Health Information Technology: Caring for Members with

Chronic Diseases

Laurie Russell MS RN CCM GCM November 15, 2011

Key Facts

2

Estimated $200 billion to $250 billion spending on Medicare beneficiaries with diabetes and CHF

High-risk, costly segment of the population continues to grow -- yet remains predominantly unmanaged

Medicare beneficiaries with diabetes and related diseases will accelerate due to higher prevalence as well as baby-boomer increases within Medicare beyond 2012

Addressing  Medicare’s  Central  Challenge  

Annual Cost per Medicare Beneficiary in 2009

$0

$20,000

$40,000

$60,000

$80,000

Healthy Stable Sick Sickest

85% of Beneficiaries = 25% of Spending

16.1 MM beneficiaries spending $6,150 each

Total Spending = 20%

($104 Bn)

23 MM beneficiaries spending $1,130 each

Total Spending = 5%

($26 Bn)

15% of Beneficiaries = 75% of Spending

7 MM beneficiaries spending $55,000 each

Total Spending = 75%

($391 Bn)

(mostly 1+ chronic illnesses)

(mostly 3+ chronic illnesses) Progressive

Illness

ESRD, Cancer

XLHealth Members CHF, DM

3

XLCare™  is  XLHealth’s  proprietary  integrated healthcare information workflow system

– Used by all medical management programs and personnel

Integrates high tech/ high touch programs

All programs are technology enabled with data captured in XLCare

Early identification of clinically frail members allows XLHealth to prioritize members and intervene in a timely fashion

Integrated IT provides:

– Gaps in care identification

– Medical cost and utilization trending data

– Outcomes tracking analysis

XLCare is Powered by Member Medical Data

Information Technology & Medical Management Tools

Pharmacy Claims

Lab Values

Physician Medical Records Reviews

(~160,000 in 2011)

HouseCalls Medical Records

(~100,000 in 2011)

Member Services

Data

Medical Claims

Hospital Records Reviews

(~40,000 in 2011)

Care Management

Data

XLHealth innovations

4

Interdisciplinary Care Team

Consists of all the care management professionals that interact with members

Helps integrate care by pulling together expertise and resources of the company

Improves member care and quality of life by providing a variety of services helping members manage their health and identify early risks of complications

Comprehensive support tailored to fit individual member health needs

XLCare integrates all programs, facilitates a “virtual  team”

External

Network

XLHealth Pharmacists

XLHealth Dieticians

Registered Nurses

Member Service Support

Medical Directors

XLHealth Social

Workers

Internal

Network

Social Services

Coordinator Member’s  

PCP

HouseCalls Practitioner

Family Caregiver

Member’s  Specialists

Behavioral Health

5

MEMBER

Combine traditional managed care tools with innovative care management programs: − Improve quality of care

− Reduce medical spending trends

− Decrease mortality

− Drive member satisfaction and retention

Integrate medical management and care management programs with IT analytics and in-home consultations

Focused on driving better care management through member interaction

Industry comparable Utilization Management (UM), tiered, comprehensive care management, transitional care and end of life planning

Medical Management Programs

Member Risk Stratification

Medication Therapy

Management (MTM) and

PharmAssist

HouseCalls

Program Critical Elements

Stratifies members based on severity Ensures focus on the highest risk members Determines frequency of outreach Uses medical and pharmacy claims data, lab values,

care management, MTM, and HouseCalls data

The  “eyes  and  ears”  of  the  Care  Team Accelerates the capture of clinical data for use in

treatment Permits rapid follow up Creates personal connection with members

Focused beyond traditional medication therapy management

Drives reduced costs and improves member health Addresses pharmacotherapy issues Intervenes with members and physicians

MedAssist Identifies untreated conditions Creates practical work plans for follow up care Leverages HouseCalls

Utilization / Care

Management

Specialized programs in transitional care, post-acute care and End of Life/Palliative care

Transitional care enables transition to a stable environment, post-hospitalization

Medical management programs are provided regardless of product

6

HouseCall /HRA within

30 days PCP receives assessment

data

Risk Stratification via XLCare

Customized Plan of Care

MedAssist - new diagnosis

found

Assigned to High Risk

Heart Failure Team

Telescale technology

utilized

Care Team monitors

telescale data daily

HouseCall- Post discharge

home visit

Dietician intervenes with diet teaching

PharmAssist – medication counseling

Member with Heart Failure

XLCare integrates all data

Impact of XLHealth on Medical Cost

XLHealth’s  care  management  and  medical  management  efforts  have  succeeded in keeping members' medical costs below national average trends

The graphs that follow are in constant July, 2011 PMPM dollars adjusted for benefit design, national average trend, and member risk (shown with DCG adjustment)

The dotted red line represents the constant July, 2011 PMPM dollars medical cost XLHealth would have incurred if our care management had performed exactly at national average trend

The solid red line shows XLHealth's actual performance for new members enrolling from April 1, 2007 through March, 2010

8

$700

$800

$900

$1,000

$1,100

$1,200

$1,300

8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Linear (All Effective Dates)

Linear (Constant PMPM Dollars)

$700

$800

$900

$1,000

$1,100

$1,200

$1,300

8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Linear (All Effective Dates)

Linear (Constant PMPM Dollars)

C-SNP Dual Eligible DCG Risk Adjusted C-SNP Non-Dual Eligible Risk Adjusted

9

Outcomes: Impact of XLHealth on Medical Cost

Outcomes: 30 Day Re-Admission Rate

Re-Admits per 1000 % of Admits that were re-admissions

80

85

90

95

100

105

110

115

CSNP Members Only, ESRD Excluded Incurred through May 2011, Paid through August 2011

Readmission Rate Linear (Readmission Rate)

16.0%

16.5%

17.0%

17.5%

18.0%

18.5%

19.0%

19.5%

20.0%

20.5%

CSNP Members Only, ESRD Excluded Incurred through May 2011, Paid through August 2011

Readmission Rate Linear (Readmission Rate)

10

Outcomes – Rx Results (Part D)

Adherence Rate improved across all major classes from 2010 to 2011

11

Arkansas/Missouri Texas

16.9% 18.7%

16.6%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

DM ACE Statin

% Improvement

21.1% 19.8% 18.8%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

DM ACE Statin

% Improvement

22.1% 21.0% 23.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

DM ACE Statin

% Improvement

South Carolina/Georgia

Adherence Rate Drug Improvements

2010 2011 % change DM 67.9 79.4 16.9%

ACE 66.4 78.8 18.7%

Statin 63.8 74.4 16.6%

2010 2011 % change DM 64.6 78.2 21.1%

ACE 65.3 78.2 19.8%

Statin 60.7 72.1 18.8%

2010 2011 % change DM 63.3 77.3 22.1%

ACE 63.7 77.1 21.0%

Statin 59 73.1 23.9%

Questions?

Thank You

12