Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

John lovelace 2011 03 25 public private p artnerships in health dublin march 25 2011 v3 pages 1 - 22

874 views

Published on

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

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

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]

×