Super-Utilizer SummitUtilizer Summit - Center for Health Care … · 2019. 5. 22. ·...
Transcript of Super-Utilizer SummitUtilizer Summit - Center for Health Care … · 2019. 5. 22. ·...
Super-Utilizer SummitSuper-Utilizer SummitIntegrating and Sustaining
Super Utilizer Programs within Delivery Systems
UnitedHealthcare - Helping People Live Healthier Lives.
February 12th 2013February 12 , 2013 Bill Hagan, President West Region &SVP National Accountable Care
Topicsp
UHC Medicaid OperationsAchieving Sustainable Funding – 4 Focused OutcomesAchieving Sustainable Funding 4 Focused OutcomesFour High Cost Targeting Strategies
High Cost CommunitiesHigh Risk Members in PracticesPeople with Serious Mental Illness High Risk Zip Codes / Neighborhood Hot SpottingHigh Risk Zip Codes / Neighborhood Hot Spotting
Delivery Model OpportunitiesEvolution of Accountable Care Models & MetricsImportance of Technology in TransformationPayment Reform ModelsChallenges of Integrating Behavioral & Physical Health
2 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Challenges of Integrating Behavioral & Physical Health
UHC’s Broad Medicaid State Experience p
24 Medicaid states plus Washington, DC24 Medicaid states plus Washington, DC~ 4 0 Million Members~ 4.0 Million Members
DE
DC
Acute, TANF and CHIP
L T C d ABD
MA
MD
NY
NJLong Term Care and ABD
Medicare D-SNP / MME
Developmentally Disabled & Children’s Rehabilitative Services
MSO Arrangements
RI
3 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
MSO Arrangements
Health Homes
Why Super-Utilizer Models are Important to Medicaid at UnitedHealthcare
Over 36% of our Medical Costs are spent on 1.4% of our members equaling about 25 times that of our members on average. Interventions must be Cohort specific and leverage Accountable Care models.
Medicaid Members > 35K Annually• 1.4% of Membership is
36% of Medical Spend
• Members with spend of >
Medicaid Members > 35K Annually
35k are 25 times the PMPM cost
• Specific Strategies are required by Cohort – forrequired by Cohort – for example High Cost Rx
• IP 54%;OP 22%; Rx 13%
4 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Sustainable Funding Comes from High Risk / High Cost Population Managementg p g
Can Support
Savings accrue from Avoidable IP stays, Non-emergent ER, Chronic Care Interventions to fund Super-Utilizer Models and Incentives
Can Support• Additional Pay-for-Value
• Care Coordination Fees• Gain Sharing• Full Risk Agreements
Core medical & pharmacy savings levers
IP Avoid Rate
ER Avoid Rate
Non Q&E Red%
Rx TotalRed%
RadRate%
IP Avoid Rate
ER Avoid Rate
Q&E Red%
Rx TotalRed%
RadRate%
T t Full Risk Agreements• Practice Growth & Volume10% 15% 25% 3% 2.5%10% 15% 25% 3% 2.5%
51% 16% 16% 12% 5%
Target Reduction
Gross Benefit Contrib.
Reduce Non Emergent
Emergency Room Visits
ImproveAccess to Care
Requires focus on 4Critical Outcomes
Improve Care ofHigh Risk Patients
Reduce InappropriateAdmissions/
Readmissions
Room VisitsTreat Whole Person –Behavioral, Physical & Social
5 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Topicsp
UHC Medicaid OperationsAchieving Sustainable Funding – 4 Focused OutcomesAchieving Sustainable Funding 4 Focused OutcomesFour High Cost Targeting Strategies
High Cost CommunitiesHigh Risk Members in PracticesPeople with Serious Mental Illness High Risk Zip Codes / Neighborhood Hot SpottingHigh Risk Zip Codes / Neighborhood Hot Spotting
Delivery Model OpportunitiesEvolution of Accountable Care Models & MetricsImportance of Technology in TransformationPayment Reform ModelsChallenges of Integrating Behavioral & Physical Health
6 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Challenges of Integrating Behavioral & Physical Health
Targeting High Risk / Cost Communities –Partnering with Hospitals & PracticesPartnering with Hospitals & Practices
1) Selection of “Community”
West TN Shelby County “Memphis”
2) Evaluate Facility Efficiency, Benchmarks and Admissions for Opportunity Days and Practices
S 2
HospName Adm
its
Day
s
LOS
Exp
ecte
d LO
S
Opp
ort D
ays-
Gro
ss
One
Day
Sta
y %
Sho
rt S
tay
0-2
Day
s %
Rea
dmit<
=30
Day
s
Pai
d A
mou
nt
Facility A 1,216 6,162 5.07 3.82 1,422 7.65% 41.53% 4.77% $16,895,915
3) Practice Group Selection and Opportunity Evaluation
Facility B 900 6,064 6.74 5.89 1,306 7.33% 23.33% 23.67% $8,393,100Facility C 647 5,342 8.26 6.40 1,223 10.51% 30.76% 11.90% $9,630,614Facility D 580 4,511 7.78 5.54 1,136 7.07% 19.66% 20.34% $6,157,515Facility E 853 4,506 5.28 4.87 1,013 9.73% 31.65% 14.89% $6,588,734
7 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Targeting High Risk / High Cost Members within a Practice with Actionable Data
Risk Score DistributionRISK SCORES = ALL
200
400
600
800
1000
Patie
nt C
ount
Risk Score DistributionRISK SCORES 1.0 < 5.0
1000
2000
Patie
nt C
ount
Risk Score DistributionRISK SCORES 5.0 < 10.0
50
100
150
Patie
nt C
ount
11,297 Total Patients 68.3% Risk < 1.0 2,846 Patients 25.2% Risk 1.0 < 5.0 392 Patients 3.5% Risk 5.0 < 10.0
0
0.1
2.1
4.1
6.1
8.1
10.1
12.1
14.1
16.1
18.1
20.1
22.1
24.1
26.1
28.1
30.1
32.1
34.1
Risk Score
01.0<2.0 2.0<3.0 3.0<4.0 4.0<5.0
Risk Score
05.0<6.0 6.0<7.0 7.0<8.0 8.0<9.0 9.0<10.0
Risk Score
Risk Score DistributionRISK SCORES 10.0 < 15.0
30
40
50
t C
ount
Risk Score DistributionRISK SCORES 15.0 < 20.0
30
40
50
t C
ount
Risk Score DistributionRISK SCORES 20.0 < 25.0
30
40
50
t C
ount
166 Patients 1.5% Risk 10.0 < 15.0 80 Patients 0.7% Risk 15.0 < 20.0 58 Patients 0.5% Risk 20.0 < 25.0
0
10
20
10.0<11.0 11.0<12.0 12.0<13.0 13.0<14.0 14.0<15.0
Risk Score
Patie
nt
0
10
20
15.0<16.0 16.0<17.0 17.0<18.0 18.0<19.0 19.0<20.0
Risk Score
Patie
n
0
10
20
20.0<21.0 21.0<22.0 22.0<23.0 23.0<24.0 24.0<25.0
Risk Score
Patie
nt
Risk Score DistributionRISK SCORES 25.0 < 30.0
20
25
t
Risk Score DistributionRISK SCORES 30.0 < 35.0
20
25
t
Risk Score DistributionRISK SCORES 35.0 and HIGHER
20
25
tResults
18 Patients 0.2% Risk 25.0 < 30.0 23 Patients 0.2% Risk 30.0 < 35.0 0 Patients 0.0% Risk 35.0 PLUS
0
5
10
15
20
25.0<26.0 26.0<27.0 27.0<28.0 28.0<29.0 29.0<30.0
Risk Score
Patie
nt C
oun
0
5
10
15
20
30.0<31.0 31.0<32.0 32.0<33.0 33.0<34.0 34.0<35.0
Risk Score
Patie
nt C
ount
0
5
10
15
20
35 +++
Risk Score
Patie
nt C
ount
Process begins with our Practice basedProcess begins with our Practice-based “attributed” population risk profile
• Risk Stratification
• Proactive CareA
ctions
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• Actionable Data
Targeting Persons with SMI and Delivering Integrated Care with Navigators & Advocatesg g
• Persons with SMI die 25 years earlier than general population, in Arizona its 30 years
• 60% of Medicaid’s highest cost• 60% of Medicaid s highest cost beneficiaries with disabilities have co-occurring physical and behavioral health conditions
SMI Clinic
• Joint Case Rounds • Patient Navigators for Visits• Embedded Care Advocate
Visit Planning & Follow-upsM hl L d hi M i
Primary Care Center of Excellence
R lt• Monthly Leadership Meetings Results
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Hot Spotting by ZIP and Neighborhood identifies Health Improvement Opportunitiesp pp
Population Characteristics in Washington DC45k members aligned with 30k families.
$120M in total spend
1% of membership drives 25% of the total spend, 6% drives 50% and 15% drives 75%
Significant opportunity to improve the health of this population ($40M+)p p ( )
4 neighborhoods have a high concentration of members and opportunity: Trinidad, Capitol View, Garfield Heights, Congress Heights
The Emergency care system is core to theThe Emergency care system is core to the utilization and costs of this population
21% of the Commercial population and 35% of the C&S population utilize the ER
Focus on the following conditions will be key toFocus on the following conditions will be key to improving the health of this population
Respiratory, Cardio Metabolic conditions including CKD / ESRD, Orthopedic, HIV, Cancer, mental health / substance abuse
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Cancer, mental health / substance abuse
OBGYN / Birth / Delivery utilization and costs are high - high rate of NICU
HOTSPOT
SUMMARY
OF
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FINDINGS
Topicsp
UHC Medicaid OperationsAchieving Sustainable Funding – 4 Focused OutcomesAchieving Sustainable Funding 4 Focused OutcomesFour High Cost Targeting Strategies
High Cost CommunitiesHigh Risk Members in PracticesPeople with Serious Mental Illness High Risk Zip Codes / Neighborhood Hot SpottingHigh Risk Zip Codes / Neighborhood Hot Spotting
Delivery Model OpportunitiesEvolution of Accountable Care Models & MetricsImportance of Technology in TransformationPayment Reform ModelsChallenges of Integrating Behavioral & Physical Health
12 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Challenges of Integrating Behavioral & Physical Health
Addressing Super-Utilizers Requires New Delivery Models – MCOs, Essential Enablers! y ,MCO capital, analytical tools, ability to bear risk, data sharing capabilities and technology delivery make them essential enablers of – Virtual ACOs, Medicaid Health Homes and ACOs. MCOs are critical change agents in healthcare transformation and reform. PCMH is not sufficient for transformation – must include the entire Continuum of Care.
Medicaid Health HomesVirtual ACO’sAccountable Care Communities TM
Strategic Resources include • Care Transition Navigators• Accountable Care Consultant / Analyst• Embedded Care Advocate RN
• Provide Strategic Resources
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• Embedded Care Advocate RN • Clinical Consultation• Facilitate Continuum Integration
• Provide Data & Technology
Seven Community-Based Collaborative Tools linked to eMR Play a Critical Role in Transformation
Secure Collaboration6. Specialty e-Consult
2. Registry1. Risk Stratification & EBM Gaps in Care
Super-Utilizer HIT
Data & Analytics
Claims, Lab & RX
Risk Profiles &
Care Alerts
e-Consult Secure
Collaboration
Community-Based Care Coordination Tool
Enrollments & Care Teams
Community
Community-Based Care Coordination Tool
Enrollments & Care Teams
Community
Risk Stratification
& EBM4.
Community-Based Care
C di ti
Patient
Assessments
Referrals
Direct &Alerts
Community Care Plan
Reporting& Analytics
Patient
Assessments
Referrals
Direct &Alerts
Community Care Plan
Reporting& Analytics
3. Automated
Care Transition
Tool
Coordination & Referral
Management
EngagementEngagement
Visit Verification
Visit Verification
Tool
7 E V V
eMR
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7. E.V.V.
5. Health Information Exchange
Super-Utilizer Network Structures have Challenges with Integrated Care Modelsg g
Delivering Health Home Services•Comprehensive care management, using team-based strategies •Care coordination and health promotion •Comprehensive transitional care between health care and community settings Indi id al and famil s pport hich incl des a thori ed representati es•Individual and family support, which includes authorized representatives
•Referral to community and social support services, such as housing if relevant •The use of health information technology to link services, as feasible and appropriate
SMI Clinics FQHC / RHC Community
Network Structure Types
SMI Clinics as Health Home
(Behavioral)
PCMH as Health Home
(Primary Care)
CommunityAggregators as
yAggregator
Health Homefor SMI
Populationse.g. Missouri,
Health Homefor Non-SMI Populations
e.g. Missouri,
Aggregators as Health Home
such as AAA, e.g. Washington, New
ArizonaChallenge is Physical Health Delivery
“Today there are legislative limitations in providing physical health services in BH clinics
also these clinics needs to be trained in
New YorkChallenge is Sparseness
“Typically only a small portion of the practice patients qualify as high risk so it is disruptive to follow Health Home processes
JerseyChallenge is Network Build & HIT
“Need to establish relationships with hospitals, community-based organizations
and network providers for assigned
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– also these clinics needs to be trained in Physical Health Care Coordination – this is a significant change – physician co-location has
volume challenges”
disruptive to follow Health Home processes for only a few patients. Potentially not able
to fully treat behavioral health”
and network providers for assigned members. Need to put HIT Infrastructure in
place with potential privacy barriers”
Questions
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Multiple Payment Models are Needed to address the Risk Readiness of the Network
C it ti
OUR MODULAR SET OF VALUE-BASED PAYMENT MODELS ARE DEPLOYED ACROSS THE CONTINUUM.WE ARE ABLE TO ALIGN OUR VALUE-BASED PAYMENT MODELS WITH A CARE PROVIDER’S RISK READINESS.
We have value-based engagement Capitation + PBC
Ris
k
Shared Risk
We have value based engagement with more than 575 hospitals, 1,100 medical groups and 75,000 physicians participating in our Accountable Care Reform Initiatives.
f Fin
anci
al R
Shared Savings
Bundled/Episode
P t
OVER $20 BILLION OF NETWORK SPEND IS TIED TO OUR ACCOUNTABLE CARE PLATFORM1
Leve
l of
Centers of
Accountable Care Programs
Payments
Performance-Based
Contracts (PBC)
Primary
Performance-based Programs
Centers of ExcellenceCare
Incentives
Fee-for-Service
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Degree of Care Provider Integration and Accountability
Targeted Interventions for High Cost Conditions – Example Wound Carep
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Our Registry Provides Communities with Real-time Data & Interventions over the Web
Care Transitions
Medical / Health Home
Daily Member
Eligibility File
Care Transitions, Chronic Care
Interventions & Patient Profiles
EBM Guidelines
A t bl C P l ti R i tDaily Admit Discharge Transfer
(HL7/ADT) (ER, OBS, IP) Care Event
Tracking
Accountable Care Population Registry
Member ADTs
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