enabling healthier lives - everett clinic · 2019-10-07 · our mission to help people live...

Lunch & Learn: How We Care for Medicare

Enabling Healthier Lives

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Today’s Agenda

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Who is Optum?

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Ranked 6th of the Fortune 500

Health Benefits Health Services

A diversified enterprise with complementary but distinct

business platforms

Our MissionTo help people live healthier lives and to help make the

health system work better for everyone.

OptumCare Today

>16M

Aligned Physicians >45k

>9k Advanced Practice Clinicians

>80 Payers

Patients

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OptumCare WA

>640k

PCPs>570

>1.7k Specialists

Patients

Northwest Physicians Network (NPN)

The Everett Clinic (TEC)

Network Locations

The Polyclinic

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Growing Primary CareEnabling Specialty

Serving Vulnerable PopulationsInviting Others

Expanding Value-Based CareEnhancing FFS

Standardizing TogetherRespecting Local Details

Focus Areas

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HealthierLives

Enabling

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Fee-for-Service vs Value Based CareTraditional Fee-for-ServiceReactive approach – “Sickcare”

Delivering care in this moment in time

• Episodic care• Rewards number of visits• Most of care is provided in the visit• Encourages utilization for reimbursement

Population Health / Value Based CareProactive approach – “Wellcare”

Delivering care throughout the year

• Prevention and early detection; keeping the patient healthy

• Rewards outcomes and quality• Much of care is provided between visits• Patient’s diagnosis determines cost of care and

resources needed

Can drive higher costs Predicts cost and more accurately reimburses for complexity of care

A mild flu season

Resolving issue via phone call

A mild flu season

Resolving issue via phone call

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Requires Providers to bill CMS for visits & proceduresTraditional Medicare Operates Fee-for-Service

TEC receives payment based on contracted services performed

Visits

Tests

X-rays

Procedures

Medicare patient visits clinician

Clinician sends claim to CMS for reimbursement

If patient has supplemental insurance, Medigap plan pays provider

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Medicare Advantage focuses on Population HealthMA is a different business model. Providers who take risk receive monthly payments for each MA member based on county of residence, demographic, and health status of the member.

Hospitals

Skilled Nursing Facilities

Other Providers

DME Providers

CMS give global fees to payers for Medicare Advantage (MA)

Payers give global fees to the Everett Clinic & NPN through risk contracts

HOLDS RISK

MA Contract

TEC & NPN are responsible for managing total cost of care for these patients

Risk Contract

Risk Contract

1) Park, Hyojun et al. “Relative contributions of a set of health factors to selected health outcomes” American Journal of Preventative Medicine 2015, 49(6). https://www.countyhealthrankings.org/sites/default/files/Park_AmJPrevMed_2015.pdf

2) Definition from the World Health Organization 3) McKinsey 2019 Consumer Social Determinants of Health Survey 11

Imagine all the factors that drive healthcare needs Research suggests that medical care contributes 30% to health outcomes, social determinants contribute 70%1.

Social determinants of health are the conditions in which people are born, grow, work, live, and age2

Food Environment

Community Safety

Housing Social Support

Transportation

More than half of seniors may be adversely affected by 1 or more of these social determinants3

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Medicare Advantage enables comprehensive careData Transparency Member Benefits Care Programs

Personalized Care Team (PCT)

MA-Only Clinics

Transitional Care Management

Complex Care Management

Hospitalist Team

Skilled Nursing Facility (SNF) Providers

ClaimsPredictive analysis, identify high risk patients

Care Gap ReportingImproves quality, preventive care

Eligibility Proactively engage patients (e.g., Annual Comprehensive Visit)

In 2020, Medicare Advantage patients can access a broader set of supplemental benefits to address social determinants such as: Meal delivery

Transportation for non-medical needs

Home environment services

Source: CMS 2020 Final Call Letter

1) TEC internal reporting; Med Adherence rates come from health plans 2) Final CMS national Star average performance for services provided in 2017 13

Impact of Data on Preventive CareCore Clinical STAR Measure TEC 2018 Rating1 Beat Benchmark CMS Benchmark2

Body Mass Index 5 4

Rheumatoid Arthritis 4 3

Breast Cancer Screening 4 3

Colorectal Cancer Screening 5 4

Diabetes – Blood Sugar Control 5 4

Diabetes – Nephropathy Screening 5 4

Diabetes – Eye Exam 5 4

Osteoporosis Management 4 2

Medication Adherence 5 3

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TEC & NPN Colorectal Cancer Screenings

Colorectal Cancer

#2 Leading Cause of Cancer Deaths in the US

+60,000 Patients1

Appropriate Colorectal Cancer Screening

1440Fewer Deaths

From Colorectal Cancer

16,200Life Years

Gained

* Lifetime benefitsLifetime benefits2: • 24 fewer colorectal cancer deaths per 1K patients • 270 life years gained per 1K patients

1) TEC/NPN internal reporting for colorectal cancer screening.2) American Cancer Society

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Our Care Model

Prevention: Provide onboarding and education to support healthy lifestyles and wellness for all patients

Complex Care: Highest level of care and team engagement for high risk patient

Condition Care: Dedicated support and coordination for patients with uncontrolled chronic diseases

Proactive Management: Proactive engagement from care team for patients with controlled chronic disease

• Extensivist Physicians (PCT)• All teammates below

• PCPs• RNs• MAs

• Specialists• Social Workers• Behavioral Health• RN Care Managers• Clinical Pharmacists• All teammates below

Other Patients(80-85%)

Highest Risk (~5%)

Rising Risk (10-15%)

Level of Care Care Team Composition

Members across all levels of care are engaged in condition-specific and transitions of care programs as appropriate

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We care for patients across the continuumOur Patients

Primary Care

Ambulatory Surgery Center

Hospitals

Specialists

Skilled Nursing Facilities

Rehab

Home Care

Hospice

Proactive Care Acute Care Post-Acute Care

Complex Care Managers MA-only Clinics* PCT*

Transitional Care Managers Hospitalists PCT*

Complex Care Managers SNF Providers PCT*

Our Teams

*TEC only

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Our Care Managers help enable healthier lives

What Your Clients Can Expect

• RN Care Manger to support them

• Develop care plan with patient

• Regular telephone calls to manage health goals

• Assistance with appointments and getting connected to providers (BH, specialists)

• Rounding during hospital admissions

• Medication management

• Immediate follow-up after hospital discharge

• Assistance accessing health plan benefits

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Skagit, Snohomish, King, Pierce, Kitsap, Clark countiesNPN at a Glance

180 180

240

2017 2018 2019

PCPs in NPN networkFounded in 1995, acquired by DMG in 2017

Headquartered in Tacoma

Over 1000 participating providers

80 multi-specialty ambulatory surgery and diagnostic imaging centers

PCPs in 6 Western WA

counties

400 ancillary facilities (Behavioral Health,

DME, HH, SNF, Rehab)

66 different specialties in over

300 locations

* Primary care providers who see MA patients

+15.5%

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Serving Eastern Pierce County for more than 30 YearsSounds Family Medicine

47 PCPs

Humana (MA HMO & MA PPO)

United Healthcare (MA HMO only)

Premera (MA HMO only)

Aetna (MA HMO and MA PPO)

Closed to Original Medicare

Plans Accepted

4 Clinics3 Walk-In Clinics

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Internal Medicine, Sound Family MedicineMeet Dr. Alexandra Vladimir

“I enjoy connecting with people. Every detail my patient shares with me is part of a care plan puzzle we put together.”

Languages: English, Romanian

Medical School: Davila University of Medicine & Pharmacy

Residency: Mount Sinai School of Medicine

Location: Puyallup – 10 St (Hartland) Mon - Thurs 7:00am – 7:00pmFri: 7:00am – 6:00pm

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Internal Medicine, Sound Family MedicineMeet Dr. Neena Chawla

“As an internist, I care for adult patients as a whole person, and approach their issues with a holistic view.”

Languages: English, Hindi

Medical School: Delhi University Medical College

Residency: University of Southern California

Location: Bonney LakeMon - Thurs 7:00am – 7:00pmFri: 7:00am – 6:00pm

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Family Medicine, Sound Family MedicineMeet Dr. Julie Komarow

“As a breast cancer survivor, I have a personal perspective on the value of heading off problems before they become serious.”

Languages: English

Medical School: University of Washington

Awards: Patient’s Choice Award (vitals.com)Compassionate Doctor Recognition (vitals.com)

Location: Bonney LakeMon - Thurs 7:00am – 7:00pmFri: 7:00am – 6:00pm

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Internal Medicine & Family Medicine PCPsOpen NPN Practices

• Peninsula Community Health Services (Kitsap)• Hanmi Medical Clinic (Pierce) • Physician Care Northwest (Pierce) • NW Family & Spinal Clinic (Pierce) • Bonney Lake Medical Center (Pierce) • Western Washington Medical Group (Snohomish) • Dr. Andrew Loomis (Pierce) • Hudson’s Bay (Clark)

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Your Feedback

• Provider directory• Meet-and-greet with open providers• Medicare Advantage education for patients• Other resources and tools?

Join us for a tour of the Smokey Point Clinic

Appendix

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>16M

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Optum Care National Footprint

DMGCare DeliveryMedical Groups MedExpressSCA

Patients Served

>80Health plans

>1.2Care Clinics

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OptumCare WA

Open NPN Practices

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Internal Medicine and Family Medicine PCPs Accepting New Patients

Sound Family Medicine

Hanmi Medical Peninsula Community Health Services

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Pain Points of Fee-for-Service Medicare

PROVIDER EXPERIENCE:

Production pressure vs. experience

Unable to address all issues in visit

Limited care management support

Disparate or disconnected data

PATIENT EXPERIENCE:

Visit feels rushed

Perception of a less caring relationship

Uncoordinated care – Is anyone talking to each other?

Inefficient, costly