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Title: Consumerism

Consumerism and Actuarial Science in A 21st
Century Intelligent Health System
Ronald E. Bachman FSA. MAAA President
CEO Healthcare Visions, Inc. 404-697-7376 www.healthcarevi   Sr. Fellow - Center for Health
Transformation Sr. Fellow - Georgia Public
Policy Foundation Fellow - Wye River Group on
Healthcare Visions, Inc. Creating the
What Is a 21st Century Intelligent Health System?
  • In a 21st Century Intelligent Health System, the
    individual has
  • Accurate, timely knowledge of personal health
  • Access to the best information about how to
    maintain personal health,
  • Knowledge of whom to see and where to go for
    health services,
  • And confidence that health providers are
    practicing medicine using best practices based on
    the most up-to-date understanding of
    outcomes-based medicine.
  • In a 21st Century Intelligent Health System, the
    individual has the right to know the price and
    quality information about health services in the
    most accurate, least expensive, and most
    convenient manner possible.
  • In a 21st Century Intelligent Health System, the
    individual is the center of knowledge and
    decision-making and has responsibility for his or
    her own health.

Consumer-directed or Consumerism?
  • Consumer-directed health plans (CDHPs) utilizing
    an HRA or HSA are the newest weapon in the
    arsenal to reduce healthcare cost.
  • But will this approach really lower your cost?
  • CDHPs are a good start and can developing
    experience shows they can lower costs.
  • CDHPs are a good 1st generation attempt. The
    market is moving rapidly to 2nd generation and
  • The transformation is NOT to CDHP but to
  • Actuaries must go beyond traditional models to
    reflect the behavioral change component of a
    consumerism design.

Healthcare Consumerism
  • Healthcare Consumerism is about transforming a
    health benefit plan into one that puts economic
    purchasing powerand decision-makingin the hands
    of participants.
  • Its about supplying the information and decision
    support tools they need, along with financial
    incentives, rewards, and other benefits that
    encourage personal involvement in altering health
    and healthcare purchasing behaviors.

Elements of Healthcare Consumerism
  • 1. Budgeting monthly versus annual
  • 2. Risk Sharing pooled claims for large groups
  • 3. Savings NEW with advent of HRAs and HSAs

The Core of Consumerism
  • The Unifying Theme
  • for a
  • Health and Healthcare Strategy is

Behavioral Change
Implement only if it supports behavioral change
consistent with the strategy
Two Basic Principles for Successful Consumerism
  • Must work for the Sickest Members, as well as the
  • 2. Must work for those not wanting to get
    involved in decision-making, as well as the

Mega Trends
  1. Personal Responsibility
  2. Self-Help, Self-Care
  3. Individual Ownership
  4. Portability
  5. Transparency (the Right to Know)
  6. Consumerism (Empowerment)

The Evolution of Healthcare and
ConsumerismFuture Generations of Consumer
Directed Healthcare

2nd Generation CDHC Focus on Behavior Changes
Traditional Plans with ConsumerInformation
1st Generation CDHC Focus on
Discretionary Spending
4th Generation CDHC Personalized
Health Healthcare
3rd Generation CDHC Integrated Health
Traditional Plans
Behavioral Change and Cost Management
Potential Low Impact ---- ---- ---- ---- ----
---- ---- ---- ---- High Impact
Major Building Blocks of Consumerism

Personal Accounts
It is the creative development, efficient
delivery, efficacy, and successful integration of
these elements that will prove the success or
failure of consumerism.
Wellness/Prevention Early Intervention
Disease Management
Information Decision Support
Incentives Rewards
2nd Generation CDHC Focus on Behavior Changes

1st Generation CDHC Focus on
Discretionary Spending
4th Generation CDHC Personalized
Health Healthcare
Summary A peek into the future of Consumerism
3rd Generation CDHC Integrated Health
Personal Accounts
Initial Account Only Activity Compliance Rewards Indiv. Group Corporate Metric Rewards Specialized Accts, Matching HRAs, Expanded QME
100 Basic Preventive Care Web-based behavior change support programs Worksite wellness, safety, stress error reduction Genomics, predictive modeling push technology
Information, health coach Compliance Awards, disease specific allowances Population Mgmt, IHM, Integrated Back-to-Work Wireless cyber support, cultural DM, Holistic care
Passive Info Discretionary Expenses Personal health mgmt, info with incentives to access Health performance info, integrated health work data Arrive in time info and services, information therapy
Cash, tickets, Trinkets Zero balance acct, activity based incentives Non-health corporate metric driven incentives Personal development plan incentives, health status related
Wellness/Prevention Early Intervention
Disease Management
Information Decision Support
Incentives Rewards
Using Information Incentives To Change
Low Users Low Users Medium Users High Users High Users Very High Users
No Claims Generally Healthy Acute Episodic Conditions O/P, Low In/P, High Maternity Acute Episodic Conditions O/P, Low In/P, High Maternity Acute Episodic Conditions O/P, Low In/P, High Maternity Chronic Persistent . Conditions . O/P, Low In/P, High Chronic Persistent . Conditions . O/P, Low In/P, High Catastrophic
Mem 15 48 14 3 3 12 4 1
Dollars 0 12 15 12 5 21 20 15

Mem 63 63 32 32 32 17 17 17
Dollars 12 12 32 32 32 56 56 56
Wellness - Lifestyle
Wellness - Lifestyle
Wellness - Clinical
Early Intervention
Wellness - Clinical
Personal Health ManagementDecision Support
Low Users Low Users Medium Users Medium Users Medium Users High Users High Users Very High Users
No Claims Generally Healthy Acute Episodic Conditions Acute Episodic Conditions Acute Episodic Conditions Chronic Persistent Conditions Chronic Persistent Conditions Catastrophic
No Claims Generally Healthy O/P, Low In/P, High Maternity O/P, Low In/P, High Catastrophic
Pre-Natal Care
Reduce Variation in Evidence-Based Medicine
Reduce Variation in Evidence-Based Medicine
Patient Safety Centers of Excellence Patient Ad
vocacy/ Case Management
Discretionary Expenses
Psycho-Social Factors / Integrated Absence
Care Continuum and Tools for Changing Behaviors
Acute Conditionse.g., Infections, Respiratory,
Health Promotion
Health Risk Management
Chronic Disease Management
High Cost Case Management
Patient Identification and enrollment
Health Risk Assessment
Navigational Support
Address Comorbid Conditions
Targeted Behavior Modification
HealthyLifestyle Promotion
Patient Advocacy
Practice Guidelines
Physical Activity Campaign
Care Coordination
Care Coordination
Address Comorbid Conditions
Integrated Services, Communications, Measurement
and Evaluation
Integrated Health Management ProgramAn
Implementation Option for Multiple Generations
General Manager
Personal Care Accts. FSAs, HRAs, HSAs
The secret is cooperation and synergy between
components supporting the corporate strategies
Integrated Absence Mgmt
Acute Case Mgmt
Disease Mgmt Programs
Demand Management
Utilization and Case Management
Potential Savings from Full Implementation of
ConsumerismAchievement of savings and improved
outcomes is dependent upon both the Type and
Effectiveness of the programs implemented.
  Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)
Effective Programs Implemented Traditional plans Traditional plans Traditional plans  
Effective Programs Implemented Consumerism Plans Consumerism Plans Consumerism Plans
Effective Programs Implemented Passive Passive 1st Generation 2nd Generation 3rd Gen Future
Basic Basic 2 3 7 10
Expanded Expanded 3-4 5-8 12-15.0 20.0
Complete Complete 4 7 17 25
Comprehensive (Future) Comprehensive (Future) 5 10 20 30
Excludes Carry-over HRAs/HSAs and any added
Administrative Costs of Specialized Programs
Major Actuarial Issues
  • Anti-selection,
  • Value of wellness,
  • Disease management ROI,
  • Actuarial credits for behavioral change

Understanding Risk Selection and
Anti-selection The primary drivers of risk
selection are employee cost and the relative
benefit richness of the competing
options. Employees will tend to choose the
option expected to provide the best economic
benefit for their situation. For healthy
individuals the selection is usually low cost/low
benefit options. For less healthy individuals the
selection is usually high cost/high benefit

Selection effect is at least directionally
predictable in most cases. Mitigating factors
tend to reduce the magnitude of selection.
Health care costs are not fully predictable.
Plan choices are usually made at a family unit
level versus the individual level. .
Potential Anti-Selection from CDHC on an
Optional Basis
  • Introduction of CDHC on an optional basis will
    limit the cost reduction because fewer members
    will be impacted and because the members that do
    select CDHC are likely to have an existing
    favorable health status (anti-selection).
    Adopting companies and its members can benefit
    most by introducing consumerism with both a CDHC
    option and consumerism for all other plans.

Example - Selection in An Option Environment Example - Selection in An Option Environment Example - Selection in An Option Environment Example - Selection in An Option Environment
OPTION 1 Current Plan OPTION 1 Current Plan OPTION 2 - CDHC OPTION 2 - CDHC
Members Participating Clms/Part.Mbr. Vs Clms/All Mbrs. Remaining Members Clms/Part.Mbr. Vs Clms/All Mbrs.
90 101 10 87
70 103 30 92
50 103 50 97
Consumerism Choices involve Options for
Behavioral Change rather than Optional Plan
  • Consumerism Choices
  • Wellness
  • Preventive care
  • Early Intervention
  • Lifestyle Options (diet, exercise, smoking,
  • Self-help, self care
  • Discretionary Expenses (e.g. OV, ER, Rx)
  • Value purchasing (e.g. DXL, o/p vs. in/p)
  • Participation in Disease Management Programs
  • Compliance with Evidence Based Medicine
    Treatment Plans

Survey ResultsWellness Assessment Risk Factors
Value of Wellness What is it?
  • How Much Physical Activity Do the Experts
    Recommend? 30? 60? 90? Minutes of What?
  • The Centers for Disease Control and Prevention
    and the American College of Sports Medicine
    recommend the following
  • 20 minutes of vigorous-intensity physical
    activity 3 times a week or
  • 30 minutes of moderate-intensity physical
    activity 5 or more times a week.
  • What is moderate-intensity physical activity? Any
    activity that burns 3.5 to 7 calories per minute
    (e.g., walking briskly).
  • What is vigorous-intensity physical activity?
    Any activity that burns 7 or more calories per
    minute (e.g.,
  • climbing up and down stairs).

National Business Group on HealthComments on
  • Recent studies indicate that moderate increases
    in employees physical activity levels can result
    in significant decreases in company costs.
    Although existing research is limited, employers
    may use calculation tools and internal data to
    calculate the potential savings of an effective
    physical activity promotion program.
  • To reach a rough estimate of the cost of its
    employees physical inactivity, a company could
    turn to for a new
    online tool.
  • This Physical Inactivity Cost Calculator was
    developed by, among others, the Active Living
    Leadership Initiative, Fifty Plus Lifelong
    Fitness and the National Coalition for Promoting
    Physical Activity and Health.

Examples of Corporate Wellness ROI
  • Motorolas wellness programs which saves the
  • 3.93 for every 1 invested.
  • Northeast Utilities WellAware Program which in
    its first 24 months reduced lifestyle and
    behavioral claims by 1,400,000.
  • Caterpillars Healthy Balance program which is
    projected to result in long term savings of 700
    million by 2015.
  • Johnson Johnsons Health and Wellness Program
    which has produced average annual health care
    savings of 224.66 per employee.

Wellness ROI Studies
  • Many studies have focused specifically on the
    return on investment (ROI) from worksite health
    promotion and disease prevention programs.
  • Findings on the return on investment for health
    promotion and disease management programs were
    reported for nine employers Canada North
    America Life Chevron. City of Mesa, AZ General
    Mills General Motors Johnson Johnson Pacific
    Bell Procter Gamble and Tenneco. These
    programs provide health education to their
    employees to promote behaviors that will improve
    health or prevent disease, and typically include
    exercise programs, health-risk appraisal, weight
    control, nutrition information, stress
    management, disease screening, and smoking
  • The review found significant return on investment
    for the programs provided by these nine
    employers, with the range of benefit-to-cost
    ratios, ranging from 1.49 to 4.91 in benefits
    per dollar spent on the program, and a median of

Savings from National Wellness Program
  • Savings estimates revealed that participation in
    the National Wellness Program was associated with
    significant savings in dollars per employee from
    1991 to 1995, with the highest dollar savings
    achieved in 1995 (16 per employee per month).
  • Evaluation of the program showed that health risk
    assessment was associated with significant and
    substantial reductions in healthcare costs.
  • Employees who completed one, two, or three health
    risk assessments on average had lower 1997 health
    care costs of 112.89, 134.22, and 152.29,
    respectively. Employees who had completed at
    least one health risk assessment and participated
    in an additional wellness activity had an average
    cost savings of 200.35 per year.

CIGNA Wellness Savings
  • The Working Well Moms Program has decreased
    pharmacy costs 62 fewer prescriptions for
    breast-fed children. The program has also
    contributed to decreased medical costs a
    savings of 240,000 in healthcare expenses. In
    addition, program participants have 74 fewer
    absences per 100 mothers, a savings of 60,000 in
    lost time annually.
  • The Working Well Triumph Program has resulted in
    healthcare costs savings of more than 900 per
    program participant.
  • The Working Well Flu Shots Program participants
    have 29 less
  • absenteeism as compared to employees not
    getting a shot. This produced a savings of 33
    per employee participant. The overall return on
    investment for the program was 3 to 1.
  • CIGNAs smoking cessation program helped 67
    percent of its participants quit smoking after 12
    months, a quit rate up to three times higher than
    comparable smoking cessation programs. CIGNA
    estimates saving 949 in health care costs for
    each successful participant, a return on
    investment of 9.5 to 1.

Disease Management for Chronic and Persistent
  • The Agriculture and Health and Human Services
    Departments Dietary Guidelines for Americans
    2005 recommend the following
  • To reduce the risk of chronic diseaseat least
    30 minutes of moderate-intensity physical
    activity on most, preferably all days of the
  • To prevent the gradual accumulation of excess
    weight in adulthood, up to 30 additional minutes
    per day may be required over the 30 minutes for
    reduction of chronic disease risk and other
    health benefits and
  • To sustain weight loss for previously
    overweight/obese people, about 60 to 90 minutes
    of moderate-intensity physical activity per day
    is recommended.

Disease Management Program ROI
First Year Aetna HealthFund Members2004 results
(9 mos.) show low medical cost increase
Continuously Enrolled Members Allowed claims
Medical Claims Change
2003 Study (13.5K members) 3.7 increase in medical cost
2004 Study (9 mos.) (49K members) Early indicators 6 increase in medical cost over 2003
Change in Utilization ( of Units) 2003 Study (12 months of data) 2004 Study (9 months of data)
Inpatient Admissions -5.2 -6.7
ER Visits -2.6 -15.9
Outpatient Events -14.4 -4.6
ALL Office Visits -3.3 -3.4
PCP Visits -10.9 -12.3
Specialists visits 3.4 3.6
Note 12 month continuously enrolled results due
in August
What Happens in the Second Year to Allowed

1Q 03 2Q 03 3Q 03 4Q 03 1Q 04 2Q 04 3Q 04 4Q 04
Allowed Claims PMPM
  • Utilization in AHF increased at a lower rate
    than PPO, based on allowed claims
  • Reinforces assumption that AHF trend will be 1
    below PPO
  • Studies will continue to evaluate AHF trend
    into the third year

Allowed Claims are total claims, eligible for
payment before benefit plan is applied Based
on all AHF members from 18 of 19 plan sponsors in
2003 study one plan sponsor removed due to large
increase in AHF enrollment.
Highlights of the 2003 Aetna HealthFund 12-Month
  • Lower medical cost increase, applicable to
    first-year AHF members - 3.7 compared to double
    digit PPO plans
  • Diabetics continue to seek necessary care,
    relative to comparative populations
  • Increases in certain preventive care services
  • Reduction in pharmacy scripts and increased
    generic usage
  • Increased use of online tools, information, and
    satisfied members

2004 United Health Plan Experience
  • The iPlan study found
  • A drop in the number of claims per 1,000
    enrollees compared to the year before enrollment
  • A decrease in total emergency room visits,
    illustrating more selective, responsible use of
    emergency services
  • Significantly less-than-expected medical cost
    trends (per member/per month) than for
    traditional health plans when iPlan was the only
    option, the annual cost trend was less than 1
  • Reductions in specialist visits, outpatient
    surgeries and radiology and lab services and
  • Higher utilization of preventive services among
    iPlan participants.

LumenosKey Results Utilization Impact
  • 15 reduction in pharmacy costs
  • 92 generic substitution rate (open formulary,
    100 of rebates go back to employer)
  • 5 increase in preventive care expenditures
  • 18 reduction in outpatient visits
  • 85 graduation rate (Health Coach Program)
  • 42 HRA completion with incentive 28 opt-in to
    Health Coach
  • 60 of clients offer integrated health
    improvement incentives.

  • Are HSAs the right vehicle for large employer

Yes, If.. Or No, Because. Need to
Understand the Consumer Movement the
Transformation that is Underway
HSAs and HRAs Very Different
  • HSA A law, with specific requirements and
    benefit design requirements.
  • Most TAX ADVANTAGED vehicle ever created

  • HRAs No Law, this is a regulatory creation
    based upon an IRS ruling.
  • Most FLEXIBLE vehicle ever created

Incentive Awards - Three Very Different Personal
Care Accounts
  • FSAs Traditional Group Plans
  • Health Reimbursements Arrangements (HRAs)
    Employers choice for cash flow flexible
    incentive based medical plan benefit designs
    (best suited for self-insured groups)
  • Health Savings Accounts (HSAs) Employees
    choice for funded portable triple tax advantaged
    with High Deductible Health Plans (best suited
    for individuals and small groups)
  • Combination Accounts creative but confusing

Important Differences between Use of HRAs and
HSAs for Supporting Behavioral Change
Generation 1 Initial Account Only Generation 2 Activity Compliance Rewards Generation 3 Indiv. Group Corporate Metric Rewards Generation 4 Specialized Accts, Matching HRAs, Expanded QME
Personal Care Accounts
Health Reimbursement Arrangements
1. Any Amount 2. Notional Acct 3. Employer Determined 4. Employer Only Contributions 1. Flexible Activity Compliance Rewards 2. Employer Determined 3. Can not be cashed out 4. Must be used for healthcare 1. Flexible Indiv Group Rewards 2. Employer Determined 3. Can not be cashed out 4. Must be used for healthcare 1. Specialized Notional Accts, 2. Can terminate by employer rules 3. Potential IRS Expanded QME
Health Savings Accounts
1. Amounts Set by law 2. Real Dollars in Acct 3. Er or Ee Contrib 4. Contributions up to plan deductible of 1000-2650 Single 2000-5250 Family 1. Ltd Potential 2. Must give Cash Option 3. Awards must be same amt or same of deductible 3. HSA can be used (with 10 penalty) for non- healthcare expenses 1. Ltd Potential 2. All participants must receive same amount or same of deductible 3. Difficult to use for Group Incentives 1. Ltd Potential 2. 100 Vested Portable 3. Can use matching HRAs, 4. Potential IRS Expanded QME
The Evolution of Personal Care Accounts

Current State
Combination Accounts
Employer-based Healthcare Traditional (Use it or
Lose it) Special Purpose Non-Plan
Employer-based healthcare Special Purpose
Accounts Incentive Matching
Employer-based Healthcare with Individual
Individual-based Healthcare Employer-based Define
d Contribution Developments
Are HSAs the Wave of the Future?Which Point of
View Direction will We Take?
  • Yes, if.
  • 1. we recognize the HSA legislation and
    regulations as a good start and another building
    block for consumerism and behavioral change.
  • 2. there is additional legislation/regulation to
    support large Er interests in providing HSAs (use
    for healthcare only, Rx coverage problem,
    combination accounts).
  • 3. there is legislative support for the common
    use of FSAs for targeted needs, HSAs as Health
    Savings Accounts and HRAs as Health
    Reimbursement Arrangements.
  • No, because.
  • 1. they were not legislated/regulated with large
    employers in mind.
  • 2. of a desire to promote individual insurance
    over individual ownership (under employer and
    individual policies)
  • 3. they are just a tool to cost shift to
    employees, they can not reward behavior change
  • 4. they are only desirable to the young, healthy,
    and wealthy

  • Are HSAs the right vehicle for large employer

Yes, If.. Or No, Because. Need to
Understand the Consumer Movement the
Transformation that is Underway
The Fundamental Policy Question
  • Will Legislation/Regulation Use HSAs to
  • mainly promote portable Individual Small
    Group Insurance,
  • OR
  • expand Personal Care Account ownership through
    in both an employer-based and individual-based
    healthcare system thru HSAs, HRAs, and FSAs.

Growth of Personal Care Accounts
  • HRAs HSAs
  • 2000 None None
  • 2001 19,000 None
  • 2002 53,000 None
  • 2003 394,000 None
  • 2004(est) 1-1.5M 400,000
  • 2005(est) 3.2 M 1.0M
  • 2006(est) 6.0M ???
  • 2007(est) 12-15M ???
  • Deliotte Consulting

The Answer Flexible Health Savings Accounts
  • FHSAs would have the tax advantages of HSAs and
    the key flexibilities of HRAs.
  • Basic Principles
  • 1. Retain personal responsibility goal of
  • 2. Focus on Behavior Change
  • 3. Recognize value of Pay for Compliance as a
    driver for behavior change and shared savings
    with personal responsibility
  • 4. Expand adoption and funding of HSAs by large

Flexible Health Savings Accounts (FHSAs)The Next
  • Four needs that would allow FHSAs the flexibility
  • 1. Provide financial Rewards and Incentives for
    Behavioral Change.
  • 2. Encourage Employer/Carrier FHSA contributions
    towards healthcare
  • 3. Be provided with plan designs other than HDHPs
  • 4. Address FHSA/HSA Technical Issues

FHSA Flexibilty to Provide Financial Rewards and
Incentives for Behavioral Change
  • 1.  Allow for compliance incentives under disease
    management programs (e.g. diabetes, asthma, CHF)
    and wellness initiatives (e.g. wellness
    assessments, smoking cessation, etc.).
  • 2. Change Comparability Rule to mean all members
    under a given program of care or treatment, such
    as, a disease management or wellness program.
  • 3. Rewards and/or incentives should not be
    limited by the deductible limit, but should be
    consistent with expected savings from programs
    for which participation is being rewarded.

FHSA Flexibility to Encourage Employer
Contributions to Healthcare
  • Allow employers/carriers to voluntarily contract
    with employees to require employer/carrier funded
    FHSAs to be used only for healthcare expenses
    while employed and covered under the plan.
  • 2. Remove cap on employer/carrier funded FHSA
    contributions or expand to at least the plans
    Maximum Out-Of-Pocket total exposure in a given
    calendar year. 

FHSAs Flexibility to be Provided with Plan
Designs Other than HDHPs
  • 1. Preventive drugs include maintenance drugs.
    Drugs now defined as preventive by the Treasury
    Dept. can be covered below the deductible, while
    the cost of maintenance drugs is now included in
    the deductible.
  • 2. Allow Rx to exist as carve out benefits at
    least for prescription drugs associated with
    chronic and persistent disease states
  • 3. Allow incentive only based FHSAs for
    employer/carrier only funding under non-HDHPs
    (i.e. no initial FHSA funding or employee
  • 4. Allow some mental health and substance abuse
    benefits (besides EAPs) to be included under
    preventive care.

FHSA Flexibility - Technical Issues
  • 1. Allow FHSA/HSAs to go into effect on the first
    day of coverage is effective.
  • 2. Allow FHSA/HSA contributions for a full
    calendar year regardless of when a plan is
  • 3. Allow FHSA/HSAs to be used to pay for health
    coverage premiums (other than current limited use
    for (1) Premiums for coverage under the
    Consolidated Omnibus Budget Reconciliation Act
    (COBRA), and (2) premiums for HDHP coverage for
    those who receive federal or state unemployment
  • 4. Allow Flexibility to "post-date" the FHSA/HSA
    effective date so that FHSA/HSA dollars can cover
    expenses incurred before the account was
    established. Allow the account to be opened under
    a "provisional status" until the necessary
    paperwork is filed, at which time the account
    becomes active.

The Ultimate Successful Implementation of
  • Its about moving from a
  • benefit
  • to an
  • accumulating asset.
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