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Ronald J Shumacher, MD FACP CMD Chief Medical Officer, Optum Complex Population Management ©AAHCM.

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Presentation on theme: "Ronald J Shumacher, MD FACP CMD Chief Medical Officer, Optum Complex Population Management ©AAHCM."— Presentation transcript:

1 Ronald J Shumacher, MD FACP CMD Chief Medical Officer, Optum Complex Population Management ©AAHCM

2 Ronald J Shumacher MD has the following financial relationship to disclose:  Employee of: Optum Services, Inc. ©AAHCM

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4 Exhibit 4 NOTE: Excludes SNPs, employer-sponsored (i.e., group) plans, demonstrations, HCPPs, PACE plans, and plans for special populations (e.g., Mennonites). Other category includes cost plans and Medicare MSAs. SOURCE: MPR/KFF analysis of CMS’s Landscape Files for 2007 – Distribution of Medicare Advantage Plans by Plan Type,

5 Greater focus on quality performance and outcomes evaluation HEDIS measures tied to revenue Financial incentives and brand identity critical to business Care coordination and management Shifts from fee for service to pay for performance and accountability Member outreach and engagement Integrated clinical data at point of care Improved coordination of services and accountability Clinical quality and STARs MA Plans face margin pressures and revenue management needs Convergence of closing gaps in care at point of service Compliance: EDPS and RADV Risk adjustment Medical expense management Health Plan Performance Admission and Re-admission prevention Post-acute and end-of life care SNF LOS management Network/Contracting ©AAHCM

6 The most expensive members offer the biggest opportunity for savings; however, these patients require a home-based care program. % 5% of the population drives 50% of the medical spend The high cost 5% of the population are generally on an erratic course These patients take more medications, see their provider more and utilize the ER three times per year on average Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue 19. AHRQ Publication No , June Agency for Healthcare Research and Quality, Rockville, MD. Members do not regularly engage with or look to payer for health support or management ©AAHCM

7 Consider the unique demographics of MA plan populations — 10% of the population averages at least one hospital visit per year and accounts for 30% of the spend Hospital Admits ER Visits Risk Score % of Population Hospital Visits/Yr ER Visits/Yr # Chronic Diseases$PMPM % of Cost <0.7050% $33021%.71 to % $71033% 1.46 to % $1,19015% 2.06 to 2.755% $1,64011% >2.755% $2,74020% Source: Nationwide Medicare 5% Sample ©AAHCM

8 Tompkins et. al. Population Health Management in Medicare Advantage; Health Affairs Blog, April 2013

9 Identify the problem being solved Determine how it is applicable to MA plans Understand the environment in which you’ll provide care (geography, etc.) Needs Assessment Implementation Plan Value Story Propose a clinical program/model Review of contract by legal Develop a road to deployment (e.g., staffing, certification, filing, delegation agreements, credentialing, etc.) Identify/align on early indicators and analytics Determine program monitoring Develop a proven ROI (e.g., executive summary, affordability analysis, ROI & quality metrics) Provide a MA Health Plan health care economics analysis Determine if there is a need to take on risk Have a willingness to contract and get credentialed with the health plan ©AAHCM

10 Member outreach and engagement Identification of members and risk stratification Demonstrate value / ROI Capture of quality and encounter data Develop clinical care model (e.g., visit types, how to manage the most challenging patients) ©AAHCM

11 Case rate (PEMPM) Capitated payment (PMPM) Gain sharing with quality metric goal(s) Full risk/percent of premium Reimbursement Structure Low health care utilization (e.g., admissions, readmission, emergency department, etc.) Manage quality measures, including STARs, HEDIS Accurate documentation/coding Simple way to share data Profitability Management ©AAHCM

12 ChallengeRisk mitigation strategies Identification and stratification Algorithms that accurately reflect implications of regression of the mean Member outreach and engagement Specialized outreach teams to manage engagement Member compliance with care plans Partner home care medicine providers with telephonic case management support Collaboration with MA Health Plan case management and other programs Establish clear criteria, communication and handoffs Navigating MA Health Plan networks Emphasize communication with network providers and provide documentation Managing operational metrics Rigorous management oversight and tracking tools Data capture and trackingRobust EHR and reporting/analytics ©AAHCM

13 Ronald J Shumacher, MD FACP CMD Chief Medical Officer, Optum Complex Population Management ©AAHCM


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