Ronald J Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management
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Ronald J Shumacher MD has the following
financial relationship to disclose:

Employee of: Optum Services, Inc.
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Exhibit 4
Distribution of Medicare Advantage Plans by Plan Type,
2007-2014
2,830
2,623
107 51
118 43
696
2,098
104 42
801
452
335
2,314
102 59
2,011
116
413
220
525
522
412
1,165
1,249
2007
2008
1,451
2009
2,074
1,974
59
101
201
100
54
180
2,014
51
93 48
120
548
511
512
504
1,218
1,104
1,114
1,195
1,242
2010
2011
2012
2013
2014
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 – 2014.
Other
Regional PPOs
PFFS
Local PPOs
HMO
Clinical quality and STARs
Care coordination and management
• Greater focus on quality performance
and outcomes evaluation
• HEDIS measures tied to revenue
• Financial incentives and brand
identity critical to business
• 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
Plan
Health
Performance
• 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
•
•
• Admission and Re-admission
prevention
• Post-acute and end-of life care
SNF LOS management
Network/Contracting
Medical expense management
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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
Members do not regularly
engage with or look to payer
for health support or
management
Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue
19. AHRQ Publication No. 06-0060, June 2006. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html
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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
4,000
% of
Population
Hospital
ER
Visits/Yr
Visits/Yr
# Chronic
Diseases
$PMPM
% of
Cost
<0.70
50%
.164
.252
0.3
$330
21%
.71 to 1.45
30%
.373
.429
1.3
$710
33%
1.46 to 2.05
10%
.660
.632
2.3
$1,190
15%
2.06 to 2.75
5%
.915
.766
3.0
$1,640
11%
>2.75
5%
1.477
.992
3.7
$2,740
20%
Risk Score
3,500
Hospital Admits
2,500
2,000
ER Visits
1,500
1,000
500
0
0.
17
0.
35
0.
55
0.
75
0.
95
1.
15
1.
35
1.
55
1.
75
1.
95
2.
15
2.
35
2.
55
2.
75
2.
95
3.
15
3.
35
3.
55
3.
75
3.
95
4.
15
4.
35
4.
68
5.
73
6.
73
7.
73
8.
73
9.
72
Rate per 1000 per year
3,000
Source: Nationwide Medicare 5% Sample
HCC Risk Score
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Tompkins et. al. Population Health Management in Medicare
Advantage; Health Affairs Blog, April 2013
Needs
Assessment
Value
Story
Implementation
Plan
• Identify the problem being solved
• Determine how it is applicable to MA plans
• Understand the environment in which you’ll provide care (geography,
etc.)
• 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
• 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
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Identification of members
and risk stratification
Member
outreach and
engagement
Demonstrate
value / ROI
Capture of quality and
encounter data
Develop clinical
care model
(e.g., visit types, how
to manage the most
challenging patients)
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Reimbursement Structure
• Case rate (PEMPM)
• Capitated payment (PMPM)
• Gain sharing with quality metric
goal(s)
• Full risk/percent of premium
Profitability Management
• 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
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Challenge
Risk 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 Establish clear criteria, communication
management and other programs
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 tracking
Robust EHR and reporting/analytics
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Ronald J Shumacher, MD FACP CMD
Chief Medical Officer, Optum Complex Population Management
rshumacher@optum.com
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