Download - Transforming Health Care Delivery
René Lerer, M.D. President, GuideWell
o Serves 15 million people across 14 states with over 5 million in Florida
o $12 billion revenue
o 11,000 employees
o A data warehouse with approximately 45 terabytes of data
o Significant available capital
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Health Insurance Business
Shift to value-based world
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o Fee-for-service: volume based
o Independent practices practicing independently, often in silos
o Limited clinical integration & information sharing
o Reactive “sick-care”
o Aligned incentives via value-based contracts across multiple products
o Common governance & shared data
o Emphasis on wellness, prevention & population health management
o Proactive “health care”
o Integrated & aligned partners that unlock the value of the partnership
o Division of responsibilities to each party based on who’s best positioned to serve the patient
o Next-generation insurance products with unique value propositions & patient experience
What are the benefits?
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o Create value from clinical integration and physician acquisitions
o Better access to longitudinal data & real time information on patient populations
o Less “mother-may-I” care management
o Better financial alignment with payors and less zero-sum gain negotiations
What hospitals expect
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o Reduced bad debt from patient liability
o Solutions that reduce the number of Floridians without insurance coverage
o Ambulatory care services (rad, lab, surg) in-migration vs. out-migration
o Support to transition from volume to value
o Serve as patient’s health care quarterback in a model that makes it financially viable to do so
o Improved cost and quality data to make more informed referral decisions for patients
o Reduced bad debt from patient liability
What physicians expect
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o Less “mother-may-I” care management
o Technology and back-office solutions that allow the option for practices to remain independent in an industry that is rapidly consolidating
o More patient time and less administrative hassle
o Support with coding and documentation for accurate risk adjustment and STARs performance
o Leverage provider partners with feet on the street, multidisciplinary care management models for high-risk patients
o Engaged primary care partners and select specialists to serve as the patient’s medical home
o Mitigation of unit cost pressure
What payors expect
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o Less provider consolidation for the wrong reasons / price arbitrage
o Delivery partners able to turn their data into patient-specific action for STARs scores
o Launch next-generation insurance products/solutions that leverage the value of accountable care
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Physician-Centered Value-Based Care
Accountable Care Organizations (ACOs) with Major Health System
Using data as an asset: To power accountable care Data transparency provided in a variety of formats:
Daily o Inpatient Census Reporting (Admissions &
Discharges for Attributed Members)
Monthly o Attribution Reports o Care Gaps o Attributed Member Participation in DM/CM
Programs o Raw Claims for Attributed Members
(Medical & Pharmacy) o Various Utilization Reports (ER, Inpatient,
GDR, No Visits, High Dollar, New Members)
Quarterly o PMPM Financial Performance Reporting o Quality Metric Performance Reporting o Additional Member Level Reports (Chronic vs.
Other Quality Metric and PMPM Performance)
What we are looking for in a partner
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Our ACO progress and results…
o Industry consolidation: Hospitals, Physicians and Payors – What is the impact to the consumer?
o A rapidly growing B2C world where consumers’ expectations are very different than employers’
– How do we meet their needs ?
o The role of: – Telehealth and remote monitoring – Retail health: CVS, Walgreens, Walmart, Target, etc. – Digital engagement, navigation and decision support
o Where does disruptive innovation come from and can the establishment disrupt itself?
o ACO structures – Hospital vs. non-hospital led ACOs
Open issues for the Industry
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