Prevention, Wellness, And Outcomes From A Payer Perspective
Miles Snowden, MD, MPH, CEBS
Chief Medical Officer – Optum, Un...
One of the largest
health information,
technology and
consulting companies
in the world

The leader in population
health m...
Clients

60,000,000+ individuals
80,000

physician practices and
other health care facilities

67,000 pharmacies*
5,000 ho...
Navigating the journey from providing care to managing health

Invest
New Capital

Generate
New Capital
Patient
Patient
Ac...
Generate new capital
Generating capital to invest in a new strategy for care delivery

1

3

5

Patient access
Patient acc...
Navigating the journey from providing care to managing health

Invest
New Capital

Generate
New Capital
Patient
Patient
Ac...
Prepare for change

Care delivery Model
Care Delivery model
Care Delivery Model

1

2

3

Consensus
Consensus

Governance
...
Navigating the journey from providing care to managing health

Invest
New Capital

Generate
New Capital
Patient
Patient
Ac...
Invest new capital
Investing in a new care delivery strategy.

Financial & Clinical
Analytics
To predict the future medica...
Information technology
Technical Blueprint for Physician Gain-Sharing Enablement

1
Electronic
Electronic
Medical Record
M...
Key opportunities in population health management
2012 medical claims cost distribution among Commercial payers
using Optu...
Four steps of Population Health Management

Physician groups who have been successful in value-based contracts
consistentl...
Step 1: Optimize network management
Refer to clinically effective and financially efficient sub-specialists.
Ensure patien...
Step 2: Manage care transitions
18 hospitals will each forego more than 1 million dollars in
Medicare reimbursement this y...
Step 3: Invest in in-home intervention
Focus intense resources on patients with highest acuity needs following acute illne...
Step 4: Expand chronic disease management
Moving chronic care from the exam room to the community.

Predictive modeling an...
Provider-based predictive modeling
Analytics to predict future medical costs of individuals and populations are limited by...
Provider-based predictive modeling
Relative strengths of data used in health care analytics vary by source, and can be
cat...
Combined data is key: Diabetes example
Optimal prediction of future medical experience of individuals and populations

Cla...
Population health management technology
Health Intelligences Management — Measurement

REGISTRIES
REGISTRIES

CARE COORDIN...
POPULATION HEALTH
POPULATION HEALTH
REGISTRIES
REGISTRIES
CARE COORDINATION
CARE COORDINATION
QUALITY & BUSINESS
QUALITY & BUSINESS
INTELLIGENCE REPORTING
INTELLIGENCE REPORTING
Navigating the journey from providing care to managing health

Invest
New Capital

Generate
New Capital
Patient
Patient
Ac...
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Miles Snowden, MD - Prevention, Wellness & Outcomes from a Payer Prospective

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  • {"6":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n","24":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n","8":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n","3":"We are privileged to serve a tremendously diverse portfolio of partners. They have to perform better everyday and so do we. These folks keep us on our toes. They are trying to solve real problems and quite frankly, the margin of error in some of these worlds isn’t very forgiving.\nWe embrace this responsibility and one of the things I am most proud of is the depth of these relationships. When this group has a tough problem…they know they can count on the people of Optum.\n(Preferred Reported Values per the Optum Source of Truth.)\n","20":"A key differentiator of Optum's approach is that Optum Care Suite supports both measurement and management of care, whereas most solutions today focus on only one side of the equation. That approach leads to mis-alignment of the tools and processes for evaluating performance and informing corrective actions, adding complexity and cost to the system. \nRegistries\nHelps health professionals understand the health of entire populations of patients so they can then devise strategies for improving population health\nCare Coordination\nPatient conditions management\nCare plans personalized to each patient, built dynamically\nConfigurable patient alerts\nReal time modification at point of care\nReal time medication and condition reconciliation\nQuality and BI Reporting\nGathers data from claims, clinical records and patient reported outcomes, and helps health administrators easily track and measure performance and compile reports for quality and compliance requirements\nAnalytics\nClassic and real-time cloud population health\nRules based components\nPredictive models\nCloud\nAn environment that supports integration and makes connecting across systems easy to do. \nData Intake / Data Management\nThe first health IT solution to integrate clinical details from digitized patient records with medical claims data, to create a complete view of the patient experience and health system performance. \n","4":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n"}
  • Miles Snowden, MD - Prevention, Wellness & Outcomes from a Payer Prospective

    1. 1. Prevention, Wellness, And Outcomes From A Payer Perspective Miles Snowden, MD, MPH, CEBS Chief Medical Officer – Optum, UnitedHealth Group
    2. 2. One of the largest 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
    3. 3. Clients 60,000,000+ individuals 80,000 physician practices and 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
    4. 4. Navigating the journey from 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
    5. 5. Generate new capital Generating capital 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
    6. 6. Navigating the journey from 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
    7. 7. Prepare for change Care delivery 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
    8. 8. Navigating the journey from 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
    9. 9. Invest new capital Investing in 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
    10. 10. Information technology Technical Blueprint for 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
    11. 11. Key opportunities in population 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
    12. 12. Four steps of Population 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
    13. 13. Step 1: Optimize network 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
    14. 14. Step 2: Manage care 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
    15. 15. Step 3: Invest in 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
    16. 16. Step 4: Expand chronic 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
    17. 17. Provider-based predictive modeling Analytics to 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
    18. 18. Provider-based predictive modeling Relative strengths 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
    19. 19. Combined data is key: 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
    20. 20. Population health management technology 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
    21. 21. POPULATION HEALTH POPULATION HEALTH REGISTRIES REGISTRIES
    22. 22. CARE COORDINATION CARE COORDINATION
    23. 23. QUALITY & BUSINESS QUALITY & BUSINESS INTELLIGENCE REPORTING INTELLIGENCE REPORTING
    24. 24. Navigating the journey from 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

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