AHIP 2023: Impacting medical loss ratio

Evan Weiss:

Hey everybody. 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, and engaging with them around MLR management and performance management, in a value-based setting.

I, again, Evan Weiss. I've been with Optum for a couple years now, working in value-based care 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.

Laura Weiss:

Hey there. Laura Weiss. Can you hear me? Oh, there we go.

Evan Weiss:

There we go.

Laura Weiss:

All right. Laura Weiss. I also work with Optum. Been in the value-based care space for about eight years. Historically worked with United Healthcare in various roles, all centered around value-based care and enabling providers and various levels on the risk continuum.

Evan Weiss:

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. We're colleagues. Also want to invite you guys to have a 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, forget about work, and just be in the moment with us. All right, so let's dive in. To get started, 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 going to let Laura start. She's going to be our primary care physician.

Laura Weiss:

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 it's a struggle. I'm a lot like you. I want to see my kids at the end of the day. I want to 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.

Evan Weiss:

So I'm going to be Mr. Jones, the Medicare Advantage P&L owner for a health plan. 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 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.

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. What are we seeing, the trends in the Medicare advantage space that compel working with this particular provider segment, and why is it important 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, as Optum, launched a program to address this particular provider segment and their attributed membership. And we want to 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.

So the cumulative trends that we're seeing in the 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. 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 100% 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 in their 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. 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 and executives are really looking to try and prevent is how do we keep these independent practices independent while engaging them in value?

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.

Speaker 3:

[inaudible 00:12:27].

Evan Weiss:

Yeah.

Speaker 3:

So that sounds [inaudible 00:12:29]. I don't know [inaudible 00:12:32].

Laura Weiss:

Dr. Hunter.

Evan Weiss:

Dr. Hunter.

Speaker 3:

Hunter. I know one or two doctors [inaudible 00:12:38]. So I don't know how market specific it is.

Laura Weiss:

Which market are you in?

Speaker 3:

Everybody's [inaudible 00:12:47]. I just don't know how many doctors [inaudible 00:12:57].

Laura Weiss:

Hunter's. So tell me more about the IPAs that you're referring to. 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.

Speaker 3:

Actually I'm kind of the opposite. So as these practices are acquired by the network [inaudible 00:13:26] largely a system can't do it. But the small group of eight docs who formed an IPA together to contract with us to manage our members, they knew how to do it. They talked to each other, they talked about each individual patient, they met with our team managers, then they get acquired by [inaudible 00:13:47]. And boom, they're gone. Their system doesn't know how to do it. And so I'm just finding the opposite of what you guys [inaudible 00:13:55]. It's like we're going away. Our percentage of value-based care is going down, not up, because of this acquisition.

Evan Weiss:

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 for every one practice like you described, there's hundreds that really are ill equipt 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.

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. Actuarially, you just can't do it. 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. 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. 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 as Dr. Hunter said, 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. Even if they did, 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. So that's a big barrier for them, which means they don't have that capacity for change.

And then at the same time, they're getting initiative fatigue. 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.

And then you see the stat here about the growing aging population, one in six American people now are covered under a Medicare benefit, or they're of 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 going to turn it over to Laura to talk about how we approached it. Because 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.

Laura Weiss:

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 a big brother, trying to push down yet another initiative. So this was very much a partnership, a collaboration. We, across seven states, about 1000 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 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 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. Some of them have 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. So 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 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 a 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 want to 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 four plus star rated plan. 92% of our suspect gaps were closed. We had a 1% improvement in acute admit spend per member per year. And then a 16% reduction in PMPY non-par specialist 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 401 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?

Evan Weiss:

Nope.

Laura Weiss:

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 me 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 had to go to the hospital for a heart arrhythmia. 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're going to hear from that member right now.

Speaker 5:

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 a little before 10. So thank you again for your professionalism, Michael. Appreciate it. Have a great day. Bye.

Laura Weiss:

I love how she was so detailed in the date and time of that message. But that's just one interaction of literally tens of thousands that we're able to support these primary care providers. So Evan and I get caught up in the numbers all the time, and 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 row. This is why we're doing it.

Evan Weiss:

We have a question. Couple questions. By the way, they did ask if people don't mind going to the microphone just because it's being recorded, but ...

Speaker 6:

Oh, it's on too. Oh, go ahead.

Speaker 5:

[inaudible 00:26:34].

Speaker 6:

So two questions. One is how big a panel of your members is enough to justify your engaging with a provider? If they have one of your members, is that enough?

Laura Weiss:

We have to draw the line. Generally it's about 150 per practice.

Speaker 6:

Oh okay.

Laura Weiss:

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.

Speaker 6:

Okay.

Laura Weiss:

Great.

Speaker 6:

So it's going to be very hard for a health plan to do that if their memberships were scattered. I agree, a practice of 100 members, absolutely worth it. How big are the incentives?

Laura Weiss:

They're meaningful. They're activity based. And so you fill out a form. 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.

Evan Weiss:

But again, four to one ROI across both the incentives and the resources needed to manage the program.

Speaker 6:

So you're paying $100 for that, you paying $10 for that, you're paying 1000? Give me a ballpark about, for each activity-

Evan Weiss:

It depends on the activity. 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 100. Just depends on the activity.

Speaker 6:

Okay.

Speaker 7:

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 fully independent providers, or are these providers who are part of IPAs who you're already engaged with prior to this pilot?

Laura Weiss:

So this is a mix. The Dr. Hunter's totally independent. It is some IPAs as well. So small to medium sized 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.

Speaker 7:

Thank you.

Evan Weiss:

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.

Speaker 8:

You have time for one more?

Laura Weiss:

Yeah.

Evan Weiss:

Yeah.

Speaker 8:

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. 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-

Laura Weiss:

Yeah. Absolutely. So our team supports referral management, and 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 want to do the right thing for their members. So we are able to help support members, even down to helping schedule appointments for them with the network providers,

Speaker 8:

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 [inaudible 00:30:47] better?

Laura Weiss:

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-

Evan Weiss:

We should do that.

Laura Weiss:

You're giving us some ideas.

Evan Weiss:

Yeah, we're going to take that one.

All right. Any other questions before we jump into just lessons learned and key takeaways?

Speaker 9:

[inaudible 00:31:20].

Evan Weiss:

Sure. Go ahead. I'll repeat it for you.

Speaker 9:

Are you charging providers, or getting [inaudible 00:31:28] the upside for you all [inaudible 00:31:34]?

Evan Weiss:

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 again, removing all the barriers to their adoption. And then in terms of shared savings, we launched this as basically just a program that we're going to run, see how it goes. And so 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.

Laura Weiss:

And to just add on to that, 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 going to 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." 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?

Evan Weiss:

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. 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.

All right. Should we wrap it up? We could take more questions.

Laura Weiss:

Any more questions?

Evan Weiss:

Keep going. All right.

Speaker 10:

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?

Evan Weiss:

We're in Optum Insight. So 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 technology, the programs, the services and the like.

Speaker 10:

And your customers are health plans?

Evan Weiss:

Yes. Optum Insight has provider customers, has health plan customers. We did this as a payer solution.

Speaker 10:

Okay. It's multi-payer. So in some ways you're like an MSO?

Evan Weiss:

Something of an aggregator model, yeah. But in this case it's a little bit different because the objective is to ... Rather than just roll up a network and then hold payers hostage for better dollars, our objective is to help health plans engage with providers and members who are outside of this spectrum. And 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 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. So we kind of take a different tact from the Aledade, Agilons of the world.

Speaker 10:

Okay. Yeah, I was you in the niche for the Agilon. And are you in all markets across the country, or where are you?

Laura Weiss:

We want to be. We're in seven states right now.

Evan Weiss:

That's the goal.

Speaker 10:

Seven states?

Laura Weiss:

Yep.

Evan Weiss:

Currently, yeah.

Speaker 10:

And they all lump together.

Evan Weiss:

So we launched this New York, Florida, Georgia, Maryland, Texas, Texas, Colorado, and Arizona. Okay.

Speaker 10:

And you have plans to expand to other states, is that what you're saying?

Evan Weiss:

Mm-hmm.

Speaker 10:

Okay, great. Thanks.

Evan Weiss:

Not that this was intended to be a commercial. We really wanted to share lessons learned and help people think through how to solve some of these problems with independence. Appreciate the airtime for the commercial too.

Laura Weiss:

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?

Evan Weiss:

Not everybody all at once. They're not going to answer. Okay.

Laura Weiss:

That's okay.

Evan Weiss:

Yes. Question.

Speaker 11:

[inaudible 00:39:22] your program [inaudible 00:39:30].

Evan Weiss:

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?

Laura Weiss:

We know that the value levers is what I call them, but it's essentially our engagement levers with the members 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. 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?

Evan Weiss:

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.