569 Woodland Road

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Presented By Jacque J. Sokolov, MD
Sokolov, Sokolov, Burgess
569 Woodland Road Pasadena, CA 91106 Phone
[phone] Email JJSPSO_at_aol.com
500 W. Main Street Louisville, KY 40202 Phone
[phone] Website ssbconsult.com
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The Consumer Driven Health Plan Philosophy
Managed care doesnt meet consumer, employer or
provider needs or expectations. We must change
the system through shared technology that
enhances performance, drives down costs, and
empowers all participants. Health Plans that
combine stability and scale with innovation can
make this change real.
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Overview

• Changing the System
• - What Are The Problems/Opportunities
  ?
• The Vision
• - The Synergy Triangle and Key
  Strategic Elements
• The Process
• - Multi-Generational Health Plan
  Evolution
• Getting To The Future First
• - Consumer Driven Health Plans

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Changing the System
The Old Managed Care Model Does Little to
Address Satisfaction/Core Performance Issues
Core Performance Issues
Dissatisfaction of Key Constituents

• Medical Errors
• Practice Variation
• Waste
• Cost

• Consumers/Patients
• Employers
• Providers
• Legislative/Regulatory
• Bodies
• Financial Community

Old Managed Care Model
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The Vision The Synergy Triangle
Technology Can Now Empower and Connect
Everyone, Creating a Powerful New Synergy

• Consumers
• Choice
• Information
• Tools
• Less Interference
• Transparent Pricing

• Employers
• Reduced Administrative Costs
• and Hassles
• Reduced Medical Costs
• Broader Health Plan Selection
• Expanded Ad Hoc Reporting

Provider

• Providers
• Automated
• - Patient Eligibility
• - Benefits Coverage
• - Claims Status
• Decreased Administrative
• Hassles
• Real Time
• - Claim Payments
• - Alerts

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The Vision Key Strategic Elements
Consumer Centric Strategy - Empowered
Consumers Market Responsive Strategy -
Generate Powerful Benefits for
Outstanding Providers/Employers Connected
Technology Strategy - WebEnabled/Digital
Infrastructure Capabilities
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The Vision Consumer Centric Strategy

• Empowering the Consumer by
• Viewing Every Aspect of the Health Care
  Experience Through the
• Consumers Eyes
• Learning, That By Meeting the Needs of the
  Consumer, All Other
• Key Constituencies Will Follow
• The Consumer Cannot Be Empowered Without the
  Right Information at
• the Right Time

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The Vision Market Responsive Strategy

• Rewarding Excellent Providers and Committed
  Employers by
• Understanding the Unique Nature of the Health
  Care
• Experience on a Market by Market Basis
• Crafting Market Based Partnerships that Link
  Excellent Providers
• and Innovative, Action-Oriented Companies
• Attaining Critical Mass Through Consumer,
  Provider Employer
• Participation

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The Vision Connected Technology Strategy
New Consumer Driven Health Plan Model
Utilizing WebEnabled/Digital Infrastructure
Capabilities to Connect the Empowered
Consumers and High Performance Providers

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The Process Multi-Generational Health Plans
Evolve
Managed Care Plans
Transparent Market Place/Plans
2nd Generation Digital Consumer Driven Health
Plans
1st Generation WebEnabled Consumer Driven Health
Plans
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The Process Administrative Fees

• Our WebEnabled/Digital Consumer Driven
  Health
• Plans Attack Administrative Costs - 12 to
  24 Months
• Clean Electronic Claims Submission 1.5-2
  Premium Decrease
• Less Complex Network Administration 1 Premium
  Decrease
• All Others
• - IVR Requirements Reduced Premium
  Decrease 0.25
• - Printing/Paper Costs Reduced Premium
  Decrease 0.25
• Benefit Design Shifts More Choice/Cost to
  Employee Variable Premium Decrease

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The Process Medical Loss Ratio

• Our WebEnabled/Digital Consumer Driven Health
  Plans Attack the Medical Loss Ratio Through
  Consumer Centric Care - 12 to 24 Months
• Consumer Centric Care Reduces Utilization of
  Top 20 of
• Patients 0.5 Premium Decrease
• All Other Savings - 3
• - Volume of Services When Patients Migrate to
  More Effective
• Providers
• - Self Care Incentive Programs/High Cost
  Patients
• - Medication/Compliance Programs
• - Changes of Provider Practice Secondary to
  Feedback
• Mechanisms
• - Drug Safety Edits

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Getting to the Future First
WebEnabled Consumer Driven Health Plan Example
Humana/ChoiceCare Health Plans
Live Internet Demonstration

• Increased Functionality Expanded Consumer,
  Provider Employer Portals
• - Search Capability, E-billing
• Expanded Content
• - Wellness, Newsletters, Policies
  Procedures
• - Administrative Manuals, Certificates of
  Coverage (SPDs)

• HMO, HMO-POS
• 150 eApplications Launched 10/2000
• First Automated/Real-time Transactions
• - ID Card request PCP Change
• - Claims, eligibility, benefit verification
• - 80 of MD/Hospital claims submitted
• electronically in Cincinnati

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Getting to the Future First
Individual Navigators
Health Plan Member
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Impact of Rx3 or Its the design!
Getting to the Future First
25.0
20.0
15.0
10.0
5.0
0.0
1Q99
2Q99
3Q99
4Q99
1Q00
2Q00
3Q00
4Q00
Total Commercial Pharmacy Trends
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Impact of Physician Knowledge of Costs
Getting to the Future First
Is cost of medicine an important consideration
when prescribing?
Is cost of medicine an important consideration
when prescribing?
Is cost of medicine an important consideration
when prescribing?
Under what circumstance do you consider patients
cost when prescribing?
Under what circumstance do you consider patients
cost when prescribing?
Under what circumstance do you consider patients
cost when prescribing?
Are you aware of actual drug costs?
Are you aware of actual drug costs?
Are you aware of actual drug costs?
Source Physicians Attitudes About Prescribing
and Knowledge of Costs of Common Medications,
Archives of Internal Medicine, Oct. 9, 2000
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Engaging the Consumer
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Getting to the Future First
Digital Consumer Driven Health Plans Example
Humana Emphesys Health Plans

• Expanded Content
• - Personal Health Record, Pre-
• Determination of Benefits, On-line
• Guides, Expanded Benefit Plan
• Information
• Expanded Adoption
• - Member and Provider Functionality
• Expanded
• Transparent Universal Network

• ePPO Products
• 200-500 eApplications
• Most Transactions Automated
• Real-Time
• Access Functionality for all
• portals
• More Complicated Transactions
• - Bill Payment, Claims Adjudication

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The Commitment
A Consumer Driven Health Plan That Exceeds
Expectations

• Efficient Implementation of Consumer Centric,
  Market Responsive, and Connected Technology
  Strategies
• Staged WebEnabled/Digital Health Plan Evolution
  that Stands on Its Own and Leads to the Next
  Level of Improvement
• Behavior Changes Among the Consumers, Providers,
  and Employers that Create Synergy that Benefits
  Everyone

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Addendum
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The Vision Key Technology Differences of the
Two Generations of eHealth Plans
Consumer Driven Health Plans
Traditional eHealth Plans

• eBusiness Layer
• 50-100 eApplications
• Inquiry/Content Updates/
• Transactions most not in real time
• Primarily Front End functionality
• without Back End system
• integration

• eBusiness Layer
• 150-500 eApplications
• Integrated Inquiry/Content Updates
• /Transactions approach in real time
• Robust functionality with both
• Front End Back End
• integration

Front End

• Legacy SystemsLimited Flexibility
• Multiple platforms lack
• compatibility
• Complex MD group contract
• admin. not auto-adjudicated

• ChoiceCare System
• CAS System
• MetaVance Plus System

Core Application Systems
Core Application Systems
Back End

• Corporate Information Factory/
• Data Warehouse
• At best, operational data stores
• data warehouse tied to less
• than optimal legacy systems
• Data integrity issues

• Corporate Information Factory/
• Data Warehouse
• Superior operational data stores
• (daily or real time)
• Data warehouses with multiple
• accurate data marts
• Accurate Information

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Multi-Generational Health Plans Evolve
Requires

• Win-Win at Each Stage
• True Partnerships
• Cant Flip a Switch and Get There
• Each Stage Must Lead to Next

Transparent Market Place/Plan
Managed Care Plans
2nd Generation Digital Consumer Driven Health
Plans
1st Generation WebEnabled Consumer Driven Health
Plans
Requirements for Success

• Lower
• administrative
• cost by
• eConnectivity
• Provider
• Tools Requires
• critical mass of
• MDs to drive
• use of eClinical
• solutions

• Providers
• create own
• prices as
• supported by
• markets
• New levels of
• information
• and transparency
• drive behavior
• change

• Consumer
• Tools To
• manage
• information
• and rate
• providers
• The best care
• provision
• shows through
• to consumers

• Minimally
• effective in
• influencing
• care
• Effective in
• contracting
• for price

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Multi-Generational Health Plans Evolve
Scale is Necessary
Transparent Market Place/Plans

• True Transparent Market
• - Cost Quality
• Driven Decisions

2nd Generation Digital Consumer Driven Health
Plans

• 85 of Providers Connected
• 50 of Employees Utilizing eFunctions
• 99 of Communication Paperless
• Full Replacement Product

1st Generation WebEnabled Consumer Driven Health
Plans

• 50 of Providers Connected
• 25 of Employees Utilizing eFunctions
• 90 of Communication Paperless
• Personal Choice Product (offered along side
  other products)

Managed Care Plans
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Access Connectivity
Consumer Portal
eChoiceCare
eChoiceCare
eChoiceCare
Employer Portal
eChoiceCare
eChoiceCare
Employer
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Expansive Benefit Design
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WebEnabled Consumer Driven Health Plans

• HEALTH PLAN ELEMENTS
• Accelerated Eligibility Determination
• Expanded Search Capability for
• - Certificate of Coverage
• - SPD
• - Provider Directory
• - Pharmaceutical Coverage
• Claims
• - Automated Adjudication
• - Improved Inquiry Capabilities
• - Historical Data Availability

• CONSUMER CENTRIC CARE
• Personal Health Record
• Health Risk Assessments
• Patient Care Alerts
• High Quality Health Information
• - Preventive Care
• - Acute Care
• - Alternative Medicine
• Interactive Health Care Decision Support Tools

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Digital Consumer Driven Health Plans
Digital Consumer Driven
Health Plans

• Consumers
• Choice
• Information
• Tools
• Less Interference
• Transparent Pricing

• Providers
• Automated
• - Patient Eligibility
• - Benefits Coverage
• - Claims Status
• Decreased Administrative
• Hassles
• Real Time
• - Claim Payments
• - Alerts

.
Consumers
Providers
Employers

• Employers
• Reduced Administrative Costs
• and Hassles
• Reduced Medical Costs
• Selection shifts more to the Employee
• Expanded Ad Hoc Reporting

Agents
Health Plan Associates

• Agents
• Expedited Quotations
• Automated Enrollment
• Specialized Underwriting
• Capabilities

• Health Plan
• Associates
• Real Time Access to Member, Provider, Payer
  Information
• Expanded Customer Relationship Management (CRM)

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Consumer Centric Model

• Connected data portals and analysis to anticipate
  members needs
• Integrated resources with personal navigation
• Personal health record
• Messages and Alerts
• Access to interactive content
• Shared decision-making health coaching services
• On-line physician and hospital rating
• Survey and evaluation capabilities to listen to
  members experiences and expectations

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Consumer Information and Survey Tools
http//www.

• DoctorQuality.com
• condition and disease-specific workbooks
• identify best practice physicians or hospitals
  and rate provider experiences
• 24,000 pages of easy-to-navigate health
  information

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Integrated DATAMART Drives Interventions
Outreach
Lifetime Navigation
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Consumer Centric Care
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Exceptional Functionality for Providers
Digital Consumer Driven Health Plans Connect to
the eClinical Information Super Highway
.
Consumers
eClinical Information Super Highway
Providers
Employers
eBusiness Process Management
Lab Data - Physician Service/
Decision-Making
Brokers
Patient/Consumer Education
Health Plan Associates
MD/Patient Relationship
Pharmaceutical Data - Co-Branding/Data
Electronic Medical Record - Content/DSM
Imaging Data - Clinical Images/Education
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eHealth Plans Evolve to Consumer Driven Health
Plans
Consumer Driven Health Plans
Traditional WebEnabled Health
Plans Incremental improvements to traditional
health insurance via Internet facilitated
automation, electronic data transfer and related
efficiencies.

• Transformative Products that are
• Consumer Centric
• Market Responsive
• WebEnabled/Digital

HighMark (W.PA) Vivius (Minneapolis
KC) HealthMarket DifinityHealth Lumenos eHealth
Direct
Traditional WebEnabled Health
Plans- United.com, Cigna.com, Aetna.com
Consumer Driven Health Plans
Consumer Driven Health Plans - Humana
ChoiceCare - Emphesys
Managed Care Plans
1998 2000
2003