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Monday, Apr 22, 2024

Better Outcomes through Value-Based Care

Value-based care provides higher quality, more effective, and less expensive care as it focuses on the whole person and prevention,” stated Dr. Amar A. Desai, president and CEO of Optum Pacific West. “It’s how we are redefining health care in America.”

For over a decade, Optum has been focused on helping people live healthier lives and helping the health system work better for everyone. Today, Optum’s California market has grown to be the largest multi-payer, value-based health care system in the United States, serving more than two million patients and growing.

Unlike traditional fee-for-service models that incentivize volume of care, value-based care relies on positive health outcomes and healthy communities as the driver of affordability. Optum succeeds when its patients do. With a clinical agenda based on broad access to high-quality primary care, a deep focus on prevention, and the intensive management of chronic conditions, Optum’s value-based care model is producing better outcomes.

Primary care is at the very heart of Optum’s model and is essential to producing better outcomes. The benefits of having a primary care provider have been well researched including one recent study published in JAMA Internal Medicine, which found that Americans with primary care reported significantly better health care access and experience, were more likely to fill prescriptions and to have had a routine preventive visit in the past year, and were significantly more likely to receive more high value care.

Due to the importance of having a primary care doctor, Optum has focused on ensuring access to primary care for everyone, regardless of insurance type. Today, Optum primary care is accessible in every community across Southern California, including historically underserved areas such as South Los Angeles and the rural Inland Empire and even in places without an Optum clinician through the development of its unique multi-payer IPA model.

As a result of the broad access to primary care and a focus on prevention, Optum boasts 28% better clinical performance for California Medicare Advantage patients vs. Medicare fee-for-service across key breast cancer, colorectal cancer, and diabetes metrics as well as a 37% better medication adherence rate for Type 2 diabetes, 88% better medication adherence rate for COPD, and a 25% lower rate of hospitalization compared to Medicare fee-for-service averages.

With more than half of the U.S. adult population having a chronic medical condition and nearly 30% with multiple chronic conditions, it’s clear that new approaches are needed. Optum has developed an intensive, coordinated system of care for chronic conditions that is working to decrease preventable hospitalizations by 16% year-over-year.

Prevention also plays a critical role in chronic disease management. For example, patients who attend just one of Optum’s Living with Diabetes classes have, on average, a one-point drop in their A1C levels. Health education in other areas such as renal care, weight management and COPD are having similar success – contributing to a 4.5-star quality rating many years running.

Optum is achieving better clinical outcomes for high-risk patients and those with chronic conditions by focusing on education, treating the whole person by coordinating care between behavioral, social, and medical care teams and by creating data-based wraparound services to assist physicians. For example, Optum’s Care Plus Acute program uses a validated algorithm to identify patients at the highest risk of hospital admission so customized care plans can be developed by a team that includes a primary care physician, pharmacist, specialists, behavioral health professional and others. As a result, Optum’s acute readmission rates for seniors ranges from 11-16% compared to the national average for Medicare, which is above 20%. Similarly, Optum’s Clinical Pharmacist program outreaches to high-risk patients to conduct comprehensive medication reviews, identify, then resolve any medication-related issues, which has led to a 14% reduction in patient readmissions.

The success of these programs and overall coordination of care for chronic disease management means Optum keeps patients healthy and out of the hospital. Optum’s Medicare Advantage and coordinated care patients spend 30% or more fewer days in the hospital when compared to traditional fee-for-service arrangements.

With nearly half of Americans saying they have delayed or skipped medical care because of the cost, affordability is a major factor in driving better outcomes.

Value-based care is also known as affordable care; in Optum’s case, affordability also coincides with better health outcomes. For example, when the location of care is considered, outcomes are improved while costs are lowered. One such example is Optum’s use of ambulatory surgery centers for 80% of eligible procedures compared to the national average of 50%. Not only does this provide greater convenience for patients than a hospital setting, but often increases the quality and lowers costs. Likewise, Optum’s large network of urgent care centers allows for the successful treatment and observation of non-life-threatening conditions outside of the ER, increasing access beyond normal clinic hours and avoiding the need to utilize overcrowded and higher-cost sites of care.

Optum’s innovative hospitalist triage system has led to more effective, personalized, and affordable care for approximately 3,000 patients a year through programs that provide coordinated care in an optimal setting, whether in a hospital, inpatient environment or at home.

By moving the focus of health care outside of the hospital setting and into primary care, Optum provides care how, when and where patients want it, further increasing access with options such as home visits, video visits and virtual same day clinics.

By focusing on helping people live healthier lives and helping the health system work better for everyone, Optum is redefining healthcare – not just imagining a world where health care works better for everyone — but creating it.

Learn more at optum.com/california.


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