Improving Quality And Bending the Cost Curve: Strategies That Work

Transcription

1 Improving Quality And Bending the Cost Curve: Strategies That Work Lewis G. Sandy MD SVP, Clinical Advancement, UnitedHealth Group UnitedHealth Center for Health Reform and Modernization AcademyHealth June 12,

2 Disclosures: Employee, Ownership Interest: UnitedHealth Group 2

3 UnitedHealth Group: A Diversified Health and Well Being Company With A Mission of Helping People Live Healthier Lives UnitedHealth Group Data Innovation, Transparency and Consumerism UnitedHealth Group serves more than 75 million Americans each year Health benefits Services Health services We process more than $115 billion in health care spend per year Partnership Foundational Competencies Clinical care management Advanced technology Health data and informatics Member engagement We partner with more than 650,000 physicians and other care providers, 6,000 hospitals, 80,000 dentists, and 65,000 pharmacies in all 50 states We touch nearly every aspect of health care delivery and financing 3 3

4 Innovating To Create Payment/Delivery Reform: Decades of Experience in Quality-Based Specialty Networks (Transplant, Congenital Heart Disease, others) Multiple Patient-Centered Medical Home Pilots, varying designs/geographies, collaborative approach Participating in ACO Learning Network-collaborating with Tucson Medical Center, others in discussion Migrating payment from FFS to Performance-Based Contracting: Rewarding Value vs. Volume Payment innovation: Gainsharing models, Oncology Bundled Payment, Episode Based payments Large scale physician performance assessment/improvement/transparency Advanced consumer engagement & activation programs/capabilities High Performing Delivery System enablement: Clinical Analytics, Care Management, Actionable Intelligence: Into the Workflows.. 4

5 UnitedHealth Premium Designation Promoting Quality & Affordable Health Care Quality First with Cost Transparency Longest running physician quality and cost efficiency designation program (since 2005) National industry, evidence-based and medical specialty society standards are used to evaluate individual physicians on more than 75 conditions and 300 measures Only physicians who meet the quality designation criteria are eligible for cost efficiency designation Access 145 markets and 21 specialties account for more than 50% of all medical costs; includes Primary Care Physicians and Specialists Broad Application Available to all members at no additional cost designations integrated into all customer service, clinical, and online experiences Benefit designs based on UnitedHealth Premium designation The UnitedHealth Premium program has received the National Committee for Quality Assurance (NCQA) Physician Quality (PQ) program certification and meets the Consumer Purchaser Disclosure Project s Patient Charter standards 5

6 Evolution of Payment From Volume Based to Value Based: Objective: transform the payment system from fee-for-service to one that rewards for quality and outcomes. New payment models Compensation Continuum (Level of Financial Risk) Performance-Based Payment (small % of financial risk) Episode-Based Payment (moderate % of financial risk) Global Payment (large % of financial risk) PBC Physician Hospital PBC Primary Care Episodic Payments PCMH ACO Gainshare Capitation Limited Integration Expansive Integration Full Integration (i.e. Unrelated Physicians/Hospitals) (i.e. Multispecialty Group, IPA, evolving ACOs) (i.e. fully integrated delivery systems) Delivery System Configuration Continuum (Level of Clinical Integration) 6 6

7 Challenges and Opportunities In Payment/Delivery Reform: Opportunities Challenges The continued attractiveness (and risk) of a bulk-up /gain market power/raise price strategy in care delivery Multi-payer, public/private effort sporadic and fitful vs. a designed feature of a national care improvement strategy Technical issues and componentware conventions (attribution, measures, bundle designs) slow to emerge Overestimating rules/incentives as change drivers; underestimating culture, leadership, inertia Uncertainty surrounding legal and regulatory issues Growing recognition of: - The gaps between current and optimal performance - The areas of focus needed to drive improvement (care coordination, readmission prevention, patient safety, patient engagement/activation, teamwork) -The critical needs for tools, technology and infrastructure to support care improvement -The need to bend the cost curve and move toward high-value care delivery models Emerging leadership aspiring to build high-performing delivery systems Growing spirit of collaboration among stakeholders A body of tacit knowledge is available to tap Increasing patient/consumer engagement capabilities, improving the health of the population, enhancing the patient/consumer experience Not everything takes a transformed delivery system to improve! 7

8 What Is Needed for Change: Modernizing the Health Ecosystem Interoperable and connecting technology Real-time information at point of decision Streamlined administration Managed compliance risks and costs Enabling Total Population Health Aligned accountabilities for patient-centered care delivery Continuity of care Performance-based and evidence-based payment models Personal responsibility for lifestyle choices and health management Everyone agrees on the what the challenge is how 8

9 The esync Platform: Comprehensive Approach to Population Health Management esync is our proprietary platform through which we synchronize health information and deliver personalized health care management and care plan adherence Synchronize diverse data points to monitor population needs Claims data Total Population Monitoring Holistic Member View for Proactive Identification Pharmacy data Lab data (for select) Health assessment results Care Provider Engagement Outreach and Health Management Network and quality and efficiency rated physician utilization Operational interactions Persistent Consumer Engagement The esync intelligence continuously monitors population data to identify opportunities using our proprietary clinical rules and industry evidence-based medicine 9

10 Holistic Member View and Real Time Insights Through esync, we are able to proactively identify and prioritize opportunities according to four major areas: Find the right provider Get the right care/ treatment Take the right medication Live the right lifestyle 10

11 Example: Actionable Intelligence Clinical Decision Support and Real time Workflows Sutter Medical Network works with OptumInsight to analyze practice pattern variation and drive Evidence Based Alerts for clinicians at the point of care Utilizing Impact Intelligence, analytical software that measures variation in physician practice patterns Impact Intelligence draws upon integrated claims, pharmacy and lab data from health maintenance organization providers to measure costs Use Intelligence to drive Evidence Based Alerts in the clinical workflow Results: 50% reduction in Imaging studies for low back pain in less than 6 months PROVIDER 1 $1,900 MRI/MRA CAT Scans Other diagnostic, X-ray The variation for similar patients can be enormous and physicians are often unaware of that or of the impact it has on cost and quality. If you re serious about changing behavior, this is a process that allows change to happen. Michael van Duren, M.D., Chief Medical Officer at Sutter Physician Services PROVIDER 2 $300 MRI/MRA Radiology, other Other diagnostic, X-ray PROVIDER 3 $250 Other diagnostic, X-ray Radiology, other 11

12 How To Live in a Post Fee For Service World: Get Aligned Unaligned: Specialist-based, siloed delivery system Fragmented delivery of chronic care ER primary access point for after hours and urgent care Providers paid to provide services not manage care Payors manage performance through inspection Current State Performance: Medicare Advantage Plans Admits per 1,000 = 315 Inpt Days per 1,000 = 1,500 to 1,700 % of Recommended Care Received by Chronic Pts: 55% EMR/EHR Adoption = < 35% Patient Satisfaction = variable Fully Aligned: Primary care centered models Continuity of care provided through electronically connected system with dedicated care extenders (NP) assisting primary care Dedicated resources for chronic/after hours urgent care Performance-based payment system resulting in aligned incentives between stakeholders (payors and providers) Market Leading Performance: Benchmark Systems Admits Per 1,000 = 225 Inpt Days per 1,000 = 800 to 1,000 % of Recommended Care Received by Chronic Pts: 95% EMR/EHR Adoption = 70-80% Patient Satisfaction > 96% Reduce total cost by 15-20% while increasing patient satisfaction 12

13 Applying Private Sector Solutions To Public Programs: Applying the Nurse Practitioner Model, which fosters UnitedHealth care coordination Group Solutions to improve patient outcomes, to just 500,000 beneficiaries across a broader base of the Medicare program would result in as much as $3.1 billion in savings for the federal government over the next 10 years. Applying an Advanced Illness Care Model to Medicare Beneficiaries advanced illness programs result in $1,400 in gross savings per engaged member in the last six months of life. Applying Services Provided by Care Management Organizations to the Medicare FFS Population providing seniors in traditional Medicare with value added comprehensive care management services could yield $1.9 trillion in savings over 25 years.* Integrated Model for Duals that Builds on Lessons Learned supported through such services as: risk stratification and early identification of needs; individual beneficiary management; care plan development and maintenance; coordination of Medicare, Medicaid, applicable waiver services; and robust member interaction to manage complex and chronic conditions. Source: Working Paper 4 US Deficit Reduction: The Medicare and Medicaid Modernization Opportunity, UnitedHealth Center for Health Reform & Modernization, October

14 "The significant problems we face cannot be solved at the same level of thinking we were at when we created them." - Albert Einstein ( ) 14