MAY 2016

CUPA - 2019

INDUSTRY TRENDS AND

BENEFITS PACKAGINGAPRIL 26, 2018

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TODD CLARKE – DIRECTOR OF ACCOUNT MANAGEMENT – MCGOHAN BRABENDER

INTRODUCTION

Todd Clarke is a Director of Account Management and Team Lead in the large group segment. Todd has 25 years in employee benefits in the Columbus, New York and Chicago markets. His expertise includes financial modeling, stop loss reinsurance, program design, and strategic planning. He has extensive experience with large, multi-site, self-funded clients, including University of Dayton, Cintas, and Dannon. Todd earned a bachelor’s degree in mathematics and an MBA from The Ohio State University. Todd assists clients by leading strategic discussions, while contributing ideas and provoking clients to think innovatively.

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Industry Trends

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EDUCATION / ENGAGEMENT

CONSUMERISM

PURCHASING RISK MITIGATION

PSYCHOGRAPHICS

COST / QUALITY EDUCATION

ACCESS TO CARE OPTIONS

OUTCOMES-BASED PLAN DESIGN

MOBILE TECHNOLOGY

DIRECT CONTRACTING

VALUE BASED PLAN DESIGN

REFERENCE BASED PRICING

Rx RE-PRICING / CARVE-OUT

CAPTIVES

STOP LOSS CARVE OUT

CHRONIC CARE MANAGEMENT

DATA ANALYTICS / INDIVIDUAL RISK SCORING

RX ADHERENCE

AIRROSTI

BIOMETRICS

PHARMACOLOGICS

ENROLLMENT OPTIMIZATION

CONCIERGE HEALTH MANAGEMENT

ONSITE / NEAR SITE CLINICS

TELEMEDICINE / VIRTUAL VISITS

CENTERS OF EXCELLENCE

PRIMARY CARE ATTRIBUTION

DECISION SUPPORT TOOLS

PRICE TRANSPARENCY TOOLS

CONCIERGE HEALTH PROS

INDUSTRY TRENDS

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ALTERNATIVE HEALTH PLANS

REFERENCE-

BASED PRICING

ON-SITE / NEAR-SITE CLINICS

ALTERNATIVE MEDICAL MANAGEMENT APPROACHES

RX CARVE OUT / SPECIALTY MANAGEMENT

INDUSTRY TRENDS

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CO-PAYS

OUT OF

POCKET

MAX

EOBsPROVIDER

STATEMENT

WHAT YOU

OWE

YOU NEED

A MEDICAL

SERVICE

DEDUCTIBLE

IS THIS

COVERED? IS THIS

IN-

NETWORK?

Confidential: Not for distribution

CURRENT HEALTHCARE PROCESS

RECEIVE ONE

SINGLE

STATEMENT

GO TO DOCTOR,

RECEIVE SERVICE

LOOK UP YOUR

SERVICE, KNOW

EXACTLY WHAT YOU’LL

OWE

Confidential: Not for distribution

YOU NEED

A MEDICAL

SERVICE

SIMPLEPAY HEALTHCARE PROCESS

SIMPLEPAY PLAN N $0

$20

$45

$15

$60

$720

$0

$50

$100

$35

$140

$1,610

Preventive Care

PCP Office Visit

SPC Office

Lab Services

Radiology

Outpatient Hospital

Inpatient Hospital

Emergency

$2,225 $4,000

$410 $410

$5

$30

$45

$0

$10

$65

$100

$130

Tier 1 Rx

Tier 2 Rx

Tier 3 Rx

Mail Order

PHARMACY

MEDICAL

$60 $130Tier 4 Rx

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“A poorly communicated benefit is no benefit at all”

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COMMUNICATION TIMELINE

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PSYCHOGRAPHIC SEGMENTATION

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PSYCHOGRAPHICS DEFINED

http://c2b.patientbond.com/mcgohanclassifier

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HOW WE COMMUNICATE

VIDEO INTERACTIVEPRINT

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HOW WE COMMUNICATE – VIDEO (SAMPLE)

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HOW WE COMMUNICATE - PRINT

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HOW WE COMMUNICATE - INTERACTIVE

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WHAT WE COMMUNICATE

COST / QUALITY KNOW YOUR

NUMBERS

ACCESS

TO CARE

MEDICALLY

HOMELESS

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COST / QUALITY

Initiative to educate employees that health care does not follow the conventional logic that

higher cost equates to higher quality. Goal is to steer covered members to highest quality

providers and facilities.

Why: Many believe health care services costs

roughly the same regardless of where they are

provided. By showing members how to ask

questions, find comparative data, and

understand how contracting actually works,

better consumerism will come about.

If we can get members to receive the highest

quality care, in most cases will lead to lower

claims costs – with better outcomes.

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ACCESS TO CARE

Initiative to educate employees as to the 5 ways to receive care when it is needed and the

pros / cons of each. Based on psychographic segmentation, this can greatly reduce your ER

/ UC visits – replacing it with value-based contracted PCP visits or telemedicine.

Why: Employees end up in ER / UC because they either don’t address conditions

before they fully manifest or because of their current PCP relationship, they simply

cannot be seen in a timely manner.

EMERGENCY

ROOMPCPURGENT

CARETELEMEDICINERETAIL-BASED

CLINICS

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KNOW YOUR NUMBERS

(1) Source: Metabolic Syndrome and Employer Sponsored Medical Benefits: An Actuarial Study, Kathryn Fitch R.N., Med, Bruce Pyenson, FSA, MAAA, KosukeIwasaki, FIAJ, MAAA, Milliman, New York, NY, September 2007.

(2) Source: Prime Therapeutics, LLC, 2009. Includes Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma and Blue Cross and Blue Shield of Texas members.

Members who have been stratified as having Metabolic Syndrome (MetS) will be offered a

clinical program. That 10 week program program has documented success at reversing this

clinical condition.

Why: Metabolic Syndrome (MetS) is a cluster of factors that puts people at

high risk for developing heart disease, diabetes and other debilitating

illnesses. MetS risk factors include elevated blood pressure, low HDL (a

component of your total cholesterol), elevated triglycerides and blood

glucose and a large waist circumference. MetS endangers your employees'

health and wellness and can have financial consequences.

An employee with MetS can incur $3,671 in monthly medical expenses,

compared to an employee without this condition whose monthly medical

costs average closer to $626 (1). Members identified with MetS spend, on

average, $1,091 in annual pharmacy costs, compared to $282 for non-

MetS members (2).

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MEDICALLY HOMELESS

Initiative to get your medically homeless population to doctors who are value-based

contracted with the carrier as well as members who are using specialists as their PCP.

Why: The financial case is fairly straight forward. According

to one national carrier, for every member you have under the

care of a value-based contracted PCP, you will save on

average $9.50 PMPM.

More importantly, a large percentage of members who use

the ER / UC are doing so because they do not have a PCP

that will see them in a timely manner. Value-based PCPs

must set aside time in their appointments every day for

patients that have issues come up.

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QUESTIONS?