Addressing Payer Costs through a Comprehensive Model · 2017 2 ADDRESSING PAYER COSTS THROUGH A COMPREHENSIVE MODEL EGR-2016-12-V-2010 Executive Summary Payers leave a lot of value

2017 AN EVEREST GROUP VIEWPOINT

w w w . e v e r e s t g r p . c o m

This report has been licensed for exclusive use and distribution by Optum.

EGR-2016-12-V-2010

Addressing Payer Costs through a Comprehensive Model

A Blueprint for Achieving Breakthrough Cost Savings

Jimit Arora, Partner

Abhishek Singh, Practice Director

Nitish Mittal, Senior Analyst

Copyright © 2017, Everest Global, Inc. All rights reserved.

http://www.everestgrp.com/

2017

2

ADDRESSING PAYER COSTS THROUGH A COMPREHENSIVE MODEL


EGR-2016-12-V-2010

Executive Summary

Payers leave a lot of value on the table when they manage IT, process, and medical

costs separately. Everest Group research shows that payers can achieve breakthrough

cost savings improvements by grouping and managing medical and operational

costs together. This viewpoint offers a plan for payers to convert their entire spectrum

of costs into a utility-based model that enables breakthrough cost savings.

After outlining the key industry imperatives payer CXOs need to focus on, we then

evaluate various outsourcing models that can help address the imperatives’ inherent

challenges. From there, we offer a case-based analysis of the cost structure of a

health plan with one million members and dissect the cost savings that result from

three different sourcing models. One of the models, comprehensive outsourcing

(which combines operations and medical cost takeout), achieves significantly better

results than the other models. The remainder of the paper addresses the key tenets of

this model and its impacts.

Structure

This viewpoint is organized in four sections, described below.

Section 1: Industry context, enterprise imperatives, and actions

Key industry drivers impacting payers

Implications and imperatives for payers

Section 2: Unravelling the cost conundrum

Medical cost components that are addressable through outsourcing

Baseline PMPM servicing cost addressable through outsourcing

Section 3: Addressing the cost conundrum through outsourcing

Value drivers of various outsourcing models

Which models are best and why

Section 4: Achieving breakthrough cost takeout

Cost reduction implications for each model

Outsourcing at zero cost: myth or reality?

Conclusion: Selecting the right model to avoid value leakage


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Industry Context, Enterprise Imperatives, and Actions

✓ Key industry drivers impacting payers

✓ Implications and imperatives for payers

Payers in the United States are experiencing a significant shift in business and

operating conditions, led by a combination of push- and pull-based drivers.

Changing regulatory environment increasing administrative burden

As the U.S. government becomes more involved and assertive on everything from

premium hike approvals to subsidies and corporate mergers, payers are facing

unpredictable times.

With the new administration, patient-centered health care reforms will likely

continue, with the end goal of choice, quality, and affordability

However, recent initiatives have been unprofitable, and the government has only

partially yielded to the requests for premium increases. As a result:

– Aetna, Humana, Cigna, UnitedHealthcare, and BCBS of Tennessee have

started drawing back their HIX plans

– Blue Cross Blue Shield of Nebraska announced its exit from HIX because of a

US$64 million loss and the subsequent argument over premium increases

The DoJ questioning of the Aetna-Humana and Anthem-Cigna deals has further

impacted large national plans’ tactical moves

Imperatives for payers:

Focus on cost containment as the key lever to combat regulatory uncertainty

Keep existing operations compliant

Carefully pursue growth initiatives that align with the evolving regulatory climate

E X H I B I T 1

Overview of industry

dynamics

Source: Everest Group

Enterprise actionsEnterprise

imperativesIndustry drivers

Changing regulatory

environment and

increasing

administrative burden

Declining viability of

existing product lines

Growing consumerism

Revenue

expansion

Customer acquisition & retention

New approach to products and

service lines

Maximizing value per member

Expense

drive-down

Streamline member servicing /

SG&A costs

Address MLR issues

1

2

3


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Declining viability of existing product lines

Driving down expenses and finding new growth avenues have become imperatives

for payers given the challenges they face.

HIX have not lived up to the hype; insurers are bleeding money on these plans

due to limited member interest, high risk exposure, and adverse selection

– UHG reported over $700 million in HIX losses (2015) and has announced

plans to drop out of many HIX markets

– Anthem reported that their profits for FY2015 dropped by 64% due in large

part to a huge loss in the HIX market

– Cigna also reported that it is not making money from the individual market

– Aetna has announced its exit from 11 of 15 state exchanges in 2017

Medicare/Medicaid plans also are facing margin issues as reimbursements

decline and the obligation for care quality (STAR ratings) shifts to both payers and

providers

E X H I B I T 2

Lackluster HIX enrollment

and demographics



Grow enrollment numbers and per-member revenue through value-added

services

Drive breakthrough cost savings by addressing both operational and medical

costs

8

15.710

23

2013 2016

HIX enrollment

millionGovernment ProjectionsActual

As the new administration seeks to repeal and replace the ACA, any changes must

account for the challenges that leading commercial payers have noted. Most C-suite

executives indicate that such a repeal will make health insurance companies more

competitive and more influential, which should bode well for large national payers’

wallets. Broad-based changes are likely to be equally, if not more, unpopular than

the perceived problems with the ACA. Most of the market has invested considerable

resources in reinventing their fundamental business models and rolling back the

clock is not really an option.


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Growing consumerism

Growing consumerism is impacting payers’ current and future strategy. On one

hand, there is a noticeable (though slow) shift toward a defined contribution model

from a defined benefits model in the groups business. On the other hand, consumers

are becoming more assertive in their expectations given the growth of available

information and the proliferation of mobile devices.

About 75% patients in the U.S. currently use some form of digital healthcare

service

Four out of every five U.S. consumers think it is important for payers to provide

tools that help consumers to plan expenses and select plan coverage levels

Even if 25% (a conservative estimate) of employer-based plans move from defined

benefits to defined contribution, end consumers will be responsible for direct

decisions impacting about US$340 billion of premium revenue by 2020

Pressure to continue developing a patient-centered healthcare system – with

increased focus on choice and price transparency measures – is likely to continue

under the new administration.


Develop personalized products (beyond just insurance coverage) driven by patient

preferences and medical history

Introduce technology to enable omnichannel consumer engagement and

underlying operational efficiency


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✓ Medical cost components that are addressable through outsourcing

✓ Baseline PMPM servicing cost addressable through outsourcing

Payers have conventionally operated on narrower margins in comparison to other

subverticals in the healthcare and life sciences market, averaging about 3-5%. Given

that cost is a constant pressure, payers must consider all components of their cost

structure when looking for savings.

Unravelling the Cost Conundrum

E X H I B I T 3

Payer’s cost base

breakdown


Understanding the addressable components of cost

Medical cost

Medical cost is the single largest spend component for payers. Managing medical

cost is an essential cog of a payer’s strategy to ensure affordability (for members) and

profitability/competitiveness (for the payer). By regulation, it is required to be at least

80%-85% (depending on the plan size). However, medical cost takeout is largely

overlooked from the outsourcing perspective primarily because medical cost

components are considered core to the business. However, there are avenues to

address it through initiatives related to upstream processes and data-driven insights

that could garner significant savings.

Profit margins in the

healthcare industry

Pharma: 12-15%

Hospitals: 8-10%

Payer: 3-5%

Payers with

about 1 million

members have a top

line of $2.5-3 billion,

with medical costs

typically in the

$2-2.5 billion range

Medical

costs

80-85% 15-20%

Admin and

IT costs

Ability to create

breakthrough value by

focusing on medical costs


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Administrative and IT costs

Payers spend another 12-16 cents of every dollar on administrative and IT expenses.

The current focus on cost takeout largely comprises “run-the-business” elements of

claims management, underwriting, sales & marketing, and technology systems &

hardware.

E X H I B I T 5

Addressing admin and

IT costs through

outsourcing


Cost

type

Components addressable through

IT/BPS outsourcing

Components NOT addressable

through IT/BPS outsourcing

Admin Provider support

Enrollment services

Claims processing and policy

administration

Benefits coordination

Wellness programs

Medical management

Consumer services / marketing

support

PBM network and information

management

Sales

Public health activities

Government administration

Real estate

Facilities management

Statutory taxes

IT IT consulting / blueprinting / SI

Infrastructure – hardware, services

Backup, disaster recovery & business

continuity

Support/maintenance

Employee training

Software services

Helpdesk

Workplace services

Business analysis

NA

E X H I B I T 4

Addressing medical costs

through outsourcing


Components addressable through

IT/BPS outsourcing

Components NOT addressable through

IT/BPS outsourcing

Payment analytics

Subrogation

Pre/post-pay waste & error

Fraud and abuse

Utilization management

Cross-claim analyses

Provider monitoring and education

Drug/pharmaceutical costs

Inpatient/outpatient costs

Physician services


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EGR-2016-12-V-2010

E X H I B I T 6

Operating expense

breakdown as a share

of revenue – 2015;

percent of total

Source: Everest Group, SEC filings

Our research indicates that a payer’s SG&A costs typically decrease in correlation

with the plan size (enrolled members) (see Exhibit 6). This happens for a variety of

reasons:

Smaller payers are more regionally/LoB-concentrated, with tighter integration

and lower overheads

Despite economies of scale, large payers wear multiple hats (multiple LoBs,

geographically spread support functions) leading to increased SG&A costs

26%

24%

19%

16%

16%

15%

13%

13%

9%

8%

66%

62%

69%

82%

77%

76%

82%

80%

83%

86%

8%

15%

12%

2%

7%

9%

5%

7%

7%

6%

UHG

Cigna

Aetna

Horizon BCBS

Anthem

Centene

Humana

HealthNet

Molina

WellCare

SG&A (Admin & IT) Medical costs Others

Key finding: For mid-tier plans (one million members and under), cost components

that can potentially be addressed through outsourcing range from $8 to $9 PMPM.


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✓ Value drivers of various outsourcing models

✓ Which models are best and why

Payers need to be fully aware of financial challenges, the evolving regulatory

environment, and changing consumer profiles – and their impacts on business

demand – as they consider outsourcing objectives and partnerships.

Change-the-business: Bring in best-in-class service partners to ensure initiatives

are faster and better than the competition. Rely on partners to address the growing

focus on digitalization and other new strategic initiatives (HIX, population health,

etc.) that are technology-native and outside of the payer’s core competency

Compliance: Select providers that have a dual pedigree – healthcare and

technology. All recent healthcare reforms (HIPAA, HITECH, ARRA, ICD, etc.) have

forced the industry further down the technology path, focusing importance on

transforming systems of transaction as well as systems of record

Run-the-business: Opt for service providers that have the experience and scale

to partner in key operational and financial engineering initiatives that will result in

increased efficiency and predictability in costs over time

Getting the sourcing model right

Payers need to consider their sourcing needs in light of the reality of their business

environment. Ideally, these needs can best be addressed by closely scrutinizing their

existing sourcing model and evolving to a right-fit sourcing model based on the

maturity curve defined below.

Addressing the Cost Conundrum through Outsourcing

E X H I B I T 7

Sourcing model options

for payers


Integrated technology, operations, and

medical cost heads

Addresses the full spectrum of medical

costs across case/disease/condition

management areas

Option 3

Comprehensive outsourcing

(BPaaS + payment integrity

+ care management)

Building blocks

Option 1

BPaaS

ITaaS

BPO

SI/consulting

Co-owned governance layer

Rebadging client employees

Option 2

BPaaS + payment integrity

Integrated technology,

operations, and medical cost

(pre adjudication and pre/post

payment functions)

Increasing le

vel of m

aturity


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EGR-2016-12-V-2010

E X H I B I T 8

Value drivers addressed

in each sourcing model


Option 1

BPaaS

Option 2

BPaaS + payment

integrity

Option 3

BPaaS + payment

integrity + care

management

Cost reduction

Efficiency

Standardization

Enhanced compliance

Access to new

skills/tech

Transparency and

predictability

Time-to-value

Simplified governance

Ability to ramp

up/down based on

business needs

Cost reduction

Efficiency

Standardization

Enhanced compliance

Access to new

skills/tech

Transparency and

predictability

Time-to-value


Ability to ramp

up/down based on

business needs

Breakthrough cost

impact

Medical cost

reduction

Zero/negative TCO

Cost reduction

Efficiency

Standardization

Enhanced compliance

Access to new

skills/tech

Transparency and

predictability

Time-to-value


Ability to ramp

up/down based on

business needs

Breakthrough cost

impact

Medical cost

reduction

Zero/negative TCO

Full-spectrum medical

cost impact

Option 1: BPaaS

The growing need to recover the value left on the table by standalone ITO/BPO and

an unpredictable business environment is pushing payers to evolve their sourcing

model through the following tenets:

Integrated sourcing seeks to address multiple functions together to address

issues related to silo-based environments, multi-vendor complexities, and trigger-

based sourcing

The utility-based model integrates IT and functional requirements into a

consumption-based utility and links them directly to an addressable aspect of

organizational metrics such as Per Member Per Month (PMPM) costs

Stronger contractual adherence driven by the service providers’ integration

within the client environment and the related linking of outcomes to business KPIs

As the sample blueprint depicted in Exhibit 9 illustrates, this model is leveraged best

in a construct that combines multiple functions, software platforms, applications, and

infrastructure.

Additional value drivers


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EGR-2016-12-V-2010


Delivers productivity gains by easing governance and vendor management

Makes cost structure/components transparent, and more flexible and agile to the

changing organizational objectives

Enables organizations to avoid sunk costs by converting capital spend into

operating expense and helps address capital allocation issues (especially from a

quarterly earnings and financial reporting scrutiny perspective)

Value drivers not addressed

While BPaaS is an excellent value proposition to address SG&A costs, it does not

address medical costs – the single biggest cost element. The ability to create

breakthrough cost takeout is limited by the exclusion of as medical costs (80-85%

of payer costs) from the model

E X H I B I T 9

Typical BPaaS solution

blueprint


Product configuration

IT infrastructure layer

Horizontal business process services

Application services

Policy servic

ing

Netw

ork m

anagem

ent

Care m

anagem

ent

Cla

ims m

anagem

ent

Modern, connecte

d core pla

tform

s

End-to-end governance

Consum

ptio

n-lin

ked m

odel

Service integration and management

Program

/proje

ct

managem

ent


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EGR-2016-12-V-2010

Option 2: BPaaS + payment integrity

Payers can achieve significant value only if they address medical costs as well as

SG&A. Focus should be on addressing aspects of medical costs that relate to prior

authorization, adjudication, pre-payment and post-payment, on top of the

operational costs addressed by BPaaS. Components of medical costs that can be

addressed through outsourcing include:

Data mining

Credit balance

Fraud, waste, and abuse

Subrogation

Claims editing

Recovery


Enhanced payment integrity can result in 2-4% savings (on a conservative basis)

on medical costs

PMPM cost savings through a comprehensive model can equal, or even exceed,

the cost of the sourcing engagement

Ease of dealing with a single best-in-class vendor results in additional savings

through ease of governance, better audit trail, and greater accountability

Value drivers not addressed

Since payment integrity can only impact a portion of all medical costs (i.e., pre-

adjudication and pre-/post-payment functions), its ability to create breakthrough

cost impact is limited


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Option 3: Comprehensive outsourcing (BPaaS + payment integrity + care

management)

Payers can achieve breakthrough only by including more medical cost components in

a comprehensive outsourcing program. This model would include additional

elements such as:

Case management: Helps individuals with high-risk diseases to manage complex

care and provide transitional care support as needed to minimize disease

progression reduce hospital readmissions

Condition management: Develops care plans for individuals with chronic illnesses

(heart failure, COPD, asthma, coronary artery disease, diabetes, etc.) to manage

care, ensure appropriate medications, and advocate lifestyle changes to minimize

disease progression

Combined case/disease management and Center of Excellence (COE) programs:

Takes a 360-degree view of complex care cases to integrate pharmacy and other

therapies for diseases such as cancer, heart failure, COPD, asthma, coronary

artery disease, and diabetes


While comprehensive outsourcing adds significant value in areas such as staffing,

governance, and administration, what truly differentiates it from other models is its

full-spectrum cost impact

On top of breakthrough cost savings, anecdotal evidence suggests an additional 5-

10% savings resulting from the reduced governance/compliance effort required

when moving from ITO+BPaaS to comprehensive outsourcing, as the number

vendor relationships declines.


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Value mapping

Option 1

BPaaS

Option 2

BPaaS +

payment

integrity

Option 3

BPaaS +

payment integrity

+ care

management

IT cost reduction ✓ ✓ ✓

Efficiency ✓ ✓ ✓

Standardization ✓ ✓ ✓

Enhanced compliance ✓ ✓ ✓

Access to new skills/technology ✓ ✓ ✓

Transparency & predictability ✓ ✓ ✓

Time to value ✓ ✓ ✓

Simplified governance ✓ ✓✓ ✓✓

Ability to ramp up and down ✓ ✓✓ ✓✓

Administrative cost reduction ✓ ✓ ✓

Medical cost reduction ✘ ✓ ✓✓

Zero / Negative TCO ✘ ✓ ✓✓

Breakthrough cost impact ✘ ✓ ✓✓

Full-spectrum medical cost impact ✘ ✘ ✓

E X H I B I T 1 0

Value mapping – by

sourcing models



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EGR-2016-12-V-2010

✓ Cost reduction implications for each model

✓ Outsourcing at zero cost: myth or reality?

As discussed earlier, payers have several sourcing options to address their expense

reduction imperatives:

BPaaS (including ITaaS)

BPaaS + payment integrity

Comprehensive outsourcing (BPaaS + payment integrity + care management)

The prior section of this paper outlined the value driver differences for each

outsourcing configuration. To understand each configuration’s potential cost savings

implications, we created sample payer case scenarios using the following

characteristics.

Achieving Breakthrough Cost Takeout

This sample scenario is based on on Blue Cross Blue Shield of Kansas City as a

representative example. Members, revenue, SG&A, and medical costs are based on

actuals while addressable SG&A and IT costs are estimated from baseline figures.

Case scenario – Plan with ~1 million members

Member base 1 million

Revenue (2015) $2.6 billion

SG&A (2015) $442 million

Medical costs (2015) $2.2 billion

SG&A (as a share of revenue) 17%

Addressable SG&A cost – Admin and IT

(internal, est.)

~$9 PMPM or $108 million

annually


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E X H I B I T 1 1

Savings from BPaaS;

$ million


Overall savings from

BPaaS: $24 million

Medical costAddressable SG&A cost

(Admin and IT)

Assumed pricing for BPaaS: $7 PMPM

In this model, the client lowers its PMPM

servicing cost from $8 to $7 and saves over

$20 million annually

Option 1: BPaaS

BPaaS implementation accrues significant value (see Exhibit 10), achieving cost

savings of 3X standalone ITO. The strong connection between business operations

and technology allow BPaaS to unlock increased operational efficiency and

predictability. Despite these benefits, this model still does not address the greatest

savings opportunity – medical costs.

E X H I B I T 1 2

Savings from BPaaS +

payment integrity;

$ million


Overall savings of $90

million are ~4x

BPaaS


(Admin and IT)

Assumed pricing for BPaaS + payment

integrity: $8 PMPM

The client unlocks additional savings of $66

million in this model.

Combining BPaaS with payment integrity creates significant added value as it

addresses not only the largest component of a payer’s cost – medical expenses – but

also unlocks efficiencies in the claims process through the payment integrity platform.

Option 2: BPaaS + payment integrity

108 84

2,200

24

2,200

Current

cost base

Savings New

cost base

Cost element IT Admin Medical

Addressed✓ ✓ ✘

Savings $24 million

108 84

2,200

90

2,134

Current

cost base

Savings New

cost base


Addressed✓ ✓ ✓

Savings $90 million


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E X H I B I T 1 3

Savings from

comprehensive

outsourcing;

$ million


Overall savings of

$258 million are ~3x

BPaaS + payment

integrity


(Admin and IT)

Assumed pricing for comprehensive

outsourcing: $9 PMPM.

The client unlocks additional savings of

$168 million in this model.

Option 3: Comprehensive outsourcing (BPaaS + payment integrity + care

management)

Bringing medical cost elements such as disease/condition/case management into the

model unlocks nearly $170 million of additional savings. This scenario takes a best-

in-class approach resulting in an integrated approach, driving breakthrough cost

savings.

108 84

2,200

258

1,966

Current

cost base

Savings New

cost base


Addressed✓ ✓ ✓✓

Savings $258 million


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Conclusion: Selecting the Right Model to Avoid Value Leakage

As has been illustrated, payers can achieve a significant increase in cost savings by

combining BPaaS, payment integrity, and care management in an integrated

comprehensive outsourcing model. As the chart below shows, cost savings from

comprehensive outsourcing are nearly 11X the savings of BPaaS alone.

E X H I B I T 1 4

Savings differential –

by sourcing option;

$ million


Payers can realize additional value on top of breakthrough cost savings:

Time-to-value: Comprehensive outsourcing helps to improve time-to-value due

to tighter integration and collaboration among the technology, operations, and

medical cost teams. Enterprises focused on initiative launch speed need to enable

faster deployment across operational and claims administration, and

comprehensive outsourcing supports this effort

Full TCO visibility: Combining operations, payment integrity, and care

management provides CXOs an integrated view of the costs. Vendor management

and service procurement costs are also simplified and drastically reduced when

the number of vendors declines. Comprehensive orchestration of the payment

integrity ecosystem (across pre-adjudication, pre-payment, and post-payment)

creates direct visibility into costs

Upstream process improvement: Because one vendor has complete visibility

across the client environment, it develops intimate process knowledge of the

systems enabling it to suggest modifications and improvements based on a

reverse feedback model. And because reporting on both operations and payment

integrity are unified with combined analytics, the process of making necessary

process improvement tweaks is seamless

Incentive alignment: In a multi-vendor environment, managing several contracts

at different times with varying Master Services Agreements (MSA) can be a

cumbersome and suboptimal exercise for enterprises, requiring significant

executive resources. Under a comprehensive outsourcing program, as the single

vendor assumes the role of strategic partner across different requirements,

aligning and monitoring financial/operational incentives linked to unique

milestones becomes easier

24

90

258

BPaaS

BPaaS + Payment integrity

Comprehensive outsourcing


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EGR-2016-12-V-2010

E X H I B I T 1 5

Value drivers mapping –

by different solution

components


What is clear is that these value drivers are not unlocked if enterprises choose to

approach BPaaS, payment integrity, and care management separately (with different

vendors).

Industry discussions on these sourcing choices indicate a typical value erosion of

10-15% in a multi-vendor environment. (This number varies with the maturity of

existing systems and processes).

However, the adoption of a single vendor model is neither easy nor free of risk. To

maximize ease and minimize risk it is vital to ensure your potential partner:

Is financially sound

Has strong healthcare operations, technology, and payment integrity experience

Is willing to engage in a guaranteed outcome model

Net-net, comprehensive outsourcing unlocks tremendous value. Enterprises should

seriously evaluate this model. While this model has its share of risks and concerns, if

the enterprise and the vendor can partner to create tightly knit contracts with strong

risk mitigation and guaranteed savings clauses, comprehensive outsourcing can be a

game changer for the payer industry.

Value drivers

mapping

Comprehensive

outsourcing

Standalone

BPaaS

Standalone

payment

integrity

Standalone

care

management

Enhanced compliance ✓ ✓ ✘ ✘

Transparency &

predictability✓ ✓ ✘ ✘

Simplified governance ✓ ✓ ✘ ✘

Administrative cost

reduction✓ ✓ ✘ ✘

Time-to-value ✓ ✘ ✘ ✘

Impact on medical

costs✓ ✘ ✓ ✓

Full TCO visibility ✓ ✘ ✘ ✘

Upstream process

improvement✓ ✘ ✘ ✘

Alignment of incentives

as a value driver✓ ✘ ✘ ✘


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EGR-2016-12-V-2010

About Everest Group

Everest Group is a consulting and research firm focused on strategic IT, business services

and sourcing. We are trusted advisors to senior executives of leading enterprises, providers

and investors. Our firm helps clients improve operational and financial performance

through a hands-on process that supports them in making well-informed decisions that

deliver high-impact results and achieve sustained value. Our insight and guidance

empowers clients to improve organizational efficiency, effectiveness, agility and

responsiveness. What sets Everest Group apart is the integration of deep sourcing

knowledge, problem-solving skills and original research. Details and in-depth content are

available at www.everestgrp.com.

For more information about Everest Group, please contact:

+1-214-451-3000

[email protected]

For more information about this topic please contact the author(s):

Jimit Arora, Partner

[email protected]

Abhishek Singh, Practice Director

[email protected]

Nitish Mittal, Senior Analyst

[email protected]

This study was funded, in part, by Optum.



mailto:[email protected]




Documents

Addressing Payer Costs through a Comprehensive Model · 2017 2 ADDRESSING PAYER COSTS THROUGH A COMPREHENSIVE MODEL EGR-2016-12-V-2010 Executive Summary Payers leave a lot of value