April 4, 2019

Understanding the Language of Payers Optum® Symmetry® for Pharma

Steve Pranke, Analytics Product Director

Shannon Reidt, PharmD, Clinical Pharmacy Lead

Unprecedented change in healthcare

TREATMENTS

Physicians

Health

plans

Administrative

leaders

Health

professionals

$

$ $

Improve outcomes and quality of life

Manage costs

Increase efficiency

Optimize financial and business risk

$

$ $

$

$

$ $

$

$

$

$

3

Symmetry — more than 25 years’ history

Episode Treatment Groups (ETGs – 1993)

Condition based episode grouping

Episode Risk Groups (ERGs – 2002)

Risk Assessment and Prediction —

Medical and Rx claims

Pharmacy Risk Groups (PRGs – 2003)

Risk Prediction – Rx claims only

Evidence-Based Medicine (EBM Connect – 2004)

• Compliance with Evidence-Based Care Guidelines

• National Standard Quality Measures

Procedure Episode Grouper (PEGs – 2008)

Procedure-based episode grouping

Procedure Quality

Measures (PQM – 2016)

Surgical and diagnostic

procedure quality

4

45 15 70 17 Research facilities or vendor partners

Hospital systems

Health plans including 20 of the top 25

State government agencies

150+ clients across payer, provider, government and academia representing over

160+ million lives

Optum Symmetry Serves

5

Issues around cost and use

• How do I identify wide variations in practice patterns across a provider group/groups?

• What disease states are prevalent in our population and are driving our costs?

• What types of services are driving the costs for episodes with higher costs?

• What are the savings opportunities if we create a narrow network?

• What is the financial feasibility of an ACO?

• What are the opportunities realized by reducing avoidable ER and/or inpatient admissions?

6

Issues around risk

• How can I refine my financial forecast by leveraging data?

• How do I adjust reserves to account for outliers?

• Will the insight information allow me to reduce financial margin?

• How can I identify my highest risk individuals and understand risk factors?

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The Symmetry suite

Medical

claims

Enrollment

Other data

sources*

Pharmacy

claims

Data quality checks

and preparation

Data

enrichment INSIGHTS

ANALYTIC

PROCESSING

S I N G L E F L A T

F I L E D A T A

I N P U T F E E D

RECEIVE

CLIENT DATA

ETG

PEG

ERG

PRG

EBM Connect

PQM

ETG: Episode Treatment Groups

PEG: Procedure Episode Groups

ERG: Episode Risk Groups

PRG: Pharmacy Risk Groups

EBM Connect: Evidence-based Medicine Connect

PQM: Procedure Quality Measures

F L E X I B L E

F L A T F I L E

O U T P U T S

*Other data sources can include labs, provider identifiers, etc.

Symmetry

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Cost and utilization management

ETG: Episode Treatment Groups

PEG: Procedure Episode Groups

• Review episodes for an individual

• Attribute episodes to providers and groups

• Assess both levels and trends using any member or service characteristic

• Manage clinical activities to support risk-based operations

• Evaluate and compare physician and specialist performance

• Assess utilization and cost patterns to identify opportunities to reduce costs

• Understand disease prevalence and severity for a population

• Enable cost-effective use of networks contracts

• Understand revenue and cost implications of out-of-network utilization

• Evaluate and benchmark provider quality and efficiency

INSIGHTS RESULTS STRATEGY

9

Symmetry Episode Treatment Groups® (ETG)

Condition classification methodology that combines related services into a complete episode of care

• Recognizes co-morbidities, complications, and treatments that dramatically change a patient’s clinical profile, health care utilization and costs

• Collects all inpatient, outpatient and ancillary services into mutually exclusive and exhaustive categories, covering the clinical breadth of medicine

• Provides a clinically consistent measurement methodology to evaluate treatment decisions, as the groupings are meaningful to all care providers

Evaluate practice pattern variation

Optum ETGs are used by over

70% of U.S. health plans to analyze cost and efficiency.

Episode Treatment Groups

Claims data

• Diagnosis codes

• Drug codes

• Procedure codes

Claims

data,

grouped by

episode

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Goal: determine which provider had the most influence on the resources consumed during the episode

These Episode Treatment Group (ETG) units of analysis calculate population-wide averages using complete, non-outlier episodes. This foundation helps compare a provider’s actual experience to the population average or “expected” amounts.

The Symmetry suite of tools creates clinically homogenous, severity- and treatment-adjusted units of analysis (for example, a severity level 2 diabetes episode without surgery).

Background

Provider and network use case

11

Drill into outliers to explore root cause

Provider and network use case

12

Selecting a provider

shows an anomaly

This is an example of Symmetry outputs in a Tableau format.

Episode analytics to examine opioid prescribing patterns

Provider and network use case

13 This is an example of Symmetry outputs in a Tableau format.

Symmetry Procedure Episode Groups® (PEG)

Condition classification methodology that groups medical and pharmacy services into procedural episodes of care

• Evaluates clinical specialists by accurately assigning procedure episodes to the clinical specialists who performed them

• Compares resource utilization of providers, networks and health plans

• Identifies workup and conservative care prior to a surgical procedure, as well as assesses follow-up care after a surgical procedure

• Gauges indicators of failed procedures

• Creates benchmarks for resource comparison

Evaluate your clinical specialty performance

Procedure Episode Groups

Claims data

• Diagnosis codes

• Drug codes

• Procedure codes

Claims

data,

grouped by

procedure

Optum PEG are the industry-first foundation for

enhanced analysis

by procedure

#1

Episode Treatment Groups

Claims data

• Diagnosis codes

• Drug codes

• Procedure codes

Claims

data,

grouped by

episode

14

Risk mitigation

• Identify individuals of highest risk

• Enable early identification of high-risk individuals using pharmacy data

• Understand levels and trends in risk and risk-adjusted costs

• Prioritize the appropriate interventions and optimize resources

• Use retrospective and/or predictive analytics to proactively manage care

• Measure and compare physician performance

• Evaluate and improve disease and care management programs

• Adjust targets for ACOs and medical homes

• Prevent adverse events in at-risk populations

• Enhance disease and care management programs

• Review and monitor population risk for actuarial purposes

ERG: Episode Risk Groups

PRG: Pharmacy Risk Groups

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INSIGHTS RESULTS STRATEGY

Symmetry Episode Risk Groups® (ERG)

An episode-based approach to population health risk assessment

• Predicts current and future health care usage through individual risk measures that incorporate episodes of care methodology, medical and pharmacy claims information, and demographic variables

• Provides a better understanding of variations in medical costs and practice by adjusting for differences in health risk

• Supports retrospective, prospective, actuarial and underwriting risk models

Predict future health care utilization

Episode Treatment Groups

Claims data

• Diagnosis codes

• Drug codes

• Procedure codes

Claims

data,

grouped by

episode

Episode Risk Groups

• Age

• Gender

• Risk markers

Risk score

for each

individual

Used by 25 health plans

and other health care organizations

covering 100 million individuals

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Symmetry Pharmacy Risk Groups® (PRG)

Uses prescription data and proprietary classification systems to help organizations better understand and measure individual health risk

• Creates markers of health risk that can indicate a individual’s disease condition, severity, and comorbidities

• Operates effective disease and care management by stratifying patients with a particular disease in order to promote timely and appropriate interventions

• Performs health risk assessment by assessing individuals without past medical utilization, including individuals more recently enrolled with a health plan

Understand and measure population health risk

Pharmacy claims lag significantly shorter than medical claims and

predictions require as little as 3 months of data to generate risk score

Pharmacy Risk Groups

Claims data

• Pharmacy Risk score

for each

individual

17

Symmetry Drug Hierarchy Categorization to support analytics

18

Symmetry Specialty Drug List

Treatment >$1200 per month

Used for rare or complex disease

Involves complex processes to manufacture

Requires specialized ongoing monitoring or special administration

Inclusion Criteria

19

A Case Study on Inflammatory Bowel Disease (IBD)

Analyzing Specialty Drug Use

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• Understand differences in treatment across disease severity

• Compare utilization patterns to clinical guidelines for IBD

• Quantify contribution of specialty drug cost to total episode of care

• Compare utilization and cost between specific drugs

• Use ETG and Specialty Drug List to evaluate utilization and cost of specialty drug use in IBD

• Compare costs among disease severities

• Enhance disease and care management programs

• Monitor drug utilization and cost

• Understand impact of specific drugs on cost and utilization

INSIGHTS RESULTS STRATEGY

Ulcerative Colitis Drug and Episode Costs

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$2,816 $3,105 $2,290 $1,959

$28,722 $31,639 $32,021

$35,069

$9,662

$13,200

$17,597

$32,474

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

Severity Level 1 (Low) Severity Level 2 Severity Level 3 Severity Level 4 (High)

Non-Specialty Drug Annual Cost* Specialty Drug Annual Cost* Per Episode Cost (Pharmacy and/or Medical)

*Average annual cost per member

(n=1,247 | 20.4% on Specialty) (n=288 | 26.7% on Specialty) (n=501 | 41.1% on Specialty)

Note: Severity levels are calculated based on expected treatment cost of disease

(n=1,690 | 13.4% on Specialty)

Data source: Optum claims 2017, commercially-insured population with continuous Rx and Medical coverage

Disease Non-Specialty Specialty

Ulcerative Colitis 4.0 0.7

Crohn’s Disease 5.4 2.9

Average # of Disease-Specific Rx Claims per Member

Crohn’s Disease Drug and Episode Costs

22

$0 $1,546 $1,323 $1,481

$0

$35,785 $35,685

$39,666

$0

$18,811

$23,144

$34,404

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

Severity Level 1 (Low) Severity Level 2 Severity Level 3 Severity Level 4 (High)

Non-Specialty Drug Annual Cost* Specialty Drug Annual Cost* Per Episode Cost (Pharmacy and/or Medical)

Note: No Low Severity in

Crohn’s (based on expected

treatment cost of disease)

Data source: Optum claims 2017, commercially-insured population with continuous Rx and Medical coverage

*Average annual cost per member

(n=1,613 | 37.1% on Specialty) (n=507 | 44.8% on Specialty) (n=924 | 50.4% on Specialty)

Disease Non-Specialty Specialty

Ulcerative Colitis 4.0 0.7

Crohn’s Disease 5.4 2.9

Average # of Disease-Specific Rx Claims per Member

0%

32.2% 34.0% 35.2%

0%

40.0% 39.5% 31.2%

27.8% 26.5% 33.6%

0%

20%

40%

60%

80%

100%

1 2 3 4

Other Specialty Drugs

Adalimumab (Humira)

Infliximab (Inflectra, Remicade, Renflexis)

Proportion of Specialty Drug Claims by Severity

A Deeper Dive into Crohn’s Disease

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Severity 1 (Low) Severity 2 Severity 3 Severity 4 (High)

Using Symmetry Groupers, Life Sciences companies can

measure condition-specific cost of care, by severity level,

by drug, through the same lens as payers

Note: No Low Severity

in Crohn’s (based on

expected treatment

cost of disease)

THANK YOU.