uhc ppo texas evalue8 2017 site visit - houstonbch.orgthe evalue8 process is used to: –articulate...

UHC PPO Texas

eValue8 2017 site visit

1

Agenda

• Introductions & Opening Remarks

• eValue8 Overview

• Overview of Plan results

• Diabetes Management

• Specialty Drug Management

• UHC Remarks: Total Cost of Care

• Discussion/Next Steps

2

2017 HBCH Company Members

6

HBCH eValue8 Perspective

What is eValue8TM?

A national, standardized health plan evaluation created by

business coalitions and employers like Marriott and General

Motors to measure and evaluate health plan performance

The eValue8 process is used to:

– Articulate Purchaser expectations

– Facilitate value-based purchasing by supplying the Quality factor in the

value equation

– Provide benchmarks for local and national comparisons - between

plans, and over time

– Identify and promote opportunities for quality improvement

– Drive collaboration between Plans and Purchasers

– Educate employees on plan quality

All Plans Participating Nationally

UHC

Cigna

HealthNet

Kaiser

Anthem

Aetna

GeisingerHealth Plan

9

2.8% 3.2%

28.3%

65.7%

Accreditation

CAHPS

HEDIS

All other

Weight of Accreditation, HEDIS and CAHPS; 1/3 of Total Points

What are HEDIS and CAHPS?The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America's health plans to measure performance

on important dimensions of care and service. Because so many plans

collect HEDIS data, and because the measures are so specifically defined,

HEDIS makes it possible to compare the performance of health plans on an

"apples-to-apples" basis. Health plans also use HEDIS results themselves to

see where they need to focus their improvement efforts.

To ensure the validity of HEDIS results, all data are rigorously audited by

certified auditors using a process designed by NCQA (National Committee for Quality Assurance)

Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys ask consumers and patients to report on and evaluate their

experiences with a range of health care services at multiple levels of the

delivery system

eValue8 Total Points = 712

7.4%

22.3%

16.9%

20.2%

2.9%

19.0%

11.3%

Business Profile

Physician and Hospital (Provider)Management and Measurement

Helping Members Stay/GetHealthy

Helping Members become GoodConsumers

Helping Members Manage Acute/Episodic Conditions and Care

Helping Members ManageChronic Conditions

Pharmaceutical Management

Contributing Organizations• Centers for Disease Control (CDC)

• Centers for Medicare and Medicaid Services (CMS)

• Agency for Healthcare Research and Quality (AHRQ)

• National Committee for Quality Assurance (NCQA)

• Joint Commission for the Accreditation of Health Care Organizations (JCAHO)

• URAC

• American Board of Internal Medicine (ABIM)

• The Leapfrog Group

• HC13/Bridges to Excellence

• NORC at the University of Chicago

• Pharmacy Quality Alliance (PQA)

• Consumer-Purchaser Disclosure Project

• Catalyst for Payment Reform (CPR)

12

13

eValue8 2017- Overview(712 Total Points Available)

22.3%16.1% 15.2%

19.5%

20.2%

14.4% 15.4%15.8%

19.0%

7.9%12.3%

12.0%

16.9%

9.9%

13.8%10.7%

11.3%

7.5%

7.0% 7.6%

7.4%

5.6%

6.2% 5.5%

2.9%

2.0%

2.2% 1.8%63.4%

72.2% 72.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Possible Best UHC TX PPO UHC RI PPO Benchmark

Helping MembersManage Acute/ EpisodicConditions and Care

Business Profile

PharmaceuticalManagement

Helping MembersStay/Get Healthy

Helping MembersManage ChronicConditions

Helping Membersbecome GoodConsumers

Physician and Hospital(Provider) Managementand Measurement

14

47.3%

18.3%

39.4%

39.4%

27.4%

18.0%

18.0%

18.0%

11.6%

9.0%

11.0%

11.0%

8.7%

8.7%

8.7%

8.7%

5.0%

4.6%

4.6%

4.6%

58.5%

81.7%

81.7%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Helping Members Stay/Get Healthy (120.5 points) Prevention Programs HEDIS & CAHPS

ResultsPrevention and Treatment of TobaccoUseObesity/Weight Management

Alignment of Plan Design

Health Assessments (HA)

Diabetes Prevention/Obesity

Management

• Client Support

• Physician Management

• Member Management

Why Obesity Management? Because the Diabetes Prevention Program is designed to: “help you change certain aspects of your lifestyle, like eating healthier, reducing stress, and getting more physical activity.”

15

Client Support

Plan educates self-insured purchasers about ACA required benefits for obesity management with:

• Print communication/online

• Email/electronic newsletter

• Review by account representative

• Review via opt-in webinars/video-on demand

• A Financial analysis on impact to client is conducted and provided

UHC Scores 85%: good job!

16

Physician Management

• Physician Monitoring

• Physician Obesity Management Support

• Physician Incentives

• Practice Support

UHC scores 90%: good job!

17

Physician Monitoring

Plan monitors that physicians are managing adults and

children >= 6 using the following:

• Electronic Medical Record and claims: Obesity screening

• Claims submitted by clinician: Obesity counseling/referral to

counseling

What other methods might be used? Chart Audits? Other?

18

Physician Obesity Management

Support

Plan support for practitioners assisting members with obesity management,

• Education/Information:

• Education on health plan program offerings,

• CME credit for obesity management education,

• Comparative performance reports (identification, referral, etc.),

• Promotes use of Obesity ICD-9 (278.0) and ICD-10

• Distribution of BMI calculator to physicians,

• Reminder to HCPs to 'turn on' BMI alert in EMR that calculates

automatically,

• Member-specific reports or reminders to screen

Excellent Support!

19

Physician Incentives and Practice

Support: Obesity

Incentives

• Incentives to conduct screening

• Incentive to refer to program or treat

• Plan reimburses for appropriate use of Obesity ICD-9 (278.0) and ICD-10 (E66.9, E66.01, E66.3 and E66.2) coding

Practice Support• The plan provides care managers and/or behavioral health practitioners

who can interact with members on behalf of practice (e.g. call members on

behalf of practice),

• Support for office practice redesign (i.e. ability to track patients)

Good incentives and support

20

Member Support

• Engaging Members

• Program Support

• Identifying Members

• Results (HEDIS)

21

Consumer Engagement

Incentives Related to Obesity Management:• Completing a Health Assessment (HA), (5.26% Complete PPO Health Assessment)

• Participation in weight-loss program (exercise and/or diet/nutrition)

Types of Incentives SupportedContingent on participation/completion:• Waive/adjust out-of-pocket payments for tests, treatments, Rx• Reduced Premium• Rewards (cash payments, discounts for consumer goods, etc.)Other• Waived or decreased co-payments/deductibles for reaching prevention goals,• Incentives to adhere to evidence-based self-management guidelines• Incentives to adhere to recommended care coordination encounters

Excellent work!

22

Member Weight Management SupportReal Appeal key program components include:• Weekly group coaching and discussion live over the Internet• On demand one-on-one coaching - live over the Internet• Tools to help support success based on individualized needs: Nutrition guides, meal

plans, recipes, shopping lists and tips for dining out• Video workouts and fitness guides• Entertaining and educational videos featuring popular celebrities and experts• Online support tools, including interactive website and digital applications• Online or mobile tracking tools to monitor nutrition and activity

Real Appeal reporting to customers on a quarterly basis.> Number of members who registered for the program> Engagement results, including the number of participants who attended 1+, 4+ and 9+ sessions> Weight loss results, including the following:

- Percent of members on track- Percent of members who lost three percent or more- Percent of members of lost five percent or more- Average pounds lost

Participant satisfaction ratings

Very comprehensive! How does this differ from the Diabetes Prevention Program? What are the results? 23

Identification

How does the plan identify members who are obese?

• Plan Health Assessment

• Employer/Vendor Health Assessment

• Claims/Encounter Data

• Disease or Care Management

• Wellness Vendor(Wellness Coaching programs are open to all individuals, whether or not they have stratified through one of the identification streams.)

However, using national data, 1.71% of the Plan's membership were identified as obese, and 29.66% of those identified as obese participated in weight management programs

3,552,041 members X 1.71% id’d X 29.66% enrolled = 18,01524

Obesity Results

For the PPO, all 4 obesity management HEDIS measures are

between the 25th and 50th percentile

1. Weight assessment and counseling for nutrition and physical

activity for children and adolescents- BMI percentile. (Total)

2. Counseling for nutrition

3. Counseling for physical activity

4. Adult BMI assessment

HEDIS Results very low.

25

Diabetes Adherence

• The Adherence Program

• Results

26

Diabetes Adherence Program

For CAD and diabetes, the Plan monitors all members on medication and acts on gaps in medication compliance with • Alerts to the patient, • Alerts to the practitioner, • Notification to telephonic coach• The Adherence Program provides physicians/providers with a member-specific

report for each non-adherent medication along with an introductory letterdescribing the program.

• The Refill Reminder Program targets members with automated HIPAA-compliant,

IVR refill reminder calls. Additionally, refill reminders can be sent to members

through text messages if members sign up for this service

Good adherence program! However…

27

Diabetes Adherence Results

The adherence to medication rate is measured as the percentage of patients 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80 percent during the measurement period. The PDC threshold is the level above which the medication has a reasonable likelihood of achieving the most clinical benefit; clinical evidence provides support for a standard PDC threshold of 80%)

Using this criteria, UHC was below the 25th %ile, meaning that 60-70% of patients met the 80% PDC criterion.

28

Diabetes Summary

• Obesity Management Program is good

• Obesity Identification is very low.

• Adherence Program is good.

• Adherence Results are low.

29

Specialty Drug Management:

The Five Rights

• Right Drug

• Right Price

• Right Place

• Right Data

• Right Support

• Scope of Specialty

Context: Percent of specialty drug spend out of all drug spend was estimated to be 30%. Percent of specialty pharmacy drug spend that is reimbursed under the medical benefit was 58% and the percent of specialty drug spend that is self-administered was 33%.

Overall: UHC does an excellent job. 93%

30

Right Drug

• Prior Authorization uses evidence-based medicine to evaluate appropriateness, severity, type of medication, frequency and duration of therapy.

• Off-label indications are not covered, unless there is substantial evidence to support the use. Additionally, medication claims with an unlisted JCodeare reviewed for clinical appropriateness and denied.

• Step Therapy steers members to less expensive, but equally effective, medications.

• Supply limits include quantity level limits (restricts amount of medication a member receives for a single copayment) and quantity duration limits (controls the quantity of medication dispensed per specified time period).

• Split fill applies to oral oncology medications and other select medications that have a high rate of discontinuation (due to adverse effects) within the first few months of therapy. This allows clinicians to assess members for safety/tolerability issues and to ultimately reduce medication waste and unnecessary costs.

• Currently, Plan has more than 50 pharmacogenomic testing requirements for specialty medications. Prescribers requesting these will need to provide proof of tests.

31

Right PriceResults from program respondent has implemented to reduce waste/inappropriate use of SPs was response from eValue8 2016 as Plan did not have time to provide results for eValue8 2017:

“Through utilization management programs, we have seen total savings of $3.70 PEPM. The therapeutic classes below have seen the following savings as a percent of their total class spend:- Growth Hormones: 60%- Infertility: 37%- Inflammatory Conditions: 13%- Multiple Sclerosis: 12%- Oral Oncology: 8%- Pulmonary Hypertension: 5%”

No outcomes based contract information was reported, as the Plan said the information is proprietary.

PMPM information is for TX market Pre-rebate Ingredient Cost:

• WBC Growth Factors- decrease in PMPM cost by $0.08

• PMPM for Oral Hepatitis C Medications was < $2.50 (large decrease by $1.20)

• MS Drug Therapies (PMPM costs decreased by $0.82)

• Oral oncolitics: (PMPM costs increased by $0.69)

• TNF Inhibitors: PMPM large increase of $1.51

32

Right Place

Channel Management (limiting acquisition by using specific suppliers)• UHC SP Network is not mandatory for Self-funded customers • Exclusive SP Network arrangement

– Provides more aggressive discounts for the medication – Members have access to patient education, adherence programs and clinical

management programs. – Self-funded customers may implement the specialty network on either a voluntary or

mandatory basis for members.

Site of care management/optimization (limiting site of delivery/drug administration)• Plan requires prior authorization before covering administration of Actemra, Entyvio,

Orencia, Remicade or Simponi Aria in an outpatient hospital site of service. • Physicians providing outpatient infusion therapy of these drugs in a hospital setting may

need to transition members to a different site of service when there is a clinically appropriate more cost-effective option available to continue benefit coverage.

How do you measure success in site of care optimization? By those measures, how are you doing?

33

Right Data

• Plan has initiatives require Providers to use NDC coding for

Specialty Pharmaceuticals (SPs) to improve monitoring and

tracking of utilization for reimbursement (changed by reviewer

from "optional "based on follow-up).

• Details: Specialty pharmacies currently bill medical benefit

drugs using NDCs and HCPCS code. As of January 1, 2017,

providers are required to submit NDC in addition to HCPCS

code

Please explain and discuss.

34

Right Support

For Hepatitis C, MS, RA, PAH, cancer and HIV the PPO monitors all members on medication and acts on gaps in medication compliance with

• alerts to the patient,

• alerts to the practitioner,

• notification to telephonic coach.

Role of the plan in reminder alert/ program;

• Proactively engage specialty medication users with refill needs through outreach of up to two calls prior to the anticipated refill date.

• Third call after the refill due date

• if still no response, fax is sent to prescriber to make sure medication therapy needs remain coordinated.

• Members are encouraged to use the text message reminders offered through Plan website to alert on refill needs, as well as when it is time to take a medication.

35

36

Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

•“If you aren’t focused on addressing the total cost of care, •you’re missing the boat.” – Dr. Robbins, CEO Texas Medical Center

Number of Units(Population Health Management)

Total Cost of

OwnershipUnit Costs

(Discounts)

Co

ntr

acte

d D

isco

un

ts

Pay f

or

Perf

orm

an

ce

Ris

k S

hare

OUR FOCUS: TOTAL COST OF CARE


Simpler consumer experience, better outcomes, lower costs.

Pla

n B

en

efi

ts PLAN DESIGN

STRATEGY

• CDHP 90% actuarial value• Gold/Platinum

• 90-80% actuarial value• Silver/Gold

•

38

General Discussion and Next Steps

Appendix 1: eValue8

UHC Performance Compared to

Benchmarks and Overall National

Observations

39

40

36.9%

23.9%

21.4%

32.4%

33.1%

30.1%

28.9%

33.1%

19.6%

8.8%

8.8%

18.9%

10.4%

9.3%

9.3%

9.3%

72.1%

68.4%

93.7%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Provider Management & Measurement (158.5 points)

Hospital Management & Payment Reform Physician Management & Payment ReformSupport to Help Patients with Chronic Conditions Support to Help Patients Stay/Get Healthy

Physician & Hosp. Mgt. & Measurement (22% of RFI points)

Highlights of Top Performance

Observed Opportunities

Hospital Management & Payment Reform(37% of Module)

• Robust programs and networks, measurement and contracting/ management for hospitals and transparency•Greater % in VB payments

• Lower all-cause readmission rate• Leapfrog: increase # reporting hospitals;

shift admission from lowest quartile hospitals to highest quartile hospitals

• Increase % $ in Non-FFS Value Payments

Outpatient/Physician Mgmt & Payment reform(36% of Module)

Robust programs and networks, measurement and contracting/ management for physician, info to steer members and transparency

• Increase % $ in Non-FFS Value Payments• Information on specialist and hospital

quality for PCPs at time of referral• Use of broad range of measures in

payment and reporting

Support to Help Patients with Chronic Conditions(19.6 %of Module)

Robust support to help manage high-risk and members with depression. Monitoring of prescribing for antidepressants, sleep & pain medications

Support and monitoring of non-BH practitioners (PCPs) in management of depression and prescribing

Support to Help Patients Stay/Get Healthy(10.4%of Module)

Robust monitoring of physicians re: USPSTF screenings and support to PCPs to manage tobacco cessation and weight management

Level of support to physicians to be on par with support for chronic conditions in education/information, reports, incentives and practice support

42

25.4%

4.8%

9.0%

19.7%

19.9%

19.9%

19.9%

19.5%

16.7%

15.0%

15.0%

13.6%

13.2%

11.4%

12.1%

11.8%

13.2%

13.2%

13.2%

12.6%

11.5%

7.2%

7.1%

9.5%

71.5%

76.3%

86.7%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Helping Members become Good Consumers (143.5 points)

HEDIS and CAHPSPerformance

Shared Decision-Making andTreatment Option Support

Addressing language andhealth literacy needs

Price Transparency - HelpingMembers Pay the Right Price(Understand Cost)Hospital and COE ChoiceSupport

Help Finding the Right Doctor

Helping Members Become Good Consumers(20% of RFI points)

Highlights of Top Performance Observed Opportunities

HEDIS & CAHPS(25% of Module)

Strong performance on overused procedures

CAHPS composite measures

Shared Decision Making (SDM) and treatment Option Support (TOS) (20% of Module)

Mobile apps, SDM includes telephonic support, identification of members who would benefit from SDM and evaluation of tool

• Integration of cost calculator• Assessing user satisfaction• Low utilization rates

Addressing language and health literacy needs(17% of Module)

Robust health literacy and cultural competency policies/programs, capture of member demographics, use of data, eval. of activities

Support of members with limited English proficiency

Price Transparency(13% of Module)

Comprehensive cost calculator, regional/provider avg paid and contracted rates, >75th %ile rating on plan cost

• CAHPS rating of Plan cost information

• Limited functionality & acct mgmt.• Low utilization rate

Hospital and COE Choice Support(13 % of Module)

• Robust tool, and evaluation• Strong incentives for use of COE with

steerage and cost/quality results

•See SDM•Steerage and cost/quality results

Help Finding the Right Doctor(10.4% of Module)

Strong Network & plan demographics, directory & tool with evaluation, comprehensive telehealth

• See SDM• Directory indexed & searchable• Network demographics

44

45.2%

11.2%

30.2%

38.2%

31.1%

21.0%

21.5%

26.1%

13.0%

3.4%

7.2%

8.8%

10.7%

6.1%

6.1%

3.0%

41.7%

65.0%

76.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Helping Members Manage Chronic Conditions (135 points)

HEDIS: CAD andDiabetes

Member Engagement- CAD and Diabetes

HEDIS: BehavioralHealth

Member Engagement:Behavioral Health

Helping Members Manage Chronic Conditions(19% of RFI points)


HEDIS: CAD and Diabetes(45% of Module)

> 90th percentile in both CAD measures; strong performance on Diabetes measures

Low HbA1c Testing rate

Member Engagement -CAD and Diabetes(31% of Module)

• Comprehensive technology, and benefit designs to support programs

• Robust adherence monitoring with adherence rates >90th percentile for all 3 listed drug classes

• Appropriate management of cholesterol in patients with CAD

• Adherence rate

HEDIS: Behavioral Health(13 %of Module)

• Strong performance (>75th and 90th

percentile) on 3 MH Measures and >50th

percentile on remaining 2 measures• > 50th and 75th percentile on 2 of 3 alcohol

measures

•Alcohol Initiation measure• Low % members receiving

MH and/or alcohol and other drug dependence services

Member Engagement: Behavioral Health(11% of Module)

• Comprehensive adherence monitoring for depression and SU medications and coverage and benefit design for alcohol & SU meds

• No barriers to access SU medications

Comprehensive adherence monitoring coverage for alcohol & SU meds

46

47.3%

18.3%

39.4%

39.4%

27.4%

18.0%

18.0%

18.0%

11.6%

9.0%

11.0%

11.0%

8.7%

8.7%

8.7%

8.7%

5.0%

4.6%

4.6%

4.6%

58.5%

81.7%

81.7%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Helping Members Stay/Get Healthy (120.5 points) Prevention Programs HEDIS & CAHPS

ResultsPrevention and Treatment of TobaccoUseObesity/Weight Management


Health Assessments (HA)

Helping Members Stay/Get Healthy (17% of RFI points)



Prevention Programs HEDIS & CAHPS Results (47% of Module)

Strong performance (>75th and 90th percentile) on cancer screening, immunizations and well care and health promotion

CAHPS NA or low rating of Plan internet materials

Prevention and Treatment of Tobacco Use (27% of Module)

Comprehensive interventions and coverage of Rx at no member OOP

• Low id and participation rates and • HEDIS

48

39.1%

22.2%

19.9%

35.8%

33.5%

31.2%

31.2%

26.8%

27.3%

13.2%

11.1%

23.2%

66.6%

62.2%

85.8%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Pharmaceutical Management (80.5 points)

Generic & Appropriate Drug Use Specialty Pharmaceuticals Quality and Safety: Outpatient Prescribing

Pharmaceutical Management (11% of RFI points)



Generic % Appropriate Use (39% of Module)

• High use of generics • >90th percentile in overuse of

antibiotics of concern measure

• 90th percentile rate for overuse of antibiotics is 43.9% - room for reduction in rate

Specialty Pharmaceuticals(34% of Module)

• Accreditation• Comprehensive management

of SPs (split fill, genomic testing, channel management) and adherence monitoring

• Transparent reporting for PMPMs

• Accreditation for specialty pharmacies• Fewer plans use site of care

management• Requiring use of NDC for

reimbursement• No third party specifications for SP

Management• Varying numerator and denominator

for PMPM • Few Outcomes based contracts

Quality and Safety: Outpatient Prescribing(27 %of Module)

• Excellent performance on HEDIS drug indicators

• Monitoring and acting on drug conflicts and opioid misuse

• Medication Management for People With Asthma: Medication Compliance 75%

• Opioid misuse (range =0.09% – 17%; average = 4.8%)

• Mechanism to track primary non-adherence

25

50

47.2%

28.1%

37.0%

35.8%

39.6%

33.7%

33.7%

39.6%

13.2%

13.2%

13.2%

13.2%

75.0%

83.9%

88.7%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Business Profile (53 points)

Accreditation and CAHPS Performance Client Support and Collaborative Practices Health Management

Business Profile(7% of RFI points)



Accreditation and CAHPS Performance (47% of Module)

• Accreditation Level of Commendable or Higher

• PHQ Certification• Average or better on CAHPS

rating for Plan and Care received

• No Accreditation • Other accreditation/certification

beyond Plan accreditation e.g., PHQ

Client Support and Collaborative Practices (40% of Module)

National and Local collaboration activities beyond agreement on common measures – all payer claims, CMS HCPLAN

Active support of and participation in local coalition activities

Health Management(13 %of Module)

Comprehensive programs for health management, transitions/care –coordination in medical management (norm)

Increase membership who have a PCP (range was 6% to 90%)

52

81.0%

49.0%

54.0%

54.0%

19.0%

19.0%

19.0%

19.0%

68.1%

73.1%

73.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Possible Best

UHC TX PPO

UHC RI PPO

Benchmark

eValue8 2017Helping Members Manage Acute/ Episodic Conditions and Care (21points)

Obstetrics and Maternityand Child


Helping Members Manage Acute/Episodic Care (3% of RFI points)


Obstetrics and Maternity and Child (81% of Module)

• Strong performance on HEDIS measures (>75th and 90th

percentile)• Comprehensive support for

deliveries (e.g., systematic screening for postpartum depression (PPD), Mid-wives credentialed and available for use as primary provider, Coverage for home health nurse visit post-discharge)

• Comprehensive pre-conception counseling services

• Report on rate of elective deliveries•Decrease C-section and NICU

admission rates• Increase VBAC rates• Providing information on C-

sections and VBAC as part of pre-conception counseling• Systematic screening for PPD

Alignment of Plan Design(19% of Module)

Plan designs/incentives to encourage shared decision-making and use of more cost-effective treatment alternatives

•Use of other broader incentives beyond rewards (e.g., waive out-of-pocket or reduce premium share)• Generally fewer plans use

incentives to encourage use of more cost-effective treatment alternatives

Appendix 2: UHC

Diabetes Prevention

54

Broad application.

• Available to members at no additional cost.

• Integrated into customer service, clinical and online experiences.

• Benefit designs based on Premium designation.

Recognition.

Received the National Committee for Quality Assurance (NCQA) program Physician Quality (PQ) certification and meets the Consumer Purchaser Disclosure Project’s Patient Charter standards.

55

The UnitedHealth Premium program:

Recognizing quality and cost efficiency.

Quality and cost transparency.

• Launched in 2005, one of the first in the industry to designate physicians for quality and cost efficiency.

• National industry, evidence-based and specialty society standards.

• Evaluates doctors on more than 75 conditions and 240performance measures.

• Physicians must first meet quality criteria to be eligible for cost-efficiency evaluation.

Access.

• Accounts for more than 80% of all medical costs.*

• Includes primary care physicians and specialists.

UnitedHealth Premium Designation Program

*Savings estimates based on UnitedHealthcare's 2015 analysis in 164 markets.

56


The eSync Platform® integrates

member clinical data

• The eSync Platform helps reveal links among decisions, costs and

outcomes – providing a strong foundation for focused intervention.

• Our eSync Platform technology constantly monitors 100% of the member population to

synchronize

each member’s individual clinical data for our identification and intervention processes.

Medical andvision claims

Lab results

Pharmacydata

Health assessments

Networkutilization

Persistent member engagement

Care provider engagement

Total population monitoring

Personal action plan

Health coaching

Uniting clinically proven

science with a

transformation coach and

engaging content.

57

Real Appeal

A Success Kit

Entertaining and aspirational messaging

Weekly group classes

One-to-one personalized consultation

Digital support and tracking

The Real Appeal weight-loss program helps members prevent disease, change behavior and

save on medical expenses.

An integrated care team using our

Disease Management nurses to help

close gaps in care and improve

clinical outcomes.

58

Clinical assessment

Inbound/outbound nurse calls

Appointment scheduling and referrals

Medication management

Provider search

Pharmacist on care team*

Support to manage risk factors

*Only applies to those using OptumRx® as their pharmacy benefit services provider.

Comprehensive Diabetes Solution

Communication/content example.

59

Appendix 3 : UHC

Specialty Pharmaceuticals

60

Driving better experience, health

and cost controlBetter Experience

Whole-person Care

Better HealthRight Support

Better CostsRight Drug

Strategies to control specialty costs

• Strategic Exclusions

• Formulary Strategies

• Prior Authorization

• Step Therapy

• Supply Limits

• Price Protection

Using a 360˚ view to go beyond specialty pharmacy

One care team engages on:

• Condition Management

• Wellness

• Behavioral

• Adherence

• Lower cost Rx options

Online resources and videos

Condition,clinical, lifestyle Support

Side effect management

Tracking impact of intervention

Measuring disease progression

61

Site of Care Optimization

Infusion SuiteIn Home

Specialty Infusions

Onsite Support

Consumer Convenience

Access to Care

Consumer Consultation

Quality Outcomes

Improved consumer satisfaction and experience as a result of payment consistency, adherence to care, better therapy management

Benefits of Site of care optimization

62

BriovaRx Therapy Solutions

Establish care and partnership

Ongoing support and interventions

Optimize connections

Consumer Coordination• Onboarding/refill processing• Consultation, BriovaLive, BriovaCommunity offerings

Medication Counseling• Initial consultation focused on education, adherence

and side effect strategies, and training• Ongoing consultations includes counseling as needed

Disease Management• Ongoing condition consultation at appropriate intervals

includes depression screening, disease-specific assessment, other disease management techniques

Specialty Synchronization• Identifying gaps in care through rules-based edits

running against medical data• Targeted consultation based on identified gaps in care

Specialty Care Management• Holistic care management focused on specialty conditions

63

Consumer-focused Holistic Care

Pharmacist Video Consultations

Condition Videos

Web, App & Text Support

64

65

Contact Information

National Alliance

John [email protected]

Foong-Khwan [email protected]

uhc ppo texas evalue8 2017 site visit - houstonbch.orgthe evalue8 process is used to: –articulate...

Documents