UnitedHealth Center for Health Reform & Modernization September 2014

Transcription

1 Health Reform & Modernization September UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.

2 Overview Why Focus on Primary Care? Advanced Service Delivery and Payment Models Assessing Value and Capacity Approaches to Expand Access and Target Capacity Building Blocks for Bolstering Capacity Summary of Solutions Please note that all sources are available in the Report at unitedhealthgroup.com/modernization Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 2

3 Why Focus on Primary Care? Primary care is the foundation of the U.S. health care system High value of primary care Accessing primary care is a major challenge for many individuals 55% of over 1 billion physician office visits annually 6% 8% of national health care spending ($200 - $250 billion annually) The ACA could generate 25 million additional visits each year Central to effective treatment and efficient care delivery Emphasis on preventive services Core element in advanced care delivery models Lack of capacity and access in rural areas and low-income communities 70% of ER visits by commercially insured individuals are non-emergencies Practical, proven, and scalable solutions exist in the marketplace to advance primary care delivery Read the Complete Report at unitedhealthgroup.com/modernization Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 3

4 Avoidable hospital emergency department visits per 1,000 Assessing Value and Capacity A higher concentration of primary care physicians is related to: Lower rates of mortality More effective preventive care Fewer avoidable admissions Fewer avoidable emergency department visits Less use of costly and often not more effective high-technology diagnostic imaging Avoidable Hospital Emergency Department Visits and Primary Care Physician Supply Primary care physicians per 100,000 Demand for primary care is growing due to: An aging population Increases in chronic conditions Reduction in uninsured population Consumers looking for more convenient ways to access care, including extended office hours and electronic communications Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 4

5 Assessing Value and Capacity Some areas of the country, including the West and the South, face greater challenges in ensuring primary care capacity in the coming years Primary Care Challenge by County, 2014 Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 5

6 Income level Providers per 100,000 Providers per 100,000 Assessing Value and Capacity Primary care physicians are more concentrated in areas with higher household incomes and lower uninsured rates, while nurse practitioners and physician assistants are more concentrated in these underserved areas Primary Care Physician Supply and Median Household Income Primary Care Physician Supply and Non-Physician Primary Care Provider Supply Decile for supply of primary care physicians, by HRR Primary care physicians per 100,000 Median household income Decile for supply of primary care physicians, by HRR Primary care physicians per 100,000 Non-physician primary care providers per 100,000 Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 6

7 Building Blocks for Bolstering Capacity Diverse Workforce Multi-Disciplinary Teams Health Information Technology (HIT) Over 190,000 nurse practitioners (NPs), as well as other clinicians, can increase primary care capacity Evidence indicates high quality of primary care delivered by NPs A primary care physician with a panel of 2,000 patients would need to spend 17.4 hours per day providing recommended care Integrating NPs and other providers into team-based care can allow practices to double the number of patients they see Practicing in teams increases the satisfaction of primary care physicians Broader implementation of HIT, including Electronic Health Records (EHRs), increases system-wide quality and care coordination Lack of interoperability prevents effective data sharing Cost of adoption and ongoing support is a challenge for smaller practices Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 7

8 Advanced Service Delivery and Payment Models Paying for value incents higher quality care instead of a greater volume of services Fee-For-Service (FFS): Value-Based Payments Encourages providers to deliver a greater volume of more costly services Fails to promote high-quality services and care coordination across providers Contributes to failures in care delivery, including overtreatment and wasteful health care spending Models using FFS rather than value-based payments have struggled to achieve success Shift away from payments based on the quantity and intensity of services delivered Reward high-quality and effective care rather than higher volume of more complex services Include multiple approaches that allow payments to be tailored to the diverse capacities of providers Advanced Service Delivery Models Medical Homes and Accountable Care Models: Multi-disciplinary care teams Health information technology Focus on care coordination Treating the whole patient Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 8

9 Advanced Service Delivery and Payment Models Medical homes that transform care delivery and pay for value have improved quality and reduced costs Medical Home Outcomes in Colorado, Ohio, and Rhode Island* 6 to 1 return on investment for care coordination activities Improved diabetes management 6.2% net savings on third-year medical costs Improved patient satisfaction Reduced avoidable hospital stays Increased care coordination Medical home models don t always succeed. A common factor in many successful models is paying for value through measures of quality, outcomes, and appropriate utilization *UnitedHealthcare Medical Homes Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 9

10 Advanced Service Delivery and Payment Models Accountable care models that pay for value have improved outcomes and reduced costs for commercially insured members Successful ACO Models Have Implemented Electronic Health Records Evening and weekend hours Disease management programs Data analytics to show where and what services their patients use outside of the ACO Payment linked to cost and quality Cost and Quality Improvements Better performance on 10 health quality metrics including: Medication adherence Blood sugar screening and control Breast and cervical cancer screenings In Order to Increase care coordination Promote best practices Reduce duplication of services Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 10

11 Advanced Service Delivery and Payment Models Accountable care models that pay for value have increased quality and reduced costs for Medicare beneficiaries Identify individuals for disease management programs, using risk analysis: Diabetes Congestive Heart Failure COPD Kidney Failure Determine care management, using multi-disciplinary teams A Care Navigator: Maintains contact with the patient Triages care needs and appointments Of CMS 32 Pioneer ACOs, Monarch Healthcare: 1 st in select quality measures Physician communication with patient Overall patient satisfaction with their physician Prevention of admissions for ambulatory sensitive conditions Change in Total Medicare Spending nd in overall cost containment 5.4% reduction in Medicare spending Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 11

12 Approaches to Expand Access and Target Capacity Leveraging retail clinics to expand and target capacity Characteristics of Retail Clinics Conveniently located Offer more hours than primary care physicians Offer services for a variety of common, nonemergent conditions Leverage non-physician providers Increasingly use Electronic Health Records that connect to primary care physicians Accept most private and some public insurance Offer transparent prices for uninsured individuals and families Quality and Cost Performance has been comparable to other primary care settings, and better than emergency departments Lower costs for treating common illnesses than physician offices, urgent care centers, and emergency departments Retail clinics are investing in new infrastructure to ensure interoperability for EHRs and greater clinical integration into primary care delivery Retail Clinic Visits Annually Million 10 Million ½ of visits occur when physician offices are closed 43% of retail clinic patients are ages 18 to 44 Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 12

13 Approaches to Expand Access and Target Capacity Utilizing Group Visits Outcomes Small groups of 5 to 20 patients sharing common conditions Includes individual appointments with clinician and group education sessions Have been used for prenatal care and chronic conditions such as diabetes Reduce hospital admissions and emergency department visits Increase patient satisfaction Improve patient outcomes Share of Family Physicians Utilizing Group Visits 2005 and 2010 Sessions Activate and engage patients Provide community support Learn lifestyle management Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 13

14 Approaches to Expand Access and Target Capacity Reaching patients where they live: Delivering primary and preventive care through home visits Conduct clinical assessment Observe home environment Adjust plan of care as needed Care management program providing annual in-home clinical visits 45 to 60 minute appointments with a physician or nurse practitioner Plan of care shared with both patient and primary care physician Educate patient on treatment plan Outcomes: Leads to needed follow-up encounters and closes gaps in care. In 2013, among UnitedHealthcare Medicare Advantage members receiving a HouseCalls visit: o Nearly two-thirds (64%) received a follow-up service under Medicare within 30 days o There was a 5.1% increase in colorectal screening and a 6.9% increase in breast cancer screening Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 14

15 Approaches to Expand Access and Target Capacity Leverage data to identify individuals with complex conditions and high expected costs Super-utilizers often have mental illness and face fragmented home and community environments Payment models should reflect the underlying analytics and encourage bundles of services tailored to defined patient subgroups Why focus on super-utilizers? 5% of people are super-utilizers in any one year Super-utilizers account for 50% of health care costs each year 38% of super-utilizers will be super-utilizers in the following year Super-Utilizers as Share of the Population in a Single Year and the Following Year Super-Utilizers as a Share of the Population and of Health Care Costs 5% of people are super-utilizers Single year superutilizers 62% Superutilizers in the following year 38% 95% 50% 50% 5% Population Health care costs Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 15

16 Summary of Solutions There is no single model to successfully expand primary care capacity and improve service delivery. Multiple, complementary pathways can be tailored to local market conditions and policy environments Leveraging the building blocks: Combining advanced service delivery models and value-based payments: Additional approaches to expand access and better target capacity: Diverse clinician workforce Multi-disciplinary care teams Health information technology Medical homes Accountable care organizations Reimbursement models that pay for value over volume Retail clinics Home visits Group visits Engaging complex patients Read the Complete Report at unitedhealthgroup.com/modernization Health Reform & Modernization 2014 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 16