4th Annual Investor Conference May 16, 2001 HEALTH PLANS DIVISION Panel Discussion: Contributing Value to Cost of Care
4th Annual Investor Conference May 16, 2001 HEALTH PLANS DIVISION Panel Discussion: Contributing Value to Cost of Care.
Dec 17, 2015
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4th Annual Investor Conference
May 16, 2001
HEALTH PLANS DIVISION
Panel Discussion: Contributing Value to Cost of Care
4th Annual Investor Conference
May 16, 2001
HEALTH PLANS DIVISION
Medical Management Strategies & Capabilities
Tim Moore, M.D.
Senior Vice President & Chief Medical Officer
3
How Health Net Provides Value in Medical Management
Improve Outcomes
Assist Members in Self-care
Help Providers Give Best Care
Avoid Being Unduly Intrusive
Contain Costs by Promoting Quality
Measure and Improve Whatever We Do
Link Activities to Product Design
4
Population Health Management
Complex Case Management
Chronic Diseases• Stable• Minimize disease progression• Coordinate care• Secondary prevention
Disease Management
Well & Acute Care • Access to information• Preventive care guidelines• Tools for self-care• How to access care
Demand Management
• Very sick• Specialists• Case Mgmt.
Intense
% ofPopulation
3 - 4
%
11 -
12 %
85%
% ofResource
Consumption
33-1/3%
33-1/3%
33-1/3%
5
Predictor Model Challenges
2001
Top 3% Utilizers
2000
3% 3%
What % of this year’s top 3% were in last year’s top 3%?
6
Predictor Model Challenges: Regression of Top 3% Utilizers
80%
20%
20012000
3% 3%
80% of this year’s top 3% were NOT in the top 3% last year
7
Profiling Examples
# Patients: 181# Services: 728Total Cost: $28,482
# Challenges: 53Challenge Cost: $1,844Challenge Rate: 7.3%
PHYSICIANS, PEDIATRICS
6/30/99 -7/1/00
EXAMPLE
8
Profiling Examples
# Challenges: 727Challenge Cost: $23,510Challenge Rate: 63.2%
# Patients: 50# Services: 1,150Total Cost: $45,639
PHYSICIANS, PEDIATRICS
6/30/99 -7/1/00
EXAMPLE
4th Annual Investor Conference
May 16, 2001
HEALTH PLANS DIVISION
National Pharmacy Strategies & Trends
Neil Higashida, Pharm.D.
Vice President, Strategy & Integration, Health Net Pharmaceutical Services
10
Pharmacy Cost Management
Continued Success in Pharmacy Cost Management Well Below Industry Trends
Three-Tier Prescription Drug Benefits Becoming the Standard Plan Design
Successful Pharmacy Utilization and Unit Cost Management Strategies
Excellent Rebate Performance
11
Pharmacy Cost Trends
1999 to 2000 Trend = 9%
Q1 2001 v. Q1 2000 = 9%
Expected 2001 Trend = 11% to 13%
12
Prescription Drug Benefit Designs
Current Penetration of the Three-Tier Benefit Design:
West (CA, AZ, OR) 60%
Northeast (CT, NJ, NY, PA) 47%
Health Plans Division 57%
13
Pharmacy Cost Management Strategy
Continue Penetration With Cost-Savings Plan Design Such as the Three-Tier Plan Benefit
Develop and Administer New Plan Designs
Implement Cost Management “Best Practices” Enterprise-Wide
– Utilization Management of Target High Cost Medications
– Market Share Management of High Cost Medications
– Electronic Prescribing Tools
– Physician Prescribing Profiles
4th Annual Investor Conference
May 16, 2001
HEALTH PLANS DIVISION
Managing the Risk Shift in California
Jenni Vargas
Senior Vice President & General Manager, Northern California
15
Well-Managed Provider Groups Continue to Receive Capitation
95% of HMO Members Are in Groups With Capitated Physicians
41% of HMO Members Are in Groups With Capitated Physicians and Hospitals
Increased Scrutiny and Technical Support of Providers Receiving Capitation
16
Risk Shift Focused Enhanced Medical Management
Hospital
On-Site Concurrent Review
20 Medical Directors and 42 Nursing Staff Overseeing Length of Stay and Discharge Planning
Specialty Review
17
Risk Shift Focused Enhanced Medical Management
Physician
Outpatient Referral Management
Physician Profiling and Visits by Medical Director and Pharmacist
Fee Schedule and Claims Management
18
Large Delegated Groups Have Turned the Corner Financially
Improving Relationships Leading to Joint Innovation and Better Definition of Risk Services
Product Development to Feature High Quality, Delegated Groups
Driving “Code of Conduct” for Health Plan and Provider Relations
4th Annual Investor Conference
May 16, 2001
HEALTH PLANS DIVISION
National Health Plan Structure
Judi Irving
President, Health Net of Arizona
20
National Health Plan Structure Creates Synergies
Operations Aligned Across Health Plans– Common Goals
– Aligned Incentives
– Opportunities to Share and Develop Staff
– Identification of Best Practices
Centralized Network Contracting– Leverage Volume
– Rx, Lab, Disease Management
21
National Health Plan Structure Creates Synergies (Cont.)
Operational Efficiencies– Centralize Front-end Claims Processing
– Out-of-Network Fee Negotiation Unit
– National PPO Contracting
National Practice Sales Leaders
– National Accounts
– Labor & Trust
22
National Health Plan Structure Creates Synergies (Cont.)
Product Development
Medical Management Strategy
Branding and Advertising Materials
Meet Local Market Needs With National Focus
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