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Total Care Plan
Joint development of a new and effective
vehicle for delivering health benefits
Tim Cappel, President, Humana of Ohio
William Banks – VP, Revenue Cycle, St. Elizabeth
Project Selection &
Purpose
• Project Selection
•
The development of the Total Care Plan was selected as a unique
opportunity to solve the problem of rising medical cost trends in a
way that increases quality and preserves patient choice
• Alignment
•
•
Both Humana and SEH stood to gain market share by developing
a unique product in the market.
Both also stand to ‘re-develop’ an understanding about how to
manage and market a limited network health plan.
• Stakeholders
•
•
Humana and SEH are both major stakeholders
Every employer in No. KY is also a stakeholder, since they stand
to gain as we learn to better manage medical trend.
Current Situation
• Identifying the Root Causes or Improvement
Opportunities
•
•
Medical cost trend statistics (Gr. Cincinnati/ No. KY market)
Key drivers – unit cost/ utilization/ mix change/ duplication
• Identifying Final Root Causes
•
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Utilization as THE actionable driver
St. E internal trend as proof that keeping care internal can help trend
• Stakeholder Involvement
•
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Humana as the keeper of data and actuaries who analyze
St. E as the keeper of local market knowledge and willing partner
Chamber of Commerce as catalyst to encourage local businesses to
consider this option.
Solution Development
• Method for Selecting Possible Solution(s)
•
To lower costs, we had three options to choose from:
1.
2.
3.
More aggressive price negotiation,
Lowered benefit levels,
Design a system that reduced utilization of services
• Final Solution Selection
•
•
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Only option #3 above offered the promise of long term price and trend
reduction
Offered a more limited access product alongside more traditional
benefit plans
Shared expected savings with employees by lowering their payroll
contribution
• Benefits to Final Solution
•
Allowed those who didn’t want to switch the ability to stay with their
current plan
Project Results
•
Results
•
•
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•
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The new product attracted 5,420 St. E
members (49%) year 1 – now our largest
offering
Humana estimates 7,500 members from all
employers by 1/1/12
Effectiveness
•
St. E overall medical trend (excluding highcost cases 2011 vs. 2010 is -2.4%)
Admits (-5.8%), ER(-2.8%), OP svcs (-2.1%)
all down
Within St. E, the HMO population showed
significantly lower utilization rates in all areas
– IP(-44%), OP(-31%), MD visits(-20%), Rx
(-25%)
Validation
•
•
54,830 member months of data (5,420
members in the HMO)
Sustainability
•
•
•
Applicability and Use By Other
Organizations
•
•
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SEH has made a long-term commitment to this
concept
To continue to attract buyers, the product must
show approximately 10% savings vs. larger
network offerings.
The product was designed from the start to be
available to any employer, fully insured or self
funded. It requires no customization
Total Care Plan is a valuable precursor to ACO
development.
Innovation
•
Previous efforts at trend management have
failed because the care providers haven’t had
incentive to reduce costs. The Total Care
product represents a new approach to
managing health care benefits in which each
player brings their unique strengths and both
are aligned around the common goal of
medical cost trend reduction.