Gregory James, DO, MPH Washington DC OptumCare Overview Gregory James, DO, MPH Washington DC November 29, 2017

Presented at the National Academy of Sciences, Engineering, and Medicine “Financing and Payment Models to Support Delivery of High-Quality Care for People with Serious Illness” Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

“Helping to make the health system work better for everyone” Provides care services to those with UHC and other managed care plans Health Services Health Benefits “Helping people live healthier lives” Pays the claims Contracts with and credentials providers Makes the product available to employers and the general public 100,000+ Employees OptumHealth Optum Advisory Services OptumRx Our business landscape: Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Optum: Connecting and serving the health system 150 global Life Sciences Organizations 4 of 5 U.S. Hospitals 300 Health plans Half the Fortune 500 Employers 31 U.S states, Many U.S. federal and global government entities 67,000 Pharmacies 115 million Individuals Creating a Healthier World Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Meet OptumCare (A Division of OptumHealth) Care Delivery designs and manages physician-centric delivery systems, touching over 2 million consumers Complex Care Management (CCM) delivers in person care to patients with complex conditions in nursing homes and in the community Physicians OptumCare SKILLED NURSING MedExpress operates over 150 neighborhood health care centers offering urgent care and primary care services in 14 states HouseCalls performs in-home health assessments to better understand patient needs, close gaps in care and improve health Urgent Care Home Visits Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. CONFIDENTIAL AND PROPRIETARY

Current state: Scope of the problem The first 30 days post-discharge from an acute setting is a critical time period that can result in a costly avoidable readmission elderly patients is readmitted to the hospital within 30 days of discharge.1 1 in 5 Primary care physicians spend a relatively small amount of time in SNFs, and when they do they often have to see many patients in a limited amount of time. of Medicare beneficiaries discharged to a post acute setting Half of these enter a nursing home. 1 40% Cost to Medicare per year in potentially avoidable readmission costs.1 $17 billion more than 1. Vincent Mor, Orna Intrator, Zhanlian Feng and David C. Grabowski, The Revolving Door Of Hospitalization From Skilled Nursing Facilities, Health Affairs, 29, no.1 (2010):57-64 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. CONFIDENTIAL AND PROPRIETARY

Transitions to SNF: Midwest Outcomes Within one year of post-acute management, the partnership between Optum and an existing Midwest client have driven significant results1: 350+ members managed 20% reduction in length of stay 52% readmission reduction Each readmission can save up to $15,000 Quality documentation that drives coding accuracy and completeness Gap closure to support STAR and HEDIS metrics Proactive, preventive, treat in place model Reduces readmissions in Hospital to SNF and manages LOS effectively 22 days 17.5 days 9% Average length of stay Readmission rate Post implementation of Optum TTS A Medicare Advantage Plan baseline 2016 Achieved results with an Optum Hospital to SNF program in Midwest market. Data compiled by Optum Data Analytics CONFIDENTIAL AND PROPRIETARY

Transitions to SNF: East Outcomes Post implementation of Optum Transitions to SNF program, the partnership between Optum and an East coast client drove significant results1: 43% reduction in length of stay 33% readmission reduction Quality documentation that drives coding accuracy and completeness Gap closure to support Star and HEDIS metrics High family satisfaction Improved discharge planning Reduces readmissions in Hospital to SNF and manages LOS effectively 23 days 13 days 8.3% Average length of stay Readmission rate Post implementation of Optum TTS A Medicare Advantage Plan baseline 2013 Achieved results with an Optum Hospital to SNF program in East market. Data compiled by Optum Data Analytics CONFIDENTIAL AND PROPRIETARY

Spotlight on Length of Stay (LOS) Savings Not every member will be readmitted, but every member will incur a length of stay. An extensive length of stay, past clinical necessity, can cost significant dollars! The tables below illustrate the potential cost savings to a health plan as a result of implementing the Transitions to SNF program, and seeing a 20% reduction in readmission versus a 20% reduction in length of stay (LOS) with a member pool of 100 members. Readmissions Baseline - 20% 20 Post TTS - 16% 16 Readmission Reduction 4 Avg. cost per admission $20,0002 Total Cost Savings $80,000 Length of Stay (LOS) Baseline - 25 days $1,025,000 Post TTS - 20 days $820,000 LOS Reduction - 5 days Avg. cost per day/per mbr $4101 Total Cost Savings $205,000 Existing client results. Data compiled by Optum Data Analytics. Internal outcomes study on acute readmissions. Data compiled by Optum Data Analytics . CONFIDENTIAL AND PROPRIETARY

Transitions to SNF overview: A path to recovery Patient Identified OptumCare Advanced Practice Clinician (APC) assigned Providing quality care with early emphasis on discharge planning Monitoring for changes in condition Initial visit/touch within 24 hours Family Support Caregivers Care coordination and collaboration Ensures smooth transition back to community providers Physician SNF staff Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. CONFIDENTIAL AND PROPRIETARY 10

TTS Model of Care: Focus Areas Areas of focus produces timely, high quality, evidence-based clinical care Initial contact within 24 business hours Visit frequency to ensure successful transition to SNF, and then to home Visit frequency based on member acuity; minimum of 2 visits per week, days 1-14 minimum of 1 visit every 5 days until discharge Intensity of visits based on clinical needs and indication of member’s status   Attending Physician collaboration occurs during the SNF stay Collaboration with SNF partners PT/OT/ST/ dietary/wound care Specialist care coordination as needed Collaboration and engagement of the member and family around discharge and ensuring safe discharge plan Discharge planning starts on day one Treat in place model for acute issues preventing avoidable readmissions during the SNF stay After discharge to home, referral to Post discharge program, for successful transition to home, and readmission prevention post discharge Ensure safe discharge plans in place prior to leaving facility Engagement Collaboration Transition Management Quality of Care Quality gaps in care closed during SNF stay Comprehensive diagnoses coded to highest level of specificity APC management and driving a safe discharge Medication Reconciliation Post-Discharge (MRP) and transition assessment completed as the member is discharged to home Ensuring services are ordered and in place for post discharge care (PT/OT/ST/HH nursing/wound care) CONFIDENTIAL AND PROPRIETARY

The Benefits of Transitions to SNF Proven success and satisfaction for patients Since 1987, OptumCare has been an innovator, within an expansive network, in changing the approach to clinical care to improve quality care in skilled nursing facilities and has a long and consistent track record of rapid implementation, early and substantial impact, strong outcomes, and satisfied customers Improving LOS Management Clinically managing members to the appropriate length of stay needed. Reducing SNF length of stay by one day saves as much as $410 per patient1 Avoiding readmissions for members Breaking the cycle of avoidable readmissions, reducing readmission rate. Each prevented readmission could save as much as $20,000 per patient1 Comprehensive coding Quality documentation that drives coding accuracy and completeness Gap Closure OptumCare care teams are committed to quality care and gap closure that address STAR and HEDIS measures. Internal outcomes study on acute readmissions. Data compiled by Optum Data Analytics CONFIDENTIAL AND PROPRIETARY

Institutional Special Needs Plan (I-SNP) Delivering a coordinated care model for Medicare nursing home long term care (LTC) residents

An Enormous Opportunity to Deliver Better Care for Medicare’s Most Expensive, and Frail Population 1.5 million Medicare beneficiaries live in a skilled nursing facility (SNF) SNF-based beneficiaries are more expensive than the average beneficiary 2x 51% of SNF-based Medicare beneficiaries had one or more ER visits (vs. 28% for non-SNF beneficiaries), and had at least one hospitalization (vs. 19% for non-SNF beneficiaries) 33% 3% Only (or about 50,000) of these SNF residents are enrolled in a private Institutional Special Needs Medicare Advantage plan today Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

High Costs Are Driven by a Broken Clinical Model for SNF Patients AVOIDABLE HOSPITALIZATIONS AND ER VISITS DRIVE SIGNIFICANT COST in the medically complex population and there are a variety of factors responsible for the unnecessary utilization: Primary care physicians generally spend a relatively small amount of time in SNFs, rounding infrequently, instead managing most of their patients remotely via telephone or faxes. The time constraint also results in poor communication and coordination with SNF staff, covering physicians, and specialty providers. Important care elements such as advance directives, goals of care or polypharmacy issues are often not adequately addressed. Challenging SNF staffing leads to higher case loads creating fragmented and uncoordinated care. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Optum is the Leader in Serving Long Term Residents in SNFs 25 year track record of superior quality and outcomes and clinical model innovation (originally known as Evercare) 50,000 #1 provider in I-SNP with nearly patients enrolled, representing share of the total market 80% 1,145 High touch, integrated care model with employed Nurse Practitioners 1,300 Relationships with SNFs nationwide, including both large national and small local players Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

High-Touch Integrated Care Model The Nurse Practitioner: Coordinator of the Care Model Nursing Home resident enrolls in ISNP Optum Nurse Practitioner provides In-Facility care Collaboration with and augmentation of the PCP Ongoing family education and engagement Comprehensive Care coordination while enrolled in ISNP Business office Facility administrator A Optum medical director Family support Resident Optum nurse practitioner Director of nursing home D Social services c Primary care provider NP = coordinator and collaborator Program overseen by local Optum market team Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17

Our Plans Also Provide Unique Benefits Above and Beyond FFS, and Further for Dually Eligible Members Medicare + Medicaid Additional plan benefits . . . No copayment on . . . Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Differentiated Cost, Quality and Satisfaction Outcomes 50% We improve quality while reducing costs by for our members 40% We have reduced hospitalizations by and ER admissions by nearly 50% 63% of our members are estimated to be in 4.0+ STAR plans effective 1/1/16 98% Member satisfaction with our plans has consistently approximated Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Gregory James, DO, MPH Senior Medical Director / OptumCare Complex Care Management (CCM) 727-517-0210 gregory.j.james@optum.com Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. CONFIDENTIAL AND PROPRIETARY