Bright News

Is Your Product Portfolio Stale?

9/21/2015

By Leesa Tori, President and CEO, The Tori Group

Chances are the answer is yes. Who has had time to focus attention on products in this age of health care reform and great uncertainty in the marketplace? For the last five years stakeholders in the US health care market have wrestled with more questions than answers, all the while preparing for the largest market reform to hit the nation since MediCare. Significant questions loomed about whether or not states would build their own marketplaces or outsource the risky endeavor to the federal government. When the marketplaces were being built we waited on pins and needles for a ruling from the nation’s highest court and a pivotal presidential re-election to direct us where to go next-- and then we raced against time to meet aggressive deadline.

As opening day of the exchange drew close, tricky policy questions about grandfathering of non-ACA compliant plans were debated and last minute decisions confused consumers who didn’t know if they were going to be covered on January 1, 2014 by a plan they were familiar with or forced into a new plan. And everyone is still waiting to understand what the guaranteed issue and individual mandate are going to do to pricing in the long run. Will the new post ACA market actually provide coverage for people who have not traditionally be covered? Or will the churn cycle simple move the same previously insured population around the complex insurance machines that have traditionally served the industry? Is the small group market shrinkage a trend and do insurers care if these changes are improving the P&L? What will market size breakdowns look like in the future? All these questions and more have been proposed and debated and maybe even a few friendly wagers have been made.

But recently, the smoke is starting to clear and we are starting to see a path forward.   Building and running an exchange is harder than some predicted and as hard as others imagined. At The Tori Group we had the unique experience of having run (and eventually retired) the nation’s largest non-profit small business exchange. Few know better than we do how difficult it is to build product portfolios, drive membership and retention, and most importantly build, a sustainable marketplace to withstand the real risk: insurance risk. Too many leaders have fallen into the trap most of our industry remember all too well from the 1980’s: big membership doesn’t mean anything if the membership is unhealthy. The answer to the question of whether or not the marketplaces are going to make it in the long run will take a few more years to figure out-- after we have more experience and early membership and retention numbers to gauge our thinking. For sure the exchanges have had the best open-enrollment they will ever have by now.

The first two years of the ACA marketplaces were the best funded and most media covered events the marketplaces will ever have. While the numbers are impressive in some states (California, Florida and Kentucky) no exchange has established itself as the leader in consumer-purchased coverage. In the case of California the marketplace is a winner for subsidy eligible consumers but for professional non-subsidy eligible purchasers, buying direct from a carrier is more appealing. So what does that mean for product portfolios in this new market? What are consumers and businesses looking for from their health insurance carrier? All good questions but perhaps the most important question and the one we need to be certain to answer correctly is: How can we take delivery and reform initiatives and build new products and powerful portfolios to take advantage of these reforms? How do you take cost saving innovations and translate them to better performing products, and bundle those into winning portfolios that deliver quality care at affordable costs? These are the new questions to be debated. For the right answers and strategies, you need an experienced, informed and clever partner to lead your organization and create new solutions. That is where we can help.

Contact us now to schedule a short demo of Brightside, our proprietary tool we use to help plans assess the strengths and weaknesses of the current portfolio, to build successful strategies.

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Transparency: A Clearer View of Health Care

7/20/2015

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By Leesa Tori, President & CEO, The Tori Group

Last month, The Tori Group team attended America’s Health Insurance Plans (AHIP) Institute in Nashville, where many of the nation’s healthcare leaders gathered to discuss innovative ways of improving population health and driving down costs in today’s value-based world of healthcare.

There are opportunities everywhere.

No doubt, the Patient Protection and Affordable Care Act has led to extensive change across the healthcare industry. Perhaps the most fascinating transformations are driven by the shift to a consumer-directed market.

This new marketplace is compelling health plans and exchanges to adjust how their products are structured, marketed and sold. Value and cost transparency have taken on new importance to consumers, while new tools and incentives are engaging them in their own healthcare. From predictive cost tools to understandable benefit plan designs, the shift in purchasing power is bringing transparency to health care.

The Tori Group applauds those in the industry who are creating value and improving our nation’s health through innovative solutions. Leesa Tori talks about how optimistic our team is about the future of healthcare in this short video.

During our years in this industry, we have learned that well-designed analytic tools, products, and portfolios can empower consumers, control costs, and improve quality care.

Call us to discuss how our experience and understanding of value-based healthcare can help your organization.

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Health Care Technology Expert Susan Bacheller Joins The Tori Group LLC

4/19/2015

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Susan Bacheller has joined The Tori Group LLC strategic health care consulting practice as a principal, bringing more than 20 years of leadership experience in complex health care business and technology initiatives.

In her most recent post as Health Innovation Technology Director at Blue Shield of California, Susan was responsible for implementing programs and technology solutions designed to achieve the Triple Aim of improved population health, increased patient satisfaction and reduced health care costs. She played a key role in the development and 2014 rollout of the California Integrated Data Exchange (Cal INDEX), which included the technology platform for aggregating patient data.

Susan is particularly adept at leading delivery teams on complex health care initiatives. Her deep knowledge comes from decades of deployment including technology platforms and health plan product portfolios. In addition to her project management skills, Susan is an expert in regulatory compliance, risk management and policy development — all core services offered by the high-performance team at The Tori Group.

A keen strategist as well as a tactical team player, Susan has served in senior management roles at Blue Shield, Pacific Business Group on Health, GE Healthcare / IDX, and Managed Health Network.

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As Health Reform Dives Into Year Two, The Talent Pool Remains Shallow

2/20/2015

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by Leesa Tori, President and CEO, The Tori Group

With health care reform facing its broadest implementation to date, the struggle to find experienced, available executives with the required specific skill sets continues.

First of all, let’s revisit the startup environment in which HBEX were born. It’s been challenge after challenge since the passage of health care reform. Once the ACA lived through the Supreme Court decision and a contentious election, there was little time to get the job done, let alone recruit the uniquely experienced individuals necessary to make it happen. With the entire nation required to “Go-Live” on the same day, and the states and federal government vying for talent, there simply wasn’t enough to go around.

In addition, the job description wasn’t exactly enticing to those qualified, private sector professionals who might be in a position to switch jobs: Take a paradigm-changing insurance concept, with a strict, aggressive timetable, a tight budget, and an extremely complex set of moving parts — and implement a sustainable public insurance marketplace.

As Peter Lee, CEO of Covered California, described the task, it was like “building a car while driving 70 miles an hour.”

Add to that scenario decreasing unemployment rates, less than enticing government pay scales, resistance to relocating for many due to under-water mortgages and/or family or two-earner relocation issues, and you have a robust recipe for outsourcing key positions. And let’s not forget (ironically) fear of losing insurance coverage. Remember, at this point there was no guaranteed issue. For more than eight decades, a majority of Americans relied on employer-sponsored coverage, so leaving your job (or your spouse leaving his or her job) could mean leaving your coverage — a scary proposition for many.

Last October, an Associated Press article questioned whether Covered California had a conflict of interest in retaining contractors (including The Tori Group) via sole source contracts to help launch what became the most successful health insurance exchange in the U.S.

In fact, in the case of The Tori Group, Covered California turned to us because our experience in building and managing health insurance exchanges is virtually unmatched. Furthermore, our credentials and detailed proposal were reviewed and approved through the highest of oversight channels.

In any industry, what CEO faced with launching a new product (especially one under an unprecedented spotlight and with so many naysayers) doesn’t want people who have done it successfully in the past? Hiring experienced people means hiring people you know or who know each other.

If this is conflict of interest, then countless organizations are guilty.

In the case of health care reform, I add that success doesn’t only require experienced people who know the health care business inside/out and can hit the ground running. It also needs people with a mission. True believers in the ACA who are willing to focus ALL their time and talent on creating a successful marketplace. The Tori Group prides itself on being optimistic proponents of the ACA. The law may not be perfect, but it’s a good start.

When building an exchange, having experienced people at the table makes all the difference. Here are some examples:

1.     How do you get multiple plans to adopt a policy for extension of applications in a matter of days? This type of issue goes beyond writing a policy. You must understand the implications for ALL of the stakeholders involved. Small plans may be nimble and able to more easily make changes in systems and staff policy; however, they often are not as well capitalized and cannot “float” payments to providers while waiting for premiums that may be affected by extension. Understanding how the policy will affect all players helps create a win-win program from the beginning as well as avoid potential alienation of some or most of your supply chain.

2.     How do you message enrollees about changes when 40% of the business was sold through insurance agents? Experienced health care leaders will tell you to be sure and message an enrollee’s agent BEFORE you send out communications to the membership. The insurance agent has worked hard to bring you this business and much of their value proposition to the consumer lies in the ability to bring them updates in a timely and proactive manner. Few things will alienate your agent distribution channel faster than getting between them and their clients.

3.     How do you train on CHOICE? Choice is both a blessing and a curse. It’s not a simple matter of telling customer service representatives there are 11 health plans for consumers to choose from — they just need to pick one. Rather, you have to educate your consumer-facing workers on how to answer questions about all of the choices, from network attributes to billing policies. And you have to be certain they are getting it right, not just in the training room but in their every interaction with potential customers. A key risk point in the cycle of building a sustainable exchange is ensuring the staff are actually administering the program the way it was meant to be administered. Assuring your participating health plans you have policies in place for proper representation, then later finding out that your team is actually dispensing wrong information can be a quick way to lose the trust of your health plan partners. Without the health plans, you simply do NOT have a product to sell.

In California’s case, did outsourcing so many key positions work? Yes. In it's first open enrollment the California exchange, launched last October, enrolled nearly 3.5 million, including more than 1.2 million in private plans and about two million in Medi-Cal, the state's Medicaid program. That equates to approximately 42% of the eligible market. No other state exchange came close.

I’m also particularly proud of the work we did and continue to do to help Covered California become self-sufficient without the The Tori Group’s help in manning those key interim positions. We think that developing and mapping detailed governance procedures, operational processes and education support systems for growing talent internally is part of our job as responsible and ethical consultants.

It’s true that, as health exchanges mature, there will be more and more experienced individuals to choose from in the talent pool. But the HBEX marketplace will remain the “wild west” for several more years. In the near future we will see the impact of the first year of claims, the first experience with consumer reaction to premium increases and changing health plan choices, the first mandated full portfolio review, the first year of SHOP launches for many exchanges, and more.

Only with time will the skilled talent pool grow. Only in time will exchanges be able to rely fully on FTEs to continue the mission of health care reform. Meanwhile, HBEX leadership must be very conscious of potential hiring practice pitfalls as they move to make this happen. In addition to the obvious — competitive salaries — you must avoid too narrow a focus in job descriptions and lengthy and complex application processes. There is no dearth of testimony that these sins have forced many a great candidate to accept another offer. Antiquated recruiting technology, too, can fail to attract many young hopefuls that could become important assets to the cause.

And finally, if your organization is faced with severe growing pains, don’t let the spectre of any type of conflict of interest inhibit you from relying on tested and trusted outsources as interim solutions.

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How A Trip To The Market Got Me Thinking About Health Exchanges

2/12/2015

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By David Greene, Senior Principal, The Tori Group

I'll admit that I'm not the one in the house who is usually in charge of household groceries. But, upon being asked, I had no hesitancy in helping out and doing so - just text me the shopping list and I'm off. However, once in the market, my efforts were squarely stalled once starring down the endless aisle containing cereals. Seemingly thousands of options, most of which seem just a millimeter apart in content and targeted buyer. The boxes look identical but one is multigrain, honey coated, vitamin C & D enriched, low sodium, flakes; and the other is multigrain, honey coated, vitamin C & D enriched, low sodium, flakes with crunch. Imagine the household disaster if the wrong one were placed in the cart?!

Having a bit of marketing geek in me, a chunk of time is then spent studying how the makers of cereal appear to be fighting for shelf space, how closely aligned differentiation is around a central concept of taste, such as wheat flakes with raisins or just plain wheat flakes, kids cereals located lower to appeal to children and healthier cereals up higher for the adult eye... you get the idea. Considered too was a bit of recent research that found if the box has a person/character that looks you in the eye, you are more likely to buy it. But the bottom line was the multitude of it all is paralyzing to a consumer wanting to make a choice. I know I was stopped in my tracks... so I had to call home for "tech support" to make sure the right box was put in the cart.

Exchanges are like Cereal Aisles

·       In Florida: One carrier has 18 plans over four metal tiers. In some cases, the premium for a platinum plan is less than a silver tier plan they offer (figure that one out).

·       In Texas: One carrier has 17 plans, there are gold plans costing less than silver, and evidently someone got tired after working the bronze through gold tiers because no platinum offerings are made.

·       In New York: There are 10 plan offerings per web page... and 71 pages available to scroll through. If you narrow your search to silver tier only (generally the most popular tier selected), the choice is narrowed to 19 pages to scroll through. More, many carriers are offering eight or more plans on one tier... one carrier had up to four pages to scroll through on a single tier!

The choice is overwhelming.

Examples could have easily been derived from other states as well. Please know the above states are not being "picked on". The offerings cited above are within the rules established - that's understood (I'll come back to this comment in a bit). The point is how much do we really expect for a consumer to deal with and still feel confident in their choice? This question becomes more emphatic when the selection is about who will be entrusted with one's health (most likely when they in the middle of a health scare and need the trust most).

Déjà Vu

Déjà Vu

Years ago we as a management team faced the problem of a coverage offering that had overwhelming choice. We had 11 different benefit plans being offered from up to seven different carriers. This created a couple of core issues:

1)     Consumers (who were actually employees of small employer groups) were confused. Brokers selling the plan wanted to ensure the employer (as the ultimate decision maker) and his/her employees were happy. To keep all parties smiling, the brokers often remained very close to the selection process and offered advisement based on their expert knowledge. The vast majority of brokers represented all as it should be. Some other brokers took other approaches and proactively limited the choices by informing the employees some plans/carriers were not part of the offering - even though this was not true and was against the design of the product. Further, some of these brokers even created their own sales collateral only showing the two or three options they were most comfortable selling. The outcome of this was some of the carrier who were "screened-out" not being too happy about working to be part of a package offering and then not being shown to potential enrollees.

2)     A broad offering of many plan types and carriers creates a more complex array of plan selections. And thus, a more complex assessment of risk management. Needing to incorporate this risk into their entire product portfolio, carriers rightfully looked closely at the membership garnered through each sales channel. Carriers always look closely at small group business. This said, with our offering they may only get a part of group's potential membership and not all of it, thus they looked even closer at plan selection and utilization coming from us. And in fact there were "winners" and "losers" between the plan designs and carriers. We had a risk adjustment process in place, but as you could imagine it had occasion to not make all the players happy.

So, brokers were not always so much working from the perspective of providing great service, they were working from the perspective that their efforts were what was as a minimum needed to sell the product. They were surviving our product, not actively selling it! And carriers were each doing deeper assessment as to remain as part of the product offering or not.

While not a perfect corollary, the above does share many of the characteristics of the issues shaping up for the new Exchange world. What is important to note is that while there are risk management provisions in existence right now that did not exist pre-Affordable Care Act (ACA), fact is two of the three risk mitigation tools put in place go away after 2017. The only one left after that will be risk adjustment. Thus, putting our longer term thinking caps on, we would do good consider how actions now will affect the lessening of risk mitigation as time marches forward.

A plausible approach

With rules in place that force actuarial values to be +/-2% of a set target for each metal tier, how much is really gained by offering 8-10 offerings per tier? Don't forget that deductibles, copays and coinsurances are complicated concepts for many looking to make their selection. And, it can be seen that this much selection turns-off consumers to the carriers and the exchanges putting forth this tsunami of odd-ball terms. While confused about what each offering is, the consumer at least walks away understanding very clearly any of these options will cost them money!

Right now carriers and exchanges are in a land grab for membership. Exchanges want to reach thresholds for operational independence per the ACA legislation and carriers want to ensure market share of the new growth provided by subsidized membership. It is in both the interest of the exchange and the carriers to put in place rules that align the distribution offering to their shared goals. Carriers have the opportunity to work under this discipline relatively fast - and become winners. However, for the Exchange this may mean considering collaboration in changing the rules under which their particular Exchange operates. And while it may seem that the focus here is on the financials, risk mitigation, and operations expenditures of maintaining massive benefit portfolios, remember what all this work is focused on: It allows for a better consumer experience. And with the consumer in this case being people who are making healthcare selections appropriate for them, that's pretty significant.

Years ago while facing the situation outlined above, the approach we took was to launch a streamlined offering with a built-in common comparison point for consumers, and then opened up offerings carriers could make to designs of their choice. This very much helped the consumers make decisions and carriers to manage their portfolios. A true win-win which sold quite well. There are reasons this can't be cut-and-paste duplicated today. And there are serious considerations to where the pendulum swing between "wide-open" and "managed" offerings should be measured. All this said, what is important is to realize we have available to us a viable approach which can be evolved to work within the new health care environment.

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How Health Care Exchanges Can Help Bend the Trend

1/6/2015

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By David Greene, Senior Principle, The Tori Group

The Current Sitch

Much has been written about why insurance rate increases delivered to Exchanges across the country for the 2015 open enrollment season are lower than in previous years. Several reasons are offered in research and reporter driven essays that can be found all over the place - and a sense of debate will continue on this (no doubt largely based on political and/or special interest perspectives). We hear about variables like guaranteed issue and the implementation of Essential Health Benefits cited. These are variations on the edges.

After being able to kick the tires of the proposed 2016 Actuarial Value Calculator (AVC), what becomes clear is - compared to output of the 2015 AVC - benefit designs people are now enrolling in for 2015 will see a significant increase in AVC results at the lower tier level (i.e. Bronze) and diminishing impact as the metal tiers increase up to the platinum level. So, what does this mean in non wonk speak: Expect that through 2016, healthcare costs are still rising at a healthy clip.

So What Gives?

Recently, there was a statement from the Centers for Medicare and Medicaid Services' (CMS) that its actuary now projects health spending will grow on average 5.7 percent each year through 2023 (this means health care's share of GDP in will go from 17.2% to 19.3% - or to about $5.2 trillion). That's a gloomy shadow being cast on hoped for cost containment. On the other hand, an article in the NY Times did a pretty good job laying out why costs may rise, but not at the CMS cited pace. It too is not necessarily a cheerful piece of reading, but it does clear out some of the gloomy clouds. So, who's right? Or, who's even less wrong? A: Doesn't matter.

There is a fundamental reason to believe we will see costs of healthcare services continue to rise post implementation of the Affordable Care Act and here it is: In and of itself, the ACA does very little, if anything, to mitigate the cost of healthcare. It's focus is on the financing of healthcare delivery. The ACA is financing the same healthcare delivery systems for health care we have had for decades. So, why should we expect the cost trend to change?

What both the CMS statement and the recent article cited show is a country who already overspends on medical services is on trajectory to overspend in greater amounts moving forward. On current path, some may see a future where premiums rise to levels where both subsidy amounts fail to be meaningful for the poor to get coverage and a growing (perhaps unsustainable) burden on tax payers exists. Feel gloomy - it does to me. This all said, a more meaningful measure to consider is what the values of the new AVC are offering to us as a look - not at what has happened - but what is to come (steady increases).

But let's consider this, there are a ton of exchanges out there. And many of these exchanges have the ability to establish rules for participation. So, what if this scale and scope were utilized to curb costs? And, what if at the same time, we could align market forces to make available metrics all could use to better transparency and ultimately drive quality? Sounds a bit "pie in the sky". But it may be closer to us than we may think.

There are some interesting things Exchanges and health insurers - and regulators - can consider to take advantage of new market dynamics resulting from the ACA implementation to curb costs.

Short (and overly incomplete) History Lesson

No matter what is written in this section, some will debate and point out some perspective nearer to them and where I may know little. But let's take the plunge anyway to talk at a high level and appreciate some of the factors affecting healthcare in the last 25 or so years.

Employers were screaming for lower premiums as costs were going through the roof, and insurance companies reacted to this with new kinds of plans. So, in the 80's and 90's, capitated plans spawned copays being driven down to a level of $5 for a doctor visit and premiums that could still be paid for in most if not all by the employer. And when you are charged $5 for an office visit, the logical conclusion for people to make is that a doc visit cost five bucks. At the time we as consumers didn't care to think through $5 being meaningful to pay office rent or staff salaries. Nor did we connect $5 being comedic against the real costs of the doctors visit when we had to pay $6 to get out of the parking garage after the visit (unless of course the doctor's office validated the visit).

The point is that while employees didn't feel the cost of care crunch before 80's/90's, employers sure did. And when the HMO based solution came to roost, consumers were not only further shielded from the cost of care, but the expectations as to its cost was even lowered! However, employer health coverage renewed annually and employers rationally shopped the business looking for lower rates and they often switched carriers. Thus, the year-over-multi-year population health potential/responsibility of HMO contracted medical groups never came to fruition - and they still had access to expensive hospital services. Premiums went down for a while and then rose again.

So look at what is happening here:
·       Consumers (you and I):
·       Learn fixing our health is cheap, so why care (about the costs or our physical condition)? Insurance is paying, so why not go to doctors frequently and get every test available.
·       Providers:
·       Learn they can still perform services with little concern for cost (why not?, most everything is still paid for by insurance companies).
·       Insurers
·       Learn finding a model that lowers consumer and employer cost has ultimately lead to higher utilization and higher costs.

So, costs temporarily dip down and then continue their rise. And in following the money, no one in the supply chain is accountable to anyone else. Check it out... in the above we aren't even accountable for our own health! How are any of these outcomes aligned to be healthy and contain costs?

Tapping Exchange Potential on Costs, Transparency, and Quality

Yes, there are many reasons healthcare costs are what they are (and will keep rising). And with all the cooks in the healthcare kitchen, no one chef is going to be able to unscramble all the intertwined connections. Exchanges can't do it all. This said, because of its market reach and impact, Exchanges and health plans have huge potential for being a key component in changing health care cost trends. What also is good is that reaching this potential does not need to take place via sweeping actions. In fact, a surgical approach would be more meaningful and efficient.

The HMO history example focused on primary care visits is purposefully selected to highlight the effect a copay can have on consumer and industry behavior. The example of an office visit is not the most powerful place for Exchanges/Carriers to instate change that drives cost consideration across the supply chain. This is because the negotiated rate most carriers have with physicians is relatively tight (typically in the $100-150 range).

However, let's now consider areas of widespread costs: Imaging, specialty drugs, inpatient care, outpatient services, skilled nursing facilities and others. These can have a huge range in cost of services - and most of them have significant impact on AVC. This is a brief blog-ish perspective, not a book. So let's just pick on Imaging today.

When we say imaging, we don't mean x-rays. Instead, we are referring to MRI's, Echo-cardiograms, CT Scans, PET Scans, and other more involved tests. For the same test, costs can be high or really high. Let's focus on echo-cardiograms. Based on Medicare database info, costs for the same test can range from under $1,000 to over $10,000 in one city. And types of facilities matter as well: In the Boston area teaching hospitals average around $1,300 for an echo-cardiogram, other hospitals in the area charge an average of $5,200.

To place a copay - instead of coinsurance - on this wide range is doable, but it comes with consequences. A copayment for an echo-cardiogram (whether it be $250, $350, or $1,000) has a short term benefit in that a consumer will know at time of purchase what the test will cost before they choose a plan (should they ever need it... and odds for most people are against them needing it). However, the longer term effects can be bad. First, consumers may be paying $350 in copay for a test that actually costs $225. But even worse, the copay would shield the cost of the test and not provide incentive for imaging facilities to disclose cost or quality of outcome information (which is information we don't have today). Although copays and coinsurance may be actuarially equivalent at first, in just a few years copays for wide range of cost benefits dilute competition at the delivery services level and dilute consumer's active participation in the cost of services. This does more harm than good. In this case, harm takes the form of higher and higher premiums.

In a World of Instant Everything, This One Will Take Time (and Faith)

The ACA kicked-off a consumer market for health care with characteristics that never before existed. What would be a shame is to not look at this and consider ways we can use the ACA to curb costs. We need to remember this new age of consumerism is in the embryo stage. Launching the ACA may feel like a sprint right now, but it in fact is a long-term endeavor.

When first launched, they were to be called "Marketplaces". Since launch, "Marketplace" (inferring a coming together where both buyers and sellers are active in the process) has already been replaced by the word "Exchanges" (a process where one thing is swapped out for another based on predefined alignment). Success longer-term will depend on active behaviors at all levels. Consumers shop... so let's let them shop. The shopping process is to learn about what you want/need, and find the right cost/quality mix for you. This decision making process has been done daily for eons, was certainly done before any of our third-grade lunch trades, and is something we all do today. The faith part is these decision making processes won't stop - which is actually a pretty safe bet. In turn, this shopping behavior is what will drive further cost transparency and development of quality measures people will refer to with confidence. This kind of transparency and measures of quality don't exist now.

However, by aligning market forces, by consumers learning to apply the shopping behavior they already do to healthcare, and by providers of services learning to more actively compete, this more healthy (pun intended) environment for us all will happen faster and in the most meaningful way.

As mentioned above, Exchanges can't in and of themselves bend the health care cost escalation trend. They are only one ingredient in the recipe. But in many states where the Exchange can (or should) influence plan design, they can be a key spice mixed in that can better enable other ingredients (e.g. new care delivery models, plan selection and use tools, availability of cost comparisons, etc.) to be more bold and meet our tastes.

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Surviving Infancy: Raising A Health Care Exchange

12/14/2014

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by David Greene, Senior Principal, The Tori Group

Your kid doesn't come with a manual either:

I've read a lot of studies and research driven papers over the past few months about challenges health exchanges across the country are facing. At the most summary level, these reports generally are rich on data about state-by-state exchange enrollment figures released across the country this past Spring and focus on topics such as preparation for the current open enrollment period and the pros/cons of "active" vs. "passive" exchange approach.* This is good information to consider for relative benchmarking. But just as the circumstance to which every child is born and raised is unique, so is the raising of an Exchange.

Don't discount either one... it's both a Nature and Nurture thing.

Like the double-helix defining our DNA make-up, there are a set of basic building blocks that make up all Exchanges. Again like the double-helix, the organization of these building blocks can seemingly be infinite in complexity. Between the initial penning of the ACA and the uncountable mutations brought on by State legislators, Insurance Regulators, and self-imposed Exchange rules, it's agreed some Exchanges may at first look distinctive from others, but they are really more similar than not. And, important to note, they have all hung on to the instinctive quest to expand coverage availability and seek enrollment. This is the nature part of the beast.

While Exchanges are similar enough in appearance and share an innate drive to seek enrollment, they do have different environments in which they are striving to reach maturity. Because of this, it's easy to see that while they are all very young, we see them developing at different rates.

With tremendous respect to the structures in place that define the genetic make-up of an Exchange and the importance of this never forgotten, I want to share some about one aspect of nurture Exchange development - while Exchange development is still in toddlerhood.

All kids need to be taught the same stuff from scratch.

No matter how many children you may have had a hand in helping raise, you come to see that each one has to learn over time how to become self sufficient. To add, it is only in retrospect you realize how much you have learned over this same time and how no matter how much you know, you will still at times be stumped.

All the above can apply when you help an Exchange take on its work. Organizationally, the Exchange is itself in a new environment for those working to make it the best it can be - Exchange staff. For its staff, it's a new experience where countless decisions need to be made each day on subject matter few, if any of them, have deep experience. Consider it all: Deciphering usually unclear policy and regulations; data transfer protocols with new entities, 2.3 million and counting ways to slice enrollment data, benefit design impact on enrollment risk-mix, potential enrollee decision processes, working to anticipate media/special interest group response (to whatever!), provider and hospital network coverage assessment, and while there are many others - another new area for most all Exchange staff is the establishment of sales channel outreach and marketing disciplines that combine consumer direct, broker, and community organizations.

The progression of juggling all the examples offered above - and more - is hard enough at any start-up looking to gain customers (i.e. for Exchanges, membership during its first open enrollment). Now, think of this start-up doing all this within a government setting. Not easy. Exchange staff as a whole are working to make it all happen. And in working to accomplish all this, they are doing something very interesting: Exchanges are learning much of what it's like to be a health plan.

Maslow was on to something

Rare is the new insurance company launching in this environment (but those trying are seriously applauded!). And for those few working to bring innovation to a significantly changing coverage marketplace, name one who now or in the past has seen an explosion of growth in a manner equivalent to an Exchange? Just when the Exchanges are looking to perform lesson-learned reviews of the last open enrollment, a whole new something is now here: Renewals. How does the Exchange manage added complexity of working to bring the right value to new enrollees while remaining a value to existing enrollees in subsequent open enrollment periods? It's much like being on point for getting multiple kids ready for school every day: You work to build a routine to make it smoother, but they keep finding new ways to make it never quite go very smooth.

However, just as parents somehow manage to get the kids to class so they keep learning, so can and will people help Exchanges evolve. In supporting Exchanges at this juncture be on path to realize their potential, those called on for help who are experienced and knowledgeable in managing price and health services availability for large numbers of people over long periods time have responsibilities. These include providing decisive direction while creating an environment where those progressing along the learning curve are allowed to engage, try, and learn. This transfer of knowledge is key to healthy growth and we must provide this as a basic tenet to Exchanges operating as efficiently as their environment will allow.

All parents have expectations. And the high expectations our country has for the ACA and each and every Exchange (public or private) is for them to become reliable conduits for improved health of us as a population. "Live, Learn, and Pass it on" is a good mantra for anyone having a hand in raising kids. It's no different for raising Exchanges.

( * Actually, all exchanges are - recognized or not - on some continuum of "active".)

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Is the Affordable Care Act Working?

10/29/2014

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by Reed Abelson, Anemona Hartocollis, Abby Goodnough, Robert Pear, Margot Sanger-Katz, and Sabrina Tavernise, October, 26, 2014

After a year fully in place, the Affordable Care Act has largely succeeded in delivering on President Obama’s main promises, an analysis by a team of reporters and data researchers shows. But it has also fallen short in some ways and given rise to a powerful conservative backlash.

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Reflections on Building California's Health Benefits Exchange

10/22/2014

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by Leesa Tori, President & CEO of The Tori Group

It’s been a year since 1.2 million Californians began enrolling in health plans under Covered California — many of them choosing insurance coverage for the first time in their lives.

As the second round of open enrollment begins, I’ve had an opportunity to reflect on what’s been accomplished — and the Tori Group’s role — in establishing the largest and most successful health insurance exchange in the United States.

The tasks were monumental, and the deadlines were tight — just the types of challenges The Tori Group is built for. I’m very proud of our team and employees of the State of California for their 24/7 commitment to the successful design, launch and management of Covered California.

Establishing a health exchange of this magnitude required The Tori Group’s unrivaled expertise in strategic health care consulting, including: plan management and contracting, policy and regulation architecting, small business group insurance and the choice market, customer service and training.

Covered California’s success has been heralded from the West Coast to Washington, D.C., as an example of how other state and federal exchanges can achieve the lofty goals of the Affordable Care Act.

If you're interested in knowing more of the details of our organization’s work with Covered California, you’ll find a brief summary here.

Here’s to guaranteed access to health care for all Americans!

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How The Tori Group Turned On The Lights At Covered California

10/22/2014

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by Leesa Tori, President & CEO of The Tori Group, LLC

Situation Overview
Facing the most sweeping health care reform since Medicare and an aggressive federal timeline for implementing changes, in 2012 the State of California was required to act quickly to introduce Covered California — a paradigm-changing insurance concept with a uniquely complex set of moving parts.

Among the challenges facing Covered California: finding experienced industry
executives to lead the charge. With the entire nation required to go live on the same day, individual states and the federal government were vying for resources from a limited pool of unique talents to set up their exchanges.

Objective
To build a health benefits exchange ready to accept enrollment by Oct. 1, 2013, despite the political stops and starts.

The Tori Group Expertise
Covered California chose The Tori Group, LLC for its team of health benefits exchange veterans with unrivaled expertise in the following:
• Senior leadership in insurance exchanges
• Deep knowledge of the California health care market
• Risk management as well as building and maintaining exchange portfolios
• Understanding of distribution and channel marketing/sales
• Project management, training and certification, and customer service operations

Leesa Tori, President and CEO of The Tori Group, served as Interim Director of Plan Management prior to, and during, the successful launch of the exchange.

Senior members of The Tori Group served on the executive team during unprecedented rate negotiations with carriers and the implementation of the Go Live process.

The Tori Group’s work included analyzing and advising Covered California on tough policy issues, including President Obama’s announcement of extended grandfathering of non-Affordable Care Act compliant plans.

Throughout the process, The Tori Group served as consumer-focused advisors to senior leaders of Covered California as they considered compass-setting policy decisions.

Plan Management
Performed the role of Interim Plan Management Director beginning in July 2013, managed the health insurance exchange portfolio, and implemented the Go-Live process for Oct. 1, 2013 — meeting strict federal timelines. Certified and contracted 11 health plans for participation. Designed, directed, and implemented the Qualified Health Plan (QHP) Certification / Recertification Program for the health plans and a multitude of dental carriers, which included participating on the executive team for rate negotiations. Restarted the Pediatric Dental program using the Tori Group’s “3 P” framework: setting policy compass first, building products, and then compiling portfolios. Developed and launched the Plan-Based Enrollment program which increased resources available for assisting California consumers during the transition. Managed stakeholder relations to help ensure collaboration of efforts.

Small Business Health Options Program (SHOP)
Developed the Small Business Health Options Program (SHOP) health insurance marketplace. Performed the role of SHOP Director until the position was filled in August 2014.. Designed, developed and negotiated products for a robust and well-priced portfolio. Authored adopted SHOP regulations, and established enrollment and eligibility rules and guidelines for SHOP. Assessed and coordinated significant changes and upgrades to SHOP administration software. Initiated project to establish agent contracting inclusion of Medi-Cal for payment — requiring over 12,000 agent contracts. Directed and oversaw the development of the renewal strategy and implementation for 2015.

Covered California Sales and Marketing
Developed a program for lead management and distribution — resulting in 12,800 closed leads and approximately 20,000 enrollments. Authored Agent Regulations as well as Agent of Record process and guidelines and served as point position for Agent interface and policy setting. (Agents represent 40% of all Exchange Sales Channel Enrollment). Provided in-person oversight of the SHOP enrollment process by the third party administrator, and made regular site visits, often with Covered California management. Monitored and managed communication issues between agents and Covered California service center. Provided Covered California leadership with agent expectations and needs relevant to 2015 individual Exchange renewals.

Company-Wide Knowledge Management System
Co-designed and staffed a Go-Live Support Center to answer and archive consumer questions, thousands of which had never been anticipated nor asked until after Go-Live. The support team channeled questions and answers to appropriate parties in addition to leveraging existing technology to develop an information management and distribution process.

Covered California University
Developed the organizational process that supported training and information distribution. Filled interim roles of: CCU Director, Learning Management System Manager and Coordinator, and Knowledge Center Analyst. Developed the Knowledge Center, Learning Management System Program, and Training Center.

Consumer Experience
Established the central governance model for Covered California Interactive Voice Response (IVR) application. Conducted assessment of Customer Relationship Management (CRM) application including overview of Knowledge Base to improve proper usage of solutions. Lead transitioning of all technical and operational support of the IVR and CRM applications to Covered California IT. Analyzed service center staffing requirements and volumes to procure sufficient resources to meet target service level agreements for an enhanced consumer experience. Provided senior leadership and operational assessment of service center with recommendations to improve efficiencies in key areas.

Measures of Success
By the end of open enrollment, nearly 1.2 million Californians enrolled in private health insurance under Covered California — many for the first time in their lives. This was nearly double the prediction of the state, policy, and health plan stakeholders.

Going into the second year of the exchange, the average weighted premium increase for all participating health plans was just 4.2 percent. This is one of the smallest weighted average increases in recent years — and is far below increases reported by other state-based agencies. The Tori Group was recognized by Covered California for its efforts in achieving this through its successful negotiations with
Qualified Health Plans.

California reduced the number of uninsured in the state by one-half -- from 22 to 11 percent — according to a recent Commonwealth Fund report.

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