A Better-Aligned System of Incentives

Optum Life Sciences embraces modern outcome-based reimbursement models to create clinical programs for the most undertreated populations

Curt Medeiros is the new president of the Life Sciences sector of Optum, the health-services sister company of UnitedHealthcare. Here, he discusses with AHL how his team can make healthcare “work better” for patients, medical professionals, and insurance partners across the country.

Optum Life Sciences uses modern analytics to drive better outcomes for your healthcare partners. What does that look like in action?

Medeiros: In general terms, we use analytics and data to understand the health of various populations and to identify opportunities to improve patient outcomes through intervention and engagement. For example, Optum One, our population-health analytics platform, provides integrated delivery networks (IDN) operating as accountable care organizations with analytical tools. Under the Affordable Care Act, ACOs are now being paid for outcomes rather than services, so they want to better understand their patient populations.

We integrate electronic health records across disparate EMR systems and normalize the data on an apples-to-apples basis—regardless of if the patient is in the emergency room, visiting with their primary-care physician, or otherwise. We then leverage this data to provide health systems, including ACOs, with the necessary analysis, which enables them to identify patients at highest risk so that they may intervene and drive better outcomes at lower total cost of care.

Another area we are involved in is predictive modeling, or measures that create a forward-looking view of the risk of the patient population and the individuals within it. This helps healthcare providers identify how much time they should spend on high-risk cases, how to keep medium-risk cases from escalating to high risk, and the actions they can take to reduce risk and avoid negative outcomes.

All of these data sets identify opportunities to improve care and are being used in over sixty-five different hospital systems that serve more than 77 million patients.

How does Optum differentiate itself from other providers of healthcare analytics?

Medeiros: There are many companies that solely provide analytics to pharmacies, hospitals, and providers, but we differentiate ourselves by also helping our clients act on the data and drive change. We set up programs partnering across payers, providers, life-sciences companies, and patients to help healthcare consumers get the treatment they need, when they need it.

Optum focuses on “real-world evidence” to provide insights to your partners on new and existing products and solutions. What does that mean to you, exactly?

Medeiros: Real-world evidence uses data that doesn’t come from a highly controlled clinical trial. Even in complex disease areas, most clinical trials have strict inclusion and exclusion criteria that limit variation in the underlying population so that they may get a true signal on safety and efficacy as required by the FDA.

So, if a team of researchers is conducting a trial for a diabetes medication, they will select diabetic participants that most likely do not have hypertension, heart failure, or any other diseases. In the real world, the patients that drive the majority of costs are complex cases that involve many other diseases or conditions that they must manage with their physicians. Often, participants in clinical trials are monitored very closely, which drastically improves medication adherence—real patients don’t always take their prescriptions every day.

We use health records and claims data from the real-life setting to paint a detailed picture of the challenges, opportunities, and value of solutions in the day-to-day practice of healthcare across the United States.

What is your team’s biggest focus at the moment?

Medeiros: We’re aiming to move beyond pure data and analysis to focus on populations that are drastically undertreated—meaning, we’re leveraging our data in partnership with payers and providers to identify individuals with certain diseases, and creating clinical programs to drive appropriate treatment.

A good example is our work with adult vaccines. When you turn sixty-five, you’re supposed to get a pneumococcal vaccine. Then, a year later, you’re supposed to get a booster. When we looked in our data assets, we found that in certain cases, only about 15–25 percent of people actually get that vaccination. We’ve partnered with provider systems to identify patients that need the vaccination so that their primary-care physician can build it into their next visit or schedule an appointment to administer the vaccine. The early results from the health systems in the pilot are very encouraging, where we’ve seen treatment rates improve by up to 30 percent. It’s win-win-win situation—for the patient’s health, the provider’s and payer’s quality ratings, and the life-sciences partners that have increased the volume of vaccines distributed.

On the payer side, we’re shifting our focus to “value-based contracting.” The shift we have seen in the ACO market, where they are being paid based on outcomes, is now moving to the pharmaceutical world. We’re helping our pharmaceutical clients design contracts tied to outcomes. If the drug performs to expectations or above, our pharmaceutical clients have an opportunity to share in the value through either improved volumes or price. However, if the pharmaceutical treatment performs worse than expected, the life-sciences client will share in the risk with a lower volume or price. In some circumstances, the insurer may pay nothing.

Take the hepatitis-C space. The disease has very effective treatments for a pretty broad percentage of the patient population where, in many cases, the disease can be cured within twelve weeks. But the medication is very expensive and does not work for every patient, so payers only want to pay if the patient is cured. These contracts better align incentives and spread the risk for achieving better health outcomes more efficiently between the payer, provider, pharmaceutical company, and patient.

This can be a very powerful tool for life-sciences companies looking to open up access to their medications for patient populations in need. Optum is leveraging our data and analytics with our clients to design, contract, and then serve as the third-party evaluator of these new payment mechanisms between payers, providers, and life-sciences clients. AHL