1 ChenMed Care Model: Creating Change and Transformation in General Practice November, 6 th, 2014

2 Average per capita health care costs by number of chronic conditions Source: Medical Expenditure Panel Survey, 2006 Chronic conditions drive health care spending, especially in Medicare Medicare spending for patients with 5+ chronic conditions

3 Who we are: Privately held, primary care-led physician group Our focus: Low to moderate income adults > 55 with multiple chronic conditions in urban areas. Typical patient searches for a PCP every 18 months, often considered “frequent flyers” by other health systems. Our focus: Low to moderate income adults > 55 with multiple chronic conditions in urban areas. Typical patient searches for a PCP every 18 months, often considered “frequent flyers” by other health systems. Care model: patients per PCP; on-site Rx, focus on culture, patient relationships, decision making, customized information technology, intensive care coordination Scale: Designed to scale quickly; Growth from 5 centers in Miami market in 2010E to 36 centers in 8 markets at 2013E. 40+k risk lives in Payment: Global risk adjusted capitation from Medicare Advantage plans Snapshot of ChenMed

4 This approach is fundamentally different

5 Miami Outcomes in CY 2011 prior to scaling

6 Designing the operations of a focused factory One-stop shopping enhances coordination, collaboration, convenience, and compliance Reproducible layout resembles an Ambulatory ICU Primary care doctors lead the care team and do not have private offices Onsite specialists to encourage physician to physician dialogue Onsite supportive services for convenience Capacity to keep patients out of hospital (e.g., IV Antibiotics, Diuresis) Door-to-doctor transportation to our clinical sites improves access to care

7 Focus creates the potential for strategic design ▪ Hire staff who are passionate about this patient segment with right skills ▪ Engineer tighter integration and links in every process ▪ Test multiple changes in different markets ▪ Streamlined organizational governance ▪ > 70% of Medicare costs driven by patients with > 4 conditions ▪ Changes in outcomes can be measured in months Faster change cycles Impact easier to measure Payor collaboration ▪ JV allows for rationalization of care programs between payor and provider (e.g., analytics, care coordination, specialized programs) ▪ Don’t focus on fee for service demands ▪ Operational challenges dramatically reduced Specialized staff and processes Reduces complexity

8 Manage across transitions ▪ Build in continuity where possible; hospitalist follows patients to first follow-up visit ▪ PCP and NP joint SNF decision-making ▪ Initial home assessment ▪ Interdisciplinary weekly team meetings by center Design around access ▪ One stop shop – most patients within 7 miles ; transportation ▪ On-site physician drug dispensing ▪ Wellness focused activities on-site ▪ Not looking to be a complete multi-specialty group, but invite external specialists on-site as feasible and practical Build up care team ▪ Nurse case manager, social worker, transitions team ▪ Developing medical assistants as coaches ▪ Qualitative judgment – the worry index ▪ Develop relationships with trusted specialists over time Integrating primary care decisions around the patient

9 Physician culture is critical to get care right “from the inside out”

10 Building the right culture requires changing mindsets and behaviors Role-modeling Behavior and mindset shifts Developing talent and skills Reinforcing with formal mechanisms Fostering understanding and convictions The McKinsey influence model “I see superiors, peers, and subordinates behaving in the new way” “I know what is expected of me – I agree with it, and it is meaningful “I have the skills and competencies to behave in the new way” “The structures, processes, and systems reinforce the change in behavior I am being asked to make” Changes in mindsets and behaviors need to happen at all levels of the organization, starting with –Front-line physicians –Clinical team –Physician leadership None of the changes in behaviors and mindsets can be mandated or dictated – each will require a coordinated set of influencing tactics to ensure traction in the organization

11 CMS risk scores Real-time internal HEDIS Metrics Real-time patient flow metrics (i.e. wait times) Comprehensive outpatient clinical data, digitized and scanned Hospital Admissions & Readmissions Real-time inpatient clinical data Claims Data Part A Part B Part D Net Promoter Scores / Customer Feedback Predictive Modeling data from Envita and Humana Providing a suite of tools to optimise decision making in the exam room

12 Using Visualization Tools to help a Physician Manage Her Panel of 450 High Risk patients

13 A care timeline is used to integrate claims, referrals and hospital data for high cost case management

14 Dash2Go

15 ▪ 3 times a week review of patient care by the physician group ▪ Transparent review of outcomes with all physicians ▪ Entire team owns the relationship ▪ Relationship evolves over time ▪ >85% of the touch-points Focus on the patient relationship Physician decision-making ▪ Selection and culture ▪ Decision support at point of care ▪ Positive incentives – the “tuned” patient panel Convenience matters ▪ Redesigned system of on-site physician drug dispensing dramatically improves adherence ▪ On-site behavioral health model coordination Communication ▪ Coordination of care ▪ Specialist – PCP communication in person ▪ Team conferences What are the key drivers of success in integrated care?