UnitedHealthcare Community Plan Accountable Care Communities Clinical Model and the Integration of...

UnitedHealthcare Community Plan

Accountable Care Communities Clinical Model and the Integration of Value Based Purchasing

AHCCCS All Contractor MeetingSeptember 16, 2015

Accountable Care Communities Clinical Model and the Integration of Value Based Purchasing

Agenda

Goals: “The Triple Aim”

Foundational: The Clinical Model

Evolutionary: Value Based Purchasing Models and Guided Practice Support

Enhanced Outcomes: Example Results

3Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Achieving the Triple Aim…

“The Triple Aim: Care, Health, And Cost,” Health Affairs, 27, no.3 (2008): 759-769. Donald M. Berwick, Thomas W. Nolan and John Whittington


Redesigning care delivery into a more Patient Centered Care Model means fully integrating medical, behavioral and social support services for our members at the community level.

1. Delivery system transformationWe partner and engage with practices (medical homes), hospitals and community providers to develop and implement more proactive strategies and care team processes – Managing convenient access to care, proactive visit planning and follow up, managing by risk, addressing gaps in care.

2. Technology and data supportWe provide actionable data to clinical teams using enabling technologies including population registry, our CommunityCare management platform and new UHC Transitions tool.

3. Care CoordinationClinical and community cared coordinators support members with care coordination, care transitions, referral management and follow up, caregiver support and – with the member – create an integrated plan of care available to the entire care team.

4. Aligning incentivesOur Value Based Purchasing models provide incentives at various levels of accountability – from performance based programs, episodes of care, to accountable care shared savings. All UHCCP AZ current models, focus predominately on Primary Care, Quality targets and Total Cost of Care.

5. Outcomes Through the above initiatives we focus on driving reduction in overall costs of care, improving quality metrics and improving the patient experience of care.

ACOs/Accountable Care Program


ACOs/Accountable Care Model

1. Improve Access to Care: Utilize practice scheduling , capacity data and best practices to improve same-day access and reduce no-shows.

2. Reduce Avoidable ER Visits: Leverage daily ADT notifications to proactively manage care transitions and reduce avoidable emergency visits.

3. Reduce Avoidable Admissions: Leverage daily discharge notifications to manage post-discharge care transitions and reduce readmissions.

4. Improve High Risk Patient Care: Identify the practice’s most fragile members though predictive modeling and cost data and proactively engage, educate and coordinate needed care

5. Maximize Quality & Revenue: Utilize bi-directional data exchange to document chronic medical/behavioral conditions and close gaps in care. Focus on Risk Adjusted revenue factors. Maximize Quality & Revenue

Reduce Avoidable ER Visits

Improve Access to Care

Reduce Avoidable Admissions

Improve High-Risk Patient Care

Hea

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Health Inform

ation Technology

Our focus is to help practices maximize revenue via appropriate primary care visits and risk adjusted payments, offer shared savings derived from lower total cost of care and increase quality outcomes and member satisfaction…


Improve Access to Care

Sample Scorecards/Reports:

Initiatives and opportunities:

• Measurably improve overall access to care by increasing same day visit rate (walk in; scheduled and kept the same day):

Evaluate current capacity vs. demand Evaluate Appointment Distribution

Monthly No Show Rates Pre-Scheduled and Same Day

Appointment Rates

• Proactive outreach newly assigned members and members without visits…

New Patient E&M Visit Rate New member ID/Risk and prioritization

• Identify and Prioritize access and engagement for High Risk patients

Risk Stratified member roster PCP visit at least once every 90 days

• Prioritize access, PCP visit within 7 days for patients discharged from ER and Inpatient stay


Reduce Avoidable ER Visits


Initiatives and Opportunities:

• Engage area hospital systems to provide daily ADTs – Admissions, Discharges & Transfers file (future use of The Network)

• Daily Hospital ADTs provide visibility to ER events; actionable & timely data

• Patient Outreach: Use Tools (i.e. Population Registry/UHC Transitions) to identify, outreach, schedule PCP follow up of patients seen in local ERs

• Patient Education: Same Day Appointments /Access practice capacity; after hours options

• Follow-up Visit with Provider and/or Specialist within 7 days post-ER Visit

• Implement targeted initiatives to reduce frequent user patterns; patients visiting ER for primary care during office hours


Reduce Avoidable Admissions /Readmissions



• UHC IP Census and Daily Hospital ADTs combined provide visibility to IP Admissions and Discharges; actionable & timely data

• Patient Outreach: Use Population Registry/UHC Transitions to identify, outreach, schedule PCP follow up within 7 days of patients post-IP discharge

• Follow-up with Provider and/or Specialist within 7 days post-IP discharge:

Patient Education Med Reconciliations Red Flags, indications of condition change

• High Risk Cohort Members prioritized follow up visits within 7 days of IP discharge


Improve High Risk Patient Care



• Population Analysis for Risk / Cost Profile to select cohorts of high risk patients for focused interventions over six months :

√ Admit Risk Scores and Distribution√ Future Risk of Cost√ Current Cost√ Quality of Care Opportunities

• Increase care coordination and referral tracking for High Risk patients

• Ensure PCP visits (and behavioral visits if appropriate) at least every 90 days

• Pre-visit plan every visit using Population Registry / UIHC Transitions - complete open care opportunities at every visit and better address the triggers of adverse events

Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Accountable Care Platform: Accountability Continuum and Payment

10

Capitation + PBC

Lev

el o

f F

inan

cia

l R

isk

Degree of Care Provider Integration and Accountability

Performance-based Programs

Bundles & Episodes Service

LinePrograms

Accountable Care Programs

Shared Risk

Shared Savings

Condition orService-Line

Programs

Performance-Based

Contracts (PBC)

Primary Care

Incentives

Fee-for-Service

Achieving specificMETRICS

Managing a specific CONDITION or SERVICE

LINE

Managing entire POPULATION HEALTH

Approximately 20% of UHCCP Total Medical Spend

is linked to VBCs

OUR SUITE OF VALUE-BASED PAYMENT MODELS SPAN THE CLINICAL INTEGRATION AND REIMBURSEMENT RISK CONTINUUM. WE MEET PROVIDERS WHERE THEY ARE - ALIGNING OUR VALUE-BASED PAYMENT MODELS WITH

THEIR OPERATIONAL SOPHISTICATION AND READINESS TO ACCEPT RISK.

We have seen a 220 basis point improvement in BCR for

providers with VBC contracts

UHCC VBC Model Comparison Grid


C&S VBC Models

Accountable Care

Population Registry

Clinical Integration Payments

Shared Savings

Opportunity

Shared Savings

Opportunity Downside

Risk

HEDIS Quality Measures

Improvement (3-10 measures)

Reimbursement for Quality

Improvement

HEDIS Quality Measures

Improvement (3-10 measures) drives Shared

Savings Distribution

Accountable Care Shared Savings (ACSS) - BCR

Accountable Care Shared Savings (ACSS) - Clinical Efficiency

Quality Shared Savings (QSS) - BCR

Quality Shared Savings (QSS) - Clinical Efficiency

Accountable Care Incentive Program

Basic Quality (BQM)

Clinical Integration Program

Quality Shared Savings: BCR Model (QSS-BCR) - Upside (or Upside/Downside)


Fee for Service

Quality Improvement

Payment

Shared Savings

Quality Shared Savings Model

QUALITY SHARED SAVINGS MODEL (QSS)

Providers receive fee-for-service reimbursement plus the opportunity to earn incentive payments for improved performance against quality measures; practices performing favorably receive a 75% interim

payment six months into each program with an annual reconciliation

Bonus opportunities are based on savings accrued against total cost of care (BCR) or clinical efficiency

metrics

A menu of measures has been developed aligned products/populations being served in each market, State-specific measures and those that favorably

impact STAR ratings

Up to ten measures and performance thresholds are determined at the practice level

Points earned for meeting performance threshold targets determine quality improvement incentive

payouts as well as shared savings/shared deficits distribution

13Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Quality Shared Savings BCR Model

Practice with a current BCR peformance of 84.8%, with line of sight to achieve savings below the 82% target performance over the next 12 to 24 months.

PRACTICE A Mbrs* BCR

Current BCR Peformance Excluding CRS 23,628 84.8%Targeted BCR - (Contract) 23,628 82.0%

Below BCR target performance 23,628 80.0%

Shared Savings Pool 1 ($M) 1.454$

Payout based on quality metrics % Share Payback $

0 Quality Metric ($M) 0% -$ 1 Quality Metric ($M) 30% 0.436$ 2 Quality Metrics ($M) 33% 0.480$

3 Quality Metrics ($M) 35% 0.509$



In addition to a Shared Savings incentive, there is a Quality Metric PMPM incentive opportunity for each measure where the target goal is achieved.


Providing a ‘Roadmap’ for success: Where do savings come from?

Total Cost of Care VBP Model :

Core Medical, Pharmacy and Ancillary savings

Inpatient AdmitReduction

EmergencyVisitReduction

Quality &EfficiencyImprovement

PharmacyManagement

Radiology Management

Gross Benefit Contribution

51% 16% 16% 12% 5%

Our Focus

How then do we guide practice partners to success?


Quality Shared Savings Model Example: Roadmap and Bridge to success

• Example Practice A has line of sight to achieve the target BCR reduction. Incremental opportunities below 82% would trigger incentive payments through the shared savings model.

• Strong collaboration, data sharing and new engagement strategies with Practice A will be needed to achieve the desired results.

Mbrs* MedEx

($M) BCR

%

Q2 14 - Q1 15 23,628 61.7$ 84.8%

Superutilizers (4.41)$ -6.1%Inpatient Admits (Tier 1 - Tier 3) (1.81)$ Inpatient Admits (Tier 4) (2.06)$ ER Visits (0.45)$ Obs/Urgent Care (0.09)$

Identified BCR 23,628 57.2$ 78.7%

Targeted BCR 23,628 59.6$ 82.0%

Pharmacy (0.50)$ -0.7%Other 340B Dispensing (1.30)$ Generic Dispensing Rate Improvement (0.20)$ Script Volume - Management to Average (0.10)$ Drug Cost / Utilizing Member - Management to Average (0.10)$

Specialist ReferralsChart ReviewsOther

Line of Sight BCR 23,628 56.7$ 80.0%

Assumed 50% discount assumption on Superutilizers for conservatismAssumed 50% discount on 340B dispensing on RX for conservatismAssumed an 80% discount on pharmacy assumptions (Excluding 340B) for conservatism

PRACTICE A


Quality Shared Savings Model Example: Roadmap and Bridge to success

Approximately 1,853 High Risk/High Needs members make up ~8% of Practice A total membership and contribute ~39% of the total medical spend.

Example Company Risk/High Needs members are averaging a 207% BCR.

ID/stratification with Proactive insight and management of this population will have the greatest impact on BCR over the long run

Line of Business Mbrs MedEx ($M) BCR% Medicare 268 8.0$ 130% Medicaid 1,585 16.0$ 293%Superutilizers Total 1,853 24.0$ 207%

Superutilzers as a % of total 7.8% 39.0%

All Other members 21,775 37.6 61.6%

Total 23,628 61.7$ 84.8%


Quality Shared Savings Model – Example: Roadmap and Bridge to success

BCR $

Risk Stratification

MbrsFuture

Risk Cost

Future Risk

InpatientBCR %

Per Member

Cost

Tier 1 83 12.9 13.8 546% 57,867$ Tier 2 122 10.3 11.3 205% 37,576 Tier 3 416 4.3 3.8 301% 24,729 Subtotal 621 6.7 6.6 301% 31,682$

Tier 4 1,232 1.3 1.0 86% 3,545$

Total 1,853 3.1 2.9 207% 12,974$

Superutilizers Risk Scores

A. Tier 1 - Highest Risk & Utilization - Focusing on members that have already utilized and are showing the highest BCR's >100%, highest future risk scores.

B. Tier 2 - High Risk & Utilization - Focusing on members that have high future risk scores combined with moderately high BCR's.

C. Tier 3 - High/Moderate Risk or Utilization - Focusing on members that have high utilization or high future risk (but not both). Members with a low BCR but high future risk scores would suggest an increased probability for significant expense in the upcoming year.


Quality Shared Savings Model:

Example of ‘Final’ QSS BCR ScorecardUnitedHealthcare Community & State - AZPRACTICE A - Performance Baseline and TargetsLOBs/PPTs: Arizona Medicaid; Arizona CHIP; UnitedHealthcare Community Medicare AdvantageDates of Service: April 1, 2014 - March 31, 2015 paid through June 30, 2015

Member Months 22,044Average Panel Size 1,837

Measurement Period Start Date

Measurement Period End Date

Baseline Period 1/1/2013 12/31/2013Acutal Performance Period 4/1/2014 3/31/2015

BCR Performance Total PMPMTotal Revenue $3,353,817 $152.14Total Medical Expenses $2,583,831 $117.21BCR 77.0%

Quality MeasuresBaseline Quality

PerformanceTarget Quality Performance

Measurement Period Quality Performance

Met Target Quality PointsQuality Bonus

PMPMQuality Bonus

Annual Dental Visit 73.5% 76.0% 76% Met 1 $0.10 $2,204Adolescent Well Care Visits 50.7% 53.0% 60% Met 1 $0.10 $2,204Well Child Visits 3-6 Yrs 59.5% 70.0% 64% Not Met 0 $0.10 $0Well Child Visits 0-15 MOS 64.2% 75.0% 53% Not Met 0 $0.10 $0ED Utilization 518.90 492.00 388.00 Met 1 $0.10 $2,204

Shared Savings Pool Calculation

Baseline BCR Performance 84.0% Quality Points % of Shared Savings Pool

Target BCR Performance 80.0% 0 0%Measurement Period BCR Performance 77.0% 1 30%Total Shared Savings Pool $99,223 2 33%

3 35%Shared Savings Bonus Calculation 4 38%

Shared Savings Pool Distribution 35% 5 40%Total Shared Savings Bonus $34,728

Plus Quality Bonus $6,613

Less Interim Payment $31,996FINAL SHARED SAVINGS BONUS $9,345

Membership (April 2014 - March 2015)

Quality Table

19

Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

MORE ACCOUNTABILITY

MORE HEALTH IMPROVEMENT

MORE ENGAGEMENT

PAYING FOR VALUE ● TRANSFORMING THE DELIVERY SYSTEM ● ALIGNING INCENTIVES

Next Steps on the journey…

Thank you!

QUESTIONS Please?

Advance and Evolve effective clinical models, using actionable data with engaged partners, while adding

adjunctive Value Based Purchasing Models and guided support to achieve mutual goals.

UnitedHealthcare Community Plan Accountable Care Communities Clinical Model and the Integration of...

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