Care Coordination:
Innovation in the Private Sector
AcademyHealth 2010 Annual Research Meeting
June 29, 2010
Lewis G. Sandy MD
Senior Vice President, Clinical Advancement
UnitedHealth Group
Overview:

“Care
Care Coordination
Coordination”, a deceptively simple term
term, is quite complex
complex, both
conceptually and operationally

While many efforts in Care Coordination focus on care delivery
improvements, perhaps the most “patient-centric” view emerges from
payer claim/administrative data, as these data represent the patient’s
actual encounters across settings, care providers, conditions, and time

These data can be analyzed for: discrete gaps in care; performance
measurement/improvement with episodes as the unit of analysis; and for
continual monitoring and intervention with both patients and care
providers

UnitedHealth Group
p has considerable experience
p
in analyzing
y g care
coordination opportunities on behalf of the 75 million consumers we
serve, and in developing scalable solutions to enhance quality and
g
reduce fragmentation
Care Today: Complex and Fragmented
Hospital
PRACTICE GROUP
Complexity
Hospital
Physicians / Nurses
Hospital
IPA
Patient
Community
Hosp
p
Lab
Hosp
p
ED
Imaging
Center
Practice Group
Hospitalist
MD
MD
MD
MD
MD
MD
Convenience
Clinic
LabCorp
Lab
Office
Nurse
Practicioner
Office
Family
Pt
Pt
Fitness
Center
Pt
Pt
Social
Network
Pt
Transport
Pt
Pt
Home
Repairs
Food
Vendor
Pt
Pharmacy
NQF Care Coordination Framework

Healthcare “Home”

Proactive Plan of Care and Follow-up

Communication

Information Systems

Transitions or Hand-offs
Hand offs
Coordination of Care
The Provider View
Coordination

The typical PCP shares patients with numerous other providers
 Pham study of Medicare data: 229 other physicians in 117 practices 
 UHC Commercial:
Pham
 ~339
339 other
th providers
id
(SRVC NPI) for
f “pure
“
PCPs”
PCP ” having
h i >$2,000
>$2 000 allw/yr
ll /
 ~136 other providers (BIL NPI) for “pure PCP practices” having >$20,000 allw/yr

Transitions of Care Multi-Society Statement of Principles 









Accountability
Transitions
Consensus Statement
Communication
g of information
Timelyy exchange
These societies agree with the NQF
Involvement of the patient and family
COC Model
Respect the hub of coordination of care
All patients should have a medical home
Patients need to know who is accountable at each step of their care
National standards
St d d metrics
Standard
t i related
l t d tto th
these standards
t d d tto llead
d tto quality
lit improvement
i
t
and accountability
A Comprehensive Approach to Population
Health Optimization
Holistic Member View for
Proactive Identification
Total Population
Monitoring
Care Provider
Engagement
Outreach and
Health Management
Persistent Consumer
Engagement
eSync Delivers Real-Time Performance
Monitoring
Right
Provider
Right
Medication
Right
Care / Treatment
Right
Lifestyle
The information we provide is personalized,
personalized specific and
timely, and it allows for real-time adjustments
7
Coordination Through Stakeholder
Synchronization
Holistic Member View
Personal Action Plan
Consumer
Personalized tools, resources and information
Personalized Portal, PHR,
Messages
g and Email
Interactive Coaches,
Online Communities,
Tools and Trackers
Onsite Resources,
Biometric Kiosks,, etc.
Direct Mail
Provider
Cell Phone
Moving from reactive care to proactive care
P
Personal
l Care
C
C
Consultant
lt t
E-enabled coordination: A schematic for the
future, but infrastructure beginning to be built
e-Clinical Decision Support
Medical
Policy
(Computable)
Health Plan Contracts
Member
Employer
Contracts
EMB
Appropriateness
HL-7 e-Measure
and QRDA
EHR – HIE
Clinical Data
Patient
Centered
Coordination
Plans
Patient
engagement
Quality &
Outcome
Reporting
Risk
Adjusted
PMPM
Provider
Provider
Contracts
Notification
Eligibility
PCCP Enhanced Fee
Claim
Service
Agreements
XSD Registry
BPEL Registry
QRDA
ETF
Distributions
within ACO
Provider
Capabilities
Analytics: Shared savings, quality and efficient reporting, practice and ACO improvement
Key Points:

While significant opportunities exist within care delivery systems to better
coordinate care, scalable capabilities exist TODAY to significantly
increase coordination, enhance quality, and reduce gaps in care

Over time, coordinated actions by both care delivery systems and
payers/care facilitators can increase the likelihood that patients will
experience more holistic, integrated care (with associated enhancements
to quality and affordability at a system level)

While spread of current best practices would be a significant
improvement over the current state
state, “e
e-enabled
enabled coordination”
coordination could lead
to breakthrough levels of performance not currently seen even in highest
quality care settings