Many health systems around the world are introducing new care models which claim to replace expensive acute inpatient care with more primary and community-based services. This paper by Milliman consultants examines the primary care redesign of seven US practices over the course of three years, including their reported utilisation and savings achievements.
The high cost of therapy for patients with chronic hepatitis C (HCV) infection has been an important topic of discussion for key stakeholders in pharmacy benefit design and management. Multiple effective treatments have been introduced, with cure rates approaching 100%.
Although costly, curing HCV early on can prevent serious liver complications, such as hepatic cirrhosis, organ failure, and cancer, for the approximately 2.7 million affected people in the United States.
In 2016, there was a downward cost and utilization trend for the HCV Specialty category. Express Scripts reported in its 2016 Drug Trend Report that utilization of HCV therapies had decreased by 27.3% and the unit cost had decreased by 6.7%. The cost per member per year (PMPY) for HCV drugs decreased to $25.26 PMPY from $38.44 PMPY the previous year.
Why have cost and utilization suddenly decreased after two years of steady growth?
Milliman has released the 2017 edition of its triennial report on the estimated costs of U.S. organ and tissue transplants. The report summarizes average annual costs per member per month (PMPM), including utilization and billed charges, related to the 30 days prior and 180 days after transplant admission for organ and tissue transplants. This includes single-organ transplants such as heart, intestine, kidney, liver, lung, and pancreas, and a number of multiple-organ transplants; tissue transplants include bone marrow and cornea.
While the findings vary greatly by transplant and population type, the study found that, when compared to all combined organ and tissue transplants in the 2014 report, billed charges saw an average annual increase of 3.5% for those under 65, and 7.7% for those over 65. The analysis also revealed a dramatic decrease in wait times for kidney transplants and intestine transplants, while wait times for organs such as heart and pancreas have increased since the 2014 report. Survival rates have generally increased slightly when compared to Milliman’s previous report.
Organ and tissue transplants are a vital but expensive healthcare service, and the costs for these transplants are not readily available. This research is an important tool for providers, payers, and the public to better understand the utilization and billed charges surrounding organ and tissue transplantation.
To view the complete report, click here.
International private medical insurance (IPMI) provides employees with long-term travel obligations access to broader healthcare services. The global IPMI market has become very competitive. Expectations are that the market will continue to grow. In this article, Milliman’s Joanne Buckle and Neha Taneja take a look at some key pricing and experience rating items for group IPMI issuers to consider.
Here is an excerpt:
Dealing with multiple geographies, changing regulations, various health systems, diverse demographics and movement of the insured population results in a number of additional complexities when compared to rating a traditional PMI policy. Here are some of the key factors IPMI providers need to consider:
- Local data limitations: The wealth of data that a traditional health insurer holds on domestic PMI policies is usually insufficient for pricing an IPMI product, because:
- IPMI policies usually offer a more much comprehensive benefit package.
- Differences in the socio-economic profile of the target market, resulting in markedly different benefit features and claims experience.
- Distinct claiming patterns due to the international nature of the benefits.
- Variation in utilisation patterns by country and nationality.
- Portability offered under an IPMI policy allows full access to benefits wherever the employees are and it is difficult to predict where different services will be consumed.Obtaining reliable and relevant data with a desired level of granularity can be challenging making it difficult to get any credible results on which to base sound conclusions.
- Geographical area of coverage: This is considered one of the key rating factors for an IPMI policy as claims costs can vary significantly between countries. For example, most insurers provide separate cover for ‘worldwide excluding US’ and ‘worldwide including US’, because healthcare costs are typically much more expensive in the United States than anywhere else in the world. Most insurers would classify countries into different regions/levels/zones that have broadly similar costs and healthcare systems for more accurate rating. However, constructing such classifications is difficult because:
- Limited claims experience for some countries and lack of data for others makes the classification statistically less sound.
- Even countries with similar costs may have different types and quality of healthcare services, disease trends and state healthcare systems which can make it difficult to group countries into particular zones. For example, insurers may experience lower claims ratio in countries with well-functioning state healthcare systems, which allow access for temporary residents. The rules on whether an overseas national is eligible to access the local state healthcare system are complex and vary by destination country, as well as nationality. In addition, the likelihood that an employee will access state coverage depends on the quality of the state healthcare system, as well as the nationality and cultural preferences of the employee.
- Volatility in exchange rates can result in the pricing zone relativities becoming rapidly obsolete.
All of these factors are likely to have a significant impact on the claim frequencies and costs. As a result, trying to price cover accurately for a multinational company with employees residing in multiple countries across the globe is quite a task.
In healthcare, return on investment (ROI) can be used to measure the effectiveness of various disease management programmes. ROI provides a framework to help determine whether additional funds should be allocated to a particular activity or alternatively whether these funds should be withdrawn and allocated elsewhere. The rapid uptake of genetic testing within the National Health Service (NHS) and current debate around genetics make evaluating tailored interventions increasingly more relevant to ensure an efficient use of NHS spend. Milliman’s Joanne Buckle and Didier Serre provide perspective in this paper.
How much does your state benefit from Patient Protection and Affordable Care Act (ACA) subsidies?
Milliman’s recently published 50-state profile of the individual health insurance market presents nationwide enrollment and subsidy data that can help states better understand the funding and coverage requirements under the ACA. The infographic below sheds light on some of the 2017 results, including marketplace enrollment numbers by state, and a closer look at the ACA cost-sharing reduction (CSR) subsidies—for which government funding is currently under legal challenge.