WEBVTT

1
00:00:02.910 --> 00:00:05.537
<v ->[AI-Generated Voice] This meeting is being recorded.</v>

2
00:00:05.537 --> 00:00:08.130
<v Sherry>Hello everyone. I'm Sherry Roling,</v>

3
00:00:08.130 --> 00:00:11.700
your host of the ACAP Value-Based Payment Showcase.

4
00:00:11.700 --> 00:00:15.120
ACAP presents periodic vendor showcases

5
00:00:15.120 --> 00:00:17.910
on a variety of topics so that our member health plans

6
00:00:17.910 --> 00:00:20.850
can hear directly from vendors on key services.

7
00:00:20.850 --> 00:00:24.030
Our next showcase will be in September, 2023,

8
00:00:24.030 --> 00:00:26.460
where vendors will be discussing social determinants

9
00:00:26.460 --> 00:00:28.170
of health offerings.

10
00:00:28.170 --> 00:00:30.840
Today I'd like to walk you into our session presented

11
00:00:30.840 --> 00:00:34.560
by Optum and our presenter today is Erik Johnson.

12
00:00:34.560 --> 00:00:37.590
He will be presenting "Operating Imperatives

13
00:00:37.590 --> 00:00:39.060
for Value-Based Care."

14
00:00:39.060 --> 00:00:42.420
But before I turn it over, I have a few housekeeping items.

15
00:00:42.420 --> 00:00:44.760
This session along with all ACAP calls

16
00:00:44.760 --> 00:00:46.860
and webinars will be held in accordance

17
00:00:46.860 --> 00:00:49.290
with the ACAP antitrust guidelines.

18
00:00:49.290 --> 00:00:51.960
These guidelines can be viewed on our website.

19
00:00:51.960 --> 00:00:53.550
We will record today's call

20
00:00:53.550 --> 00:00:55.830
and will post it in the slide deck

21
00:00:55.830 --> 00:00:59.430
on the value-based purchasing showcase website available

22
00:00:59.430 --> 00:01:01.530
to all of our member health plans.

23
00:01:01.530 --> 00:01:04.590
Always remember if your plan is seeking services,

24
00:01:04.590 --> 00:01:06.000
be sure to check out the list

25
00:01:06.000 --> 00:01:08.040
of preferred vendors on our website.

26
00:01:08.040 --> 00:01:10.080
Just look at the top of our homepage

27
00:01:10.080 --> 00:01:12.330
and click on the preferred vendor's link.

28
00:01:12.330 --> 00:01:13.650
When you're seeking services,

29
00:01:13.650 --> 00:01:16.770
you can also post a query or even an RFP

30
00:01:16.770 --> 00:01:19.260
on the Preferred Vendor Connection portal.

31
00:01:19.260 --> 00:01:20.400
During today's session,

32
00:01:20.400 --> 00:01:22.020
you can ask a question at any time

33
00:01:22.020 --> 00:01:24.780
by clicking the Q&amp;A icon in your Zoom window

34
00:01:24.780 --> 00:01:26.790
and typing in your question.

35
00:01:26.790 --> 00:01:29.550
All questions will be answered during our session.

36
00:01:29.550 --> 00:01:32.253
Now I'll pass it over to Erik to kick it off.

37
00:01:34.050 --> 00:01:35.220
<v Erik>Thanks, Sherry. Thanks very much</v>

38
00:01:35.220 --> 00:01:37.170
and welcome to the the webinar today.

39
00:01:37.170 --> 00:01:38.280
I'm Erik Johnson.

40
00:01:38.280 --> 00:01:41.430
I'm Senior Vice President at Optum Advisory Services.

41
00:01:41.430 --> 00:01:44.190
I run the value-based care practice here at Optum

42
00:01:44.190 --> 00:01:47.010
and it's a pleasure to be speaking with you all today.

43
00:01:47.010 --> 00:01:49.140
For the next 45 minutes or so,

44
00:01:49.140 --> 00:01:51.870
we're gonna try to leave some time for Q&amp;A at the end,

45
00:01:51.870 --> 00:01:53.670
we're gonna try to address some of the operational

46
00:01:53.670 --> 00:01:56.730
and functional demands that value-based care

47
00:01:56.730 --> 00:01:58.710
is putting on both payers and providers

48
00:01:58.710 --> 00:02:00.510
in the marketplace today.

49
00:02:00.510 --> 00:02:02.640
We're gonna talk a little bit about that in context

50
00:02:02.640 --> 00:02:05.730
about why value-based care, why now,

51
00:02:05.730 --> 00:02:08.220
what are the market imperatives

52
00:02:08.220 --> 00:02:10.290
in addition to the operating imperatives

53
00:02:10.290 --> 00:02:12.180
that payers and providers are facing

54
00:02:12.180 --> 00:02:14.163
in this ever-evolving market.

55
00:02:15.090 --> 00:02:17.400
So we'll talk a little bit about the models of VBC

56
00:02:17.400 --> 00:02:19.440
that are out there, the payment models that are out there,

57
00:02:19.440 --> 00:02:21.840
the partnership models that are out there,

58
00:02:21.840 --> 00:02:23.670
and really some of the strategic questions

59
00:02:23.670 --> 00:02:28.410
that folks are asking us as their consultants,

60
00:02:28.410 --> 00:02:29.730
but also asking of each other

61
00:02:29.730 --> 00:02:32.343
as different stakeholders in the marketplace today.

62
00:02:33.360 --> 00:02:36.240
As we go through this presentation,

63
00:02:36.240 --> 00:02:39.300
there's some questions I want folks to keep in mind

64
00:02:39.300 --> 00:02:41.520
that maybe will trigger some questions at the end.

65
00:02:41.520 --> 00:02:43.140
And feel free to ask these questions back

66
00:02:43.140 --> 00:02:47.490
to me as we get to the Q&amp;A session later this morning

67
00:02:47.490 --> 00:02:50.490
if I haven't addressed some of these in full.

68
00:02:50.490 --> 00:02:52.140
But we really wanted to bucket

69
00:02:52.140 --> 00:02:55.917
about four big sort of macro-categories of questions.

70
00:02:55.917 --> 00:02:59.640
And the first is, in these payer provider arrangements,

71
00:02:59.640 --> 00:03:01.860
how close to first dollar premium risk

72
00:03:01.860 --> 00:03:04.080
do providers really want to be?

73
00:03:04.080 --> 00:03:06.660
Because there's no single right answer

74
00:03:06.660 --> 00:03:08.130
for any particular stakeholder.

75
00:03:08.130 --> 00:03:09.690
Some folks will want to go

76
00:03:09.690 --> 00:03:12.210
to a full delegated capitation model

77
00:03:12.210 --> 00:03:14.580
in various product lines, whether that's Medicare,

78
00:03:14.580 --> 00:03:16.260
Medicaid or commercial.

79
00:03:16.260 --> 00:03:18.720
Some will only want to participate

80
00:03:18.720 --> 00:03:21.510
in upside downside ACO type models

81
00:03:21.510 --> 00:03:23.820
where there's a fairly narrow risk corridor,

82
00:03:23.820 --> 00:03:25.168
but they're still being rewarded

83
00:03:25.168 --> 00:03:27.990
for participating in a value based care arrangement

84
00:03:27.990 --> 00:03:31.200
with particular emphasis on the quadruple aim.

85
00:03:31.200 --> 00:03:34.920
The next set of questions that folks I think need to answer

86
00:03:34.920 --> 00:03:37.110
or at least think about as they go down this route is,

87
00:03:37.110 --> 00:03:39.513
which populations should we be taking risk on?

88
00:03:40.380 --> 00:03:42.600
Because they all represent very different risk profiles.

89
00:03:42.600 --> 00:03:45.900
If you think about Medicare ACO populations

90
00:03:45.900 --> 00:03:47.910
versus Medicare advantage populations

91
00:03:47.910 --> 00:03:50.130
versus managed Medicaid populations

92
00:03:50.130 --> 00:03:52.440
versus commercial populations,

93
00:03:52.440 --> 00:03:54.390
they all have very specific needs

94
00:03:54.390 --> 00:03:56.940
and you as a health system,

95
00:03:56.940 --> 00:04:00.060
you as a payer may be particularly well positioned

96
00:04:00.060 --> 00:04:02.910
to take on one or two of those product lines,

97
00:04:02.910 --> 00:04:03.960
but maybe not all.

98
00:04:03.960 --> 00:04:05.760
So I think it's important to be intentional

99
00:04:05.760 --> 00:04:07.950
about the populations that we're targeting

100
00:04:07.950 --> 00:04:09.783
these value-based contracts on.

101
00:04:11.160 --> 00:04:13.698
As we think about value-based models

102
00:04:13.698 --> 00:04:16.710
and having providers take on greater responsibility,

103
00:04:16.710 --> 00:04:19.230
there does become an imperative

104
00:04:19.230 --> 00:04:21.120
for the providers to think about,

105
00:04:21.120 --> 00:04:22.530
do we have the necessary assets

106
00:04:22.530 --> 00:04:24.690
that we need in order to manage these populations?

107
00:04:24.690 --> 00:04:26.877
Do we have the right sites of care, the right care models,

108
00:04:26.877 --> 00:04:28.512
and the right primary care footprint

109
00:04:28.512 --> 00:04:31.590
in order to take on risk at scale

110
00:04:31.590 --> 00:04:33.750
with the populations that we choose

111
00:04:33.750 --> 00:04:36.180
to engage in value-based contracting?

112
00:04:36.180 --> 00:04:37.013
And then finally,

113
00:04:37.013 --> 00:04:38.460
and this is maybe just giving away a little bit

114
00:04:38.460 --> 00:04:40.590
of our mindset at Optum,

115
00:04:40.590 --> 00:04:43.410
we do think that these are largely partner-based models.

116
00:04:43.410 --> 00:04:47.640
We are generally not big fans doing it all by yourself,

117
00:04:47.640 --> 00:04:50.400
whether that's owning all of the delivery assets

118
00:04:50.400 --> 00:04:52.080
that you need or whether it's starting

119
00:04:52.080 --> 00:04:54.090
your own provider sponsored health plan.

120
00:04:54.090 --> 00:04:55.200
In some cases, again,

121
00:04:55.200 --> 00:04:56.430
those may be the right answers,

122
00:04:56.430 --> 00:04:58.560
but in most cases what we have found is that

123
00:04:58.560 --> 00:05:02.190
that is a big ask from a capital standpoint,

124
00:05:02.190 --> 00:05:04.530
from an organizational change standpoint,

125
00:05:04.530 --> 00:05:06.030
and from a clinical standpoint.

126
00:05:06.030 --> 00:05:08.070
And so we very much think about this in terms

127
00:05:08.070 --> 00:05:09.690
of do you have the right partnerships

128
00:05:09.690 --> 00:05:13.530
in place in order to be successful in this endeavor?

129
00:05:13.530 --> 00:05:15.530
So that's kind of how we think about it.

130
00:05:16.710 --> 00:05:18.210
What I wanna get into now is sort of

131
00:05:18.210 --> 00:05:20.430
what are the fundamentals of value-based care?

132
00:05:20.430 --> 00:05:21.840
And I think a lot of us,

133
00:05:21.840 --> 00:05:24.630
at least I have been working in the world of VBC

134
00:05:24.630 --> 00:05:28.980
for about 15 years now, and the definitions have evolved,

135
00:05:28.980 --> 00:05:31.530
the marketplace has evolved.

136
00:05:31.530 --> 00:05:33.720
And I think if you ask, you know,

137
00:05:33.720 --> 00:05:36.120
10 consultants what a good definition

138
00:05:36.120 --> 00:05:39.750
of value-based care is, you might get 11 different answers.

139
00:05:39.750 --> 00:05:42.090
So we think of it very much along the,

140
00:05:42.090 --> 00:05:44.370
what we were gonna cover in the next two slides.

141
00:05:44.370 --> 00:05:46.800
First of all, this is a contracting model.

142
00:05:46.800 --> 00:05:47.850
Value-based care ultimately

143
00:05:47.850 --> 00:05:50.370
is about value-based contracting.

144
00:05:50.370 --> 00:05:53.550
And that contract should include incentives

145
00:05:53.550 --> 00:05:56.340
that will enable a community partnership

146
00:05:56.340 --> 00:05:58.710
to make progress against the quadruple aim

147
00:05:58.710 --> 00:06:01.710
of lower costs, improved patient experience,

148
00:06:01.710 --> 00:06:04.923
improved provider experience, and higher quality.

149
00:06:05.820 --> 00:06:08.340
Now, there's some disagreement about this.

150
00:06:08.340 --> 00:06:12.349
Some folks have anchored very much on the triple aim,

151
00:06:12.349 --> 00:06:16.170
ignoring the provider satisfaction element of this.

152
00:06:16.170 --> 00:06:18.990
And some folks have extended this to the quintuple aim

153
00:06:18.990 --> 00:06:22.713
and included health equity in the equation.

154
00:06:23.940 --> 00:06:27.120
I think health equity is a good set of capabilities

155
00:06:27.120 --> 00:06:29.490
that may be appropriate for certain types

156
00:06:29.490 --> 00:06:30.870
of value-based care arrangements

157
00:06:30.870 --> 00:06:33.000
for certain types of populations.

158
00:06:33.000 --> 00:06:36.060
But in and of itself, health equity is almost too big

159
00:06:36.060 --> 00:06:41.060
of a lift to later laden onto a value-based care contracting

160
00:06:41.070 --> 00:06:44.790
if it doesn't require those sets of capabilities.

161
00:06:44.790 --> 00:06:46.110
So we're very intentional

162
00:06:46.110 --> 00:06:48.750
about these four elements being represented

163
00:06:48.750 --> 00:06:51.030
in a value-based contract.

164
00:06:51.030 --> 00:06:53.130
And having those four elements

165
00:06:53.130 --> 00:06:57.150
in a VBC arrangement has some very specific implications.

166
00:06:57.150 --> 00:06:59.430
And we lay out four of those right here.

167
00:06:59.430 --> 00:07:02.040
The first is the implication for payment.

168
00:07:02.040 --> 00:07:04.645
Moving away from that fee for service chassis

169
00:07:04.645 --> 00:07:06.720
to something that is risk based.

170
00:07:06.720 --> 00:07:08.640
Again, it doesn't necessarily have

171
00:07:08.640 --> 00:07:11.040
to be a capitated payment.

172
00:07:11.040 --> 00:07:13.290
It could be a risk based fee for service model,

173
00:07:13.290 --> 00:07:15.840
like what we're seeing in in the MSSP program

174
00:07:15.840 --> 00:07:19.260
across the country and what a lot of MA plans have adapted

175
00:07:19.260 --> 00:07:22.380
into their own arrangements with their provider networks.

176
00:07:22.380 --> 00:07:24.270
But we are looking to move towards risk

177
00:07:24.270 --> 00:07:27.720
and we will talk about the elements of risk in a minute.

178
00:07:27.720 --> 00:07:29.820
The second key implication is the implication

179
00:07:29.820 --> 00:07:32.040
for where that care is being delivered.

180
00:07:32.040 --> 00:07:35.040
And this is moving away from facility based care

181
00:07:35.040 --> 00:07:36.395
as the primary delivery model

182
00:07:36.395 --> 00:07:40.170
and moving that care as close to home as possible.

183
00:07:40.170 --> 00:07:41.850
That is not to say we are arguing

184
00:07:41.850 --> 00:07:45.660
for a hospital at home model in every, you know,

185
00:07:45.660 --> 00:07:47.130
in every community or a snip

186
00:07:47.130 --> 00:07:49.020
at home model in every community,

187
00:07:49.020 --> 00:07:51.300
but we are looking to move it into the community

188
00:07:51.300 --> 00:07:54.960
and out of the facilities to the degree that we can.

189
00:07:54.960 --> 00:07:57.450
The third implication is for risk management

190
00:07:57.450 --> 00:08:00.943
and who's gonna end up managing that risk?

191
00:08:00.943 --> 00:08:05.943
And in a value-based model, at least at a minimum,

192
00:08:06.450 --> 00:08:08.190
the risk management responsibility

193
00:08:08.190 --> 00:08:11.130
is shared between payer and providers.

194
00:08:11.130 --> 00:08:12.570
And in the most aggressive models,

195
00:08:12.570 --> 00:08:15.060
the risk management is delegated entirely

196
00:08:15.060 --> 00:08:17.280
to the provider network.

197
00:08:17.280 --> 00:08:18.690
And then finally, the implications

198
00:08:18.690 --> 00:08:20.820
for care design and delivery.

199
00:08:20.820 --> 00:08:23.370
And that is moving the payment model

200
00:08:23.370 --> 00:08:25.080
and the clinical model away

201
00:08:25.080 --> 00:08:28.800
from visit based and episodic based care models

202
00:08:28.800 --> 00:08:31.260
to longitudinal care models

203
00:08:31.260 --> 00:08:33.300
where instead of treating the episode,

204
00:08:33.300 --> 00:08:34.620
now you're treating the life

205
00:08:34.620 --> 00:08:36.510
or treating the patient or at least a year

206
00:08:36.510 --> 00:08:38.130
in the life of that patient

207
00:08:38.130 --> 00:08:41.850
for whom you have risk during that benefit period.

208
00:08:41.850 --> 00:08:45.420
And some of this may sound somewhat reductive

209
00:08:45.420 --> 00:08:48.270
to many of you, but I think it is important

210
00:08:48.270 --> 00:08:49.620
to keep in mind that all of these have

211
00:08:49.620 --> 00:08:52.620
to move in parallel as we look

212
00:08:52.620 --> 00:08:56.100
to find a sustainable value-based care contracting

213
00:08:56.100 --> 00:08:59.463
and delivery model for the partnerships involved.

214
00:09:00.570 --> 00:09:03.720
We talk a lot about risk in value-based contracting

215
00:09:03.720 --> 00:09:07.260
and there are four elements of risk in a VBC arrangement.

216
00:09:07.260 --> 00:09:09.420
And I think a lot of the attention is focused

217
00:09:09.420 --> 00:09:11.520
on that first one, that insurance risk.

218
00:09:11.520 --> 00:09:13.950
Ultimately a value-based contract

219
00:09:13.950 --> 00:09:18.600
that includes insurance risk is an actuarial challenge.

220
00:09:18.600 --> 00:09:21.540
Making sure that we have priced that risk correctly,

221
00:09:21.540 --> 00:09:23.670
that we've addressed the total cost of care,

222
00:09:23.670 --> 00:09:27.120
even if we're still only operating upside downside models

223
00:09:27.120 --> 00:09:28.080
where you're not on the hook

224
00:09:28.080 --> 00:09:30.063
for the entire total cost of care.

225
00:09:31.110 --> 00:09:33.270
That insurance risk has to be calculated.

226
00:09:33.270 --> 00:09:36.240
That insurance risk has to be shared.

227
00:09:36.240 --> 00:09:37.830
We have to come to some agreement

228
00:09:37.830 --> 00:09:41.130
that the provider network that is taking on some of

229
00:09:41.130 --> 00:09:44.010
that risk has an accurate understanding

230
00:09:44.010 --> 00:09:46.170
and complete visibility into

231
00:09:46.170 --> 00:09:48.840
how that insurance risk is calculated.

232
00:09:48.840 --> 00:09:50.730
And I think in a lot of cases,

233
00:09:50.730 --> 00:09:54.720
insurance risk is where a lot of the risk discussion stops,

234
00:09:54.720 --> 00:09:56.190
but there are other elements

235
00:09:56.190 --> 00:09:57.990
of risk in value-based contracting

236
00:09:57.990 --> 00:10:00.450
and I think they're largely accretive.

237
00:10:00.450 --> 00:10:03.270
I don't think you need to tread one off versus the other.

238
00:10:03.270 --> 00:10:05.550
In some cases you're gonna need all four.

239
00:10:05.550 --> 00:10:07.080
The second is quality risk

240
00:10:07.080 --> 00:10:11.550
and we're very familiar with that in the healthcare economy.

241
00:10:11.550 --> 00:10:14.820
CMS has been doing various elements of quality measurement

242
00:10:14.820 --> 00:10:18.990
and quality rewards and penalties for almost 20 years now

243
00:10:18.990 --> 00:10:21.840
through the inpatient hospital reporting mechanisms.

244
00:10:21.840 --> 00:10:23.850
And I think that is a good backstop

245
00:10:23.850 --> 00:10:26.910
to make sure that we are hitting our insurance risk goals

246
00:10:26.910 --> 00:10:29.760
without sacrificing our quality goals.

247
00:10:29.760 --> 00:10:32.910
The quality world is evolving fairly rapidly

248
00:10:32.910 --> 00:10:34.320
and expanding fairly rapidly

249
00:10:34.320 --> 00:10:38.160
to move beyond sort of the task list based quality metrics

250
00:10:38.160 --> 00:10:41.130
that were the sort of first generation of quality measures,

251
00:10:41.130 --> 00:10:44.010
moving into then outcomes based measures.

252
00:10:44.010 --> 00:10:48.150
Things like readmission penalties for hospital readmissions.

253
00:10:48.150 --> 00:10:49.800
And now we've extended beyond that

254
00:10:49.800 --> 00:10:53.220
into consumer and patient satisfaction.

255
00:10:53.220 --> 00:10:55.047
We've seen that in the MA program

256
00:10:55.047 --> 00:10:57.810
as the star rating regime starts to move away

257
00:10:57.810 --> 00:11:01.230
from what we would consider more

258
00:11:01.230 --> 00:11:02.940
of a HEDIS based environment

259
00:11:02.940 --> 00:11:04.170
and more towards caps

260
00:11:04.170 --> 00:11:06.240
and really getting at consumer satisfaction

261
00:11:06.240 --> 00:11:09.780
with their benefits and with their access points.

262
00:11:09.780 --> 00:11:11.220
That's quality risk.

263
00:11:11.220 --> 00:11:12.870
The third element could be operating risk.

264
00:11:12.870 --> 00:11:14.130
Making sure that we're efficiently

265
00:11:14.130 --> 00:11:16.140
managing the anticipated demand

266
00:11:16.140 --> 00:11:18.480
by taking advantage of all of the sites

267
00:11:18.480 --> 00:11:21.090
of service available to the network

268
00:11:21.090 --> 00:11:24.600
and optimizing at the lowest cost,

269
00:11:24.600 --> 00:11:28.650
highest quality site of care and rewarding networks

270
00:11:28.650 --> 00:11:32.400
for managing those referral patterns intelligently.

271
00:11:32.400 --> 00:11:33.930
And then the last element of risk

272
00:11:33.930 --> 00:11:35.550
is what we call episodic risk.

273
00:11:35.550 --> 00:11:36.960
And that is managing episodes

274
00:11:36.960 --> 00:11:39.780
and procedures as efficiently as possible.

275
00:11:39.780 --> 00:11:41.010
This is an area where providers

276
00:11:41.010 --> 00:11:42.660
have had a lot of experience,

277
00:11:42.660 --> 00:11:45.960
roughly 40 years of experience to be precise

278
00:11:45.960 --> 00:11:48.840
since Medicare first introduced diagnosis related groups

279
00:11:48.840 --> 00:11:50.970
back in the early eighties.

280
00:11:50.970 --> 00:11:52.470
Those diagnosis related groups

281
00:11:52.470 --> 00:11:55.470
or DRGs are really small bundled payments

282
00:11:55.470 --> 00:11:56.430
that really are meant

283
00:11:56.430 --> 00:11:59.280
to cover just the inpatient hospital stay.

284
00:11:59.280 --> 00:12:01.590
We have seen a lot of experimentation

285
00:12:01.590 --> 00:12:04.950
over the last 10 years with bundled payments.

286
00:12:04.950 --> 00:12:09.630
Certainly CMS invested quite a bit of of time and energy

287
00:12:09.630 --> 00:12:11.370
in rolling out various models

288
00:12:11.370 --> 00:12:14.070
of bundle payments over the last decade or so

289
00:12:14.070 --> 00:12:16.950
with varying degrees of success.

290
00:12:16.950 --> 00:12:19.300
And I think there's a moment now

291
00:12:19.300 --> 00:12:21.420
where we're taking a little bit of a pause

292
00:12:21.420 --> 00:12:22.680
to see whether those types

293
00:12:22.680 --> 00:12:25.320
of episodic risk arrangements are sustainable

294
00:12:25.320 --> 00:12:26.790
in the long run.

295
00:12:26.790 --> 00:12:29.400
But certainly when you get into a full delegated model,

296
00:12:29.400 --> 00:12:31.410
there are certain types of providers you don't want

297
00:12:31.410 --> 00:12:35.040
to hold insurance risk, but you still want them accountable.

298
00:12:35.040 --> 00:12:37.410
We're talking about proceduralists and surgeons

299
00:12:37.410 --> 00:12:40.950
and subspecialties where they might not own a life

300
00:12:40.950 --> 00:12:43.440
during an entire 12 month benefit period,

301
00:12:43.440 --> 00:12:46.140
but they're gonna have a disproportionate impact

302
00:12:46.140 --> 00:12:48.000
on the amount of resources devoted

303
00:12:48.000 --> 00:12:51.540
to that life in a very discreet type of episode.

304
00:12:51.540 --> 00:12:53.220
And I think that's an important model

305
00:12:53.220 --> 00:12:55.620
to keep in mind as we go forward.

306
00:12:55.620 --> 00:12:57.630
So these are the various elements of risk

307
00:12:57.630 --> 00:12:59.790
that we include in risk-based contracting.

308
00:12:59.790 --> 00:13:00.960
These are the various elements

309
00:13:00.960 --> 00:13:05.640
that are largely present in accountable care models

310
00:13:05.640 --> 00:13:08.940
that CMS and CMI have put forward

311
00:13:08.940 --> 00:13:12.780
through the MSSP program and now the ACO reach program.

312
00:13:12.780 --> 00:13:14.970
And I think all four of them are things

313
00:13:14.970 --> 00:13:18.150
that we need to think about and negotiate

314
00:13:18.150 --> 00:13:20.643
with our provider networks as we go forward.

315
00:13:22.650 --> 00:13:24.540
Now, as I mentioned at the beginning of the call,

316
00:13:24.540 --> 00:13:25.950
I've been working in value-based care

317
00:13:25.950 --> 00:13:28.560
for better part of a decade and a half

318
00:13:28.560 --> 00:13:31.350
and it's always been the next big thing.

319
00:13:31.350 --> 00:13:34.140
And the question I think a lot of folks ask me now

320
00:13:34.140 --> 00:13:38.400
and that you may be getting asked as well is why now.

321
00:13:38.400 --> 00:13:41.378
And I think there are a couple reasons for that.

322
00:13:41.378 --> 00:13:43.860
The first is there are some significant

323
00:13:43.860 --> 00:13:47.490
macro headwinds facing the provider market today,

324
00:13:47.490 --> 00:13:49.200
which is making their business models

325
00:13:49.200 --> 00:13:52.560
that are based on fee for service increasingly difficult

326
00:13:52.560 --> 00:13:55.830
to maintain given the contracts

327
00:13:55.830 --> 00:13:57.570
that they have previously put in place.

328
00:13:57.570 --> 00:13:59.640
There are extraordinary inflation pressures

329
00:13:59.640 --> 00:14:01.830
across the healthcare economy.

330
00:14:01.830 --> 00:14:04.350
They're easing a bit over the last six months,

331
00:14:04.350 --> 00:14:06.895
but certainly the workforce shortages

332
00:14:06.895 --> 00:14:09.150
and supply chain disruptions that we've seen

333
00:14:09.150 --> 00:14:10.650
over the last 24 months

334
00:14:10.650 --> 00:14:13.440
have increased the operating cost basis

335
00:14:13.440 --> 00:14:16.263
for a lot of our healthcare providers

336
00:14:16.263 --> 00:14:17.943
in the last couple of years.

337
00:14:18.870 --> 00:14:20.610
We've also seen some pressures,

338
00:14:20.610 --> 00:14:24.120
some legislative and regulatory pressures on reimbursement

339
00:14:24.120 --> 00:14:29.120
and most recently on MA rates coming out from CMS.

340
00:14:30.270 --> 00:14:31.890
We've seen some market downturns

341
00:14:31.890 --> 00:14:34.230
in the stock market eroding some of the value

342
00:14:34.230 --> 00:14:36.630
of the endowments and cash reserves

343
00:14:36.630 --> 00:14:40.200
and liquid reserves that health systems have had

344
00:14:40.200 --> 00:14:42.840
in the past, which is further tightening their ability

345
00:14:42.840 --> 00:14:45.540
to operate with with some latitude.

346
00:14:45.540 --> 00:14:47.370
And finally we see the expiration

347
00:14:47.370 --> 00:14:50.130
of the public health emergency a couple weeks ago,

348
00:14:50.130 --> 00:14:52.230
which is contributing to some dramatic swings

349
00:14:52.230 --> 00:14:55.440
in coverage through the Medicaid redeterminations

350
00:14:55.440 --> 00:14:58.350
that are ongoing and will be through the rest of the year,

351
00:14:58.350 --> 00:14:59.670
as well as some of the clawbacks

352
00:14:59.670 --> 00:15:02.670
from some of the waivers that providers

353
00:15:02.670 --> 00:15:05.283
have enjoyed since March of 2020.

354
00:15:06.450 --> 00:15:08.220
All of this is projected

355
00:15:08.220 --> 00:15:11.220
to put some significant downward pressure

356
00:15:11.220 --> 00:15:15.420
on provider operating income over the next few years.

357
00:15:15.420 --> 00:15:18.300
And I think that's an important consideration

358
00:15:18.300 --> 00:15:22.260
to have as provider systems and provider networks look

359
00:15:22.260 --> 00:15:24.540
to what is the next opportunity

360
00:15:24.540 --> 00:15:27.273
for margin in the market today.

361
00:15:28.200 --> 00:15:31.470
So those are sort of the macro economic dynamics

362
00:15:31.470 --> 00:15:33.060
that are forcing providers

363
00:15:33.060 --> 00:15:35.001
to think about value-based contracting

364
00:15:35.001 --> 00:15:37.650
as an alternative path to margin.

365
00:15:37.650 --> 00:15:39.754
But there are also sort of

366
00:15:39.754 --> 00:15:42.210
what we would call endemic market disruptions

367
00:15:42.210 --> 00:15:43.800
that are happening to the provider market.

368
00:15:43.800 --> 00:15:46.770
And that's been going on for quite a bit of time as well.

369
00:15:46.770 --> 00:15:48.660
We lay out a couple of those dynamics

370
00:15:48.660 --> 00:15:51.270
on this on slide eight.

371
00:15:51.270 --> 00:15:55.590
The first dynamic that we call out

372
00:15:55.590 --> 00:15:58.290
for the purposes of today's discussion are

373
00:15:58.290 --> 00:16:01.500
what we would call the physician aggregators.

374
00:16:01.500 --> 00:16:03.810
These are the vendors that are going out,

375
00:16:03.810 --> 00:16:05.780
Aledade and the Agilon and the Privia

376
00:16:05.780 --> 00:16:07.080
of the world who are going out

377
00:16:07.080 --> 00:16:10.980
and creating what are essentially synthetic IPAs

378
00:16:10.980 --> 00:16:14.580
with the idea of moving those into synthetic ACOs.

379
00:16:14.580 --> 00:16:17.884
And they are largely focused on the ambulatory market

380
00:16:17.884 --> 00:16:20.913
and on the independent practice groups

381
00:16:20.913 --> 00:16:24.060
that are still out there today giving them sort

382
00:16:24.060 --> 00:16:26.400
of purchasing power with payers

383
00:16:26.400 --> 00:16:28.560
in order to take on some of that risk

384
00:16:28.560 --> 00:16:30.960
and take on some of that delegator responsibility

385
00:16:30.960 --> 00:16:34.170
for populations primarily in Medicare advantage today,

386
00:16:34.170 --> 00:16:35.760
but I think increasingly moving

387
00:16:35.760 --> 00:16:38.760
into the commercial world as well.

388
00:16:38.760 --> 00:16:42.330
And in that dynamic what we see is a cutting out

389
00:16:42.330 --> 00:16:44.029
of the hospital as the middleman

390
00:16:44.029 --> 00:16:46.500
and the hospitals are struggling

391
00:16:46.500 --> 00:16:49.620
with the loss in volume from that.

392
00:16:49.620 --> 00:16:51.540
Second related trend

393
00:16:51.540 --> 00:16:56.540
is increasingly large physician practices scaling up

394
00:16:57.660 --> 00:17:00.630
to meet the VBC challenges that MA presents itself

395
00:17:00.630 --> 00:17:03.870
as an opportunity for top line revenue growth

396
00:17:03.870 --> 00:17:05.760
and bottom line margin improvement.

397
00:17:05.760 --> 00:17:07.860
About a fifth of physicians today

398
00:17:07.860 --> 00:17:09.090
are in large medical groups,

399
00:17:09.090 --> 00:17:10.170
what we would consider to be a hundred

400
00:17:10.170 --> 00:17:15.030
or more physicians and about 50% of Medicare release today

401
00:17:15.030 --> 00:17:16.620
are in MA products

402
00:17:16.620 --> 00:17:19.500
that those physician groups are targeting.

403
00:17:19.500 --> 00:17:22.650
Again, threatening to cut out sort of the IDN health systems

404
00:17:22.650 --> 00:17:23.490
in the marketplace

405
00:17:23.490 --> 00:17:26.070
and also increasing their negotiating leverage

406
00:17:26.070 --> 00:17:29.640
with MA plans in their marketplaces.

407
00:17:29.640 --> 00:17:32.760
And finally, we have sort of the more consumer orientation

408
00:17:32.760 --> 00:17:34.350
that is happening in the marketplace today

409
00:17:34.350 --> 00:17:35.940
with the development

410
00:17:35.940 --> 00:17:40.940
of large ambulatory care centers of delivery.

411
00:17:41.550 --> 00:17:43.200
We see this with CVS and Walgreens

412
00:17:43.200 --> 00:17:46.050
in particular making dramatic investments

413
00:17:46.050 --> 00:17:49.230
in their in-store clinics as well

414
00:17:49.230 --> 00:17:53.940
as the rising up of standalone urgent care centers.

415
00:17:53.940 --> 00:17:56.010
DMS has also contributed to this.

416
00:17:56.010 --> 00:17:59.040
There's about 115, 116 now hospital

417
00:17:59.040 --> 00:18:00.510
at home demonstration projects

418
00:18:00.510 --> 00:18:03.450
that are underway in various stages of maturity.

419
00:18:03.450 --> 00:18:04.560
All of this is starting

420
00:18:04.560 --> 00:18:08.760
to really fundamentally change the course

421
00:18:08.760 --> 00:18:11.280
of the river of demand of healthcare services

422
00:18:11.280 --> 00:18:14.400
and forcing health systems, physician groups,

423
00:18:14.400 --> 00:18:16.554
specialty practices to think about

424
00:18:16.554 --> 00:18:19.020
what does the consumer journey look like today

425
00:18:19.020 --> 00:18:21.720
and can we manage that journey going forward

426
00:18:21.720 --> 00:18:24.510
with the existing assets that we have.

427
00:18:24.510 --> 00:18:26.070
So it's a very interesting time

428
00:18:26.070 --> 00:18:27.570
to be looking at the delivery,

429
00:18:27.570 --> 00:18:29.820
the market for the delivery of healthcare services

430
00:18:29.820 --> 00:18:33.180
given the macroeconomic challenges that folks are facing,

431
00:18:33.180 --> 00:18:36.690
which by nature are gonna be temporary and transient,

432
00:18:36.690 --> 00:18:39.690
but also looking at some of these more tectonic shifts

433
00:18:39.690 --> 00:18:42.060
in how healthcare is delivered

434
00:18:42.060 --> 00:18:44.710
and how healthcare is organized in local communities.

435
00:18:45.600 --> 00:18:47.340
It's creating urgency in other words

436
00:18:47.340 --> 00:18:49.770
for more and more providers to think more

437
00:18:49.770 --> 00:18:52.590
and more seriously about alternative contracting methods

438
00:18:52.590 --> 00:18:53.730
in order to make sure

439
00:18:53.730 --> 00:18:56.763
that they have sustainable business models going forward.

440
00:18:57.960 --> 00:19:00.480
And the way we've encouraged our payer

441
00:19:00.480 --> 00:19:02.430
and provider clients to think about this

442
00:19:02.430 --> 00:19:05.580
is that there are really two value levers

443
00:19:05.580 --> 00:19:08.040
in value-based care and it's where we start

444
00:19:08.040 --> 00:19:11.817
to see alignment between plans and providers.

445
00:19:11.817 --> 00:19:16.380
And the first lever is growing market share in lives

446
00:19:16.380 --> 00:19:19.470
because we do believe value-based care is a growth strategy.

447
00:19:19.470 --> 00:19:21.210
It's not just an opportunity

448
00:19:21.210 --> 00:19:24.150
to take unnecessary utilization out of the system.

449
00:19:24.150 --> 00:19:26.850
It's an opportunity to grow the number of lives

450
00:19:26.850 --> 00:19:28.950
that we are responsible for

451
00:19:28.950 --> 00:19:31.650
as a partnership between plans and providers

452
00:19:31.650 --> 00:19:35.220
by providing more affordable products in the marketplace,

453
00:19:35.220 --> 00:19:38.010
richer benefit packages in the marketplace,

454
00:19:38.010 --> 00:19:40.380
and easier access to their benefits

455
00:19:40.380 --> 00:19:42.120
through the contracting mechanisms

456
00:19:42.120 --> 00:19:44.643
that payers put in place with their networks.

457
00:19:45.870 --> 00:19:50.870
Once you have all of those lives in those product,

458
00:19:51.060 --> 00:19:53.758
then the next challenge largely is to make sure

459
00:19:53.758 --> 00:19:55.980
that we're managing network integrity

460
00:19:55.980 --> 00:19:59.250
and driving demand into the select networks

461
00:19:59.250 --> 00:20:01.800
that we have put in place for those product lines,

462
00:20:01.800 --> 00:20:03.420
so what we call share of wallet,

463
00:20:03.420 --> 00:20:06.780
to make sure that when there is necessary

464
00:20:06.780 --> 00:20:08.850
and required care to be delivered,

465
00:20:08.850 --> 00:20:11.750
that it is being delivered by our chosen network partners.

466
00:20:12.840 --> 00:20:13.770
Those are the value levers.

467
00:20:13.770 --> 00:20:15.510
Those are the things that we measure.

468
00:20:15.510 --> 00:20:18.330
Then the next question is are the enablers in place?

469
00:20:18.330 --> 00:20:21.210
And we'll talk more and more about the enablement factors

470
00:20:21.210 --> 00:20:23.400
in a couple of slides as we think about sort of

471
00:20:23.400 --> 00:20:26.160
how do you assess a provider network's capabilities

472
00:20:26.160 --> 00:20:29.790
for managing risk and managing populations at scale.

473
00:20:29.790 --> 00:20:31.670
But all of this applies to all

474
00:20:31.670 --> 00:20:34.380
of the different payment models that are out there today.

475
00:20:34.380 --> 00:20:39.380
And CMS I have argued over the last 10 or 12 years has been

476
00:20:40.230 --> 00:20:41.610
for better or for worse,

477
00:20:41.610 --> 00:20:44.730
the most creative and innovative payer

478
00:20:44.730 --> 00:20:46.950
that we see in the marketplace.

479
00:20:46.950 --> 00:20:50.640
They have tried more programs with more results

480
00:20:50.640 --> 00:20:52.200
with different types of providers

481
00:20:52.200 --> 00:20:55.590
than just about any other health plan out there.

482
00:20:55.590 --> 00:20:57.060
Largely because they have the scale to do it

483
00:20:57.060 --> 00:20:59.670
and they have a congressional mandate to do it.

484
00:20:59.670 --> 00:21:03.210
And they started with upside only MSSP models,

485
00:21:03.210 --> 00:21:06.150
rewarding networks who are able

486
00:21:06.150 --> 00:21:09.300
to manage utilization below certain thresholds

487
00:21:09.300 --> 00:21:11.520
without penalizing them for going

488
00:21:11.520 --> 00:21:16.200
over a pre-agreed upon benchmark.

489
00:21:16.200 --> 00:21:18.180
Those upside models still exist today

490
00:21:18.180 --> 00:21:19.890
in the MA and commercial world.

491
00:21:19.890 --> 00:21:21.480
Quite extensively in fact,

492
00:21:21.480 --> 00:21:24.390
and we tend to be relatively enthusiastic

493
00:21:24.390 --> 00:21:28.680
about upside only risk models as a good point

494
00:21:28.680 --> 00:21:32.359
at which to start this type of investment campaign

495
00:21:32.359 --> 00:21:35.280
and this type of care model redesign.

496
00:21:35.280 --> 00:21:40.280
It gives providers practice at ingesting new sets of data,

497
00:21:41.850 --> 00:21:43.980
understanding how to analyze and model

498
00:21:43.980 --> 00:21:46.170
that data to identify opportunities

499
00:21:46.170 --> 00:21:47.430
for performance improvement

500
00:21:47.430 --> 00:21:49.860
and clinical utilization improvement.

501
00:21:49.860 --> 00:21:52.920
It gives payers who have adopted these models the ability

502
00:21:52.920 --> 00:21:55.670
to identify which provider networks are going

503
00:21:55.670 --> 00:21:59.343
to be good recipients of that claims data.

504
00:22:00.480 --> 00:22:01.590
Are they gonna be collaborative

505
00:22:01.590 --> 00:22:05.130
in generating new care models for the populations

506
00:22:05.130 --> 00:22:07.200
that are enrolled in those products?

507
00:22:07.200 --> 00:22:09.870
But it is in and of itself not an end game.

508
00:22:09.870 --> 00:22:12.660
And I think CMS is increasingly thinking

509
00:22:12.660 --> 00:22:14.940
about this as just a starting point,

510
00:22:14.940 --> 00:22:16.647
but moving more and more providers

511
00:22:16.647 --> 00:22:20.760
and more and more patients in the two-sided risk models.

512
00:22:20.760 --> 00:22:24.960
That's where we see a lot of the MSSP tracks today

513
00:22:24.960 --> 00:22:29.220
presenting various levers and various models of upside

514
00:22:29.220 --> 00:22:32.970
and downside risk as well as the ACO reach model

515
00:22:32.970 --> 00:22:36.210
that they rolled out about a year ago.

516
00:22:36.210 --> 00:22:37.980
This is the first year live with that

517
00:22:37.980 --> 00:22:39.570
where they really are taking a fee

518
00:22:39.570 --> 00:22:42.337
for service chassis in Medicare and saying,

519
00:22:42.337 --> 00:22:45.660
"Okay, now we're gonna hold you pretty much at full risk

520
00:22:45.660 --> 00:22:46.680
for this population

521
00:22:46.680 --> 00:22:49.102
without fundamentally changing the benefit model

522
00:22:49.102 --> 00:22:51.720
and giving patients freedom of choice."

523
00:22:51.720 --> 00:22:53.130
It's a risky model,

524
00:22:53.130 --> 00:22:54.750
but it is sort of the natural evolution

525
00:22:54.750 --> 00:22:57.030
of where CMS has been taking the debate

526
00:22:57.030 --> 00:22:58.380
over the last decade or so.

527
00:22:59.627 --> 00:23:01.020
Now that's CMS.

528
00:23:01.020 --> 00:23:05.550
But what we continually advise our clients,

529
00:23:05.550 --> 00:23:07.920
our provider clients as well as our payer clients is that

530
00:23:07.920 --> 00:23:10.830
for these models to work, it needs to work at scale.

531
00:23:10.830 --> 00:23:12.870
You need to be able to do it across all of the,

532
00:23:12.870 --> 00:23:15.270
as many of the populations that you serve.

533
00:23:15.270 --> 00:23:19.410
And that necessitates providers going to their plans

534
00:23:19.410 --> 00:23:22.230
in their marketplace to build upon the successes

535
00:23:22.230 --> 00:23:24.060
that they've had in those CMS programs

536
00:23:24.060 --> 00:23:25.650
and leverage those lessons learned

537
00:23:25.650 --> 00:23:29.100
into private contracting arrangements.

538
00:23:29.100 --> 00:23:31.860
You can do that by mimicking the CMS models

539
00:23:31.860 --> 00:23:34.890
upside downside risks and ACL models

540
00:23:34.890 --> 00:23:37.470
or depending on the maturity level

541
00:23:37.470 --> 00:23:40.020
that you've attained through those experiments,

542
00:23:40.020 --> 00:23:43.830
moving into full cap risk arrangements

543
00:23:43.830 --> 00:23:46.173
with your payers in your marketplace.

544
00:23:47.130 --> 00:23:49.980
There's a wide plethora of payment models

545
00:23:49.980 --> 00:23:50.813
that are out there,

546
00:23:50.813 --> 00:23:53.457
but they essentially exist on this continuum.

547
00:23:53.457 --> 00:23:54.290
Now you've noticed,

548
00:23:54.290 --> 00:23:57.540
I haven't talked about bundled payments very much

549
00:23:57.540 --> 00:23:59.433
in these types of payment models,

550
00:24:00.600 --> 00:24:02.670
and that sort of does betray a little bit

551
00:24:02.670 --> 00:24:05.160
of our point of view on bundles.

552
00:24:05.160 --> 00:24:10.110
I think bundle payments can be a good tactic embedded

553
00:24:10.110 --> 00:24:12.690
in one of the four payment models you see

554
00:24:12.690 --> 00:24:14.400
at the bottom of this slide.

555
00:24:14.400 --> 00:24:15.450
But in and of itself,

556
00:24:15.450 --> 00:24:18.960
it's not really a value-based care approach

557
00:24:18.960 --> 00:24:20.190
to a marketplace.

558
00:24:20.190 --> 00:24:23.070
And that's because it is still largely dependent

559
00:24:23.070 --> 00:24:25.560
on volume and fee for service.

560
00:24:25.560 --> 00:24:27.330
And what we have found in certain markets

561
00:24:27.330 --> 00:24:29.820
is in both Medicare as well

562
00:24:29.820 --> 00:24:32.190
as in private pay bundle payment arrangements

563
00:24:32.190 --> 00:24:35.580
is that some provider networks are really good

564
00:24:35.580 --> 00:24:36.990
at managing bundles.

565
00:24:36.990 --> 00:24:38.645
They can make significant margin

566
00:24:38.645 --> 00:24:40.770
on particular types of bundles

567
00:24:40.770 --> 00:24:42.540
and then they end up doing more.

568
00:24:42.540 --> 00:24:47.540
So while they're optimizing their episodic risk performance,

569
00:24:47.700 --> 00:24:50.880
they're actually sub performing on a total cost of care

570
00:24:50.880 --> 00:24:53.040
for a population standpoint

571
00:24:53.040 --> 00:24:54.750
because they're just doing more and more volume

572
00:24:54.750 --> 00:24:56.880
of things that they're really, really good at.

573
00:24:56.880 --> 00:24:59.250
So I think that's an an important element

574
00:24:59.250 --> 00:25:01.080
of why we talked about operating risk

575
00:25:01.080 --> 00:25:03.090
as one of those four risk models

576
00:25:03.090 --> 00:25:06.120
that we're not overloading our specialty groups

577
00:25:06.120 --> 00:25:08.100
with too much volume simply

578
00:25:08.100 --> 00:25:09.630
because they're particularly efficient

579
00:25:09.630 --> 00:25:10.930
at a particular procedure.

580
00:25:13.020 --> 00:25:16.110
Talked a little bit earlier about growth

581
00:25:16.110 --> 00:25:19.050
and why this really is a growth model

582
00:25:19.050 --> 00:25:21.630
and we lay out a little bit of the math on this slide.

583
00:25:21.630 --> 00:25:23.520
Attribution as a growth metric.

584
00:25:23.520 --> 00:25:26.490
I think this is sort of second nature

585
00:25:26.490 --> 00:25:28.320
for a lot of payers to think

586
00:25:28.320 --> 00:25:31.620
about growing the enrollment that they have

587
00:25:31.620 --> 00:25:33.390
in particular product lines,

588
00:25:33.390 --> 00:25:37.230
but it's a new model for a lot of providers out there

589
00:25:37.230 --> 00:25:38.063
in the marketplace

590
00:25:38.063 --> 00:25:40.320
and it really does require some education

591
00:25:40.320 --> 00:25:42.420
to think about attributable lives

592
00:25:42.420 --> 00:25:43.620
and what the opportunity is

593
00:25:43.620 --> 00:25:46.191
to grow your primary care footprint

594
00:25:46.191 --> 00:25:49.950
and the productivity of that primary care network.

595
00:25:49.950 --> 00:25:52.830
And I won't get too much into the details here.

596
00:25:52.830 --> 00:25:54.690
But what we have found is that there

597
00:25:54.690 --> 00:25:57.870
is significant productivity growth available

598
00:25:57.870 --> 00:26:00.330
in a lot of these primary care networks.

599
00:26:00.330 --> 00:26:02.700
They can certainly think about partnering

600
00:26:02.700 --> 00:26:05.220
beyond their existing owned

601
00:26:05.220 --> 00:26:07.830
or aligned primary care practices

602
00:26:07.830 --> 00:26:09.750
in order to have more exposure

603
00:26:09.750 --> 00:26:12.123
and more visibility into more lives.

604
00:26:13.020 --> 00:26:15.030
But what we see the real lift being

605
00:26:15.030 --> 00:26:17.310
is on that share of wallet capture.

606
00:26:17.310 --> 00:26:18.900
How much of the medical spend

607
00:26:18.900 --> 00:26:23.370
in that MOR is leaking out of the network

608
00:26:23.370 --> 00:26:25.350
and how much of that can we pull back?

609
00:26:25.350 --> 00:26:26.850
And that is going to be driven

610
00:26:26.850 --> 00:26:29.850
by how well you partner with the independent groups

611
00:26:29.850 --> 00:26:30.840
in a marketplace,

612
00:26:30.840 --> 00:26:33.960
how well designed those networks are,

613
00:26:33.960 --> 00:26:36.210
and how well information is shared

614
00:26:36.210 --> 00:26:37.860
across those different practices

615
00:26:37.860 --> 00:26:40.680
and with the health system itself.

616
00:26:40.680 --> 00:26:44.700
That upside is going to be top line revenue growth

617
00:26:44.700 --> 00:26:47.640
for most health systems with the proper contracts

618
00:26:47.640 --> 00:26:51.600
in place that can still represent an overall decrease

619
00:26:51.600 --> 00:26:54.870
in total cost of care for a given population.

620
00:26:54.870 --> 00:26:58.680
The trade-off there is in the denominator.

621
00:26:58.680 --> 00:26:59.610
Now what we're really looking

622
00:26:59.610 --> 00:27:01.650
to do here is grow the denominator

623
00:27:01.650 --> 00:27:05.730
so that the average per capita spend is lower,

624
00:27:05.730 --> 00:27:08.490
but you're doing it across a much broader population.

625
00:27:08.490 --> 00:27:10.650
That becomes immediately attractive

626
00:27:10.650 --> 00:27:12.870
to health plans who are looking to grow.

627
00:27:12.870 --> 00:27:14.190
And it becomes immediately attractive

628
00:27:14.190 --> 00:27:17.850
to health systems who can fundamentally execute

629
00:27:17.850 --> 00:27:20.160
against that referral management.

630
00:27:20.160 --> 00:27:22.380
And that's where incentives start to align

631
00:27:22.380 --> 00:27:23.213
and that's where you can really

632
00:27:23.213 --> 00:27:25.410
build some very interesting partnerships

633
00:27:25.410 --> 00:27:28.860
between payers and partners, payers and providers,

634
00:27:28.860 --> 00:27:31.920
and start to contract and memorialize those agreements

635
00:27:31.920 --> 00:27:33.063
in those contracts.

636
00:27:34.500 --> 00:27:36.540
Those contracts then need to really talk

637
00:27:36.540 --> 00:27:40.170
about four big things in order for this to work.

638
00:27:40.170 --> 00:27:42.870
And the first is those contracting models.

639
00:27:42.870 --> 00:27:45.000
Have we gotten a risk correct?

640
00:27:45.000 --> 00:27:47.010
Is the revenue diversification something

641
00:27:47.010 --> 00:27:48.873
that we can live with

642
00:27:48.873 --> 00:27:51.420
and does it give everybody the best chance

643
00:27:51.420 --> 00:27:54.933
to grow in attributed lives and share of wallet?

644
00:27:56.220 --> 00:27:57.090
Then the next question

645
00:27:57.090 --> 00:28:01.470
is are we giving our beneficiaries the tools

646
00:28:01.470 --> 00:28:02.370
that they need in order

647
00:28:02.370 --> 00:28:05.400
to access their benefits most effectively?

648
00:28:05.400 --> 00:28:08.580
And this is kind of a new dynamic

649
00:28:08.580 --> 00:28:10.230
that we have seen emerge with payers

650
00:28:10.230 --> 00:28:11.913
over the last three years

651
00:28:11.913 --> 00:28:14.310
and we, I think we saw the seeds of this planted

652
00:28:14.310 --> 00:28:16.890
during the summer of 2020.

653
00:28:16.890 --> 00:28:20.910
About four months into the public health emergency,

654
00:28:20.910 --> 00:28:24.450
health plans were in very good shape.

655
00:28:24.450 --> 00:28:27.060
People were not going in for elective care.

656
00:28:27.060 --> 00:28:30.330
There wasn't a lot of unnecessary demand

657
00:28:30.330 --> 00:28:32.670
in the healthcare system at that point in time.

658
00:28:32.670 --> 00:28:34.650
But I think gradually,

659
00:28:34.650 --> 00:28:37.800
very quickly health plans realized

660
00:28:37.800 --> 00:28:40.140
that at some point, those individuals

661
00:28:40.140 --> 00:28:42.360
who were not seeking care were not just those

662
00:28:42.360 --> 00:28:43.980
who were avoiding elective care.

663
00:28:43.980 --> 00:28:45.270
They were individuals who were scared

664
00:28:45.270 --> 00:28:48.870
about coming in but had real chronic healthcare needs.

665
00:28:48.870 --> 00:28:51.240
And at some point, they would come back into the system

666
00:28:51.240 --> 00:28:53.910
and they were gonna be much more expensive

667
00:28:53.910 --> 00:28:57.210
and much sicker than they would've otherwise had been

668
00:28:57.210 --> 00:29:01.320
if they'd been able to maintain their care regimes.

669
00:29:01.320 --> 00:29:05.100
So plans got pretty smart in some respects

670
00:29:05.100 --> 00:29:07.290
and in many markets about reaching out

671
00:29:07.290 --> 00:29:10.710
to those rising risk and identified risk populations

672
00:29:10.710 --> 00:29:13.560
to keep them engaged with their benefits

673
00:29:13.560 --> 00:29:16.380
to keep them engaged with their providers.

674
00:29:16.380 --> 00:29:18.480
And what we saw was a lot of collaboration

675
00:29:18.480 --> 00:29:20.949
between health plans and their networks

676
00:29:20.949 --> 00:29:24.900
to make sure that those at-risk populations were able

677
00:29:24.900 --> 00:29:26.850
to maintain their health during a time

678
00:29:26.850 --> 00:29:28.620
of great uncertainty in their ability

679
00:29:28.620 --> 00:29:31.800
to physically access a physician office

680
00:29:31.800 --> 00:29:32.943
or an emergency room.

681
00:29:33.780 --> 00:29:36.630
Those are good lessons to have learned during the pandemic

682
00:29:36.630 --> 00:29:39.690
and I don't think that they were limited to the pandemic.

683
00:29:39.690 --> 00:29:44.100
They are lessons that we should mature and integrate

684
00:29:44.100 --> 00:29:46.230
into the way we think about benefit design

685
00:29:46.230 --> 00:29:49.650
and patient access and beneficiary access going forward.

686
00:29:49.650 --> 00:29:53.100
Because what we have found in a lot of the engagements

687
00:29:53.100 --> 00:29:55.170
that we have done in Optum Advisory

688
00:29:55.170 --> 00:29:56.730
is that the more you can get those patients

689
00:29:56.730 --> 00:29:58.710
to engage with their benefits in a predictable way

690
00:29:58.710 --> 00:30:00.950
that leaves them satisfied with the experience

691
00:30:00.950 --> 00:30:03.270
is that you also end up with better outcomes

692
00:30:03.270 --> 00:30:04.773
and lower total cost of care.

693
00:30:05.790 --> 00:30:08.160
And then finally, I think what what we're looking

694
00:30:08.160 --> 00:30:10.080
to do in a lot of these joint contract

695
00:30:10.080 --> 00:30:13.170
payer provider partnerships is to memorialize some

696
00:30:13.170 --> 00:30:14.310
of these new care models

697
00:30:14.310 --> 00:30:17.318
and make sure that those care models are jointly designed

698
00:30:17.318 --> 00:30:19.480
by partnerships in place

699
00:30:21.180 --> 00:30:26.180
and that some of the ongoing care management functions

700
00:30:26.370 --> 00:30:29.464
are delegated down to providers.

701
00:30:29.464 --> 00:30:30.960
This is where I normally tell a quick story

702
00:30:30.960 --> 00:30:33.630
about sitting on a panel a few years ago

703
00:30:33.630 --> 00:30:38.280
with a representative from a large national carrier,

704
00:30:38.280 --> 00:30:40.680
a representative of a physician group.

705
00:30:40.680 --> 00:30:44.220
And I was representing health systems on that panel.

706
00:30:44.220 --> 00:30:46.170
And it had nothing to do with what I said,

707
00:30:46.170 --> 00:30:47.003
but it had something to do

708
00:30:47.003 --> 00:30:48.420
with what the representative

709
00:30:48.420 --> 00:30:49.830
of a national insurance carrier said,

710
00:30:49.830 --> 00:30:53.610
which was that we hate risk as payers.

711
00:30:53.610 --> 00:30:56.790
We really hate the idea of having to manage risk.

712
00:30:56.790 --> 00:30:59.857
And I remember sitting in that panel thinking,

713
00:30:59.857 --> 00:31:01.740
"Well, that's why insurance companies exist.

714
00:31:01.740 --> 00:31:03.420
It's to manage risk."

715
00:31:03.420 --> 00:31:06.150
So I was a little befuddled by the statement.

716
00:31:06.150 --> 00:31:09.510
And afterwards, I asked him what he actually meant

717
00:31:09.510 --> 00:31:11.010
by that statement.

718
00:31:11.010 --> 00:31:15.120
And he said, "Health plans are great at pricing risk.

719
00:31:15.120 --> 00:31:17.490
We have tremendous actuarial assets

720
00:31:17.490 --> 00:31:21.480
that can help us price that risk for beneficiaries.

721
00:31:21.480 --> 00:31:24.930
But we can't manage risk because we have beneficiaries

722
00:31:24.930 --> 00:31:27.300
and risk is managed at the patient level."

723
00:31:27.300 --> 00:31:28.140
And he wasn't trying

724
00:31:28.140 --> 00:31:31.020
to make a needless semantic distinction.

725
00:31:31.020 --> 00:31:33.630
I think he was making very meaningful distinction

726
00:31:33.630 --> 00:31:36.240
that risk is managed at the patient level,

727
00:31:36.240 --> 00:31:39.330
that patient, that the most direct relationship

728
00:31:39.330 --> 00:31:41.070
that will inflect that patient's behavior

729
00:31:41.070 --> 00:31:42.420
is with the provider.

730
00:31:42.420 --> 00:31:44.700
And we need to do a better job of delegating down

731
00:31:44.700 --> 00:31:47.550
to those providers, utilization management,

732
00:31:47.550 --> 00:31:49.920
care management, prior decision making,

733
00:31:49.920 --> 00:31:52.050
and functions that have normally existed

734
00:31:52.050 --> 00:31:56.100
at the payer level but that we have historically struggled

735
00:31:56.100 --> 00:31:57.960
in doing a good job with.

736
00:31:57.960 --> 00:31:58.793
To a certain degree,

737
00:31:58.793 --> 00:32:01.020
we could help price that risk correctly,

738
00:32:01.020 --> 00:32:02.610
but then delegate the responsibility

739
00:32:02.610 --> 00:32:06.690
for managing it down to providers and for that,

740
00:32:06.690 --> 00:32:09.590
new care models should be memorialized in those contracts.

741
00:32:11.093 --> 00:32:13.170
So that gets us to sort of our large structure

742
00:32:13.170 --> 00:32:15.600
and our maturity model for value-based care.

743
00:32:15.600 --> 00:32:16.980
And I think this applies

744
00:32:16.980 --> 00:32:19.770
to all of the partnerships that we think about.

745
00:32:19.770 --> 00:32:22.590
The first is on your strategy

746
00:32:22.590 --> 00:32:24.600
and we're really looking to answer three questions there.

747
00:32:24.600 --> 00:32:27.900
One is, who do you want to take risk on?

748
00:32:27.900 --> 00:32:29.490
Medicare, Medicaid, commercial.

749
00:32:29.490 --> 00:32:31.170
How much risk do you want to take?

750
00:32:31.170 --> 00:32:35.040
Upside only, upside downside, or full capitation?

751
00:32:35.040 --> 00:32:37.020
And third, who are you gonna partner with

752
00:32:37.020 --> 00:32:40.140
to go into this market with this new type of contract?

753
00:32:40.140 --> 00:32:42.780
What's your governance model going forward?

754
00:32:42.780 --> 00:32:45.150
Once you've established that north star,

755
00:32:45.150 --> 00:32:46.650
then the next question is who's gonna go on

756
00:32:46.650 --> 00:32:47.610
that journey with you?

757
00:32:47.610 --> 00:32:50.370
And that's the network build and management function

758
00:32:50.370 --> 00:32:52.560
that you see on the top left there.

759
00:32:52.560 --> 00:32:54.090
I'm not necessarily just talking

760
00:32:54.090 --> 00:32:55.560
about clinically integrated networks here.

761
00:32:55.560 --> 00:32:58.290
I'm talking about a network that is sufficient

762
00:32:58.290 --> 00:33:00.240
to treat the patients that you have.

763
00:33:00.240 --> 00:33:02.220
And I know that sounds somewhat reductive,

764
00:33:02.220 --> 00:33:04.350
but if you think about Medicare Advantage

765
00:33:04.350 --> 00:33:06.069
or Medicare ACO populations,

766
00:33:06.069 --> 00:33:08.610
that network is gonna have to include skilled nursing

767
00:33:08.610 --> 00:33:09.690
and home health facilities

768
00:33:09.690 --> 00:33:13.050
that do more than just meet rate requirements.

769
00:33:13.050 --> 00:33:15.660
There are high quality skilled nursing

770
00:33:15.660 --> 00:33:17.940
and home health agencies who can manage populations

771
00:33:17.940 --> 00:33:21.570
on the extended tail of a post-discharge admission.

772
00:33:21.570 --> 00:33:23.063
It's gonna look different in Medicaid

773
00:33:23.063 --> 00:33:24.930
and it's gonna look different in commercial,

774
00:33:24.930 --> 00:33:27.390
but whatever it is, and then you can do all three.

775
00:33:27.390 --> 00:33:30.510
Those networks have to be bespoke to those populations.

776
00:33:30.510 --> 00:33:31.920
The next question is what are you gonna ask them

777
00:33:31.920 --> 00:33:34.230
to do differently from a population health management

778
00:33:34.230 --> 00:33:36.150
and coding perspective?

779
00:33:36.150 --> 00:33:38.545
Are the care models in the care transition programs

780
00:33:38.545 --> 00:33:41.010
being put in place sufficient

781
00:33:41.010 --> 00:33:43.800
and scalable enough on the provider side

782
00:33:43.800 --> 00:33:46.410
to manage the volume

783
00:33:46.410 --> 00:33:48.660
that those populations are going to represent?

784
00:33:48.660 --> 00:33:50.700
And this requires a lot of change management both

785
00:33:50.700 --> 00:33:52.560
at the practice level as well as

786
00:33:52.560 --> 00:33:55.203
at the inpatient point of care as well.

787
00:33:57.030 --> 00:33:59.100
You're still gonna have a lot of necessary care.

788
00:33:59.100 --> 00:34:00.600
And so we wanna make sure that we're getting

789
00:34:00.600 --> 00:34:03.120
that operational episodic risk right

790
00:34:03.120 --> 00:34:05.250
through improvements in our care delivery.

791
00:34:05.250 --> 00:34:07.740
It's still gonna matter that we manage length of stay

792
00:34:07.740 --> 00:34:10.020
in all institutional settings effectively.

793
00:34:10.020 --> 00:34:12.090
It's still gonna matter that we take advantage

794
00:34:12.090 --> 00:34:15.930
of site of service arbitrage across all of our populations.

795
00:34:15.930 --> 00:34:18.240
All of that is gonna sit on an data analytics

796
00:34:18.240 --> 00:34:22.530
and reporting platform that ingest the right level of data

797
00:34:22.530 --> 00:34:26.670
with the right cadence and produces the right level

798
00:34:26.670 --> 00:34:29.040
of granularity for decision makers

799
00:34:29.040 --> 00:34:31.110
at the provider level to make decisions

800
00:34:31.110 --> 00:34:33.750
about where performance improvement initiatives need

801
00:34:33.750 --> 00:34:35.400
to take place.

802
00:34:35.400 --> 00:34:37.950
And finally, we wanna make sure

803
00:34:37.950 --> 00:34:40.680
that the enterprise risk is appropriately priced.

804
00:34:40.680 --> 00:34:43.230
And that is something that providers

805
00:34:43.230 --> 00:34:44.938
have very little experience in.

806
00:34:44.938 --> 00:34:48.420
Providers, payers have a great deal of experience in.

807
00:34:48.420 --> 00:34:49.253
And we wanna make sure

808
00:34:49.253 --> 00:34:51.090
that there's a new equilibrium established

809
00:34:51.090 --> 00:34:53.400
for payers and providers to jointly negotiate

810
00:34:53.400 --> 00:34:56.040
what that risk needs to look like.

811
00:34:56.040 --> 00:34:57.420
This is a long-term strategy

812
00:34:57.420 --> 00:34:59.280
and I won't get into the ones on the side,

813
00:34:59.280 --> 00:35:01.380
the enterprise governance, organizational commitment,

814
00:35:01.380 --> 00:35:04.110
and change management because that's its own webinar.

815
00:35:04.110 --> 00:35:05.850
But what we're really talking about here

816
00:35:05.850 --> 00:35:08.820
from a value-based care standpoint is patients.

817
00:35:08.820 --> 00:35:11.700
We need these new partnerships to have a three

818
00:35:11.700 --> 00:35:15.600
to five year point of view on this new opportunity.

819
00:35:15.600 --> 00:35:18.810
These are not that thick payoff in 12 months.

820
00:35:18.810 --> 00:35:20.367
It does require sort of a multi-year

821
00:35:20.367 --> 00:35:24.360
and in many cases a multi-product line approach

822
00:35:24.360 --> 00:35:27.300
under a single infrastructure

823
00:35:27.300 --> 00:35:29.400
that the payer and provider partners have decided

824
00:35:29.400 --> 00:35:31.920
to erect around their communities

825
00:35:31.920 --> 00:35:33.360
and around the different populations

826
00:35:33.360 --> 00:35:34.950
that live in those communities.

827
00:35:34.950 --> 00:35:36.330
But it really does require folks

828
00:35:36.330 --> 00:35:39.720
to take that three to five year point of view.

829
00:35:39.720 --> 00:35:42.113
We'll talk about a couple opportunities here

830
00:35:42.113 --> 00:35:44.430
that are probably top of mind for a lot of folks.

831
00:35:44.430 --> 00:35:46.950
And the first is the Medicare imperatives.

832
00:35:46.950 --> 00:35:49.020
And I'm sure many of you're already familiar with this,

833
00:35:49.020 --> 00:35:51.720
but Medicare Advantage is insanely popular.

834
00:35:51.720 --> 00:35:54.450
Medicare Advantage is taking most of the growth

835
00:35:54.450 --> 00:35:56.640
in the over 65 population today.

836
00:35:56.640 --> 00:35:59.850
These are a few MSAs that we've charted out

837
00:35:59.850 --> 00:36:02.130
to show just how popular Medicare Advantage

838
00:36:02.130 --> 00:36:04.890
has become over the last few years.

839
00:36:04.890 --> 00:36:07.560
And this is true largely across the country

840
00:36:07.560 --> 00:36:12.560
and I don't really see that waning anytime soon.

841
00:36:13.470 --> 00:36:15.660
CMS has a couple key priorities

842
00:36:15.660 --> 00:36:17.190
that they're constantly trying to achieve.

843
00:36:17.190 --> 00:36:20.700
The first is protecting the Medicare trust funds,

844
00:36:20.700 --> 00:36:22.050
and the second is making sure

845
00:36:22.050 --> 00:36:25.470
that their beneficiaries are happy.

846
00:36:25.470 --> 00:36:28.290
And Medicare Advantage is extremely popular

847
00:36:28.290 --> 00:36:29.640
for any number of reasons

848
00:36:29.640 --> 00:36:32.610
that I'm sure many of you are more familiar with than me.

849
00:36:32.610 --> 00:36:34.200
But this is the direction of travel

850
00:36:34.200 --> 00:36:35.910
for the over 65 population.

851
00:36:35.910 --> 00:36:38.277
And for providers who are seeing more

852
00:36:38.277 --> 00:36:40.020
and more of their volume represented

853
00:36:40.020 --> 00:36:41.587
by the over 65 population,

854
00:36:41.587 --> 00:36:43.890
they have to have a new approach

855
00:36:43.890 --> 00:36:45.390
to that population in order

856
00:36:45.390 --> 00:36:47.853
to make the economic models work for them.

857
00:36:48.810 --> 00:36:50.190
And there are really three ways

858
00:36:50.190 --> 00:36:51.840
to make these economic models work.

859
00:36:51.840 --> 00:36:55.560
It is to make those MA products more profitable

860
00:36:55.560 --> 00:36:58.050
for the plans that sponsor them

861
00:36:58.050 --> 00:37:00.810
and on whose licenses these products ride.

862
00:37:00.810 --> 00:37:04.407
And the first is to get accurate patient coding in place.

863
00:37:04.407 --> 00:37:07.380
Now I realize that there's a lot of discussion

864
00:37:07.380 --> 00:37:10.306
around how HCC scores are calculated

865
00:37:10.306 --> 00:37:12.210
and will be calculated going forward

866
00:37:12.210 --> 00:37:13.620
over the next three years.

867
00:37:13.620 --> 00:37:14.940
It's not going away,

868
00:37:14.940 --> 00:37:16.890
but it will be constrained a little bit

869
00:37:16.890 --> 00:37:19.260
by some of the decisions CMS is making.

870
00:37:19.260 --> 00:37:22.050
Nevertheless, for provider networks to show value,

871
00:37:22.050 --> 00:37:24.030
they have to be able to show in part

872
00:37:24.030 --> 00:37:28.356
that they're good at coding the visits that they get.

873
00:37:28.356 --> 00:37:32.430
The second is your total cost of care and your star ratings.

874
00:37:32.430 --> 00:37:34.386
Are the providers in the network

875
00:37:34.386 --> 00:37:37.590
providing the necessary level of population health

876
00:37:37.590 --> 00:37:40.386
that you can bring down total cost of care

877
00:37:40.386 --> 00:37:43.470
and are they providing a consumer experience

878
00:37:43.470 --> 00:37:45.823
that will help the plan achieve the maximum level

879
00:37:45.823 --> 00:37:49.230
of star ratings in this new regime,

880
00:37:49.230 --> 00:37:51.933
which is largely based on consumer satisfaction.

881
00:37:52.950 --> 00:37:55.800
And then finally, is this a high value network?

882
00:37:55.800 --> 00:37:58.290
Back to some of the capabilities we talked

883
00:37:58.290 --> 00:37:59.640
about in the maturity model.

884
00:37:59.640 --> 00:38:03.180
Is this a network that is relatively seamless,

885
00:38:03.180 --> 00:38:04.983
operates as a network,

886
00:38:06.300 --> 00:38:08.550
has fairly seamless referral patterns,

887
00:38:08.550 --> 00:38:11.820
and provides the provider network itself

888
00:38:11.820 --> 00:38:15.240
its share of gains in demand.

889
00:38:15.240 --> 00:38:18.003
So we're minimizing that leakage.

890
00:38:19.710 --> 00:38:22.080
Increasingly the payer clients that we work with,

891
00:38:22.080 --> 00:38:25.320
that's really what they're looking for from their networks.

892
00:38:25.320 --> 00:38:27.690
And I think that's largely new.

893
00:38:27.690 --> 00:38:29.130
A lot of this is largely new

894
00:38:29.130 --> 00:38:30.300
to the networks that we work with

895
00:38:30.300 --> 00:38:32.670
on the provider side of the shop.

896
00:38:32.670 --> 00:38:36.150
That model is probably gonna sustain itself going forward,

897
00:38:36.150 --> 00:38:38.820
but there's a lot of pressure on that model going forward.

898
00:38:38.820 --> 00:38:40.770
And we lay out some of those pressures here

899
00:38:40.770 --> 00:38:42.540
and we've talked about most of these

900
00:38:42.540 --> 00:38:45.000
over the last 40 minutes or so.

901
00:38:45.000 --> 00:38:46.680
The expiration of some

902
00:38:46.680 --> 00:38:48.960
of the pandemic related rating adjustments

903
00:38:48.960 --> 00:38:49.800
going away this year,

904
00:38:49.800 --> 00:38:53.100
it's gonna make star ratings a whole lot harder.

905
00:38:53.100 --> 00:38:56.760
Only about 51% of MA plans had a star rating four

906
00:38:56.760 --> 00:38:57.810
or more this year.

907
00:38:57.810 --> 00:39:01.080
That's down significantly from 2022.

908
00:39:01.080 --> 00:39:04.230
And that's largely because of the change,

909
00:39:04.230 --> 00:39:05.340
the ongoing change

910
00:39:05.340 --> 00:39:10.340
towards a more caps focused survey Medicare beneficiaries.

911
00:39:10.830 --> 00:39:13.080
But also because of some of expiration

912
00:39:13.080 --> 00:39:17.580
of the pandemic relief that congress put in place in 2020.

913
00:39:17.580 --> 00:39:19.320
This heightened focus on health equity

914
00:39:19.320 --> 00:39:21.810
is becoming a really interesting challenge

915
00:39:21.810 --> 00:39:25.140
for MA plans as well as providers to start to grapple with.

916
00:39:25.140 --> 00:39:28.110
Health equity is still a relatively new dynamic

917
00:39:28.110 --> 00:39:29.940
that is creating some uncertainty

918
00:39:29.940 --> 00:39:33.510
and some disequilibrium in these partnerships

919
00:39:33.510 --> 00:39:36.630
to try to figure out how to address it most effectively.

920
00:39:36.630 --> 00:39:39.900
I think there's a lot of innovation happening in this world

921
00:39:39.900 --> 00:39:41.550
and I encourage it and I think

922
00:39:41.550 --> 00:39:43.440
that there should be ongoing innovation

923
00:39:43.440 --> 00:39:45.060
in this because I don't think right now there

924
00:39:45.060 --> 00:39:49.020
is a right answer in how to approach the inequities

925
00:39:49.020 --> 00:39:50.790
that we see in our communities.

926
00:39:50.790 --> 00:39:52.440
I think there's a lot of experimentation

927
00:39:52.440 --> 00:39:53.850
and innovation happening,

928
00:39:53.850 --> 00:39:56.040
but I don't think we're to a new equilibrium

929
00:39:56.040 --> 00:39:58.500
in how we incorporate that into our benefit models

930
00:39:58.500 --> 00:39:59.950
and into our network designs.

931
00:40:01.260 --> 00:40:03.210
We've talked about the narrowing opportunities

932
00:40:03.210 --> 00:40:08.070
in coding that CMS roll out in their advanced notice earlier

933
00:40:08.070 --> 00:40:11.100
in the spring and then in the final notice last month.

934
00:40:11.100 --> 00:40:14.640
This is gonna put pressure on top line revenue opportunities

935
00:40:14.640 --> 00:40:15.990
for MA plans as well as

936
00:40:15.990 --> 00:40:18.947
for those taking delegated full cap arrangements

937
00:40:18.947 --> 00:40:21.990
from MA plans on the provider side.

938
00:40:21.990 --> 00:40:24.090
It hasn't completely eliminated it,

939
00:40:24.090 --> 00:40:26.190
but I think it is going to change the points

940
00:40:26.190 --> 00:40:29.130
of emphasis away from top line revenue growth,

941
00:40:29.130 --> 00:40:32.490
more toward managing total cost of care

942
00:40:32.490 --> 00:40:34.740
and really starting to get at some of

943
00:40:34.740 --> 00:40:38.400
that previously unaddressed, unanticipated,

944
00:40:38.400 --> 00:40:40.260
and unnecessary demand.

945
00:40:40.260 --> 00:40:43.170
And finally, we've talked about cap surveys.

946
00:40:43.170 --> 00:40:44.970
All of this requires some partnership.

947
00:40:44.970 --> 00:40:47.130
I don't think a payer is gonna be able to do this

948
00:40:47.130 --> 00:40:49.440
on their own and I don't think a provider network

949
00:40:49.440 --> 00:40:51.090
is gonna be able to do it on its own.

950
00:40:51.090 --> 00:40:54.060
It's gonna require the combined thinking

951
00:40:54.060 --> 00:40:55.770
and the combined insights from both sides

952
00:40:55.770 --> 00:40:57.720
of that equation in order to come up

953
00:40:57.720 --> 00:41:01.200
with sustainable solutions to this challenge.

954
00:41:01.200 --> 00:41:05.280
And I think it's worth coming up with an approach,

955
00:41:05.280 --> 00:41:08.103
a joint approach to this because for providers,

956
00:41:09.540 --> 00:41:12.120
MA is really the only place left for them

957
00:41:12.120 --> 00:41:15.420
to find margin in the Medicare population.

958
00:41:15.420 --> 00:41:20.420
Right now, they basically break even on Medicare populations

959
00:41:20.430 --> 00:41:21.930
and they basically break even

960
00:41:21.930 --> 00:41:24.030
on Medicare advantage contracts,

961
00:41:24.030 --> 00:41:26.220
whereas all of the value right now,

962
00:41:26.220 --> 00:41:28.440
all of the excess value

963
00:41:28.440 --> 00:41:32.070
or all of the margin is focused on the provider.

964
00:41:32.070 --> 00:41:35.520
Around 8% to 10% margin for most

965
00:41:35.520 --> 00:41:37.740
of the payers that we work with.

966
00:41:37.740 --> 00:41:41.970
In order to grow, we think MA plans are gonna have

967
00:41:41.970 --> 00:41:43.410
to be willing to sacrifice some

968
00:41:43.410 --> 00:41:44.820
of that margin down to providers

969
00:41:44.820 --> 00:41:47.250
in order to grow membership.

970
00:41:47.250 --> 00:41:50.460
There is no other place for providers to get that.

971
00:41:50.460 --> 00:41:51.750
There is in the commercial world

972
00:41:51.750 --> 00:41:54.150
and that's largely where we've seen providers make money

973
00:41:54.150 --> 00:41:55.980
over the last few years.

974
00:41:55.980 --> 00:41:58.290
But given some of the challenges

975
00:41:58.290 --> 00:42:02.430
that we have seen in site of service reallocation,

976
00:42:02.430 --> 00:42:05.160
some of those disruptive tectonic trends

977
00:42:05.160 --> 00:42:06.750
that we talked about earlier,

978
00:42:06.750 --> 00:42:08.460
this is becoming less and less available

979
00:42:08.460 --> 00:42:10.590
to most health systems as they are starting

980
00:42:10.590 --> 00:42:12.900
to feel themselves marginalized

981
00:42:12.900 --> 00:42:14.760
by some of the new market entrants.

982
00:42:14.760 --> 00:42:16.440
So they are gonna have to double down

983
00:42:16.440 --> 00:42:18.120
on their Medicare advantage bets

984
00:42:18.120 --> 00:42:19.530
and they're gonna have to double down

985
00:42:19.530 --> 00:42:21.581
on the discussions that they have

986
00:42:21.581 --> 00:42:23.280
with their community health plans

987
00:42:23.280 --> 00:42:26.280
in order to make sure that everybody can grow

988
00:42:26.280 --> 00:42:29.490
in a way that is sustainable going forward.

989
00:42:29.490 --> 00:42:31.203
That's the Medicare challenge.

990
00:42:33.810 --> 00:42:36.160
Medicaid opportunity is a little bit different.

991
00:42:37.457 --> 00:42:40.293
And in some respects from an analytic point of view,

992
00:42:41.400 --> 00:42:43.140
much more interesting in some respects

993
00:42:43.140 --> 00:42:44.550
because these populations have

994
00:42:44.550 --> 00:42:47.467
such heterogeneous needs going forward.

995
00:42:47.467 --> 00:42:50.910
And it is so difficult to keep these lives long enough

996
00:42:50.910 --> 00:42:53.430
for some of these population health investments

997
00:42:53.430 --> 00:42:54.750
that you make in these communities

998
00:42:54.750 --> 00:42:58.440
to really take hold and generate a positive ROI.

999
00:42:58.440 --> 00:43:00.840
But we have seen that it can be done.

1000
00:43:00.840 --> 00:43:02.700
We have seen, in our experience,

1001
00:43:02.700 --> 00:43:04.230
at least within Optum Advisory,

1002
00:43:04.230 --> 00:43:06.870
we have seen plenty of Medicaid managed care plans,

1003
00:43:06.870 --> 00:43:09.540
provider sponsored Medicaid managed care plans

1004
00:43:09.540 --> 00:43:12.060
really succeed in their ability

1005
00:43:12.060 --> 00:43:14.910
to deliver high quality care to their communities

1006
00:43:14.910 --> 00:43:18.030
as well as make some top line revenues

1007
00:43:18.030 --> 00:43:19.800
and bottom line margin.

1008
00:43:19.800 --> 00:43:23.190
But to do that, they've had to become very aggressive

1009
00:43:23.190 --> 00:43:25.770
in a couple of areas.

1010
00:43:25.770 --> 00:43:30.480
One is to get very aggressive in their approach to analytics

1011
00:43:30.480 --> 00:43:34.260
to understand what are some of the underlying trends

1012
00:43:34.260 --> 00:43:38.583
in the Medicaid populations that might hide something

1013
00:43:39.510 --> 00:43:42.090
that is gonna come back in later years

1014
00:43:42.090 --> 00:43:43.830
and start to really affect their ability

1015
00:43:43.830 --> 00:43:47.520
to make margin on those delegated arrangements.

1016
00:43:47.520 --> 00:43:49.650
And the second area of major investment

1017
00:43:49.650 --> 00:43:51.810
is investing in the community.

1018
00:43:51.810 --> 00:43:54.690
And this is where Medicaid is really quite different

1019
00:43:54.690 --> 00:43:57.390
from other VBC arrangements.

1020
00:43:57.390 --> 00:44:01.530
It's that emphasis on community assets

1021
00:44:01.530 --> 00:44:04.560
that can address these populations in place

1022
00:44:04.560 --> 00:44:06.390
and address some of their social determinants

1023
00:44:06.390 --> 00:44:09.213
of health in an effective way.

1024
00:44:10.170 --> 00:44:11.003
Medicare Advantage,

1025
00:44:11.003 --> 00:44:12.840
I think the playbook there is pretty straightforward.

1026
00:44:12.840 --> 00:44:16.350
We talked about some of those elements a few minutes ago.

1027
00:44:16.350 --> 00:44:18.780
And Medicaid, what we have seen work,

1028
00:44:18.780 --> 00:44:21.600
and this slide is, comes to us from our sister company,

1029
00:44:21.600 --> 00:44:22.433
the Advisory Board,

1030
00:44:22.433 --> 00:44:24.600
and I think they've done a really nice job here

1031
00:44:24.600 --> 00:44:27.120
of identifying some of the community resources

1032
00:44:27.120 --> 00:44:30.450
that they have seen in their best practice research,

1033
00:44:30.450 --> 00:44:33.750
certainly that we have seen in our consulting engagements

1034
00:44:33.750 --> 00:44:35.970
that overemphasis that over indexing

1035
00:44:35.970 --> 00:44:38.669
on community health workers, clinical social workers,

1036
00:44:38.669 --> 00:44:42.810
behavioral health, and social determinant analytics,

1037
00:44:42.810 --> 00:44:46.410
that is really gonna provide much greater access

1038
00:44:46.410 --> 00:44:49.560
and insight into the the needs of those populations,

1039
00:44:49.560 --> 00:44:53.280
which is very different from a fully insured commercial life

1040
00:44:53.280 --> 00:44:54.113
and very different

1041
00:44:54.113 --> 00:44:57.420
from a fully insured Medicare advantage life in general.

1042
00:44:57.420 --> 00:44:59.220
One example I'll give you.

1043
00:44:59.220 --> 00:45:00.660
We had a health system client

1044
00:45:00.660 --> 00:45:03.430
that was taking delegated risk on Medicaid

1045
00:45:04.500 --> 00:45:08.670
and they articulated to us what they called the $20 problem.

1046
00:45:08.670 --> 00:45:11.100
They operated and served a community

1047
00:45:11.100 --> 00:45:13.900
that had very little in the way of public transportation

1048
00:45:14.880 --> 00:45:16.380
and those folks may be

1049
00:45:16.380 --> 00:45:19.770
in the Medicaid managed care arrangement.

1050
00:45:19.770 --> 00:45:21.060
And after they left the hospital,

1051
00:45:21.060 --> 00:45:23.130
they faced this $20 dilemma

1052
00:45:23.130 --> 00:45:24.850
because after they left the hospital,

1053
00:45:24.850 --> 00:45:29.580
they were prescribed a drug or a suite of drugs

1054
00:45:29.580 --> 00:45:32.280
and they were scheduled for a follow-up visit

1055
00:45:32.280 --> 00:45:33.980
with their primary care physician.

1056
00:45:35.370 --> 00:45:37.170
But that patient,

1057
00:45:37.170 --> 00:45:40.920
that beneficiary could really only afford one

1058
00:45:40.920 --> 00:45:42.690
of those two options.

1059
00:45:42.690 --> 00:45:45.390
They could either get a Uber to CVS

1060
00:45:45.390 --> 00:45:47.430
or they could get an Uber to their physician practice,

1061
00:45:47.430 --> 00:45:51.000
but they probably couldn't do both in a timely enough way.

1062
00:45:51.000 --> 00:45:53.430
So the investment there was to determine

1063
00:45:53.430 --> 00:45:56.280
from a community health worker perspective,

1064
00:45:56.280 --> 00:45:58.830
let's go identify those who have transportation needs

1065
00:45:58.830 --> 00:46:01.170
and then let's just provide the transportation

1066
00:46:01.170 --> 00:46:02.400
to the beneficiary.

1067
00:46:02.400 --> 00:46:06.540
It's easy enough to spend $20 on the Lyft ride

1068
00:46:06.540 --> 00:46:09.450
or the Uber ride if what we're doing is getting

1069
00:46:09.450 --> 00:46:12.300
that person compliant with their medication regimen

1070
00:46:12.300 --> 00:46:13.500
and mitigating the risk

1071
00:46:13.500 --> 00:46:15.210
that they're gonna have a a flare up

1072
00:46:15.210 --> 00:46:16.470
or an emergency room visit later

1073
00:46:16.470 --> 00:46:19.200
that's gonna cost thousands of dollars.

1074
00:46:19.200 --> 00:46:21.330
That's a trade off that they were willing to make.

1075
00:46:21.330 --> 00:46:24.780
And that's not the most necessarily creative arrangement,

1076
00:46:24.780 --> 00:46:27.420
but it is a little bit of that outside of the box thinking

1077
00:46:27.420 --> 00:46:30.150
that you can only get when you have community health workers

1078
00:46:30.150 --> 00:46:33.330
in the community assessing for social determinants

1079
00:46:33.330 --> 00:46:36.780
and then coming up with an actual cost effective solution

1080
00:46:36.780 --> 00:46:38.160
to it going forward.

1081
00:46:38.160 --> 00:46:41.130
That's the investment in the community.

1082
00:46:41.130 --> 00:46:42.150
The investment in analytics,

1083
00:46:42.150 --> 00:46:43.313
we talked a little bit about here

1084
00:46:43.313 --> 00:46:44.340
and I'm gonna sort of wrap up here

1085
00:46:44.340 --> 00:46:47.610
so we spent some time on Q&amp;A.

1086
00:46:47.610 --> 00:46:49.080
Same client.

1087
00:46:49.080 --> 00:46:52.080
Looking at sort of trend lines over time

1088
00:46:52.080 --> 00:46:56.343
and in aggregate, the trend lines were pretty good.

1089
00:46:58.470 --> 00:47:01.080
What the trend trendline analytics

1090
00:47:01.080 --> 00:47:03.150
were hiding were two things.

1091
00:47:03.150 --> 00:47:05.280
One was catastrophic expense

1092
00:47:05.280 --> 00:47:07.560
amongst a population that's in the,

1093
00:47:07.560 --> 00:47:09.570
that sort of that middle row there,

1094
00:47:09.570 --> 00:47:13.530
you see that 24.3% non-chronic decline.

1095
00:47:13.530 --> 00:47:15.660
That's decline in their MLR.

1096
00:47:15.660 --> 00:47:18.570
These non-chronic folks who had catastrophic events,

1097
00:47:18.570 --> 00:47:20.973
whether those were accidents, organ transplants,

1098
00:47:21.810 --> 00:47:26.763
that's hidden in the trendline numbers.

1099
00:47:28.320 --> 00:47:30.300
When that trendline reverses

1100
00:47:30.300 --> 00:47:35.190
and the catastrophic events decline over time,

1101
00:47:35.190 --> 00:47:39.360
what they end up finding is almost a 20% annual increase

1102
00:47:39.360 --> 00:47:42.570
in spending on chronic care conditions.

1103
00:47:42.570 --> 00:47:45.420
Asthma, diabetes, CHF and COPD in particular

1104
00:47:45.420 --> 00:47:47.620
that you see down there on the bottom right.

1105
00:47:48.690 --> 00:47:50.430
They needed to understand

1106
00:47:50.430 --> 00:47:53.810
how much catastrophic expense was either masking

1107
00:47:53.810 --> 00:47:58.810
or outperforming their ongoing chronic trend spend line.

1108
00:48:00.780 --> 00:48:04.080
And until they were able to get it that level of granularity

1109
00:48:04.080 --> 00:48:06.120
and identified those patients with asthma,

1110
00:48:06.120 --> 00:48:08.163
diabetes, CHF, and COPD,

1111
00:48:08.163 --> 00:48:10.020
they were unable to figure out where

1112
00:48:10.020 --> 00:48:13.380
to invest their population health programs going forward.

1113
00:48:13.380 --> 00:48:15.330
This is a level of granularity in the analytics

1114
00:48:15.330 --> 00:48:18.090
that is available through the claims data.

1115
00:48:18.090 --> 00:48:22.110
If you know and commit enough time to really getting down

1116
00:48:22.110 --> 00:48:27.090
to that level of care and understanding of the populations.

1117
00:48:27.090 --> 00:48:28.080
That in Medicaid,

1118
00:48:28.080 --> 00:48:29.970
that's where we spend a great deal of time working

1119
00:48:29.970 --> 00:48:32.280
on these Medicaid value based care arrangements,

1120
00:48:32.280 --> 00:48:33.750
figuring out the community needs

1121
00:48:33.750 --> 00:48:35.730
and making sure that the analytics are flying

1122
00:48:35.730 --> 00:48:38.130
at the right altitude to provide us the understanding

1123
00:48:38.130 --> 00:48:40.290
that we need in order to understand

1124
00:48:40.290 --> 00:48:43.090
where we might be vulnerable in the next 6 to 12 months.

1125
00:48:44.519 --> 00:48:47.310
So with that in mind, I think we get you right

1126
00:48:47.310 --> 00:48:49.620
about 10 minutes to the top of the hour.

1127
00:48:49.620 --> 00:48:50.583
I'm just back to the questions

1128
00:48:50.583 --> 00:48:55.260
that I sort of proposed at the top of the discussion here.

1129
00:48:55.260 --> 00:48:57.330
How close to first off premium risk

1130
00:48:57.330 --> 00:48:59.280
do we want our providers to be

1131
00:48:59.280 --> 00:49:03.180
for which populations in which types of partnerships

1132
00:49:03.180 --> 00:49:04.620
and what kind of assets are we gonna need

1133
00:49:04.620 --> 00:49:07.140
to develop as part of that partnership

1134
00:49:07.140 --> 00:49:08.910
in order to successfully manage

1135
00:49:08.910 --> 00:49:11.460
that level of risk with that level of population.

1136
00:49:11.460 --> 00:49:13.590
And with that, I think I might turn it

1137
00:49:13.590 --> 00:49:16.263
over to Sherry to facilitate any Q&amp;A.

1138
00:49:17.850 --> 00:49:20.820
<v Sherry>Thanks Erik. We do have a a few questions.</v>

1139
00:49:20.820 --> 00:49:23.310
The first one is, what role, if any,

1140
00:49:23.310 --> 00:49:26.670
do you see for pharma as part of these models?

1141
00:49:26.670 --> 00:49:29.400
Is it an outcomes based contracting or payers

1142
00:49:29.400 --> 00:49:31.050
and providers open partnerships

1143
00:49:31.050 --> 00:49:32.520
with pharma that extend

1144
00:49:32.520 --> 00:49:37.520
beyond that into health equity for et cetera?

1145
00:49:39.750 --> 00:49:41.790
<v Erik>Health equity is the first frontier I think</v>

1146
00:49:41.790 --> 00:49:45.840
for pharma partnerships in these models.

1147
00:49:45.840 --> 00:49:48.810
I think certainly we've seen some sort

1148
00:49:48.810 --> 00:49:51.300
of innovative contracting to address some

1149
00:49:51.300 --> 00:49:52.830
of the social determinants

1150
00:49:52.830 --> 00:49:55.860
for the Medicaid population in particular.

1151
00:49:55.860 --> 00:49:57.600
I think outcomes based contracts

1152
00:49:57.600 --> 00:50:00.690
are really interesting in this realm.

1153
00:50:00.690 --> 00:50:03.030
And I'll be honest, I'm not quite sure

1154
00:50:03.030 --> 00:50:05.370
that outcomes based contracts

1155
00:50:05.370 --> 00:50:06.720
have gotten to a level of maturity

1156
00:50:06.720 --> 00:50:11.700
that we know what the best practices there are,

1157
00:50:11.700 --> 00:50:14.610
but I think there's a lot of attention spent

1158
00:50:14.610 --> 00:50:16.080
on pharmaceutical pricing

1159
00:50:16.080 --> 00:50:18.690
and I think that's certainly nothing

1160
00:50:18.690 --> 00:50:21.153
that we can ignore in these contracts.

1161
00:50:22.560 --> 00:50:25.014
But I also think that there's an access issue

1162
00:50:25.014 --> 00:50:27.480
that we're probably missing

1163
00:50:27.480 --> 00:50:30.570
with a lot of our at risk populations

1164
00:50:30.570 --> 00:50:33.750
and I think being able to reconcile the medication regimes

1165
00:50:33.750 --> 00:50:34.583
that they're on,

1166
00:50:34.583 --> 00:50:36.900
making sure that they have access

1167
00:50:36.900 --> 00:50:38.910
through discounting programs and the like

1168
00:50:38.910 --> 00:50:42.150
and the ability to manage the outcomes of those populations.

1169
00:50:42.150 --> 00:50:46.140
It goes beyond sort of the pharmaceutical contract

1170
00:50:46.140 --> 00:50:48.030
and gets into what does that contract mean

1171
00:50:48.030 --> 00:50:49.740
for what the physician practices

1172
00:50:49.740 --> 00:50:51.300
and the physician extenders need to do

1173
00:50:51.300 --> 00:50:55.080
in order to follow up once those scripts are filled.

1174
00:50:55.080 --> 00:50:57.060
I think there's, it's a,

1175
00:50:57.060 --> 00:50:58.830
I think largely been approached

1176
00:50:58.830 --> 00:51:02.190
as sort of a bilateral equation

1177
00:51:02.190 --> 00:51:05.190
to solve between the pharmaceutical company

1178
00:51:05.190 --> 00:51:06.540
and the risk bearer.

1179
00:51:06.540 --> 00:51:08.730
I think it's a little bit more multidimensional than that.

1180
00:51:08.730 --> 00:51:10.800
We have to sort of tease out what that's gonna mean

1181
00:51:10.800 --> 00:51:13.410
for physician follow up,

1182
00:51:13.410 --> 00:51:15.150
physician extended follow up to make sure

1183
00:51:15.150 --> 00:51:17.610
that the patients are taking the drugs the way

1184
00:51:17.610 --> 00:51:18.443
that they need to.

1185
00:51:18.443 --> 00:51:19.580
And I think pharmaceutical companies,

1186
00:51:19.580 --> 00:51:22.260
at least in my limited experience with pharma,

1187
00:51:22.260 --> 00:51:23.550
is that they have good ideas

1188
00:51:23.550 --> 00:51:26.340
about how to engage the provider networks

1189
00:51:26.340 --> 00:51:30.090
to make those contracts as valuable as possible.

1190
00:51:30.090 --> 00:51:31.050
But I think it's early days.

1191
00:51:31.050 --> 00:51:32.100
I think it's very early days

1192
00:51:32.100 --> 00:51:34.193
in figuring out what best practice there is.

1193
00:51:35.220 --> 00:51:37.397
<v Sherry>Okay. We do have a couple other questions.</v>

1194
00:51:37.397 --> 00:51:40.527
How is the lack of data available impacting things

1195
00:51:40.527 --> 00:51:42.393
and what can be done to improve it?

1196
00:51:45.900 --> 00:51:48.570
<v Erik>So, yeah. I get that question a lot.</v>

1197
00:51:48.570 --> 00:51:50.914
There isn't a lack of data.

1198
00:51:50.914 --> 00:51:54.060
There's a lot of data in healthcare as everybody is aware

1199
00:51:54.060 --> 00:51:58.153
and I think we're sort of past this as an industry,

1200
00:51:58.153 --> 00:52:00.240
but I think it's relatively recent

1201
00:52:00.240 --> 00:52:03.870
that people were waiting for complete data sets.

1202
00:52:03.870 --> 00:52:05.640
We want clinical, we want claims,

1203
00:52:05.640 --> 00:52:06.720
we want social determinants,

1204
00:52:06.720 --> 00:52:08.970
we want it all before we can do anything.

1205
00:52:08.970 --> 00:52:12.150
And I think we're largely past that.

1206
00:52:12.150 --> 00:52:16.590
I think claims data in and of itself can tell you a lot.

1207
00:52:16.590 --> 00:52:19.380
Now there's a latency to that that I acknowledge

1208
00:52:19.380 --> 00:52:20.213
and if you're looking

1209
00:52:20.213 --> 00:52:22.713
to do real time performance improvement claims data,

1210
00:52:22.713 --> 00:52:26.459
it's not gonna be a sufficient data set

1211
00:52:26.459 --> 00:52:28.230
for you to use.

1212
00:52:28.230 --> 00:52:30.450
But if you're doing long-term planning,

1213
00:52:30.450 --> 00:52:33.000
and trying to figure out an analytical basis

1214
00:52:33.000 --> 00:52:35.730
on which to base the investment decisions that you make,

1215
00:52:35.730 --> 00:52:37.770
certainly from a pop health perspective,

1216
00:52:37.770 --> 00:52:39.450
claims data can give you a lot.

1217
00:52:39.450 --> 00:52:43.350
I think the challenge has been making sure that

1218
00:52:43.350 --> 00:52:46.380
that data is shared with the provider networks

1219
00:52:46.380 --> 00:52:48.300
that you're asking to perform either

1220
00:52:48.300 --> 00:52:50.163
in a value-based contract or not.

1221
00:52:51.270 --> 00:52:53.280
I think providers would tell you,

1222
00:52:53.280 --> 00:52:54.300
health systems would tell you

1223
00:52:54.300 --> 00:52:56.580
that they don't have enough access

1224
00:52:56.580 --> 00:52:58.920
to the claims data for the populations

1225
00:52:58.920 --> 00:52:59.790
that they serve.

1226
00:52:59.790 --> 00:53:02.340
And that is more of a legal

1227
00:53:02.340 --> 00:53:03.480
and negotiating question

1228
00:53:03.480 --> 00:53:07.470
than it is whether there's oil in the ground.

1229
00:53:07.470 --> 00:53:09.600
There's plenty of oil in the ground to be drilled,

1230
00:53:09.600 --> 00:53:11.640
but you need to have those contracts in place

1231
00:53:11.640 --> 00:53:13.620
that enable both parties to be able

1232
00:53:13.620 --> 00:53:16.320
to take advantage of that asset.

1233
00:53:16.320 --> 00:53:19.080
I think now we're in a world where we're starting

1234
00:53:19.080 --> 00:53:21.060
to integrate clinical data with that claims data,

1235
00:53:21.060 --> 00:53:24.780
which can produce more real time data for sure

1236
00:53:24.780 --> 00:53:28.170
if we can aggregate it and model it effectively

1237
00:53:28.170 --> 00:53:32.160
to drive maybe near real time performance improvement.

1238
00:53:32.160 --> 00:53:33.600
But there are all sorts of questions

1239
00:53:33.600 --> 00:53:36.570
about sharing that data back with the payers

1240
00:53:36.570 --> 00:53:38.790
because the providers can own the clinical data.

1241
00:53:38.790 --> 00:53:40.650
So there's, again,

1242
00:53:40.650 --> 00:53:42.450
there's plenty of data assets out there

1243
00:53:42.450 --> 00:53:44.850
that can provide properly modeled,

1244
00:53:44.850 --> 00:53:46.560
the right level of insight

1245
00:53:46.560 --> 00:53:48.870
into the populations that you serve.

1246
00:53:48.870 --> 00:53:50.520
It's just a question of sitting down

1247
00:53:50.520 --> 00:53:52.260
and making sure that both parties are getting

1248
00:53:52.260 --> 00:53:53.793
what they need out of it.

1249
00:53:54.864 --> 00:53:58.920
That's the first order challenge.

1250
00:53:58.920 --> 00:54:00.810
I think the second order challenge is making sure

1251
00:54:00.810 --> 00:54:04.410
that you have the ability and the resources in-house

1252
00:54:04.410 --> 00:54:07.440
or through a third party to model the data

1253
00:54:07.440 --> 00:54:10.800
in a way that is useful and will tell you something.

1254
00:54:10.800 --> 00:54:12.690
One of the things that we have found

1255
00:54:12.690 --> 00:54:15.750
is that there's plenty of data reporting,

1256
00:54:15.750 --> 00:54:19.650
but there's, but that data reporting is serving sort

1257
00:54:19.650 --> 00:54:21.720
of very discreet financial needs

1258
00:54:21.720 --> 00:54:24.360
and when shared with clinicians,

1259
00:54:24.360 --> 00:54:26.880
with physician groups and with practices,

1260
00:54:26.880 --> 00:54:30.750
it doesn't really give them much to act on.

1261
00:54:30.750 --> 00:54:32.820
And I think modeling it in such a way

1262
00:54:32.820 --> 00:54:33.720
and getting 'em out,

1263
00:54:33.720 --> 00:54:36.950
getting that modeled data out to those physician practices

1264
00:54:36.950 --> 00:54:39.453
in a way that they can actually use it,

1265
00:54:39.453 --> 00:54:41.520
that's the real art of all of this

1266
00:54:41.520 --> 00:54:44.010
and that requires some change management

1267
00:54:44.010 --> 00:54:45.810
on the part of the physician groups.

1268
00:54:47.790 --> 00:54:51.000
<v Sherry>Okay. Beyond what's mandated by stars,</v>

1269
00:54:51.000 --> 00:54:52.560
where do you see the biggest area

1270
00:54:52.560 --> 00:54:55.773
of investment for BBC implementation?

1271
00:54:59.160 --> 00:55:01.920
<v Erik>I think it depends a little bit on product line.</v>

1272
00:55:01.920 --> 00:55:05.820
In Medicare Advantage, I think we continue

1273
00:55:05.820 --> 00:55:10.820
to see post-acute models of care being maybe an area

1274
00:55:11.520 --> 00:55:15.090
of underinvestment by both plans and providers.

1275
00:55:15.090 --> 00:55:19.110
It represents a part of the continuum

1276
00:55:19.110 --> 00:55:23.730
that I think honestly represents

1277
00:55:23.730 --> 00:55:25.922
probably the biggest near term savings

1278
00:55:25.922 --> 00:55:29.160
that are available to these types

1279
00:55:29.160 --> 00:55:30.720
of value-based care arrangements.

1280
00:55:30.720 --> 00:55:34.080
I think post-acute isn't super well understood

1281
00:55:34.080 --> 00:55:35.790
by acute care hospitals.

1282
00:55:35.790 --> 00:55:36.900
I don't think it's super well understood

1283
00:55:36.900 --> 00:55:38.670
by most primary care physicians

1284
00:55:38.670 --> 00:55:41.460
and I don't think MA plans totally understand

1285
00:55:41.460 --> 00:55:42.540
what the levers are there

1286
00:55:42.540 --> 00:55:45.720
and I think there's a lot of opportunity in MA

1287
00:55:45.720 --> 00:55:48.420
to get better at managing length of stay

1288
00:55:48.420 --> 00:55:52.260
in skilled nursing, to manage people out

1289
00:55:52.260 --> 00:55:55.050
of skilled nursing and into home health models,

1290
00:55:55.050 --> 00:55:56.790
and to manage people in the community.

1291
00:55:56.790 --> 00:55:58.590
So in Medicare Advantage,

1292
00:55:58.590 --> 00:56:00.870
I think that's where the biggest investment is.

1293
00:56:00.870 --> 00:56:02.430
I think in Medicaid,

1294
00:56:02.430 --> 00:56:06.540
I think it's in social determinant data collection

1295
00:56:06.540 --> 00:56:09.990
and analysis and tying that

1296
00:56:09.990 --> 00:56:13.674
to some of the health equity objectives in Medicaid.

1297
00:56:13.674 --> 00:56:16.980
That is, again, I think this is a very new field

1298
00:56:16.980 --> 00:56:18.750
even though we've been talking about it for a couple years,

1299
00:56:18.750 --> 00:56:20.430
it's still very new.

1300
00:56:20.430 --> 00:56:22.560
And I think that's where, you know,

1301
00:56:22.560 --> 00:56:25.500
if I were in a Medicaid managed care arrangement

1302
00:56:25.500 --> 00:56:27.783
or I was taking on that level of risk,

1303
00:56:28.770 --> 00:56:30.570
I would've been making significant investments

1304
00:56:30.570 --> 00:56:34.590
in SDOH because I think that's a,

1305
00:56:34.590 --> 00:56:36.840
that field hasn't been delimited yet.

1306
00:56:36.840 --> 00:56:38.970
I think there's still a lot of variables

1307
00:56:38.970 --> 00:56:41.340
that we probably don't understand very well

1308
00:56:41.340 --> 00:56:44.430
that if we did, it would give us a lot more insight

1309
00:56:44.430 --> 00:56:46.485
into how to engage with the community

1310
00:56:46.485 --> 00:56:51.485
and some of the community stakeholders like school clinics,

1311
00:56:52.380 --> 00:56:57.380
churches, senior centers, community centers, YMCAs,

1312
00:56:57.390 --> 00:57:02.390
where you can start to address some of the health inequities

1313
00:57:02.580 --> 00:57:04.680
and actually start to inflect patient's care.

1314
00:57:04.680 --> 00:57:06.840
So in those two product lines,

1315
00:57:06.840 --> 00:57:08.070
that's, those are the two areas

1316
00:57:08.070 --> 00:57:09.900
where I find there to be a lot

1317
00:57:09.900 --> 00:57:11.493
of fertile ground for farming.

1318
00:57:13.230 --> 00:57:15.920
<v Sherry>Okay. I know we're at the end of our session,</v>

1319
00:57:15.920 --> 00:57:17.640
but we've got one quick question.

1320
00:57:17.640 --> 00:57:21.240
Why is patient satisfaction key to successful programs

1321
00:57:21.240 --> 00:57:24.243
and what happens when the patient doesn't buy in?

1322
00:57:25.500 --> 00:57:27.750
<v Erik>Yeah, great question.</v>

1323
00:57:27.750 --> 00:57:30.360
Two things I think come immediately to mind.

1324
00:57:30.360 --> 00:57:33.690
The first is you wanna own the life.

1325
00:57:33.690 --> 00:57:35.490
I mean, ultimately the corner of the realm

1326
00:57:35.490 --> 00:57:37.980
in value-based care is owning the life

1327
00:57:37.980 --> 00:57:40.890
and having that life as long as possible

1328
00:57:40.890 --> 00:57:42.930
because you're gonna be making investments

1329
00:57:42.930 --> 00:57:46.020
on behalf of those lives in population health

1330
00:57:46.020 --> 00:57:47.340
and care management programs

1331
00:57:47.340 --> 00:57:49.380
and sometimes the return on that investment

1332
00:57:49.380 --> 00:57:51.780
is gonna require more than one benefit period.

1333
00:57:51.780 --> 00:57:56.250
So keeping the patient happy and satisfied so they stay

1334
00:57:56.250 --> 00:58:00.150
in your insurance product gives you a much longer runway

1335
00:58:00.150 --> 00:58:02.160
in order to realize the return

1336
00:58:02.160 --> 00:58:03.510
on some of those investments

1337
00:58:03.510 --> 00:58:05.880
that you're gonna wanna make anyway.

1338
00:58:05.880 --> 00:58:07.770
So I think that's the first reason

1339
00:58:07.770 --> 00:58:09.720
patient satisfaction matters so much.

1340
00:58:09.720 --> 00:58:11.277
I think the second reason it matters so much,

1341
00:58:11.277 --> 00:58:14.280
and I sort of alluded to this maybe middle

1342
00:58:14.280 --> 00:58:15.480
of the presentation,

1343
00:58:15.480 --> 00:58:20.040
is that you do want a lot of your patients actually

1344
00:58:20.040 --> 00:58:22.050
to engage with their benefit plans

1345
00:58:22.050 --> 00:58:25.500
and to engage more aggressively with their providers.

1346
00:58:25.500 --> 00:58:30.500
And making that hard ultimately is going to result

1347
00:58:30.540 --> 00:58:33.780
in worse health outcomes and higher spend.

1348
00:58:33.780 --> 00:58:35.310
If it's just too much of a hassle

1349
00:58:35.310 --> 00:58:39.330
to schedule a colonoscopy for particular individuals,

1350
00:58:39.330 --> 00:58:42.540
then a lot of colonoscopies are gonna go undone

1351
00:58:42.540 --> 00:58:44.610
and some of those are gonna result

1352
00:58:44.610 --> 00:58:49.610
in cancer going down the line.

1353
00:58:49.650 --> 00:58:51.210
Making it easy on the other hand,

1354
00:58:51.210 --> 00:58:54.990
while it's gonna cost you a lot in maybe May,

1355
00:58:54.990 --> 00:58:57.600
it might prevent the occurrence

1356
00:58:57.600 --> 00:59:01.620
of a real acute, expensive episode 16 months from now.

1357
00:59:01.620 --> 00:59:04.110
And I think patients are pretty smart

1358
00:59:04.110 --> 00:59:09.110
and I think they know what easy looks like today

1359
00:59:09.390 --> 00:59:12.060
because of their experiences in other product lines.

1360
00:59:12.060 --> 00:59:15.582
Not healthcare, but consumer retail,

1361
00:59:15.582 --> 00:59:17.520
airlines, banking, what have you.

1362
00:59:17.520 --> 00:59:20.670
That all looks easy. Healthcare looks hard.

1363
00:59:20.670 --> 00:59:22.620
And making it easy for them to engage

1364
00:59:22.620 --> 00:59:24.870
with their benefits I think will result

1365
00:59:24.870 --> 00:59:26.130
in them being happier.

1366
00:59:26.130 --> 00:59:26.970
You'll keep them longer

1367
00:59:26.970 --> 00:59:29.003
and you'll ultimately have better outcomes.

1368
00:59:30.990 --> 00:59:32.730
<v Sherry>Well, thanks. That's the end of our questions.</v>

1369
00:59:32.730 --> 00:59:33.930
And I want to thank everybody

1370
00:59:33.930 --> 00:59:37.500
for attending today's showcase session presented by Optum.

1371
00:59:37.500 --> 00:59:40.110
I'd also like to thank the Optum team

1372
00:59:40.110 --> 00:59:42.090
for a great presentation.

1373
00:59:42.090 --> 00:59:44.310
Remember that today's session has been recorded

1374
00:59:44.310 --> 00:59:46.597
and will be posted along with the slide deck

1375
00:59:46.597 --> 00:59:49.560
and some additional information

1376
00:59:49.560 --> 00:59:51.990
on the value-based payment showcase event page

1377
00:59:51.990 --> 00:59:55.350
on the ACAP website under vendor showcases.

1378
00:59:55.350 --> 00:59:56.343
Thanks again.