North America Equity Research May 20, 2014
STRICTLY PRIVATE AND CONFIDENTIAL
GNPH ACA WEBINAR–PAYOR PERSPECTIVE
Managed Care & Healthcare Facilities Justin Lake AC
Global Government Relations and Public Policy Pierce Scranton
383 Madison Ave, 32nd Floor, New York, NY, 10179 212-622-6600
[email protected] J.P. Morgan Securities LLC
Executive Director
Michael Newshel
Neal Miniyar
Andrew Tom
212-622-5075
[email protected] J.P. Morgan Securities LLC
212-622-3662
[email protected] J.P. Morgan Securities LLC
212-622-5846
[email protected] JP M J.P. Morgan S Securities iti LLC
See the end pages of this presentation for analyst certification and important disclosures, including non-US analyst l t disclosures. di l J.P. Morgan does and seeks to do business with companies covered in its research reports. As a result, investors should be aware that the firm may have a conflict of interest that could affect the objectivity of this report. Investors should consider this report as only a single factor in making their investment decision.
Justin Lake – The Payor Perspective Managed Care & Healthcare Facilities Justin Lake 383 Madison Ave Ave, 32nd Floor, Floor New York York, NY NY, 10179 212-622-6600
[email protected] J.P. Morgan Securities LLC
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Managing Director in the healthcare group at J.P. Morgan Research. Specialize in coverage of managed care, hospitals and small/mid cap healthcare providers including dialysis and surgical facilities. Justin is currently dual-ranked No. 1 in Institutional Investor’s “All-American Research Team” survey for both Managed Care and Health Care Facilities. Similarly, in the Greenwich Associates poll, Justin is ranked No. 1 in Healthcare Services. Prior to joining J.P. Morgan in 2012, Justin worked at UBS in a similar capacity covering the space for 11 years. MBA from NYU Stern School of Business and CFA charter holder.
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Pierce Scranton – Congressional Update Global Government Relations and Public Policy Pierce Scranton J P Morgan Chase & Co J.P. Co.
Pierce Scranton is Executive Director of Global Government Relations and Public Policy. Policy He is responsible for coordinating the firm’s position and advocacy strategy on tax and fiscal policy and also works on advocacy related to financial regulatory reforms. Pierce joined JPMorgan Chase after a decade of government service in which he held a variety of senior positions and political roles, most recently serving as Economic Policy Director for Governor Romney’s presidential campaign. He previously served as Chief of Staff at the White House Council of Economic Advisers, where he advised senior White House and Administration officials ffi i l on a wide id range off d domestic ti and d iinternational t ti l economic i iissues.
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Before joining the White House, Mr. Scranton served as Senior Policy Advisor to the Secretary of Commerce where he was a key advisor on international trade and investment policy. He previously worked in the International Trade Administration, where he helped develop strategies to assist U.S. businesses in resolving international trade disputes. Mr. Scranton M S t also l spentt severall years on Capitol C it l Hill working ki ffor fformer Washington W hi t State St t Congresswoman C Jennifer J if Dunn, D who h served on the House Ways and Means Committee and the Joint Economic Committee. Mr. Scranton graduated from Kenyon College with a degree in political science.
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Overview of Healthcare Reform Coverage Expansion
– Subsidized private coverage on Health Exchanges/Marketplaces – Medicaid expansion to higher income threshold Pay-Fors
– Medicare reimbursement cuts for providers and health plans – Premium taxes and other fees Delivery System Change
– Quality bonuses and penalties in Medicare reimbursement – Accountable Care Organizations (ACOs) and bundled payments – Comparative effectiveness research
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Broader Trends Beyond the Affordable Care Act
– – – – –
More integrated care and risk sharing with providers Narrow networks and value Consumer/retail level choice Private exchanges Utilization trends
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Reform Impact on Insurers
Additional Medicaid members New exchange market with subsidies
PROS
Dual eligible shift to managed care
Margin compression in existing business No more underwriting 3-to-1 3 to 1 ma maximum im m age bands for premi premiums ms Rate review
CONS
Possible employer “dumping of coverage” Premium taxes and other fees Minimum medical loss ratios
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Medicare Advantage cuts
Ultimate net impact of reform depends on the long-term viability and profitability of exchanges and employer responses
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Coverage Expansion Estimated Coverage Changes from ACA ACA core is
expanding health coverage, expected to reach 26M of ~50M uninsured Half expected to enroll
on exchanges, with ~80% qualifying for government subsidies
2014
2015
2016
2017
2018
Exchanges
+6
+13
+24
+25
+25
Medicaid
+7
+11
+12
+12
+13
Employer
–
-2
-7
-7
-8
Nongroup
-1
-3
-4
-4
-4
Uninsured
-12
-19
-25
-26
-26
Revisions to CBO Estimates About half to get
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Official Congressional g
Budget Office projections have been lowered over time
Mar 2012
Mar 2010
Jul 2012
30
Net C Coverage Expansion
covered by Medicaid expansion, half by exchanges
35
Feb 2013
26m Current Est
25
May 2013/Feb 2014
20
15
10 2014
Source: CBO
2015
6
2016
2017
2018
2019
2020
2021
2022
3 R’s R s – Premium Stabilization Risk adjustment, reinsurance and risk corridor programs (known as 3Rs) should mitigate most
extreme downside scenarios for exchange earnings Risk Adjustment
Description Risk Mitigated g
Risk Corridors
Reinsurance
Permanent Plans with lower-than-average risk scores transfer funds to plans with higher risk scores Enrolling patients with higher health risks relative to competitors
Temporary (2014-16) C Costs ffor an individual above Losses/gains / reduced when attachment point and below cap allowable costs are +/- 3% of are reimbursed at coinsurance % target Guaranteed issue Underestimated total medical disproportionately drawing highercosts cost patients into exchanges
But timeline means 2014 exchange earnings won’t be known definitively until mid-2015 Plans have to submit pricing for 2015 in two months, with limited claims experience
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It may take until 2016 or 2017 for pricing to be adjusted appropriately to the risk pool
3/31/14 2014 Open Enrollment Ends
5/1/14 Latest Coverage Start for Open Enrollment
5/31/14 2015 Rate Submissions Due
11/15/14-1/15/15 2015 Open Enrollment
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6/30/15 Notified of 2014 Risk Adjustments & Reinsurance
7/31/15 2014 Risk Corridor and MLR Calculations Due
Risk Corridors
% of Target Costs (Premiums - Allowable Admin Costs/Profits)
92% Pay 80% of gain to HHS
97% Pay 50% of gain to HHS
103% No Payments or Charges
108%
HHS compensates 50% of loss
HHS compensates 80% of loss
50% 40% 30%
Limits upside
EB BIT Margin
20% 10% 0% 10% -10%
Mitigates downside
-20% -30%
Corridors - HHS C S Definition
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120%
Without Risk C Corridors
115%
MLR
110%
105%
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
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-40% 40%
Private Exchanges Overview Public Exchanges
Private Exchanges Active
Private Exchanges Retirees
Stakeholders
Federal and/or state gvt, individual, small group employers
Employer and employee
Retired employees and employers
Plan Design
Actuarial metal tiers catastrophic, bronze, silver, gold, platinum and 10 essential benefits
Customizable product to address the needs of any employer group
Medicare Advantage, Med Supp, Part D, and traditional Medicare
Target Market
Individuals and small group. Current size of the uninsured and individual market is 50M/11.5M
Employer-sponsored coverage. Current size of the employer market is 150M (80M in ASO)
Retired employees. 12M of 48M total eligibles today have some form of employer-sponsored coverage
Plan Options
O average, a consumer can On choose from 53 plans from at least 2 different companies
S Single carrier exchanges can have 3-5 plan options vs. a multicarrier which can have 10+
Traditional Medicare and Part D offered everywhere and MA/Med Supp options vary by county
Risk-based insurance
Risk or self-insured
Risk or self-insured
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Risk
Public Exchanges
Private Active Exchanges
Trader Joe’s “dumped” part-time
Walgreens shifts 160,000 active
employees’ health care coverage
employees to the Aon Hewitt private active employer exchange
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Private Retiree Exchanges IBM moves 110,000 retirees to
Extend Health private retiree active
Private Exchange Players Towers Watson
Aon Hewitt
Mercer
Buck
Hi t History
Launched au c ed O OneExchange e c a ge in Jan 2013
St t d in Started i late l t 2011
Launched au c ed Mercer e ce Marketplace in Jan 2013
Launched in 2010 under MMA product. d t RightOpt Ri htO t launched in 2014.
Number of Employers
Not disclosed but major employers include IBM, Time Warner, DuPont, Caterpillar, CSX, General Electric and Whirlpool
19 employers
At least 5 major employers for 2014
20-30 employers
400,000 retirees
600,000 active, 250,000 retirees
Not disclosed
>400,000 total
60% growth for 2014 with 20% long-term growth rate
Corporate exchange to more than triple in 2014
At least 5 major employers that range in size from 800-25K each
No guidance
2014 Covered Lives Growth Expectations
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Pl Participation Plan P ti i ti
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2014 Est Private Exchange g Lives Aon 850,000 Towers Watson 400,000 Buck (Xerox) 400,000 CaliforniaChoice 150,000 HealthPass 30,000 Bloom Health 25,000 Medica 13,000 Liazon 10,000 GlidePath 1,500 Mercer ? Optum ? Willis North America ? Total ~1.5-2M
Private Exchange Attraction to Employers 1. Shift to Defined Contribution Shift from defined benefit to defined contribution (1) removes employer from employee health benefit decisions, (2) gives
employer greater health benefit subsidies – moves to CPI growth over medical cost inflation, inflation and (3) greater transparency – may drive behavioral change
2. Greater Product Choice Likely greater choice of products for employees (Metal level plans)
3. Best-in-Class Local Market Discounts Potential for g greater plan choice including g best-in-class local market discounts
4. Reduced Admin Costs Employers can lower admin costs by outsourcing benefit designs to the insurers and avoiding the back office costs of
overseeing benefits and processing claims
5. Product Innovation Greater employee cost responsibility and increased individual cost-sharing may drive competition and greater innovation from
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managed care such as narrow networks, ACOS, etc.
6. Risk- Based Annual Contracts Can be set up under risk based annual contracts which give more definitive defined contribution
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Cost Hurdle for Converting to Risk COSTS
Medical Costs
Avoiding state-mandated benefits and implementing wellness and disease management programs can lower medical costs for f self-insured f plans
Commissions
Self-insured employers pay consultants to help them choose and negotiate g with claims administrators, but the costs are typically yp y less than the broker commissions that are baked into risk premiums. May be offset by lower admin costs on back end
3-6%
Health Plan Profits
Profits per life covered are much higher for insured plans to compensate them for taking on the underwriting risk
0 2% 0-2%
Premium Taxes
Self-insured Self insured plans do not have to pay existing state premium taxes that are baked into the price of full-risk plans
New Industry Fee
Self-insured S lf i d plans l also l avoid id the th Aff Affordable d bl Care C Act’s A t’ new iindustry d t premium fee that insurers are passing along through higher premiums
1-2% 1 2%
1%
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2-2.5% %
9-11%
Savings can be achieved by self-insuring instead of buying full risk plan
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Interest in Private Exchanges % of Surveyed Employers Considering Private Exchanges Result 7-29% * 32% 33% 44% 47% 52% 50 80% ** 50-80%
Source Kaiser/HRET Survey of Employer-Sponsored Health Benefits 2013 Mercer Marketplace Private Exchange Survey National Business Groupp Surveyy Aon Hewitt Corporate Health Care Exchange Survey J.D. Power and Associates 2012 Member Health Plan Survey HealthPass New York Survey Oliver Wyman Wyman'ss Employer-Sponsored Employer Sponsored Healthcare: What Happens Now
*7% for firms with 200-999 employees, 13% for 1,000-4,999 employees, and 29% for ≥5,000 employees.
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**62% for firms with 10-50 employees, 57% for 51-100, 55% for 101-3,000, and 49% for >3,000 employees. Additional ~20% would consider as long as they saw savings >10% savings.
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Medical Cost Trend Utilization has been depressed since recession but concerns about inflection Severe Q1 weather and reform implementation make it harder to detect underlying shift Increase in aggregate health spending in Q1 likely driven by newly insured 2014 premium pricing generally assumes 50-100 bps uptick in utilization
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Personal Health Care Spending Growth – Price & Utilization
Source: Altarum Institute, based on Health Sector Economic Indicators Data 14
Cyclical vs vs. Secular Debate Rebound in utilization has historically had long lag time behind economic recovery Increasing recognition that secular factors could restrain utilization long term Deductibles and employee burden of healthcare costs are increasing and more focus on
controlling costs at employers, payors and providers But so far health plans have been reluctant to assume a “new normal” in pricing
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Growth of HSA-Qualified High Deductible Health Plans (millions)
Source: America’s Health Insurance Plans (AHIP). 15
Delivery System Changes in ACA ACA primarily focused on getting coverage for uninsured, but includes a number of initiatives to
base more Medicare reimbursement on value and quality ACOs and bundled payments allow providers to benefit financially from controlling costs Funding for comparative effectiveness research Cost controls in ACA experimental, potentially laying groundwork for more significant changes
Quality and Value-Related Reforms to Medicare in the Affordable Care Act 2011 Innovation Center Coordinated Care
Office for Dual Eligibles
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Physician Bonuses
for Quality Data
2012 Hospital
Readmissions Penalties Medicare Shared
Savings (ACOs)
2013 Hospital Inpatient
Value Based Purchasing Bundled Payment
Pilot
Independence at
Home
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2014 Quality data reporting
for LTCHs, IRFs, hospices, inpatient psychiatric facilities, and cancer facilities
2015 Penalty for hospital
acquired conditions Physician value-
based payment modifier
Value Shift is Broader than ACA With or without ACA, the healthcare delivery system is moving from volume-based, fee-for-service
reimbursement for providers to value-based value based, risk risk-sharing sharing systems that incentivize doctors to control costs and integrate care “Land grab” as hospitals, insurers and large management groups consolidate physicians Price transparency and narrow networks to restrain unit costs; integrated care and standardized
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protocols to prevent hospitalizations and other more costly downstream care
Source: Health Affairs. 17
Narrow Network Adoption The use of tiers of health care providers and facilities based on specified performance metrics,
including cost efficiency and measures of quality quality. Copayments are then reduced for consumers who seek care from those providers and facilities that fall into a higher-performing tier and are increased for those providers and facilities that fall into a lower performing tier. Particularly prevalent in the individual public exchange market where cost is key In a recent McKinsey study of exchange plans, 70% of networks were found to be narrow or ultra-
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narrow
Source: McKinsey. 18
Perspectives on Narrow Networks
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Payor Perspective
Provider Perspective
• Market segmentation - offer different value propositions at difference d e e ce p price ce po points s
• Some are voluntarily removing themselves from narrow networks where the economics won’t work
• Value-based Value based purchasing and bending the healthcare cost curve
• P Potential t ti l opportunity t it to t partner with a payor
• Migrate care away from the high-cost settings
• Fighting exclusion in instances where the volume growth won’t offset the discount
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Hospital Owned Health Plans In the transition to fee-for-service to fee-for-value, a growing number of hospitals are managing
risk thru directly providing insurance coverage Research from a recent Advisory Board Company survey indicates 20% of hospital networks now
market an insurance product and another 20% are exploring insurance options Notable players:
• Geisinger • Intermountain Healthcare • University of Pittsburgh
• Henry Ford Health System • Kaiser Permanente
Potential to create more competition for the standalone insurers, but if this trend has legs, we
are likely in the very early days of a transition
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“Many of [the hospital systems] are also folks we do business with,” said Juan Davila, Blue Shield of California’s senior vice president for network management. “There’s a potential for that to be difficult.”
Source: Advisory Board Company, WSJ. 20
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