transform or perish - the millennium alliance · transform or perish the need for transformative...
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Transform or Perish
The need for transformative technology in a rapidly changing/struggling industry
Dannette Coleman SVP & GM, Medica
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Thelackofsufficientmarketinnova4onhasresultedinsignificantlymoreGovernmentinterven4on
• 1850s–1sthealthcareinsurancepoliciessold• 1920s–Hospitalsofferpre-payforcertainservices• 1930s–1stBlueCrossplansintroduced• 1960s–Medicare&Medicaidlaunched• 1980s–DRGsappliedtoproviderreimbursement• 1990s–HIPAAsignedintolaw• 2010s–ACAandMACRAsignedintolaw(ACA–someorallrepealed–replacedwithwhat?)
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PressingChallengesfortheIndustry
RegulatoryChanges
• MedicareAccessandCHIPReauthorizationAct(MACRA)
• PatientProtectionandAffordabilityCareAct(PPACA)
EconomicPressures
• Lowercostswhileimprovingoutcomes• Design/Implementnewreimbursementmodels
• Reduceadministrativecosts
Meet/Exceedconsumers’expectations
• Personalizedandhasslefree• Retail-likeexperience• 24/7access
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Whatisthebiggestbarriertothesechallenges?
Technology• Legacysystemsareexpensivetooperate,maintainandmodify• Businessleadersmusttranslatechangingbusinessrequirements
toITresourcesincreasingrework,whichiscostanddelayeddeployment
• Componentsarenotintegrated,increasingcostsandminimizinginnovation
• Systemsbuiltdecadesago,nevercontemplatedtheuniquepaymentmethodologies/capabilitiesbeingexploredtoday
The secret of change is to focus all of your energy, not on fighting the old, but on building the new
-Socrates
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HealthcareReimbursementisposi4onedtochangerapidly–butisthemarketprepared?
AccordingtoaMcKessonHealthSolutionsandORCInternational2016nationalresearchstudy:• Payersestimatethat60%ofpaymentswillbeamixofcapitation/
globalpayment,payforperformanceandepisodeofcare/bundledpaymentsin`iveyears
• Halfofpayersandonly40%ofproviderssaidtheyarereadytoimplementbundles
• PayersaremoreoptimisticthanhospitalsthatVBRwillimprove`inancials(61%versus41%)
• ProviderssaidthattheirpaymentstiedtoFFSwilldeclineto39%within`iveyears
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Moderntechnologyallowsustoautomatenewpaymentmethodologies
Episodes/Bundles:Removestheadministrativehassleforprovidersbyallowingclaimstobesubmittedindividuallyandpayerstoprovidesinglepaymentorproportionatepayments,basedontheagreement.AllowsyoutodeIineperiodsoftreatmentusingservicedates,servicedeIinitionorotherconditionalclaimscriteriaasan“episode”
Capitation:Technologysupportsstandarddelegationofriskmodelincluding,primary,secondaryandglobalcapitationmodels.AlsosupportsdelegationofriskandadministrationwhichallowsformorecomplexrelationshipsbetweenIndependentPhysicianAssociations(IPAs)andahealthplanorasub-delegationagreementwithanotherclinicinsideoroutsidetheIPA
Compliancebasedpayments:AComplianceProgramcanbedeIinedforanAccount,Productortheoverallorganization(allmembers).Memberscanbeenrolledinaprogram,andthenevaluatedforcompliancewiththeprogram.Theircompliance,ornon-compliance,canbeusedtodrivebeneIitsand/orpremiumbillingrates.Forexample,youcouldcreateacomplianceprogramcalled"FitnessClubMembership,"wheremembersreceiveabillingcreditiftheyareenrolledinahealthclubfortheyear.
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Moderntechnologyallowsustoachieveadministra4veefficienciesandenablesefficienciesinpartnerships
Autoadjudication:Weachieved90%autoadjudicationwith99.6%quality“outofthegate”forcommercialclaims
Businessprocesses:Product“speedtomarket”:Built81“Zombie”productsin10days.Fullydeployed/testedinweeks.Previoustimelinewouldhavebeensixmonths+IntegratedCapabilities:Inatimestudy,reducedtheamountoftimetoreviewandcompleteapriorauthorizationby28%.Additionally,integrationnegatestheneedfor“adjustments”(measuredat$30-$45peradjustment)NewBillingRules:SuccessfullyautomatedACAgraceperiods
Provider/payerpartnerships:Assistingproviderswithaccountsreceivablechallenges:Buildingvalueforprovidersbycreatinginnovativeinitiativesincluding“one-stop”billingandreal-timeautoadjudicationCareManagerframeworkallowsinnovationindelegation:Plansandproviderscanhaveaccesstothesamedatainreal-time
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Technologyneedstobeacatalyst,notaninhibitor
• Streamliningandautomatingexistingbusinessprocesses
• DeliveringnewproductlinesfasterandwithmoreinnovativebeneIitdesigns
• Establishingnewproviderpaymentmethodologies• IncreasingefIiciencyandtransparency• Improvingcustomerservice
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Questions
DannetteColemanSVP&GM,Medica