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Strategies, Plans or Programs

Strategies, Plans or Programs. PacifiCare / UnitedHealthcare Number of commercial HMO enrollees: 724,200 (12/2009) Demographic profile: Heart Disease 1. Number with Heart Disease: 4,000 Percent with blood pressure controlled: 67% (<140/90)

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Strategies, Plans or Programs

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  1. Strategies, Plans or Programs PacifiCare / UnitedHealthcare • Number of commercial HMO enrollees: 724,200 (12/2009) • Demographic profile: Heart Disease 1. Number with Heart Disease: 4,000 • Percent with blood pressure controlled: 67% (<140/90) • Percent with cholesterol controlled: 63% (<100mg/DL)

  2. Strategies, Plans or Programs PacifiCare / UnitedHealthcare • Number of commercial HMO enrollees: 724,200 (12/2009) • Demographic profile: Hypertension 2. Number with Hypertension: 52,100 • Percent with blood pressure controlled: 67%(<140/90)

  3. Strategies, Plans or Programs PacifiCare / UnitedHealthcare • Number of commercial HMO enrollees: 724,200 (12/2009) • Demographic profile: Diabetes 3. Number with Diabetes: 42,400 • Percent with blood pressure controlled: 70% (<140/90) • Percent with cholesterol controlled: 51% (<100mg/DL) • Percent with HbA1c > 9: 25%

  4. Key Strategies for Reaching Targets • UnitedHealthcare • Encourages group specific DM programs and CM through capitated /delegated network model. • Encourages member activation through “Taking Charge” population-based, member programs. • Tracks and reports clinical measures by Medical Group • Home blood pressure cuffs • Discounts are available to members. • The percent of hypertensive patients with home blood pressure cuffs is not available. • Implemented EBM rules through our PBM for specific clients, exploring more generalized use of EBM based programs. • Implemented multiple DM programs • Optum – Multiple DM programs (division of UHG) • Alere – Congestive Heart Failure Program

  5. Results & Lessons Learned • Improvements from 2007 to 2010: • Diabetes Hb1c control = 24% improvement • Diabetes LDL control = 26% improvement • Diabetes BP control = 14% improvement • CV LDL control = 11% improvement • CV BP Control = 24% improvement • Lessons Learned: There is wide variation in Medical Groups. Some of the variation relates to inadequate encounter data capture and coding. Some groups appear to be successful and other unsuccessful in implementing programs, success is often related to the resources available to the group e.g. whether the group is part of a larger healthcare delivery system. Larger groups, part of integrated delivery systems maybe less dependent on plan programs than smaller groups. • What is working, what isn’t and what changes are being made: Large fully capitated groups perform better than smaller groups. Risk models which pass professional and facility risk to medical groups pose a challenge to plan as data to evaluate programs may be insufficient. CPT coding is often not specific enough to support evaluation..

  6. Resources Needed • Barriers: • Incomplete data from fully capitated medical groups. • Unwillingness to implement plan-based DM programs (CHF). • Smaller groups without resources - The San Diego Right Care Pilot initiative represents a potential breakthrough in improving the performance of low scoring medical groups. This program may allow health plans to collaborate through the RCI with cost effective community providers to improve clinical performance (HEDIS) and the health of the HMO population. • Additional resources needed: • Adoption of CPT codes by medical groups. • Capture of lab results data. • Activities health plans and medical groups can take : • Support medical group and physician-specific profiling. • Share registries of members with gaps in care.

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