Optum | November 3, 2020
The dueling disasters of a pandemic and a recession have created unprecedented challenges for the global health system. But they are also creating opportunities to accelerate a transition to a health system based on value, affordability, and engaged consumers.
“We’ve been talking for 20 years about moving from volume to value, from fee-for-service to different payment models. It’s been slow going, and we often talk about the role of payers, providers, federal government and states in driving a value-based system,” said Mitch Morris, MD, President of Optum Advisory Services. “But we don’t talk that much about the role of consumers, and some of the choices they make, in the direction that we take in health care.”
Morris hosted the Health Evolution virtual gathering, Mission Possible: Engaging Consumers to Drive Value and Sustainable Health Care Economics, with Dave Wichmann, CEO, UnitedHealth Group and Laura Kaiser, President & CEO, SSM Health.
“The health care industry is still in the fairly early stages of understanding what consumers want and how we best meet their desires – providing services when, where and how they want them,” Kaiser said. “We need to continue to lean in and learn more about the individuals we are collectively serving.”
The natural question becomes how can health care leaders leverage consumerism to enable the transition to value-based care?
Kaiser, Morris, and Wichmann identified the following strategies:
Transitioning from sick care to wellness
“America is chronically ill,” Wichmann said. “By the time we get to 2025, nearly 60 percent of Americans will have one chronic disease or more. By 2030, a full 30 million will be polychronic. The burden of disease is significant.”
Stark projections, such as those, mean that having the right information is critical — and the data must be accessible by consumers and physicians, as well as translatable into appropriate care pathways.
“Health and wellness requires partnership between each person and their provider, along with the concept of shared accountability,” Kaiser said. “We still need to think through the alignment for payment models that incentivize health and wellness, so that people need less of the expensive rescue care that we provide so beautifully in this country. If we can stave off rescue care, we can re-deploy those resources toward keeping people well in the first place.”
That will require motivating consumers to act. But as Wichmann said, better health is not enough motivation for all 330 million people in America.
“If you combine better health with rewards to maintain their wellness, as opposed to falling into the situation where they’re seeking sick care, you can motivate them through rewards-based system and also provide the avenue for an engaged physician,” Wichmann added.
To achieve patient and physician engagement, UnitedHealth Group reduces the panel size of its physicians and adds advanced practice clinicians to deepen levels of engagement with consumers and improve follow-through on necessary actions. UnitedHealth Group is also driving alignment incentives for people to proactively manage their own health.
“We’ve moved away from traditional checklist-based items to things that are deeply personal, next best actions to advance an individual’s health,” Wichmann said. “That comes about as a result of being able to develop a full medical record and evaluate the health system’s performance against evidence-based practices, identify the gaps, and then prioritize those as the places that both the consumer and the doctor should pursue.”
Establishing shared risk arrangements
As a self-professed “big believer in ACOs,” Kaiser said SSM Health has earned success as a partially integrated delivery system with experience in risk-based models and approximately 170,000 lives in its ACOs.
“ACOs are a key ingredient for moving us more to value-based care delivery,” Kaiser said. “But we need to do that in partnership with others.”
Optum’s Morris pointed to SSM Health’s strategic asset, the Dean Health Plan.
“We are an integrated delivery system in our Wisconsin market and we’ve been able to improve quality while reducing the total cost of care for our patients,” Kaiser explained. “We want to bring this model into the other markets we serve, and this year we expanded into Missouri with products available on the exchange and commercially.”
Kaiser continued that SSM Health has to be careful to remain payer agnostic because it continues to work with United and other insurers. “It makes sense to align all of our work together so that we can best serve our members and our patients. You can improve health status when you’re aligned, when you have the opportunity to work collaboratively for everyone,” she said.
Wichmann added that the transition to value-based care is a true journey.
“That journey is very different depending upon where you are geographically, because it has to do is be accepted within the community you’re operating in,” Wichmann said. “We’re definitely seeing a very strong migration because of the Cares Act and I suspect we’ll see practices aligning, and more well-formed organizations become even stronger risk bearing entities over time.”
Value-based care also requires consumers to be play an active role, which necessitates a marked shift for an industry that has typically focused on sick care more than wellness. While ACOs will need to use data and analytics, moving people into wellness and maintaining their health has the potential to help them better understand their patients and members.
“We continue to learn more and more about consumer behavior and preferences, which will help us better design systems to keep them well,” Kaiser said. “We need to continue to lean in and truly understand the people we are collectively serving.”
Leveraging Medicare Advantage for consumer choice
Morris pointed out that Medicare Advantage drives consumer choice and, in fact, approximately 35% of Medicare beneficiaries choose MA programs, which could accelerate.
“Medicare Advantage has outperformed Medicare fee-for-service, which leaves an enormous gap that has to be filled both supplemental coverage and Part D,” Wichmann said.
Wichmann added that high performing systems of care have saved between 35% and 40% and are earning Net Promoter Scores in the mid-80’s to low 90’s.
“That’s a nice consumer response to a world-class level of service,” Wichmann said. “It’s because they’re utilizing information and technology and advancing aligned incentives.”
Another benefit: Seniors don’t see any of that going on in the background; what they do see is easier access to their doctor for longer durations of time and a smaller but more coordinated care team than under fee for service.
“When you’re not coordinating care, that’s where all the mischief occurs in health care and causes a lot of contra-indications, drug therapies, and things that work against one another on that system,” Wichmann said. “And it’s very important that consumers have choice.”
Medicare Advantage is also appealing to SSM Health as a provider because it offers more opportunities to partner with consumers to achieve optimal levels of health, Kaiser said. “It’s a more flexible system that can yield better outcomes than traditional approaches,” she said.
Laura Kaiser, SSM Health
Creating an end-to-end, digital patient experience
As far back as two decades ago, Morris was conducting telemedicine appointments — “second opinion at a distance.” He said he thought at the time that everyone would eventually be using the technology. But it took 20 years and the pandemic to accelerate virtual care such that people now have the option to stay at home, school or work rather than going to a doctor’s office.
SSM Health, for example, created telehealth capabilities in the form of both synchronous and asynchronous visits two and a half years ago.
“Before COVID hit, we were seeing about 200 patients a day and at the height of the pandemic were seeing 5,000 patients a day. Now, it has leveled off at about 3,000. So, I think it’s here to stay and can be a really effective platform for care.” Kaiser said. “It’s also another means for us to better meet people where they are.”
On the physician side, SSM Health clinicians were appropriately concerned about the alignment of payments and fitting virtual care into the traditional office visit. The enterprise also had to work through the ways it factors productivity and compensation formulas.
“I was very happy when there was essentially universal adoption of reimbursements for telehealth,” Kaiser said. “These payments now need to be implemented permanently because telehealth has become another key access point.”
Of the 120,000 Optum clinicians, about 1,000 were working in telemedicine environments before the outbreak and within 30 days that escalated to 15,000, Wichmann said, effectively making UnitedHealth Group one of the largest telehealth networks in the nation.
If that sounds simple, it was not. While UnitedHealth Group wanted to deliver care services to patients, it ran into two barriers: scaling the systems to make them available within appropriate timeframes, and the realization that among its senior population they didn’t want to go to just any doctor, then wanted to see their own doctor.
“For anybody who is chronic or poly-chronic, it’s really important that we enable people to see their own doctor. And that’s one of our initiatives,” Wichmann said. “What enhances that experience is if that doctor can be informed.”
Presenting the individual health record so the physician and the consumer both have the appropriate information is the foundation. UnitedHealth Group is also leveraging its home-based signaling platform to support consumers.
The digital patient experience is about more than interacting with consumers. On the provider and payer side, it also presents the opportunity to use analytics to better understand who is at risk, who needs assistance of various sorts including addressing social determinants such as education, and how health care enterprises can intervene to offer assistance that will help people stay healthy.
“The idea is to evaluate medical records through the use of artificial intelligence to identify where the gaps in care are, because every one of those gaps is a signal,” Wichmann said.
Morris added that payers are likely to be interested in sponsoring programs and platforms designed to keep people out of the hospital or doctor’s office, because it fits their business models, while providers would naturally be interested as well.
“We both need to be involved because we bring different skills and strengths to the equation,” Kaiser said. “We’re all in this for the same reason: to provide the best care that we possibly can for the patients and the members that we serve. We are part of the same fabric.”
Continuing commitments to health equity
Before COVID-19, the widespread disparities in health care were already understood to a certain extent.
“There are real health care disparities and underlying comorbidities associated with COVID-19 that are disproportionately affecting populations that already experience socioeconomic distress,” Kaiser said.
SSM Health and other organizations were learning from data in real-time as the pandemic was spreading. SSM Health forged partnerships with Federally Qualified Health Centers, public health departments, elected officials, businesses and others in the communities it serves. The organizations worked together to distribute masks, to help with public health campaigns, to increase awareness about handwashing, wearing a mask and social distancing — and then to equip those communities, accordingly.
“We reached out to other health systems in the community that we normally compete against and have been collaborating throughout this entire crisis,” Kaiser said. “We’re continuing to do that now by establishing a framework to collaborate on community health going forward, in order to improve the health status in every community we serve.”
UnitedHealth Group initiated a multi-dimensional effort involving its scientific R&D team enable to scale up PCR (Polymerase Chain Reaction) kits significantly, utilizing analytics capacities to identify correlations between COVID-19 and certain medications or conditions that individuals have, and working on 20 academic research studies to validate those as causal. Wichmann pointed as an example to an ACE inhibitor that helped reduce hospitalizations by 40 percent.
Predicting that the economic fallout accompanying COVID-19 would also lead to a rise in homelessness, UnitedHealth Group also invested in affordable housing to receive homeless people with complex conditions. Those services included transportation systems and services addressing food insecurity.
UnitedHealth Group also set up centers in Philadelphia, one in Orleans Parish, Louisiana, and the other in Los Angeles to help make testing and follow-up care more equitable. The centers also enabled UnitedHealth Group clinicians to use the opportunity, while testing to educate people about hygiene and other safety aspects related to COVID-19 that might not come through clearly in public service messaging.
“We will take all the learnings from that and apply those to the management of all infectious disease because we know that a lot of the behaviors we’re undertaking today to prevent COVID-19 spread also apply to flu, pneumonia and a number of other conditions that take lives,” Wichmann said.
Ultimately, transforming health care into a value-based system will require new ways of engaging with consumers for wellness — and that will mean leveraging digital tools to enhance the patient experience, taking advantage of opportunities such as Medicare Advantage to offer people choices and continuing to focus on equity by reaching people where they are.
Payers and providers will have to work together in order to achieve that future.
“The orientation of payer versus provider or otherwise has shifted quite a bit, and I think it’s the best change in health care,” Wichmann said. “Maybe we’ve learned a little bit to walk a mile in each other’s shoes and apply the knowledge that we have together to drive transformative change.”
Wichmann said that change will create greater productivity levels that also reduce stress on consumers and clinicians, while mitigating the risk on fee for service organizations by being able to provide care in crisis situations.
“We really need to think about alignment of our payment system to fuel the consistent delivery of high-quality care that is sustainable, affordable, and accessible for all people. That’s where value-based care for all of us is so compelling,” Kaiser said.
Kaiser, Morris and Wichmann agreed that patients are the real winners because they’ll be able to enjoy a healthier life.
“In the last few months, we’ve seen a lot of change with a pandemic and also a recession having a big impact on health care in our country,” Optum’s Morris said. “There are also opportunities to accelerate change, particularly around the move to value, affordability, engaging with consumers.”
Watch the Mission Possible: Engaging Consumers to Drive Value and Sustainable Health Care Economics webcast here: