1. Gregory James, DO, MPH Washington DC
OptumCare Overview
Gregory James, DO, MPH
Washington DC
November 29, 2017

2. Presented at the National Academy of Sciences, Engineering, and Medicine
“Financing and Payment Models to Support Delivery of High-Quality Care
for People with Serious Illness”
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3. “Helping to make the health system work better for everyone”
Provides care services to those with UHC and other managed care plans
Health Services
Health Benefits
“Helping people live healthier lives”
Pays the claims
Contracts with and credentials providers
Makes the product available to employers and the general public
100,000+ Employees
OptumHealth
Optum Advisory
Services
OptumRx
Our business landscape:
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4. Optum: Connecting and serving the health system
150 global
Life Sciences Organizations
4 of 5 U.S.
Hospitals
300
Health plans
Half the Fortune 500
Employers
31 U.S states, Many U.S. federal and global
government entities
67,000
Pharmacies
115 million
Individuals
Creating a
Healthier
World
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5. Meet OptumCare (A Division of OptumHealth)
Care Delivery designs and manages physician-centric delivery systems, touching over 2 million consumers
Complex Care Management (CCM) delivers in person care to patients with complex conditions in nursing homes and in the community
Physicians
OptumCare
SKILLED NURSING
MedExpress operates over 150 neighborhood health care centers offering urgent care and primary care services in 14 states
HouseCalls performs in-home health assessments to better understand patient needs, close gaps in care and improve health
Urgent Care
Home Visits
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6. Current state: Scope of the problem
The first 30 days post-discharge from an acute setting is a critical time period that can result in a costly avoidable readmission
elderly patients is readmitted to the hospital within 30 days of discharge.1
1 in 5
Primary care physicians spend a relatively small amount of time in SNFs, and when they do they often have to see many patients in a limited amount of time.
of Medicare beneficiaries discharged to a post acute setting
Half of these enter a nursing home. 1
40%
Cost to Medicare
per year in potentially avoidable readmission costs.1
$17 billion
more
than
1. Vincent Mor, Orna Intrator, Zhanlian Feng and David C. Grabowski, The Revolving Door Of Hospitalization From Skilled Nursing Facilities, Health Affairs, 29, no.1 (2010):57-64
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7. Transitions to SNF: Midwest Outcomes
Within one year of post-acute management, the partnership between Optum and an existing Midwest client have driven significant results1:
350+ members managed
20% reduction in length of stay
52% readmission reduction
Each readmission can save up to $15,000
Quality documentation that drives coding accuracy and completeness
Gap closure to support STAR and HEDIS metrics
Proactive, preventive, treat in place model
Reduces readmissions in Hospital to SNF and manages LOS effectively
22 days
17.5 days 9%
Average length of stay
Readmission rate
Post implementation of Optum TTS
A Medicare Advantage Plan baseline
2016 Achieved results with an Optum Hospital to SNF program in Midwest market. Data compiled by Optum Data Analytics
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8. Transitions to SNF: East Outcomes
Post implementation of Optum Transitions to SNF program, the partnership between Optum and an East coast client drove significant results1:
43% reduction in length of stay
33% readmission reduction
Quality documentation that drives coding accuracy and completeness
Gap closure to support Star and HEDIS metrics
High family satisfaction
Improved discharge planning
Reduces readmissions in Hospital to SNF and manages LOS effectively
23 days
13 days
8.3%
Average length of stay
Readmission rate
Post implementation of Optum TTS
A Medicare Advantage Plan baseline
2013 Achieved results with an Optum Hospital to SNF program in East market. Data compiled by Optum Data Analytics
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9. Spotlight on Length of Stay (LOS) Savings
Not every member will be readmitted, but every member will incur a length of stay. An extensive length of stay, past clinical necessity, can cost significant dollars!
The tables below illustrate the potential cost savings to a health plan as a result of implementing the Transitions to SNF program, and seeing a 20% reduction in readmission versus a 20% reduction in length of stay (LOS) with a member pool of 100 members.
Readmissions
Baseline - 20% 20
Post TTS - 16% 16
Readmission Reduction 4
Avg. cost per admission
$20,0002
Total Cost Savings
$80,000
Length of Stay (LOS)
Baseline days
$1,025,000
Post TTS - 20 days
$820,000
LOS Reduction - 5 days
Avg. cost per day/per mbr
$4101
Total Cost Savings
$205,000
Existing client results. Data compiled by Optum Data Analytics.
Internal outcomes study on acute readmissions. Data compiled by Optum Data Analytics .
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10. Transitions to SNF overview: A path to recovery
Patient Identified
OptumCare Advanced Practice Clinician (APC) assigned
Providing quality care with early emphasis on discharge planning
Monitoring for changes in condition
Initial visit/touch within 24 hours
Family Support Caregivers
Care coordination and collaboration
Ensures smooth transition back to community providers
Physician
SNF staff
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11. TTS Model of Care: Focus Areas
Areas of focus produces timely, high quality, evidence-based clinical care
Initial contact within 24 business hours
Visit frequency to ensure successful transition to SNF, and then to home
Visit frequency based on member acuity; minimum of 2 visits per week, days minimum of 1 visit every 5 days until discharge
Intensity of visits based on clinical needs and indication of member’s status
Attending Physician collaboration occurs during the SNF stay
Collaboration with SNF partners PT/OT/ST/ dietary/wound care
Specialist care coordination as needed
Collaboration and engagement of the member and family around discharge and ensuring safe discharge plan
Discharge planning starts on day one
Treat in place model for acute issues preventing avoidable readmissions during the SNF stay
After discharge to home, referral to Post discharge program, for successful transition to home, and readmission prevention post discharge
Ensure safe discharge plans in place prior to leaving facility
Engagement
Collaboration
Transition Management
Quality of Care
Quality gaps in care closed during SNF stay
Comprehensive diagnoses coded to highest level of specificity
APC management and driving a safe discharge
Medication Reconciliation Post-Discharge (MRP) and transition assessment completed as the member is discharged to home
Ensuring services are ordered and in place for post discharge care (PT/OT/ST/HH nursing/wound care)
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12. The Benefits of Transitions to SNF
Proven success and satisfaction for patients
Since 1987, OptumCare has been an innovator, within an expansive network, in changing the approach to clinical care to improve quality care in skilled nursing facilities and has a long and consistent track record of rapid implementation, early and substantial impact, strong outcomes, and satisfied customers
Improving LOS Management
Clinically managing members to the appropriate length of stay needed. Reducing SNF length of stay by one day saves as much as $410 per patient1
Avoiding readmissions for members
Breaking the cycle of avoidable readmissions, reducing readmission rate. Each prevented readmission could save as much as $20,000 per patient1
Comprehensive coding
Quality documentation that drives coding accuracy and completeness
Gap Closure
OptumCare care teams are committed to quality care and gap closure that address STAR and HEDIS measures.
Internal outcomes study on acute readmissions. Data compiled by Optum Data Analytics
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13. Institutional Special Needs Plan (I-SNP)
Delivering a coordinated care model for Medicare nursing home long term care (LTC) residents

14. An Enormous Opportunity to Deliver Better Care for Medicare’s Most Expensive, and Frail Population
1.5 million
Medicare beneficiaries live in a skilled nursing facility (SNF)
SNF-based beneficiaries are more expensive than the average beneficiary 2x
51%
of SNF-based Medicare beneficiaries had one or more ER visits
(vs. 28% for non-SNF beneficiaries), and had at least one hospitalization (vs. 19% for non-SNF beneficiaries)
33% 3%
Only (or about 50,000) of these SNF residents are enrolled in a private Institutional Special Needs Medicare Advantage plan today
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15. High Costs Are Driven by a Broken Clinical Model for SNF Patients
AVOIDABLE HOSPITALIZATIONS AND ER VISITS DRIVE SIGNIFICANT COST in the medically complex population and there are a variety of factors responsible for the unnecessary utilization:
Primary care physicians generally spend a relatively small amount of time in SNFs, rounding infrequently, instead managing most of their patients remotely via telephone or faxes.
The time constraint also results in poor communication and coordination with SNF staff, covering physicians, and specialty providers.
Important care elements such as advance directives, goals of care or polypharmacy issues are often not adequately addressed.
Challenging SNF staffing leads to higher case loads creating fragmented and uncoordinated care.
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16. Optum is the Leader in Serving Long Term Residents in SNFs
25 year
track record of superior quality and outcomes and clinical model innovation (originally known as Evercare)
50,000 #1
provider in I-SNP with nearly patients enrolled,
representing share of the total market
80%
1,145
High touch, integrated care model with employed Nurse Practitioners
1,300
Relationships with SNFs nationwide, including both large national and small local players
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17. High-Touch Integrated Care Model
The Nurse Practitioner: Coordinator of the Care Model
Nursing Home resident enrolls in ISNP
Optum Nurse Practitioner provides In-Facility care
Collaboration with and augmentation of the PCP
Ongoing family education and engagement
Comprehensive Care coordination while enrolled in ISNP
Business office
Facility administrator A
Optum medical director
Family support
Resident
Optum nurse practitioner
Director of nursing home D
Social services c
Primary care provider
NP = coordinator and collaborator
Program overseen by local Optum market team
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18. Our Plans Also Provide Unique Benefits Above and Beyond FFS, and Further for Dually Eligible Members
Medicare +
Medicaid
Additional plan benefits . . .
No copayment on . . .
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19. Differentiated Cost, Quality and Satisfaction Outcomes
50%
We improve quality while reducing costs by for our members
40%
We have reduced hospitalizations by and ER admissions by nearly
50%
63%
of our members are estimated to be in 4.0+ STAR plans effective 1/1/16
98%
Member satisfaction with our plans has consistently approximated
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20. Gregory James, DO, MPH Senior Medical Director / OptumCare
Complex Care Management (CCM)
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