1. The Role of the Disease Management/Chronic Care Industry in Health Reform

2. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 2 Redefining the topic Value, not role − What have we learned and how will these learnings add value to any reform plan ? Population Health Improvement, not disease management − How has disease management evolved, and what is the current “state of the art” ? Infrastructure, not industry − How can the knowledge, systems, technology, and experience developed over the last 20 years be applied to new models and delivery systems?

3. The Role Value of the Disease Management/Chronic Care Industry Population Health Improvement Strategy and Infrastructure in Health Reform

4. The Value of the Population Health Improvement Strategy and Infrastructure in Health Reform Patrick Mattingly MD September 23 2008

5. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 5 The challenges of health reform A successful reform scenario will likely include: Financing reform that supports universal coverage Payment reform that aligns incentives Delivery system reforms that change behavior of providers and consumers Expect reform to be incremental, but with an “end-game” that will require: change in behavior, and medical cost savings,while improving quality and not compromising choice. A population health improvement strategy and supporting infra- structure is essential to success of any comprehensive reform plan

6. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 6 Population Health Improvement Includes whole population, whole person, across full continuum from healthy to complex chronic illness Integrates activities of disease management, care coordination, case management –i.e. all components of “care management” or “health support” services

7. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 7 Whole person, whole population support Analytic Support: Population and patient database Chronic Conditions Preference Sensitive Conditions prostate, arthritis, back, etc Healthy Living Urgent Conditions Complex Care Whole Person Behavior Change Support

8. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 8 Population Health Improvement Includes whole population, whole person, across full continuum from healthy to complex chronic illness Integrates activities of disease management, care coordination, case management –i.e. all components of “care management or “health support services Supports primary care physician directed medical care plan and medical care coordination Stresses prevention at all levels; education and self-care ; consumer responsibility and behavior change Addresses economic, social, cultural and environmental obstacles to quality efficient care, factors which are major contributors to health disparities and health literacy issues Utilizes comprehensive population data analysis to identify best opportunities for improvement Population Health Improvement strategy is agnostic as to who funds or provides these services; but it does require patient-centered integration and coordination; and accountability for outcomes

9. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 9 Support Infrastructure Multi-channel communication processes and systems Information technology and systems Consumer marketing expertise Population analytics and data management Outcomes measurement Behavioral change methodologies Training and development, particularly for personal care managers 24/7 personal telephonic support at scale Etc, etc.. Providers of current population health programs should be thinking more broadly about how the infrastructure they have built can support future “reformed” delivery system. Their business models and organizational relationships may need to change.

10. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 10 The value opportunity in health reform Improving quality Supporting consumers Reducing medical cost trends Almost all organizations responsible for quality and cost of health services (i.e. health plans, employers, providers, governments, pharmacy benefit managers etc.) have determined that health support services provide significant value to their members. In a “reformed” health care system, there will be significant opportunity to translate the learnings from these successful experiences into more diverse, broader and deeper applications

11. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 11 Improving quality Improving adherence to evidence-based standards - particular emphasis on medical care plan and medication adherence - targeted outreach marketing expertise to close gaps in care Supporting community-based prevention and public health campaigns - broader screening, immunization and other preventive measures - reform agenda: major lifestyle risks (obesity, depression, hypertension) - mass customization and segmentation techniques Enabling improved access and efficiency in delivery system - timely acute care access and communication between providers and patients - providing critical information feedback to both consumers and providers Both published studies and market experience document significant impact on quality processes and outcomes in almost all settings and populations. Reform will expand the quality agenda to include new measures, such as access and efficiency, and population health metrics

12. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 12 Supporting consumers Behavior change − lifestyle and healthy activities, preventive tests and treatments − accessing and using information, making choices − self management and adherence to medical care plans − teaching and transferring skills to improve chronic care Navigating the health care system − information, guidance and advocacy with both old/new rules and systems Health literacy and disparities − mitigating economic, cultural, racial, language and psychosocial barriers Solid track record of engaging, informing and activating consumers in the current fragmented system. Reform will bring new consumers, many with greater issues around health literacy and other socio-cultural barriers that contribute to disparities in care processes and outcomes

13. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 13 Effective Care : “Proven effectiveness, no significant trade-offs” Beta blocker use among patients post heart attack varies from 5% - 92%, when it should be ~100% Preference-Sensitive Care : “Involves trade-offs, (at least) two valid alternative treatments are available” In Southern California, a patient is 6 times more likely to have back surgery for a herniated disk than in New York City Supply Sensitive Care : “If they build it you will come” Per-capita spending per Medicare enrollee in Miami, FL is almost 2.5 times as great as in Minneapolis, MN Reducing medical cost trend Unwarranted Variation Framework

14. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 14 Proportion of health care costs attributed to the three categories of unwarranted variation Preference Sensitive Care Effective Care Supply Sensitive Care Reducing medical cost trend

15. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 15 Reducing medical cost trend Comparative effectiveness − putting evidence-based research into practice using shared decision-making Primary care transformation and practice efficiency − incorporating population health interventions in the “medical home” Care efficiency and coordination − preventing hospitalization and re-admissions − intensive ambulatory care programs Reform planners will look for savings to fund universal coverage. Preponderance of evidence suggests that integrated population-based programs that effectively target key opportunities can achieve this. Published/experimental studies have been equivocal; actuarial and non-experimental measurements continue to show savings against trend. Recent unpublished studies document savings opportunity

16. Copyright © Health Dialog Services Corporation 2008. All rights reserved. 16 Summary Disease management has evolved into a more integrated comprehensive population based service, supported by a highly developed infrastructure This population health approach and infrastructure are critical to meet the critical challenge of reform - improving quality, reducing cost while supporting consumers and preserving choice Health plans and other organizations accountable for providing value to purchasers are convinced of this value proposition, and as financing, payment and accountability changes, these services need to continue to evolve pmattingly@healthdialog.com