Miles Snowden, MD - Prevention, Wellness & Outcomes from a Payer Prospective

Miles Snowden, MD - Prevention, Wellness & Outcomes from a Payer Prospective

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  Prevention, Wellness, AndOutcomes From A Payer Perspective Miles Snowden, MD, MPH, CEBS Chief Medical Officer – Optum, UnitedHealth Group
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  One of thelargest health information, technology and consulting companies in the world The leader in population health management serving the physical, mental and financial needs of both individuals and organizations The pharmacy management leader in service, affordability and clinical quality Market leaders within a dynamic health services market Becoming Optum © Optum, Proprietary and Confidential 2
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  Clients 60,000,000+ individuals 80,000 physician practicesand other health care facilities 67,000 pharmacies* 5,000 hospitals 400 global life sciences organizations 300 health plans 150 state, federal and municipal agencies and departments Statistics as of 6/30/13 except where noted; *as of 1/17/13 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3
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  Navigating the journeyfrom providing care to managing health Invest New Capital Generate New Capital Patient Patient Access Access Medical Medical Necessity Necessity Financial and Financial and Clinical Analytics Clinical Analytics Population Health Population Health Management Management Reimbursement Reimbursement Providing Care Aligned Incentives Clinical Clinical Care Care Coding and Coding and Documentation Documentation Care Delivery Care Delivery Model Model Quality Patient Satisfaction Managing Health Cost Prepare for Change Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 4
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  Generate new capital Generatingcapital to invest in a new strategy for care delivery 1 3 5 Patient access Patient access Medical necessity Medical necessity Reimbursement Reimbursement Enhancing Enhancing Patient Flow Patient Flow Proactively Addressing Proactively Addressing Payer Compliance Payer Compliance Augmenting Cash Flow Augmenting Cash Flow 2 4 Clinical care Clinical care Coding and Coding and documentation documentation Simplifying Clinical Simplifying Clinical Workflow Workflow Automating && Automating Optimizing Coding Optimizing Coding Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5
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  Navigating the journeyfrom providing care to managing health Invest New Capital Generate New Capital Patient Patient Access Access Medical Medical Necessity Necessity Financial and Financial and Clinical Analytics Clinical Analytics Population Health Population Health Management Management Reimbursement Reimbursement Providing Care Aligned Incentives Clinical Clinical Care Care Coding and Coding and Documentation Documentation Care Delivery Care Delivery Model Model Quality Patient Satisfaction Managing Health Cost Prepare for Change Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6
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  Prepare for change Caredelivery Model Care Delivery model Care Delivery Model 1 2 3 Consensus Consensus Governance Governance Structure Structure Agreement on the Goal Agreement on the Goal Accountability for the Goal Accountability for the Goal Alignment to the Goal Alignment to the Goal Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7
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  Navigating the journeyfrom providing care to managing health Invest New Capital Generate New Capital Patient Patient Access Access Medical Medical Necessity Necessity Financial and Financial and Clinical Analytics Clinical Analytics Population Health Population Health Management Management Reimbursement Reimbursement Providing Care Aligned Incentives Clinical Clinical Care Care Coding and Coding and Documentation Documentation Care Delivery Care Delivery Model Model Quality Patient Satisfaction Managing Health Cost Prepare for Change Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8
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  Invest new capital Investingin a new care delivery strategy. Financial & Clinical Analytics To predict the future medical To predict the future medical experience of individual health experience of individual health consumers as well as defined consumers as well as defined populations populations Population Health Management To identify, engage, and impact To identify, engage, and impact every individual with aahealth every individual with health need within aadefined population need within defined population Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 9
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  Information technology Technical Blueprintfor Physician Gain-Sharing Enablement 1 Electronic Electronic Medical Record Medical Record Collect the data Collect the data generated within aa generated within physician practice physician practice Utilize the activities Utilize the activities delivered within the delivered within the physician’s office to physician’s office to build each patient’s build each patient’s clinical database clinical database 2 3 Health Health Information Information Exchange Exchange 4 Clinical Clinical Analytics Analytics Aggregate the data Aggregate the data generated within the generated within the health care health care community community Augment the Augment the physician’s EMR with physician’s EMR with patient data from patient data from community specialists, community specialists, hospitals hospitals and ancillary services and ancillary services Population Health Population Health Management Management Convert aggregated Convert aggregated data into actionable data into actionable information information Take action Take action Catalyze action to Catalyze action to mitigate identified risk: mitigate identified risk: Identify and stratify: Identify and stratify: •Patients at risk for •Patients at risk for unfavorable future unfavorable future medical experience medical experience •Physician performance •Physician performance relative to best practice relative to best practice •Action for physician at •Action for physician at point-of-care point-of-care •Action for health •Action for health coaches remotely coaches remotely •Action for patients to •Action for patients to engage in self-care engage in self-care Registries (Pre-defined Registries (Pre-defined &&dynamic) dynamic) Care coordination Care coordination Quality &&Business Quality Business Intelligence reporting Intelligence reporting Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10
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  Key opportunities inpopulation health management 2012 medical claims cost distribution among Commercial payers using Optum for Population Health Management services Ambulatory Medical Chronic Illness 69% Acute Illness (32% of members) 60% Inpatient Medical 27% COST BY CONDITION (19% of members) 25% COST BY SETTING Healthy Pharmacy 4% 15% (49% of members) (5.5 million eligible members) (5.5 million eligible members) Population medical costs are largely from treatment of chronic conditions in the ambulatory setting. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11
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  Four steps ofPopulation Health Management Physician groups who have been successful in value-based contracts consistently cite the same four areas of critical focus for success in PHM. Care delivery model Population Health Management Population Health Management 1 Optimize network Optimize network management management 2 Manage care Manage care transitions transitions 3 4 Invest in in-home Invest in in-home intervention intervention Expand chronic Expand chronic disease disease management management Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12
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  Step 1: Optimizenetwork management Refer to clinically effective and financially efficient sub-specialists. Ensure patient experience with referral and specialty care is optimal. Impact to individual Impact to individual • 10% reduction in surgical intervention rate for spine, hip and knee surgeries • $10,000–15,000 average medical Impact to population Impact to population • 49% fewer redos and 60% lower complication rate for implantable cardiac device surgeries when performed by quality-designated cardiothoracic surgeons cost savings per redirection • 14% total cost savings when population is consistently referred to the highest quality and most cost-efficient physicians for all specialty care Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 13
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  Step 2: Managecare transitions 18 hospitals will each forego more than 1 million dollars in Medicare reimbursement this year due to readmission penalties. Utilize onsite and post-discharge resources to reduce readmission: 37% •Onsite RNs •Home visits Reduction in 30-day readmit rates* •Telephonic case managers •Telemedicine * For adults with medical (non-surgical, non-maternal) admitting diagnosis Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14
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  Step 3: Investin in-home intervention Focus intense resources on patients with highest acuity needs following acute illness Among high-risk patients Post-acute care Post-acute care •Complete thorough in-home •Complete thorough in-home assessment using mobile device assessment using mobile device •Share results with clinical team •Share results with clinical team •Trigger alerts for potentially urgent •Trigger alerts for potentially urgent health issues health issues •Identify key topics for patients to •Identify key topics for patients to discuss with primary physician discuss with primary physician •Recommend and ensure appropriate •Recommend and ensure appropriate follow-up appointments follow-up appointments 34% reduction in 30-day readmit rates 51% fewer prescriptions per high-risk member* 64% drop in acute admit rate *9 or more initial prescriptions Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15
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  Step 4: Expandchronic disease management Moving chronic care from the exam room to the community. Predictive modeling analytics Systematic, population-based care manager outreach 20% improvement in optimal care compliance among chronically ill The chronic disease patient with the greatest need … is also the one least likely to show up in your office Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16
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  Provider-based predictive modeling Analyticsto predict future medical costs of individuals and populations are limited by the characteristics of the three types of available data. Claims data generally comes from generally comes from medical or pharmacy medical or pharmacy benefit managers/payers benefit managers/payers Clinical data usually comes from an usually comes from an electronic medical record electronic medical record (EMR), biometric feeds, (EMR), biometric feeds, lab feeds, pharmacy feeds lab feeds, pharmacy feeds or health assessments or health assessments (by either the patient or (by either the patient or care manager) care manager) Abstracted data may come from hospital may come from hospital notice of discharge, notice of discharge, admission, ED visit or admission, ED visit or skilled nursing facility skilled nursing facility transfer transfer Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17
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  Provider-based predictive modeling Relativestrengths of data used in health care analytics vary by source, and can be categorized by sensitivity (ability to detect all conditions), specificity (ability to identify conditions accurately), timeliness and availability. Claims data – insensitive – insensitive – non-specific – non-specific – untimely – untimely + always available + always available Clinical data + sensitive + sensitive + specific + specific + timely + timely –– variably available (may be variably available (may be incomplete or unstructured incomplete or unstructured in EMR, or unavailable from in EMR, or unavailable from non-EMR users) non-EMR users) Abstracted data + sensitive + sensitive –– non-specific non-specific + timely + timely + generally available + generally available Variations in strengths and weaknesses between these three data sources suggests aggregation will provide a more effective basis for prediction of future medical outcomes and costs. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18
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  Combined data iskey: Diabetes example Optimal prediction of future medical experience of individuals and populations Claims data When used for chronic When used for chronic disease management, disease management, improved treatment improved treatment compliance about 20% compliance about 20% Clinical data 30% of individuals 30% of individuals identified as diabetic identified as diabetic by clinical data were by clinical data were missed by claims data missed by claims data Abstracted data 37% decrease in 30-day 37% decrease in 30-day readmission rates when readmission rates when care manager promptly care manager promptly notified of discharge notified of discharge •2/3 identified only through •2/3 identified only through abnormal EMR lab results abnormal EMR lab results •1/3 identified only through •1/3 identified only through EMR prescription data EMR prescription data Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 19
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  Population health managementtechnology Health Intelligences Management — Measurement REGISTRIES REGISTRIES CARE COORDINATION CARE COORDINATION QUALITY & BI REPORTING QUALITY & BI REPORTING Pre-defined Registries Pre-defined Registries Workflow Management Workflow Management Dynamic Registries Dynamic Registries Longitudinal Care Plan Longitudinal Care Plan Performance && Performance Management Reporting Management Reporting Population Opportunities Population Opportunities Care Plan Adherence Care Plan Adherence Assessments Assessments ACO Measures ACO Measures Risk Scores Risk Scores CLOUD COMPUTING Claims Data Clinical Data Practice Mgmt Medical, pharmacy, lab Biometric, disease-specific Billing data and scheduling Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 20
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  POPULATION HEALTH POPULATION HEALTH REGISTRIES REGISTRIES
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  CARE COORDINATION CARE COORDINATION
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  QUALITY & BUSINESS QUALITY& BUSINESS INTELLIGENCE REPORTING INTELLIGENCE REPORTING
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  Navigating the journeyfrom providing care to managing health Invest New Capital Generate New Capital Patient Patient Access Access Medical Medical Necessity Necessity Financial and Financial and Clinical Analytics Clinical Analytics Population Health Population Health Management Management Reimbursement Reimbursement Providing Care Aligned Incentives Clinical Clinical Care Care Coding and Coding and Documentation Documentation Care Delivery Care Delivery Model Model Quality Patient Satisfaction Managing Health Cost Prepare for Change Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 24