Super-Utilizer SummitUtilizer Summit - Center for Health Care … · 2019. 5. 22. · Super-Utilizer SummitUtilizer Summit Integrating and Sustaining Super Utilizer Programs within

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


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%


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


Topicsp






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


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


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


30

40

50

t C

ount


30

40

50

t C

ount


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


20

25

t


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

8 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. 8

• 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


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


Cancer, mental health / substance abuse

OBGYN / Birth / Delivery utilization and costs are high - high rate of NICU

HOTSPOT

SUMMARY

OF


FINDINGS

Topicsp






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


• 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


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


– 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


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

17 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.17

Degree of Care Provider Integration and Accountability

Targeted Interventions for High Cost Conditions – Example Wound Carep


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


Documents

Super-Utilizer SummitUtilizer Summit - Center for Health Care … · 2019. 5. 22. · Super-Utilizer SummitUtilizer Summit Integrating and Sustaining Super Utilizer Programs within