From behavioral health to oncology, UnitedHealth Group's bustling management and technology subsidiary is trying to synchronize healthcare for populations, providers and individuals.
"Remember the days where we just did provider CM and DM?" asked Heather Jarrett, a registered nurse and VP of population health at Optum, referring to case management and disease management. At the America's Health Insurance Plans Institute in Nashville, Jarrett outlined the vast and varied work of Optum in the transformation of American healthcare financing and delivery--suggesting that while times have changed in many ways, in some they are still the same.
With Americans paying more than ever for their healthcare and outcomes that do not correspond to the nearly-$3 trillion annual bill, the nation's largest insurer is betting that providers and other health plans can turn to Optum for "synchronization"--data-driven disease management and consumer engagement in the digital age.
Take prescription drugs, for example. Optum is the third largest drug plan manager following the takeover of Catamaran. "Seventy five percent of our calls inbound are related to a pharmacy call," Jarrett said. "They want to know: Are drugs expensive? Is there a way to get them cheaper?"
When members call with a pharmacy question, Jarrett said, "this is an opportunity to evolve care management," to help navigate the formulary and their choices and other healthcare issues members might be facing. "They don't want to be called on the phone," Jarrett said.
In other areas, there are a lot of opportunities to systematically approach how people live with disease and receive healthcare, and to prevent the need for costly interventions.
"One in four Americans have some form of a diagnosable behavioral health conditions," and one in eight emergency care visits are related to behavioral health concerns, Jarrett said. Depression alone is estimated to account for a 200 percent increase in the rate of lost productivity at work, and total healthcare costs are estimated to be 180 percent more for those with a depressive condition.
How to address this issue is a difficult question, especially considering that health insurers really do not have the best reputation when it comes to covering mental health benefits.
Optum pitches a kind of multi-pronged approach that promises to improve the experience for all involved, including discounts of around 40 percent on provider reimbursement rates. Among the strategies are early identification and employee assistance programs, measurements of clinician and network effectiveness, and community-based and online support services.
Then there is oncology, the second leading cause of death after heart disease and perhaps the most difficult area that Optum is addressing.
U.S. cancer cases are expected to number some 1.6 million this year, and by 2020 annual costs could reach $207 billion annually. As the population ages, with some 60 percent of new cancer patients being 65 and older, there are approximately 1,000 drugs in the pipeline that cost $10,000 per month.
Jarrett said that Optum's oncology management spans the providers and patients. The company works with clinicians to track the evidence base across cancers, use pre-authorization and offer hard-to-treat patients clinical trials. Patients can also receive in-home assessments and support.
The goal is "being proactive in preventing side effects and unnecessary hospitalization," according to Optum's senior medical director, Bernie Elliott, MD. And being "proactive in using appropriate palliative care."
Aggressive oncology management by Optum--or any other payer--could face resistance from physicians and providers, which is why the approach to evidence-based implementations and prior authorization must be one of collaboration, Elliott said. There are also signs that clinicians are open to having a partner help with navigation, given the cost trends in cancer; "it has become accepted in the provider community," Elliott said.
Related: Insurers line up for CMS oncology pilot The trajectory of cancer care is so costly and problematic that payers are flocking in droves to the federal government's multi-payer alignment experiment.