(upbeat music beginning)
-: Hello everybody. (upbeat music ending)
Thank you all for joining us this afternoon.
I'm Evan Weiss with Optum.
We'll be doing introductions in a minute,
but for today's presentation,
we wanted to talk about innovative ways,
proven methodologies for engaging
with independent primary care practices,
the small mom-and-pop practices, in engaging with them
around MLR management and performance management,
a value-based setting.
I, again, Evan Weiss.
I've been with Optum for a couple years now,
working in value-based care for pretty much
since the Affordable Care Act came out,
and prior to joining Optum.
Well, at Optum, I'm responsible for provider enablement,
specifically around this space of independent primary care.
I joined Optum from Lumeris,
where I ran operations nationally for all
of our health system partnerships in value-based care.
So I've done pretty much every aspect of value-based care
during my tenure.
And this is a subject I'm passionate about.
So, Laura, I'll let you introduce yourself,
and then we can kick things off.
-: Hey there, Laura Weiss.
Can you hear me?
-: Oh, there we go.
-: All right, Laura Weiss.
I also work with Optum.
Been in the value-based care space for about eight years.
Historically worked with UnitedHealthcare in various roles,
all centered around value-based care and enabling providers
and various levels on the risk continuum.
-: Great.
So before we dive in, first off,
I just want to dispense with the one question
that is on everybody's mind.
No, we're not related. (Laura laughing)
So just, we're colleagues.
(laughs) Also want to invite you guys to have
a kind of moment of zen, if you will,
take yourselves back in time to before wifi,
before cell phones,
when people couldn't get ahold of you at a moment's notice
and you didn't have to respond to work emails constantly.
Feel free to unplug for this hour and just forget about work
and just be in the moment with us.
So, all right, so let's dive in.
To get started, we thought it would be,
we wanted to make it a little bit more fun for everybody,
so we wanted to start off with a little bit
of a role play exercise, and talk about
the kind of personas that we're representing
in this session.
So I'm gonna let Laura start.
She's gonna be our primary care physician.
-: Okay. So I am going to represent Dr. Hunter,
who is a family physician.
I took over my father's practice in 2011.
I have about 2000 to 2,500 patients at any given time
in what we would call my panel.
Mostly that population is leaning towards adults.
I have a small practice, it's me,
I have two part-time registered nurses that help support me
in my practice.
I have a front office manager, and my cousin helps me
with my IT support.
That's about it.
I have a few exam rooms,
and I do not have my own dedicated office.
So I use one of the exam rooms as my office.
I am fee-for-service with all payers.
I am frustrated with the rates,
but I also know that I really don't have
a lot of negotiating power as an independent provider.
I am really interested in staying independent.
I took over my father's practice.
He was independent.
I've been approached numerous times by large health systems
within my community to join up
to become part of their system.
But it's really important to me to give my patients
the level of care that I know that I can have
when I'm an independent practitioner.
So, I, it's a struggle.
I'm a lot like you.
I wanna see my kids at the end of the day.
I wanna manage my practice well enough to be able
to pay my staff, but also be able to pay myself.
And I also, the most important thing
is providing the highest quality of care I can
to my patients.
-: And so I'm gonna be Mr. Jones,
the Medicare Advantage P&L owner for a health plan.
And I have several hundred primary care practices
that look like Dr. Hunter's in my network.
So I've been pushing value-based care initiatives
to try and drive improved performance of my P&L
and better outcomes for my members.
But about 40 to 50% of my membership is tied up in practices
like Dr. Hunter's,
who are completely outside the value-based spectrum today.
And they're sprinkled across all those providers.
And that's putting an albatross around the neck of my MLR.
The MLRs associated with that population are, you know,
typically is in the 88 to 90% range, sometimes even higher.
So I'm trying to figure out strategies for how do I engage
with that provider segment,
and really improve my overall financial performance,
as well as improve my quality scores, my star ratings,
and get better results and growth for my business.
So, all right.
So we want to talk about some proven methodologies
for achieving this.
So we'll want to talk through first the why in all of this.
Like, what are we seeing the trends
in the Medicare advantage space that are,
that compel working with this particular provider segment?
And why is it important to address,
to have a value-based strategy for that segment?
And then we'll also talk about what are the barriers
to working with those providers.
And then we'll do a case study.
We want, as Optum performed,
launched a program to address this particular
provider segment and their attributed membership.
And we wanted to,
we wanna share with you guys the learnings
for what we've found works specifically
as it relates to working with these small to mid-size
primary care practices.
Okay?
So the cumulative trends that we're seeing
in the MA space right now
really highlight the need to work
with small to mid-size independent primary care
and move them into value.
So first of all, most people should be aware
of the 2024 CMS advanced notice as it relates
to risk adjustment, and the flattening of the curve
for risk-adjusted revenues.
So I think that was an event that we all considered probably
a three year event horizon.
And it's now happening today.
So that creates a lot of pressure on health plans
to really focus on affordability and quality
to drive their performance.
Even if the final regulations don't end up being
what the advanced notice looked like,
the shot has been fired across the bow, right?
So we know it's coming.
Additionally, advisory board did a survey
of CEOs of health plans nationwide,
and the four priorities
that those health plan CEOs identified
as their top priorities all point towards value-based care
as a linchpin strategy for Medicare Advantage plans
going forward.
They're looking for improved relationships
with their providers.
They're looking for better affordability
in terms of the results they're getting
and the cost of care.
They're looking for improved member experience
and member satisfaction,
and they're looking for growth,
and they're looking to use affordability
to drive dollars into growth.
All of those things point towards a value-based
relationship with providers,
shared economics with providers, keeping them happier,
giving them additional new opportunities to share in the
economics of the plan and to partner effectively
with the plan, and in the process, drive a better
patient experience and a better patient outcome.
Third major trend that we see is that the move
to value-based care has been slower than people anticipated,
I think, when the Affordable Care Act came out
and the government really started pushing it in a big way,
CMMI is looking to get a hundred percent
of Medicare beneficiaries into some sort
of value-based model in the next decade or so.
But currently 43% of MA patient spend
is still tied up in pure fee-for-service models.
So that drag is caused in large part
because there's a lot of providers
that are currently off the table and outside
of the value-based spectrum as health plans are looking
to drive those value-based strategies.
You can quickly get the large medical groups
into value-based models and the large IPAs and ACOs.
Most health systems in their clinically-integrated networks
are dabbling in it to, you know, in their
kind of early stages in their trajectory.
But then you have this massive swath
of independent primary care that's still not participating.
And then the last key factor is the primary care land grab,
which has been going on for a long time,
but acquisitions of small independent practices
actually grew 38%, acquisitions by health systems grew 38%
from 2019 to 2021.
And when those acquisitions happen,
costs go up, right, up immediately,
you can see up to a 20% increase in cost
tied to that practice.
And then you have all the in-system utilization drives
and the like.
So that's one of the things that health plan
executives are really looking to try and prevent,
is "How do we keep these independent practices independent
"while engaging them in value?"
I'll actually, by the way,
if people have questions as we go,
let's keep it interactive.
We have no problem fielding questions,
if there's any questions on what I've laid out so far.
Yeah.
Audience #1: So...
(Audience #1 speaking indistinctly)
-: Dr. Hunter.
(Audience #1 speaking indistinctly)
-: Which market are you in?
(Audience #1 speaking indistinctly)
-: Mhm.
(Audience #1 speaking indistinctly)
-: So tell me more about the IPAs that you're referring to.
You know, we encounter quite a few IPAs who really
are loosely affiliated, at best.
And so they're not really providing the population health
overarching services that we would expect from a large
health system or a really clinically integrated network.
Audience #1: Actually, I'm the opposite, right?
So as these practices are acquired by the network, large,
a system can't do it. -: Mhm.
-: Small group of eight docs who formed an IPA together
to contract with us to manage our members,
they knew how to do it, right?
They talked to each other,
they talked about each individual patient,
they met with our managers,
then they get acquired by and boom, they're gone.
Their (indistinct) doesn't know how to do it.
And so I'm just finding the opposite of what you guys just,
it's like we're going away.
Our percentage of value-based care is going not up
'cause of this acquisition.
-: Yeah, the acquisitions are definitely hurtful,
depending on who the acquirer is, for sure.
But when we think about clinically integrated networks
and health systems, it can create a big drag.
Our experience is that for every one practice,
like you described,
there's hundreds that really are ill-equipped
to do anything around value and population health.
And let's actually turn to some of the barriers that we're
seeing in the market with these providers, right?
So for the most part,
these practices are just too small to really put
into an outcomes-based arrangement.
When you're talking about total cost of care, right?
Actuarially, you just can't do it, right?
So that's number one, because you need to get
the lives volume so that one person in the risk pool
doesn't throw off the performance for the entire practice
and then you lose them, right?
So to have credibility, they're generally too small.
Number two is they're hard to engage at scale,
because they're all on very disparate systems.
They all have disparate resources.
It's a practice-by-practice log to really work
with these practices.
And then even if you are working with them,
they generally lack the infrastructure time,
energy, resource, to take it on, right?
They're on the fee-for-service hamster wheel.
They're seeing a patient every seven minutes.
They are really just killing themselves just to stay afloat
in fee-for-service.
And you know, as Dr. Hunter said, you know,
cousin is managing the books or managing the IT
it's not a sophisticated shop.
So they don't have the people on hand
to take on population health activities.
They don't even, even if they did, they don't know,
they don't have the data and insights to identify who are
the patients that they need to address for what,
and stratify and prioritize, right?
So that's a big barrier for them.
And then,
which means they don't have that capacity for change.
And then at the same time
they're getting initiative fatigue, right?
They've got each payer coming to them looking for,
"I want you to do this for me,"
"I want you to do that for me."
"I've got this program, I've got this incentive."
And to manage across that complexity
of 10 different programs, and approaches, and processes
across all these different payers,
it's a lot for them to absorb, right?
So the,
and then you see the stat here about the growing
per the aging population,
one in six American, one in six people now
are covered under a Medicare benefit, right?
They're of age, so senior age.
So that means that as the population gets older,
that's a lot of opportunity for MA to grow the book.
But it also means that the practices are having a lot more
stress put on the practice in terms of the needs
of the panel they're supporting,
and the capacity to absorb the change
for a more senior population gets harder and harder.
So those are the bare,
we wanted to kind of lay that out.
I'm gonna turn it over to Laura to talk about
how we approached it, 'cause what we wanted to do
was to set up, we wanted to run a pilot program
to address this segment and figure out
how do we address those root cause barriers
for a plan to really work effectively with these providers.
And she'll share with you what we did
and the results we saw, and the lessons learned.
-: So first off, I want to say that
it became a lot about collaboration and partnership
with these providers.
We did not want to come in as a payer, as Big Brother,
trying to push down yet another initiative.
So this was very much a partnership, a collaboration.
We, across seven states, about a thousand groups,
360,000 members, between commercial and Medicare Advantage.
And what we did was really threefold.
We deployed a geo-located virtual team to add
as an extension to these practices, to Dr. Hunter's office,
supplementing the staff that they don't have,
or maybe they're missing because of COVID,
turnover of staff, what have you.
And so we essentially
virtually embedded a team to support their members
and in population health initiatives,
we also offered provider incentives.
And so that, between the provider incentives
and the care teams,
we really focused on incentivizing providers
for activity-based operations
around these population health initiatives.
So first and foremost, what we heard from the Dr. Hunters
of the world is that they don't even know
every time their patients are in the hospital.
So care transitions management was a huge gap
for a lot of these practices.
So they're not getting the discharge feeds into their EMRs,
you know, some of them have, you know,
the very basic EMR systems not set up with interoperability
from the health systems.
So that's something that we could really help dive in
and support, and then get the data to the providers
in an actual meaningful format.
We also supported high-risk member management
for these providers,
really engaging their high-risk members,
making sure that they're regularly engaged with their PCP.
Still all of these population health initiatives,
you'll notice we're still keeping the PCP as the captain
of the ship, and that's hyper-critical to our partnership
and our collaboration.
Of course, gaps in care, very important.
But also what we all found was medication optimization
for those members who had a care transition,
an ER event, for those high risk members,
really making sure that they are,
have a level of medication therapy management
from our pharmacist that is part of that care team.
So let me go take a little bit of step back.
The care team consists of a clinical pharmacist,
care coordinators who are either registered nurses,
social workers, we have community health workers,
and then embedded clinical administrative support team
to help support these providers
in acting as that additional reach for their practice.
So really, it's all about helping the providers
get the right meaningful data for their members
at the right time.
They don't wanna be overburdened
by administrative paperwork.
We really took an approach where we met these providers
where they were,
whether they needed technology to support them, or whether
they needed just the care team, or a combination of both,
that's what we did.
We met them where they were.
And that's super important for this population of providers,
again, small to mid-size independent providers.
So what we saw through this partnership,
through engagement in these population health interactions
with the members, and thus feedback to the providers
on what we were doing,
we had some really phenomenal results.
So we had 83% of the members in a 4+ star rated plan.
92% of our suspect gaps were closed.
We had a 1% improvement in acute admits, sorry,
acute admits spend per member per year.
And then a 16% reduction in PMPY non-par special use.
We had a 5% decrease in ER use and a,
I call it total cost of care,
but in this it's medical spend and pharmacy spend,
10.6% reduction in PMPM.
All of that rolled up is 4:1 ROI on this program.
We also did a provider NPS survey and received an NPS of 85,
which is excellent,
almost unheard of in healthcare from the provider space.
So really proud of those results,
really continuing to roll out this program,
but really a lot of great lessons learned,
and what we can go into in just a second.
Anything to add?
-: Nope.
-: So one thing I do want to show you guys is...
Make this larger.
It's really easy to get up here and talk about findings,
but we were really engaging with providers and members.
So we have this feedback from one of our members.
So a little bit about this member interaction.
So again, one of the most important population
health initiatives you can do
is care transitions management.
So engaging with the member after discharge,
making sure that they're connecting back to their PCP,
connecting back to any post-discharge referral
or specialist needs.
And then also engaging in that medication reconciliation
post-discharge.
So this member had historically been on a medication
for migraines, and when the new year rolled around,
they were no longer able to afford that medication.
They stopped taking the medication, and they actually went,
had to go to the hospital for a heart arrhythmia,
and really sad case.
But what we were able to do, it was really great.
We were able to catch the member after discharge,
understand what was going on with the medications,
work with the provider to provide a less costly medication
to keep that member out of the hospital,
keep them adherent to that medication,
and then help them prevent missing work.
And then just overall improved quality of life.
So we were gonna hear from that member right now.
Member #1: And I just wanted to call Michael
and tell him thank you so much
for his considerable time for me today.
And he was very professional, very helpful, and caring.
And I just wanted to say thank you, and appreciate so much
the good care from him this morning.
And the date today is February 8th,
Wednesday, and it's about a little before 10.
So thank you again for your professionalism, Michael.
Appreciate it.
Have a great day.
Bye.
-: I love how she was so detailed
in the date and time of that message, (laughs)
but that's just one interaction
of literally tens of thousands that we're able to support
these primary care providers in.
So Evan and I get caught up in the numbers all the time,
and it's just, I really like these patient examples.
I love the provider examples of provider feedback
of how much we're able to support in these type of programs.
So it's where the rubber meets the road.
This is why we're doing it.
-: We have a question.
Couple questions.
By the way, they did ask if people don't mind going
to the microphone just 'cause it's being recorded, but...
Audience #2: Oh, it's on too.
(Evan laughing)
Oh, go ahead.
Oh, so I have two questions.
One is, how big a panel of your members do you,
is enough to justify your engaging with a provider?
I mean, if they have one of your members, is that enough?
-: We have to draw the line.
Generally it's about 150 per practice.
-: Oh, we should also say, not our members.
We're engaging on behalf of health plans, and so we're able
to roll up membership across multiple payers,
or multiple lines of business, in order to get
to a critical mass with a given practice.
-: Okay. -: Great.
-: So it's gonna be very hard for a health plan to do that
if their memberships were scattered.
I agree.
A practice of a hundred members absolutely worth it.
How big are the incentives?
-: They're meaningful, you know,
they're activity based, and so you fill out a form.
It's, I'll give you an example of one, care transitions.
We've found something in our medication reconciliation
post discharge.
It's meaningful enough for the provider to take the time,
look at the form, and then provide feedback.
-: It's, but again, 4:1 ROI across both the incentives
and the resources needed to manage the program.
-: So I mean, so like, I mean,
you're paying a hundred dollars for that?
You paying $10 for that, you're paying a thousand?
How about, I mean, give me a ballpark about,
for each activity.
-: It depends on the activity.
If you're talking about...
If you're talking about a pharmacy report,
it can be around 50 bucks.
If you're talking about a prospective health assessment,
that can be more like 75 to a hundred.
Just depends on the activity. -: Okay.
Audience #3: I was just curious logistically,
you mentioned that a lot of the providers you work with
are part of larger groups,
whether it be an IPA or whatever else.
Were these like fully independent providers, or are these
providers who are part of IPAs who you're already, you know,
engaged with prior to this pilot?
-: So this is a mix.
It's the Dr. Hunters, totally independent,
it is some IPAs as well.
So small to medium size groups that are not associated
with large health systems.
What you wouldn't normally go after in the value-based
care arena, as it stands now.
-: Thank you.
-: We should say, we actually did get sponsored in
by one plan to work with a health system affiliated
clinically-integrated network.
And they were in an ACO arrangement that was in the red,
and we were able to move them into the black
through this program.
So.
-: You have time for one more? -: Yeah.
-: What do you do to incentivize,
or how do you assist providers
with a non-par specialist referral process
when they deal with 10 different plans,
knowing how to refer, I mean,
that's just a challenge we all deal with as providers.
It's tough to know who's all in network.
They establish a rapport with specialists
they tend to refer to,
but they may not be in for all the plans.
Anything you do around that to help drive?
-: Yeah, absolutely.
So our team supports referral management, and that's,
they come in with the knowledge of all of these plans,
who's par, who's not par.
Historically, providers do have a referral network,
but what we found is that when we let them know
that the referral network that they have
is either high cost, low quality, or out of network,
they're willing to adjust, because ultimately,
they wanna do the right thing for their members.
So we are able to help support members,
even down to helping schedule appointments for them
with in-network providers.
-: That's the big piece.
Do you do anything to connect them to where they can
communicate and be comfortable with each other,
or set up meetings where they have an opportunity to meet,
to feel comfortable with the referral?
-: We haven't taken it that far.
It's kind of a mixed bag on,
we have some providers who throw their hands up and say,
"I don't care where my member goes."
But there are some providers who are also very vested
in their network.
We haven't gotten that far to set up meetings,
but- -: We should do that.
-: You're you're giving us some ideas.
-: Yeah, we're gonna take that one.
All right.
Any other questions before we jump into just lessons learned
and key takeaways?
Sure, go ahead.
I'll repeat it for you.
Audience #4: Are you charging providers for...
-: Yeah, so the question was,
"Do we charge the providers anything for this service?
"Do we participate in the outcomes?"
So the answer is it's completely free of cost to providers.
In our experience, they're looking to make more money,
not pay more money.
So we're creating economic opportunities for them
and providing them, again,
removing all the barriers to their adoption.
And then in terms of shared savings,
this was launched as, you know,
we launched this as basically just
a program that we're gonna run, see how it goes.
And so we just, for the payers that we were supporting,
we did it on a cost basis,
but we actually are now moving in our own version of this,
we're moving to an outcomes-based model.
So some underlying fees and then a outcomes-based payment,
shared savings model.
-: And to just add on to that, I mean,
we want our incentive model for providers
to evolve over time as we get more sophisticated,
as they get more sophisticated,
and really going up that continuum towards risk.
We want to be able to go from activity-based payments
to other, more favorable models.
Okay.
Lessons learned.
Leverage aggregation.
We leverage the geo-located care team for a more dedicated,
one-to-one approach with providers.
We need to remove administrative burden.
We don't need to add any administrative burden.
So again, meeting the provider where they are at the time
in order to make sure that we're giving them the right data
in a meaningful way at the right time to do the right thing
for their members, whether that's care team, technology,
data, or even workflows.
Make the incentives count.
So right now, like I mentioned,
we're at the level of activity-based payments
that are directly tied to those population
health value levers that we know are gonna drive value
to the health of our providers,
I'm sorry, the health of our members.
And it's actionable information that the provider can tie
to value to their patient as well.
And then move those providers from activity-based payments
over time to a more outcome-based incentive model.
And then streamline.
A lot of times we have feedback from providers that say,
"I can't wait for you to do all this for all of our members,
"all of my patients, all payers," right?
So that's a goal.
Go multi-line of business, go multi-payer, be able to go in
and support members across the board for any payer.
Evan, anything to add?
-: I think it was good.
There's also one point on here
about not ignoring the intangibles.
A lot of the feedback that we get from providers
doesn't relate to the incentives that we offer.
A lot of it is about how we're enabling them to deliver
better care for their patients
with less administrative burden.
Giving them better insight into what's going on
with their patients.
I mean, they didn't become doctors just to make money.
They're not coin-operated machines.
And it means a lot to them that we're bringing these
additional clinical resources to the table to help them
be successful and to help them keep their patients healthy.
So, all right.
Should we wrap it up?
I would take more questions.
-: Any more questions?
-: Keep going.
All right.
Audience #5: Oh yeah.
So I guess I'm not sure who you are.
So you say Optum, Optum doesn't mean anything.
Optum does everything for everybody.
So what part of Optum are you?
-: We're an Optum Insight.
So we're outside of, we're not in Optum Health.
We're not part of the medical group wing of Optum.
We're in the solutions and services arm of Optum
that does the data and technology, the programs,
the services and the like.
Audience #5: So and your customers are health plans?
-: Yes.
For, I mean, we have provider,
Optum Insight has provider customers,
has health plan customers.
We did this as a payer solution.
Audience #5: Okay, it's a multi-payer.
So in some ways you're like an MSO?
-: Something of an aggregator model, yeah, but it's,
in this case it's a little bit different,
because the objective is to kind of,
rather than just kind of roll up a network
and then hold payers hostage for better dollars, right?
Our objective is to help health plans engage with providers
and members who are outside of this spectrum.
And we can also,
we can also better tie in and coordinate with other programs
that the health plan is getting, either from Optum,
or that they have on their own.
So like we have, for instance, Optum Behavioral Health,
we have the ability to get patients better plugged into
their behavioral health benefit,
get a feedback loop on what happens with that referral,
and bring it back into the practice.
We can also do that same thing if the plan
has a different behavioral health solution as well, but,
so we kind of take a different tact from the Aledades,
Agilons of the world.
Audience #5: Okay.
Yeah, that's what I was trying to put,
what I was trying to put you in the niche for the...
(Evan laughing)
And are you in all markets, or where across the country,
or where... -: We wanna be.
(Evan and Laura laughing)
We're in seven states right now.
-: Seven states? -: Yep.
-: Currently, yeah.
Audience #5: And they all lump together?
-: So we launched this, New York, Florida,
Georgia, Maryland,
-: Texas. -: Texas,
Colorado, and Arizona.
Audience #5: Okay.
And you have plans to expand to other states,
is that what you're saying?
-: Mhm. -: Okay, great, thanks.
-: Not that this was intended to be a commercial.
(Evan laughing)
We really wanted to like share lessons learned
and help people think through
how to solve some of these problems with independence.
But appreciate the airtime for the commercial too.
-: So I'm curious,
do you guys also see these independent providers
who are still hard to reach, or are you also in agreement
with the gentleman that it's not a problem in your areas?
-: Not everybody all at once. (Laura laughing)
They're not gonna answer.
Okay. -: That's okay.
-: Yes, question?
(Audience #6 speaking indistinctly)
So for those who couldn't hear the question, it was,
"How much of the program is designed to avoid an admit
"to the inpatient setting, and keep patients
"out of the hospital?"
-: We know that the lever,
the value levers is what I call them,
but it's essentially our engagement levers with the members
is drives lower readmissions over time.
It's all population health management, so it does take time.
So care transitions prevents readmissions.
High risk member management prevents admissions, period.
You know, getting your ER frequent flyers under control,
doing a level of medication therapy management
with a percentage of your population
will also bring down admissions over time.
So I would say it's very much focused
on keeping people healthy and out of the hospital.
Does that answer your question?
-: Other questions?
Okay.
All right, well, we appreciate everybody's time today.
We're around if anybody wants to ask questions offline.
And thank you all for joining us.
(audience applauding)