UnitedHealthcare
Patient-Centered Medical Home
Program Status
September 2012
Confidential property of UnitedHealthcare
Do not reproduce
Patient-Centered Medical Home Defined*
Patient-Centered Medical Home (PCMH) is an approach to providing
comprehensive primary care to adults, youth and children.
Principal Characteristics of PCMH:
 Personal Physician
 Physician Directed Practice
 Whole Person Care Orientation
 Coordinated Care
 Quality and Safety
 Enhanced Care Access
 Full Value Payment
 Optimization through HIT integration
(eRx, patient registry)
The PCMH is a health care setting that facilitates partnerships between individual
patients, their personal physicians and, when appropriate, the patient’s family.
* United currently uses the NCQA PPC-PCMH recognition program as a basis for defining “medical home”
capabilities but will review other alternative assessment and recognition programs as they become endorsed by
the medical professional societies.
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Network Strategy & Innovation
 A shift toward increased collaboration between payors and providers,
outcome-based payment and new benefit design is driving innovation in
payment models and delivery system configuration.
 We are developing and implementing a suite of value-based incentive
programs that reward care providers for improvements in quality and
efficiency.
Payment Reform Strategy
Delivery System Strategy
Aligned Product Strategy
 We are supporting delivery systems as they become more integrated and
accountable for cost, quality and experience outcomes.
 Alignment across our Network, Product and Clinical innovations allows
us to increase value for customers and consumers.
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Value-Based Contracting
•
Performance-Based Contracting: Pay for performance incentive program that rewards hospitals and physician
practices for performance against quality and cost of care measures on top of fee-for-service base.
•
Episode/Bundled Payments: Provider receives a lump sum for all health services delivered for a single episode of
care and/or over a specified time period - integrates risk and creates a continuum of care.
•
Shared Savings/Shared Risk: Payer and provider share upside and downside risk against an agreed-upon budget
after meeting quality and experience thresholds.
•
Capitation: Provider is responsible for the quality, cost and experience outcomes of specific population of patients
and receives payments based on per member per month, rather than fee-for-service – promotes efficient and high
quality care and coordination among providers for population health management.
Value-Based Payment Initiatives Go Hand In Hand With Practice Transformation
•
Patient-Centered Medical Home (PCMH): Promotes comprehensive primary care for a population of patients,
facilitating partnerships between individual patients and their personal physicians. Incorporates shared savings
payments on top of fee-for-service base.
•
Accountable Care Organizations (ACOs): Integrated provider organizations take accountability for care of a
specific, defined population. Reimbursement is primarily capitated and incorporates shared savings/risk based on
quality, cost and patient experience.
Benefit Designs
•
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Navigate - New lower cost alternative in our broad product portfolio, Cost savings come from: Primary care physician,
Referral management and Prior authorization
Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Network Innovation:
Value-Based Contracting
CT
DE
DC
MA
MD
NH
NJ
RI
Hospital PBC
Active ACO Pilot
PCMH Pilot
Physician PBC
ACO Pilot Candidate
Specialty Network Pilot
PCP Incentive
Shared Savings
Episodic Payment
Capitation
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Commercial
Medicare
Medicaid
All LOBs
Comm &
Mcare
Comm & Mcaid
Mcare & Mcaid
UHC PCMH Snapshot
Expected Benefits:
Commercial Activity:
Eleven active programs; five started in 20008/2009,
others started in 2011 and 2012
• Eight multi-payer: NY, CT, MD, RI, OH, CO, TX, MO
• Two single-payer in AZ and TX
• More time for patients
• Better care continuity
• Improved care transitions
• Chronic care medical home pilot in MO – partnering
with BOEING, MONSANTO, GE, and UNITED
• Improved clinical indicators
• Membership: 100K+ members impacted
• Lower per capita costs
• Physician Practices: 150+
• Primary Care Providers: 1200+
• Participating employer groups: 650+
New activity:
CMS Comprehensive Primary Care Initiative (CPCi)
Demonstration Project in CO, NJ, and OH starting
November 2012
• Increased patient participation in
health care decisions and adherence
to care plans
• Increase in practice profitability and
satisfaction
• Simplified and less fragmented
coordinated health care experience
• Projected 200+ additional practices
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Pilot Reimbursement Model
This is the primary reimbursement model adapted to each pilot market.
FEE FOR SERVICE
+
CARE MANAGEMENT
FEE
+
PERFORMANCE BONUS /
GAIN SHARE
=
TOTAL REIMBURSEMENT
PCMH reimbursement model builds on the current Fee for Service (FFS) schedule with a PMPM
Care Management Fee and in some cases a bonus / gain share option based on performance.
 FFS: Physicians remain on current contracted
fee schedules and continue to be reimbursed
based on actual services provided (no plan redesign or FFS payment schedule changes)
 CARE MANAGEMENT FEE: Prospective
fixed-rate, PMPM payments for anticipated
quality, efficiency and satisfaction
improvements under the PCMH Model [note.
contract addendum required]
 BONUS: For some Programs, practices are
eligible for a periodic performance bonus or rate
adjustment that aligns with clearly defined
clinical quality, medical cost and operational
measures
 GAIN SHARE: For some Programs, the
practices have a lower Care Management Fee in
consideration for sharing in the risk/benefit of
realized cost reduction outcomes
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Program Observations and Learning’s
• Observations
– Practices need to be ready and willing to change
– Need clearly defined, engaged physician and administrative leadership
– Structure alone does not drive outcomes
– Processes need to be adopted and sustained to realize clinical and
operational efficiency improvements
– Multi-stakeholder pilots provide the economies for sustainable change
• Early Learning’s
– Dedicated embedded, care manager and coordination is key to
success of overall patient population management
– Two-way data sharing enables better care management actions
– Performance payments can affect change in behavior
– Practice collaboration is key to leveraging best practices
– This is hard stuff which requires heavy lifting..….if there were easy
answers, primary care wouldn’t be in crisis!
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
UHC’s PCMH Guiding Principles
• Clearly defined, engaged physician and practice administrative leadership
• Motivated practice transformation engagement
• Proactive engagement of patients in the practice
• On-site, dedicated care manager role
• Improved access for patients/members
• Performance management processes centered around access, population
management, care coordination, care transitions
– E.g. registries, data reports, care protocols, etc.
• Incentives to reward quality and cost outcomes
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Update on Results - Overall
•The commercial Patient-centered Medical Home model in our Rhode Island, Ohio,
Colorado and Arizona markets has demonstrated:
– 4-4.5% medical cost reduction
– 2:1 Return on Investment (ROI)
•Each are in various stages of reporting data
•Clinical quality measures are demonstrating improvement across all pilots
•Too early to publish statistically validated utilization results
•Measurement to date shows mixed results with respect to Emergency Room Visits,
Inpatient Stays and Readmissions and Costs for each pilot. However, on average,
measurement to date shows 4% to 5% impact on total allowed cost and a 2:1 Return
on Investment (ROI).
•Third party aggregators are currently compiling data across pilots and we anticipate
we will have more robust evaluation of results by the end of 2012 or early 2013.
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Update on Results – Rhode Island
In comparison to propensity matched controls the current evaluation indicates:
• Adjusted Total Cost (PMPM) impact of 5% in Year 1
• Admits/1000 impact of 15% to 18% over two years
*Adjusted: Members with >$99k in annual allowed and/or members with >21 ERG (episode risk grouper) score (top 2% of high risk
members) are excluded.
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Questions
Kathleen_schwab@uhc.com
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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.