Changing Landscape in Provider Reimbursement Models Presentation to National Association of County...

Changing Landscape in Provider Reimbursement ModelsPresentation to National Association of County Behavioral Health and Developmental Disability DirectorsMarch 4, 2013Sandra Forquer, PhDSVP, State Government ProgramsOptum Public [email protected]

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

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Helping people live healthier lives.

Optum Is Part of UnitedHealth Group


“A shift toward increased collaboration

between payors and providers is driving

innovation in outcome-based payment models

and delivery system configuration.”

— Sam Ho,

Chief Medical Officer, UnitedHealth Group

Changing Landscape in Provider Reimbursement Models


•Payment Reform Strategy

•Delivery System Strategy

Network Innovation Strategy to Increase Value

• We are developing and implementing a suite of value-based incentive programs that reward care providers for improvements in quality and efficiency

• We are supporting delivery systems as they become more integrated and accountable for cost, quality and experience outcomes

• Alignment across our Network, Product and Clinical innovations allows us to increase value for customers and consumers


Transition of the Model

•Compensation Continuum(Level of Financial Risk)

•Small % of financial risk •Large % of financial risk

•Moderate % of financial risk

•No Accountability •Full Accountability•Moderate Accountability

•Fee-for-service

•Performance- based Contracting

•Bundled and Episodic Payments

•Shared Savings

•Shared Risk

•Capitation

•a. 100% case by case UM

•Capitation + Performance- based Contracting

In selected provider arrangements, we will be transitioning and supporting financial risk, accountability and utilization management practices.

• Basic Q and U measurements

• b. Utilization stats review supplemented by case review

• c. Data management and system

• Modifications to achieve targets

• d. Internal ownership of performance using data management

• Max quality process and outcomes driven measurements

• Passive involvement • Provider engaged • Provider active in management • Assumes accountability

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6

Nearly 10% of our total spending on network-based health care services across all OptumHealth Behavioral Solutions lines of business is tied to performance-based incentive contracts that reward providers for increased collaboration, outcome-based results, and improved cost-efficiencies.

Performance-Based Contracting

CA

AZ NM

MO

GA

RI

MA

FL

OHIL

WI

MN

States with formal performance-based agreements

States with performance-based agreements in process

TX

CTIA

NE

WA

KSCO

OK

KY

NY


Performance-Based Contracting – At A Glance

Demonstrated use of Evidence-Based Practices (EBP)

• Qualifies as High-Volume provider• Participates in periodic meetings with clinical operations staff to review data• Submits claims electronically

•Sample Facility

•Participation

•Requirements

•Sample Metrics

• Facility will earn escalator based sharing of savings if performance is within targeted range• Facility will earn performance bonus for achievement of quality metrics

•Sample Performance Incentives

• Reduction in Average Length of Stay• Reduction in 30 day Readmission rate to any inpatient LOC• Improved results on ambulatory follow-up rates (7 days post inpatient discharge)

•Incentivizing provider performance leads to better outcomes for consumers


Feet on the Street

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• UnitedHealthcare Community Plan partnered with Recovery Connection to provide behavioral health care especially designed to meet patients at the point of need: on the street

• Recovery Connection is a program designed to manage behavioral health care for the top 195 “high-utilizer” TennCare members in West Tennessee.

EXAMPLE 1: Necessity as the Mother of Innovation


Helping Our Members Where They Live

• A Majority of members were in the defined area of Shelby county

• West region, which includes many of these members, has a high rate of homelessness

• Higher overall expenses for members in area

• Significant problem with continuity of care in area

• Service Coordinators have a minimum of Bachelors-level education

• They are trained as a community interventional specialist, in conjunction with Neumann College, through a special curriculum

• Are supervised by a licensed Behavioral Health clinician

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Role of Service Coordinators

Service Coordinators are responsible for providing street-based care coordination and connections to service providers and groups.•They take part in discharge planning when members discharge from Inpatient care•Help ensure members receive timely follow-up appointments with a Behavioral Health provider after Inpatient discharge•Assist members connect with Primary Care Providers to address co-morbid conditions•Connect members with family support systems to assist in community stabilization

Pay for Performance•The Recovery Connection group is paid a basic case rate, with an identified pool for meeting performance measures:

– Initial assessments for hospital admissions with 24 hours of admission– Full assessments for all members completed with 30 days of assignment– Increases in 7-day follow-up after hospitalization (FUH) appointment– Decreases in 30-day readmissions

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Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11

Pilot Background & Objectives

• In New Mexico, a performance-based contracting initiative aimed at improving affordability, quality outcomes and member health was launched July 2010

• Specific objectives were to increase community tenure for consumers with history of Out-Of-Home (OOH) placements within the New Mexico public sector population

Participation Requirements

Program Execution

Payments

• Demonstrated use of EBP and support models• Minimum membership levels

• Weekly rounds with OHBS• Data reviews• Timely claims submission

ProgramStructure

Measured Outcomes

Metric Target Achievement

Reduction in OOH Units 20% 55%

Readmit Rate Not to exceed baseline by more than 2%

Readmit Rate Declined

Critical Incidents Not to exceed baseline by more than 2%

Critical Incident Rate Declined

Post-Pilot Expansion

• Identified 25 high volume facilities serving both commercial and public sector members as part of a phased implementation effort

• Aligning incentives to achieve reduction in ALOS, readmissions, and improvements in HEDIS 7-day ambulatory follow up

• Provider has opportunity to earn rate escalator based on achievement levels

Pay-for-performance Contracting Improves System of Care


Thank you.

For more information, please contact:[email protected]

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