UPMC Health Plan April 11, 2018 1
Agenda 1. Overview of UPMC 2. Major Medicare Policy Items 3. Community HealthChoices 2
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. 3
UPMC: Our Commitment UPMC started building an integrated delivery and financing system over 20 years ago to position for the new paradigm. • 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 . . . 4
UPMC Today • $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 5
UPMC Commitment to the Community • 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. 6
UPMC: Global Academic Integrated Delivery and Finance System 85,000 employees & $17 B Revenue UPMC Health Services Insurance UPMC International Division Services Enterprises Services • • • 3.4 M 30+ hospitals 20+ countries • • 500 outpatient Hospitals: Italy Members • • Top ranked locations Established • Quality 310,000 IP partnerships in: • admissions Italy, Ireland, 4.5 Star • Medicare 4.2 outpatients China, Columbia, • visits Kazakhstan Service • 3,800 Excellence: Stevie Award employed physicians Winner • 5,700 total physicians 1 a
UPMC Insurance Services: A Diverse Product Portfolio • 2 nd Largest in Nation Provider Led • 3 rd 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 • 10 th 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) 8
UPMC Insurance Services Division Priorities • 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 9
UPMC: Membership All Products Total PA Members January 2018 = 1,281,180 Change From Jan 2017 = 68,589 Updated: 1/15/2018 UPMC-Owned Facilities 10
UPMC for You Service Area 11
UPMC for Life , Inc. Medicare Membership + Service Area Total PA Members January 2018 = 174,738* Change From Jan 2017 = 10,946 *25,255 total D- SNP Members as of 2/15/2018 Updated: 1/15/2018 UPMC-Owned Facilities 12
UPMC for Life Medicare Advantage HMO Service Area HMO Expansion Tioga Sullivan Lycoming Clinton Current 2017 Service Area Union Snyder 2018 Expansion Dauphin Perry Lebanon Counties Bucks Montgomery Cumberland Chester Fulton Delaware 13
UPMC for Life Medicare Advantage PPO Service Area PPO Expansion Current 2017 Service Area Lehigh Dauphin Berks Perry 2018 Expansion Lebanon Counties Cumberland Lancaster Fulton York Adams 14
UPMC for Life , Inc. Medicare Advantage Special Needs Plan (SNP) Current 2017 WPA 28 Counties Service Area UPMC Enrollment: 22,928 UPMC Market share: 42% 2018 Expansion Counties Reflects Jun, 2017 CMS enrollment data. 15
Medicare Policy Issues 1. Bipartisan Budget Act of 2018 2. Health Related Supplemental Benefits 16
Bipartisan Budget Act of 2018 Highlights • 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). 17
Bipartisan Budget Act of 2018 Highlights • 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. 18
Health Related Supplemental Benefits • 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. 19
Community HealthChoices UPMC Health Plan
PA Medicaid Expenditures by Population • Older adults and people with disabilities account for 29% of the PA Medicaid Enrollment and 62% of 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 21 Source: 2017- 2018 Governor’s Executive Budget As of 12/6/2017
MLTSS by State Active MLTSS Program in 2014 Active MLTSS Program in 2015 Currently Implementing MLTSS (2017-2018) Capitated Duals Demo (MLTSS for duals in demo) 22 States to Watch for Potential MLTSS Activity
Three Domains of Service Current LOB ▪ Primary care is the first line of support for health and wellness ▪ Includes routine check-ups and preventative services Primary ▪ Focused mainly on physical health ▪ Acute care for catastrophic events ▪ Acute care may also become necessary when the support systems in Acute one of the other two domains fail or break down ▪ Includes emergency room visits, inpatient, and skilled nursing facility ▪ Long-term services and supports (LTSS) help older adults and people with disabilities accomplish everyday tasks that many of us take for LTSS 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 23
5 Different Programs Become 1 • The “Waivers” serve a very diverse population Aging: Frail older adults or living • Over half of participants are in the Aging Waiver with disabilities (over age 60) HCBS $21,700 per year • Under 60 programs serve a range of physical disabilities with varying levels of independence CommCare: People living with traumatic brain injury – Examples include people who are: $76,300 per year • Relatively independent wheelchair users OBRA: People with physical and ( Attendant Care ) developmental disabilities • Ventilator dependent ( Independence ) $61,000 per year • Living with HIV/AIDS ( Independence ) Independence: Severe physical • Living with Brain Injury ( CommCare ) disability resulting in multiple functional limitations • Intellectually and physically disabled but $39,200 per year not in services before age 21 ( OBRA ) Attendant Care: Physical • Each is a stand-alone program today with slightly disability lasting more than a different services and utilization year, able to self-direct $24,000 per year 24
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