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Lunch & Learn: How We Care for Medicare
Enabling Healthier Lives
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Today’s Agenda
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Who is Optum?
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Ranked 6th of the Fortune 500
Health Benefits Health Services
A diversified enterprise with complementary but distinct
business platforms
Our MissionTo help people live healthier lives and to help make the
health system work better for everyone.
OptumCare Today
>16M
Aligned Physicians >45k
>9k Advanced Practice Clinicians
>80 Payers
Patients
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OptumCare WA
>640k
PCPs>570
>1.7k Specialists
Patients
Northwest Physicians Network (NPN)
The Everett Clinic (TEC)
Network Locations
The Polyclinic
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Growing Primary CareEnabling Specialty
Serving Vulnerable PopulationsInviting Others
Expanding Value-Based CareEnhancing FFS
Standardizing TogetherRespecting Local Details
Focus Areas
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HealthierLives
Enabling
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Fee-for-Service vs Value Based CareTraditional Fee-for-ServiceReactive approach – “Sickcare”
Delivering care in this moment in time
• Episodic care• Rewards number of visits• Most of care is provided in the visit• Encourages utilization for reimbursement
Population Health / Value Based CareProactive approach – “Wellcare”
Delivering care throughout the year
• Prevention and early detection; keeping the patient healthy
• Rewards outcomes and quality• Much of care is provided between visits• Patient’s diagnosis determines cost of care and
resources needed
Can drive higher costs Predicts cost and more accurately reimburses for complexity of care
A mild flu season
Resolving issue via phone call
A mild flu season
Resolving issue via phone call
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Requires Providers to bill CMS for visits & proceduresTraditional Medicare Operates Fee-for-Service
TEC receives payment based on contracted services performed
Visits
Tests
X-rays
Procedures
Medicare patient visits clinician
Clinician sends claim to CMS for reimbursement
If patient has supplemental insurance, Medigap plan pays provider
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Medicare Advantage focuses on Population HealthMA is a different business model. Providers who take risk receive monthly payments for each MA member based on county of residence, demographic, and health status of the member.
Hospitals
Skilled Nursing Facilities
Other Providers
DME Providers
CMS give global fees to payers for Medicare Advantage (MA)
Payers give global fees to the Everett Clinic & NPN through risk contracts
HOLDS RISK
MA Contract
TEC & NPN are responsible for managing total cost of care for these patients
Risk Contract
Risk Contract
1) Park, Hyojun et al. “Relative contributions of a set of health factors to selected health outcomes” American Journal of Preventative Medicine 2015, 49(6). https://www.countyhealthrankings.org/sites/default/files/Park_AmJPrevMed_2015.pdf
2) Definition from the World Health Organization 3) McKinsey 2019 Consumer Social Determinants of Health Survey 11
Imagine all the factors that drive healthcare needs Research suggests that medical care contributes 30% to health outcomes, social determinants contribute 70%1.
Social determinants of health are the conditions in which people are born, grow, work, live, and age2
Food Environment
Community Safety
Housing Social Support
Transportation
More than half of seniors may be adversely affected by 1 or more of these social determinants3
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Medicare Advantage enables comprehensive careData Transparency Member Benefits Care Programs
Personalized Care Team (PCT)
MA-Only Clinics
Transitional Care Management
Complex Care Management
Hospitalist Team
Skilled Nursing Facility (SNF) Providers
ClaimsPredictive analysis, identify high risk patients
Care Gap ReportingImproves quality, preventive care
Eligibility Proactively engage patients (e.g., Annual Comprehensive Visit)
In 2020, Medicare Advantage patients can access a broader set of supplemental benefits to address social determinants such as: Meal delivery
Transportation for non-medical needs
Home environment services
Source: CMS 2020 Final Call Letter
1) TEC internal reporting; Med Adherence rates come from health plans 2) Final CMS national Star average performance for services provided in 2017 13
Impact of Data on Preventive CareCore Clinical STAR Measure TEC 2018 Rating1 Beat Benchmark CMS Benchmark2
Body Mass Index 5 4
Rheumatoid Arthritis 4 3
Breast Cancer Screening 4 3
Colorectal Cancer Screening 5 4
Diabetes – Blood Sugar Control 5 4
Diabetes – Nephropathy Screening 5 4
Diabetes – Eye Exam 5 4
Osteoporosis Management 4 2
Medication Adherence 5 3
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TEC & NPN Colorectal Cancer Screenings
Colorectal Cancer
#2 Leading Cause of Cancer Deaths in the US
+60,000 Patients1
Appropriate Colorectal Cancer Screening
1440Fewer Deaths
From Colorectal Cancer
16,200Life Years
Gained
* Lifetime benefitsLifetime benefits2: • 24 fewer colorectal cancer deaths per 1K patients • 270 life years gained per 1K patients
1) TEC/NPN internal reporting for colorectal cancer screening.2) American Cancer Society
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Our Care Model
Prevention: Provide onboarding and education to support healthy lifestyles and wellness for all patients
Complex Care: Highest level of care and team engagement for high risk patient
Condition Care: Dedicated support and coordination for patients with uncontrolled chronic diseases
Proactive Management: Proactive engagement from care team for patients with controlled chronic disease
• Extensivist Physicians (PCT)• All teammates below
• PCPs• RNs• MAs
• Specialists• Social Workers• Behavioral Health• RN Care Managers• Clinical Pharmacists• All teammates below
Other Patients(80-85%)
Highest Risk (~5%)
Rising Risk (10-15%)
Level of Care Care Team Composition
Members across all levels of care are engaged in condition-specific and transitions of care programs as appropriate
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We care for patients across the continuumOur Patients
Primary Care
Ambulatory Surgery Center
Hospitals
Specialists
Skilled Nursing Facilities
Rehab
Home Care
Hospice
Proactive Care Acute Care Post-Acute Care
Complex Care Managers MA-only Clinics* PCT*
Transitional Care Managers Hospitalists PCT*
Complex Care Managers SNF Providers PCT*
Our Teams
*TEC only
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Our Care Managers help enable healthier lives
What Your Clients Can Expect
• RN Care Manger to support them
• Develop care plan with patient
• Regular telephone calls to manage health goals
• Assistance with appointments and getting connected to providers (BH, specialists)
• Rounding during hospital admissions
• Medication management
• Immediate follow-up after hospital discharge
• Assistance accessing health plan benefits
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Skagit, Snohomish, King, Pierce, Kitsap, Clark countiesNPN at a Glance
180 180
240
2017 2018 2019
PCPs in NPN networkFounded in 1995, acquired by DMG in 2017
Headquartered in Tacoma
Over 1000 participating providers
80 multi-specialty ambulatory surgery and diagnostic imaging centers
PCPs in 6 Western WA
counties
400 ancillary facilities (Behavioral Health,
DME, HH, SNF, Rehab)
66 different specialties in over
300 locations
* Primary care providers who see MA patients
+15.5%
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Serving Eastern Pierce County for more than 30 YearsSounds Family Medicine
47 PCPs
Humana (MA HMO & MA PPO)
United Healthcare (MA HMO only)
Premera (MA HMO only)
Aetna (MA HMO and MA PPO)
Closed to Original Medicare
Plans Accepted
4 Clinics3 Walk-In Clinics
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Internal Medicine, Sound Family MedicineMeet Dr. Alexandra Vladimir
“I enjoy connecting with people. Every detail my patient shares with me is part of a care plan puzzle we put together.”
Languages: English, Romanian
Medical School: Davila University of Medicine & Pharmacy
Residency: Mount Sinai School of Medicine
Location: Puyallup – 10 St (Hartland) Mon - Thurs 7:00am – 7:00pmFri: 7:00am – 6:00pm
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Internal Medicine, Sound Family MedicineMeet Dr. Neena Chawla
“As an internist, I care for adult patients as a whole person, and approach their issues with a holistic view.”
Languages: English, Hindi
Medical School: Delhi University Medical College
Residency: University of Southern California
Location: Bonney LakeMon - Thurs 7:00am – 7:00pmFri: 7:00am – 6:00pm
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Family Medicine, Sound Family MedicineMeet Dr. Julie Komarow
“As a breast cancer survivor, I have a personal perspective on the value of heading off problems before they become serious.”
Languages: English
Medical School: University of Washington
Awards: Patient’s Choice Award (vitals.com)Compassionate Doctor Recognition (vitals.com)
Location: Bonney LakeMon - Thurs 7:00am – 7:00pmFri: 7:00am – 6:00pm
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Internal Medicine & Family Medicine PCPsOpen NPN Practices
• Peninsula Community Health Services (Kitsap)• Hanmi Medical Clinic (Pierce) • Physician Care Northwest (Pierce) • NW Family & Spinal Clinic (Pierce) • Bonney Lake Medical Center (Pierce) • Western Washington Medical Group (Snohomish) • Dr. Andrew Loomis (Pierce) • Hudson’s Bay (Clark)
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Your Feedback
• Provider directory• Meet-and-greet with open providers• Medicare Advantage education for patients• Other resources and tools?
Join us for a tour of the Smokey Point Clinic
Appendix
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>16M
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Optum Care National Footprint
DMGCare DeliveryMedical Groups MedExpressSCA
Patients Served
>80Health plans
>1.2Care Clinics
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OptumCare WA
Open NPN Practices
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Internal Medicine and Family Medicine PCPs Accepting New Patients
Sound Family Medicine
Hanmi Medical Peninsula Community Health Services
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Pain Points of Fee-for-Service Medicare
PROVIDER EXPERIENCE:
Production pressure vs. experience
Unable to address all issues in visit
Limited care management support
Disparate or disconnected data
PATIENT EXPERIENCE:
Visit feels rushed
Perception of a less caring relationship
Uncoordinated care – Is anyone talking to each other?
Inefficient, costly