Uncategorized Archives - Page 2 of 4

Transitioning from patchwork to quilt: NY and PA’s path to integrating HIEs at the state level

James Matheson June 26, 2012

Last month, NY and PA announced plans for how they will integrate data sharing across local HIEs. The state planning efforts share some key parameters: Roughly equal funding with about $20 million in federal grants Initially targeting the integration of data for about 13 million people (in PA’s case the entire state, in NY’s case the NYC metro area) Using a “thin” umbrella model to knit the various existing local HIEs together into a decentralized model Want community involvement of local doctors, community workers, and payers Beyond those parameters, however, the plans look quite different. NY’s approach: Start

Heartland Health: Marching towards Kansas City with Mayo on its shoulder

Tory Wolff May 31, 2012

Earlier this month, Heartland Health signed a deal with the Mayo Clinic for its doctors to virtually consult cases with Mayo physicians in return for an undisclosed fee. Heartland Health is a regional medical system in northwest Missouri and includes a ~350 bed acute care hospital (Heartland Regional Medical Center) with 200+ medical staff physicians, and the Heartland Clinic with 100 providers in 23 locations. Heartland is now the fifth hospital system to join the Mayo Clinic Care Network (MCCN), a structure launched by Mayo in September 2011. The deal substantially

The Blues system and PHIXs: not standardizing on a single utility

Tory Wolff May 29, 2012

BCBSMN has licensed the platform for its private health insurance exchange (PHIX) and defined contribution product from eHealth (original announcement April 30). For eHealth, which has seen its government systems revenue fall off by $2M year-over-year in the most recent quarter (per Q1 2012 analyst call), the deal will be a welcome addition to its non-commission revenue stream. It also represents a significant in-road into the Blues system (the previous deal with Blues I could uncover was in mid-2010 for licensing the technology behind Premera’s online Medsupp sales). It appears

Towers Watson’s bold move in private insurance exchanges: leapfrog Aon and leave Mercer’s alliance compromised

Tory Wolff May 23, 2012

With its acquisition of Extend Health, Towers Watson has ensured that (1) PHIXs will be a key competitive arena among the major benefits consultants and (2) that it has taken the lead. Extend Health serves 170K members and has annual revenues of ~$50M+, EBITDA margins of ~30% and a growth rate in the most recent reported quarter of 40% vs. a year ago (all taken from the S-1 filing and acquisition press release). Two leading competitors have been publicly discussing their capability building: Aon Hewitt began their exchange in April

CIGNA fills in its Medicare portfolio with Great American acquisition

Tory Wolff May 15, 2012

Last week, CIGNA acquired the Great American Supplemental Benefits from American Financial Group (AFG) for $295M in cash. Per press releases, the key financials for the acquired business are: A few observations on the acquired business: ~90% of the acquired revenue is driven by MedSupp. Public reports suggest 100K-125K MedSupp lives (250K lives total for the acquired business). Historically, AG’s MedSupp lives have been well distributed in the US with the exception of a sizeable position in Texas (the acquired business is Austin-based). The other 10% includes a variety of

Big box retail as health insurance channel: thoughts on the Aetna-Costco deal

Tory Wolff April 27, 2012

Summary Aetna has struck a deal to sell individual health insurance with Costco, the #6 retailer. The deal targets 9 populous states first with more to follow in 2012 While the deal lacks some of the levers of the very successful Walmart-Humana Part D deal, there is real potential for this channel to attract consumers if employers opt-out on a large scale Given that Aetna has some arrangements with Best Buy (the #9 retailer) and an established alliance with CVS (the #7 retailer), it looks like Aetna is building out

Payment reform: some observations on skepticism

Tory Wolff April 19, 2012

There have been some blog posts (here and here) about a discussion on payment reform at the Massachusetts Health Data Consortium last week. While I did not attend, the commentary is provocative and I would like to offer a few observations. The discussion included some critical perspectives on the prospects for implementing payment reform and whether its implementation will really bend the trend. My main point in response to the dialog is that payment reform needs to be understood as part of a dynamic trajectory, a multi-stage game. Couple variations

Franchising specialties: model for breaking down geographic barriers to competition?

Tory Wolff April 17, 2012

Summary Geographic barriers to provider competition are a headache for payers By importing capabilities, specialty franchising could help reduce some of the barriers to cross-geography competition It is too early to tell whether the recent Sarasota-Columbia is a good example of what franchising could do given the rapid growth in capacity for high-end cardiology in the area; it may be more about preserving network status and price point But payers should not assume the model will be a disappointing supplement to provider leverage: Instead, consider encouraging providers with differentiated outcomes

The ASO escape hatch for small group: California says “not so fast”

Tory Wolff March 31, 2012

Next week, the California insurance commissioner will propose legislation to deter small employers from exiting the traditional health insurance market and going self-insured. The legislation will put a floor on the amount of losses an employer must incur with any one employee before the stop-loss coverage is triggered (“attachment point”). This won’t affect larger employers which benefit from the balancing impact of their large numbers and so only need to protect themselves from the most catastrophic risks. The bottom lines of self-insured smaller employers are much more vulnerable to even

Home health’s LHC Group decoupling from the stock market: where is it going next?

Tory Wolff March 22, 2012

The PE firm TPG is reportedly considering investing in LHC, a publicly-held home health agency (LHC announced earlier this year they were exploring strategic options). PE funding could allow LHC to pursue a much bolder strategy in the wide-open post-acute care market. Home health With home health revenues of ~$560M, LHC is #3 behind Amedisys ($1.25B) and Gentiva (~$1.1B) and ahead of #4 Almost Family. These four operate in an incredibly fragmented industry of $70B/year (though most of their attention is on the $20B year Medicare FFS market). The vast

Lumeris, NaviNet and the emerging battle for cloud-based ACO enablement

Tory Wolff February 16, 2012

Summary Administrative clearinghouse NaviNet has been acquired by 3 Blues plans and a provider of analytics capabilities for plans and providers (Lumeris). Both NaviNet and Lumeris appear to need a strategic breakout. The key opportunity is coupling sophisticated cloud-based (=EMR agnostic) analytics with a real time communications platform touching 130K physician offices. If viable, cloud approaches to ACO enablement could reduce the upfront infrastructure cost for providers to go at-risk, therefore allowing smaller scale provider groups to participate in the new economics – an attractive proposition for payers unnerved by

Compete by creating more competitors: the Heartland Health deal and Aetna’s strategic jiu jitsu

Tory Wolff January 21, 2012

Yesterday, Aetna announced a deal with Heartland Health (an integrated delivery system serving northwest Missouri, northeast Kansas and southeast Nebraska) to create a new health plan for the small group market (2-50 employees) for 2 counties in Missouri and 1 county in Kansas. Heartland Health has a ~350 bed acute care hospital (Heartland Regional Medical Center) with 200+ medical staff physicians, and the Heartland Clinic with 100 providers in 23 locations. Most important, recent financial evaluations have given Heartland Health a startling 82% market share in primary service area (!).

Aetna and Best Buy: a new twist on retail in healthcare

Tory Wolff January 12, 2012

Aetna has struck a deal with Best Buy to sell four online coaching programs (fitness, weight management, smoking cessation and stress management) in new 1,200 sq. ft. “health technology departments” in 3 suburban Chicago locations. In these departments, Best Buy is selling a broad range of technologies and tools for fitness, sleep, nutrition and beauty alongside the Aetna programs. The strategy: target Best Buy’s tech savvy customers when they are thinking about health and when they have an expectation to buy (vs. for example being on-line when there is more

“Savings illusion” can become savings reality in the long haul: baby boomers to the rescue

Tory Wolff December 20, 2011

A recent article in the NEJM argues that cost savings from quality improvements are illusory because of the lumpy nature of healthcare capacity. Quality’s impact on utilization is just too small to be captured in a heavily fixed cost environment. Any reduction in utilization results in a trivial savings of direct costs and, more importantly, unchanged fixed costs simply being reallocated across the smaller volume. Cost reduction in a high overhead environment is indeed difficult (ask any of the big process consulting houses). It can be done, though it will

Bubble in acquisition pricing of Medicare Advantage lives?

Tory Wolff December 7, 2011

Several recent acquisitions suggest a rapidly growing valuation on Medicare Advantage (MA) lives. Last August, Healthspring paid about $3.6K per adjusted MA life with its acquisition of Bravo. (My adjustments extract the value of the PDP lives using the CVS acquisition of Universal American PDP lives as a benchmark and for the share of Special Needs Plan or SNP lives which typically have higher utilization levels and higher reimbursement). This past November, there were two major MA acquisitions, both with sharply higher prices. Cigna (CI) bought Healthspring for $3.8B —

XL Health in play: what do the three suitors see?

Tory Wolff November 18, 2011

UPDATE: United buys XL Health! Here’s what we surmised in the original post on this topic: “That leaves United. A leadership position in C-SNPs would fit well with United’s leading position in Medicare Advantage overall, #1 position in D-SNPs and #2 position in I-SNPs. The capabilities would also seem to be readily applicable to the broader Medicare population (given, for example, the potential transfers back and forth across between C-SNP and regular Medicare Advantage). The curious thing is that United dramatically reduced its C-SNP business last year (went from about

Emerging Unintended Consequences of Health Care Reform

Nikhil Bhojwani November 14, 2011

In complex system, even small changes can have big, unexpected consequences. These are occasionally beneficial but more often than not have a negative impact. Over the last year we have started to see some evidence for unintended consequences from the health care reform act. Negative impacts that we see are of two kinds: Perverse effects that directly affect the objectives of the act and side-effects that manifest in seemingly unrelated areas (see figure below). It is not the intent here to comment on the overall merits or demerits of

The CIGNA-Healthspring deal: local share key to top-line synergies but still missing from the equation

Tory Wolff November 10, 2011

Summary Provider discounts are a key priority for national accounts – which puts CIGNA (CI) and Aetna at a disadvantage; CI responding in part by trying to get closer to providers A provider collaboration strategy requires a critical mass of patients and provider mindshare. CI does not have it; nor will the Healthspring (HS) acquisition provide it given the limited geographic overlap between the two companies CI must therefore grow share in key markets to capture the deal’s potential provider collaboration synergies (though other synergies are certainly accessible) If CI

Six strategic choices made by CMS in the final ACO rules

Tory Wolff November 1, 2011

1. The final ACO rules largely maintain the demanding economic parameters for mature ACOs (Track 2) found in the originally proposed version (relative, for example, to the original PGP demonstration project): Potential for both downside and upside reward. Maximum shareable savings of 60% (less than in the original PGP demo); and the rewards are limited to an upper bound of total costs. In this regard, the ACO contract payoff locks a lot like your classic “collar” financial option (see graphic below). The starting cost benchmark based on the ACO’s actual

Narrow networks: adoption growing among smaller groups

Tory Wolff September 30, 2011

Kaiser’s latest employer benefits survey offers some interesting data on the adoption of narrow (or high performance) network products. See chart below: Couple of observations: Overall adoption at the firm level appears to stand at almost 20%. The data probably under-represents the share of firms with a narrow network product: firms which have narrow networks in their second or third most common plan would not appear in this data. However, the share of lives in a narrow network product is probably lower: I would think narrow network products are adopted

Category: Uncategorized

Recon takes an analytical look behind select developments in healthcare