3. Clients
60,000,000+ individuals
80,000
physician practices and
other health care facilities
67,000 pharmacies*
5,000 hospitals
400 global life sciences organizations
300 health plans
150
state, federal and municipal
agencies and departments
Statistics as of 6/30/13 except where noted; *as of 1/17/13
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
3
4. Navigating the journey from providing care to managing health
Invest
New Capital
Generate
New Capital
Patient
Patient
Access
Access
Medical
Medical
Necessity
Necessity
Financial and
Financial and
Clinical Analytics
Clinical Analytics
Population Health
Population Health
Management
Management
Reimbursement
Reimbursement
Providing
Care
Aligned
Incentives
Clinical
Clinical
Care
Care
Coding and
Coding and
Documentation
Documentation
Care Delivery
Care Delivery
Model
Model
Quality
Patient
Satisfaction
Managing
Health
Cost
Prepare
for Change
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
4
5. Generate new capital
Generating capital to invest in a new strategy for care delivery
1
3
5
Patient access
Patient access
Medical necessity
Medical necessity
Reimbursement
Reimbursement
Enhancing
Enhancing
Patient Flow
Patient Flow
Proactively Addressing
Proactively Addressing
Payer Compliance
Payer Compliance
Augmenting Cash Flow
Augmenting Cash Flow
2
4
Clinical care
Clinical care
Coding and
Coding and
documentation
documentation
Simplifying Clinical
Simplifying Clinical
Workflow
Workflow
Automating &&
Automating
Optimizing Coding
Optimizing Coding
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
5
6. Navigating the journey from providing care to managing health
Invest
New Capital
Generate
New Capital
Patient
Patient
Access
Access
Medical
Medical
Necessity
Necessity
Financial and
Financial and
Clinical Analytics
Clinical Analytics
Population Health
Population Health
Management
Management
Reimbursement
Reimbursement
Providing
Care
Aligned
Incentives
Clinical
Clinical
Care
Care
Coding and
Coding and
Documentation
Documentation
Care Delivery
Care Delivery
Model
Model
Quality
Patient
Satisfaction
Managing
Health
Cost
Prepare
for Change
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
6
7. Prepare for change
Care delivery Model
Care Delivery model
Care Delivery Model
1
2
3
Consensus
Consensus
Governance
Governance
Structure
Structure
Agreement on the Goal
Agreement on the Goal
Accountability for the Goal
Accountability for the Goal
Alignment to the Goal
Alignment to the Goal
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
7
8. Navigating the journey from providing care to managing health
Invest
New Capital
Generate
New Capital
Patient
Patient
Access
Access
Medical
Medical
Necessity
Necessity
Financial and
Financial and
Clinical Analytics
Clinical Analytics
Population Health
Population Health
Management
Management
Reimbursement
Reimbursement
Providing
Care
Aligned
Incentives
Clinical
Clinical
Care
Care
Coding and
Coding and
Documentation
Documentation
Care Delivery
Care Delivery
Model
Model
Quality
Patient
Satisfaction
Managing
Health
Cost
Prepare
for Change
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
8
9. Invest new capital
Investing in a new care delivery strategy.
Financial & Clinical
Analytics
To predict the future medical
To predict the future medical
experience of individual health
experience of individual health
consumers as well as defined
consumers as well as defined
populations
populations
Population Health
Management
To identify, engage, and impact
To identify, engage, and impact
every individual with aahealth
every individual with health
need within aadefined population
need within defined population
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
9
10. Information technology
Technical Blueprint for Physician Gain-Sharing Enablement
1
Electronic
Electronic
Medical Record
Medical Record
Collect the data
Collect the data
generated within aa
generated within
physician practice
physician practice
Utilize the activities
Utilize the activities
delivered within the
delivered within the
physician’s office to
physician’s office to
build each patient’s
build each patient’s
clinical database
clinical database
2
3
Health
Health
Information
Information
Exchange
Exchange
4
Clinical
Clinical
Analytics
Analytics
Aggregate the data
Aggregate the data
generated within the
generated within the
health care
health care
community
community
Augment the
Augment the
physician’s EMR with
physician’s EMR with
patient data from
patient data from
community specialists,
community specialists,
hospitals
hospitals
and ancillary services
and ancillary services
Population Health
Population Health
Management
Management
Convert aggregated
Convert aggregated
data into actionable
data into actionable
information
information
Take action
Take action
Catalyze action to
Catalyze action to
mitigate identified risk:
mitigate identified risk:
Identify and stratify:
Identify and stratify:
•Patients at risk for
•Patients at risk for
unfavorable future
unfavorable future
medical experience
medical experience
•Physician performance
•Physician performance
relative to best practice
relative to best practice
•Action for physician at
•Action for physician at
point-of-care
point-of-care
•Action for health
•Action for health
coaches remotely
coaches remotely
•Action for patients to
•Action for patients to
engage in self-care
engage in self-care
Registries (Pre-defined
Registries (Pre-defined
&&dynamic)
dynamic)
Care coordination
Care coordination
Quality &&Business
Quality Business
Intelligence reporting
Intelligence reporting
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
10
11. Key opportunities in population health management
2012 medical claims cost distribution among Commercial payers
using Optum for Population Health Management services
Ambulatory
Medical
Chronic
Illness
69%
Acute
Illness
(32% of
members)
60%
Inpatient
Medical
27%
COST BY
CONDITION
(19% of
members)
25%
COST BY
SETTING
Healthy
Pharmacy
4%
15%
(49% of
members)
(5.5 million eligible members)
(5.5 million eligible members)
Population medical costs are largely from treatment of
chronic conditions in the ambulatory setting.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
11
12. Four steps of Population Health Management
Physician groups who have been successful in value-based contracts
consistently cite the same four areas of critical focus for success in PHM.
Care delivery model
Population Health Management
Population Health Management
1
Optimize network
Optimize network
management
management
2
Manage care
Manage care
transitions
transitions
3
4
Invest in in-home
Invest in in-home
intervention
intervention
Expand chronic
Expand chronic
disease
disease
management
management
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
12
13. Step 1: Optimize network management
Refer to clinically effective and financially efficient sub-specialists.
Ensure patient experience with referral and specialty care is optimal.
Impact to individual
Impact to individual
• 10% reduction in surgical
intervention rate for spine, hip and
knee surgeries
• $10,000–15,000 average medical
Impact to population
Impact to population
• 49% fewer redos and 60% lower
complication rate for implantable
cardiac device surgeries when
performed by quality-designated
cardiothoracic surgeons
cost savings per redirection
• 14% total cost savings when
population is consistently referred
to the highest quality and most
cost-efficient physicians for all
specialty care
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
13
14. Step 2: Manage care transitions
18 hospitals will each forego more than 1 million dollars in
Medicare reimbursement this year due to readmission penalties.
Utilize onsite and post-discharge
resources to reduce readmission:
37%
•Onsite RNs
•Home visits
Reduction in 30-day
readmit rates*
•Telephonic case managers
•Telemedicine
* For adults with medical (non-surgical, non-maternal) admitting diagnosis
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
14
15. Step 3: Invest in in-home intervention
Focus intense resources on patients with highest acuity needs following acute illness
Among high-risk patients
Post-acute care
Post-acute care
•Complete thorough in-home
•Complete thorough in-home
assessment using mobile device
assessment using mobile device
•Share results with clinical team
•Share results with clinical team
•Trigger alerts for potentially urgent
•Trigger alerts for potentially urgent
health issues
health issues
•Identify key topics for patients to
•Identify key topics for patients to
discuss with primary physician
discuss with primary physician
•Recommend and ensure appropriate
•Recommend and ensure appropriate
follow-up appointments
follow-up appointments
34%
reduction in 30-day
readmit rates
51%
fewer prescriptions per
high-risk member*
64%
drop in acute admit rate
*9 or more initial prescriptions
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
15
16. Step 4: Expand chronic disease management
Moving chronic care from the exam room to the community.
Predictive modeling analytics
Systematic, population-based
care manager outreach
20% improvement in optimal care
compliance among chronically ill
The chronic disease
patient with the
greatest need …
is also the one least
likely to show up in
your office
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
16
17. Provider-based predictive modeling
Analytics to predict future medical costs of individuals and populations are limited by the
characteristics of the three types of available data.
Claims data
generally comes from
generally comes from
medical or pharmacy
medical or pharmacy
benefit managers/payers
benefit managers/payers
Clinical data
usually comes from an
usually comes from an
electronic medical record
electronic medical record
(EMR), biometric feeds,
(EMR), biometric feeds,
lab feeds, pharmacy feeds
lab feeds, pharmacy feeds
or health assessments
or health assessments
(by either the patient or
(by either the patient or
care manager)
care manager)
Abstracted data
may come from hospital
may come from hospital
notice of discharge,
notice of discharge,
admission, ED visit or
admission, ED visit or
skilled nursing facility
skilled nursing facility
transfer
transfer
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
17
18. Provider-based predictive modeling
Relative strengths of data used in health care analytics vary by source, and can be
categorized by sensitivity (ability to detect all conditions), specificity (ability to identify
conditions accurately), timeliness and availability.
Claims data
– insensitive
– insensitive
– non-specific
– non-specific
– untimely
– untimely
+ always available
+ always available
Clinical data
+ sensitive
+ sensitive
+ specific
+ specific
+ timely
+ timely
–– variably available (may be
variably available (may be
incomplete or unstructured
incomplete or unstructured
in EMR, or unavailable from
in EMR, or unavailable from
non-EMR users)
non-EMR users)
Abstracted data
+ sensitive
+ sensitive
–– non-specific
non-specific
+ timely
+ timely
+ generally available
+ generally available
Variations in strengths and weaknesses between these three data sources suggests
aggregation will provide a more effective basis for prediction of future medical outcomes
and costs.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
18
19. Combined data is key: Diabetes example
Optimal prediction of future medical experience of individuals and populations
Claims data
When used for chronic
When used for chronic
disease management,
disease management,
improved treatment
improved treatment
compliance about 20%
compliance about 20%
Clinical data
30% of individuals
30% of individuals
identified as diabetic
identified as diabetic
by clinical data were
by clinical data were
missed by claims data
missed by claims data
Abstracted data
37% decrease in 30-day
37% decrease in 30-day
readmission rates when
readmission rates when
care manager promptly
care manager promptly
notified of discharge
notified of discharge
•2/3 identified only through
•2/3 identified only through
abnormal EMR lab results
abnormal EMR lab results
•1/3 identified only through
•1/3 identified only through
EMR prescription data
EMR prescription data
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
19
20. Population health management technology
Health Intelligences Management — Measurement
REGISTRIES
REGISTRIES
CARE COORDINATION
CARE COORDINATION
QUALITY & BI REPORTING
QUALITY & BI REPORTING
Pre-defined Registries
Pre-defined Registries
Workflow Management
Workflow Management
Dynamic Registries
Dynamic Registries
Longitudinal Care Plan
Longitudinal Care Plan
Performance &&
Performance
Management Reporting
Management Reporting
Population Opportunities
Population Opportunities
Care Plan Adherence
Care Plan Adherence
Assessments
Assessments
ACO Measures
ACO Measures
Risk Scores
Risk Scores
CLOUD
COMPUTING
Claims Data
Clinical Data
Practice Mgmt
Medical,
pharmacy, lab
Biometric,
disease-specific
Billing data
and scheduling
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
20
24. Navigating the journey from providing care to managing health
Invest
New Capital
Generate
New Capital
Patient
Patient
Access
Access
Medical
Medical
Necessity
Necessity
Financial and
Financial and
Clinical Analytics
Clinical Analytics
Population Health
Population Health
Management
Management
Reimbursement
Reimbursement
Providing
Care
Aligned
Incentives
Clinical
Clinical
Care
Care
Coding and
Coding and
Documentation
Documentation
Care Delivery
Care Delivery
Model
Model
Quality
Patient
Satisfaction
Managing
Health
Cost
Prepare
for Change
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
24
Notas del editor
{"6":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n","24":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n","8":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n","3":"We are privileged to serve a tremendously diverse portfolio of partners. They have to perform better everyday and so do we. These folks keep us on our toes. They are trying to solve real problems and quite frankly, the margin of error in some of these worlds isn’t very forgiving.\nWe embrace this responsibility and one of the things I am most proud of is the depth of these relationships. When this group has a tough problem…they know they can count on the people of Optum.\n(Preferred Reported Values per the Optum Source of Truth.)\n","20":"A key differentiator of Optum's approach is that Optum Care Suite supports both measurement and management of care, whereas most solutions today focus on only one side of the equation. That approach leads to mis-alignment of the tools and processes for evaluating performance and informing corrective actions, adding complexity and cost to the system. \nRegistries\nHelps health professionals understand the health of entire populations of patients so they can then devise strategies for improving population health\nCare Coordination\nPatient conditions management\nCare plans personalized to each patient, built dynamically\nConfigurable patient alerts\nReal time modification at point of care\nReal time medication and condition reconciliation\nQuality and BI Reporting\nGathers data from claims, clinical records and patient reported outcomes, and helps health administrators easily track and measure performance and compile reports for quality and compliance requirements\nAnalytics\nClassic and real-time cloud population health\nRules based components\nPredictive models\nCloud\nAn environment that supports integration and makes connecting across systems easy to do. \nData Intake / Data Management\nThe first health IT solution to integrate clinical details from digitized patient records with medical claims data, to create a complete view of the patient experience and health system performance. \n","4":"Purpose of the Provider Map:\n• To facilitate a dialogue to understand the prospects goals, critical issues and journey\n• Use it as a diagnostic/discovery tool \nProvide the introduction, sit back and listen\nIntroduction to the Map\nAs we talk to clients and prospects, they share they are looking for ways to maximize the fee for service world today, while at the same time, determining how and what their move to fee for value should look like. \nWhat are your strategic goals and where is <hospital name> on your journey?\n"}