Title: 1999 CAS SEMINAR ON HEALTH AND MANAGED CARE Health Care Provider Excess Insurance
11999 CAS SEMINAR ON HEALTH AND MANAGED
CAREHealth Care Provider Excess Insurance
- This presentation will probably involve audience
discussion, which will create action items. Use
PowerPoint to keep track of these action items
during your presentation - In Slide Show, click on the right mouse button
- Select Meeting Minder
- Select the Action Items tab
- Type in action items as they come up
- Click OK to dismiss this box
- This will automatically create an Action Item
slide at the end of your presentation with your
points entered.
- Prepared By
- Milliman Robertson, Inc.
- Arthur L. Wilmes, FSA, MAAA
2Prospective Trends in Healthcare
- Healthcare Providers Need to Consider Strategies
That Increase Efficiency - Forces in the Healthcare Market Will Make It Very
Difficult for Status Quo Providers to Compete
Effectively - Healthcare Providers Will Need to Develop Their
Patient Management Processes as if They Are Being
Paid Under Capitation
3Health Care Delivery Systems
- Independent Practice Associations (IPAs)
- Physician Practice Management Companies (PPMCs)
- Group Practice Without Walls
- Medical Group Practice
- Physician Hospital Organizations (PHOs)
- Medical Service Organization (MSOs)
- Foundation Model
4Independent Practice Associations
- Umbrella Contracting Entity for Multi-Specialty
or Single Specialty Physicians - Individual Physicians Reimbursed by the IPA
- Composed of Independent Physicians With Only
Central Contracting Being Common - Not Necessarily a Lean Mean Fighting Machine
- Some States will Regulate Like MCOs
5Physician Practice Management Companies
- Tend to Be Venture Capitalized Public Companies
- Last Two Years Have Not Been Kind to PPMCs
- Continue to Be a Force in Healthcare Market
- Approximately 27 Publicly Traded PPMCs
- Combined Equity Value Declined 49.3 During 1998
- Several High Profile Collapses
6PPMCs Have Experienced Some Recent Equity
Improvement
- At the End of 1998, the Aggregate Stock Value of
PPMCs is Up 12.8 Over the Last Six Months of
1998. - SP Rose 7.5 During the Same Period.
- Total Capitalization of PPMCs was Estimated at
Approximately 4.8 Billion. - Some of the Largest PPMCs Continue to Have
Difficulties. - Medpartners
- FPA Medical Management
7Group Practice Without Walls
- Independent Physicians That Aggregate Their
Practices Into a Single Legal Entity - Legal Merging of All Assets of the Individual
Physicians - Individual Physician Incomes are Affected by the
Performance of the GPWW as a Whole - Independent Nature of Practices Within GPWW Means
Independent Action - Difficult to Align Incentives
- Weak Capitalization
8Medical Group Practice Model
- Like the GPWW, but Physicians Become a Fully
Integrated Medical Group - No Multi-Site Independent Practice Groups
- Tends to be More Integrated Than a GPWW
- Be Wary of Top Heavy Groups
9Physician Hospital Organizations
- Joint Hospital and Physician Entity That is
Primarily a Negotiating Vehicle - Integration Tends to Be Weak
- Trial Courtship Before a Serious Relationship
- Open vs. Closed PHOs
- MCOs tend to View PHOs as Ugly Cousins
10Medical Service Organizations
- Service Bureau and Contracting Entity for
Physicians - Physicians Remain in Independent Practice
- MSO may purchase all or Some of the Physicians
Assets - Also Viewed as an Ugly Cousin by MCOs
- Purpose Tends to Be Centralized Common Services
11Foundation Model
- Generally Created as a Not-For-Profit
Organization Which Purchases Physicians
Practices - Must Provide a Substantial Community
Value/Benefit - Not Generally Formed With an Eye Towards Planned
Resources - Loose Control Over Physician Behavior
12Physician Compensation
- Fee-For-Service
- Capitation
- Withholds and Risk/Bonus Provisions
- Carve-Outs
- PCP vs. Specialist vs. Hospital
- Individual vs. Pooled Risk
- Affecting Physician Behavior
- Product
13Reimbursement is Key Underwriting Factor
- Usual and Customary Fees
- FFS and Discounts
- Relative Value Schedules (RVS)
- Capitation
- Diagnosis-Related Groups (DRGs)
- Per Diems (With and Without Outliers)
- Case Rates
- Ambulatory Patient Groups (APGs)
14Example of Effect of Reimbursement on CPDs
- Prudential
- The Travelers
- NYL Care
15Example of Effect of Reimbursement on CPDs
- Prudential
- The Travelers
- NYL Care
16Case Study - Scope of Engagement
- Feasibility of Offering Stop-Loss Coverage to
PCPs for Institutional Services - 12 PCP Care Councils (Practice Groups)
- 100,000 Excess Maintained by MGA
- Care Councils Going to Full Risk, Want Lower
Excess Limits
17Historic Costs and Variability
18Developing a Claims Probability Distribution
- Combined Individual Distributions of Historic
Claims - Trended Historic Costs by Assumed Incurred Trend
- Assumed a Piece-Wise Lognormal Distribution
Developed by Minimum Distance Method
19Empirical vs. Lognormal Distribution
20Effect of Age and Gender
21Effect of Group Size and Confidence Intervals
22Putting it All Together