Integrating Clinical Pathways Into OptumCare Practices

Winston Wong, PharmD: Tell us about yourself, your background, and your role within OptumCare.

Ann Nguyen, PharmD: My role within OptumCare is looking at how to bring forward clinical strategies that are anchored in technology enablement to allow our clinicians on the frontline to be most effective at the point of care, to bring in clinical information and the fast, rapidly evolving clinical trials to the frontline to enable care decisions.

Our CEO, Wyatt Decker, speaks to all OptumCare practices across the US to ensure that our patients have a seamless experience from one location to the next. So, a clinical decision made in California should not be any different than that in Florida—that being said, as long as the patients have the same clinical attributes and conditions or situations. Or if it’s the same patient visiting multiple states, it would be the same experience in clinical decisions at each location. That’s really the intent of the clinical pathways, how do we ensure that we’re making similar clinical decisions while remaining consistent in driving the standard of care.

Wong: That sounds like a very powerful role. As we think about OptumCare and we think about UnitedHealthcare, I don’t think there’s a firm understanding out there of how the two organizations are related. How does the UnitedHealthcare Group relate to Optum Care vs that of the pharmacy benefit management (PBM) vs that of the insurer?

Nguyen: Our parent company is UnitedHealth Group, and we have the division that’s UnitedHealthcare, so health benefits. That’s our typical payer insurance types of makeup with our commercial Medicaid and Medicare plans and sponsors.

Underneath, we have Optum, which is made up of three divisions in which we call health services. The health services are divided into three buckets. The first is PBM Health Services. The second is Technology and Data Analytics (traditionally called OptumInsight). The third, which is where we reside, is Optum Health. This bucket has all of our primary groups, surgical centers, and urgent care centers.

Wong: How many physicians do you have? I think you said you are national. Is it a mix of primary care specialties and other services?

Nguyen: As of 2020, we have over 53,000 and growing aligned physicians. Though the bulk of it is primary care, we are multispecialty with oncology centers, rheumatology, gastrointestinal, etc, within our practices. Our surgical center is a subcomponent of Optum. It stands alone and primarily focuses on surgical procedures.

Wong: How about home care or institutional care?

Nguyen: We don’t have or own any direct hospitals, but we take on global risk as part of that. We manage and work with our hospital entities within each of our markets and state locations. Not necessarily a direct ownership, but definitely a partnership within that arrangement.

Optum at Home provides care within the patient’s home with our advanced practitioners who visit the patient’s home. There’s also Optum HouseCalls that do make certain calls to the home to actually take a look at patients, do some various assessments, and make any referrals that are needed for the patient into other types of health care services or health care settings.

Wong: Along with the value-based care term, a corollary term that’s growing with at least interest from the manufacturers is the integrated delivery network (IDN). Are you an IDN, clinically integrated network, a staff model, or a hybrid?

Nguyen: I would say right now we’re somewhat of a hybrid. We do have our sister plans, but because we are a group of medical groups, we have multi-payer partnerships with the Anthems, the Aetnas, and the Uniteds, and that’s slightly different than the staff model where the primary insurance, for example, at a Kaiser facility is Kaiser. We are coordinating care between the hospital, institution, and primary care facilities, in addition to any other specialty care.

Wong: Are you acting as a true fee-for-service provider or are you negotiating contracts where you’re taking risk?

Nguyen: Both. We still have traditional fee-for-service in many of our markets, but we’re also heavily concentrated in the global risk arrangement. So, depending on which numbers you’re looking at, I would say right now as an OptumCare entity, we have over four million in our shared or global risk arrangement. We’re probably one of the largest medical groups that actually is taking full risk for our patients.

Wong: When you say “full risk,” do you mean literally everything? Medical, drug, institution?

Nguyen: Correct. It’s the entire caboodle of medical expenses, which includes our outpatient services, institutional services, professional services, and ancillary services that may include pharmacy services or otherwise.

Wong: Are you implying that all of those services are integrated in or are you just trying to manage through practices?

Nguyen: They are integrated in and through practices. If we’re thinking like a Kaiser system, where all of the systems are integrated, I was a Kaiser patient myself, which I can go back 20 years and all my records are still there, from whether I’m visiting Kaiser in Oakland or Kaiser in Colorado. I think it’s a unique setup that Kaiser has.

To that point, I don’t think that that’s where we are now. We do have the intent to move toward integration, maybe a single platform like an electronic medical record (EMR), but with anything else, it’s actually having all these multiple practices that takes time to then help us actually integrate EMR systems and other types like that. So that’s why when we create different things, such as pathways, we’re ensuring that it’s EMR compatible and independent of which EMR it’s on. Whether it’s an Epic System, an Allscript system, a NextGen, etc.

Wong: As we take a look at your clinical pathways, what is your main focus? Is it outcome? Is it appropriate utilization? Is it cost control? Is it all three?

Nguyen: It’s all three; outcome, quality of care, also physician and patient experience, and then affordability anchors somewhat of that as well. Since we’re thinking about bringing all those aspects into play, when we’re thinking about clinical pathways, it has to be right for the patient based on their unique preferences and clinical attributes. It has to bring, I think that physician, reduce the burden of administration as we’ve probably heard from a lot of physicians and providers. There are too many things to click on the EMR or things like that.

But at the same time, we’re honing in on value-conscious decisions that are jointly made with the patient based on the best clinical evidence. How do we bring that to the forefront of pathways and bring consistency that’s going to be measurable by outcomes, because now we have the ability since we are full risk and global risk to not only see our own claims data, but then to also see the clinical data that’s residing within our EMR system. We can bridge the two to really say, does the pathway really produce the outcomes that we intended?

Wong: In a previous discussion that we had, you did kind of mention that you were bringing in the social determinants of health at a local level to kind of drive it into your pathways. How do you frame your pathway at that point? Do you start with the medical evidence and whatever the most cost-efficient treatment is, then bring in the social determinants? And at that point, do you consider it as being on-pathway but not based upon the medical evidence, but the patient in general?

Nguyen: I would say that we probably have not completely integrated that. It’s still a work in progress as we started piloting that type of model. Social determinants, or another term that I’ll use is financial toxicity, is a big one and can get a little clunky. We’re trying to collect a lot of this information upfront. But as you know, social determinant information is hard to quantify, collect, and systematically report on and act on.

It takes both kinds of the proactive collection; the kind of current, real-time validating, in that discussion with the patient, and how to bring forward choices so that as we start to look through these types of decisions is choice A, B, or C part of the pathway that actually might alleviate the financial toxicity as well.

Wong: When you talk about the pathway, is it just the typical thing that we think about being medical per se, like for oncology, med onc vs that of labs vs that of radiology, home care, stuff like that? Are your pathways comprehensive to include “cradle to grave”?

Nguyen: I would say ideally our vision is to be end to end, cradle to grave, which is when we first see a patient as a primary care. Even with cardiology referral, at that point, what are some of those decision trees that go into a clinical pathway that actually then helps us decide down who we’re referring to, what we’re referring to, what tests should be appropriate, and things like that as well before we even get into treatment.

Wong: How do you choose the areas for which you have pathways developed?

Nguyen: Good question. That’s usually a joint discussion with many of our decision makers or stakeholders within OptumCare. As you can imagine, in large organizations, there’s quite a few. That’s part of what’s on the radar right now. What’s hitting the literature or where do we see there’s either quality or safety issues and then also where we’re seeing emerging evidence or emerging lack of evidence. It’s a mixture. Do we see something that’s an outlier in our data? Are there emerging trends that we need to look into a little further? Any one of our physician groups or committees can also bring that to bear.

Wong: Is there any integration or link between your pathways and the utilization management program over at the insurer/payer?

Nguyen: That’s something that we’d definitely like to get to. We’re not there yet because it requires a collection of data and probably a good pool of data to substantiate some of that. But again, it doesn’t take away from the medical decisions and the treatment decisions jointly made between our clinicians on the front-line with the patients.

Wong: How many disease states do you have pathways for?

Nguyen: We have about five or six. Oncology is one. We’ve started down rheumatology, that’s in a little bit of pilot phase. Our clinicians and physicians specifically developed one for cardiology.

Wong: You referred to the data that went into the formation of the development of your guidelines or pathways. What else do you use?

Nguyen: I think it’s the typical things that are reviewed; clinical evidence, national guidelines or societies. I would say international as well. We’re seeing health care become global emerging information. And then of course, anything that’s real-world data, pharmacoeconomics analysis, or budget impact analysis.

Wong: One of the things we hear from physicians is technology burden or the technology barrier. You mentioned being able to go into any EMR. Is that across all OptumCare practices?

Nguyen: No. Probably two of the most common system we have on is Allscripts and Epic. Everyone is challenged with interoperability, so how do we do a lot of that work without heavy integration, bidirectionally and others? That’s something we’re working on and exploring. So, in short, no, it’s not fully integrated into all practices. The nonideal kind of low hanging fruit is could we actually have a standalone?

Wong: What’s the overall acceptance from your physicians?

Nguyen: I would say it’s fairly widely accepted. And when I say that, it does take a lot of effort, it takes coaching, reinforcement, peers, to look at the information and to also share their experience. It takes leadership to buy in and sometimes a little bit of, “Hey, why aren’t you doing this, what we’re seeing?” There is somewhat of a scorecard mechanism in there to just see initially when we’re introducing to new markets, what does that look like?

In short, I think it’s better than it was years ago when there was a lot of resistance and more of, “Hey, you’re cook booking medicine,” or “You’re not having patient choice.” I think going in with those types of efforts that can pave the way, acceptance is better, but it does take reinforcement.

Wong: Are you using your pathways and the results of these pathways to have discussions with payers to have the value-based or performance-based contracting our models?

Nguyen: Yes. We’re kind of in its infancy of how do we structure some of that for conversation, or how do we test pilot with a couple of payers and say is this something that would resonate with you? We already have global risk in some of these instances, so it’s less of a negotiation than a discussion of what does that value entails vs our fee-for-service book that may be a different discussion set. And that fee-for-service book, do we and are we ready to take on more value structure in the reimbursement model? I think there’s kind of that duality of our current book of business that we already have value. Where do we want to go and how do we use our insights across our different pockets?

Wong: Do you have a sense of what percentage of your patient population you have at risk, per se?

Nguyen: I would say, depending on which website you’re looking at and which year, about 20 million patients walk through our doors. Of that, four million or so are fully at risk, 20% to 25% that’s at risk and 75% still fit for service.

Wong: Is there anything else you think would be enlightening regarding OptumCare?

Nguyen: It’s rapidly growing. It’s always interesting to hear from you or others who are in the marketplace, what are you hearing about OptumCare, or Optum in general, that may actually help us pivot or strengthen or maneuver.

Wong: This discussion has become very timely for me, because I just finished a project, looking at IDNs, and OptumCare was listed as one of the top noninstitutional-based IDNs out there. I can’t remember what the exact numbers were and where actually you stood, but it was one of those where they said that you had national coverage and you were doing a great job of managing. Now, that came from one person who had interviewed a bunch of practices, but at least you’re being recognized. But as I started preparing for this talk and working on that other project, that’s actually what drove the question “What exactly are you?”

Anyway, thank you Ann, for a very interesting discussion. It’s super enlightening to hear about the application of clinical pathways outside of the oncology arena and how pathways are still being a vital tool as we move into the value-based care era.