James Schuster, MD, MBAVP, Behavioral Integration
May 21, 2015
Using data to engage members with complex medical conditions
• 2.5 million members
• 10,200+ employer groups
• $5.5B annual revenue
• 10% average annual growth YOY
• 124 hospitals and other facilities and more than 11,500 physicians in network
• Medicaid and CHIP plans have the largest membership in western PA
• 4-Star HMO Medicaid plan
• Integrated population health and productivity products
• J.D. Power certified UPMC Health Plan’s Health Care Concierge Contact Center in 2014
• National Business Group on Health Platinum recognition (5x since 2009)
• 2013 ICMI Global Call Center Award Best Customer Experience Program
UPMC Insurance Services Division
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By the numbers:
Divisions and Products
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Divisions Products
Who they are:•Team includes nurses, social workers and community health workers (certified peer specialists)•Strong focus on psychosocial and behavioral complications•Driven by data with plan for rigorous evaluation
What they do:•Address chronic conditions like asthma, diabetes, COPD, coronary artery disease, heart failure, etc.•Engage residents through education and training about healthy lifestyles, nutrition, and exercise.•Continued enhancement of five-year program that provides community-based care management for individuals with complex conditions
UPMC Community Team
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• Members with medical admissions or observational stays within 12 months
• Allegheny (Pittsburgh), Butler, Beaver, Washington, Westmoreland counties
• Other predictors of clinical severity
UPMC Community Team Clinical Focus
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Exclusions:•Same-day electives•Physical rehabilitation•Admissions for chemotherapy•Admitted from skilled nursing facility•Pregnancy
As a health insurance organization, have the unique ability to capture data from members who see UPMC providers and non-UPMC providers.
•Insurance claims (services and pharmacy)
• Insurance authorizations
• Hospital admission data
• Hospital and community provider clinical information
UPMC Community Team Data Sources
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• Engagement rates
• Number of members seen while hospitalized
• Number of members seen within seven days after discharge
• Rate of PCP follow up within one week of discharge
• Average number of contacts per team member per day
• Summary of interventions using the SAMHSA 8 Dimensions of Wellness framework
Sample Process Indicators
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• HEDIS measures
• Medicare Stars rating
• Total medical costs per member
• Total pharmacy costs per member
• Return on investment (ROI)
• Reassessment of members one year after discharged from community team
Sample Outcomes Indicators
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