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The Case for a Comprehensive Cross-Payer Health Database. Mac McCarthy, FSA, FCA, MAAA Middle Atlantic Actuarial Club September 13, 2013. Speakers. Mac McCarthy, FSA, FCA, MAAA McCarthy Actuarial Consulting Mac@McCarthyActuarial.com 804-651-5293. Tom Persichetti , ASA, FCA, MAAA

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the case for a comprehensive cross payer health database

The Case for a Comprehensive Cross-Payer Health Database

Mac McCarthy, FSA, FCA, MAAA

Middle Atlantic Actuarial Club

September 13, 2013

speakers
Speakers

Mac McCarthy,

FSA, FCA, MAAA

McCarthy Actuarial Consulting

Mac@McCarthyActuarial.com

804-651-5293

Tom Persichetti,

ASA, FCA, MAAA

Persichetti & Associates

Tom.Persichetti@PersichettiLLC.com

202-321-5426

www.McCarthyActuarial.com

agenda
Agenda
  • Current State of Healthcare Claim Data
  • Affected Parties’ Issues
    • Buyers
    • Payers
    • Researchers & Policymakers
    • Providers
  • Consequences
  • Why Consolidated, Shared Data Makes Sense
  • Potential / Emerging Solutions
  • Impediments & Concerns
  • Audience Q&A

www.McCarthyActuarial.com

current state of healthcare claim data
Current State of Healthcare Claim Data
  • Each payer has proprietary database
    • Payers include government programs, insurance companies (including HMOs), and employers
  • State all-payer databases
  • Data warehouse services
  • No central repository
    • Little or no information sharing

www.McCarthyActuarial.com

buyers issues
Buyers’ Issues
  • Buyers =
    • Individuals / Consumers / Patients
    • Employers
  • Inability to ascertain providers’ and competing treatments’ value
  • Information overload & credibility deficits
  • Frustration due to:
    • Poor communication between care providers
    • Inconsistent billing and benefit statements
    • Lack of accountability
  • Distrust is widespread

www.McCarthyActuarial.com

payers problems
Payers’ Problems
  • Payers =
    • Insurers
    • Employers
    • Governments
  • Projecting future costs
  • Fraud and waste
  • Assuring value for clients/employees/constituents
  • Managing financial risk

www.McCarthyActuarial.com

policymakers researchers needs
Policymakers’ & Researchers’ Needs
  • Credible data on alternative treatments for specific conditions
    • Prevalence, effectiveness & costs
    • Stratified by population characteristics
    • Considering comorbidities
  • Reliable information on the impact of:
    • Plan design
    • Alternative payment strategies
    • Wellness & disease management programs
    • Provider consolidation & density
  • Quantification of fraud, abuse and waste in the healthcare industry

www.McCarthyActuarial.com

providers concerns
Providers’ Concerns
  • Inappropriate / unmanageable risk assumption
  • Demand anticipation
  • Revenue protection
  • Reputation
  • Control

www.McCarthyActuarial.com

consequences
Consequences
  • FBI estimate for 2009 fraud1: 3% - 10% of total health spending ($75–$250 billion)
    • Recoveries in 2012? Only $4.2 billion2
  • Truven Payment Integrity Analysis3:
    • Annual fraud and abuse = $125 – 175 billion
    • Lack of care coordination = $25 - $50 billion
    • Provider inefficiency and errors = $75 - $100 billion
  • 1: Health Affairs, 28, no.5 (2009):
    • Combating Fraud In Health Care: An Essential Component Of Any Cost Containment Strategy
  • 2: HHS/DOJ Healthcare Fraud and Abuse Control Program, FY2012
  • 3: Truven Health Analytics: Payment Integrity Analysis, April 2013

www.McCarthyActuarial.com

consequences1
Consequences
  • Time for recommended evidence-based practice to be fully implemented4:

9 years

  • National Health Expenditures increase, relative to GDP growth, 2000 - 2011: Double

4: Commonwealth Fund: Blueprint for the Dissemination of Evidence-Based Practices in Health Care

www.McCarthyActuarial.com

consolidated shared data makes sense
Consolidated, Shared Data Makes Sense
  • Fraud payment avoidance
  • Consumer Driven Health Plans
  • Shared risk models
    • ACOs, PCMHs, Bundled Payments
  • Efficient capital investments and provider workforce development
  • Comparative effectiveness studies
  • Enhanced disease tracking for early identification of emerging epidemics and localized “hotspots”

www.McCarthyActuarial.com

potential emerging solutions
Potential / Emerging Solutions
  • Verisk Health
    • Pooled-Data Alliance between health insurers
    • “For the first time, healthcare payers will be afforded the same comprehensive view of suspect providers and schemes that has proved so successful for the property/casualty industry.”
    • Applies fraud detection tools developed in the property & casualty insurance markets, adapted to the healthcare environment

www.McCarthyActuarial.com

potential emerging solutions1
Potential / Emerging Solutions
  • HealthcarePays
    • Member-owned “industry utility”
      • Membership is open to healthcare payers and providers
    • “The HealthcarePays network connects employers, payers, providers, banks, key government agencies and waste and fraud systems to provide a level of transparency that enables unparalleled waste and fraud detection.”
    • Mirrors fraud avoidance techniques used by credit card industry
    • Cross-payer / cross-provider claims data will be available to members , subject to member defined governance and applicable privacy regulations

www.McCarthyActuarial.com

impediments concerns dialogue
Impediments & Concerns Dialogue

No one understands me

What do you mean?

www.McCarthyActuarial.com

slide15

You have

Questions

We have

Answers

www.McCarthyActuarial.com