List of recommendations based on UnitedHealth’s extensive database and experience
Every sector of the healthcare industry is offering both Congress and the Center for Medicare & Medicaid Services (CMS) advice on how to reform the system to improve quality of care, while reducing costs. Too often, the search for ways to save money that can be redirected to covering uninsured is a game of taking money from one existing health service and shifting it to another.
Recently UnitedHealth Group (NYSE:UNH) stepped into this debate over how to save money. In important ways, it is better positioned to provide this advice than most other entities. For example, UnitedHealth Group is the nation’s largest insurer in terms of revenue. UNH funds and organizes care for 70 million Americans. It arranges $115 billion in health care services provided by 5,000 hospitals and 650,000 physicians nationwide. Because of this, UNH’s Center for Modernization and Reform has collected more data on clinical services provided and resulting healthcare outcomes than anyone else.
UNH recently made public its assessment of 15 treatment options or initiatives with the potential to save CMS up to $540 billion over the next decade. “It is that experience of the diversity of the U.S. health care system, including employer-sponsored insurance, Medicaid and Medicare, allied with our 20 years of experimentation in managing care that has given rise to the data and insights we draw on in this document,” stated the report author, noting that these savings assessments offered by UnitedHealth err on the conservative side.
Dark Daily reproduces the summary of UNH’s 15 recommendations below. These fall into four categories. These recommendations give pathologists and clinical laboratory managers insights about the types of changes to the healthcare system that UnitedHealth believes would lower healthcare costs and improve patient outcomes.
Incentivizing Member / Beneficiary Use of High Quality Providers
- Incentives to Use Highest Quality Providers: Assessment of quality and efficiency of providers using “episodes of care” analytics measured against evidence-based standards and efficiency benchmarks. Provide members with incentives to use highest quality physicians. Savings, $37 billion.
- Cancer Support Programs: Voluntary guidance on cancer treatment best practices and patient options, including hospice care. Provide case management to prevent hospital readmissions between therapy sessions. Savings, $5 billion
- Transplant Solutions Program: Voluntary guidance for patients on selecting the best transplant centers in the nation for their condition. Savings, $0.7 billion
Reducing Avoidable and Inappropriate Care
- Institutional Preadmission Program: Provision of onsite nurse practitioners at skilled nursing facilities to manage illnesses and prevent avoidable hospitalizations. Savings, $166 billion
- Transitional Case Management Program: Follow-up with patients after leaving the hospital to reduce readmissions by checking on recovery progress and supporting adherence to discharge plans and recommended medical care. Savings, $55 billion
- Advanced Illness Program: Provides information and guidance to patients and their families about both their condition and benefits of further treatment options, including palliative care at the end of life. Savings, ~$18 billion
- Disease Management for Congestive Heart Failure: Voluntary coaching for members with higher-acuity chronic illness to ensure treatment compliance. Savings, $25 billion
- Gaps In Care Program: Voluntary intervention for members with chronic illness, but relatively good health to ensure ongoing treatment compliance. Savings, $1.4 billion
- Integrated Medical Management: Application of clinical evidence-based care management tools with targeted preventative care and patient education tools to reduce admission rates. Savings, $102 billion
Incentivizing Physicians to Encourage High Quality Care
- Patient-Centered Medical Home: Establish a primary-care physician as the central, ongoing coordinator of patient care to reduce inappropriate or duplicative treatments, while ensuring needed “anticipatory” care is provided. Savings, $20 billion
- Physician Additional Compensation Program: Reward physicians for providing comprehensive medical care and utilizing resources appropriately. Savings, $24 billion
- Specialist Data Sharing: Share comparative quality and effectiveness data with physicians to induce behavioral change towards evidence-based clinical practice. Savings, $15 billion
Applying Evidence-Based Standards to Reimbursement Policies
- Radiology Benefit Management: Application of clinical evidence to determine clinically appropriate diagnostic radiology studies. Savings, $13 billion
- Radiology Therapy Management: Application of clinical evidence to determine clinically appropriate usage of radiology therapies. Savings, $5 billion
- Prospective Claims Review: Analysis of claims before they are paid to detect upcoding, duplicate billing and billing for non-existent patients. Savings, $57 billion
UnitedHealth identifies $540 billion in potential savings from the implementation of these 15 suggestions. None would directly reduce or constrain use of laboratory tests. In fact, those recommendations which call for closer patient monitoring of patients being admitted to skilled nursing facilities (potential savings of $166 billion ) and transitional case management of patients being discharged from hospitals (potential savings of $55 billion) would require increased use of laboratory testing to achieve the stated goals of improved outcomes at a reduced cost of care.