The Evolution of UnitedHealth Premium

Transcription

1 The Evolution of UnitedHealth Premium Power to transform heath care delivery <Insert Specialty Society Name> <Insert Date>

2 Why We Do What We Do? Achieving the The Triple Aim! The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping these three aims separate. Society, on the other hand, needs these three aims optimized (given appropriate weightings on the components) simultaneously. Improve the individual experience Improve population health Tom Nolan, PhD, Don Berwick, MD, MPH Control inflation of per capita costs Triple Aim The Triple Aim: Care, Health, And Cost, Health Affairs, 27, no.3 (2008): Donald M. Berwick, Thomas W. Nolan and John Whittington, 2

3 UnitedHealth Premium Program Consumer Driving Value for All Stakeholders Empowering consumers by delivering actionable information that helps them make more informed care decisions. Employer/Payer Maximizing affordability for employers/payers to assist their efforts to manage total health care cost by promoting quality and affordable health care. Care Provider Supporting physicians and hospitals with actionable performance information to improve care delivery and maximize value across the entire delivery system. Better Health, Better Care and Lower Cost 3 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

4 UnitedHealth Premium Physician Designation PROMOTING VALUE: QUALITY FOR A GIVEN COST Quality and cost transparency Longest running physician quality and cost efficiency designation program (2005) National industry, evidence-based and specialty society standards Evaluate doctors on more than 75 conditions and 300 measures Physicians who fail to meet quality not eligible for cost efficiency Access Broad application Recognition 148 markets and 27 specialties evaluated* Accounts for more than 80% of all medical costs* Includes primary care physicians and specialists Available to members at no additional cost Integrated into customer service, clinical and online experiences Benefit designs based on Premium designation Received the National Committee for Quality Assurance (NCQA) program Physician Quality (PQ) certification and meets the Consumer Purchaser Disclosure Project s Patient Charter standards *Data as of January 1, Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

5 Version 6 Enhancements Enhancement Enhanced Quality: Addition of appropriateness and outcomes measures for the OB-GYN specialty. Enhanced Quality: Addition of UnitedHealthcare Medicare and Retiree data to assess physician quality. New feature allows creation of separate Commercial and Medicare and Retiree benchmarks. Enhanced Cost Efficiency: Evaluation of risk-adjusted population cost ( Total Cost of Care ) in addition to episode cost for both primary care and select nonsurgical specialist physicians. Enhanced Cost Efficiency: Addition of surgical episodes for the OB-GYN specialty. Value Expands the number of specialties that are assessed for appropriateness and outcome measures in addition to process measures. Increases the proportion of an OB-GYN's work assessed by the program providing for a more comprehensive view of performance. Adds 1,200,000 patients worth of data (equivalent to adding almost 4 million commercial patients due to higher utilization), thereby increasing data sufficiency and the volume of physicians who can be assessed for quality. Increases the proportion of a physician's work assessed by the program providing for a more comprehensive view of performance. Complements episode methodology by addressing the appropriate number of episodes as well as capturing non-episode costs. Covers over 80% of medical spend providing the opportunity to generate higher levels of savings than current episode measures. Aligns measurement of primary care and specialists to provide patient centered care. Increases the proportion of an OB-GYN's work assessed by the program providing for a more comprehensive view of performance. 5

6 Version 6 Key Features Changes in Bold Subject to modeling and analysis of impacts Program Standards Physician s performance compared to expected results Testing to determine if the performance differences are statistically significant Group assessment performed at the specialty level Minimum 45-day interval to review results prior to public display Reconsideration of physician and group outcomes Eligibility Standards Active commercial contract as a Network Physician, in a designated market Medical license without sanctions Board certification no longer required but continues to be displayed on provider directories Quality Standards Quality is assessed first and if quality criteria is not met, the physician is not eligible for the Efficiency designation Measures may be attributed to multiple physicians involved in the patient s care Measures are compared to national benchmarks, at the 50 th percentile performance Medicare data with separate benchmarks are included Minimum sample size: 20 measures among 5 unique patients are required for measurement Cost Efficiency Standards Population cost in addition to episode cost is used for assessment Minimum sample size is 10 episodes (episode cost) and 10 patients (population cost) Attribution: Minimum cost threshold (episode cost); type, recency and count of visits (population cost) Case-mix and severity-adjustment for episode cost and case mix and risk-adjustment for population cost Benchmarks are region and specialty specific Benchmark performance is at the 75th percentile Confidence level is 90% Must be statistically lower cost to be designated for cost efficiency Academic credit no longer given 6

7 Public Display and Product Offerings Subject to modeling and analysis of impacts Designations/Public Display Did not meet criteria changes from blank to Did Not Meet Quality and Cost Efficiency Add new value: Cost Efficiency & Not Enough Data to Assess Quality Change stars to a different icon schema Specialty Adds General Surgery (includes Colon and Rectal Surgery) Urology Ophthalmology Ear, Nose, Throat (ENT) Benefit Design Change tiering to both specialists and primary care; Currently tier on specialists only Add Cost Efficiency & Not Enough Data to Assess Quality to preferred benefit tier in addition to Quality and Cost Efficiency 7

8 Delivery System Transformation What Does It Look Like? Better Health, Better Care and Lower Cost Consumer and Employer/Payer Consumers and employers/payers are operating within an environment in which they have: Care Provider Physicians, hospitals and delivery systems are operating within an environment in which they are: Aligned incentives around common measures and desired outcomes Transparency and decision support tools that enable increased engagement Empowered to make more informed and personally appropriate choices for their medical care Increased satisfaction with patient experience Improved quality outcomes Lower cost Integrated both clinically and financially Able to coordinate care across all care settings Accountable for cost, quality, and experience outcomes Rewarded for improvements in quality and cost efficiency Reimbursed through value-based payment models 8

9 Appendix 9

10 Software Tools EBM Connect (Evidence-based medicine measures) Tool that provides a paid claims analysis component to identify deviations from clinical guidelines in patient care More than 200 evidence-based medicine measures (guidelines) for 35 common chronic diseases Used to evaluate quality of care Episode Treatment Groups (ETG ) Tool that aggregates paid claims into episodes of disease The ETG methodology allows for case mix adjustment, clinical homogeneity, episode building, concurrent and recurrent episodes and shifting episodes Used to evaluate cost-efficiency for non-proceduralists Procedure Episode Groups (PEG ) Tool that generates episodes centered on procedures and is used to evaluate quality and cost efficiency for procedural specialties. Used to evaluate quality and cost efficiency for proceduralists All Patient Refined Diagnosis Related Groups (3M APR DRG) Generates a severity score related to hospitalizations Used for severity adjustment related to inpatient procedure Episode Risk Groups (ERGs ) Tool that predicts current and future health care usage for individuals and groups by creating individual risk measures that incorporate episodes-of-care methodology, medical and pharmacy claims information, and demographic variables. Assigns an individual s health care services are assigned to appropriate treatment groups. Categorizes each ETG into an Episode Risk Group (ERG), a grouping that combines episodes of similar clinical and risk characteristics. Creates a clinical and risk profile is created for each individual with age, gender and ERGs as inputs. Computes a risk score for each person is computed by combining weighted ERG scores and demographic variables. Each individual risk score predicts a member s current and future need for health care services and associated costs. 10

11 Release 6 Premium Designation Specialties 27 specialties covering > 80% of medical spend Primary Care Family Medicine Pediatrics Obstetrics & Gynecology Internal Medicine Specialists Allergy Ophthalmology (1) Cardiology Orthopaedics-General Cardiology-Electrophysiology Orthopaedics-Foot/Ankle Cardiology- Interventional Orthopaedics-Hand Ear, Nose and Throat (ENT) (1) Orthopaedics-Hip/Knee Endocrinology Orthopaedics-Shoulder/Elbow General Surgery (1) Orthopaedics-Spine General Surgery Colon/Rectal (1) Orthopaedics-Sports Medicine Infectious Disease Pulmonology Nephrology Rheumatology Neurology Urology (1) Neurosurgery-Spine (1) Inclusion is subject to impact analysis and modeling Summer

12 UnitedHealth Premium Availability by State AK WA OR NV CA ID UT AZ MT WY CO NM ND SD NE KS OK MN IA MO AR WI IL MS IN MI AL OH GA PA VA NC SC VT NH ME NY MA RI CT NJ DE MD DC Available TX LA Partial Availability* HI FL Not Available * Illinois: Not available in Southwest Illinois Michigan: Not available in Upper Michigan Pennsylvania: Not available Philadelphia Missouri: Not available in St. Louis, St. Joseph and Jefferson City 12

13 Evolution of UnitedHealth Premium UnitedHealth Premium is evolving into an integrated platform with aligned, enhanced measurement for multiple programs to empower informed decision making and shared accountability to drive improved outcomes. Alignment Measurement Transformation Physician and facility Alignment designation of performance using improvement claimsbased quality accountability and and shared cost efficiency measures Aligned measures across programs Consistent analytics and reporting Shared accountability for outcomes Enhanced analytic capabilities and data with comprehensive, focused performance measurement Additional specialties Additional data sources Enhanced methodology Includes more medical spend Provides actionable information to transform the health system CARE MANAGEMENT PROGRAMS VALUE-BASED BENEFITS VALUE-BASED CONTRACTS PERFORMANCE TRANSPARENCY 13

14 UnitedHealth Premium: Powering delivery system transformation Our Accountable Care Platform, powered by UnitedHealth Premium, drives delivery system transformation An aligned, flexible, integrated platform PERFORMANCE TRANSPARENCY Engage and inform consumers, maximize affordability for employers/payers and support care providers with actionable information. VALUE-BASED CONTRACTS Align care provider payment with value. VALUE-BASED BENEFITS Incent consumers to select higher performing care providers. CARE MANAGEMENT PROGRAMS Support better health outcomes for consumers and drive value across the entire health system. HIGH PERFORMANCE NETWORKS Utilize multiple, distinct approaches to encourage use of higher quality, lower cost providers Enhanced transparency in pricing, quality, and clinical information Comprehensive view of performance creates greater alignment across programs Alignment fosters shared accountability for improved outcomes and lower costs Consumers and providers both incented around common measures and desired outcomes/behavior Empowers more informed decision making Platform drives quality and affordability to improve outcomes 14 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.