School Employee Health Care Board Conference

Joe San FilippoChief Health Care StrategistNationwide Better Health

Water LevelHealth Promotion/ Lifestyle Management

Disease Management

Populationat risk

who havefiled a claim

Health Maintenance

Population withno known

risk factors

Total PopulationTotal PopulationTotal PopulationTotal PopulationPopulationwith risk

but not sick

Water Level

Understanding Health RisksUnderstanding Health Risks

Total Population Health Management

Boden WE et al.Boden WE et al.

NEJM 2007;356NEJM 2007;356

Treatment Groups

PCI (n=1149)PCI (n=1149) OMT (n=1138)OMT (n=1138)

Both groups received OMT, which included cardio-protective medications (e.g., ASA, BB, ACE-inhibitors, anti-platelet agents, statins) as well as smoking

cessation, exercise, weight control and nutrition counseling.

Cumulative Event Rates at 4.6 Years

PCI GroupMedical Tx

Groupp

ValueOutcome # % # %

Death, nonfatal MI 211 19.0 202 18.5 0.62

Death, MI, Stroke 222 20.0 213 19.5 0.62

Death 85 7.6 95 8.3 0.38

Nonfatal MI 143 13.2 128 12.3 0.33

Stroke 22 2.1 14 1.8 0.19

Hospitalization* 135 12.4 125 11.8 0.56

Revascularization ** 228 21.1 348 32.6 <0.001

* for ACS; ** PCI or CABG

Approximate Mortality Reduction Potential of Drug Vs Lifestyle Interventions in Patients with Coronary

Disease*

Drug

Lifestyle

LowLow dosedose aspirinaspirin 18%18%StatinsStatins21%21%ßß Blockers

Blockers23%23%ACEACE Inhibitors

Inhibitors 26%26%

SmokingSmoking cessation

cessation35%35%

PhysicalPhysical activityactivity

25%25%ModerateModerate alcohol

alcohol20%20%

Combined lifestyle

Combined lifestyle changeschanges

45%45%

Iestra JA et al. Circ 2005;112:924

Two meta-analyses now suggest

Two meta-analyses now suggest

that regular exercise can reduce

that regular exercise can reduce

the overall risk of cardiovascular

the overall risk of cardiovascular

events by up to

events by up to 50%50%50%50%

Powell KE et al. Annu Rev Publ Health 1987;8:253Berlin JA et al. Am J Epidemiol 1991;134:232

Ben

efit

Dose- ResponseCurve

A = SedentaryB = Moderately ActiveC = Active

Baseline Activity Status

AA BB CCLow High

Walk toWalk tobus stopbus stop

NoonNoon--time jogtime jog

AfterAfter--dinnerdinnerwalkwalk

1010

88

66

44

22

0000 22 44 66 88 1010 1212 1414 1616 1818 2020 2222 2424

SedentarySedentaryLifestyle exerciseLifestyle exerciseLeisureLeisure--time exercisetime exercise

Energy Expenditure, METsEnergy Expenditure, METs

Time (hours)Time (hours)

Conventional Risk Factors for Coronary Heart Disease

4 Risk Factors4 Risk Factors4 Risk Factors4 Risk Factors

CigaretteCigaretteSmokingSmokingCigaretteCigaretteSmokingSmoking

Hyper-Hyper-lipidemialipidemia

Hyper-Hyper-lipidemialipidemia

Hyper-Hyper-tensiontensionHyper-Hyper-

tensiontension DiabetesDiabetesDiabetesDiabetes

• 87% to 100% of patients who experienced a fatal coronary event had an antecedent exposure to 1 risk factor.*

• > 80% of patients with coronary disease had 1 of the 4 conventional risk factors.**

* JAMA 2003;290:891 ** JAMA 2003;290:898

Lifetime Risk: Age 50

Lloyd-Jones DM et al. Circ 2006;113:791

0.70.6

0.5

0.4

0.3

0.2

0.1

050 60 70 80 90 50 60 70 80 90

≥ 2 Major RFs1 Major RF≥ 1 Elevated RF≥ 1 Not Optimal RFAll Optimal RFs

69%69%

50%50%46%46%

36%36%

5%5%

50%50%

39%39%

27%27%

8%8%

Adj

uste

d C

umul

ativ

e In

cide

nce

Attained Age

HRA Stratification ReferralsDisease Management and Lifestyle

Management

HRATrigger

Questions

• Diabetes

• Confirmed CAD

• Confirmed Hypertension

• Confirmed Hyperlipidemia

• Maternity

• COPD

• Asthma

• Depression

• Recurrent Long-term Lower Back Pain

• Unconfirmed CAD or Hyperlipidemia

• Unconfirmed Hypertension

• Anxiety / Stress

• Overweight

• Physical Activity / Exercise

• Tobacco Cessation

Lifestyle Management Referrals

Disease Management Referrals

Ref

erra

ls F

rom

“T

rig

ger

s”

Our predictive modeling tool determines relative risk scores unique to conditions and identifies risk 12 months prior to an episode.

• Predictive Modeling

• HealthCheck HRA

• Gaps in Care

• TreatmentCompliance

Stratification / Intervention

Elements

Combines predictive modeling that identifies and stratifies members with our proprietary business rules, so that we effectively prioritize and manage co-morbidities

Proprietary RiskScreen®

HighAcuity

LowAcuity

ModerateAcuity

RiskScreen® Process

Medical Claims Data Pharmacy Claims Data

Population With Risk Factors

• Diabetes

• Coronary Artery Disease

• Congestive Heart Failure

• Chronic Obstructive Pulmonary Disease

• Low Back Pain

• Asthma

Core Conditions

All Chronic Conditions

Precursors

Maternity

Oncology

1 year program

• Arthritis • GERD • HIV • Self Referral • Depression

Optional Coverage

Core Conditions represent the health conditions where we can have the maximum impact on improving health and reducing costs.

• Hypertension • Hyperlipidemia

Runs through six weeks post-partum

tailored to member during treatment cycle

Obesity

Disease Management Program

Welcome Kit

Telephonic Outreach

Clinical Assessment

Determine Appropriate Program

HighAcuity

LowAcuity

ModerateAcuity

Identification

LOW Intervention

MODERATE Intervention

HIGH Intervention

Components of the Disease Management Process

Disease Management Process

Welcome Kit

Telephonic Outreach

Clinical Assessment

Disease Management Process

HighAcuity

LowAcuity

ModerateAcuity

Identification Methods of Identification

Determine Appropriate Program

RiskScreen® Predictive Modeling

Health Risk Assessment Biometric Screening Referral Opportunities

Case Management Disability Management EAP Lifestyle Health Coaching Maternity Management Nurse Advice Line On-site opportunities

(health fairs, clinics) Self referral Utilization Management

LOW Intervention

MODERATE Intervention

HIGH Intervention

Clinical Assessment

Disease Management Process

Welcome Kit Contents

Determine Appropriate Program

Welcome Kit

Telephonic Outreach

HighAcuity

LowAcuity

ModerateAcuity

Identification

Welcome letter Disease-specific educational

materials Instructions to access specific

lifestyle management kits online Self-assessment tool to encourage

engagement with a coach Member experience brochure

Note: if member self-refers they will only receive applicable disease-specific literature

LOW Intervention

MODERATE Intervention

HIGH Intervention

Telephonic Outreach

Clinical Assessment

Disease Management Process

Telephonic Outreach

Determine Appropriate Program

Welcome Kit

HighAcuity

LowAcuity

ModerateAcuity

Identification

Up to 8 calls in 30 days Track time of day and day of week

to maximize outreach

If we are unable to contact member during initial outreach phase, we’ll continue to contact them via phone and mail for the remainder of the year.

LOW Intervention

MODERATE Intervention

HIGH Intervention

Disease Management Process

Clinical Assessment•Lifestyle

•Functionality

•Disease specific behaviors

•Disease specific clinical values

Welcome Kit

Telephonic Outreach

Clinical Assessment

HighAcuity

LowAcuity

ModerateAcuity

Identification

Determine Appropriate Program

LOW Intervention

MODERATE Intervention

HIGH Intervention

Disease Management Process

Program Interventions

Welcome Kit

Telephonic Outreach

Clinical Assessment

HighAcuity

LowAcuity

ModerateAcuity

Identification

Determine Appropriate Program Results of the clinical assessment as well

as member's readiness determines the most appropriate program and intensity level

Low acuity members may ultimately be assigned to any level of intervention.

LOW Intervention

MODERATE Intervention

HIGH Intervention

Avoiding Costsper member/

per year

Disease Management Success

0%

50%

100%

Cardiac Disease

$12,077

Following Physician’s Medication Regimen

Asthma $1,340

Diabetes $12,672

Typical Compliance*

NBH Program Compliance**

98%

50%

*US food and Drug Administration Dept of Health and Human Services 2006 – AND– National Council on Patient Information and Education 2008**Based on 2007 NBH operational outcomes

0-5 5 10 15 20 25 30 35 40

Alcohol consumption <2 drinks / day

Willing to make changes to improve health

Blood pressure tested

Cholesterol checked yearly

Going to doctor

Taking medication (compliance)

Pneumonia vaccination in last 5 years

Urine tested for protein (yearly)

Flu Shot in last 12 months

Feet examined yearly

Eye exam yearly

Understand diabetes and type

Monitoring blood sugar

Exercising 3 times/week

Following a special diet

Percent Change

Program Measurement Behavior Changes for the Population

52%

48%

70%

HbA1c < 7HbA1c >= 7

Post DM HbA1c LevelPre DM HbA1c Level

30%

HbA1c < 7 or Met GoalHbA1c >= 7

n = 593

n = 696

n = 899

n = 390

Program Measurement Clinical Changes for the Population

Diabetes

HbA1c Level (%) Pre-Disease Management

Post-Disease Management

Target (< 7.0) 54% 67%

Suboptimal (≥ 7.0 and ≤ 8.0) 22% 21%

Poor Control (> 8.0 and ≤ 9.5)

15% 10%

Markedly Elevated (> 9.5) 9% 2%

Total 100% 100%

Asthma

Coronary Artery Disease Hypertension

*Excludes members with diabetes, CAD or CHF

OutcomesMedication Compliance

Pre-Disease Management

Post-Disease Management

Full Compliance 87% 97%

Partial Compliance 10% 2%

Non-Compliance 3% 1%

Total 100% 100%

LDL Cholesterol (mg/dL)

Pre-Disease Management

Post-Disease Management

Target (< 100) 64% 74%

Suboptimal (100 - 129) 16% 16%

Poor Control (≥ 130) 20% 10%

Total 100% 100%

Blood Pressure (mmMg)*

Pre-Disease Management

Post-Disease Management

Elevated BP 33% 7%

Controlled BP 67% 93%

Total 100% 100%

Maternity Program

14%

44%

1st Trimester

3rd Trimester

42%

2nd Trimester

Enrollment % by Trimester

46%38%

1st Trimester

3rd Trimester

16%

2nd Trimester

High Risk & Very High RiskDesignations by Trimester

N=253

N=807 Dedicated maternity nurse Enroll All expectant mothers,

starting in first trimester – not just ‘high risk’ as many programs do

Extends through postpartum Same nurse manages all chronic

and co-morbid conditions

Differentiators:

Source: 2007 NBH Outcomes

We reduce the

average NICU

length of stay

by 21%.

Average Savings:

$51,099

Maternity Program NICU Results

Results:

For 2007, preterm birth rate is 10.6% (National average = 12.5%)

NICU days per 1000: NBH has 1,302 days /1000 newborns

Low birth weight and very low birth weight rate for NBH for 2007 is 7.7% (National average = 8.1%)

NBH reports $8.8 million in savings for NICU admissions for 2007

Source: 2007 NBH Outcomes