We help health insurers profitably optimize their Strategy and Execution, aligning Marketing and Risk Management in the ACA (Individual and Small Group) and Government (Medicare and Medicaid) segments with regulated Risk Transfer mechanisms, as well as in the increasingly consumer oriented B2B2C Large Group Employer business with its competitive and market driven Risk Transfer mechanisms.
ACA (Individual and Small Group Business) and Government (Medicare and Medicaid) are mostly consumer business with regulated Risk Transfer mechanisms.
- To make optimal strategic decisions impacting the business for the next year, the current membership needs to be considered “on-leveled” to future pricing and costs, and Risk Adjusted for the future rules. DeMystify Healthcare facilitates this data transformation to optimize the fact base upon which they base strategic decisions. To evaluate current performance, our Dashboards use the current (post-Risk Adjusted) data.
- Regulation limits the ability to price to risk, and therefore actionable surrogates need to be found to attract market risk or better. We create a robust micro-segmented and granular understanding of pre and post Risk Adjusted profitability to minimize controllable cross subsidization (by OEP/SEP, area, provider, HCC/disease/conditions, subsidy, FPL, utilization, network, agent, SIC, product etc).
- Tools are needed to optimize product to attract a target population rather than the average; and to provide and frequently update strategically derived, actionable lists of targets for acquisition, retention, coding and care management.
Large Group is employer based B2B2C business with market driven risk transfer mechanisms.
- Most payers take a pooled approach to risk, and weight pricing on experience and a manual rate and change in risk is reflected with a long lag. Actual risk is influenced by the competitive choices facing an employee, based on their individual healthcare needs and their share of premium and claims costs. This results in favorable risk selection to some payers (lean benefits and formulary, self-funded and narrow network plans) and unfavorable to others (rich, PPO, broad network plans). DeMystify Healthcare tools compensate for this by optimizing product features and underwriting the prospective risk.
- The 50-500 employee group sizes are particularly compromised by the prevalent underwriting and pricing models. DeMystify approaches these group sizes from two perspectives, the traditional model as well as a more granular, sum of individual risks model. Pooling only addresses unknowable risks, and known, repeating risks are not socialized. Preventable cross subsidization is minimized. As a result, pricing is more reflective of true risk, and well-priced groups are retained, and lapses are favorably selective.
- DeMystify Healthcare also focuses on in-group risk shifts, measuring and guiding Employee and Dependent migration and selection at lapse. Winning at initial or open enrollment to drive member risk mix within an Employer is critical to success in a B2B2C model, just as it is in OEP in the regulated markets. Our Product Configurator optimizes product features for both the group and for targeted member segments, based on actual experience at a group, or based on custom pools of experience with similar competitive conditions.