Strategies, Plans or Programs Strategies, Plans or Programs

PacifiCare / UnitedHealthcarePacifiCare / UnitedHealthcare • NumberNumber of commercial HMO enrollees: of commercial HMO enrollees: 724,200 724,200 (12/2009)(12/2009)

• Demographic profile: Demographic profile: Heart DiseaseHeart Disease

1. Number with Heart Disease: 1. Number with Heart Disease: 4,0004,000– Percent with blood pressure controlled: Percent with blood pressure controlled: 67% 67% (<140/90)(<140/90)

– Percent with cholesterol controlled: Percent with cholesterol controlled: 63% 63% (<100mg/DL)(<100mg/DL)

Age Male Female Total18-44 2% 1% 4% White 62% Hispanic 21%45-64 59% 19% 78% Asian 18% Other 79%65+ 18% 4% 22% Black 6% Total 100%Total 79% 25% 100% Other 14%

Total 100%

Race Ethnicity

Strategies, Plans or Programs Strategies, Plans or Programs

PacifiCare / UnitedHealthcarePacifiCare / UnitedHealthcare • NumberNumber of commercial HMO enrollees: of commercial HMO enrollees: 724,200 724,200 (12/2009)(12/2009)

• Demographic profile: Demographic profile: HypertensionHypertension

2. Number with Hypertension: 2. Number with Hypertension: 52,10052,100 – Percent with blood pressure controlled: Percent with blood pressure controlled: 67%67%(<140/90)(<140/90)

Age Male Female Total18-44 10% 7% 17% White 62% Hispanic 21%45-64 38% 37% 74% Asian 18% Other 79%65+ 4% 4% 8% Black 6% Total 100%Total 38% 37% 100% Other 14%

Total 100%

Race Ethnicity

Strategies, Plans or Programs Strategies, Plans or Programs

PacifiCare / UnitedHealthcarePacifiCare / UnitedHealthcare • NumberNumber of commercial HMO enrollees: of commercial HMO enrollees: 724,200 724,200 (12/2009)(12/2009)

• Demographic profile: Demographic profile: DiabetesDiabetes

3. Number with Diabetes: 3. Number with Diabetes: 42,40042,400– Percent with blood pressure controlled: Percent with blood pressure controlled: 70% 70% (<140/90)(<140/90)

– Percent with cholesterol controlled: Percent with cholesterol controlled: 51% 51% (<100mg/DL)(<100mg/DL)

– Percent with HbA1c > 9: Percent with HbA1c > 9: 25% 25%

Age Male Female Total18-44 8% 8% 17% White 62% Hispanic 21%45-64 39% 32% 71% Asian 18% Other 79%65+ 5% 8% 13% Black 6% Total 100%Total 52% 48% 100% Other 14%

Total 100%

Race Ethnicity

Key Strategies for Reaching Targets Key Strategies for Reaching Targets

UnitedHealthcareEncourages 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

Results & Lessons LearnedResults & 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..

Resources NeededResources 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.