Optum Healthcare Solutions Inc was founded in 1983 and is currently a

subsidiary of Optum Health Holdings LLC Optum is head!uartered in "olden #alley

$innesota It primarily ser%es the &nited States of 'merica( howe%er they operate in
o%er 1)* countries worldwide including +orth 'merica( 'sia( ,urope( and South
'merica as well as the $iddle ,ast Currently Optum has o%er si-ty fi%e thousand
employees. which includes upwards of se%en thousand nurses( 1)** /hysicians and o%er
1(*** health economists and data scientists 'll these indi%iduals wor0 collaborati%ely in
their respecti%e arenas to ensure there is a continuous impro%ement in care deli%ery(
!uality and cost effecti%eness
's healthcare reform become more and more e%ident to health insurance
companies( they see it necessary to create more uni!ue opportunities to grow their
businesses by del%ing into new mar0etplaces and appeal to a %ariety of demographics by
becoming more consumer friendly and to offer new and e-citing products Optum
de%eloped three main tools geared towards these needs of healthcare plans especially in
areas of Clinical $anagement( Operations and $anagement and 'c!uisition and
1etention Clinical analytics use member data to identify target opportunities to reduce
costs 2arget data such as
3e%elop integrated( comprehensi%e strategies to
address cost( !uality( and re%enue
,n%ironmental forces are combining to cause ma4or changes in the health
industry Health care deli%ery and payment models are dramatically changing
and information and data are becoming increasingly a%ailable Chronic disease
incidence is reaching epidemic proportions and the number of people in the
health care system is increasing as a result of the 'ccountable Care 'ct
2ogether( these forces will push health plans past the point of incremental
change and into new business models and capabilities centered on
comprehensi%e care of their member populations and more effecti%e
management of pro%ider networ0s Health plans must prioriti5e foundational
clinical capabilities as part of their goal to pro%ide the best care to members(
strengthen pro%ider relationships( and dri%e o%erall plan performance /lan
capabilities must span si- core areas6

/ro%ider networ0 effecti%eness

,-panded networ0 to meet speciali5ed areas of care

Information7powered clinical decision ma0ing

Integrated member ser%ices and care management

8uality impro%ement

1is07based reimbursement
Optum supports these areas with comprehensi%e solutions 9e help positi%ely
affect health outcomes by matching inter%entions and pro%ider networ0s to
each member:s needs 2he result6 impro%ed !uality( utili5ation( and ris07based
reimbursement

Clinical 'nalytics

Speciali5ed +etwor0s

+etwor0 'dministration

8uality

1is0 'd4ustment

$ember ,ngagement
Clinical Analytics
&tili5e member data to proacti%ely identify
opportunities to reduce costs
9ith new benefit mandates( $edical Loss 1atio ;$L1< regulations( and
population shifts( it is more critical than e%er for health plans to access and
analy5e member information 3ata such as a member:s health status( the %alue
deli%ered through networ0s( and the performance of clinical management
programs helps e%eryone deli%er the best care possible 'ccess and e%aluation
of clinical information helps identify trends in utili5ation( disease pre%alence(
and their related costs
Specialized Networks
,-tend current pro%ider networ0s to effecti%ely
meet the needs of members who re!uire
specialty areas of care
2he price tag to treat certain conditions can be staggering ' relati%ely small
number of medical conditions account for a disproportionate share of treatment
spend Health plans: traditional networ0s are not e!uipped to pro%ide care to
people with this type of speciali5ed need 't Optum( we build integrated
systems of care focused on specialty areas that complement e-isting networ0s
and medical programs
Network Administration
,fficiently manage networ0 contract
information( address pro%ider credentialing
needs( and accurately price claims
+etwor0s are one of the greatest assets a health plan has +etwor0s ser%e the
primary point of connection with customers and are one of the primary
determinants of cost of ser%ices co%ered 's a result( health plans must focus on
the !uality of their networ0s and acti%ely pursue strategies for ongoing
impro%ement
Quality
Impro%e !uality measure performance
1ising medical costs( affordability pressure( new reimbursement models(
increased regulatory re!uirements( and public reporting of !uality metrics( ha%e
shifted how plans %iew the importance of a !uality focus 's a result( plans
today focus on6
Risk Adjustment
,nsure reimbursement for $edicare( $edicaid(
and indi%idual membership
2o prepare for population shifts caused by the 'ccountable Care 'ct
pro%isions( plans will need to de%elop strategies that assess financial e-posure
and estimate ris07based reimbursement /lans may find it challenging to predict
how much health care will cost for newly insured members( which ma0es the
tas0 of mitigating those costs e%en more difficult
Member Engagement
Help members actively engage in clinical
programs
There is growing evidence that an integrated, population-based health
management approach empowers people to live healthier lives. Health
management also decreases avoidable chronic complications and
reduces health care costs.
Pressing challenges,
unprecedented opportunities
A new health care marketplace is taking shape one that presents
greater quality, cost and compliance pressures. Health reorm and
shiting demographics have created unique opportunities or health
plans to grow their business by entering new markets, oering new
products, and becoming increasingly ocused on consumers.
Optum !elps !ealt! plans"

!ngage consumers as they select, navigate and manage health

options and e"penses

#everage data and analytics to improve population health

$ptimi%e networks and build strategic partnerships with providers

&treamline administrative costs while increasing eiciency

#ocus on w!at matters
To thrive in today's complicated health care environment, beneit plans
must ocus on what matters most.
Acquisition and (etention
Optum viewpoints on the 2015 CMS rate
announcement and final call letter
$n April ), *+,- ./& released changes impacting /edicare Advantage
payment rates or *+,0. 1t includes positives such as not e"periencing
revenue reductions rom transitioning to the *+,- H.. and a delay in
eliminating the data provided by 1n-Home Assessments, as well as new
challenges relative to historic regulation as well as the release o initial
drats in 2ecember and the Advance 3otice in 4ebruary.
5hile the impact will vary amongst plans, $ptum is uniquely positioned
to provide payer clients with a holistic approach to population
management ocused on cost, quality and utili%ation plan needs
including inancial and operational consulting, prospective risk
ad6ustment services, in-home assessments, analytics, and quality
improvement tools including7

Actuarial and inancial models with the e"perience needed to

complete ./& bid submission processes

Pro6ections, assessments, processes, dashboards, and other

critical components to improve 8uality $utcomes and resulting revenue
impact

.linical and operational guidance and delivery to improve risk

score documentation combined with the analytics to illustrate the
return on investment and critical path or such initiatives.

2eep e"perience in care management, network management,

and hands-on e"perience in creating transormational provider risk-
sharing arrangements.
9nprecedented changes demand insightul
analytics and innovative strategies.
1ncreasing demand or individual health coverage, the introduction o
Health :eneit !"changes, and Aordable .are Act ;A.A< regulations
have created new challenges in health care. 1t's more important than
ever to align business practices with the needs o consumers.
$ptum= makes sure health plans are ready. 5ith proven
methodologies, customi%able tools, and e"perienced proessionals who
have a deep understanding o the health care market, we provide
insights in the ollowing areas7

Analysis and evaluation o new business opportunities

/odeling and impact o e"pected population shits

1mplications o new regulations and deadlines

Health plans o all si%es will need to ad6ust to remain competitive in this
changing landscape. The A.A law included program e"pansions, rating
reorms, new subsidies and penalties that have created unprecedented
shits in coverage sources. Payers will seek the lowest prices in their
targeted growth markets, bringing about ierce competition. Traditional
product development and distribution channel strategies are no longer
enough. To ensure proitable growth and retention, businesses must
align all internal capabilities to engage targeted consumers, manage
their health and drive eiciencies.
2irect-to-consumer marketing strategy requires rapid positioning and
realignment or payers to succeed both on and o state e"changes and
in the private market. 3ew competitors are entering the market ;A.$s,
.$-$Ps, Traditional /edicaid plans< and some have competitive
advantages> new alliances and 6oint ventures are orming to e"cel in
direct-to-consumer capabilities.
$ver 0+ versions o e"change requirements will challenge health plans
to develop scalable solutions. $ptum can help plans deliver proitable
($1. 5e help ensure that o-e"change business models still maintain
growth, deliver optimal service and maintain a close eye on the medical
loss ratio ;/#(< and administrative costs.
$ptum drives health plan growth through innovative strategies and
analytics. This means stronger consumer engagement, improved
processes or designing products, and better methodologies or rating
and pricing ? all to help your health plan stand out in a competitive
market.
(esources

$!ite %apers

+ew Opportunities for $anaging 1is0( Impro%ing ,ngagement and 3ri%ing "rowth

1edefining the =our /s6 how consumerism is reshaping the fundamentals for health
plans

Attract and (etain .onsumers

/anage 4inancial (isk

Attract and Retain Consumers
&trengthen engagement and consumer
loyalty as change continues.
5ith the initiation o Health :eneit !"changes, increased demand or
individual health coverage and the ongoing impact o 4ederal Health
.are (eorm, the ocus must be on consumers. To remain relevant and
competitive, health plans must engage more directly and consistently
with consumers, proactively analy%e and evaluate business
opportunities, model e"pected population shits, and understand the
impact o new regulations and their associated deadlines.
Manage #inancial Risk
Reduce risk& Rein'ent strategy& Rede(ine
success&
#earn how the inancial risk management solutions at $ptum can
streamline rating and pricing processes and allow your health plan
organi%ation to improve risk identiication, increase sales, and reduce
actuarial and underwriting costs.
(educe the comple"ity and cost o health
plan operation and technology
Health plans are under pressure to transorm their operations, support
new health care business models and reduce administrative costs.
/odern technology, nimble operating models and advanced analytics
are required to thrive in the evolving market place. $ptum can help.
$ptum reduces the comple"ity and cost o health plan operations and
technology. 5e oer comprehensive analytics, sotware, services and
consulting with a dierentiated set o payment integrity and core
administrative capabilities.

.ore :usiness Process $utsourcing

Payment 1ntegrity

Administrative &trategy and 1nnovation .onsulting &ervices

Core )usiness %rocess Outsourcing
4ree-up resources, improve daily
perormance and reduce costs
$ur transormative business process outsourcing model enables payers
to launch new products, deploy new beneit designs, and enter new
markets more rapidly while reducing administrative costs.
%ayment *ntegrity
&impliy systems to reduce costs and
increase accuracy
5e proactively drive payment integrity, and improve provider
relationships and member e"perience. $ur solutions transorm end-to-
end claims processing perormance by simpliying the payment system,
improving accuracy and reducing costs.
Administrati'e Strategy and *nno'ation
Consulting Ser'ices
.ontrol comple"ity and cut costs with
innovative insights and solutions
$ptum can help your organi%ation manage comple"ity and costs with
consulting services that ocus on administrative strategy and innovation.
Take advantage o the proven e"pertise o $ptum consultants, who
have successully run health plans, managed core ad6udication system
implementations, and can apply e"tensive claims data on more than
,++ million member lives to help resolve your organi%ation's challenges.