Transcript Francis S. Soistman President and CEO

Pennsylvania HealthCare
Cost Containment Council
Seeing is Believing
Francis S. Soistman
President and CEO
June 4, 2003
HealthAmerica
Overview
• Subsidiary of Coventry Health Care, Inc.
• HealthAmerica & HealthAssurance
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Regional health plan founded in 1975
Over 650,000 members
132 hospitals & 17,000 doctors
Over $1.3 billion in revenue run rate
Full product spectrum
Highly experienced leadership team
Service Area
Our Approach
• Never compromise quality
–HEDIS®--highest quality ratings in the
region and above national averages
• Customer-driven
• Efficiency through
technology
• Innovative in medical
management and products
Utilization of PHC4
• Shows how we compare against
our peers & state averages
• HealthAmerica and/or
HealthAssurance:
–Surpassed competitors in 10 of 15
measures for preventive care
–Surpassed state and national
averages in all but1of 15 measures
HEDIS Scores
HEDIS Scores
HEDIS Scores
HEDIS Scores
HEDIS Scores
Utilization of PHC4
• Gives ideas for new initiatives for
improving
–Always room for improvement
–Diabetic incentive program to improve
outcomes
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We are well organized to supply
data
–HEDIS
–Data warehouse
Quality Improvement
Baseline
•Identify issue
•Collect data
•Analyze data for concern
•Draw conclusion
•Formulate action plan
•Implement plan
•Remeasure
•Modify as needed
Improvement
Utilization PHC4
• Quality comparative information about
health care is minimal
• Heath care decisions can be the most
important of an individual’s life
• Plethora of subjective, erroneous, and
biased information
• Comparative information can be of help
Filling the Void
• To make educated decisions, unbiased
information is needed
• PHC4 fills part of the void
• Useful to those who emphasize quality
• Cost of care is still important
• The available information serves as a
good foundation
Managed Care
• Focus on competitive differences
• Optimize outcome
• Stimulates plans with lower scores to
improve
• Plans with higher scores still focused on
improvement
• Size of plan doesn’t matter
• Health of community is improved
Future
• Help foster discussion between all
players
• Set the stage for collaboration
• Best health care system in the
world
• Solutions exist
Solutions
ISSUES
Medical Malpractice
Costs
Medical Technology
Costs
Patient Safety
Issues
Inefficiencies in
hospitals
STAKEHOLDER(S) WITH
POTENTIAL SOLUTIONS
GREATEST INTEREST/STAKE
Physicians/
1) Tort Reform
Hospitals
2) Legislative
3) Increase Malpractice Insurers Competition
Hospitals/
1) Use evidence based medicine to assess new
Health Plans
technologies
2) Education of providers/patients/employers
Physicians/
1) Adoption of Leapfrog Group Initiatives
Hospitals
2) Adoption of IOM recommendations by
hospitals/physicians
3) Computerized Physician Order
Entry/Electronic Medical Records
4) Regulatory oversight
Hospitals
1) Performance Improvement Processes
2) 7 day a week work environment for hospitals
Solutions
ISSUES
Lack of controls
over hospital
building projects
Lack of hospital
competition in
certain regions
Physicians
underutilizing
evidence based
medicine for medical
decision making
Society/patient
demand for medical
resources
STAKEHOLDER(S) WITH
GREATEST INTEREST/STAKE
Hospitals
Health Plans/Employers
Health Plans/Employers
Health Plans/Employers
POTENTIAL SOLUTIONS
1) Hospitals to perform detailed analysis before
instituting services
2) Health Plans to develop “Centers of
Excellence” for certain procedures
3) Education of employers to understand
concepts
1) Cooperation with all hospitals in a market
2) Antitrust oversight in affected markets
1) Education of physicians on nationally
accepted guidelines
2) Rewards/Incentives for those physicians
following guidelines
1) Education of physicians on nationally
accepted guidelines
2) Rewards/Incentives for those physicians
following guidelines
1) Education of patients/families
2) Media perceptions
Solutions
ISSUES
End of life costs
STAKEHOLDER(S) WITH
GREATEST INTEREST/STAKE
Employers
Pharmacy costs
Health Plans/Employers
Inefficiencies in
Health Plans
Health Plans/Employers
Fraud and Abuse
Health Plans/Employers
Regulatory
Requirements
Health Plans/Employers/
Hospitals
POTENTIAL SOLUTIONS
1) Emphasize use of hospice to
patients/families/physicians
2) Design benefits to cover hospice services
3) Case Management
1) Aggressive use of closed formularies and
generic drugs
2) Shift costs of patient requested drugs to
patients
3) Shift more costs of injectable medications to
patients
1) Performance Improvement activities for claims
and recoveries
2) Service excellence by all health plans
1) Education of those providers with aggressive
coding habits
2) Aggressive recovery of payments using a
strict, disciplined approach to offenders
1) Decrease use of clinical decision making by
legislation with education to legislators
2) Simplification of accrediting bodies/regulatory
bodies
Future
• Accountability by all
• We’re in this together
• Courage to make change