REDESIGNING CARE FOR THOSE WHO NEED IT MOST…

Since 1993, CareMore and its founder, CareMore Medical Group, Inc., have been successful in delivering quality care to the Medicare population. CareMore’s only line of business is Medicare Advantage HMO, and its plans are uniquely designed for the frail elderly. We place a strong emphasis on early detection and identification of chronic conditions and co-morbidities and implement preventive and maintenance health care services that help to keep beneficiaries healthy, detect diseases at an early stage, and work to avoid preventable illnesses. CareMore joined the Anthem family of plans in 2011.

California Plans in Los Angeles, Orange, Riverside, San Bernardino, Santa Clara and Stanislaus Counties Offer Standard HMO plans, CSNPs, DSNPs and ISNPs

Nevada Plans in Clark County Offer Standard HMO plans, CSNPs and ISNPs

Arizona Plans in Maricopa and Pima Counties Offer Standard HMO plans, CSNPs and ISNPs

Virginia Plans in Richmond, VA Offer Standard HMO plans, CSNPs and ISNPs

A Brief History

OUR MISSION

Providing innovative and focused healthcare approaches to the complex process of aging.

WHY OUR MISSION

We are here to:

serve our members by prolonging active and independent life

serve caregivers and family by providing support, education, and access to services

protect precious financial resources of seniors and the Medicare Program through innovative methods of managing chronic disease, frailty, and end of life

CAREMORE

Our Members

44% diabetics

40% hypertensive

16% COPD, ESRD, asthma, kidney disease

66% Have co-morbidities

50% at or below $30k annual income

45% Hispanic

A Chronic Care Special Needs Plan

Healthcare Cost and Quality Problems are Concentrated….Not Widespread

Healthy Stable Sick Sickestmostly 1 + Chronic Illness mostly 3 + Chronic Illness

Progressive Illness2010 MedicareSpending Projection = $522 B46 Million BeneficiariesSpending Per Beneficiary = $11,347

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

Ann

ual Cos

t/Be

nefi

ciar

y 23 Million Beneficiaries- Spending $1,130 each- Total Spending = 5%

($26 B)

16.1 Million Beneficiaries- Spending $6,150 each- Total Spending = 20%

($104 B)

7 Million Beneficiaries- Spending $55,000 each- Total Spending = 75%

($391 B)

AverageSpending

CHF, DM

85% of Beneficiaries = 25% Spending 15% of Beneficiaries = 75% Spending

ESRD, CANCER

The CareMore Model

Chronic Diseases are Generally Managed Poorly

Patients receive appropriate care only half of the time (EA McGlynn et al)

Diabetic complications could be cut 90% with best care and involved patients (Center for Disease Control and Prevention), yet

• Diabetes related admissions have risen from 3.5 to 6.5 million since 1993 (Dept. HHS)

• Low income diabetics are 80% more likely to be hospitalized (Dept. HHS)

Second heart attacks can be reduced 40% (J.R. Jowers)

More doctors involved in care decreases information exchange and leads to unnecessary hospitalizations (Wennberg/Dartmouth)

But...

• Patients with serious conditions see 11 different doctors

CareMore addresses these problems directly

CareMore System Functions in Parallel with Community Physicians

Non-Frail Population

Primary Care Physicians

Extensivists

Member Services

Continuous Frailty Assessment Tools

Provider Relations

CareMore Care Centers

CareMoreExtensivist

CareMore Care Centers

Home Based Services

Specialists

Case Managers

Primary Care Physicians

Close monitoring of non-frail members to proactively identify at-risk members and aggressive management of chronic conditions to prolong the onset of frailty

Intensive management of frail and chronically ill members, identified through predictive models, data scans, PCP referrals or member self-identification

Frail & Chronically Ill Population

The Essentials of CareMore’s Model

CareMore Solution – New Model of Care

Conduct pre-operative exams

Manage patient hospitalization decision

Take control of entire inpatient stay, including specialist consultation, diagnostics, PCP communication, family communication

Create and manage discharge plan

Retain lead physician role during Skilled Nursing stay

Follow patients on an out-patient basis until acute episode or frailty resolves

Manage high-risk outpatient events, such as fall prevention programs, dementia evaluations, transplant evaluations, bariatric surgery evaluations

Create transition to palliative care and end-of-life teams as appropriate

Acute EpisodesTake “ownership” of patient at point

of admission Prepare patient and family for

dischargeDispatch all services necessary to

avoid readmission

Long Term Management“Own” patient for remainder of lifeDispatch home-based servicesFacilitate CCC and other

necessary visitsFacilitate transportation and other

social services

Chronic CareConduct annual health risk

assessments and create care plansMicro-manage chronic conditions and

lead interdisciplinary teams specific to a patient’s needs

Provide all wound care (diabetic, ulcerative, post-surgical)

Staff all home wireless monitoring systems

Available for 24/7 telephonic patient consultation

Frailty and Palliative CarePrimary care provider and case

manager for home-bound patientsAssume primary clinical role for

palliative care patients

Institutional/Custodial/Assisted Living ResidentsMake weekly visitsBecome first point of contact for

facilities and family for ALL care needs

Extensivists Nurse Practitioners Case Managers

CareMore’s Model Allows for Efficient Allocation of Clinical Resources

CAREMORE

Care Center

Community Focus

•Located in the heart of the neighborhood

Social Environment

•Designed for seniors •Resource for family and caregivers

•Frequent classes and activities

Clinical • Disease Management

• Foot Center• Healthy Start

• Pre- Op • Fall Prevention

• Wellness programs

A Newly Defined Medical and Social Home

Healthy Start – Initial EvaluationComplete medical evaluation for all new members

Goals Early identification of chronic diseases; referral to chronic

disease management programs One complete H&P Immediate referral to specialist if needed

Results 80% of members have appt within 30 days 42% referred to prevention or support program 23% referred to a chronic care program 18% diagnosed with depression (previously unknown) 3% diagnosed with Diabetes for the first time

Healthy Start – Initial EvaluationComplete medical evaluation for all new members

Goals High touch evaluation for high acuity patients Ensures at least one complete evaluation per year:

“second pair of eyes” when PCP/member engagement low

Results 70% of SNP members undergo in-person annual

assessment 100% Update to Care Plan and Medication Plan

Johns Hopkins Predictive Modeling Software

Healthy Journey –Ongoing EvaluationComplete medical evaluation for all new members

Goals High touch evaluation for high acuity patients Ensures at least one complete evaluation per year:

“second pair of eyes” when PCP/member engagement low

Results 70% of SNP members undergo in-person annual

assessment 100% Update to Care Plan and Medication Plan

Ascender Predictive Modeling Tool identifies targets based on claims data

Monthly run of claims, Rx, lab data, age correlated to identify 5% most at-risk members

72% plugged into appropriate chronic care of frailty program

CARSIdentifies sick patients through software

CareMore’s Model Allows for Predictive Modeling and Early Intervention

OUTCOMES

Diabetes Programo Members with A1c>9 on initial visit reduced to average of 7.08

when in programo 65% less amputations than Medicare FFS average (8.7

Medicare vs 2.96 Caremore)o Delayed Progression of Chronic Kidney Disease – Medicare

average of 6 years vs Caremore 24 years based on our predictive modeling

o ESRD program members have 37% less admissions and 64% fewer hospital days than Medicare average

Based on 2013 CareMore data and the most recent Medicare information

OUTCOMES

Chronic Heart Failure Program memberso 28% Fewer admissions than Medicare averageo 45% fewer hospital days than Medicare averageo 47% fewer readmissions than Medicare averageo 97% in program record daily weight through a wireless scale

Based on 2013 CareMore data and the most recent Medicare information

OUTCOMES

Chronic Lung Disease Program 48% fewer re-admissions than non-Program members 52% fewer admissions than Medicare average Members with COPD on Oxygen

o 33% fewer admissions than non-Program memberso 47% fewer hospital days than non-Program memberso 47% fewer readmissions than Medicare averageo 97% in program record daily weight through a wireless scale

Based on 2013 CareMore data and the most recent Medicare information

Payers & Providers

Drivers of Payer viability:

Membership/Growth

Patient Satisfaction

HCC Documentation & Coding

HEDIS measures

Specialist utilization

ER Visits

In Patient Utilization

Physician group Impact

Identify patients who benefit from Health Plan products and services

Short wait times; same day appointments; Timely communication-lab/test results; 5 STAR service

Comprehensive patient visit; documentation to the highest level of specificity

Comprehensive patient visit collecting HEDIS measures or referring for HEDIS-related visits

Reduced referrals to specialists where appropriate; utilization of preferred/aligned specialist providers

Short patient wait-times while in office; same day appointments, scheduled follow up visits, utilization of CareMore care center

All of the above

Alignment of Incentives

Primary Care Physicians Quality Bonuses

o HEDISo Patient Satisfaction

HCC documentation bonuseso Patient assessment formso Coding accuracy

Shared savings o Membership panel viewed as stand alone financial statement for Medical Group or

POD

PARTNERING

Specialists Bonuses for HEDIS capture

Retinopathy screenings

Shared savings on admission/re-admission reduction Cardiology COPD Nephrology

Episodic care management/Bundled payment Cardiology Orthopedics

PARTNERING

Hospitals Quality and Patient Satisfaction bonuses Shared savings on admission/re-admission reduction Episodic care management/Bundled payment

Cardiology Orthopedics

PARTNERING

IMPACT OF PATIENT SATISFACTION

GROWTHMEDICARE STARS

MEMBER COMPLAINTS MEMBERS LEAVING THE PLAN

HCC CAPTURECOMPLIANCE WITH CLINICAL PROGRAMS

Getting Care Quickly:• Setting appropriate and realistic expectations• Offering adequate and informative explanations• Acknowledging patient’s presence in the waiting room• Courteous and respectful staff

Getting Needed Care:• Submitting prior authorizations in a timely manner• Ensuring pharmacy receives prescriptions in a timely manner• Collaboration between PCPs and Specialists

Coordination of Care:• Using health plan resources for sharing clinical information• Set appropriate and realistic expectations regarding test results• Offering adequate and informative explanations

Member perception of all of these is KEY!

IMPROVING PATIENT SATISFACTION

HOW DO WE START?

Open the dialogue with payers Understand the quality and financial

issues Get the data Find partners with same goals