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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