John Lovelace President, UPMC  for You March 24, 2011 Public-Private Partnerships and the UPMC Experience
<ul><li>Overview of UPMC Health Plan </li></ul><ul><li>Focus on Medicaid </li></ul><ul><li>What is managed care? </li></ul...
UPMC & Insurance Services Division Overview <ul><li>UPMC (University of Pittsburgh Medical Center) </li></ul><ul><li>1 of ...
<ul><li>Medicaid is a Federal-State program, administered by states, providing health insurance for low income legal resid...
<ul><li>More efficient </li></ul><ul><li>Caps predictable risk by moving it down to the insurance company </li></ul><ul><l...
Share of Medicaid Beneficiaries in Managed Care Rising Percent enrolled in managed care: Source: 2009 Medicaid Managed Car...
<ul><li>What induces a provider to participate </li></ul><ul><ul><li>Generally better payment rates </li></ul></ul><ul><ul...
<ul><li>64% of Medicaid beneficiaries; 20% of costs nationally </li></ul><ul><li>HealthChoices </li></ul><ul><ul><li>Contr...
Prescription Drug Costs Increasing Faster than Other Costs of Medical Care Average Annual Percentage Increase in Selected ...
Pharmacy Management – Flat Pharmacy Trends  Expenditures PMPM for behavioral health related medications remained flat over...
<ul><li>Patient incentives </li></ul><ul><ul><li>Department store gift card </li></ul></ul><ul><ul><li>Implemented April 2...
<ul><li>Patient incentives </li></ul><ul><ul><li>Department store gift card </li></ul></ul><ul><ul><li>Implemented April 2...
<ul><li>$169,720 paid to members in CY2010 </li></ul><ul><li>$981,951 paid to providers in CY2010 </li></ul><ul><li>Increa...
HEDIS Improvements CY2008 to CY2010
<ul><li>Owned providers </li></ul><ul><li>Affiliated providers </li></ul><ul><li>Non-affiliated providers </li></ul><ul><u...
Management of Chronic Conditions
Pennsylvania Establishes the  Chronic Care Model Rx for Pennsylvania “  Prescription for Pennsylvania is a set of integrat...
Medical Home <ul><li>Practice based Clinical Care Managers at selected sites </li></ul><ul><li>Provided Disease Registries...
UPMC Health Plan Partners in Excellence Program – Patient-Centered Medical Home
Spring, 2008 - Present
John Lovelace President, UPMC  for You [email_address]
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John lovelace 2011 03 25 public private p artnerships in health dublin march 25 2011 v3 pages 1 - 22

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John Lovelace, President, UPMC for you
Presentation at the 2011 National Healthcare Conference in Dublin

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  • Definition – “ Medicaid is a means-tested, state-administered entitlement program jointly funded by the Federal and State governments that provides health care coverage to PA’s neediest, most vulnerable residents.” (Source: The Basics of MA in PA (PA Medicaid Policy Center) http://www.pamedicaid.pitt.edu/documents/MA%20Basics%20FS%2008.pdf) Medicaid provides health and long-term care coverage to roughly 1 in 5 Americans (Source: KFF, Medicaid and Managed Care: Key Data, Trends, and Issues) Who is enrolled? – Eligibility; individuals must fit: Fit into a specified coverage group Meet the income requirements for that coverage group (calculated as a % of the FPL) Meet the asset requirements for that coverage group Be a U.S. citizen Be a PA resident Primary coverage groups: Infants and children to age 19 Pregnant women TANF Individuals with disabilities The elderly Other coverage groups: Workers with disabilities Title IV-E adoptive or foster children Women enrolled in the Breast and Cervical Cancer Prevention and Treatment program Medically needy individuals (optional group consisting of those who qualify by income level; may meet this level by “spend-down” process) Low income Medicare beneficiaries Women with incomes up to 185% of the FPL for family planning services *Low income, non-disabled adults without children are generally not eligible. “ Many groups of people are covered by Medicaid. Even within these groups, though, certain requirements must be met. These may include your age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group. There are special rules for those who live in nursing homes and for disabled children living at home.” (Source: CMS) &amp;quot;You must meet income, resource (in most cases), and other eligibility requirements in order to be eligible for Medical Assistance. These categories are grouped by: Individuals who are aged (age 65 and older), blind and disabled. (Identified for Medical Assistance purposes as SSI-related) Families with children under age 21. (Identified for Medical Assistance purposes as TANF-related) Single and married individuals with a temporary disability, age 59 through 64, limited income or special circumstances (Identified for Medical Assistance purposes as GA-related): Under-going drug and alcohol treatment Victim of domestic violence Caring for a child or disabled person Special Medical Assistance conditions “ (Source: DPW) For how long? – How are we paid? – Financed jointly by federal and state governments. In PA, the mix is 55.64%/44.36% (68.95%/31.05% enhanced) for FY11. As a MCO, we are paid on a risk-based capitation model. The state Medicaid agency (DPW) contracts with UPMC for You for the provision of an agreed upon set of services for a fixed monthly fee per person. Pharmacy – Pharmacy utilization is a major focus of the Medicaid program. Prescription drugs costs are rising faster than costs of other areas of expenditure (Kaiser – next slide). Controlling these costs through managed care policies (mandate substitution of generics, etc) can have a major impact on overall medical costs.
  • Unduplicated count. Includes all managed care enrollees receiving both comprehensive and limited benefits. By comparison, share of MA beneficiaries enrolled in managed care in PA in 2009 was 82.1% (Source: 2009 Medicaid Managed Care Enrollment Report, CMS), 81.1% in 2008 (Source: 2008 Medicaid Managed Care Enrollment Report), 81.2% in 2007 (Source: 2007 Medicaid Managed Care Enrollment Report), 86.3% in 2006 (Source: 2006 Medicaid Managed Care Enrollment Report) *** CMS has taken down all former reports and any other site I found with a the reports only goes back to 2006. I can include this information in the graph if you would like but without the info for years prior to 2006 it might be hard to explain that the highest percentage of the 4 data points we have is also the oldest when nationwide MMC is trending upward. I want to include per beneficiary expenditure here, but can’t find a data source. Perhaps we can put inflationary trends in?
  • 64% of Medicaid beneficiaries enrolled in managed care in 2007 accounted for only 20% of total Medicaid spending on services (Source: KFF, Medicaid and Managed Care: Key Data, Trends, and Issues, February 2010) however, studies have found that this is because enrollees in MMC are generally are generally families and children (TANF) and highest-cost beneficiaries are still FFS (Source: Herz, 2006. Medicaid Managed Care: An Overview and Key Issues for Congress. Congressional Research Service) HealthChoices Medical escalation costs held to 7.4% (MC) compared to 10.5% (average annual cost escalation for FFS programs) -even more impressive because HealthChoices inflationary trend is on a higher cost platform (urban areas vs. rural) -$2.7 billion in estimated savings (Lewin Report – Comparative Evaluation of Pennsylvania’s HealthChoices Program and FFS Program, 2005) -largely attributable to comprehensive and coordinated care facilitated by MC organizations participating in HealthChoices FFS model makes care coordination difficult -15% figure = estimated 15% savings in the SE and 10% in SW and Lehigh Cap
  • Calculated with National Health Expenditures Data (CMS) There are a number of slides in another presentation I have focusing on UPMC for You pharmacy trends and initiatives if you would like that to be added in.
  • This slide seems like it could be useful, but perhaps in a different spot.
  • Provider satisfaction with P4P program – Increased provider engagement Prospective rosters allow providers sufficient time to contact members Helped providers identify and manage gaps in care and chronic conditions Additional P4P revenue has helped providers support additional expenses in conducting outreach and follow-up for UPMC for You members
  • John lovelace 2011 03 25 public private p artnerships in health dublin march 25 2011 v3 pages 1 - 22

    1. 1. John Lovelace President, UPMC for You March 24, 2011 Public-Private Partnerships and the UPMC Experience
    2. 2. <ul><li>Overview of UPMC Health Plan </li></ul><ul><li>Focus on Medicaid </li></ul><ul><li>What is managed care? </li></ul><ul><li>Impact of managed care </li></ul><ul><li>Preventive care </li></ul><ul><li>Chronic care </li></ul><ul><li>Provider relationships </li></ul><ul><li>Public-Private partnership values </li></ul><ul><li>Chronic Disease Management Partnerships </li></ul>Agenda
    3. 3. UPMC & Insurance Services Division Overview <ul><li>UPMC (University of Pittsburgh Medical Center) </li></ul><ul><li>1 of 13 “Honor Roll” health systems </li></ul><ul><li>U.S. News & World Report “Best Hospitals” </li></ul><ul><li>48,000 employees </li></ul><ul><li>$8 billion annual revenue </li></ul><ul><li>#5 in National Institute of Health funding </li></ul>Insurance Services <ul><li>1.5 million members </li></ul><ul><li>10,000+ provider network </li></ul>Hospital <ul><li>21 PA hospitals </li></ul><ul><li>International operations </li></ul>Physician/Outpatient <ul><li>400 outpatient/physician sites </li></ul><ul><li>Home health </li></ul><ul><li>DME </li></ul><ul><li>2,800 employed physicians </li></ul><ul><li>2,500 affiliated physicians </li></ul>Commercial Service Development <ul><li>IBM </li></ul><ul><li>General Electric </li></ul><ul><li>Alcatel-Lucent </li></ul>
    4. 4.
    5. 5. <ul><li>Medicaid is a Federal-State program, administered by states, providing health insurance for low income legal residents </li></ul><ul><ul><li>Income test </li></ul></ul><ul><ul><li>Asset test </li></ul></ul><ul><li>Medicaid is an entitlement, meaning the Federal government has to match whatever the state spends </li></ul><ul><li>Eligible enrollees include </li></ul><ul><ul><li>single parents with dependent children </li></ul></ul><ul><ul><li>Pregnant women </li></ul></ul><ul><ul><li>Adults and children with disabilities </li></ul></ul><ul><li>Average person is on for 8-24 months </li></ul>Focus on Medicaid
    6. 6. <ul><li>More efficient </li></ul><ul><li>Caps predictable risk by moving it down to the insurance company </li></ul><ul><li>Greater flexibility </li></ul><ul><li>Greater insulation from political scene </li></ul><ul><li>Improved quality </li></ul><ul><li>Employs strategies known to impact wellness and disease management </li></ul><ul><li>Constrains utilization: </li></ul><ul><ul><li>The right care, at the right time, in the right place (and at the right price) </li></ul></ul>Privatizing Medicaid
    7. 7. Share of Medicaid Beneficiaries in Managed Care Rising Percent enrolled in managed care: Source: 2009 Medicaid Managed Care Enrollment Report, CMS:
    8. 8. <ul><li>What induces a provider to participate </li></ul><ul><ul><li>Generally better payment rates </li></ul></ul><ul><ul><li>Offsets loss of volume </li></ul></ul><ul><ul><ul><li>Medicaid is generally not a good payer, so providers are helped by lower Medicaid volume </li></ul></ul></ul><ul><ul><li>Faster claims payment </li></ul></ul><ul><ul><li>Innovations in: </li></ul></ul><ul><ul><ul><li>Care management and coordination resources </li></ul></ul></ul><ul><ul><ul><li>Contract terms </li></ul></ul></ul><ul><ul><ul><li>Information sharing about patients </li></ul></ul></ul>Provider Partnerships
    9. 9. <ul><li>64% of Medicaid beneficiaries; 20% of costs nationally </li></ul><ul><li>HealthChoices </li></ul><ul><ul><li>Controls medical escalation costs </li></ul></ul><ul><ul><ul><li>7.4% vs. 10.5% </li></ul></ul></ul><ul><ul><ul><li>$2.7 billion in savings over first 5 years (2000-2004) </li></ul></ul></ul><ul><ul><li>Represents an estimated savings of 15% over FFS </li></ul></ul>Cost Trend
    10. 10. Prescription Drug Costs Increasing Faster than Other Costs of Medical Care Average Annual Percentage Increase in Selected National Health Expenditures, 1996-2008 Source: Kaiser Family Foundation
    11. 11. Pharmacy Management – Flat Pharmacy Trends Expenditures PMPM for behavioral health related medications remained flat over the last 24-months, and utilization was reduced 2%. Note: the rolling 12-month medical trend (non-pharmacy) is -3.35% (approximately -2% after accounting for category of assistance membership shifts over time).
    12. 12. <ul><li>Patient incentives </li></ul><ul><ul><li>Department store gift card </li></ul></ul><ul><ul><li>Implemented April 2010 </li></ul></ul><ul><ul><ul><li>Breast cancer screening, child lead screening, PCP visits </li></ul></ul></ul><ul><ul><li>New for 2011 </li></ul></ul><ul><ul><ul><li>Cervical cancer screening, cardiovascular screening </li></ul></ul></ul><ul><li>Provider incentives </li></ul><ul><ul><li>P4P program </li></ul></ul><ul><ul><ul><li>Implemented CY2008; points based </li></ul></ul></ul><ul><ul><ul><li>Pediatric measures </li></ul></ul></ul><ul><ul><ul><ul><li>Adolescent well-care visit, lead screening </li></ul></ul></ul></ul><ul><ul><ul><li>Maternity measures </li></ul></ul></ul><ul><ul><ul><ul><li>Timely prenatal and post partum care </li></ul></ul></ul></ul>Preventive Care
    13. 13. <ul><li>Patient incentives </li></ul><ul><ul><li>Department store gift card </li></ul></ul><ul><ul><li>Implemented April 2010 </li></ul></ul><ul><ul><ul><li>Diabetes screening (HbA1c and LDL), Connected Care consent forms </li></ul></ul></ul><ul><ul><li>New for 2011 </li></ul></ul><ul><ul><ul><li>HHEP (asthma) program incentive </li></ul></ul></ul><ul><li>Provider incentives </li></ul><ul><ul><li>P4P program </li></ul></ul><ul><ul><ul><li>Implemented CY2008; points based </li></ul></ul></ul><ul><ul><ul><li>Diabetes measures </li></ul></ul></ul><ul><ul><ul><ul><li>HbA1c screen, eye exam, lipid profile </li></ul></ul></ul></ul><ul><ul><ul><li>Asthma measures </li></ul></ul></ul><ul><ul><ul><ul><li>Use of appropriate medications </li></ul></ul></ul></ul>Chronic Care
    14. 14. <ul><li>$169,720 paid to members in CY2010 </li></ul><ul><li>$981,951 paid to providers in CY2010 </li></ul><ul><li>Increased provider satisfaction </li></ul><ul><li>Through first two years (CY2009 and CY2010), increased HEDIS measures 5-11 percentage points </li></ul><ul><ul><li>Better quality scores </li></ul></ul><ul><ul><li>Improved MCO Pay for Performance results </li></ul></ul><ul><ul><ul><li>$4.8 million earned in FY2010 </li></ul></ul></ul><ul><li>Projected net return of $1.58 million for CY2011 </li></ul>Results/ROI
    15. 15. HEDIS Improvements CY2008 to CY2010
    16. 16. <ul><li>Owned providers </li></ul><ul><li>Affiliated providers </li></ul><ul><li>Non-affiliated providers </li></ul><ul><ul><li>Behavioral health coordination </li></ul></ul><ul><ul><li>Patient Centered Medical Home </li></ul></ul><ul><ul><li>Highest cost patients and improving cost/outcome profile </li></ul></ul><ul><ul><li>Results </li></ul></ul>Provider Relationships
    17. 17. Management of Chronic Conditions
    18. 18. Pennsylvania Establishes the Chronic Care Model Rx for Pennsylvania “ Prescription for Pennsylvania is a set of integrated, practical strategies for improving health care and containing costs for all Pennsylvanians. The core components are affordability, accessibility and quality.” Edward Rendell, Governor Commonwealth of Pennsylvania Source: Prescription for Pennsylvania
    19. 19. Medical Home <ul><li>Practice based Clinical Care Managers at selected sites </li></ul><ul><li>Provided Disease Registries; Predictive Modeling and Patient Risk Profiles </li></ul><ul><li>Timely Data: Emergency Inpatient, Pharmacy, Specialty and Care Gaps Data </li></ul><ul><li>Practice Coaches </li></ul><ul><li>(Process Improvement </li></ul><ul><li>for Workflow) </li></ul><ul><li>Patient Outreach </li></ul><ul><li>Education </li></ul><ul><li>Virtual Extender </li></ul><ul><li>Team at Health Plan </li></ul><ul><li>including Health </li></ul><ul><li>Coaches for Lifestyle </li></ul>
    20. 20. UPMC Health Plan Partners in Excellence Program – Patient-Centered Medical Home
    21. 21. Spring, 2008 - Present
    22. 22. John Lovelace President, UPMC for You [email_address]

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