.
Eventually, we will reach a tipping point in which it will no longer make economic sense to buy health insurance and health insurers need to make sure they don't reach that tipping point.
Here are five changes health insurers need to make now in order to survive in 10 years:
1. Invest in technology. A no-brainer, right? Some insurers haven't realized this yet and are falling behind. With meaningful use an important issue for providers, insurers need to help them implement technology, such as EHRs and online portals. Insurers can benefit by creating computer networks that allow providers to have information about their patients, while also allowing the insurer with more clinical information from the provider. Insurers should also invest in self-management tools that are targeted to the individual and allows the person to improve his or her health with assistance—if needed—from a call center nurse or physician depending on health status.
2. Hire consumer experts. The individual market is one of the few growth areas for health insurers and this will only continue as most Americans will be required to have health insurance. The market is changing and insurers will have to switch focus. No longer will they be able to deal mostly with employers and benefits people. They will have to reach down to the individual level. As a way to get a better view of consumers, insurers should explore other consumer markets to see how they connect with customers. Step one is hiring some of those experts to help implement new strategies.
3. Design benefits that reward value and make sure you have doc buy-in. As I wrote in part two of the series, innovative health insurers and employers understand they cannot continue to pass more costs onto the individual. One other avenue is to create tiered health plans that reimburse doctors based on type of care and its value. Health insurers and employers should not design these plans in a vacuum. They need to get physician buy-in, which means having doctors help design the programs.
4. Design benefits for the individual. Rather than simply creating a handful of plans, such as a PPO, HMO, and POS, UnitedHealthcare recently created a health plan designed specifically for diabetics and prediabetics. Using aspects of value-based insurance design, the insurer is lowering or removing copays for value-based services and medications for members in those plans. As everything becomes more individualized, it only makes sense that health insurers will create plans that focus on the member.
5. Collaborate with providers to get more data. Claims data serves its purpose, but the holy grail for health insurers is tapping into providers' clinical data. This is beginning to happen, but providers understandably are leery about how that information will be used. As quality contracts become more common, health insurers will have more access to clinical information, but the key is how they use it. This information should not be used strictly as a way to reimburse (or not reimburse) for providing a certain level of quality. Insurers need to also create processes and analytics so the information can be used to help care management programs.
Having the clinical and claims data together, health insurers will have a more-rounded view of the patient/member. So, rather than waiting a month or two or three for claims information that may or may not have enough data, insurers would have more specific information about the visit. They must also understand they have to share claims data and pay more promptly to providers through better technology, such as real-time claims adjudication.
Insurers are trying to figure out how to do business in a post-health reform world and there are no guarantees. But by taking these five steps insurers will be prepared for whatever the future has in store for them.
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No matter which sports team you follow, you have most likely seen health insurance advertisement in your favorite stadium, ballpark, or arena.
It could be the Highmark ads on the boards in the Pittsburgh Penguins' Mellon Arena, the Kaiser Permanente ads on the outfield walls at Dodger Stadium, or the Emblem Health ads on the upper decks of the New York Mets' Citi Field.
Expect this kind of health insurer outreach even more over the next decade.
Health insurers, healthcare organizations, and health groups know there is an audience in sports. Major League Baseball has spotlighted health causes, such as breast cancer and colon cancer. It's become a Mother's Day tradition for batters to swing pink bats to raise breast cancer awareness.
Baseball teams have opened up areas in their stadiums to allow health organizations an avenue to promote their messages. Now, health insurers are also a regular fixture at arenas and stadiums.
Blue Cross and Blue Shield of Minnesota has placed advertising in the Minnesota Twins' new Target Field, branded two first aid stations, and the Twins are airing scoreboard videos that spotlight people improving their health. They will publicize Blue Cross' "do" campaign, which encourages Minnesota residents to eat better and exercise and asks Minnesotans to share their stories of physical fitness.
BCBS of MN knows that Target Field is the hottest ticket in town and where better to promote their programs than the Twins' new ballpark.
The Massachusetts Connector, which oversees the state's health reform project, also hooked itself onto a hot brand when it partnered with the Boston Red Sox to promote the Connector and the individual mandate that requires nearly all Massachusetts residents buy health insurance. The Red Sox even hosted Health Connector Days at Fenway Park and the NESN broadcast team hosted Connector officials in the booth.
The result: more than 97 % of Massachusetts residents are insured. The Red Sox were not the only reason people bought coverage (the penalty was likely the biggest driver), but they were part of a public outreach campaign.
In the time leading up to the federal health reform's individual mandate kicking in, expect insurers to use local sports teams even more to get out the word about their offerings. With people needing individual insurance, it will be critical for health insurers to devote more time and effort in marketing their plans.
Who better to promote health insurance to Texans than the Dallas Cowboys or to Missourians than the St. Louis Cardinals? These are trusted, beloved brands, and health insurers will use these franchises to disseminate their messages—while also flooding the sports teams' coffers with cash.
The individual health insurance market is one of the few growth areas for insurers—and health reform will provide even more opportunity and potential new members. Insurer advertising and sponsorships will be everywhere over the next four years. The insurers whose advertising and outreach connect with sports fans quickly and with an engaging message will be the ones who hit homeruns in the post-health reform world.
—Les Masterson
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Health insurance companies are rightfully criticized when they make mistakes, but there are times when an insurer creates programs that could help improve the health status of its members.
That's the case in four states where UnitedHealth Group launched two diabetes programs with help from YMCA of the USA and Walgreens last week that the companies hope will prevent and control diabetes, pre-diabetes, and obesity.
UnitedHealth Group has been a leader in designing disease-specific programs, most notably its Diabetes Health Plan. As someone whose father died from complications of diabetes, I know firsthand what the disease can do to a person and how it leads to further complications. As a child and young adult, I watched my father waste away as diabetes led to heart attacks and kidney failure. Ultimately, he spent all but one week of the last 18 months of his life in a hospital.
My father passed along his blue eyes and love of baseball and animals to me, but I also got his predisposition to diabetes. The last time my blood sugar was tested, about a year ago, I was on the cusp of pre-diabetes so there is a legitimate chance that I too will have to live with diabetes one day. I do not look forward to a possible future of insulin shots, diabetes complications, and diet restrictions, but that's the hand I, and millions of other Americans, have been dealt.
UnitedHealth Group's programs are the Diabetes Prevention Program and the Diabetes Control Program. The Diabetes Prevention Program is designed to help those who are at-risk of diabetes prevent the disease through learning healthy eating strategies, increased activity, and other lifestyle changes. YMCA of the USA will partner with UnitedHealth to offer the prevention program. Trained lifestyle coaches will conduct behavior-modification programs over 16 sessions. After the core sessions, participants will meet monthly for added support.
UnitedHealth said the prevention program is based on the U.S. Diabetes Prevention Program that was funded by the NIH and CDC. That program found that "lifestyle changes and modest weight reduction" can prevent or delay the onset of the disease.
The Diabetes Control Program, meanwhile, will help those already with diabetes learn how to better control their illness through education and support from trained Walgreens pharmacists. The pharmacists will teach diabetics using NIH and CDC guidelines about reducing risk factors and improving health.
UnitedHealth will provide the services free of charge to plan participants enrolled in employer-based health insurance plans. The large insurer said this is the first time that a U.S. health plan will pay for all the costs for evidence-based diabetes prevention and control programs.
"For the first time in the U.S., health plans and employers will offer real-time reimbursement to community-based healthcare providers and pay for services not historically covered," said Tom Beauregard, executive vice president of UnitedHealth Group. "The pilot data showed that paying for these services works—people get and stay healthier, leading to dramatically lower healthcare costs for employers and the healthcare system."
Not only will the trainers and pharmacists get paid for their work, but will get higher payments for helping participants exceeding weight loss goals. UnitedHealth is also providing swipe cards so Walgreens will process payments at the point of service and get paid within 24 hours.
The programs will start in six markets in four states: Cincinnati, Columbus, and Dayton, OH; Indianapolis; Phoenix; and Minneapolis-St. Paul. The collaboration hopes to roll out the programs nationally in the next three years.
This project brings together powerful entities, but one key missing ingredient is the primary care physician. If this program is to become a success, including PCPs will be critical. This will mean regular communications among the insurer, pharmacist, and physician so they all know the medications, treatments, and test results for the patient.
Having a pro-active, properly trained pharmacist to help an individual improve his or her health status is a positive step, but only if it's done with physician involvement.
That being said, there is reason for hope. Creating a benefit design that removes cost barriers has been shown to improve patient medication and treatment adherence. Focusing on diabetes is the right start because the disease can lead to other ailments, but these projects hopefully will lead to other specific disease plans, such as heart disease and asthma.
These are the kinds of innovations health insurers and employers will need to try in order to remove cost barriers and lower long-range health costs. That's beneficial on a systemwide level, but let's also remember the personal reasons for these kinds of programs—they may help diabetics and prediabetics live longer lives and cause fewer young men to lose their fathers too soon.
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Medical loss ratio restrictions may not be the best way to reduce health costs, but federal and state lawmakers are increasingly turning to legislating MLR as a way to contain expenses.
Forcing insurers to maintain a certain spending percentage on medical care is an easy win and on the surface sounds like a fair plan. However, it's not that simple.
For instance, individual insurance plans usually have to invest more on marketing, consumer outreach, and customer service than group plans so requiring both plans to comply with the same rules isn't fair.
Nevertheless, that's the world health insurers are living in and the recently approved health reform package will require some plans to spend 85% directly on patient care. This will have many insurers scrambling to find ways to reduce overhead costs.
"They are going to have to really put more effort around what that 15% looks like on the administrative side so they can maintain some level of margin," says Ned Moore, CEO of Portico Systems, an Blue Bell, PA-based Integrated Provider Management solutions company.
Here are three ways insurers can look to reduce overhead costs and get into line with the new MLR requirements:
Know your MLR. Before understanding the issue and knowing how to respond, health insurers need to compute their plans' MLR. There is great MLR variations depending on plan, region, and state regulations so all insurers can't expect that they are in compliance with the 85% MLR.
If they are within a couple percentage points, a review of processes and streamlining systems could help reach the 85% goal. However, those a long way off will have to take a much larger approach.
"If I'm running a decent margin and my administrative cost structure is built around 83% MLR for a Medicaid patient, I now have to figure out how I am going to get into that 85% range while my membership opportunity and growth will come from those types of members. That will put more pressure on how to wring out some administrative costs so I can maintain reasonable margin levels, while also seeing the increased opportunity around membership with millions of members coming into these plans over the next few years," says Moore.
Review and improve workflow. Health plans need to review their workflow and find what is labor intensive and how care can be provided cheaper. Automation can come in the form of administrative simplification, such as real-time claims adjudication that could lead to lower personnel costs, better efficiencies, and better relations with providers, who will appreciate knowing immediately which claims are being rejected.
Simplify provider contracts. Brenda Snow, executive vice president of strategic planning at Firstsource Solutions Limited, a business outsourcing company, says healthcare under managed care got very complex as health plans implemented carve outs and tiering, which added costs.
By standardizing provider contracts and automating the system, health insurers could reduce labor costs associated with compiling and differentiating numerous provider contracts.
Moore says he's seeing plenty of insurers reviewing their provider contracts and managing provider networks.
"We're seeing a lot of innovative plans looking at the provider support structure and trying to figure out how can we maintain our competitive advantage without dramatically increasing our cost structure in the process," says Moore.
Rather than simply looking for one magic bullet, health insurers need to first understand the issue and then realize that reducing administrative costs is more than just outsourcing jobs and responsibilities.
"It's not just outsourcing, but improvements, automation, and a level of detail should be done. Don't think a single solution will solve it. Insurers need to look at a number of different ways to glean these savings," says Snow.
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CMS issued an immediate sanction notice to Aetna after the insurer "continued to improperly administer the Medicare drug benefit in the plan's national standalone prescription drug plan and its 25 Medicare Advantage prescription drug contracts," according to CMS.
The immediate sanction prevents Aetna from marketing to and enrolling new beneficiaries effective April 21. The sanction will remain in place until Aetna "demonstrates to CMS that it has corrected its deficiencies and they are not likely to recur."
There are about 1 million Medicare Advantage and Part D members enrolled in Aetna plans, but CMS said the sanction will not impact them.
CMS said the problems were raised by members and physicians and if they are not corrected, the federal government may levy fines or terminate Aetna's contract with Medicare.
The specific issues raised by CMS are:
"Failing to meet Medicare's transition requirements by ensuring that existing beneficiaries were able to continue to receive drugs they had been receiving in 2009 that were not on the plans' formularies in 2010.
"Improperly processing coverage determinations and expedited appeal requests in cases where delays would jeopardize the life or health of the enrollee.
"Applying prior authorization and step therapy drug requirements that had not been approved by Medicare.
"Failing to take timely and proper steps to ensure that enrollees are eligible for the Part D low-income subsidy."
After the announcement, Aetna released a statement that said the company is cooperating with CMS and working to resolve the issues.
"Compliance problems are unacceptable to Aetna; the issues raised to us by CMS have our utmost attention," said Aetna President Mark T. Bertolini. "Aetna takes our obligations to our Medicare beneficiaries seriously, and our priority is to help ensure they have access to high-quality care, excellent service, and needed medications. We are working with CMS to resolve these matters, and we also will be doing proactive outreach to impacted members to resolve these issues."
McKesson Corporation announced Thursday that it has signed a definitive agreement to sell its McKesson Asia Pacific (MAP) business to Medibank Private Ltd., an Australian health services provider and insurer that covers more than 3.4 million people.
MAP, which was founded in 1995 and acquired by McKesson in 2000, is a provider of phone- and Web-based healthcare services and focuses on telephone triage, health and wellness advice, chronic disease management, and mental health services in Australia and New Zealand. Medibank is a current customer of MAP.
McKesson, a healthcare services and information technology giant, said the deal resulted from an unsolicited offer from Medibank. The San Francisco-based company plans to continue operating in the Asia Pacific region through the company's other offerings.
"This was a unique opportunity to join two highly successful partners," said Emad Rizk, MD, president, McKesson Health Solutions. "McKesson Asia Pacific has delivered telephonic health management programs in Australia and New Zealand serving both the national and state governments of those countries over the past five years. We have also served Medibank's members with chronic care services and are excited about Medibank's potential to leverage the MAP business to provide even more of their members with access to high quality, convenient healthcare services."
The deal, which will make McKesson Asia Pacific a wholly-owned subsidiary of Medibank's Health Services Australia Pty Limited, is expected to close in the second quarter of 2010 after regulatory review in Australia. Terms of the sale were not disclosed.
When healthcare stakeholders and officials talk about reducing health costs, they usually look to three areas: providers, health insurers, and patients. Another healthcare stakeholder—the employer—has a huge influence, but it's often an afterthought in the public debate.
As part of a three-part series profiling the health plan of 2020 that I wrote for HealthLeaders magazine, I tackled how insurers and employers need to become more innovative in terms of benefit design.
Some employers are already leaders in this area, most notably Caterpillar and Marriott. These leaders are already investing in benefit design that is based on value and quality and looks to reduce overutilization of services and medications that are not top value.
While other employers keep dumping more premiums and copays onto the backs of their employees, other leaders are finding new ways to avoid a future of $10,000 deductibles.
The average health plan deductible is now about $5,000—and that's not just consumer-directed health plans. That includes PPOs and HMOs.
In my magazine article, I profiled Jack Friedman and Providence Health Plans in Beaverton, OR. Friedman, who is the company's CEO, has been a leader in bringing value to benefit design.
His health plan, which serves more than 380,000 people in Oregon and southwest Washington, is working with employers to create a three-tiered system that takes into account value, prevention, chronic illness care, and overutilization of services:
Tier 1: No copay or low copay for ambulatory care for those with chronic conditions, as well as preventive services to help people from becoming chronically ill.
Tier 2: This would resemble the current healthcare system and would ask consumers to chip in 20% coinsurance for normal healthcare.
Tier 3: This tier would require consumers to pay more out of pocket for services that do not provide a high clinical value.
As you might expect, healthcare stakeholders—including patients, doctors, employers, and health plans—like the first two tiers. Prevention and chronic care would be covered at 100% so there are no cost barriers to that care and consumers in Tier 2 would have a stake in their day-to-day healthcare.
Stakeholders fret about the third tier because:
Doctors worry how insurers may define "high clinical value."
Patients don't like the idea of insurance not covering some services that the individual believes are valuable.
Employers don't want an angry workforce demanding to know why their insurer refuses to pay for services that the individual may find valuable, but the insurer (and research) finds is not worth the money.
Oregon already has experience in this model. The state's Medicaid program has had a similar tiering design in place for 20 years, which Friedman says has controlled costs. The state found the three-tiered program costs about 10% less than the traditional PPO benefit design.
The leaders in benefit design have already stepped forward to test out innovation programs. Innovation usually comes from the private sector and then public programs try it later. (One only needs to see that value-based insurance design—also known as VBID—is part of health reform though leading employers have incorporated VBID into benefit design for almost five years.)
Though the private sector often leads, there are still plenty of employers not willing to test out new programs. Instead, they often look for more arcane ways to save on healthcare, such as shifting more costs onto the individual.
But that way of thinking is not sustainable.
Health insurers should help educate employers that trying benefit designs that reward value is the way to go. Yes, making these changes require employee education and will likely cause some employee pushback, but in the long run adding value is a possible way to avoid the $10,000 deductible.
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In response to the growing health insurance consumer market, Highmark Inc., plans to open four more health insurance stores in Pennsylvania.
Highmark, an independent Blue Cross Blue Shield plan with 4.8 million members, expects to open three Highmark Direct stores in the Pittsburgh area, as well as one in Harrisburg.
The insurer opened its first Highmark Direct in Pittsburgh's McKnight Seibert Shopping Center and in Mechanicsburg's Silver Spring Square in March 2009. Highmark said those first two stores have seen a total of more than 20,000 visitors.
"When we opened our first two stores last year, our goal was to provide Pennsylvanians with access to the information they need to make informed decisions about health insurance," Kenneth R. Melani, MD, Highmark Inc., president and CEO, said in a statement. "The stores have exceeded our expectations during the first year of operation. By opening four new facilities, our Highmark Direct stores will reach many more people in our community."
The stores offer consumers one-on-one time with a Highmark health insurance specialist to discuss health insurance options. Highmark Direct stores sell plans to individuals, seniors, and small businesses. The insurer also recently added United Concordia Dental to its offerings.
Highmark will add 16 employers to staff the new store locations.
"As consumers become more involved in buying health insurance, we want to help them better understand their options," said Steven Nelson, Highmark senior vice president of corporate marketing and consumerism. "We've heard from customers that they want one-on-one support. The stores have helped them to better understand what they are purchasing and make more informed decisions about their health."
Nelson said health reform sparks greater consumer involvement in healthcare decisions, which fits well with the Highmark Direct stores.
"The Highmark Direct stores represent an important community resource for consumers as more and more individuals will be responsible for purchasing health insurance on their own."
The fourth annual study found that member satisfaction averages dropped from 712 on a 1,000-point scale in 2009 to 701 this year. J.D. Power and Associates measures health plan satisfaction of 133 health plans in 17 U.S. regions in seven areas: coverage and benefits, provider choice, information and communication, claims processing, statements, customer service, and approval process.
J.D. Power and Associates reported that member satisfaction dropped in all areas except customer service, which remained flat.
"The significant decline in overall satisfaction is partially driven by a lack of members' understand of their plans' coverage and benefits and how to successfully access them," said Jim Dougherty, director of J.D. Power and Associates' healthcare practice. "Understanding alone does not explain member satisfaction, although it may help to mitigate other problems with the member experience. While satisfaction with many plans has declined this year, satisfaction decreases are less severe for those plans able to substantially increase member understanding."
According to J.D. Power and Associates, members in Pennsylvania, Michigan, and New England remained the most satisfied with their health plan experience though the satisfaction scores have dropped in those regions this year too.
Dougherty said health plans can improve member satisfaction by providing new and existing members with a better understanding of their coverage and "proactively" communicating with members about impending changes in benefits, physician or hospital networks or costs. Dougherty added that plans should build relationships through "member education; communication; and reliable, consistent delivery of health insurance services."
About 60% of members surveyed said they do not fully understand their plans. That's an issue for insurers because having members better understand their benefits usually lead to more loyal and "better advocates for the health plan," according to J.D. Power and Associates.
In fact, members with the highest satisfaction levels are seven times more likely to remain with their insurer and 13 times more likely to recommend their insurer to others when compared to members with the lowest satisfaction levels.
Health insurance companies were largely winners in health reform as millions of new customers will soon flood their care pools.
Sure, there will be those with pre-existing conditions and people who have gone years without preventive care because they have not had insurance. But reform will also mean many of the so-called "young invincibles" will buy insurance rather than face a fine. Yes, the fines are paltry and it won't push all young, healthy people into insurance, but it should move most of them into insurance and they will help pay for the infusion of sicker people who insurers will have to accept.
That's good news for health insurers.
But there is a segment of health insurance that may get an even bigger boost—Medicaid managed care. Depending on your political slant or place in healthcare, Medicaid managed care is either a cost-effective way to control health costs and create medical homes for Medicaid beneficiaries or it's the privatization of Medicaid.
No matter where you stand on the issue, expect Medicaid managed care expansion. Here are two reasons why:
Cash-strapped states will look to private insurers for help
As part of health reform, the feds will pay in full for newly eligible Medicaid recipients over the next three years. The problem is that Medicaid expansion becomes an unfunded mandate after three years and states, which already have trouble paying for Medicaid, will have to pick up the tab. Faced with their own budget crises, states don't always pay promptly.
One avenue they will likely look: Medicaid managed care. What better solution is there for states, especially those with a conservative bent, than to pass the issue of insuring poor, at-risk residents onto insurers with the belief they can control costs. Hopefully, states will create a framework so insurers maintain a certain level of quality and care coordination. That is just as important as keeping costs under control.
States with Medicaid managed care programs can now receive drug benefits
Health insurance companies, particularly Medicaid managed care companies, received a huge gift in health reform that could lead more states to create Medicaid managed care programs.
Reform will allow states with Medicaid managed care programs to receive drug rebates.
The feds created the Medicaid Drug Rebate Program in 1990, which requires drug manufacturers to enter into an agreement with HHS to offer the rebate to Medicaid state programs. However, until health reform, Medicaid managed care pharmacy programs were not eligible, which meant some states carved out pharmacy from their managed care program so they could take advantage of the rebate.
There are about 550 pharmaceutical companies that participate in the program and until the rebate was expanded to Medicaid managed care, states had a difficult decision: Do they save money and remove pharmacy from their Medicaid managed care programs that are run by private insurers? Or, do they keep pharmacy within private health insurers' Medicaid programs and gain the benefit of better care coordination, and lose out on the rebate?
The failure to integrate immediate pharmacy benefit information because drugs are carved out of Medicaid managed care leaves out an important piece of care coordination. Without having that pharmacy information, health insurers don't know if their members were placed on a particular medication that may signal the need for a disease management program.
Medicaid managed care is one of the few growth areas for health insurers. Forward-thinking health plans have already invested in Medicaid, but health reform will likely interest others to follow suit.
Health reform could boost Medicaid managed care and woo more insurers into the program.
Medicaid managed care is a great opportunity for insurers, but there are pitfalls. As I wrote in December, Medicaid beneficiaries are quite different from the typical group market member. There are housing, transportation, and education issues in Medicaid populations that are not common in the employer-based insurance market. Insurers not used to dealing with these issues will have to implement new programs and outreach efforts.
Health reform will spark Medicaid managed care, but insurers should understand that Medicaid comes with its own unique challenges. If they don't develop population-specific programs, their Medicaid managed care programs will likely fail.
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