UPMC Health Plan April 11, 2018 1 Agenda 1. Overview of UPMC 2. - - PowerPoint PPT Presentation

UPMC Health Plan

April 11, 2018

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Agenda

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1. Overview of UPMC 2. Major Medicare Policy Items 3. Community HealthChoices

UPMC’s Mission

UPMC’s mission is to serve our community by providing outstanding patient care and to shape tomorrow’s health system through clinical and technological innovation, research, and education.

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• Our strategy allows us to focus on what matters most:

– Improving the health the communities – Implementing cost-effective solutions – Providing service excellence – Leveraging our unique structure to partner with all stakeholders: community providers, patients, members, employers . . .

UPMC: Our Commitment UPMC started building an integrated delivery and financing system over 20 years ago to position for the new paradigm.

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• $17 billion integrated global health enterprise with

85,000 Employees

• Ranked #10 Best Hospitals U.S. News & World

Report

• More than 30 hospitals with more than 6,000

licensed beds

• More than 600 doctors' offices and outpatient sites
• More than 5,700 affiliated physicians, including

3,800 employed by UPMC

• 23 senior communities, assisting over 2,900

residents on a daily basis

• Affiliated University of Pittsburgh – ranked #5 in

NIH funding

• 3rd largest GME program (1,360 residents)
• 4.6 million outpatient visits

UPMC Today

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• Total Economic Impact of $30 Billion as every dollar directly spent by

UPMC creates more than twice as much impact.

• Provides more than $960 million in community services contributions

in Fiscal Year 2016, or more than 15 percent of net patient revenue.

• UPMC is Pennsylvania’s largest nongovernmental employer and

supports more than one in five hospital jobs.

• UPMC committed more than $100 million in support for minority and

women-owned businesses. UPMC Commitment to the Community

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UPMC: Global Academic Integrated Delivery and Finance System

85,000 employees & $17 B Revenue

Insurance Services Health Services Division UPMC International Services

• 3.4 M

Members

• Top ranked

Quality

• 4.5 Star

Medicare

• Service

Excellence: Stevie Award Winner

• 30+ hospitals
• 500 outpatient

locations

• 310,000 IP

admissions

• 4.2 outpatients

visits

• 3,800

employed physicians

• 5,700 total

physicians

• 20+ countries
• Hospitals: Italy
• Established

partnerships in: Italy, Ireland, China, Columbia, Kazakhstan

UPMC Enterprises

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UPMC Insurance Services: A Diverse Product Portfolio

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• 2nd Largest in Nation Provider Led
• 3rd Largest Insurer Operating in PA
• Over 3.4 M Members
• Annual Revenues $7 B (run rate)
• 10,000+ Employer Groups
• Fastest Growing Medicaid and CHIP Plan
• Top tier Medicaid plan in PA
• 4 Star Medicare Dual Special Needs Plan
• 10th Largest SNP Nationally
• Top 10 Nationally in Medicaid Quality
• Highest Ranked Provider Satisfaction

(PA)

• J.D. Power Certified Call Center
• National Business Group on Health

Platinum Winner

• 2012 Global Call Center of the Year

Awardee (ICMI)

• Launching and expanding Community Health Choices (CHC)
• Improving health outcomes and quality metrics for SMI (goals of

SMI population health management)

• Substance Use Disorder
• Addressing the Social Determinants of Health
• Aligning CHC and D-SNP clinically and financially
• D-SNP enrollment

UPMC Insurance Services Division Priorities

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UPMC: Membership All Products

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Total PA Members January 2018 = 1,281,180 Change From Jan 2017 = 68,589

Updated: 1/15/2018 UPMC-Owned Facilities

UPMC for You Service Area

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UPMC for Life, Inc. Medicare Membership + Service Area

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Total PA Members January 2018 = 174,738* Change From Jan 2017 = 10,946

UPMC-Owned Facilities Updated: 1/15/2018

*25,255 total D- SNP Members as of 2/15/2018

UPMC for Life Medicare Advantage HMO Service Area

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Tioga Lycoming Clinton Perry Bucks Chester Fulton Dauphin Sullivan Union Snyder Cumberland Lebanon Montgomery Delaware

HMO Expansion

Current 2017 Service Area 2018 Expansion Counties

UPMC for Life Medicare Advantage PPO Service Area

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York Berks Perry Lancaster Adams Fulton Dauphin Lehigh Cumberland Lebanon

PPO Expansion

Current 2017 Service Area 2018 Expansion Counties

UPMC for Life, Inc. Medicare Advantage Special Needs Plan (SNP)

15 Current 2017 Service Area 2018 Expansion Counties

WPA 28 Counties UPMC Enrollment: 22,928 UPMC Market share: 42%

Reflects Jun, 2017 CMS enrollment data.

Medicare Policy Issues

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1. Bipartisan Budget Act of 2018 2. Health Related Supplemental Benefits

• Permanently reauthorizes Medicare Advantage (MA) Special

Needs Plans (SNPs)

• Two-year extension of funding for outreach and education

activities for Medicare beneficiaries.

• Allows MA plans to offer a wider array of targeted supplemental

benefits to chronically ill enrollees beginning in 2020.

• Makes coverage of speech generating devices under durable

medical equipment permanent under the Medicare program (removing the 2018 sunset under current law).

Bipartisan Budget Act of 2018 Highlights

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• Accelerates the closure of the Part D program coverage gap,

known as the "donut hole" by decreasing beneficiary contribution to 25% in 2019.

• Increases drug manufacturer discount from 50% to 70% under

Part D.

• Increases Medicare reimbursement for home health agency

providers by 1.5 percent in 2020.

• Increases Medicare reimbursement for skilled nursing facility

(SNF) providers by 2.4 percent in FY19.

Bipartisan Budget Act of 2018 Highlights

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• Recent CMS Guidance will allow MA plans to include additional

services that “increase health and improve quality of life, including coverage of non-skilled in-home supports and other assistive devices.”

• Expansion of the definition of “primarily health related.” The new

definition will allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.

• Under this reinterpretation, CMS will allow supplemental benefits if they

are used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization. Health Related Supplemental Benefits

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Community HealthChoices UPMC Health Plan

PA Medicaid Expenditures by Population

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• Older adults and people with disabilities account

for 29% of the PA Medicaid Enrollment and 62%

• f spending
• Community HealthChoices includes a large

proportion of this population and spending – Major drivers of cost are reliance on nursing facilities and poorly coordinated care – Figures do not include Medicare spending for the same population

• According to the MLTSS Association, LTSS duals

are 6% of the total Medicaid population accounting for 43% of spending

Source: 2017-2018 Governor’s Executive Budget As of 12/6/2017

MLTSS by State

Active MLTSS Program in 2014 Currently Implementing MLTSS (2017-2018) Capitated Duals Demo (MLTSS for duals in demo) States to Watch for Potential MLTSS Activity Active MLTSS Program in 2015

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Three Domains of Service

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▪ Long-term services and supports (LTSS) help older adults and people with disabilities accomplish everyday tasks that many of us take for granted – bathing, dressing, fixing meals, and managing a home ▪ Services can be delivered: at home (HCBS), in an adult day, nursing facility (NF), and, newly to Pennsylvania, assisted living

Primary Acute LTSS

▪ Primary care is the first line of support for health and wellness ▪ Includes routine check-ups and preventative services ▪ Focused mainly on physical health ▪ Acute care for catastrophic events ▪ Acute care may also become necessary when the support systems in

• ne of the other two domains fail or break down

▪ Includes emergency room visits, inpatient, and skilled nursing facility

Current LOB

5 Different Programs Become 1

Attendant Care: Physical disability lasting more than a year, able to self-direct $24,000 per year Independence: Severe physical disability resulting in multiple functional limitations $39,200 per year CommCare: People living with traumatic brain injury $76,300 per year OBRA: People with physical and developmental disabilities $61,000 per year Aging: Frail older adults or living with disabilities (over age 60) $21,700 per year

HCBS

• The “Waivers” serve a very diverse population
• Over half of participants are in the Aging Waiver
• Under 60 programs serve a range of physical

disabilities with varying levels of independence – Examples include people who are:

• Relatively independent wheelchair users

(Attendant Care)

• Ventilator dependent (Independence)
• Living with HIV/AIDS (Independence)
• Living with Brain Injury (CommCare)
• Intellectually and physically disabled but

not in services before age 21 (OBRA)

• Each is a stand-alone program today with slightly

different services and utilization

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CHC Goals

95% of Pennsylvanians say they would rather age in their home or community than in a nursing facility, but only 41% of the waiver-eligible population currently does so

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Rebalance the long term care systems

• Provide services in the least

restrictive setting

• Keep Pennsylvanians aging in place
• Transition those who are able out of

nursing facilities and back into the community Improve coordination across Medicare, Medicaid, and LTSS

• Care for duals, especially those receiving

LTSS, is highly fragmented

• All CHC-MCOs are required to have an

aligned D-SNP in the zones in which they

• perate

Community HealthChoices Program

Nursing Facility Home and Community- Based Services D-SNP (not included)

CHC includes revenue to support:

Medicaid Secondary Medicaid Primary Medicaid Medicare (not included) Participants will need to voluntarily elect D-SNP coverage Mandatory enrollment for eligible participants LTSS Healthcare

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• CHC includes :

– Health Care

• Medicaid Secondary Coverage for duals who may or may not be in our D-SNP
• Medicaid Primary Coverage for people living in nursing facilities or on

Home and Community Based Services (HCBS) Waivers without Medicare – Long-Term Services and Supports (LTSS)

• Ongoing support of custodial nursing home residents
• Nursing home eligible older adults and people with disabilities who receive home and

community-based services (HCBS)

• D-SNP revenue will grow rapidly as auto-assigned Medicaid CHC members elect to have coverage
• Each zone will have a Continuity of Care Period

– All LTSS providers currently serving participants will be contracted for 6 months – Critical window for performance evaluation of new provider partners

Community HealthChoices Program

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347k Pennsylvanians Included

Non-LTSS Duals

HCBS Nursing Home

Age < 60 115,291 Age >= 60 116,151 Age < 60 22,498 Age >= 60 37,950 Age < 60 5,692 Age >= 60 49,858

HCBS: Home and Community Based Services Southwest Southeast Lehigh/Cap Northeast Northwest Total Community Dual 58,254 73,131 45,793 35,014 19,250 231,442 Nursing Facility 12,320 15,861 12,413 9,933 5,023 55,550 HCBS 10,391 33,940 6,459 5,352 4,306 60,448 28

Circle size represents total LTSS sub-population by zone

22,711 49,801 18,872 15,285 9,329

2019 2020 2020 2020

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$7 Billion State Procurement

• Includes nursing home, traditional Medicaid, and Medicaid secondary coverage

– it does not include the D-SNP financial impact

• HCBS include services not offered by Health Plans through our traditional

network – Examples of new services: Personal Care, Adult Daycare, Nursing Home Services, Job Coaching, Non-Medical Transportation, Pest Eradication, Vehicle and Home Modification

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Selected Bidders

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• DHS selected three plans to join them in integrating care and “rebalancing”

Same Zones as HealthChoices

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2018 2019 2020 2020 2020

General Program Status

– CHC implementation is staggered ₋ Southwest: January 1, 2018 ₋ Southeast: January 1, 2019 ₋ Rest of State: January 1, 2020 – Southwest plan enrollment ended on December 28 ₋ Approximately 50% of participants made an active choice; remaining participants were auto-assigned ₋ Participants can make plan changes monthly

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Questions?