0 Cleveland, Ohio June 17, 2008 Delivering Health in Cuyahoga County The Plain Dealer Editorial Board The following report is proprietary information of the MetroHealth System and should not be disclosed in whole or part to any external parties without the express consent of the MetroHealth System.

1 Mission  Academic Health Care System  Committed to Community  Saving Lives, Restoring Health, Promoting Wellness  Outstanding, Life-long Care  Accessible to All The MetroHealth System  Owned by Cuyahoga County  400+ bed Acute Care Medical Center  Physicians on CWRU School of Medicine Faculty  Complete Specialist Coverage  Nationally Recognized Quality  Nursing Magnet Status  County’s Only Level I Trauma & Burn Center  Largest Local ED with 100,000 Visit Capacity  Nine Community Health Centers  New Senior Health and Wellness Center in Old Brooklyn  Skilled Nursing  Significant Clinical/Behavioral Research  6,500 Employees

2 Serving Cleveland’s urban core

3 Safety net for the citizens of Cuyahoga County Note: IP - Market and MH are Cuyahoga residents only Source: CDC NHAMCS; OHA Inpatient and Outpatient Data, 2006; MH Internal Data, US Statistical Abstract 25K 206K Inpatient Discharge Distribution by Payor All Cuyahoga Providers vs. MetroHealth, 2006 Inpatient Discharges by Payor 60% 78K 505K ED Visit Distribution by Payor All Cuyahoga Providers vs. MetroHealth, 2006 ED Visits by Payor 76%

4 Long-term decline in regional economy Source: US Census Bureau; US Decennial Census; American Community Survey; Consumer Price Indexes, Bureau of Labor Statistics; Booz & Company Analysis Total Population 1960 – 2006 Cuyahoga County and City of Cleveland Total Pop. (000s) National and Cuyahoga Median Household Real Income (2006 Dollars) Median HH Income Cuyahoga HH Income to US HH Income Ratio 118%107%95%93%86% (1) Data for 1969, 1979, 1989, and 1999 has been sourced from US Decennial Census; Data for 2006 has been sourced from American Community Survey (2) Census questionnaires request for income for the previous financial year; Census conducted every decade (e.g., 2000) therefore reports income for the prior year (e.g., 1999)

5 Increased need for health safety net Unemployment Rate Cleveland Cuyahoga National Uninsured Rate (as % of Civilian Workforce) Source: Ohio Department of Jobs and Family Services; Census ACS Survey; Ohio Medicaid Reports ( ) Cuyahoga Uninsured and Medicaid Population (<65) Cuyahoga County Population (000s) <200% FPL 29% 33% 14.8% 5.1%

6 Managing in a constrained environment MetroHealth Operating and Net Income/Loss Source: MetroHealth audited financial statements and 2008 budget MetroHealth Charity Care and Subsidies $ millions Budget $94M County Subsidy $40M HCAP $15M Gap $39M Note: $9.6M is also received from UPL as a Medicaid Supplement Budget

7 MetroHealth’s priorities  Expand service selectively –The Center for Community Health –Senior Health and Wellness Center  Implement screening exams to improve patient experience  Launch revenue and operational upgrades  Capture immediate budget opportunities Improve TodayTomorrow  Improve public health  Implement new care model for the uninsured  Attract patients with affordable quality Reinvent

8 Other communities are progressing Incremental levels of sophistication/progression Service Enhancements Care Delivery Management Initiatives Patient Centered Care Execute targeted initiatives to address utilization of high-cost services Enroll uninsured in “program” designed to manage care delivery most efficiently Adopt a patient-centric approach to health care  Open access formats/extended hours clinics to increase access for non-emergent care – e.g., Hudson River HealthCare (NY)  Increased urgent care clinics and enhanced nurse triage to alleviate ER non-emergent care – e.g., Harborview Medical Center (WA)  “Frequent user” case management including high cost utilization analysis and intense follow-up – e.g., “Frequent Users of Health Services Initiative” (CA)  Robust program for management of care delivery (a ‘virtual insurance’ model) – e.g., “Carolina Access” –Utilization and Care Management across services –Appropriate authorization of services –Referral management  Expanded chronic disease management – e.g., “Voices of Detroit Initiative” (MI)  Assignment of medical homes to help coordinate care and information across care continuum – e.g., San Francisco Universal Access Program  Integration across care continuum, easily accessible including well located primary care sites, access to specialty care – e.g., Kaiser Permanente CA  Support for patients beyond basic medical care including patient navigators, social workers, transportation – e.g., MD Anderson Navigators  Community outreach to proactively target underserved

9 MetroHealth leadership in the community  Extensive community-based services through MetroHealth’s Center for Community Health  Extensive research on care delivery in underserved populations –Proven outcomes in the management of chronic disease –Center for Reducing Health Disparities $6 million NIH grant focused on hypertension and kidney disease Novel community-based research programs –Center for Health Care Research and Policy Robert Wood Johnson Foundation initiative  Full service specialty/ tertiary care medical center