bigdata,big+trends: summit what’s+new+in+dental+ 2017 ...€¦ · session1....

Confidential and Proprietary

Learning & Informatics Summit 2017

Learning & Informatics Summit

2017Big Data, Big Trends: What’s New in Dental Informatics

Session 1




2017Big Data in the Dental Insurance Market

Part 1



Big Data in Business

Cost Reduction

Faster,better decision making

Newproducts& services



DentaBase™: Feeds Big Data and Analytics in the Dental Industry

Over 60 dental payers contributing monthly

data updates

Providesstatistically validdata set for over154,000 U.S.dentists

Claims datafrom over 64 MillionMembers(Current)Expert

determination/certification ofde-identificationof the datawarehouse

Representsdentists fromevery statein the country

v.1.0e

Data

Warehouse

2.1 BILLIONRecords in the database

75 MILLIONRecords added per quarter



The Unintended Costs of Siloed Operations

INCREASED $$ COST TO PAYER

!ANY WILLINGPROVIDER

Network RecruitmentBuild

Network

Sign up Any Provider

IncreaseAccessPoints

Network Management

!CONDONING

ABUSIVE BEHAVIOR

HighProvider

Satisfaction

Pay EveryClaim

FewerIncoming

Calls

Actuarial

!NON-COMPETITIVEDENTAL PRODUCTS

UtilizationUnnecessarily

Inflated

InaccuratePricing

Assumptions

Higher Employer Premiums

Claims

!FASTER PAYMENT OFUNWARRANTED CLAIMS

HighMember & Provider

Satisfaction PayClaimsFaster

IncreaseAuto-

Adjudication Rates

Less/StaticClaim Review

v.1.0e

Sales

!COMMODITIZEDPRODUCT

IncreaseNumber ofMembers

LowerPremiums

MoreAccessPoints



INCREASED EFFICIENCES/$$ SAVINGS TO PAYER

powered by DentaBase™

Target the Right Dentists with the Right Discounts

Manage Financial Risk of Abusive Behavior

Dynamic Claim Review Selection – Rank Order Probability of Savings

Competitive Pricing/ New Products

Big Data as a Tool: Enterprise Performance Optimizer Solution

Network Recruitment Network Management ActuarialClaims

!ANY WILLINGPROVIDER

!CONDONING

ABUSIVE BEHAVIOR

!FASTER PAYMENT OFUNWARRANTED CLAIMS

!NON-COMPETITIVEDENTAL PRODUCTS

!COMMODITIZEDPRODUCT

Sales

v.1.0e

More membership with better loss ratio



Audience Poll



Audience Poll

Are you using analytics in your operations today?

• Enterprise-wide• Specific functions• Not yet• No



Audience Poll

Do you have a burning issue? Where do you think big data and analytics can have the most immediate impact for your specific objectives?

• Recruitment and/or Network Management• Directory Accuracy• Utilization Management• Fraud Waste & Abuse Management• Competitive Pricing/Market Share• Other• None




2017Big Picture Dental Trends

Part 2



What is the distribution of treatments YOY?

Over 85% of all submitted treatments are Diagnostic, Preventive and Restorative!



What is the distribution of payments YOY?

Over 70% of paid $ are Diagnostic, Preventive and Restorative!



Where’s your membership’s treatment utilization?

• Over 90% of treated patients receive at least one diagnostic service! • Over 80% of treated patients receive at least one preventive service! • Over 30% of treated patients receive at least one restorative service! • Periodontics, Oral Surgery, and Adjunctive Services each impact about 10% of the treated patients.

• Endo and Ortho impact less than 5% and Prostho and Implants are all about or less than 1%.



DentaBase™ YOY Trends – Average Submitted by Procedure Category



DentaBase™ YOY Average Paid per Patient and Average Treatments per Patient

Calendar Year DentaBase™ Average Paid per Patient

DentaBase™Average Treatments per Patient

2015 $397 6.32016 $422 6.7

Average paid in 2015 is 47% of the Submitted Average. Average paid in 2016 is 47% of the Submitted Average.



Trend View for 2017

• Q1 2017 has a 1.9% increase in Total Treatments per 100 Patientscompared to Q1 2016.

• Q2 2017 is projected to achieve a similar year-over-year increase of 1.9% compared to the same quarters in 2016.



Taking it Large

• Mr. DeCapua has established actuarial insights that you can put into action in your company affecting and optimizing the bottom line through improved pricing.

• In addition, a brief step-by-step outline is provided that can be used to gauge the overall benefit and cost competitiveness of your product offering in new, unknown markets before entry.

• 30 years of actuarial experience in the insurance industry.

• Over 20 years of experience specializing in dental pricing and product development.

• 15 years experience working for insurance companies.

• 15 years experience working for a dental actuarial consulting firm.



Basic Building Blocks

• DentaBase™ - Key Data Elements• Submitted, Allowed, and Paid Amounts• Number of Treatments• Unique Patient Counts

• Metrics Developed from these Data Elements:• Price per Treatment (Price)• Treatments per Patient (Utilization)• Cost per Patient (Cost)

• Deeper Dives that get to the actionable insights:• In-Network (INN) and Out-of-Network (OON) performance• Adult claim costs compared to Children claims costs• Procedure Code and Procedure Category distribution• Geographic Implications (e.g., regional, statewide, zip code specific, etc.)

Basic Pricing Trend Elements



MarketVector™ - Using DentaBase™ to Determine Pricing TrendBased on trailing 12-month trends, average Price per Treatment trend has been dropping from a high of 1.3% in Jul-15 to -0.9% in Dec-16. It is projected to increase only slightly to -0.6% during the projection period.



MarketVector™ - Using DentaBase™ to Determine Pricing TrendBased on trailing 12-month trends, average Patient Utilization trend has been dropping from a high of 1.6% in Dec-15 to 0.2% in Dec-16. It is projected to remain at this level during the projection period.



MarketVector™ - Using DentaBase™ to Determine Pricing TrendBased on trailing 12-month trends, average Cost per Patient trend has been dropping from a high of 2.8% in Aug-15 to -0.7% in Dec-16. It is projected to increase slightly to -0.3% during the projection period.



In-Network Pricing Trend compared to Out-of-Network Pricing Trend



In-Network Costs Compared to Out-of-Network Costs

The data indicates that while average price per treatment is lower in-network, patient utilization is not. This results in higher cost per patient in-network when compared to out-of-network.



Differences in Pricing Trend by Procedure CategoryOral Exam Treatment Trends Oral Exam Submitted ChargesQ1 2017 has a 2.9% increase in Total Treatments per 100 Patientscompared to Q1 2016.

Submitted Charges per Patient for oral exams in Q1 & Q2 2017 are projected to see a 5.9% increase year-over -yearcompared the same quarters in 2016.



Procedure Category TrendsImaging Treatment Trends Imaging Submitted Charges

Q1 2017 has a 3.7% increase in Total Treatments per 100 Patientscompared to Q1 2016.

Submitted Charges per Patient are projected to see a 5.8% increase year-over-year in Q2 2017.



Procedure Category Trends

Preventive Treatment Trends Preventive Submitted ChargesQ1 2017 has a 3.3% increase in Total Treatments per 100 Patients compared to Q1 2016.

Submitted Charges per Patient are projected to see a 5.7% increase year-over-year in Q2 2017.



Procedure Category Trends

Restorative Treatment Trends Restorative Submitted Charges

Q1 2017 has a 2.1% decrease in Total Treatments per 100 Patientscompared to Q1 2016.

Submitted Charges per Patient are projected to see a modest year over year increase of 0.3% in Q2 2017.



Audience Poll



Audience Poll

What source(s) are you using to guide pricing trend today?

• CPI• Traditional 4%• Actuarial trend reports• Other




2017Turning DentaBase™ Aggregates into Insights for Your Company

Part 3



Overall Pricing Trend

Total Trend (2016/2015)

Price per Treatment

Patient Utilization

Cost per Patient

Total – DentaBase™ -0.9% 0.2% -0.7%SAMPLE PAYER 1 -1.3% -1.4% -2.8%

The ‘Cost’ trend is the total trend for use in pricing new and renewal business.



Deeper Dive – Overall Pricing Trend

In Network Out of Network

Price per Treatment

Patient Utilization

Cost per Patient

Price per Treatment

Patient Utilization

Cost per

Patient

Total –DentaBase™

-1.1% 0.2% -0.9% -0.6% 0.4% -0.2%

SAMPLE PAYER 1

-1.3% -1.6% -2.9% 0.0% -1.7% -1.7%

Drilling down provides even more insight to determine where the 3 metrics might be diverging from the market:• Adult/Children• Area 1/ Area 2• Exam Amounts, Restorative Amounts, etc.



Overall Competitive Position – Existing Market

Total Allowed AmountPrice per Treatment

Patient Utilization

Cost per Patient

Total – DentaBase™ $96 3.00 $286SAMPLE PAYER 2 $114 3.13 $357

‘Cost per Patient’ provides insight into ‘Premium’ differences in the Market.



Deeper Dive – Overall Competitive PositionExisting Market

In Network Out of Network

Price per Treatment

Patient Utilization

Cost per Patient

Price per Treatment

Patient Utilization

Cost per

Patient

Total –DentaBase™

$93 3.09 $286 $101 2.82 $285

SAMPLE PAYER 2

$110 3.19 $351 $147 2.73 $401




Effective Network DiscountINN/OON

Price per Treatment

Patient Utilization

Cost per Patient

Total – DentaBase™ 0.91 1.10 1.00SAMPLE PAYER 2 0.75 1.17 0.88The combined impact of patient utilization and price per treatment on ‘Cost’ is the resulting ‘Effective’ Network Discount.

Does the result of this measure mirror the ‘Effective’ network discount used in pricing?




Overall Relative Benefit Differential

Total Paid AmountsPrice per Treatment

Patient Utilization

Cost per Patient

Total – DentaBase™ $63 3.00 $191SAMPLE PAYER 1 $68 2.97 $203The combined impact of plan design, patient utilization and provider reimbursement affect the relative benefit differential.

This provides an even better proxy for evaluation of overall ‘Premium’ competitiveness.




Step by Step Evaluation for Competitive New Market Entry

P&R Dental Strategies determines the DentaBase™ and Sample Payer’s average INN & OON provider reimbursement levels by procedure code for the known area. This is average Price per Treatment, and also includes the metrics, Procedures per Patient and Cost per Patient that we’ve been discussing.

P&R Dental Strategies determines the DentaBase™ average INN & OON provider reimbursement levels by procedure code for the target area. Sample Payer determines their average INN & OON provider reimbursement levels by procedure code for the target area.

STEP1

STEP2



Universal Step by Step for New Market Entry Competitive Evaluation

P&R Dental Strategies calculates the relationship of the DentaBase™ known area to target area average INN & OON provider reimbursement levels and applies them to the Sample Payer’s known area INN & OON provider reimbursement levels to arrive at the Sample Payer’s Expected Price per Treatment in the target area.

P&R Dental Strategies calculates the relationship of the DentaBase™ known area to target area average INN & OON Procedures per Patient and applies them to the Sample Payer’s target area Expected Price per Treatment to arrive at the Sample Payer’s expected Cost per Patient in the target area.

The resulting Sample Payer’s target area expected Cost per Patient can then be compared to the DentaBase™ Cost per Patient in the target area to arrive at a proxy for the expected ‘Premium’ differential of the Sample Payer to DentaBase™ in the target area.

STEP3

STEP4

FINAL



Audience Poll



Audience Poll

In new business pricing, is trend applied equally to both INN and OON claim cost development, and is trend applied equally across all procedure categories (i.e. exams, prophy, x-rays, etc.)?

• Equally to INN & OON Claim Cost Development AND equally across all procedure categories

• Equally to INN & OON Claim Cost Development BUT not equally across all procedure categories

• Not equally to INN & OON Claim Cost Development AND not equally across all procedure categories

• Not equally to INN & OON Claim Cost Development BUT equally across all procedure categories

bigdata,big+trends: summit what’s+new+in+dental+ 2017 ...€¦ · session1....

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