Transcription
Changing Landscape in Provider Reimbursement ModelsMarch 3, 2014
Optum’s context within UnitedHealth GroupHealth Benefits and ServicesPublicly Traded Registrant(NYSE)UNHUnitedHealthcareOptumHealth care coverage and benefits businesses,unified under a master brand:Information and technology-enabled healthservices platform, encompassing: Employer & Individual Technology solutions Medicare & Retirement Intelligence and decision support tools Community & State Health management and interventions Military & Veterans Administrative and financial services UnitedHealthcare International Pharmacy solutionsConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.1
Specialty health solutionsWe build systems of care We manage financial risk We manage provider networks We manage clinical care We ensure quality measures are achievedBehavioralHealth ComprehensiveBehavioral Health Medical/BehavioralIntegration EAP and WorkLife Community BasedProductsComplexMedicalConditions Transplant SolutionsKidney SolutionsInfertility SolutionsBariatric ResourceSolutionsPhysicalHealthOptumInternational ChiropracticPhysical TherapySpeech TherapyOccupational TherapyAlternative MedicineEAPWellnessWellbeingTechnology SolutionsNetwork ManagementConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.2
Engaging providers to influence member outcomesEnabling ServicesStreamline Business Practices Align incentives to promotequality results Reduce the hassle factor, especiallyaround payment and utilizationmanagement practices Invest in enabling success(technology, reporting, staff, incentives) Engage providers with holisticprograms and invest to enable changeFeedback and EngagementPartner for Success Use regular, consistent, andbenchmarked information feedbackfor improvement Move from transactional relationshipsto collaborations Provide technology (e.g., electronicheath records) to support point-ofservice information Assess joint opportunities to bettermeet the needs of the market tocreate competitive differentiatorsConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.3
Continued enhancements to Optum provider performance metrics Launching outpatient pay-for-value effective March 1 for providers achievingtwo-star rating (effectiveness first and supplemented with efficiency ratings) Enhancing facility pay-for performance initiative to tie to enhanced facilitymetrics under ACE – Achieving Clinical ExcellenceClinician MetricsQualitySeverity-adjusted effect size from theWellness AssessmentsCostNEW: Case-mix-adjusted averagenumber of visitsNEW: Average cost per episodeFacility MetricsQualityNEW: 30-day readmission rateENHANCED: Risk-adjusted 30-dayreadmission rateENHANCED: Follow-up after mentalhealth hospitalization (HEDIS)NEW: Peer review rateCostENHANCED: Case-mix-adjustedaverage length of stayNEW: Spending per beneficiaryConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.4
The future of providing health care has arrivedIntroducing Achievements in Clinical Excellence (ACE)A program that rewards providersthat deliver both effective and efficient clinical care.Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.5
Why is ACE necessary, and where does it fit?The purpose of ACE is to guide and reward providers fordelivering services more effectively and efficientlyThese are achievable goals that perfectly align with thewants and needs of patients, providers and OptumACE helps facilities reach these goals by: Obtaining unbiased, risk-adjusted data that is quantifiedand benchmarked against regional facilities Pinpointing and eliminating variations in practice patterns,which drive increased costs and poor clinical outcomes Assign facility-specific tier designations and incentivizefacilities to achieve and maintain Platinum statusConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.6
Helping guide every facility to the platinum tierPLATINUMpassed effectiveness and efficiencyGOLDpassed quality onlySILVERpassed cost and peer reviewBRONZEpassed cost but not peer reviewCRITERIA NOT METnot meeting quality or cost metricsConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.7
Measurements for success - Achieving platinum statusACE encourages excellence across network facilities by promoting thosefacilities that provide the highest quality of care as measured by seven keyperformance indicators2., 3. Follow-up AfterHospitalization4., 5. ReadmissionRates6. Residual Length of Stay7. Behavioral Health Spendper Inpatient Episode1. Peer ReviewConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.8
Platinum benefits – Great effort has its rewardsStreamlinedClinicalReviewsEase of ClaimsAccess Efficient, streamlined review process requiring far fewer phone calls Always-available, online secured website for initial and discharge reviews Optum intervention on an “as needed” basis Designated contact for claims assistance and resolution Assigned Regional Medical Director for immediate resolution of issuesIncreased Assigned team of Optum staff including Facility Practice Specialist and FacilityTransparency andPerformance ManagerImproved Access Monthly review of effectiveness and efficiency data in order to share data trendsMarketing onProvider Behalf Optum will work in collaboration with your current marketing efforts to promote yourPlatinum achievement Recognition on Provider Express Certificate of achievement to display in the facility Specially targeted messaging to area clinicians promoting a facility’s Platinum statusConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.9
Compensation continuumIn selected provider arrangements based on provider readiness, we are supportingfinancial risk, accountability, and utilization management practices.Compensation ContinuumSmall % of financial riskFee-forserviceLow AccountabilityPerformance- basedContractingModerate % of financial e AccountabilityLarge % of financial riskSharedRiskCapitationCapitation PerformancebasedContractingFull AccountabilityConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.10
Performance-based contracting – At a glanceIncentivizing provider performance leads to better outcomes for formanceIncentives Adheres to our utilization management process, Level of Care Guidelines and CoverageDetermination Guidelines, including attending MD visits, pre-authorization requirements,and discharge planning Qualifies as an OptumHealth High-Volume provider Participates in periodic meetings with OptumHealth clinical operations staff to review data Submits claims electronically Reduction in Case Mix Adjusted Average Length of Stay Reduction in Risk-Adjusted 30 day Readmission rate to any inpatient LOC Improved results on ambulatory follow-up rates (7 days post inpatient discharge) Facility will earn escalator based sharing of savings if performance is within targeted range Facility will earn additional escalator through greater sharing of savings if performanceexceeds range (up to a cap) Can earn an enhanced payment for exceeding effectiveness metricsConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.11
Performance-based contracting footprintNearly 10% of our total spending on inpatient network-based health care services across all Optum’sbehavioral lines of business is tied to performance-based incentive contracts that reward providers forincreased collaboration, outcome-based results, and improved ALTXBased oncurrent path,performancebased contractswill account for20% of spend byend of 2014GAStates with formalperformance-basedagreementsLAFLStates with performancebased agreementsplanned for 2014Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.12
Leading the wayOutpatient ACE and Pay for ValueIncludedExcludedMember TransparencyNot Targeted Reward providers for increasedoutcome-based results and improvedefficiencies Preferred clinicians “star-rated” for qualitycan earn a second star rating for meetingcost-efficiency standards Launching March 1st for providersserving commercial members andachieving 2-star rating Seeking formal accreditation for our providerperformance programs through NCQAPhysician Quality Accreditation programConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.13
Advancing our value-driven approachWell-establishedLeading the WayComing teredValueMotivatingEmployeeBehaviorsRigorous CredentialingPerformance Metrics, P4PConfigured NetworksNegotiated DiscountsTransparencyEmployee EmpowermentRobust CoverageTiered NetworkIncentivizationEmployee accessto quality careEmployee accessto best careEmployees routinelyusing best careConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.14
Network innovation strategy to increase value We are developing and implementinga suite of value-based incentiveprograms that reward care providersfor improvements in quality andefficiencyPayment ReformStrategy We are supporting delivery systemsas they become more integrated andaccountable for cost, quality andexperience outcomes Alignment across our Network,Product and Clinical innovationsallows us to increase value forcustomers and consumersDelivery SystemStrategyConfidential property of Optum. Do not distribute or reproduce without express permission from Optum.15
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2. Specialty health solutions. We build systems of care We manage financial risk We manage provider networks We manage clinical care We ensure quality measures are achieved. Behavioral Health Comprehensive Behavioral Health
