Embed Size (px)
Citation preview
Session 111PD, International Health Insurance Innovation
Moderator/Presenter:
Presenters: John Rogers, ASA, MAAA
Jane Wang
SOA Antitrust Disclaimer SOA Presentation Disclaimer
Cloveris a whole newkind of Medicare.
CarmenClover member
John Henrik Rogers, MS, ASA, MAAASociety of Actuaries, Health SectionAustin, TexasJune 23 – 25, 2018
We’re not just using technology to pay out claims. We’re building a learning machine, and we’re using it for health. By operating at the nexus of care and cost, we think wecan fix how care is given and for how much.
Vivek GaripalliClover founder
2
Since launching in 2013:• We’ve grown from 190 members in Hudson
county, NJ to 30,000 members to over 18 counties across four states
• In 2017, we became the #2 insurer in the individual Medicare Advantage market in the New Jersey counties we serve
Bucks County, Pennsylvania
Savannah,Georgia
San Antonio,Texas
2013
7,274 members
17,000 members
26,000 members
190 members
2015
2016
2017
Clover currently operates in 18 counties across four states: NJ, GA, PA, and TX.
30,000+ members
2018
2014
2,074 members
3
Clover currently operates in 18 counties across four states: NJ, GA, PA, and TX.
Since launching in 2013:• We’ve grown from 190 members
to 30,000+ members• In 2017 we became the #2
insurer in the individual Medicare Advantage market in the New Jersey counties we serve
.
4
On Medicaid
DisabledHospitalizedin the pastsix months
With a behavioral health diagnosis
Average age
15%
29% 17%
25%
70Yrs
5
Care & Technology: Data Feedback Loops
6
Care
Technology
Care: Our clinicians can make time with your patients more meaningful.
Annual nurse practitioner visit • Clover members can receive an
annual Clover Care Visit at no extra cost.
• Nurse practitioners can do routine checkups, work with physicians to carry out treatment plans, and help remove barriers to care.
• We can help patients lower medication costs, refill prescriptions, and schedule appointments.
• In 2017 35% of our members took advantage of this service.
Member outreach• Our team of social workers and
field-outreach coordinators is committed to the health, well-being, and safety of Clover patients.
• Field-outreach coordinators help ensure members have access to the care they need.
• Licensed social workers provide counseling, behavioral health assessments, and access to a referral network of community and psychosocial resources.
Post-hospitalization visits• When a Clover patient has been in
the hospital, our team is here to help ensure continuity of care.
• We will proactively inform the patient’s physician about hospital admissions, discharge dates, and discharge plans.
• We will also offer to meet with our members for an in-home visit, and report back to their doctor with important details.
7
AcutePre-Acute Post-Acute
Acui
ty /
Cos
t
Social CareHome
Primary Care Physician
Hospital / Inpatient
Emergency Department
Retail Pharmacy
SkilledNursing Facility
Long Term Care / Institutional
Home Health / Palliative/
Hospice
Clipart provided in free trial of conceptdraw.com
PreventionOften Chronic
Inpatient Rehab
Specialist / Urgent Care
/ MHSA
Observation Care
Utilization Management
Provider AlignmentClinical Ops (Home Visits, Campaigns, Principium)
Social Work / MHSA
Home Care
Medicaid Covered Only
Care: Encourage Care in the Most Appropriate Setting
Our technology can help prevent serious health problems.
Our proprietary software aggregates and integrates health data across every spectrum of the member’s healthcare experience, from labs and UM requests to customer experience encounters and nurse and social worker home visits.
Our system runs on a feedback loop. It “gets smarter” over time, so our clinical and experience teams always have the most up-to-date information on our members, allowing them to identify potential issues and intervene if needed.
Member ProfileOur internal member profile software helps our clinical and experience teams get a complete view of a member’s background before Clover Care Visits and when members call in with issues or questions.
9
TECH: Our Tech Stack
10
TECH: Our Tech Stack
11
TECH: What is Decision Science?
12
Actuarial• Pricing, Reserving, and Finance Support• The “Original” Data Scientist
Business Analytics• Executive Insights, Special Tasking, and Finance Support• Risk Scores, UM, Stars, Care Management, Member-level Outcomes
Product Science• Improving operations through data
Machine Learning• Automated, granular decisions
John Henrik Rogers, MS, ASA, MAAA
John is a Senior Actuary at Clover Health on the Business Analytics team. John works closely with data scientists and engineers to build insights into Clover’s results through data readiness and analysis. Recent projects include consolidating and tracking CMS Stars measures using real-time data, analysis of Clover’s Complex Care Management program, and analysis of Clover’s Utilization Management program.From 2015 – 2016, John was an actuarial advisor for KPMG London. He was the technical lead to provide actuarial modelling and pro forma financial projections for a major international life insurer expanding into Europe and Southeast Asia. He also evaluated software options including liability modelling software, statistical software, and risk reporting platforms for KPMG’s economic capital working group.From 2011 – 2015, John worked for Milliman. He performed detailed cost analysis to support policy decisions by California Health Benefits Board and carrier implementation of Affordable Care Act (ACA). He was the lead developer for Milliman’s MyRxConsultant.com and developed software supporting the Milliman Atlas of Public Employer Health Plans. Prior his actuarial career, John served as the Executive Officer of USS Chinook and Patrol Coastal Crew INDIA. John received an honorable discharge from the United States Navy in 2011 and three Navy Achievement Medals.John is a daily user of SQL and Python. He has also used R, Prophet, SAS, Excel, ASP.NET, Java, C, C++, LISP, graph algorithms, Apache Tomcat, SMS, Django, and networking protocols (BGP, OSPF, RIP).
Education:MS, Computer Science, Naval Postgraduate SchoolBS, Mathematics, Massachusetts Institute of Technology
13
Thank you
14
Appendix
15
Physician+
Patient
Affordable PPO plansfor easy access to care
CARECare coordination
by nurse practitioners, social workers, and our member experience team
TECHData-driven technology
that analyzes patient behavior and needs to identify interventions and
reduce costs
16
Clover identifies risks early on in order to keep members healthier and prevents future expensive medical and hospital bills. This reduces overall costs—a savings passed directly back to members.
Forbes MagazineJanuary 2016
17
2012Vivek and Kris Gale found Clover with the idea of using technology to improve patient outcomes.
2014Clover grows its membership to 1,800, opens an office in San Francisco to deepen our tech & data talent.
2013Clover operates a Medicare Advantage plan for 190 members in Hudson County.
2015Clover grows its membership to 6,216, expands to five new counties, forms a clinical operations team and achieves a 3.5 star rating.
2016Clover grows its membership to 15,904, expands to nine counties.
2017Clover grows its membership to 26,000+, expands to nine counties, reaches #1 market share in Hudson county, and makes plans for a major expansion to 3 new states.
18
VALUE: Our plans make every dollar go further.
Benefits for patients…The benefits of a PPO withthe cost and ease of an HMO
No/low copays for in-network providers
Prescription coverage
Rich plan benefits
Choices in doctors
Preventive services
Rewards programs for managing wellness
…that directly benefit physiciansWe don’t get in between doctors and their patients
No/low cost barrier toinitiating care
No referrals
No pre-authorizations for typical,in-office visits
Less administrative burden
19
Clover Health Co-foundersVivek Garipalli is a serial healthcare entrepreneur and turnaround expert focused on innovation to increase quality healthcare access and improving patient outcomes. In 2008, Vivek founded CarePoint Health, a fully integrated healthcare system in New Jersey. Through his role at CarePoint—whose mission is to serve uninsured and underinsured patient populations—Vivek experienced the misalignment of providers and insurance companies first-hand.
Kris Gale is a recognized leader in building and scaling engineering teams and was part of the founding engineering team at Yammer. During his six years there as vice president of engineering, he helped grow Yammer’s engineering organization from three people to over 200. Kris also spearheaded the platform’s direction and ensured its ability to scale, culminating in its acquisition by Microsoft in 2012.
20
21
Pritam Baxi, CFO
Management Team
Prior to becoming Chief Financial Officer at Clover, Pritam led multiple teams at Sears Holdings, including finance, member experience and operations. Before that, he spent 15 years at Amazon managing the Worldwide Operations Finance function.
Varsha Rao, COOVarsha joined as Chief Operating Officer from Airbnb where she oversaw operations, customer experience and safety in 15 countries as Head of Global Operations. She is also the co-founder and CEO of cosmetics company eve.com.
Wendy Richey, CCOWendy is Clover’s Chief Compliance Officer and boasts over 35 years of corporate compliance, government programs and operations experience in the healthcare industry.
Andrew Toy, CTOAn experienced technology leader, Andrew spent several years at Google where he ran Machine Learning and Analytics for the G-suite team. Before that, he was CEO of Divide, which was acquired by Google in 2014.
CARE: Case Studies
Application for financial assistanceOne of our social workers helped a member complete his Specified Low Income Medicare Beneficiary application. A social worker in a community center had started the process but the member, who is illiterate, was unable to finish on his own. The member’s Social Security check increased by $134.00/month and he received a reimbursement of $750.00 for the months he was eligible for SLMB.
Making sense of medications During a Clover Care Visit, a member admitted that he hadn’t taken his medication in over a week and doesn't take it regularly. The visiting nurse spoke to him at length about the importance of being compliant with medication, gave him two pill boxes—"day" and "night”—and called the pharmacy to refill three of his prescriptions.
Milkshake for cancer patientA member came home from the hospital after cancer surgery. He said he felt nauseous after chemo and just wanted to drink something to settle his stomach. When the visiting nurse suggested he try Ensure, he said it was boring and tasted terrible. So she suggested he put fruit in it — strawberries and bananas to make it like a milkshake — and she even made one for him.
Intervention for alcoholismA member had a long history of readmits for psychiatric hospitalizations due to co-occurring alcohol and mental health issues. The team collaborated in working together with the member to ensure that he is receiving the necessary treatment. We were able to successfully refer the member to ICMS where he receives intensive community case management service.
22
L I V E . W O R K . P L A Y .
www.optimity.life
Engagement Platform for Life Insurance Carriers
Optimity Helps
Insurance Companiesattract and retain policyholders with customized & branded mobile apps.
New Experience for this New Generation of Policyholders
Who we are & Why proactive health?
Zhiren Lou (1958-2011)Late-detection of cancer6 months of intensive treatment3 rounds of chemo
… but the best of reactive health just isn’t enough.
Team
Advisors’ Experience
Average High RiskSuper Fit
DEMENTIA
Optimity improves the health of the full population
Selling Engaging
Proactive Engagement
Today’s professionals want…
• Mobile-first: check phones 48X a day • Community: based on common interests • Value-add: useful tips & insights • Self-care: data exchange • Gamified: progress & rewarding experiences
Proactive Engagement
The Solutions
Fun & Holistic
Access 3000+ healthy activities
Sync 100+ wearables & health apps
A personalized pocket health coachWhat do they get?
Members can do daily activities personalized based on their goals and schedule
Micro-activities
Easy as 1-2-3
1. JoinPotential & current customers via your branded lifestyle companion
2. Interact dailyEngage with useful content and health tips,
interact within their affinity community.
3. Earn Rewards Accumulate loyalty points for
member perks, products & rewards.
Engagement is about value you add to their lives, not how many ads they see.
Business Benefits
where Optimity adds value through engagement
Insurtech Value Chain
Marketing, Distribution,
SalesUnderwriting,
PricingService &Customer Retention
Claims Management
L I V E . W O R K . P L A Y . L I V E . W O R K . P L A Y .
Attract target customer segments
Access member benefits & perks
Pre-qualify leads for cross-sell and up-sell
Support healthy behaviors
Engage members in affinity communities
Build loyalty and affinity with points and rewards
Boost persistency
The old marketing and sales playbook is broken, Because the way people buy has changed.
63% ignore internet ads
94% skip TV ads
27% direct mail is
never opened
50% (over 200M)
are on do-not-call lists
Seed with current
customers• Establish your unique brand
of health and lifestyle
• Build contacts• Attract your target customer
segments to a community
ATTRACT PRIME DELIGHT REFERRAL CONVERT
In-force, Group,
Customers
Engaged Members
Rewarded Members
Promoters Repeat Customers
Value-add healthy
experiences• Leverage Optimity content
libraries to support members
• Accumulate data to form customer personas, segments
and pre-qualify leads
Loyalty points &
member benefits• Introduce exclusive products
and brag-worthy member perks
to create affinity to your brand• Boost your NPS and increase
persistency
Viral growth with
“like audience”• Open community where
members invite their peers,
family and colleagues• Grow desired leads with
no additional cost or effort
Engagement Methodology
A lifetime of
cross-sell / up-sell • Engage at the right times to
members’ developing life-stage,
goals and needs• Avoid price competition:
Service (instead of sell to) your captive loyal community
Personalized Offers
• Are you looking to identify potentials needs to offer relevant insurance products at opportune times?
• Do you want to turn data into meaningful insights about your customers and move closer to personalized offers?
• Generate leads to cross-sell and up-sell relevant insurance products• Perform needs analysis for current group population to offer additional insurance products (Life, Auto, Home)• Create member segments using Health Risk Assessment, Wearable data, social and demographic information• Experiment with member segments to personalize support and offers based on persona• Support future underwriting with this dynamic data wallet (working with Reinsurers)
We help carriers perform qualification and needs analysis with current in force population to expand the number of products they hold with the carrier.
Client Example (CA, 3M+ Life & Health Insurance Policyholders)
Play Demo: Admin
Health Benefits
Classroom Coaching
no follow-up
Wearables
low adoption
Use
r Eng
agem
ent
Traditional Solutions Lack Sustained Usage
Web Portals
seasonal
Fitness Apps
fad
Use
r Eng
agem
ent
Our Dynamic Solution Delivers Better Engagement
CentralizedML-enabled
Sustainablyengaging
Opportunisticcoaching
Connectedapps & device
(IoT)
Physician-driven preventive micro-actions
DEMENTIA CANCER COPD DIABETES HEARTDISEASE OBESITY DEPRESSION KIDNEY
DISEASE
Our Medical Advisors
Mark Stone
Eli Rosenberg
Eduardo Franco
Primary Physician
MBA, Rotman
Cardiologist
St. Paul Hospital
MBA, Ivey
Professor of Oncology, Epidemiology & Biostatistics
McGill University
Editor in Chief, Journal of Preventive Medicine
Expert Content
User segmentation: Moving users into a healthier state
Healthy & Building good habits
Providing fresh, new challenges
Keeping motivated
Healthy & Exhibiting poor habits
Motivating habit change
Educating on consequences
Unwell & Trying to improve
Seeking guidance & support
Preventing regression
Unwell & Doing nothing
Improving engagement with health programs
Preventing catastrophe
Healthy & Building good habits
Providing fresh, new challenges
Keeping motivated
Healthy & Exhibiting poor habits
Motivating habit change
Educating on consequences
Unwell & Trying to improve
Seeking guidance & support
Preventing regression
Unwell & Doing nothing
Improving engagement with health programs
Preventing catastrophe
Healthy & Building good habits
Providing fresh, new challenges
Keeping motivated
Healthy & Exhibiting poor habits
Motivating habit change
Educating on consequences
Unwell & Trying to improve
Seeking guidance & support
Preventing regression
Unwell & Doing nothing
Improving engagement with health programs
Preventing catastrophe
Healthy & Building good habits
Providing fresh, new challenges
Keeping motivated
Healthy & Exhibiting poor habits
Motivating habit change
Educating on consequences
Unwell & Trying to improve
Seeking guidance & support
Preventing regression
Unwell & Doing nothing
Improving engagement with health programs
Preventing catastrophe
Health state: Improvements
Engaged Optimity users rated themselves at the beginning of a 90-day measured program. Data shows that the initial scores are diverse with a large standard deviation, and after 90-days on Optimity the shift in health outcomes is statistically significant.
Average score5.1 – 7.4
Std. deviation1.25 - 2.75
Median: 5 – 8Modes: 4 – 10
Average High RiskSuper Fit
DEMENTIA
Optimity improves the health of the full population
Dynamic Health Assessments and Risk Scores
ROI Reduction in Claims
analysis supported by Insurance Research Labs at
Reduced Risk
Higher Profits
Renewals
Better Retention
Referrals
More Sales
