Transcript MBM 2011 Stump final 511

A Roadmap To Creating
A Real Health Care System
Mike McCallister, Chairman and Chief Executive Officer, Humana Inc.
Grandon Lecture
Jefferson School of Population Health
Thomas Jefferson University
Philadelphia, Pennsylvania
May 12, 2011
Humana Inc. – Overview
• Fortune 79 company, NYSE, $34 billion in annual revenues
• Founded in 1961, Louisville, KY
• Offers industry-leading health and supplemental benefits
solutions, and a nationwide network of primary care facilities
• Focus on lifelong well-being
• 35,000 associates
• 10.9 million medical members, 7.2 million members in
specialty products, more than 300 medical centers and 240
worksite medical facilities
• Second-largest Medicare provider, 5th largest pharmacy
provider in U.S.
• Dr. David Nash, member of Humana’s Board of Directors
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Outline
• Health Reform: Unintended Consequences
• After Reform, The Real Problems Persist – And Get Worse
• Since We Broke It, We Can Fix It: Behavior Change, One
Person At A Time
• Putting It All Together: An Innovative Well-Being Ecosystem
• Conclusion
3
Health Reform: Unintended
Consequences
4
Reform Timeline – Past and Future
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January 19, 2010
Scott Brown (R) wins MA Senate race
February 9, 2010
WLP files 39% premium increase in CA
March 23, 2010
President signs reform bill into law
2010-2013
(Commercial)
•
•
•
•
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•
Health insurance reforms
tax credits to small business
reinsurance to large employers with retiree coverage
web portal for comparative insurance shopping
temporary high risk pool
some provider rate adjustments
2014-2019
(Commercial)
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•
•
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•
Insurance exchange
mandates; rate restrictions
no pre-X
guarantee issue
premium taxes
wellness incentives
2010-2019
(Medicare)
• Medicare Advantage payment changes
• addition of Medicare FFS benefits
• Part D benefit enhancements
What the Public Thinks
• President’s Approval Rating (Gallup 3/19)
– 49% approve; 43% disapprove
• Congressional Job Approval (Rasmussen 2/11-3/13)
– 24.2% approve; 66.2% disapprove
• Health Insurance Industry Image (Public Opinion Strategies 2/19-24)
– 21% Favorable; 47% Unfavorable (20%/53% in 3/2010)
• Direction of Country (Rasmussen 3/1-3/13)
– 26.6% Right Way; 64.8% Wrong Way
• Health Reform Law (Rasmussen 3/12-13)
– 39% Support; 51.9% Oppose
• Reason for Higher Health Care Costs (Public Opinion Strategies 2/19-24)
– 42% Health insurer profits; 45% higher costs (47% / 42% in 3/2010)
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Unintended Consequences:
Rapid Growth of Hospital Charges in California
Statewide Absolute Growth in Net Inpatient
Revenue per Day, by Payer Category,
California Hospitals, 2000 - 2009
Possible Causes:
1.Market power of some
hospital systems
2.Slow growth in
reimbursements from MediCal
3.Moderately growing
Medicare payments
4.Uncompensated care for
uninsured patients
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Source: State of California, Office of Health Planning and Development
(OSHPD). Calculations by AHIP Center for Policy and Research
159%
76%
18%
Average Price for Selected Inpatient Hospital
Procedures, Oregon Statewide, Nine Health
Insurance Plans, 2005 – 2009
Normal Vaginal Delivery
Knee Joint Replacement
$28,682
$19,866
Absolute
Growth
69%
8
Source: Office for Oregon Health Policy and Research (OHPR).
Calculations by AHIP Center for Policy and Research.
Note: Mild/Moderate severity indicators
Absolute
Growth
44%
California Hospital Costs per Discharge:
The Public-to-Private Cost Shift
Net Inpatient Revenue per Discharge
Medi-Cal*
Medicare
Commercial
2000
$8,842
$8,324
$8,240
2001
$9,257
$8,798
$9,263
2002
$9,472
$9,559
$10,865
2003
$9,499
$9,871
$12,738
2004
$10,102
$10,162
$14,531
2005
$10,262
$10,800
$15,810
2006
$9,513
$11,493
$16,983
2007
$9,766
$12,007
$17,921
2008
$10,052
$12,841
$19,788
2009
$10,453
$14,168
$20,800
18%
70%
152%
2%
6%
11%
2000-2009 Growth
2000-2009 Avg. Annual Growth
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Source: State of California, Office of State Health Planning and Development (OSHPD) – tabulations by AHIP Center for Policy and Research.
Note: OSHPD data on comparable hospitals do not include data from Kaiser Permanente hospitals, or certain specialty hospitals, such as long-term
or psychiatric hospitals.
*Includes other programs paying for care for the indigent.
The Cost-Shift Is Not Greed – It’s A Response
To Skewed Incentives
Estimated Overall California Hospital Profit Margin: 3.2%
California Hospital Profit Margins by Payer
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Source: 2008 California Office of State-Wide Health Planning and Development (CA OSHPD)
Hospital Financial Reports
The Insurance Companies Aren’t Greedy Either
(Despite What You Hear)
Profit Margins by Sector - 2010
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Source: Fortune 500 Rankings, May 2011
Signs of the Times
“Health insurance premiums are high, and growing, because the
medical costs they cover are high and growing.”
- Mark Pauley
Health Reform Without Side Effects, March 2011
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After Reform, The Real Problems
Remain – And Get Worse
National Health Expenditures Per Capita, 1990-2019
$16,000
Projected
Historical
$14,000
$13,387
(2019)
$12,000
$8,047
(2009)
$10,000
$8,000
$6,000
$4,000
$2,814
(1990)
Per Capita
$2,000
Projected Per Capita
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90
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91
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92
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93
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95
19
96
19
97
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$0
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Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at
http://www.cms.hhs.gov/NationalHealthExpendData/ (Historical data from NHE summary including share of GDP,
CY 1960-2008, file nhegdp08.zip; Projected data from NHE Projections 2009-2019, Forecast summary and
selected tables, file proj2009.pdf).
Increasing Impact of Chronic Conditions
Prevalence of Chronic Illness (in millions)
Over 25% of young adults, roughly 50% of middle-aged adults and 69%
of the elderly have one or more chronic conditions
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Source: Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation.
The RAND Corporation/RAND Health, Document PM-1144
Hoffman C, Rice D, Sung HY. Persons with chronic conditions: their prevalence and costs.
JAMA. 276 (18): 1473-1479.
Health Literacy
• More than 90 million American adults have difficulty reading
and understanding instructions on prescriptions, appointment
slips, insurance forms and health education materials*
• Costs the nation $150 billion annually in waste and duplication
of medical services*
• Only 12 percent of adults have “proficient” health literacy and 14
percent have “below basic” literacy**
• Result: Higher costs, poorer outcomes
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*Institute of Medicine
** National Assessment of Adult Literacy
The Three Scariest Slides You’ll Ever See – 1…
Obesity Trends* Among U.S. Adults – 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
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<10%
10%–14%
Source: CDC Behavioral Risk Factor Surveillance System
…2…
Obesity Trends* Among U.S. Adults – 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
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<10%
10%–14%
15%–19%
≥20%
Source: CDC Behavioral Risk Factor Surveillance System
…3
Obesity Trends* Among U.S. Adults – 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
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<10%
10%–14%
15%–19%
20%–24%
25%–29%
Source: CDC Behavioral Risk Factor Surveillance System
≥30%
The Good News: It’s Our Fault
Access to Care
10%
Genetics
HEALTH
BEHAVIORS
20%
50%
20%
Environment
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Source: New England Journal of Medicine
Since We Broke It, We Can Fix It:
Behavior Change, One Person
At a Time
What Is The Solution?
• The obvious answer is – people should eat less, exercise more,
quit smoking, and read at a higher level
• They have been told to do that for two generations with
little to show for it
• So the obvious answer is the wrong one
• Clearly something different is needed
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Fostering Positive Behavior Change
That People Want To Pursue
• People must be motivated so they will happily choose
to change behavior
• Not shamed, forced, or badgered
• Instead: Powered up – through
– Transparent, actionable information
– The ability to seek out value in the health system,
then decide what’s best for them
– Programs that make healthy things fun and fun things healthy
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The Result
• Engagement that’s sustainable – because people want to engage
• Long-term positive behavior change
• Lower costs, for them and the system
• Better health outcomes
• Lifelong well-being
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Expanding the Focus
The Health Spectrum
Focus on Insurance:
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•
Risk management
•
Claims analysis
•
Disease management
•
Utilization management
•
Plan design
•
Wellness Programs
Focus on Population
Health & Lifelong Well-Being:
•Consumerism & Guidance
•Health risk avoidance
•Health analytics
•Behavioral economics
•Holistic view of person
Well-Being Approach
The Full Spectrum of Well-Being
Living happily with a balanced sense of purpose, belonging, security & health.
Purpose
Service
Vocational
Advocacy
Belonging
Social
Community
Family
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Consumer needs
Delivered by
Health
Physical
Emotional
Spiritual
Security
Financial
Personal Safety
Family
Environmental
Well-Being Components
Pillar
Health
Security
Purpose
WELL-BEING
is living happily
with a balanced
sense of purpose,
belonging,
security, and
health.
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Belonging
Area
Physical
Emotional
Spiritual
Financial
Personal Safety
Environmental
Vocation
Advocacy
Service
Social
Community
Family
Well-Being Pilots for Humana’s Associates
• Personal Health Score:
– Purpose: Provide objective clinical data coupled with actionable information to
drive health improvement
– Results: More than half (55%) of associates improved their individual score
• Personal Well-Being:
– Purpose: Improve participants’ sense of their own overall well-being
– Results: After five months, associates’ “thriving” self-assessment increased from
26% to 41% and “suffering” decreased from 10% to 6%
• The BiggestLoserClub.com:
– Purpose: Deliver a social, mobile and virtual weight loss pilot for associate
participants who have a BMI ≥ 28 and a desire to adopt healthy behaviors
– Results: Total pounds lost for all members – 3,474.40 lbs.
• Win, Place, Show Me The Money:
– Purpose: To understand the efficacy of financial incentives in facilitating behavior
change and healthy weight maintenance relative to weight loss over time
– Results: Total net weight loss across all participants = 8,657.81 lbs.
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Implementing Well-Being For Our Customers
Health
How can
Humana help me
stay healthy??
Security
Purpose
Belonging
Preventive Campaigns –
Encourage members to utilize
preventative services to support healthy
lifestyles and keep costs low.
Humana Cares® –
Interactive case management
helps seniors stay healthy, out
of the hospital, and at home.
e-Prescribing – Allow members
to receive instant feedback on
prescriptions regarding costs, effects
and generic alternatives while still in
the doctor’s office.
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Mobile Health
Screenings –
Conveniently offer members
screenings in their areas of
residence to boost health and
satisfaction.
Mobile health apps –
Programs like Didget and Famscape
help members stay active and healthy
through fun games and online
connections.
Humana Cares®: Improving Quality of Life
and Cutting Costs for America’s Growing
Senior Population
Humana Cares helps seniors stay healthy, out of
the hospital, and at home
The right member at the right time
for the right intervention
•Integrates past, present and future Health Risk Analytics
•Identifies members with Impactable risk
•Identifies and prioritizes members by tiers and rank ordering
•Promptly triages for a holistic clinical focus
– Conditions and diagnoses
– Clinical alerts
– Frail elderly score
– Increasing PMPM costs
– Medications
– Fall and safety risk
– Post discharge support
– Care transitions
•Benchmarks and monitors quality and financial outcomes
•Leverages community resources
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Belonging
Community
Social
Health
Physical
Humana Cares: Meeting a Growing Need
The number of Medicare beneficiaries will be growing dramatically
over the next decade as the baby boomers age in to the program.
Age-ins
Population Turning 65: Projected 2010 – 2020
Source: The U.S. Census Bureau, Population Projections
(http://www.census.gov/population/www/projections/files/nation/download/NP2008_D1.xls)
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File 1. Projected Population by Single Year of Age, Sex, Race, and Hispanic Origin for the
United States: July 1, 2000 to July 1, 2050
Humana Cares Is A Multi-Disciplinary Team
Delivering Positive Member Outcomes and
Lowering Costs for Seniors
An independent survey revealed that 77% of Humana Cares members
reported agreement with the statement, “As a result of the program
experience, I feel more prepared to manage my own health.”
Life-Enhancing Progress Achieved Through Humana Cares Participation*
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* Self-reported study of over 2,000 Humana members managed through Humana Cares for more than one year
The Infrastructure Driving Humana Cares
Humana CareHub:
Integrated Systems and Processes
Provider
Alerts
Nurse
Outreach
Nurse
Alerts
Customer
Service
Alerts
Member
Communications
Direct Mail – Email – Fax –
Smart Summary
Rules Guidance eXchange (RGX)
Business Rules – Prioritize and Route
Clinical Rules – Identify and Evaluate
Clinical Profile
Health
Assessment
Responses
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Pharma
Claims
Data
Medical
Claims
Data
External
Data
Sources
Lab & Test
Results
Personal
Health
Profile
Biometrics
& Health
Fairs
Benefits
Structure
Humana Cares – Community Resource Directory
1
Resource information
submitted electronically by
all staff
2
3
Resource filtered through
inclusion/Exclusion Flow
For credibility & use with Humana Membership
Verification of resource
contact & description
of services
CRS does not enter the resource into the
CRD. Humana Cares Team & Member gather
necessary information from
Humana Customer Service
CRD
Inclusion
Decision
CRS does not enter the resource into the
CRD. Humana Cares Team refers Member to
other persons for referral information (i.e.,
physician, family members, neighbors)
Yes
Is the resource
a State Unit on Aging
No
or state funded
resource?
No
Is the resource an Area
Agency on Aging?
No
Is the resource a
community based, notfor-profit agency?
Yes
Yes
No
Is the resource a
community based service
provided by a faith based
organization?
No
Is the resource
provided by Humana (Silver
Sneakers; MTM)?
Yes
No
Yes
No
Yes
Is it possible to divide
the resources into multiple
service categories as
separate entries?
Is the resource a
for-profit company that
provides services to the
general public?
Yes
CRS conducts a quality check including
information on the following:
- Resource Name
- All Location and Contact Information
- Description of Services Provided
- Point of Contact
- Hours of Operation
- Service Fees/Financial Aid Offered
- Website/Email
- Funding Cycle
- Languages Spoken
CRS obtains confirmation of the approval for the
resource; confirms approval with appropriate
Regional Director; conducts quality check on
information and enters into the CRD.
Yes
Does the resource
appear to be an approved
Market Office Humana
preferred organization?
Yes
Does the resource fall within
any of the other categories of
resource?
No
No
Is the resource a
long-term care facility; assisted
living facility or provider of
medical services?
Yes
No
CRS conducts a quality check
including information on the
following:
- Resource Name
- All Location and Contact
Information
- Description of Services Provided
- Point of Contact
- Hours of Operation
- Service Fees/Financial Aid Offered
- Website/Email
- Funding Cycle
- Languages Spoken
CRS divides resources into appropriate
categories and enters into the CRD
CRS follows process flow to make appropriate
decision about entering the resource.
CRS does not enter the resource into the
CRD. Humana Cares Team refers Member to
other persons for referral information;
Customer Service or available non-profit
resource to assist.
No
CRS seeks assistance from CRS Team and
Director for assistance in classification of
resource and further steps.
CRS enters resource into the CRD
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6
Quality Monitoring based on
Resource Categorization
Categorization
Basic Needs
Individual and Family Life
Health
Government Programs
Legal Services
Associations
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Frequency
3 Months
6 Months
9 Months
12 Months
12 Months
12 Months
Printer Friendly version
for Member
Sectioned areas with large font
Resource published
4
On The Forefront of ACOs
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•
Humana has 23 years of experience with accountable care models
•
Over 500,000 Medicare Advantage and 90,000 commercial
members in accountable care
•
System capabilities designed for robust exchange of clinical and
financial information with provider partners
•
Flexible reimbursement models to serve various ACO
arrangements
•
Prefer highly engaged and independent Primary Care Physician at
the core of the ACO but have track record of success with
Integrated Delivery Systems
Humana’s Accountable Care Organization pilot
• Unites expertise of Humana and Norton Healthcare of Louisville
• One of only five pilots in the U.S. authorized by Dartmouth
and Brookings
• Accountability of measured outcomes, cost, and patient delivery
• Industry-standard performance measures including financial,
quality, regulatory
• Core principles:
– Integrated care delivery among provider teams
– Defined patient population to measure
– Pay-for-results based on improved outcomes and cost
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How Can Health Care IT Help Create A Real Health
and Well-Being System?
• Standardization
• Simplification
• Real-time claims adjudication
• Multi-payer portals
• Evidence-based medicine for physicians
• Actionable information for consumers
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Availity – Setting The Standard
“Availity is one of the best-kept secrets in health care.”
– Newt Gingrich, Founder, Center for Health Transformation
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Availity CareProfile
• Real-time electronic health records
– Office visits and hospitalizations
– Diagnoses and associated
procedures
– Prescription history
– Lab event history
– Lab results
– Radiology event history
– Immunization history
– Clinical messaging
• Currently sourced from information
which resides with the health plans
• Offered to providers at no charge
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Well-Being Leadership on a Global Scale –
2011 And Beyond
• Humana heads the World Economic Forum’s Workplace
Wellness Alliance
• A global consortium of 34 multinational corporations,
representing three million employees worldwide
• Dedicated to measuring the link between better employee
wellness and improved employee engagement and productivity
• Interactive website, with metrics and best practices, launched at
the WEF Davos Summit in January
• Will be showcased at United Nations preventable disease
summit in September
• Sponsor of Be Well Week as part of United Nations conference
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Putting It All Together: An
Innovative Well-Being Ecosystem
The Context
• Wellness is “squishy”
• Needs intellectual, statistical and actuarial rigor to make
a measurable positive difference in people’s lives
• A South African company, Discovery, has developed a proven
health-behavior-change model, supported by an actuarially
sound incentives program
• HumanaVitalitySM is a new joint venture with Discovery’s
U.S. subsidiary
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HumanaVitality’s
Personal Pathways in Action: Meet Chris
Complete an
HRA
Determine Vitality Age
and set health goals
Risk assessment
Vitality Age
1. BP high
Actual Age: 37
2. Glucose high
Vitality Age: 58
3. Cholesterol high
4. BMI > 30
Goals
5. Smoker
6. No exercise
1. Quit smoking
2. Lose weight
3. Start to exercise
4. Manage diabetes
5. Reduce
cholesterol
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Obtain a Personal
Pathway
Earn Vitality Bucks and
achieve a Vitality Status
Enjoy Vitality
Rewards
Vitality Lottery
Sample Activities That Chris Can Choose to Get
Rewarded for Health Improvement
Education
Prevention
Health Risk Assessment
Pap smear, Mammogram
First Aid certification
Prostate exam
CPR certification
Childhood immunizations
Online calculators
Flu shots
Vitality Check™ blood screenings
Healthy Living
Fitness
Workouts at partner health clubs
Tobacco free
Workouts with verifiable devices
Weight management
Onsite fitness centers
Blood pressure
Fitness activities (ex. 5k race)
Blood glucose
Group fitness activities
Cholesterol
Organized wellness activities
Blood donation
Member can take over 30 actions to improve their health status. Automatic feeds allow
for accurate monitoring and direct link between action, health status and incentives.
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Integrated Online Vitality Mall Provides Broad Rewards
to Motivate Differing Aspirations
Value
Vitality Mall
provides access
to over 600,000
rewards
Frequency of use
46
HumanaFit: Chris’s Integrated Member Experience In
A Digital Environment
•
•
•
An experience that extends across
multiple communications channels –
web, email, mobile (iPhone,
Android, BlackBerry, and soon,
iPad)
Leverages an existing solution that
delivers a competitive and best-inclass program, with a unique
branded advantage, in a total digital
environment
Personalized and socially networked
47
Mobile – iPhone (Apple app store), Android (Android market), BlackBerry (Site download)
Putting It All Together: The Well-Being Ecosystem
48
Conclusion
Conclusion
• Out-of-control health costs, resulting largely from negative
health behaviors, is the problem
• Sustainable behavior change, powered by data that’s
personalized, actionable, and digitally available in real time,
is the solution
• Lower costs and better outcomes is the result
• Humana is dedicated to helping people achieve
lifelong well-being
• In other words …
50
Making Healthy Things Fun . . .
. . . And Fun Things Healthy
Humana
Active Outlook
53