Anne Boland Docimo, MD, MBA

Improving Healthcare: Payer-Provider Collaboration

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• One of the nation’s largest Integrated Delivery Systems

• 5th in NIH funding, affiliated University of Pittsburgh

• $8.0 billion in Annual Revenue

• 50,000 Employees

• 2,700 employed physicians and 2,500 affiliated physicians

• 21 hospitals and 43 regional cancer centers

• 400+ service locations; home care; rehab, urgent care

• 1.5million members in Insurance Division programs

• 20,000+ contracted network providers

• Global and Commercial Enterprise (UK; Italy)

• $1 billion+/five years investment in technology

UPMC Today

Vision of UPMC

UPMC will create a new economic future for western Pennsylvania — a future built on new ways of thinking about health care and sparked by

leveraging the uniqueness of the integrated health enterprise. By exporting excellence nationally and internationally, and fueling the development of new businesses that emerge from UPMC’s intellectual capital, core capabilities, and management expertise, UPMC will catalyze a regional economic renaissance. At the same time, UPMC will remain steadfastly committed to providing premier health care services to our region and contributing to this community.

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Hospital and

Community Services

InsuranceServices

International and

Commercial Services

UPMC Organizational Structure

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PhysicianServices

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• UPMC named to 2010 U.S. News & World Report Honor Roll as one of “America’s Best Hospitals” for the 11th time

• Ranked in 15 of 16 clinical specialties; in the top 10 in seven of them

• UPMC Insurance Companies highly ranked with NCQA “Excellence” status

Our Record of Success

Population Health

Per Capita Costs

Experience of Care

Patient Centered

Care

Good Science

The Right Incentives

Meaningful Information

Seamless Systems of Care

Public Health

Orientation

OutcomesBased Care

Payment AlignedWith Value

Smart Systems

PatientCentered

Healthy Communities

Goal of Accountable Care: Improve Value

6Best in Class Administrative Infrastructure

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Standard Claims Mapping: Clinical/Financial Integration

Financial and clinical integrationFinancial and quality modelingStandard reporting

GovernmentalEmployerProvider contractingIntervention designMember benefit design

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Data Source (Incremental)N = 31,204

Condition Claims Only Claims & RxClaims, Rx &

HRAClaims, Rx, HRA & Screenings/Labs

Diabetes 1,596 1,994 2,197 2,344

Hyperlipidemia 4,086 5,698 5,698 6,774

Hypertension 4,324 6,588 6,588 7,658

Asthma 982 2,715 2,715 2,715

Depression 2,200 6,366 7,597 7,597

Low Back Pain 2,738 2,738 2,738 2,738

Smoking 1,442 5,721 6,119

Obesity 132 132 8,593 8,878

All Conditions 11,795 16,036 21,005 21,913

Identifying Health Conditions by Data Source

75% of Healthcare Costs Driven by Chronic Disease

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Medicare Key Chronic ConditionsPrevalence and PMPM

Hypertension

CADNeoplasm

Arthritis

CHF

Diabetes

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Chronic Care

Costs 75%

Acute Care Costs25%

Escalating

Costs

Population

Health

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

50%

7%

30%

19%

10%

18%

5%

17%

4%

24%

1%

15%

% of Members % of Expenditures

$135,465,6902,349 MembersMER = 271%

$92,562,2702,936 MembersMER = 199%

$100,457,5205,872 MembersMER = 124%

$108,665,60917,616 MembersMER = 55%

$39,153,95629,361 MembersMER = 19%

$81,550,410587 MembersMER = 446%

Medicare HMO CY 2009 Distribution of Healthcare Expenses by Membership

5% members = 40% costs

Inpatient manager/Hospitalist

Readmission/transition programs

Coordinated care teams

Patient-Centered Medical Home

Supportive care

Population Management

Approaches

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Pre-Admission

Review

Concurrent Review

Discharge Planning

Evidenced Based

Guidelines

Inpatient Manager

Discharge Advocate + Ongoing

Coordination with Care Team

Traditional UM Accountable Care

Transitional Approach

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Payer-Provider Collaboration

• Create Value: Accountable Care Organization– Evidence-based Clinical Pathways – Right care, Right time, Right setting, Right price

• Common outcome metrics define value– Process measures: Following pathway– Clinical outcomes: Quality and Safety– Utilization of Resources

• Admissions, Length of stay, Readmissions• Diagnostics, Specialty Care, Pharmaceuticals

– Financial Outcomes

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• Partners in Excellence – Patient Centered Medical Home• Transitional approach to utilization management• Project RED – transitions program• Wound Care – Telemedicine• Anticoagulation – multidisciplinary• Heart Failure – multidisciplinary• Doula Maternity• Connected Care• Going Home Program• Pharmacy quality initiatives• Member engagement strategy

Payer-Provider Collaboration: Seamless Systems of Care

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

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Quarterly Acute Inpatient Admits per 1,000 Exponential Trends (July 1, 2007 - December 31, 2010)

July

2007

August 2007

September

2007

October

2007

November

2007

December

2007

January

2008

February 2008

March 2008

April 2008

May 2008

June 2008

July

2008

August 2008

September

2008

October

2008

November

2008

December

2008

January

2009

February 2009

March 2009

April 2009

May 2009

June 2009

July

2009

August 2009

September

2009

October

2009

November

2009

December

2009

January

2010

February 2010

March 2010

April 2010

May 2010

June 2010

July

2010

August 2010

September

2010

October

2010

November

2010

December

2010

40.00

44.00

48.00

52.00

56.00

Commercial Admits / 1,000

CommercialExponential (Commercial)

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Source: NEJM, April 2009, S. Jencks.

Rate of Rehospitalization within 30 Days

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 Shared Goals• Improve quality of care• Decrease readmission rates• Decrease adverse events after discharge• Increase follow-up activity with the PCPs and specialists

 Elements of Complete Transition Home• Medication reconciliation• Compare discharge plan against national guidelines and

clinical pathways• Schedule follow-up appointments• Review post discharge instructions• Provider written discharge plan  After Hospital Care Plan  • Symptom Response Plan• Patient Education• Discharge Summary to the PCP

Improving Care Transitions

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Physician• Works with team on admission to start discharge planning • Completes medication reconciliation on admission and discharge• Transition to post-acute team

Bedside Nurse• Shares patient needs with care team• Provides patient education

Health Plan Pharmacist• Assist with

discharge planning• Comprehensive medication review on post hospital call

Team Work and

Collaborations

Collaboration

Discharge Advocate

Physician

Health Plan Pharmacist

Bedside Nurse Patient/Member

Discharge Advocate • Education on admission, during stay, and at discharge• Care coordination with home care and DME• Makes follow-up appointments• Calls patient 48 hrs after

discharge• Connect to HP Care

Management Team

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The UPMC Safe Discharge Hand-Off Initiative provides organized clinical information to both our patients and

providers on discharge or transfer from the hospital

current problem list vital sign trends major tests and procedures safety risks vaccines and immunizations tests results not available at time of

DC (for follow-up) communication process to access

the hospital/unit and provider

UPMC Safe Hand-Off

My UPMC Safe Discharge Reports include:

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Post-DC Office Visit

Skilled Facilities

Rehabilitation

Home HealthCreating tools for safe hand-off communication

during care transitions

Engaging the patient in the process with

enhancements for self-management

Sharing the clinical

information with

downstream providers

UPMC Safe Discharge Hand-Off

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October November December January February0

102030405060708090

100

% of Safe Hand-Off Reports Transmitted to PCPs

33,715The # of Safe

Discharge Reports Transmitted

80

% of physicians

who agreed or strongly agreed

Report was timely to follow-up on DC needs

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75

Content assisted with transition of care

Delivery method was suitable for work flow

UPMC Safe Discharge Hand-Off Outcomes Implemented October 2010

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2008/11

2008/12

2009/01

2009/02

2009/03

2009/04

2009/05

2009/06

2009/07

2009/08

2009/09

2009/10

2009/11

2009/12

2010/01

2010/02

2010/03

2010/04

2010/05

2010/06

2010/07

2010/08

2010/09

2010/10

15.0%

15.5%

16.0%

16.5%

17.0%

17.5%

18.0%

18.5%

19.0%

19.5%

20.0%

MC: 30 Day Any DRG Readmission Rate Trend

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2008/11

2008/12

2009/01

2009/02

2009/03

2009/04

2009/05

2009/06

2009/07

2009/08

2009/09

2009/10

2009/11

2009/12

2010/01

2010/02

2010/03

2010/04

2010/05

2010/06

2010/07

2010/08

2010/09

2010/10

14.0%

14.5%

15.0%

15.5%

16.0%

16.5%

17.0%

17.5%

18.0%

All LOB: 30 Day Any DRG Readmission Rate Trend

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Components of Readmission Survey

• Is this a planned readmission?• Is this a related readmission?• What may have led to this readmission? (check all that apply)?

Medication related No PCP or specialist visit since last hospitalization Complication related to original stay Unrelated causes Discharge planning Care giver support Unable to determine

• Could this admission have been avoided with alternate care plan?

• Did patient receive discharge instructions?

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Collaborative Care Plans

• Patients with complex needs require comprehensive, coordination of care: – Frequent use of ED services– Frequent hospital admissions – Use of multiple hospitals– Seeing multiple physicians – Non-compliance with care in outpatient setting– Patients with known narcotic seeking behavior– Complex psychosocial issues– Patients in top 5% use 40% of resources

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Care Plan Committee

• Identify key individuals to participate: – Patient’s Clinical Care Team

• Primary Care Provider• Key Specialists relevant to patient’s clinical needs

– Hospital Care Management (RN and SW)– Behavioral Health Liaison– Chronic Pain Service – UPMC Health Plan Care Management Team

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Creation of Care Plans

• Template for Care Plans– Emergency Department:

• Text-page/ email alerts to clinical and CM team on registration • Worklist alert in HealthPlaNET Care Management system• Clinical care plan, discharge care plan, follow-up instructions

– Hospital Care• Establish criteria for admission• Admission team: Consistent Care givers: hospitalist team, key

specialists• Compliance to clinical treatment plan, medications, behavior

– Transition to Community Caregivers /Outpatient Care Management

• Communication: – Care Plan in e-record, CM system updated on each admission and

as needed

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Results of FY2010 compared to FY2009 for patients in

Collaborative Care Plan Pilot:

• Number of ED visits 7%

• Number of hospital admissions 40%

• Number of outpatient visits 17%

Collaborative Care Plan

Total Cost of Care 24%

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Complex Care Plan Case Study:Chronic Pain Patient

Outpt Visits

ED Visits

Hospitalizations

0 5 10 15 20 25 30 35 40

17

13

5

13

36

15

20092010

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• Pharmacy Programs– Drug therapy optimization

• Intelligent Formulary Design• Promote safe, appropriate drug use• Evidence-based algorithms• Promote generic utilization

– Medication therapy management– Provider partnerships

• Pharmacist as virtual team member• Combine algorithms with real life clinical practice

Pharmacy Initiatives

Right Practice- Strong

Administrator

- High Volume/ in P4P

- Generic Utilization

Right Rx Data: Prescribing

Profiles- Provider, Practice and Network Level

- Visual Chart versus Peers

- Correlate to QIRP/P4P

Right Clinical Data: Provider Education

- Objective Clinical Evidence

- Prove Patient Outcomes &/or

Savings

- Patient Education

Provider Partnership Strategy: Rx for Success

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Generic Fill Rates

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63.9

%

67.7

%

73.8

%

68.4

%

72.9

%

76.7

%

79.3

%

62.8

%

66.2

%

68.7

%

74%

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Clinical Management of Oxycontin Improving Quality and Cost

0

100

200

300

400

500

600

700

800900

1000

JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC

Total Prescriptions

2008

Oxycontin vs. Opana -Medicaid Utilization 2008

OXYCONTIN OPANA IR OPANA ER

Nearly $1 million inannual savings and 16%

walk aways

Clinical Management of Designer Narcotics Improving Quality and Cost

• A narcotic painkiller that looks like a lollipop -- designed for quick pain relief to cancer patients.

• Narcotic painkiller Actiq, is ONLY FDA-approved for use in treating cancer pain.

• The Wall Street Journal published these findings in 2006:– Oncologists accounted for only 1 percent of the 187,076 Actiq

prescriptions in the first 6 months of 2006.– More than 80% of patients receiving Actiq had no cancer

diagnosis. – Two children died after confusing the drug for candy.

• UPMC Health Plan has always required clinical approval of Actiq based on FDA label in order to ensure safe, on-label use and mitigate abuse potential.

• 2010 UPMC HP: 18 members out of 535,000 lives = 0.0034% of total population.

• Other designer narcotics with potential for abuse are also clinically managed include: Avinza, Kadian and Magnacet

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Over 633 Biologics In Development

• Exploding pipeline - Oncology dominates

• Currently half of all new drug approvals are specialty drugs

• Expanding uses for existing products

• Orals changing the landscape – becoming maintenance therapy

• Management requires Evidence Based Guidelines developed with Clinical Experts.

Specialty Drug Cost Drivers - More Drugs, More Uses, More Patients

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Move to Accountable Care

• Create Value– Defined by common metrics across payer-provider tracking clinical

and financial outcomes

• Position of strength moving forward: – Build sustainable programs that will deliver quality and use

resources efficiently.

• What next?

“Prediction is very hard”

“Especially about the future.”

Yogi Berra

Source: Susan Dentzer, Editor-in-Chief, Health Affairs at the Grand Rounds, Department of Orthopedics, University of Pittsburgh Medical Center, October 21, 2009.

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Thank You40