DistilINFO had an opportunity to interview Dr Roger Shedlin, CEO of Optum MBM. Dr. Shedlin outlines how health plans should prepare for the new normal.
Susheel: Dr. Shedlin, thank you for taking time out of your busy schedule to talk with us. DistilINFO appreciates it!
To start with, tell us about yourself, your career journey so far and your current role at Optum.
Dr. Shedlin: I applied my training in medicine and law to become an early developer of the medical specialty benefit management industry and a serial entrepreneur of successful health services companies.
Currently, I am the President and CEO of Optum Medical Benefit Management (MBM). MBM works with payers and providers to coordinate care delivery for populations with high cost, complex conditions including musculoskeletal conditions, cancer, heart disease, obesity, transplants and kidney disease.
Because of my experience dealing with the most clinically challenging patients, I consult frequently with many stakeholders seeking insight and advice on the management of specialty conditions.
Dr. Shedlin: There are three current factors creating challenges for treating patients with complex diseases. The first is the significant impact of COVID-19 on these high-risk populations. The second is the introduction of new treatment modalities (e.g. immunotherapy) and specialty pharmaceuticals, which are difficult to navigate for both patients and providers. Finally, landmark regulatory changes are being enacted that will change how complex populations are managed.
Each of these individually creates challenges for payers and plan sponsors; together, they have produced an unprecedented potential disruption in financing and caring for costly, complex patient populations.
Susheel:What is the impact of COVID-19 on complex conditions? What clinical trends are you seeing?
Dr. Shedlin: There are several important COVID-related impacts we have observed in the populations MBM serves:
- Impact of decline in clinical services utilization: Because all patients – but especially high-risk patients, such as those with cancer who can be immunocompromised — have been reluctant to visit a health care facility for fear of exposure, there was a dramatic decline in accessing necessary clinical services.
Data from Epic Health indicates that cancer screenings for cancers such as breast, colon and cervical are down 86-94%,1 and the British Journal of Surgery estimates that more than two million cancer surgeries worldwide have been delayed or canceled due to COVID-19.2Delays in cancer diagnosis and treatment can have a substantial impact on the prognosis and cure rate of many cancers: low screening rates and delayed treatment may lead to cancers being diagnosed at later stages, associated with less favorable outcomes. In many cases, patients are electing to receive chemotherapy at home or at the oncologist office rather than at the hospital.
- Overtaxed medical delivery system: We saw a decrease in supply of medical resources because intensive care beds are occupied by COVID patients. For example, a decrease in transplants was due to a number of factors, one of which is an overtaxed medical delivery system that needs to allocate resources to treating the pandemic. I learned of a transplant surgeon at one of our Centers of Excellence (an academic medical center in New York), who said he was spending 12-hour shifts treating people in the ICU and was not able to spend time with his transplant patients as a result. As the number of COVID cases has decreased and there has been an improvement in the ability of facilities to deliver other medical services, the number of transplants has increased.
- Trends in elective procedures: Elective and non-emergent procedures experienced a decrease, then rebounded along with a substantial increase in virtual and at-home therapies. The most obvious example is orthopedics. Most musculoskeletal elective procedures can safely be postponed without a lasting negative impact on the patients. In fact, for many musculoskeletal patients, there has been a significant increase in the availability of virtual and at-home therapy, which may reduce the need for surgery even though elective procedures have now resumed.
Dr. Shedlin: In addition to COVID-19, there are constant changes in the clinical and regulatory spaces that impact providers and health plans. Pay attention to emerging clinical technologies like CAR-T cell therapy and the rapid advancement of cancer drugs, as more than 30 were approved by the FDA in 2017 alone. Site of service changes, such as the advancement of telehealth and home care options like home dialysis, are rapidly expanding to improve care for complex conditions.
I also advise industry leaders to carefully consider the implications of legislation and trends impacting specialty disease states, and to take actions that improve costs and outcomes for the populations they serve.
One example is the 21st Century Cures Act. CMS is expecting 83,000 end stage renal disease (ESRD) patients to take advantage of the option to enroll in Medicare Advantage plans with the onset of the Cures Act, with half enrolling in the first year alone. This influx of ESRD patients presents health plans with scale and medical-expense-containment concerns, which can be addressed through disease management. For example, complex care management can help delay progression of kidney disease, move patients toward pre-emptive renal transplant and, for ESRD members that need dialysis, provide a highly accessible and cost-effective dialysis network.
Dr. Shedlin: Patients with complex conditions present a unique set of challenges because they are managed with different treatment modalities at different sites of care. This creates wide variations in outcomes, and costs are typically high. Complex condition management is challenging enough, but with the broad clinical impact of COVID, these populations are even more difficult to manage.
The impact of the pandemic has underlined the need for a comprehensive strategy. It is essential for health plans and employers to help manage medical costs and get these high-risk members the right care at the right place at the right time.
A successful approach to managing these patients, who often experience multiple complex conditions, should leverage four specialized strategies that work together: care management, utilization management, network management and payment integrity.
- Care management: The best care management for specialty conditions deploys dedicated specialist care managers and medical directors with years of condition-specific experience, along with sophisticated tools to find and engage patients. Together, they help patients navigate the complexities of their condition and the health care system and move them toward the best health outcomes.For example, care management of chronic kidney disease (CKD) is far more effective when using experienced CKD-specialized clinical advocates. They have the knowledge to manage the full continuum of care for this chronic, progressive condition; refer patients to the best resources; and promote quality through the use of preferred networks and sites of service, including centers of excellence for services such as transplants.When patients transition to End Stage Renal Disease (ESRD), specialized strategies can promote durable dialysis access (A-V fistula creation). This makes the transition to dialysis is as smooth as possible, avoids emergency admissions and related in-hospital dialysis, and promotes home dialysis.Disease-specific recommendations like these improve patient outcomes and save dollars, but all too often are not offered by generalist case managers and clinicians.
- Utilization management: When people hear about “utilization management,” they sometimes equate it with limiting services for patients. In fact, utilization management (UM) promotes quality and reduces costs by driving increased adherence to evidence-based treatments.The most innovative programs — those supported by condition-specific medical reviewers — capture insights from clinical data, and guide providers to the highest-quality and most appropriate treatments. By promoting the right care the first time, which is always the most cost-efficient route, UM can lead to significantly better health outcomes.
- Network management: Rigorously-qualified specialty networks, including Centers of Excellence and broader-based networks, enable patient access to a network of providers who are committed to following evidence-based medicine and who demonstrate superior results, even for the most complicated condition categories.As the health system returns to operation in the wake of COVID-19, Centers of Excellence and other select providers are best suited to adopt changes in quality based on provider availability and methods. Payers and employers must invest in network management to help patients and members navigate to the highest-quality options for care.
- Claims review/payment integrity: The fourth strategy of a comprehensive benefit management ensures that health plans pay billed claims correctly and avoid fraud, waste and abuse. Using like-specialty clinicians to review claims and assure that the billed codes accurately describe services provided can help address this. Specialized physicians are able to find billed codes that do not accurately describe services recorded in the medical record, billing errors that automated systems cannot detect.
Dr. Shedlin: The role of technology in treating patients with complex diseases is extremely important.
Point of care decision support, using platforms purpose-built for specialty conditions, has the potential to meaningfully impact the patient, provider experience and care path. Take the rapid approval of new and expensive cancer drugs I mentioned before. The cost of these new drugs is enormous, and the consensus and National Comprehensive Cancer Network (NCCN) guidelines around their use change frequently. A specialty-driven clinical decision support tool at the point of care offers a distinct advantage in helping providers select the most appropriate treatment.
Specialized predictive models enable early identification of sick patients, encouraging early interventions and delaying disease progression. A great example is the kidney space: patients with CKD who are identified early are more likely to receive a pre-emptive kidney transplant, which lasts on average 15-20 years with clear benefits of improved quality of life. Pre-emptive transplants also save roughly $500,000 per patient (including the transplant) because high long-term dialysis costs are avoided. Plans and plan sponsors want to make sure they have access to these kinds of predictive models, which can identify savings opportunities early.
Telehealth and virtual care have been growing in sophistication in the past few years, and the COVID-19 pandemic is dramatically accelerating their acceptance as viable alternatives with comparable outcomes to traditional treatments. This is particularly helpful in the musculoskeletal space, where early indications are that virtual physical therapy may increase compliance and reduce the need for surgery as elective procedures resume.
Dr. Shedlin: My highest priorities as a physician and clinical leader are achieving clinical excellence and ensuring appropriate access to specialty care and enabling the best possible patient experience. At MBM, our vision is to leverage the latest technologies, most robust data/actuarial capabilities, highest-performing providers and clinical expertise to achieve these goals.
Dr. Shedlin: Given the impact of the clinical, regulatory and pandemic-related challenges we have been discussing, I suggest that payers and employers assess whether they have all the strategies and capabilities we talked about in place. This is an essential foundation for managing complex populations, especially at this critical time.
This is a significant moment in health care, especially for patients with complex diseases, and I believe that using comprehensive specialty benefit management we can take the challenges we are seeing and turn them into opportunities to better addresses clinical outcomes, costs and patient and provider experience for patients at their most critical time of need.