claims data utilization & population health management · 3/1/2017 · health management...

CONFIDENTIAL AND PROPRIETARY: This presentation and the information contained herein is confidential and proprietary information of USI Insurance Services, LLC ("USI"). Recipient agrees not to copy, reproduce or distribute this document, in whole or in part, without the prior written consent of USI. Estimates are illustrative given data limitation, may not be cumulative and are subject to change based on carrier underwriting. © 2017 USI Insurance Services. All rights reserved.

Lara Bunn, MS & Wendy Carmichael, Esq. | USI Southwest www.usi.biz

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CLAIMS DATA UTILIZATION & POPULATION HEALTH MANAGEMENT

EMPLOYER WELLNESS ROUNDTABLE

© 2017 USI Insurance Services. All rights reserved. | 2

USI is a preeminent national insurance brokerage and consulting firm with more than 140 local offices connected across the U.S. and a leading market position in all core businesses.

Commercial P&C

Employee Benefits

Personal Risk

Retirement Consulting

Leading middle market broker with ~$1B in U.S. Revenue

Over 100 years of brokerage experience

Six Pennsylvania office locations (including Harrisburg and Carlisle)

Broad and deep knowledge based on the shared expertise and experience of 4,400+ professionals across industry verticals

Over 100,000 clients served across all lines of business with superior account service and targeted solutions

USI Brings National Capabilities & Local Expertise

| 3 © 2017 USI Insurance Services. All rights reserved.

USI ONE™ Employee Benefit Solutions USI’s employee benefit practice is designed to contain cost, promote

regulatory compliance, and deliver superior account service. We focus on seven primary employee benefit service areas.

Pharmacy

Solutions to increase

transparency and minimize

pharmacy costs

Population Health

Management Wellness

design, disease management analysis, and

aligned incentives to

improve health

HR Services

Administration platforms, call centers, and

service calendars to

ease your administrative

burdens

Compliance/ Healthcare

Reform Tools, expert

guidance, and policies to promote

compliance with federal and

state regulations

Underwriting & Analytics

Negotiation & management

to contain plan costs

Care Intervention

Options for members to make more

efficient care decisions without

sacrificing quality

Ancillary Benefits

Competitive marketing

and scoring drives results

for other plan services

A Comprehensive, Holistic View of Your Employee Benefits Plan


Introduction: CEO or CFO perspective EXPENSES FOR A COMPANY COST CONTROL Compensation Cost of goods sold Health-related costs

Employee benefits Workers’ compensation

HEALTHCARE SPEND = ADMIN + (UNIT COST X UNITS CONSUMED)


Healthcare consumption trends Underutilization Physician engagement Preventive visits

Above norms Disease prevalence: high blood pressure,

high cholesterol, and diabetes

Lack of compliance Gaps in care:

Undiagnosed cancers Chronic diseases (diabetes and heart

disease)

BEHAVIORS THAT NEED REFORM

Presenter

Presentation Notes

These are employee behaviors that need to be reformed


Building the case: Standard outcomes

6

“Employees will adopt healthier lifestyle habits, reduce risk, improve productivity, and save you lots of money.” -Standard Broker Promise

© 2017 USI Insurance Services. All rights reserved. © 2017 USI Insurance Services. All rights reserved.

How to Understand and Track Health Insurance Data

Data Drives Decisions

Medical Claims Rx Claims Eligibility File(s) Health Risk Forms

Intelligence Risk profiling, benchmarks, use trends, gaps in care, predictive modeling

Tools Standard/ad hoc reporting, user interface, drill downs, claims re-pricing

Data Aggregation Flexible warehousing with robust quality control

Program Design Guiding your efforts to engage the right people, at the right time, for the right reasons

Vendor Selection & Management Using data to find opportunity, track progress and perform audits.

Risk Profiling & Budgeting Applying predictive models to project costs and help you set appropriate budgets

Evaluation Supporting your expertise of your business with our domain and clinical expertise

Benefit Design Revealing opportunity to drive behavior change and provide quality coverage for your population

Other Data

Data Intelligence Creativity Consultative Solutions Informative Decision Making

Decisions Based on Informative Data and Sound Strategy = Employer Savings & Bending of Cost

Curves


USI 3D: Data Drives Decisions

MEDICAL INTELLIGENCE Risk profiling tools, benchmarks, data trends,

gaps in care, and predictive modeling

Eligibility Files

Rx Claims

Medical Claims

•Supporting your expertise of your business with our benefit consulting and clinical experience

Evaluation

•Uncovering opportunities to drive behavior change and provide quality coverage for your population

Program Design

•Applying predictive models to project cost and set appropriate budgets

Risk Profiling


USI example (100 life group):

Client had onsite biometric screenings

Total Cholesterol Result 2010 2011 Normal 59 (63%) 56 (60%)

Borderline At Risk 30 (32%) 28 (30%)

At Risk 5 (5%) 10 (11%)

LDL Cholesterol Result 2010 2011 Normal 72 (77%) 73 (78%)

Above Normal 22 (23%) 21 (22%)

HDL Cholesterol Result 2010 2011 Normal 73 (78%) 79 (84%)

Above Normal 21 (22%) 15 (16%)

Triglycerides Result 2010 2011 Normal 69 (73%) 70 (74%)

Borderline High 14 (15%) 9 (10%)

High 11 (12%) 13 (14%)

Very High 0 (0%) 2 (2%) USI Client Data


USI example (same 100 life group): Client moved to physician engagement

2012 Average 2013 Average Average Variance

Same Cohort Same Cohort

Weight 181.80 178.10 -3.70

BMI 29.80 28.60 -1.20

Blood Pressure Systolic 130.7 127.40 -2.67

Blood Pressure Diastolic 79.96 75.59 -4.38

Blood Glucose 96.23 93.60 -2.63

A1c 6.07 6.10 0.03

Total Cholesterol 188.47 184.02 -4.45

HDL 53.98 53.65 -0.33

LDL 113.32 109.40 -3.92

Triglycerides 129.35 98.00 -31.35

USI Client Data


How we use 3D data 7 Keys to Successful Plan Management 1. Relative Risk Score 2. Disease prevalence 3. Preventive office visits 4. ER utilization 5. Expense distribution 6. Age and gender-specific

screenings 7. Gaps in care for diabetes


1. RELATIVE RISK SCORE: PREDICTIVE MODELING

Value

Quality and Risk Full cycle

Average RRS (Model #18) 1.25



AGE + GENDER + LAST 12 MONTHS DATA = YOUR TREND


# of Members Members per 1,000

Diseases Current New Actual Adjusted Norm

High blood Pressure

76 4 250 95

High cholesterol 54 16 174 63

Back Pain 40 0 134 140

Diabetes 35 1 114 59

2. DISEASE PREVALENCE

Value

Metrics Metric Type Actual Adjusted Norm

Total Office Visits Per 1000 4,425 4,213

Regular Office Visits Per 1000 3,212 3,075

Preventive Office Visits Per 1000 434 484

3. PREVENTIVE OFFICE VISITS

Value Metrics Metric Type Actual Adjusted

Norm

ER Visits Per 1000 355 252

ER Claimants Member Per 1000 409 167

ER Visits resulting in an Admission

% of Admissions 48 35

4. ER UTILIZATION


Member Distribution

# of Mbrs

Average Cost

Cost Distribution

Actual Norm

1% 7 $175,959 17.9% 30.5%

2-5% 26 $62,228 23.5% 27.7%

6-15% 67 $26,676 26.0% 22.7%

16- 30% 99 $12,908 18.6% 12.1%

31-60% 199 $4,346 12.6% 6.4%

61-100% 266 $391 1.5% 0.6%

Member Distribution

# of Mbrs

Average Cost

Cost Distribution

Actual Norm

1% 8 $198,590 37.0% 30.5%

2-5% 33 $30,168 23.2% 27.7%

6-15% 83 $11,176 21.6% 22.7%

16- 30% 124 $4,055 11.7% 12.1%

31-60% 248 $1,039 6.0% 6.4%

61-100% 330 $48 0.4% 0.6%

5. EXPENSE DISTRIBUTION: GROUP WITH SIGNIFICANT OPPORTUNITIES

GROUP PERFORMING WELL


Condition Description Individual

Actual Norm W/

Condition W/

Gap

>= 50 y/o Patients w/o any colorectal screen in last 24 m 84 61 72% 72%

Women: 21 – 65 y/o

Women w/o pap smear in the past 24 m 100 56 56% 47%

Women: 40 – 49 y/o

Women w/o mammogram in the last 2 yrs 32 19 59% 47%

6. AGE- AND GENDER-CANCER SCREENINGS

Description Individual

Actual Norm With Condition With Gap/ Risk

Patients without HbA1c test in last 12 months 34 5 14% 21%

Patients without retinal eye exam in the last 12 months 34 28 82% 69%

Patients without micro or macro albumin screening test in the last 12 months

34 12 35% 37%

7. GAPS IN CARE FOR DIABETES MANAGEMENT


Where do we go from here?


Discovery √ •Review claim data to determine program impact on cost drivers and utilization

Multi-Year Plan •Identify goal and objectives to implement a customized solution

•Integrate health management into a comprehensive employee benefits strategy

Implementation •Design strategic incentives to drive higher program participation

•Aid in creating targeted communications to all members

Compliance •Evaluate compliance concerns surrounding wellness programs

Measuring Results •Evaluate and enhance your program year over year

Developing your strategy

© 2017 USI Insurance Services. All rights reserved.

The USI Health Management Strategy is Based on Five Key Pillars: 1. Connect to the PCP 2. Target all members 3. Meaningful incentives 4. Integrated disease management 5. Evaluate data


1. Connect members to PCP Why physician engagement: Immediate care management for individuals who are outliers for cholesterol,

diabetes, and high blood pressure

Preventive care to identify early stages of cancer

Address other lifestyle issues in a confidential and non-threatening manner. Connected to resources for:

Weight loss (nutrition and physical activity)

Tobacco cessation

Stress

Substance abuse

Creates the most cost efficient entry point to the health care system


Employees 40%

Spouses 40%

Children 20%

0% 100%

HEALTHCARE COSTS

2. Target all members Why target all members? Our USI 3D Data indicates the following:

Spouses make up approximately 30% of the members Spouses cost over 53% more than employees Spouses and dependents account for nearly 60% of the total healthcare

costs. Creates awareness Drives behavior change


Creates a cost neutral program Though premium differentials & surcharges, HSA contributions Ease of administration

Drives participation ERISA counsel to ensure compliance

3. Meaningful incentives


HIPAA 5 Factors

1. Individuals must have the opportunity to qualify for the reward at least once per year

2. 30%/50% reward threshold

3. Designed to promote health and prevent disease

4. The reward must be available to all similarly situated individuals and provide for a reasonable alternative

5. Provide disclosure regarding the availability of a reasonable alternative


Wellness Program Incentives – ADA and GINA

Good news

We now have clear guidance to ensure compliance with ADA and GINA Title II

Bad news

Not same as HIPAA requirements

Still unknown how to comply with GINA I

AARP pursing legal action to invalidate these new rules


Wellness Program Incentives – ADA and GINA (cont.)

New ADA notice requirement. Model notice available

Confidentiality. Information from wellness programs may be disclosed to employers only in aggregate terms except as necessary to administer a health plan

Effective date. First day of 2017 plan year

Clarification already effective: A program that allows employees who

participate in a risk assessment to enroll in a comprehensive health plan, while non-participating employees are only eligible for a less comprehensive plan, violates the ADA


Incentives include all rewards, including gift cards, Fitbits, etc.

Percentage based on total cost of coverage = full premium. For self-funded plan = premium equivalent = expected cost = COBRA rate without 2% admin. fee.

Wellness Program Incentives

HIPAA ADA GINA II

Rewards related to medical plan

Health-contingent (activity-based or outcomes) - 30%* of tier of participating individuals, reasonable alternative

Participation-only - participation available to similarly situated individuals

Medical test such as biometrics/physical or health risk assessment, even if participatory, does not have to be related to a medical plan

30% of lowest cost employee-only tier as to employee

No limit as to spouse/child

Spouse HRA or medical exam, even if participatory, does not have to be related to a medical plan

30% of lowest cost employee-only tier as to employee plus same as to spouse

No incentive may be offered for a child re: current or past health status


Wellness Program Incentives (cont.)

Putting it together: For a program subject to all three laws with spouse participation, the new maximum reward is the lesser of: 30% of the employee+spouse premium (HIPAA); and 30% of the lowest cost employee-only premium for the employee PLUS 30% of the

lowest cost employee-only premium for the spouse (ADA and GINA) * Tobacco use limits: HIPAA – 50% of the total cost of coverage of tier of participating individuals ADA – N/A unless employer uses medical tests to detect nicotine (e.g., blood draw

or mouth swab) in which case 30% of employee-only tier as to employee. No limit as to spouse/child.

GINA – N/A Has to be separate reward, otherwise the other laws will apply


Wellness Program Incentives (cont.)

Benign discrimination

No incentivized family history questions on health risk assessments

For premium differentials: Affordability Policy terms 125 change in cost

Bottom line on incentives: Compliant if the total maximum reward is 30% of the lowest cost of employee-

only rate or less and leave children out of it Otherwise, need to evaluate a bit further

But don’t forget to look at:


Wellness Program Gotchas Stand alone wellness programs violate the ACA? Taxability

For federal, de minimis fringe benefit exception never cash/gift card and definitely not more than $100 in value

ADEA Workers’ comp Compensable time ERISA COBRA HIPAA Privacy


Wellness Program Gotchas (cont.) HSA Eligibility Rule: Employees must meet the deductible before medical expenses are covered. Exception for Preventive Care: Drugs or medications will fall within the safe harbor for preventive care services when they are taken by a person who has developed risk factors for a disease that has not yet manifested itself or has not yet become clinically apparent (i.e., the individual is asymptomatic) or when the drugs are taken to prevent the recurrence of a disease from which a person has recovered. Hard to determine which drugs are preventive. For example: Could the treatment of high cholesterol with cholesterol-lowering medications to

prevent heart disease or the treatment of recovered heart attack or stroke victims with ACE inhibitors be seen as preventing a recurrence? Probably.

Is blood pressure medication for an individual who is pre-hypertensive preventive because there has been no event yet? Probably not.

Is treating diabetics before they develop a worse condition (e.g., blindness) “preventive”? Probably not.


Budget Neutral Wellness Program Company ABCNumber of Benefit Eligible Employees 500Participation Rate 70%Incentive Reward (Per Pay Period) $23.08 $50.01 MonthlyIncentive Reward Differential Per Year per EE $600.08

Program Non-Participants Scenario A Scenario B Scenario CAdministration Cost $1,827.38 $9,635.25 $11,462.63

Incentive Budget (collected from non-participants) 150 $90,012 $90,012 $90,012Net Program Cost $88,185 $80,377 $78,549

Notes1. Total program costs may vary due to specific or customized solutions to meet the needs of the individual client2. Incentive calculation based on the non-participants and or the non-qualifiers additional contributions.


4. Integrated disease management When members are properly managed: Decrease in annual healthcare costs when engaged Disease management initiatives to target closure of gaps in care resulting in

closing potentially catastrophic claimants Reduced repeat events Less medical complications Healthier lives


Does this strategy work?

© 2017 USI Insurance Services. All rights reserved. | 33

Our USI Program

• Our CEO is challenging and expects results

• Our CEO is looking for innovation and wants to push the legal limits

• White collared workforce

CEO’s Population Health Management Goals: 1. Connecting members to a primary care

physician – physician engagement model

2. Nutrition 3. Physical activity


2011 & 2012: Health risk assessment & physician form for annual physical (powered by CIGNA)

CEO’s PHM Goals: 1. Connecting

members to a primary care physician – physician engagement model

2. Nutrition 3. Physical

activity

What has been implemented

2013: Preventive care compliance (certify

preventive cancer screenings) Outcomes based program for

biometric values with reasonable alternative standards (Tobacco, BMI, TRI, HDL, BP, and GLU)

2014: Added stringent tobacco affidavit

language to the program guide • Providing false information

on this form will subject the employee to immediate revocation of the discount and can subject the employee to disciplinary action up to and including termination of employment.

Added in wellness challenges and health coaching to the program structure

Employee contribution for non-wellness went from 20% to 30% differential


2014 results reviewed in 2015

Consistent performers – members who participate improve risk: The average Health Score for Cohort Participant members increased 0.4% the second year and the average number of (high) risk factors per member decreased 5.1% for this group. Therefore, risks are being reduced in members who consistently participate in the health management program.1

Preventative care compliance is working:

77.7% of the participant cohort group reported their annual

preventive care visits and utilization is trending up 30.3%, compared to the non-participant group, where 23.3% received preventive care.2

Preventative care compliance is working: From July 2012 through

June 2015 our percentage with gap is below the 3D norms for colorectal cancer screenings, PSA, pap smears, and mammogram.3

USI’s Care gap Index (CGI) is decreasing: Jul 13 - Jun 14 our CGI was 1.08

from Jul 14 - Jun 15 it has dropped to 1.00. While the 3D norm has remained at 1.29. This is being positively reflected in Cardiac and Diabetes gaps in care because we are below the CGI 3D norm for both categories.

1 Cohort population – 1,825 members who have participated in the wellness program last three

year 2 USI Insurance Services, Inc. Wellness Reporting Review 2015 from Viverae 3 Data pulled from USI 3D July 2012 through June 2015

2013 Program Year

2014 Program Year

2015 1/1 to 7/21/15

MHA + Screening Complete Employee/Spouse

2,839 (76%)

3,022 (53.3%)

3,716 (66.1%)

Health Score: USI vs Viverae’s BOB


2015: • For BMI, HDL, TRI, BP and GLU we implemented any

improvement over 2014 would get you points in 2015

• Verifiable activity - My Healthy Life to address: physical activity, nutrition, and stress.




activity



2015 results reviewed in 2016 Disease management: Cohort enrolled members’ cost has decreased 8.6% from year 1 to year 3,

while members who were not enrolled increased 8.0% during the same time Average cost savings PMPM for cohort engaged members (n= 20)

Engaged members have higher compliance scores than non engaged

members for four of the five chronic conditions measured in year 1 and three of five in year 3

Care gap index had decreased. Average care gap index in 2014 was 1.17 and decreased to 1.12 in 2015. (Norm is 0.96)

Preventative care compliance is working: 74.6% of the participant cohort group were reported to have their annual

preventive care visits and utilization is trending up 32.7%. The nonparticipant group only had 26.6% reported to have preventive care in year 3, but rate is up 27.5% from year 1.

Preventive visits per 1000 have increase in 2015. Preventive visit in 2014 were 859.8 and in 2015 they have increased to 880.3.

Gaps in preventive care coverage are below the norm for colorectal cancer, PSA, pap smear, and mammogram.

Utilization: The trends for inpatient utilization are slightly up

from year 1 for cohort participants and flat for non-participants, but utilization rates in year three are higher for non-participants compared to participants.

Both participants and non-participants have seen an increase in ER utilization, but the participants’ utilization is increasing at a much lower rate (11.8% vs 22.6% since year 1), and the average cost per emergency visit for participants is 45.4% lower than non-participants.

Risk: The average Health Score for cohort participant

members increased 0.7% since year 1, and the average number of (high) risk factors per member decreased 8.8% for this group. Therefore, risks are being reduced in members who consistently participate in the health management program.


2016: Removed the HDL and triglycerides component and

replaced with total cholesterol Removed health challenges and the stress

component of My Healthy Life Added Naturally Slim as a component to count

towards the My Healthy Life – nutrition component (2 classes)

Added the gateway DM/coaching program based off of the health score to increase engagement in the DM programs

DM engagement incentive – You take care of you and we take care of the rest (USI will pay a month of household bills in a drawling for one person who enrolls in the USI DM program)




activity



What is working Major cultural shift that our employees have adopted our strategy (the stick painted orange – average around 70% participation year

over year)

Physician engagement is working Increase in preventive care visits per 1000 steadily increases

• 2013 – 793.2 • 2014 – 859.8 • 2015 – 880.3

Percentage of members with no claims is decreasing • 2014 – 6.47% • 2015 – 6.30%

Preventive care compliance is working

• PSA, mammogram, and colorectal screening percentage with gaps are below the Verisk norm (paid: Jan 2013 through December 15)

Average care gap index is decreasing year over year – members are meeting national medical standards of care

2013 – 1.20 2014 – 1.17 2015 – 1.12

Health coaching is positively impacting members

Members who had at least one coaching session raised their Health Score (HRA + blood) 5.2% on average by 2015, compared to members who did not utilize coaching, whose average Health Score only increased 0.4%.*

*USI Insurance Services, Inc. Wellness Reporting Review 2015 from Viverae looking at 2013-2015 data.

Presenter

Presentation Notes

Utilization 77.7% of the participant cohort group were reported to have their annual preventive care visits and utilization is trending up 30.3%, compared to the non-participant group, where 23.3% received preventive care and their utilization is trending down 10.1%. *USI Insurance Services, Inc. Wellness Reporting Review 2015 from Viverae


This presentation contains confidential & proprietary information of USI Insurance Services and may not be copied, reproduced, and/or transmitted without the express written consent of USI. The information contained herein is for general information purposes only and should not be considered legal, tax, or accounting advice. Any estimates are illustrative given data limitation, may not be cumulative, and are subject to change based on carrier underwriting.


claims data utilization & population health management · 3/1/2017 · health management...

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