changing landscape in provider reimbursement models presentation to national association of county...
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Changing Landscape in Provider Reimbursement ModelsPresentation to National Association of County Behavioral Health and Developmental Disability DirectorsMarch 4, 2013Sandra Forquer, PhDSVP, State Government ProgramsOptum Public Sectorsandra.forquer@optum.com
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Information- and technology-enabled health services
Helping to make the health care system work better for everyone.
Health care coverage and benefits
Helping people live healthier lives.
Optum Is Part of UnitedHealth Group
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
“A shift toward increased collaboration
between payors and providers is driving
innovation in outcome-based payment models
and delivery system configuration.”
— Sam Ho,
Chief Medical Officer, UnitedHealth Group
Changing Landscape in Provider Reimbursement Models
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
•Payment Reform Strategy
•Delivery System Strategy
Network Innovation Strategy to Increase Value
• We are developing and implementing a suite of value-based incentive programs that reward care providers for improvements in quality and efficiency
• We are supporting delivery systems as they become more integrated and accountable for cost, quality and experience outcomes
• Alignment across our Network, Product and Clinical innovations allows us to increase value for customers and consumers
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Transition of the Model
•Compensation Continuum(Level of Financial Risk)
•Small % of financial risk •Large % of financial risk
•Moderate % of financial risk
•No Accountability •Full Accountability•Moderate Accountability
•Fee-for-service
•Performance- based Contracting
•Bundled and Episodic Payments
•Shared Savings
•Shared Risk
•Capitation
•a. 100% case by case UM
•Capitation + Performance- based Contracting
In selected provider arrangements, we will be transitioning and supporting financial risk, accountability and utilization management practices.
• Basic Q and U measurements
• b. Utilization stats review supplemented by case review
• c. Data management and system
• Modifications to achieve targets
• d. Internal ownership of performance using data management
• Max quality process and outcomes driven measurements
• Passive involvement • Provider engaged • Provider active in management • Assumes accountability
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6
Nearly 10% of our total spending on network-based health care services across all OptumHealth Behavioral Solutions lines of business is tied to performance-based incentive contracts that reward providers for increased collaboration, outcome-based results, and improved cost-efficiencies.
Performance-Based Contracting
CA
AZ NM
MO
GA
RI
MA
FL
OHIL
WI
MN
States with formal performance-based agreements
States with performance-based agreements in process
TX
CTIA
NE
WA
KSCO
OK
KY
NY
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Performance-Based Contracting – At A Glance
Demonstrated use of Evidence-Based Practices (EBP)
• Qualifies as High-Volume provider• Participates in periodic meetings with clinical operations staff to review data• Submits claims electronically
•Sample Facility
•Participation
•Requirements
•Sample Metrics
• Facility will earn escalator based sharing of savings if performance is within targeted range• Facility will earn performance bonus for achievement of quality metrics
•Sample Performance Incentives
• Reduction in Average Length of Stay• Reduction in 30 day Readmission rate to any inpatient LOC• Improved results on ambulatory follow-up rates (7 days post inpatient discharge)
•Incentivizing provider performance leads to better outcomes for consumers
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Feet on the Street
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• UnitedHealthcare Community Plan partnered with Recovery Connection to provide behavioral health care especially designed to meet patients at the point of need: on the street
• Recovery Connection is a program designed to manage behavioral health care for the top 195 “high-utilizer” TennCare members in West Tennessee.
EXAMPLE 1: Necessity as the Mother of Innovation
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Helping Our Members Where They Live
• A Majority of members were in the defined area of Shelby county
• West region, which includes many of these members, has a high rate of homelessness
• Higher overall expenses for members in area
• Significant problem with continuity of care in area
• Service Coordinators have a minimum of Bachelors-level education
• They are trained as a community interventional specialist, in conjunction with Neumann College, through a special curriculum
• Are supervised by a licensed Behavioral Health clinician
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EXAMPLE 1: Necessity as the Mother of Innovation
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Role of Service Coordinators
Service Coordinators are responsible for providing street-based care coordination and connections to service providers and groups.•They take part in discharge planning when members discharge from Inpatient care•Help ensure members receive timely follow-up appointments with a Behavioral Health provider after Inpatient discharge•Assist members connect with Primary Care Providers to address co-morbid conditions•Connect members with family support systems to assist in community stabilization
Pay for Performance•The Recovery Connection group is paid a basic case rate, with an identified pool for meeting performance measures:
– Initial assessments for hospital admissions with 24 hours of admission– Full assessments for all members completed with 30 days of assignment– Increases in 7-day follow-up after hospitalization (FUH) appointment– Decreases in 30-day readmissions
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EXAMPLE 1: Necessity as the Mother of Innovation
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11
Pilot Background & Objectives
• In New Mexico, a performance-based contracting initiative aimed at improving affordability, quality outcomes and member health was launched July 2010
• Specific objectives were to increase community tenure for consumers with history of Out-Of-Home (OOH) placements within the New Mexico public sector population
Participation Requirements
Program Execution
Payments
• Demonstrated use of EBP and support models• Minimum membership levels
• Weekly rounds with OHBS• Data reviews• Timely claims submission
ProgramStructure
Measured Outcomes
Metric Target Achievement
Reduction in OOH Units 20% 55%
Readmit Rate Not to exceed baseline by more than 2%
Readmit Rate Declined
Critical Incidents Not to exceed baseline by more than 2%
Critical Incident Rate Declined
Post-Pilot Expansion
• Identified 25 high volume facilities serving both commercial and public sector members as part of a phased implementation effort
• Aligning incentives to achieve reduction in ALOS, readmissions, and improvements in HEDIS 7-day ambulatory follow up
• Provider has opportunity to earn rate escalator based on achievement levels
Pay-for-performance Contracting Improves System of Care
EXAMPLE 2: Necessity as the Mother of Innovation
Thank you.
For more information, please contact:sandra.forquer@optum.com
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