UnitedHealthcare to Offer Risk-Sharing in Type 2 Diabetes Program

More and more plan sponsors are interested in introducing risk-based reimbursement in their contracts with health insurers. That interest has grown into a range of plan designs: On the extreme end, plan sponsors like CalPERS are introducing upside and downside risk to entire third-party administrator contracts. A more incremental approach sees health insurers offering upside risk to plan sponsors based on the health insurer’s ability to control costs for a specific condition.

UnitedHealthcare on June 26 launched such an offering, called the Level2 Assured Value Program. It’s a new payment model for an existing Type 2 diabetes management benefit design called Level2.

According to a UnitedHealthcare spokesperson, the new risk-based program allows “eligible employers with more than 125 covered employees with Type 2 diabetes [to] have 100% of program fees reconciled against actual medical and pharmacy claims savings generated by improved diabetes care for employees. If actual value generated is less than paid program fees, Level2 gives back the difference to eligible employers.”

UnitedHealthcare claims it can generate impressive results by enrolling members in the Level2 program, according to results drawn from a UnitedHealthcare study published in Diabetes, a medical journal of the American Diabetes Association. A UnitedHealthcare white paper citing those results states that “73% of UnitedHealthcare members enrolled in Level2 with a starting hemoglobin A1C above 7.0 had a clinically meaningful improvement in this measurement. Among members included in the study, the average reduction in A1C was 1.39 percentage points after one year and 1.36 at two years.”

When asked by AIS Health, a division of MMIT, for specifics about the way that the “program fees” in question were “reconciled” with pharmacy claims — especially GLP-1 agonists — a UnitedHealthcare spokesperson says that “Level2’s Assured Value Program is based on projected total cost of care claims inclusive of both medical and pharmacy for the member. The program aims to guarantee savings against those projections.”

When asked the same question, Rhonda Randall, D.O., the chief medical officer of UnitedHealthcare’s employer and individual segment, adds that the Level2 Assured Value Program is “creating predictability for that employer in their cost. And they can add that Level2 Assured Value Program to most UnitedHealthcare administered plans, so [employers] can offer this alongside the traditional plans that they offer today.”

In an exclusive interview with AIS Health, Randall explained in depth how the Level2 program works.

Editor’s note: This interview has been edited for length and clarity.

AIS Health: Is Level2 something that United came up with on its own, or was there demand for it from plan sponsors?

Randall: Working with employers, diabetes has been on the forefront of their concerns for quite some time.

We’ve seen the growing epidemic of diabetes in our country where we have now reached the highest level of diabetes that we’ve ever seen, with 30 million Americans living with diabetes, most of that being Type 2 diabetes, which is very much influenced by lifestyle [factors like] physical inactivity and obesity. In addition to that, we know 98 million more people have prediabetes, and many of those individuals don’t even know they have the condition.

So there’s been a lot of concern in health care and with employers on the unpredictability of where those health care costs are going in the future. At the same time, a significant amount of research has been done into programs that included coaching and lifestyle modification for diabetes.

Using metabolic and behavioral science, UnitedHealthcare and our partners at Optum brought together a program that combined the use of a continuous glucose monitor with real time feedback. That includes lifestyle, their activity level, what they were eating and drinking, and how that affected their blood sugar. We pair that with a coach to create a customized plan for them on what would be successful in monitoring and managing their blood sugar and glycemic control levels.

People who joined this program have a significant improvement in their blood sugar levels, and they’re able to sustain that over a multi-year period.

AIS Health: Wearables and remote monitoring have been hyped up in recent years, but costs and outcome data for these products is hard to come by. How have you avoided those pitfalls? How does continuous glucose monitoring generate value in Level2?

Randall: I agree with you. I see the data as well with continuous glucose monitors when they’re used all by themselves. Without a coordinated program, you don’t see the results that you do when you put this together as a care team.

[Level2] is demonstrating that the coordination of the care…[will determine if] that program works. If you’re receiving [support] from your health care provider, from a coach, the data that you’re receiving from a wearable [becomes more valuable]. It fits into the support you’re getting with lifestyle modification, whether or not it includes the utilization of pharmaceuticals. It could be things like food choices, how much exercise you’re getting.

[Because of that, Level2 has] a customized approach, not a one-size-fits-all. Are you seeing a primary care physician? Are you also seeing an endocrinologist? When is it time to escalate that care?

Many of the individuals who come into our program aren’t wearing that continuous glucose monitor forever. They’re generally wearing it until they really have some pattern recognition. Some may need to wear it again a little bit later to refresh that, but they don’t have to wear it forever.

AIS Health: Are GLP-1s used in the same way? Is the idea to try to get people to a healthy place where they can manage their condition, but not necessarily keep a GLP-1 script as a maintenance medication?

Randall: We know GLP-1s are an expensive class of drugs. You can get more value from them when you combine them with a comprehensive lifestyle modification program like Level2.

GLP-1 medications started as treatment for diabetes and still are one of the mainstay classes of medication. It’s one of many. We have other medications, some of which have been around for a very long time, some of which are generic and very inexpensive. There are some other new classes like SGLT-2s [sodium-glucose cotransporter-2 inhibitors] in addition to GLP-1s. Prescribers have a pretty wide armamentarium of what medication to use given the situation and the blood sugar patterns of the patient in front of them.

AIS Health: Does UnitedHealthcare approach plan sponsors about Level2, or does the plan sponsor need to initiate it? Is this something that plans select during their requests for proposals, or can it be bolted on as needed?

Randall: Some employers will have the option to select this during their RFP process. Others who are already UnitedHealthcare customers have the opportunity to do it in time for their [next] open enrollment period.

AIS Health: How are plan members enrolled in this program?

Randall: Members will see their choices [during open enrollment], one of which would be the Level2 Assured Value Program. For the employee, what they’ll see is Level2. We would provide that employer with communication materials to share with their employees, and to reach out to those who may have a diagnosis of diabetes so that they can consider that among their options during their open enrollment period.

AIS Health: Are there financial incentives for employees to enroll in Level2? Will they get reimbursed for any of the savings Level2 generates?

Randall: The general answer to your question is a lot of that’s going to be based on the design that the employer offers. So there could be some variation depending on how the employer wants to present that benefit design to their employees.

A UnitedHealthcare spokesperson later added that, as far as “providing any rewards or incentives” is concerned, “Level2 participants receive personalized care from a dedicated team of clinicians, registered dietitians, and coaches that the member may not otherwise be able to receive in the community, including access to a continuous glucose monitor covered at no charge to the member.”

AIS Health: Do members stay enrolled in Level2 for the entire plan year, or can they “graduate” if they make significant progress?

Randall: During each open enrollment period, they would have an opportunity to select a new [plan] or the same benefit. The way that most employers do it is, if you if you don’t make an active change, you will retain the same plan that you have the prior year in most cases.

What we do know is there’s a lot of stickiness with this plan, because members who enroll in a Level2 program have a great consumer experience. In fact, the Net Promoter Score in this program is 82.

They’re getting a great deal of support…there’s a lot of positives that can happen when [a patient is] working with an experienced care team.

AIS Health: Is a Level2 member’s care team made up of only Optum practitioners and Optum employees?

Randall: It’s a combination of doctors, nurses, coaches, registered dieticians, who collaborate across UnitedHealthcare…[they] are employed by UnitedHealth Group.

But when we say care team, I consider that the entirety of the member’s care team….We partner very closely with their personal physician — whether that’s a primary care physician or an endocrinologist — on the information that we’re seeing, what [patients] want to do around adjusting the medications, and any additional follow-up or testing that individual needs.

We want to make sure that they’re also getting comprehensive care from their primary care physician….Across all UnitedHealthcare plans, one of our primary goals is to make sure that all of our members have a primary care physician. Whether it is in Level2 or another health plan, whenever we have an interaction with somebody who doesn’t have a personal physician, it’s a mainstay of what we do to help them find one who is a good fit for them.

This article was reprinted from AIS Health’s weekly publication Health Plan Weekly.