© 2013 Health Catalystwww.healthcatalyst.com

© 2013 Health Catalystwww.healthcatalyst.com

February 12, 2014

The Analytics of Healthcare CO-OPs

© 2013 Health Catalystwww.healthcatalyst.com

What is a CO-OP?

·Consumer Oriented and Operated Plans

– Commercial, non-profit health plan licensed by its

state(s) – (501(c)29 designation) ... tax exempt

– Must be a “start-up” healthcare entity

– 51% of Board must be consumers of the plan and may

not have been in management after 7/17/2009

– Must be consumer governed with > 51% of members

being individuals & small groups

– May direct market and/or offer through Exchanges

© 2013 Health Catalystwww.healthcatalyst.com

What is a CO-OP?

·CO-OP main features Annual profits can only be spent to:

1.Lower future Premiums

2.Improve the quality of care delivered to members

3.Repay Loans awarded by the Federal Government

4.Accumulate sufficient reserves to provide for growth

& financial stability

© 2013 Health Catalystwww.healthcatalyst.com

CO-OP Financial Model

·Funding – Start-up Loans (CMS/Federal Government)

Repaid through CMS within five (5) years of each withdrawal Fixed interest rate at 1% below benchmark 5 year treasury rate with

significant late payment penalties

– Subsidy Loans Provided incrementally as milestones are met Repaid with interest through CMS within fifteen (15) years from the

date of each disbursement Fixed interest rate at 2% below the benchmark treasury rate with

significant late payment penalties

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Benefit Plan Design - EHB

Required to comply with specific state’s EHB

Essential Health Benefit must consist of:

Minimum standard of coverage for benefit design – Reasonable out-of-pocket spending limits – Cannot include any annual or lifetime maximum caps

Limits cannot be placed on coverage to invoke adverse selection Limits are placed on the number of plan choices for decision- making Insurers must offer full range of benefit plan designs

THIS IS KENTUCKY

KENTUCKY STATE SPECIFIC PARAMETERS

640,000 uninsured Kentuckians

34% of those with incomes at or below 138% of Federal Poverty were uninsured.

34% of Kentuckians who earn up to 200% of FPL were currently uninsured as well.

20% of Kentuckians were covered by some form of public insurance

THIS IS KENTUCKY ,TOO

Ranks 45th in overall health status by America’s Health Rankings

(2013)

Ranks 49th in overall health status by Gallup Healthways Well-Being

Index (2012)

#1 for highest smoking rate in the U.S.

#1 for preventable hospitalizations

#1 for cancer deaths

#6 for premature deaths

#6 for obese adults (1.1 million)

#7 for cardiovascular deaths

#9 for diabetes

2014 ENROLLMENT RESULTS

Offered all plan levels in the state(individual) Platinum Gold Silver Bronze Catastrophic

Open network which we continue to build

In-house medical management

State based exchange

Results: Approximately 24,000 lives to date

ESSENTIAL HEALTH BENEFITS

Ambulatory patient services

Emergency services

Hospitalization

Maternity and newborn care

Mental health and substance abuse disorder services, including behavioral health treatment

Prescription drugs

Rehabilitative and habilitative services and devices

Laboratory services

Preventive and wellness services, and Chronic disease management

Pediatric services, including oral and vision care.-

MEMBER EDUCATION

These members have been forced to navigate the social and medical systems alone due to their lack of insurance and often fail to receive many of the services they need.

KYHC Clinical Care staff will seek to educate our membership on the services available to them through our benefit designs.

INFORMATION COLLECTION

Use of Health Risk Assessments

Member interviews

Member outreach

Medical/Pharmacy claim review

CARE COORDINATION

• Engage patients with chronic illnesses while hospitalized

• Follow patients intensively post-discharge

• Teach/coach patients about medications, self-care, and symptom recognition and management

• Remind and encourage patients to keep follow-up physician appointments

PLAN ANALYTICS

Initial Pharmacy data will provide the first insight into membership

Concurrent review of hospital stays will also provide information

HRAs though self reported may also shed some light on membership

As medical claims are processed they can also provide valuable information

2015 GOALS

Received approval of federal loan for expansion into West Virginia for 2015

Already working on rates for plans for 2015 in Kentucky and Initial plan for West Virginia

Maintain member centric approach for medical management and partner with our PBM for analysis of trends in KY and preparation initial formulary for West Virginia expansion.

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Colorado HealthOP

A Health Insurance Cooperative That Is Turning Health Insurance Upside Down

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Colorado HealthOP Overview

●Created through funds from the Affordable Care Act and with the partnership of the Rocky Mountain Farmers Union

●We are a new, non-profit health insurance co-op●Our board will include members who buy our insurance

and will help to make decisions about how we spend our funds

●Commitment to community health through ongoing partnerships and campaigns

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Colorado HealthOP Mission & Vision

●MissionTo improve the health of individuals and communities through trusted partnerships with members, employers, and providers.

●VisionTo be a catalyst for the transformation of the health and vitality of Colorado communities.

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Insurance Designed to Make Members Sustainably Healthy

●Preventive care and healthy action incentives ●Shared responsibility ●Primary care provider partnerships

Insurance is supposed to help when people get sick or injured; we think insurance should also be there to help people stay healthy.

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(the Marketplace)

●Colorado HealthOP is one of the options on the marketplace

●The marketplace was created through the ACA

●Works like a airline booking website – you can compare plans and rates

●Metal tiers help to distinguish each plan and its benefits (bronze, silver, gold)

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This Is Colorado

●Overall Rank of 8th by America’s Health Rankings (2013)

●Overall Rank of 2nd by Gallup Healthways Well-Being Index (2012)●Lowest prevalence of obesity in the U.S.

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This Is Also Colorado

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And So Is This

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Health Is A Community Affair

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Community of Solution

●Problem Sheds●What is the problem?●Where is it?●Who does it impact?

●Asset Sheds●Local identification of

health problems●Local data●Local solutions

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“… and he stoppeth one of three…”

I would like you to meet Bill…

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no health?”

Cold –

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How do we get there? Where?

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Song of the Open Road…

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Big Data … or Dark Matter?

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Wide Data is part of the solution…

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Meaningful Data is …

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Bridge to Data

● Claims● HRA● Biometrics● EMRs● MEPS● BRFSS● CHAS● CO APCD

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David NapoliDirector of Performance Improvement & Strategic Analytics

David.Napoli@COHealthOP.org

Twitter: @Biff_Bruise

© 2013 Health Catalystwww.healthcatalyst.com

Questions and Answers

Additional Information• See us at HIMSS 2014 booth #6076

• Call 801.708.6800 to request a meeting

• Listen to two clients speak:‒ “Improving Outcomes with an

Innovative Approach to Population Health Analytics”» Stanford Hospital & Clinics » Yohan Vetteth, Pravene Nath, MD» Date/Time: Thursday, 2/27, 12 PM» Location: Room 304A, Session #229

‒ “Blending Clinical and Financial Data to Drive the Value Equation”» Texas Children’s Hospital» Charles Macias, MD» Date/Time: Wednesday, 2/26, 1 PM» Location: Room 304A, Session #191

• Follow us on Twitter: @HealthCatalyst

• Explore our site: www.healthcatalyst.com

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