Primary Care First payment model overview

The Center for Medicare and Medicaid Innovation’s (CMMI) new voluntary payment model, Primary Care First (PCF), will debut in 2020. As its name indicates, the model focuses on primary care. PCF aims to offer additional flexibility in how physicians care for patients while holding them accountable for patient outcomes. It also provides providers a payment model option for accepting accountability for the high-need seriously ill population. Milliman consultants Raheel Sohail, Cory Gusland, and Daniel Henry provide an overview of the payment model in their paper “Early thoughts on the Primary Care First model.”

Best practice considerations for third party provider risk-sharing contract audits

Shared-risk contracts between health plans and healthcare providers are becoming increasingly common and sophisticated. As these arrangements become more prevalent, there is an increasing amount of money at stake between health plans and providers. Transparency and verification are best practices in any relationship between parties that involves money, and this includes provider risk-sharing agreements. A settlement audit prepared by an independent third party is a recommended best practice for any organization considering entering into or already participating in one of these arrangements.

The underlying principle in these agreements is straightforward: healthcare providers are in the best position to identify and reduce unnecessary, duplicative, or inefficient care, and shared-risk arrangements provide a financial incentive for providers to do just that. While shared-risk contracts may be conceptually simple, the actual real-world financial adjudication of them is usually complex.

This paper by Milliman consultants Colleen Norris and Tom Snook explores some proposed best practices for an independent audit of provider risk-sharing settlements, and discusses the value of this review for all parties involved.

How to lower defense costs using analytics (infographic)

For medical malpractice insurers, market pressures continued in 2018 despite overall profitability, according to a May report by AM Best. One way to combat potential headwinds is by lowering defense costs using advanced analytic techniques. In 2017, NORCAL Group began using Milliman’s Datalytics-Defense®, which uses proprietary data-mining techniques to analyze companies’ defense cost invoices and produce actionable insights. The results shown in the case study infographic below demonstrate the extent NORCAL was able to reduce their defense costs, all the while maintaining their overall claims-with-payment ratio.

India’s new Mental Healthcare Act: What does it mean for the insurers?

Mental health is a major concern worldwide with approximately 14% of the global burden of disease attributable to neuropsychiatric disorders. In India, mental healthcare faces challenges in terms of existing public health priorities and their influence on funding, shortage of mental health services facilities and resources, poor utilisation of available services by patients and caretakers and issues with the recovery and reintegration processes of those who are mentally ill.

The Mental Healthcare Act, 2017 (Act) was passed in India in April 2017 and put into effect in July 2018. It grants a legally binding right to mental healthcare to all citizens of India and is intended to set a foundation for delivering high-quality healthcare and protecting the rights of individuals receiving such care.

The Act aims to bring a number of changes in the healthcare sector through provisions that place greater emphasis on the type of care, treatment, and welfare of those suffering from mental illness. Additionally, the Act places an obligation on insurance companies to provide health insurance for mental illness on the same basis as other physical illness.

In this paper, Milliman’s Joanne Buckle, Neha Taneja, Rachin Aggarwal and Vidhi Gupta look at the key provisions of the Act, mental illness prevalence, supply-side indicators and the current treatment gap. They also discuss the results of an industry survey they carried out to understand the impact of the Act on the Indian health insurance market and the mental health landscape in select international markets to arrive at key learnings for the Indian market.

Long-term care valuation survey

Milliman has conducted its sixth triennial long-term care (LTC) insurance valuation survey. This year’s survey focused on individual LTC and did not include group business. Many of the survey questions remain consistent with the previous surveys, which allows for comparisons of the changes in response over time.

The objectives of this survey are to review and document the assumptions and methodologies related to the determination and testing of active life and disabled life reserves as well as the asset strategies and investments backing the reserves.

The information presented includes brief commentary on the application of various methods and approaches of several technical LTC valuation issues. The results of the survey are intended to provide interested parties with general benchmarks regarding insurers’ current valuation assumptions.

To read the full report by Milliman’s Al Schmitz and Tim Kempen, click here.

Making direct-to-provider contracting work

Are recent announcements of direct-to-provider contracting arrangements a bellwether of the direction that value-based care will take in the United States? Direct-to-provider contracting is a strategy in which a self-insured entity negotiates a contract directly with a provider of healthcare services rather than through a third-party administrator (TPA), often with the goal of driving value-based care. As part of a value-based contract, the provider is held accountable for improving patient outcomes through achieving key quality, cost, and utilization metrics on a wide range of services. This provides the “value” in value-based care for the self-insured entity.

The interest that providers and employers have expressed for direct-to-provider solutions is complicated by the numerous ways these arrangements can be structured. The key challenge is implementing a model that is acceptable to both the employer and the provider. In this article, Milliman’s Andrew Timcheck, Cory Gusland, and Mike Gaal discuss what each stakeholder wants in a direct-to-provider arrangement and how they can make it work.