John LovelacePresident, UPMC for You

March 24, 2011

Public-Private Partnerships and the UPMC Experience

• Overview of UPMC Health Plan

• Focus on Medicaid

• What is managed care?

• Impact of managed care

• Preventive care

• Chronic care

• Provider relationships

• Public-Private partnership values

• Chronic Disease Management Partnerships

Agenda

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UPMC (University of Pittsburgh Medical Center)

• 1 of 13 “Honor Roll” health systems• U.S. News & World Report “Best

Hospitals”• 48,000 employees• $8 billion annual revenue• #5 in National Institute of Health funding

Hospital• 21 PA hospitals• International operations

Physician/Outpatient• 400 outpatient/physician sites• Home health• DME• 2,800 employed physicians• 2,500 affiliated physicians

Commercial Service Development

• IBM• General Electric• Alcatel-Lucent

Insurance Services

UPMC & Insurance Services Division Overview

• 1.5 million members• 10,000+ provider network

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• Medicaid is a Federal-State program, administered by states, providing health insurance for low income legal residents– Income test

– Asset test

• Medicaid is an entitlement, meaning the Federal government has to match whatever the state spends

• Eligible enrollees include – single parents with dependent children

– Pregnant women

– Adults and children with disabilities

• Average person is on for 8-24 months

Focus on Medicaid

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• More efficient

• Caps predictable risk by moving it down to the insurance company

• Greater flexibility

• Greater insulation from political scene

• Improved quality

• Employs strategies known to impact wellness and disease management

• Constrains utilization:– The right care, at the right time, in the right place (and at the

right price)

Privatizing Medicaid

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Share of Medicaid Beneficiaries in Managed Care Rising

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Percent enrolled in managed care:

Source: 2009 Medicaid Managed Care Enrollment Report, CMS:

• What induces a provider to participate• Generally better payment rates

• Offsets loss of volumeMedicaid is generally not a good payer, so providers

are helped by lower Medicaid volume

• Faster claims payment

• Innovations in: Care management and coordination resourcesContract termsInformation sharing about patients

Provider Partnerships

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• 64% of Medicaid beneficiaries; 20% of costs nationally

• HealthChoices– Controls medical escalation costs

• 7.4% vs. 10.5%

• $2.7 billion in savings over first 5 years (2000-2004)

– Represents an estimated savings of 15% over FFS

Cost Trend

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Prescription Drug Costs Increasing Faster than Other Costs of Medical Care

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Average Annual Percentage Increase in Selected National Health Expenditures, 1996-2008

Source: Kaiser Family Foundation

Pharmacy Management – Flat Pharmacy Trends

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Expenditures PMPM for behavioral health related medications remained flat over the last 24-months, and utilization was reduced 2%.

Note: the rolling 12-month medical trend (non-pharmacy) is -3.35% (approximately -2% after accounting for category of assistance membership shifts over time).

• Patient incentives– Department store gift card

– Implemented April 2010

• Breast cancer screening, child lead screening, PCP visits

– New for 2011

• Cervical cancer screening, cardiovascular screening

• Provider incentives– P4P program

• Implemented CY2008; points based

• Pediatric measures– Adolescent well-care visit, lead screening

• Maternity measures– Timely prenatal and post partum care

Preventive Care

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• Patient incentives– Department store gift card

– Implemented April 2010

• Diabetes screening (HbA1c and LDL), Connected Care consent forms

– New for 2011

• HHEP (asthma) program incentive

• Provider incentives– P4P program

• Implemented CY2008; points based

• Diabetes measures– HbA1c screen, eye exam, lipid profile

• Asthma measures– Use of appropriate medications

Chronic Care

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• $169,720 paid to members in CY2010• $981,951 paid to providers in CY2010• Increased provider satisfaction• Through first two years (CY2009 and CY2010),

increased HEDIS measures 5-11 percentage points– Better quality scores

– Improved MCO Pay for Performance results

• $4.8 million earned in FY2010

• Projected net return of $1.58 million for CY2011

Results/ROI

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HEDIS Improvements CY2008 to CY2010

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P4P Program Metrics

HEDIS Measure

UPMC 2008 (CY 2007) --

Before Program

Began

UPMC 2009 (CY 2008)

First Year of Program

UPMC 2010 (CY 2009)

Second Year of Program

Results are based on Initial (Administrative Only) HEDIS Data

PCP

P4P

Mea

sures

Diabetes

HbA1c Screen 73.01% 76.67% 79.84%

Eye Exam 47.38% 52.46% 57.84%

Lipid Profile (LDL -C Screening) 68.82% 74.08% 78.05%

Monitor Nephropathy 71.39% 74.52% 76.91%

Asthma Use of Appropriate Medications for People with Asthma - Overall 89.93% 94.43% 88.89%

Pediatric

Combo 2 (all of Combo 1 plus VZV) 41.24% 48.44% 52.29%

Adolescent Well-Care Visit 52.36% 56.89% 53.74%

Lead Screening 57.10% 63.22% 68.92%

Mat

erni

ty

P4P

Mea

sure

s Prenatal Timeliness of Prenatal Care 75.67% 82.40% 79.28% Prenatal Frequency of Ongoing Prenatal Care >81% 55.36% 61.53% 59.52%

Post Partum

Post Partum Care 32.30% 40.00%

43.84%

Mem

ber

Ince

ntiv

es Women's

Health Breast Cancer Screening (ages 42-69) 44.73% 49.72% 55.05%

Cervical Cancer Screening 57.42% 61.17% 61.55%

Cholesterol Cholesterol Management Post-CV Event: LDL Screen 79.52% 84.09%

80.28%

• Owned providers• Affiliated providers• Non-affiliated providers

– Behavioral health coordination

– Patient Centered Medical Home

– Highest cost patients and improving cost/outcome profile

– Results

Provider Relationships

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Management of Chronic

Conditions

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Pennsylvania Establishes the Chronic Care Model

Rx for Pennsylvania

“ Prescription for Pennsylvania is a set of integrated, practical strategies for improving health care and containing costs for all Pennsylvanians. The core components are affordability, accessibility and quality.”

Edward Rendell, Governor

Commonwealth of Pennsylvania

Source: Prescription for Pennsylvania

Medical Home

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Practice based Clinical Care Managers at selected sites

Provided Disease Registries; Predictive Modeling and Patient Risk Profiles

Timely Data: Emergency Inpatient, Pharmacy, Specialty and Care Gaps Data

Practice Coaches (Process Improvement for Workflow)

Patient Outreach Education

Virtual Extender Team at Health Plan including Health Coaches for Lifestyle

UPMC Health Plan Partners in Excellence Program – Patient-Centered Medical Home

Spring, 2008 - Present

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John LovelacePresident, UPMC for You

lovelacejg@upmc.edu