Transcript Presentation Title - The Commonwealth Fund

Driving Quality and Affordability in a
Consumer-Focused World
Lewis G. Sandy M.D.
Bipartisan Congressional Health Policy
Conference
January 13, 2007
Confidential property of UnitedHealthcare. Do not distribute or reproduce without the express permission of UnitedHealthcare.
The Affordability Crisis: Diagnosis
• Cost increases are intrinsic to the delivery system:
 Technology advancement
 Baumol’s Disease (slow productivity improvement in service
sector)
 Induced Demand
 Poorly functioning markets (for information, for care)
• Latest employer response: consumer cost-sharing
 Has potential as a game-changer (but not by itself)
• Beware the single “magic bullet”:
For every complex problem there is an
answer that is clear, simple and wrong.
H.L.Mencken (1880-1956)
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2
The Way Ahead: Empowering Consumers
(and their physicians) with information
• Not all healthcare is the same
• Physicians may not know how they are doing
• Consumers want information, may not know how to get it, or how to
best use it
• We need to turn raw data:
 First, into useful information
 Second, into an “operating system” for improvement
Elyria has three times the rate of angioplasties of Cleveland, 30 miles away (8/18/06)
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3
Turning Data into Improvement:
4
Network
Management
e
Analytics
Eligibility
Clinical
Claims
Network
Cost
Pricing
Data and Clinical
Expertise
 “Ingenix inside” – The most
comprehensive set of
clinical data in the industry
 We collaborate with
medical societies to ensure
we incorporate the latest
science on quality and
effectiveness
 Supports every program
we develop
Common
Clinical
Data Set
Tools
Clinical
Management
Expertise
Applied to Care Delivery
 Target high cost, complex areas
 Focuses on minimizing variation to
drive out waste
 Dedicated teams focused on clinical
lines of service – network, care
delivery, patient support
 Utilizes full suite of clinical
management tools on a targeted
basis
Engagement
Tools
Personal Health
Solutions
Total Affordability
Management
 The right care, by the right
care provider
 Eliminates waste
 Improves health care
outcomes
 Increases cost efficiency
Confidential property of UnitedHealthcare. Do not distribute or reproduce without the express permission of UnitedHealthcare.
Promoting quality, efficiency and
transparency
5
Future Premium Specialties
Premium
Transplantation
Premium
Performan
Oncology
Performan
cePremium
Musculoskeletal
Premium
Performan
ce
Network
Cardiac
Premium
Performan
ce Premium
Network
Physicians
Performan
ce
Network
Designations
ce
Network
Network
Facilities
Increased Quality
Based on
External Standards
National
Networks
Improved Efficiency Based
on Comparative Benchmarks
Confidential property of UnitedHealthcare. Do not distribute or reproduce without the express permission of UnitedHealthcare.
Practice Variation- Market Level
Quality and Efficiency of Care Distribution
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Distribution of Interventional Cardiologists: Cleveland
Bubble size reflects number of UnitedHealthcare cases seen by physician
120
115
Quality Score
110
105
100
95
90
85
80
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
Efficiency (Cost Compared to Market Average)
Source: UnitedHealthcare Episodes of Care Analysis, claims 2003-2004. All data risk and severity adjusted. Physicians limited to those with >20
UnitedHealthcare cases (with the exception of some physicians who saw customer patients- added for purposes of showing actual customer volume)
Confidential property of UnitedHealthcare. Do not distribute or reproduce without the express permission of UnitedHealthcare.
How the Program Works
24 months of
data is
Collected and
analyzed
On all
physicians in
the specialties
eligible for
designation
The quality
screens are
applied based
on specialty
and, where
applicable,
focus
Only those
physicians who
meet/exceed
the quality
criteria are
designated by a
quality star and
move on to the
efficiency
analysis
7
Episodes/
procedures
analyzed for
cost efficiency
benchmarking
market
specialty
averages and
case
mix/severity
adjusted
Confidential property of UnitedHealthcare. Do not distribute or reproduce without the express permission of UnitedHealthcare.
Those who
meet or
exceed
market
cost
criteria are
designated
by two
gold stars
The Designation Process
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Quality of Care Measures
• Quality standards are national; do not vary by geographic region
• National standards for quality care developed externally by specialty
societies and health care industry organizations
• Specific to specialty and performance reviewed annually
• Continuous quality improvement measures; thresholds adjusted
• Physician engagement regarding program methodology and strategy
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Specialties
across the
Network
Quality Review
Efficiency
Review
Efficiency Measures (Use and Cost of Health Care Assets)
• Efficiency risk-adjusted and measured at market and specialtyspecific levels
• Only physicians who meet quality designation criteria are analyzed for
efficiency
Premium
Designation
Selected Methodology Enhancements (Fall 2006)
47%
Not
designated
12%
Quality
designated

41%
Quality &
efficiency
designated

• Evaluation of 13 additional clinical conditions
• 100 new EBM rules being added, for total of 263 rules
• Designation methodology for medical groups and individual
physicians
SOURCE: Designations as of 4/06 based on 54 markets and 80,000 eligible physicians
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Driving Both Quality and Efficiency
Non-Proceduralists
Proceduralists
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Condition
% Physicians
% of Attributable
Episodes
Episode Cost
Compared to
Market Average
Insufficient Data, Do
Not Meet Quality
Criteria, or Meet
Quality Criteria Only
62%
40%
+15%
Designated Quality
and Efficiency
38%
60%
-15%
Condition
% Physicians
% of Attributable
Episodes
Episode Cost
Compared to
Market Average
Insufficient, Do Not
Meet Quality, or Meet
Quality Only
52%
29%
+24%
Designated Quality
and Efficiency
48%
71%
-13%
*Based on UHPD Methodology for 20 Markets
Designated Physicians are Higher Quality and More Efficient
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Key Engagement and Support Components:
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Medical Professional
Plan Sponsor
Individual
• Comprehensive reporting to
support decision-making on
employer benefit programs
• Physicians engaged and managed
• Utilization
based on performance
• On-line performance reports and
patient-level detail reports
• Medical director outreach to
discuss quality and efficiency
improvement opportunities
• Practice Rewardssm to reward
demonstrated performance
Performance
Report
• Quality Improvement
• Savings
• Provider directory: physicians and
facilities (on-line and phone)
• Hospital comparison program for
approx. 75 IP/OP procedures in
over 140 markets
• Educational information on value
of quality and efficiency
• 24/7 NurseLine to assist with
provider selection, treatment and
follow-up decisions
Premium
Reports
Patient
Detail
Report
Directories
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The Evolving Vision of Modern
Health Care
Universal Access Card
Internet Portals
Enterprise Wide Databases
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One Processing Environment
Modular Product Flexibility
Personal Health
Record
Private Health Care
Public Programs
Quality
Affordability
300 million consumers
Predictive Clinical
Analytic Data Models
Access
Consumer Access and
Services
Care Management, Disease
and Wellness Programs
Modular
Products
Usability
Specialty Needs
National Performance
Networks
Transparent Quality
and Efficiency
Premium
Premium
Networks
Specialties
High Tech/High Touch
Real Time, Paperless, Inter-Operable, Secure, Six Sigma
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• Rx
• Lab
• Radiology
• Devices
An “Operating System” for Improvement:
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• Promote and disseminate information on evidence-based medicine
• Analyze and share data on variations in care practices
• Build specialty networks with best quality and cost outcomes
• Identify and promote physicians with superior quality and efficiency
practices through a “designation” strategy, while retaining broad choice
and access
• Support consumer engagement and activation to:
 Seek and use information on quality and efficiency of care
 Become more empowered in interacting with the healthcare system
 Promote wellness and a broad perspective on health and well-being
An integrated, comprehensive, data-driven, multi-level program =
meaningful and sustainable impact on affordability and quality
Confidential property of UnitedHealthcare. Do not distribute or reproduce without the express permission of UnitedHealthcare.