UnitedHealth Premium Designation Program. Driving informed choices and quality, efficient care

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1 UnitedHealth Premium Designation Program Driving informed choices and quality, efficient care

2 Today s health care system is fraught with wide variation in medical practices that often result in inconsistent clinical outcomes and inefficient care delivery for consumers and increased costs for employers. Care variation Variation in treatment practices continues to exist, despite the availability of established, published evidence-based medical guidelines. The New England Journal of Medicine reports that even when physicians are aware of best practices, they adhere to them only 50 percent of the time. 1 A 2007 study found that up to 75,000 deaths in the United States were due to unexplained variations in the quality of care received. 2 Cost variation Today, U.S. health care spending has reached a staggering $2 trillion, comprising 16 percent of our Gross Domestic Product. 3 This is well over twice the amount spent in 1990, and seven times the amount spent in To address these issues UnitedHealthcare established the UnitedHealth Premium designation program which recognizes physicians and facilities for meeting national, evidence-based criteria for quality and local market benchmarks for cost efficiency. UnitedHealthcare has taken an integrated approach to transparency programs. We provide quality and cost efficiency information for primary and specialty care to support individuals in making informed decisions throughout the continuum of care. } Consumers have access to quality information and personal support at all touch points. To encourage informed decisions, we provide engaging employee campaigns using online tools, s and printed materials. Financial and wellness incentives and other tools are available to assist consumers in understanding treatment options and the value of the care they receive. } Physicians are provided with actionable feedback through high-level performance and detailed patient reports to demonstrate practice-level variation and facilitate improvement. We use this information to engage physicians in improvement activities. } Employers receive consultative assistance in the development of consumer strategies that support the use of quality and cost efficient care. These include detailed utilization and savings opportunity reports, comprehensive employee marketing campaigns and administration of consumer benefit incentive programs aimed at increasing the use of quality and cost efficiency designated physicians and hospitals. Our goal is to deliver information to all stakeholders to drive actionable information, foster informed decisionmaking and improve care delivery across the nation. 1 Asch, Steven M. et al. The New England Journal of Medicine March 16; 354: State of Health Care Quality 2007, National Committee for Quality Assurance, Ibid. 1

3 Reduced variation better care delivery Expected Program Impact The UnitedHealth Premium designation program can make a difference to both employers and employees. For example, our designated physicians and facilities deliver higher quality care at 14 percent lower cost per episode 5. UnitedHealth Premium designation program As part of our overall network value, the UnitedHealth Premium designation program targets those clinical areas that drive variation and provide a significant opportunity to impact the quality and cost of care. Focusing on primary care, specialty physicians, and facilities, this program is designed to drive improvements along the continuum of care, with a goal of delivering value to employers and employees. UnitedHealth Premium is consumer-focused, delivering transparent information that includes quality and cost efficiency information to consumers, when they need it. Designations are applied across 21 physician specialties. } Choosing a physician } Identifying a facility } Understanding treatment and follow-up decisions The program evaluates the following specialty areas, which account for 50% of total health care spend. Primary Care Specialty Areas } `Family Medicine } `Internal Medicine } `Obstetrics and Gynecology } `Pediatrics Other Specialty Areas } ` Allergy } `Cardiology } `Cardiology - Electrophysiology } ` Cardiology - Interventional } ` Endocrinology } ` Infectious Disease 6 } `Nephrology } ` Neurology } ` Neurosurgery - Spine } `Orthopaedics - General } `Orthopaedics - Hand } `Orthopaedics - Foot/Ankle } `Orthopaedics - Hip/Knee } ` Orthopaedics - Shoulder/Elbow } `Orthopaedics - Spine } `Pulmonology } `Rheumatology 5 Estimated savings based on UnitedHealth Premium program experience with 28.4 million completed episodes of care. Savings based on 14% average. Actual savings estimates would vary from 7% to 19% based on physician specialty. 6 Not available in MN, ND, SD and Western WI. 2

4 Broad access to the UnitedHealth Premium program The UnitedHealth Premium program is available in 145 markets across 41 states. A listing of availability by state is provided in the map below. WA OR AR MT WY ND SD MN WI MI NH VT NY ME MA RI CA AK NV UT AZ CO NM NE KS OK IA MO AR IL MS IN TN AL KY OH GA WV SC PA VA NC DE MD DC CT NJ Available TX LA Partial Availability* HI FL Not Available **Illinois: Not available in Springfield Michigan: Not available in Upper Michigan Pennsylvania: Not available in Philadelphia Missouri: Only available in Kansas City 3

5 The UnitedHealth Premium designation program was developed with employer and employee needs in mind Employer benefits } Information transparency } Sustained focus on quality improvement and evidence-based medicine } Informed and engaged employees } Accountability through impact and cost trend reports How the designations are determined Employee benefits } Information transparency } Easy access to information and simple tools } Informed choice } Access and choice retained Quality standards Quality criteria are based on national evidence-based medical standards and practices and are developed by specialty physicians, scientific advisory boards, and specialty societies. The criteria used to measure individuals or group practices are based on process standards and outcomes indicators that measure the following aspects of care: } Preventive care - cancer screening and other indicated screening interventions } Appropriate care - appropriate use of medications and diagnostic tests } Chronic disease care - monitoring for control, progression, and complications } Patient safety - avoiding duplicate testing or adverse drug interactions, and monitoring safety } Sequencing of care - diagnostic tests and procedures, treatment, and monitoring } Effectiveness of procedures - lack of failed therapy and complications The clinical criteria is developed using published literature and information from organizations such as: } The AQA Alliance (formerly the Ambulatory Care Quality Alliance) } The National Committee for Quality Assurance (NCQA) } Specialty societies relevant to a specific disease and clinical condition } Government agencies } Other national expert panels Quality criteria spans the entire spectrum of care. A physician s quality outcome is determined by comparing the number of times their patients received the recommended care with a benchmark number based on the UnitedHealthcare national rate of the same recommended care for each quality measure. For example, medical evidence indicates that patients with diabetes should receive HbA1c testing at regular intervals, and patients with pharyngitis should be tested for group A streptococcus before being treated with antibiotics. Physicians must perform at a level that meets or exceeds the equivalent of the 75th percentile performance for all physicians measured to meet the quality of care criteria. 4

6 Cost efficiency standards Physicians and facilities who meet the quality criteria are then analyzed for cost efficiency in the use of health care assets. Cost efficiency criteria are based on patient care provided over an entire episode of care including appropriate use of diagnostic testing, prescribed medication, the procedure, and follow-up care. Total treatment costs are compared to market standards. Symmetry EBM Connect EBM Connect is an Ingenix tool that assesses quality measures related to preventive care and medical conditions. Each instance of an EBM Connect quality measure, applied to a patient, is referred to hereafter as an EBM measure. Symmetry Episode Treatment Groups (ETG ) ETG is an Ingenix tool that creates condition-oriented episodes of care, referred to hereafter as ETG episodes. Symmetry Procedure Episode Group (PEG ) PEG is an Ingenix tool that creates procedure-based episodes. Additional software then creates quality measures related to sequencing of care around procedures, their complications, and repeat studies or related repeat surgery/ procedures. Each instance of a procedural episode-based quality measure, applied to a patient, is referred to as a PEG measure. The major procedure performed during the episode is referred to hereafter as the anchor procedure. Related interventions are the targets. If more than one major procedure occurs in a PEG episode, clinical logic determines the anchor. PEG episodes are also used for cost efficiency analysis of procedure related episodes, referred to hereafter as PEG episodes. Examples of PEG anchor and target logic: } For an outpatient diagnostic cardiac catheterization, the catheterization is the anchor. Myocardial perfusion imaging (SPECT MPI) performed close in time, on the same patient, would be a target. } If a diagnostic catheterization is performed soon before placement of a drug-eluting stent, the stent is the anchor and the diagnostic catheterization is a target. 3M All Patient Refined Diagnosis Related Groups (APR DRG) APR DRG software from 3M creates severity of illness levels for risk adjusting inpatient PEG quality measures and inpatient PEG episode costs. 5

7 Consumer activation strategy Inform - Educate - Activate. Critical to the success of this program is the ability to effectively engage consumers. Collaboration between employers and health plans is critical to maximizing program results. Activating health care consumers requires increasing awareness, knowledge, skills and confidence and providing the tools necessary to support informed choice. For instance, research shows that there is a substantial gap between consumers definition of quality doctors (e.g., spends time with me, recommended by friend, etc.) and the evidence-based definition of quality (e.g., follow evidence-based guidelines for care, have redo rates in line with market norms). Research also shows that many consumers do not know where and how to find helpful information and are uncomfortable asking questions about physicians recommendations. The first step in activating consumers is articulating the personal value of quality and cost efficiency. Information on how well a physician or facility does with the treatment being sought should be an important consideration in making that health care choice. Questions consumers should feel comfortable asking themselves: } Am I getting an accurate and timely diagnosis? } Could I have a greater chance of getting the right procedure/treatment by going somewhere else? } Does my treatment adhere to the latest treatment guidelines on care? } How can I avoid a complication? Second, activation requires combining consumer education and appropriate resources to influence consumer behavior before, during and after care. We engage consumers via website technology, face-to-face interactions at open enrollment, discussions with nurses and customer care and a full set of written tools. This allows highly engaged consumers to reach in through self service and for UnitedHealthcare to reach out to less activated consumers who need personal assistance in making decisions. Activating health care consumers requires increasing awareness, knowledge, skills and confidence, and providing the tools necessary to support informed choice. Third, because physicians remain the trusted advisor to most health care consumers in making decisions about care, UnitedHealthcare is working closely with physicians to provide individual physician performance reports and feedback on meeting quality and cost efficiency criteria. An activation strategy might include: } Comprehensive awareness campaigns that engage consumers at key touch points. } Integrated technology and tools that provide transparent quality, cost, logistical and other general information about physicians, groups and facilities. } Personal support from nurses and customer care. 6

8 The UnitedHealth Premium designation program is a resource for informational purposes only. Designations are displayed in UnitedHealthcare online physician directories at myuhc.com. You should always consult myuhc.com for the most current information. Premium designations are a guide to choosing a physician and may be used as one of many factors you consider when choosing the physicians from whom you receive care. If you already have a physician, you may also wish to confer with him or her for advice on selecting other physicians. Physician evaluations have a risk of error and should not be the sole basis for selecting a physician. Please see myuhc.com for detailed program information and methodologies. Only individual physicians and facilities that meet UnitedHealth Premium designation criteria, or physicians in designated specialties who are part of medical groups that meet UnitedHealth Premium criteria for group practices and who have sufficient claims data for analysis, may be designated. All physicians and facilities that contract with UnitedHealthcare have met credentialing requirements. Regardless of designation, plan enrollees have access to all physicians and facilities in the UnitedHealthcare network. Specialties for which there are no quality guidelines currently established in the program are excluded from evaluation and are noted as such. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance Company, United HealthCare Services, Inc., or their affiliates. Confidential property of UnitedHealthcare. Do not reproduce or redistribute without the expressed written consent of UnitedHealthcare / United HealthCare Services, Inc.