1. Do You Know Your Numbers? National Governors Association Using Data, Technology, and Benefit Design to Manage State Employee and Retiree Health Programs Loews Madison Hotel, Washington, DC June 24, 2013

2. Why focus on obesity? Inconsistent long-term health care outcomes  Deaths and catastrophic claims resulting from surgery  Many who had the surgery regained weight Health care claims cost  Obesity-related conditions were 29% of FY 2010 claims dollars  Projected $12 million cost for obesity surgery in FY 2010  $750,000 catastrophic claim resulting from obesity surgery 6/24/2013 2

3. General Assembly Action Mandated coverage by Code of Virginia Proposed elimination of bariatric surgery coverage to 2010 General Assembly Objected to by bariatric surgeons Developed alternative in lieu of coverage elimination Included language in Appropriations Act to develop pre-gastric bypass surgery pilot program 6/24/2013 3

4. Pilot Program Goals Long-term, sustainable weight loss Improve outcomes  Reinforce lifestyle changes  Address behavioral health issues  Educate about risks and post- surgery requirements Offer options to deal with obesity before decision to have surgery Leverage learnings as appropriate 6/24/2013 4

5. Program Components Strictly enforced medical policy criteria - NIH guidelines 12-month coaching program prior to surgery  Weight  Behavioral health  Nutrition  Disease management 24 months of post-surgery follow-up  Weight coach with incentive for continued engagement 6/24/2013 5

6. 6 February 2010 to May 2013 Program Participation 341 members enrolled 232 members actively participated 109 members discontinued participation Reasons for disengagement  Commitment change  Eligibility change  Backed out after learning more  No longer wanted surgery  Length of program 6/24/2013

7. Program Engagement Engagement is key 60 days is turning point for engagement  Anger and resentment turn to acceptance and understanding  Level of engagement is an indicator of successful post-surgery outcome  Connection with coach is a primary motivator for staying on track After 75 days participation, there is positive correlation between length of engagement and decrease in participant’s BMI 6/24/2013 7 BMI change vs. length of engagement by surgery disposition and status with least squares regression and 95% CI in shade. (n = 78)

8. February 2010 to June 2012 Program Results Focus is on lifestyle changes necessary for post-surgery success 88% have demonstrated weight loss Weight loss is not a program requirement 6/24/2013 8 Condition Improvement Diabetes 50% Blood Pressure 46% High Cholesterol 15% 8

9. Program Satisfaction Survey Results 63 members participated in a post year-one satisfaction survey 6/24/2013 9

10. 10 COVA Care FY 2008 to FY 2013 Number of Patients Treated 6/24/2013  Rollout of the pilot program began in 2010  20% reduced number of patients in FY 2013 from FY 2008  93% reduced number of original surgeries in FY 2013 from FY 2008

11. 11 COVA Care FY 2008 to FY 2013 Medical Expense 6/24/2013  Rollout of the pilot program began in 2010  86% reduced expenses in FY 2013 from FY 2008 Medical Expense

12. DRGs 619 to 621- Inpatient Only - All Payers - CY 2010, 2011 Discharges Virginia Health Information 12 Collaborated with Bariatric Doctors Reduced complications by 3% V 6/24/2013

13. Comparison of Pilot to Control Group Future Metrics  Have pilot participants received more pre-surgery interventions to support weight management without surgery?  Are pilot participants better prepared?  Did pilot members have better clinical outcomes?  Did co-morbidities improve?  Are pre-surgical, surgical and post-surgical costs comparable to the control group?  Were costs lower for those individuals that still required surgery?  Did the additional spend by the Commonwealth for those pilot participants result in better outcomes for the members? 6/24/2013 13

14. Questions 6/24/2013 14