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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

Published in: Health & Medicine
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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]