2016年-德勤全球_Collaboration_meets_innovation_15页_1mb

Summary of Provider-Sponsored Health Plans (PSPs)

Core Content

Provider-sponsored health plans (PSPs) are emerging as a critical component of the evolving healthcare landscape, particularly in response to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These plans allow health systems to take full financial risk for managing population health, which can lead to greater rewards for innovative care models. The collaboration between health systems and health plans is seen as a strategic move to combine the strengths of both entities—health systems offer clinical expertise and brand trust, while health plans provide financial resources, technology, and risk management capabilities.

Main Points

• PSPs and MACRA: MACRA encourages the adoption of value-based care models by tying reimbursement to quality and cost performance. PSPs are uniquely positioned to succeed under MACRA due to their ability to align incentives and manage risk effectively.
• Collaborative Models: PSPs are often formed through joint ventures or partnerships between health systems and health plans. These models are seen as attractive due to the shared expertise and resources.
• Scale and Success: Scale is essential for the long-term success of PSPs. While they currently represent only 9% of the health insurance market, their presence is growing across 30 states.
• Key Capabilities: Successful PSPs require a range of capabilities, including actuarial skills, claims processing, patient engagement tools, and analytics. These are typically not found within health systems, making collaboration necessary.
• Challenges: PSPs face significant challenges, including internal silos, financial and regulatory risks, and aligning the goals of both health systems and health plans. These challenges can be mitigated through focused leadership and transparent governance.

Key Information

Examples of PSP Collaborations

• Anthem & Aurora Health Care: Launched a PSP in Wisconsin.
• Aetna & Texas Health Resources: Established a jointly owned health plan in Texas.
• SIHO & Blessing Hospital: A joint venture in Illinois to develop a self-insured product.
• Optima Health & Huntsville Hospital System: A collaboration in Alabama to create a Medicaid product.

Attributes of Successful PSPs

• Leveraging Collaboration: Combining health plan and health system strengths.
• Physician Alignment: Using financial incentives and information-sharing to align clinical practices.
• Population Health Focus: Emphasizing care coordination and data analytics.
• Customer Service: Prioritizing the patient experience and satisfaction.
• Geographic and Market Expansion: Expanding into new markets with local presence and tailored strategies.

PSP Opportunities

• Multiple Customer Channels: Serving individual, small group, Medicare Advantage, and Medicaid markets.
• Nimbleness and Local Presence: PSPs can operate with less complexity and without shareholders.
• Innovation Catalyst: Driving the development of new clinical models, tools, and technologies.
• Defensive Strategy: Helping health systems avoid predatory tactics by other health plans.

PSP Threats

• Physician Buy-In: Resistance to change from FFS to value-based models.
• Financial Performance: Poor performance in either the health plan or delivery system can threaten the viability of a PSP.
• Regulatory Complexity: Compliance with health plan regulations is a significant challenge.
• Market Competition: Competing with established health plans that have a broad market presence.

Strategic Considerations for Developing a PSP

• Start Small but Aim for Scale: Begin with a manageable scope and focus on expanding to achieve broader impact.
• Experiment with Different Lines of Business: Include employee and family coverage as a starting point.
• Determine Focus: Decide whether to prioritize Medicare, Medicaid, or commercial markets based on local conditions.
• Align Incentives: Ensure that both the health system and health plan are aligned in goals and operations.
• Invest in Technology and Analytics: Develop robust systems for data collection, analysis, and care delivery.
• Seek Compatible Partners: Choose partners with similar culture, vision, and market position.
• Prepare for Capital Investment: PSPs require significant financial resources.
• Maintain Transparency: Share performance data and ensure open communication between all stakeholders.

Conclusion

PSPs represent a promising avenue for health systems to innovate in care delivery and financial models, especially under MACRA's performance-based payment framework. While the path to success is complex and requires careful planning, collaboration, and investment, the potential rewards—both financial and clinical—are substantial. The lessons from existing PSPs highlight the importance of strategic alignment, focus on population health, and leveraging the combined strengths of health systems and health plans.