The Great Reveal Demystifying Healthcare Costs€¦ · Demystifying Healthcare Costs How to Regain...

The Great RevealDemystifying Healthcare Costs

How to Regain Control of Your Health Plan Costs

november 15, 2019

Educating MitigatingIntegrating

How to Actively Manage Your Health Plan

Real World Success Stories from DeSoto Memorial Hospital Bending the Healthcare Cost Curve

How can DPC Doctors acquire clients ?• Educate yourself – become a student of the game• Knowledge is Power = become a veracious reader

• Read the following books

Homework Assignment

How can DPC Doctors acquire clients ?• Educate yourself – become a student of the game• Knowledge is Power = become a veracious reader

• Read the following books• Biggest roadblock is the Broker• All Brokers aren’t created equal as all DPC Doctors aren’t• Find Benefits Advisors who aren’t 1099 employees of the BUCAH’s• Find Benefits Advisors who are Population Health Managers such

as the Health Rosetta Advisors

Employer

Claims Data Analytics

UM/DM/CM

Medical Plan Participant

(Patient)

Population Health Manager (Benefits Advisor)

Pharmacist CPESN

PCP / DPCSpecialist

Third Party Administrator

(TPA)

Rx Consultant

Local Care Team

PBM

Population Health Manager (Benefits Advisor)

Patient-Centric Care Model

Employer

Claims Data Analytics

UM/DM/CM

Medical Plan Participant

(Patient)

Pharmacist CPESN

PCP / DPCSpecialist

Third Party Administrator

(TPA)

Rx Consultant

Local Care Team

PBM

Population Health Manager (Benefits Advisor)

Claims Data Analytics UM/DM/CM

Local Care Team

Employer

Medical Plan Participant

(Patient)

Patient-Centric Care Model

Integration of Data & Care

Fill Data

Fill Data

DPC

Rx

Specialists

ImagingAmbulatory Services

• Authorization• Claims Processing• Trend Mgt

Rx Script InfoData/Gaps in Fill

Claims D

ata

Claims Data

Patient

Authorization R

equest

Facilities

Notification of request

Seek the right care

Education on appropriateness of care

Gaps in Fill

RxRx

FairCo$t

Master TPA

How can DPC Doctors acquire clients ?• Educate yourself – become a student of the game• Knowledge is Power = become a veracious reader

• Read the following books• Biggest roadblock is the Broker• All Brokers aren’t created equal as all DPC Doctors aren’t• Find Benefits Advisors who aren’t 1099 employees of the BUCAH’s• Find Benefits Advisors who are Population Health Managers such

as the Health Rosetta Advisors• Find Benefits Advisors that understand DPC and know how to

integrate into a health plan for optimum performance• Partner with Benefits Advisors and take them on meetings with you• Build a Community Marketing Plan

Build a Community Marketing Plan Type Description

C-Level and Board-level CEE, CFO, board members, etc.

General Business Chambers of commerce, business leagues, Rotary, etc.

Physician Associations DPC-related orgs, state medical associations, etc.

Professional Networking YPO, Vistige, EO, Six Sigma, BCorp, Lean, etc.

HR/Benefits Leaders Business Groups on Health, HR associations, etc.

Local/Regional CXO Service Provider law firms, community banks, accounting firms, consulting firms, etc.

Legal Associations General counsel, employment law, ERISA, etc.

Local Unions actual unions and orgs for unions

Professional Organizations Accountants, Marketing, etc.

Trade Associations Sector-specific orgs., like manufacturers

Investors PE funds, angel groups, VC funds

Financial Advisors Wealth managers, etc.

Public Entity Coalitions State municipal leader groups, education leaders, etc.

Community Foundations philanthropists, health foundations, etc.

Build a Community Marketing Plan

Org Name Org Type WebsiteHave

Relationship?Primary Contact Email # members

Type DescriptionC-Level Exec/Org LeaderOther Executive/Org. LeaderHR LeaderClinicianInvestorPhilanthropistLocal InfluencerPolitical LeaderCommunity OrganizerBenefits Vendor or TechHealth Plan or TPAOther HIT/VendorPatientOther EntrepreneurOther

Build a Community Marketing Plan

First Name Last Name Person Type Organization Have Relationship? Email Role

How can DPC Doctors acquire clients ?• Biggest roadblock is the Broker• All Brokers aren’t created equal as all DPC Doctors aren’t• Find Benefits Advisors who aren’t 1099 employees of the BUCAH’s• Find Benefits Advisors who are Population Health Managers• Find Benefits Advisors that understand DPC and how to integrate

into a health plan for optimum performance• Take Benefits Advisors on meetings with you• Build a Community Marketing Plan• Speak at relevant local events or to local groups• Organize an event with a Benefits Advisor• Find the local business coalitions

Key Themes Today• Build EMPLOYER-Built Healthcare versus Insurer-Built Healthcare • Do Active Management vs. traditional “passive management”• Re-localize care (re-personalization of health care) • Focus on building COMMUNITY-Owned Healthcare versus

building the archaic Insurer-Owned Healthcare.• Maximize The Local Care Team (Community Pharmacist,

Physician, Hospital, and Patient) i.e Marcus Welby, M.D.• Through active management of your health plans, YOU can

break free of the status quo and offer 10X the benefits for ½ the cost.

• There is a way for you to have Health Insurance YOUR Way and on YOUR Terms.

Cristy Gupton’s Healthcare Solutions Podcast

• Episode 6: Part 1 - Hope for Rural Healthcare with Carl Schuessler

• Episode 7: Part 2 - Hope for Rural Healthcare with Carl Schuessler

• In these episodes, Cristy and Carl Schuessler, founder of Mitigate Partners and creator of the FairCo$t Health Plan, talk about the state of rural health in our nation and how he is helping a small Florida hospital remake themselves from the inside out. Better than that, the long-term goal is to elevate this hospital as a hub for healthcare services available to local employers in their community. So, grab your headphones and #letsfixhealthcare.

Real World Success Stories from Florida Employer

• Vince Sica, JD, CEO • Dan Hogan, CPA, CFO• Lois Hilton, Human Resource Director

• State Hospital District• 49 Bed Rural Community Hospital • Eligible Employees: 220• Medical Plan Participants: 157 ee’s / 318 members

Moderated by: Carl Schuessler, Jr.

DeSoto Memorial Hospital

•4th Poorest County in Florida

Challenges

Community Health Plan Initiative

•4th Poorest County in Florida•BUCAHs were extracting millions from the community

Challenges

Rank Company Revenues ($M)

1 (1) Walmart $500 Billion

2 (4) Exxon Mobil $205 Billion

3 (2) Berkshire $242 Billion

4 (3) Apple $229 Billion

5 (6) UNITED HEALTHCARE GRP $201 Billion

6 (5) MCKESSON $198 Billion

7 (7) CVS HEALTH $184 Billion

12 (11) AMERISOURCEBERGEN $153 Billion

14 (15) CARDINAL HEALTH $129 Billion

19 (17) WALGREENS BOOTS ALLIANCE $118 Billion

25 (22) EXPRESS SCRIPTS $100 Billion

(56), Pfizer (57), Merck, Cigna (73) Anthem (29), Aetna (49), Humana(78)

2018 Fortune 500

•4th Poorest County in Florida•BUCAHs were extracting millions from the community•“Passively Managed” Risk •Lost Obstetrics in February 2018 - members drive 1 hour for deliveries•Foreign Medical Spend averaged 79% the last 4 years•$2,178,562 Total Medical/Rx spend ($482,159 Rx)

Challenges

•Eliminate “Middles” - Implemented The FairCo$t Health Plan & moved from BUCAH ASO Model to Independent TPA•Active Management eliminating “passive management”

Solutions

Traditional Passive Health Plan

IT’S EASY

Pharmacy

Outpatient

Hospitals

Physicians

Labs

ImagingBUCAH Insurer

Built

Actively Managed Health Plan

Employer BuiltRx Optimization

Medical Bill Review

Active Data Mining

Cost & Quality Guidance/Navigation

UM / DM / CM

Direct Contracting

Defined Benefit Pricing Strategy Strategy

Direct Primary Care

Health Plan

Medical Tourism

•Eliminate “Middles” - Implemented The FairCo$t Health Plan & moved from BUCAH ASO Model to Independent TPA•Active Management eliminating “passive management” •Relocalize Care = Neighborhood Healthcare

Solutions

The World is a Big Place

The World is a Big Place

The World is a Big PlaceRelocalize Care - Build Community Health Plan

Neighborhood HealthcareIn summary, by eliminating counterproductive

communication barriers inherent in more traditional insurance/employer/health provider relationships can

lead to more effective and less costly outcomes for Community health plans while providing better protections for the employees and enhancing the

Pharmacists’, Physicians’ and Hospitals’ ability to engage with the community it serves

•Eliminate “Middles” - Implemented The FairCo$t Health Plan & moved from BUCAH ASO Model to Independent TPA•Active Management eliminating “passive management” •Relocalize Care = Neighborhood Healthcare•Utilized Cost&Quality Transparency Tool w/Direct CASH Pay

Solutions

•BUCAH’s know about provider cost (and quality) differentials.•Yet they stand passively by and pay $40,000 for one knee replacement and $135,000 for another

Lack of Pricing Transparency

…………..WITH YOUR MONEY

•We have access to CMS Databases•Cost of Procedure (as reported to CMS)•What Medicare Pays•What Hospital Bills (by DRG Code)

•Our plans include a Nurse Advocate to help employees “shop” for services•Identifies QUALITY Cost Effective Providers

Solved Lack of Pricing Transparency

In order to engage employees, plan design must reward good decisions

•Eliminate “Middles” - Implemented The FairCo$t Health Plan & moved from BUCAH ASO Model to Independent TPA•Active Management eliminating “passive management” •Relocalize Care = Neighborhood Healthcare•Utilized Cost&Quality Transparency Tool w/Direct CASH Pay•10x Benefits for ½ the cost - “weaponized” plan design and hospital became their own PBM

Solutions

Member

Employer2018 Fortune 500 – PBM Shell GameDeSoto Memorial Pharmacy Benefit Manager (PBM)

Community

• 2 plans – DPC and Non-DPC• Rich plan design eliminates deductibles & coinsurance• 3 choices for Hospital Services – Inpatient / Outpatient /

Imaging, ER, etc. - Go to any hospital of your choice üDeSoto Memorial Hospital = $0 Deductible/No CoinsuranceüDeSoto Friends & Family Hospitals = $500/$1,000 Deductible PLUS admission

copays ($250 OP/$500 IP) PLUS Coins. to $2,500/$5,000 Out-of-Pocket MAXüNON-DeSoto Memorial Hospital = $1,000/$2,000 Deductible PLUS admission

copays ($1,500 OP/$2,500 IP) PLUS Coins. to $4,000/$8,000 Out-of-Pocket MAX

Plans Changes effective January 1, 2019

Direct Primary Care

•Eliminate “Middles” - Implemented The FairCo$t Health Plan & moved from BUCAH ASO Model to Independent TPA•Active Management eliminating “passive management” •Relocalize Care = Neighborhood Healthcare•Utilized Cost&Quality Transparency Tool w/Direct CASH Pay•10x Benefits for ½ the cost - “weaponized” plan design and hospital became their own PBM•Implemented DPC

Solutions

Why DPC ?

The number one cost driver in health care is the fact that we use insurance to pay for

high probability, low cost events-- David Goldhill, Formed CEO “The Game Show Network”

Author of Catastrophic Care – Why Everything We Think We Know About Healthcare is Wrong

Why DPC ?

Direct Primary Care

Award-winning physicians

Nationally acclaimed DPC program

Epiphany HEALTH Direct Primary Care

• Lee Gross, M.D., Founder• Locations: Northport and Arcadia• Phone: (941) 423-9936• Website: https://www.epiphanyhealth.org/

Direct Primary Care

•Eliminate “Middles” - Implemented The FairCo$t Health Plan & moved from BUCAH ASO Model to Independent TPA•Active Management eliminating “passive management” •Relocalize Care = Neighborhood Healthcare•Utilized Cost&Quality Transparency Tool w/Direct CASH Pay•10x Benefits for ½ the cost - “weaponized” plan design and hospital became their own PBM•Implemented DPC•Implemented FairCo$t proprietary claims data analytics•Implemented Integrated Coordinated Care (IC )2

Solutions

Active Mgmt. OpportunityPredictive Modeling with Big Data

• The Top 10% of members by claim spend account for 73% of total cost• Averaging $33,000 annually per member

• The Bottom 75% of members by claim spend 10% of total annual cost averaging $625 annually per member

• The Bottom 50% (16,462) of active members consumed 2% of total annual plan dollars @ $184/member

The Value of Knowing - Plan Expense Distribution*

Typical Self-Funded plan covering 32,000 members spending $150 million

*Aggregated data from 12 self-funded clients

•66 participants identified from BUCAH Claim Reports for participation in Custom Population Health Management Program based off prevalence of chronic conditions

•97 participants identified for participation via proprietary data analytics – 31 more identified in just 3 months•Participating in HPHS program within one of three levels of

management: • 36 Lifestyle Program participants (< $5,000 claims)• 42 Disease Management Program participants (> $5,000 - < $10,000 claims)• 19 Chronic Care Mgmt. Program participants (> $10,000 claims)

Predictive Modeling with Big Data

Opioid Management• Members in Health plan -

(Employee/Spouse/Children/dependents): 428• Members with a high-risk prescription: 141 (33%)• Estimated Plan Cost due to high Risk Rx (75%): $120,000

Opioid Management

•Relocalize Care = Neighborhood Healthcare•$150,000 Savings (58%) in Stop Loss Premiums w/Rx in Agg. –wasn’t included when hired •10x Benefits for ½ the cost - “weaponized” plan design •Reduced Foreign Medical Spend to 62% from 79% (avg. 4 yrs.) •Hired 1st full-time Surgeon in County history•Renewal: Rate decrease of -3.2% SL and -14% on Agg. funding factors – 2nd Rate Decrease in Ins. Carrier’s History

First Year Savings $1,186,579 or 54%

Results

3 Months BUCAH ASO vs. 7 Months

Employee Lives: 157Bellybuttons: 318

1 Year - BUCAH ASO vs. Employee Lives: 157Bellybuttons: 318

•Just finished first year•10x Benefits for ½ the cost - “weaponized” plan design•Rate decrease of -3.2% and -14% on funding factors

Impact on Renewal

•City, County & School•Medium to Large Employers

Taking It To The Streets

Taking it Forward: Action Items•Do your clients know what their benchmark costs are?•Medical Expense Per Employee Per Year (PEPY) • Prescription Drug Expense Per Member Per Month (PMPM)

•Employers you heard about are doing this!• It is possible!•All it takes is a good Advisor, DPC and a little courage• “UBER” your client’s Health Plan before it gets “Kodaked”

Real World Success Stories from Florida Employer

• Vince Sica, JD, CEO • Dan Hogan, CPA, CFO• Lois Hilton, Human Resource Director

• State Hospital District• 49 Bed Rural Community Hospital • Eligible Employees: 220• Medical Plan Participants: 157 ee’s / 318 members

Moderated by: Carl Schuessler, Jr.

DeSoto Memorial Hospital

It is time for a Revolutionary New Approach!“We cannot solve our problems with the same thinking we

used when we created them” Albert Einstein

Thanks for your time!