1. 1 1 Improving the Quality and Value of Health Care Friday, May 30, 2008 National Association of Insurance Commissioners Summer Meeting Health Innovations (B) Working Group San Francisco, CA Applying What Works Best A Health Plan’s View Steven Halpern, MD CIGNA HealthCare

2. 2 2 The Problems that Health Plans are Trying to Solve and the Solutions They Provide Problem: Fragmentation and under-delivery of evidence-based care in the health care system. Solution: – Disease and case management programs – Gaps in care programs Problem: Wide variation in the performance (quality and total costs of care) of providers and the lack of competition on value (quality and total costs). Solution: – Consumer information on provider quality and costs – Benefit incentives to seek high quality, low cost providers – Pay for value Problem: Lack of individual incentives for health and wellness. Solution: – Health risk appraisals and health coaching programs – Benefit designs that provide incentives for health lifestyles – e.g. Health risk appraisal participation, disease management participation, smoking cessation.

3. Case Management Centers of Excellence and High Performing Specialists Opportunity to mitigate cost exists through earlier intervention 15-20% of employees drive 65-70% of costs, but that segment of employees is different every year “A system that waits for disease and illness to occur can never be optimally effective. The logical strategy is to maintain people at the lowest or most appropriate level of health care use possible.” Dee Edington,Ph.D., Director, Health Management Resource Center, University of Michigan, as quoted in the Detroit News, April 2004. Proactive vs. Reactive Approach Can Change Medical Cost Trend $ Disease mgmt Lifestyle Modification Health Risk Assessments Biometric Screenings Wellness

4. 4 4 Disease Management Improving Outcomes and Driving Significant Savings Admission Rate Reduction Medical Cost Savings* Asthma Diabetes Cardiac Low Back Pulmonary (COPD) Total: 9.0% 8.0% 15.9% 20.3% 5.0% 12.6% 5.7% 8.7% 16.5% 17.3% 10.0% 11.0% Condition 7 – 12% improvement in clinical measures Behavioral screening identifies risk of depression in 37% of low back patients and 5-6% of diabetics and cardiac patients. 90% patient satisfaction across all plans 11% of medical cost savings for disease managed conditions. A 2004 study published in Health Affairs validates Well Aware diabetes program quality improvements and cost savings. * CIGNA BoB averages; actual customer experience will vary based on number of members with conditions and number of cases.

5. 5 5 What Provider Information is Available to CIGNA Members Nationwide Hospitals - nationwide, for 29 most common admissions – quality based on JCAHO, Leapfrog, CMS measures and risk-adjusted, all-payor, mortality and complication rates – Risk-adjusted total hospital costs per admission Physicians - nationwide, for 21 most common specialists – Quality based on NQF and/or AQA measures. Board certification and NCQA physician recognition – Total episode cost – ETG groupers High tech radiology – nationwide, price transparency for CT, MRI and PET scans Ambulatory procedures – nationwide, price transparency for 16 most common ambulatory care procedures Pharmacy – nationwide, price transparency for all CIGNA pharmacy drugs – both employer’s cost and member’s cost

6. 6 6 What is Provider Competition on Value (Quality and Total Cost of Care) Worth? Specialist physicians who are designated high value (approximately top one-third) consistently outperform average specialists – 4-5% improvement in clinical quality indicators – 29% reduction in re-admission rates – 8-12% lower total medical costs Hospitals designated as high value (Centers of Excellence), approximately top one third, consistently outperform average hospitals. – 30% fewer deaths – 28% fewer complications – 39% lower costs per admission

7. 7 7 Hospital Estimated Average Facility Cost Range Estimated Average Out Of Pocket Cost Range Virginia Hospital Center Arlington Patient outcomes: Cost efficiency: $5,994 - $10,995$4,199 - $4,700 Washington Adventist Hospital Patient outcomes: Cost efficiency: $10,995 - $15,997$4,700 - $5,200 George Washington University Hospital Patient outcomes: Cost efficiency: $17,199 - $23,269$5,320 - $5,927 Washington Hospital Center Patient outcomes: Cost efficiency: $5,994 - $10,995$4,199 - $4,700 Total Hip Replacement, 25 mile radius from zip code 20005

8. 8 8 Low Risk Medium Risk High Risk 53% 30% 17% Before Risk Reduction = Improved Health, Improved Productivity, Lower Cost Productivity Impact: +3.1% Absence Impact: -2.2 days per employee year Projected Medical Cost Savings $229 per employee per year Mills et al, American Journal of Health Promotion, September 2007 ; 22 : 45-53 Use of Health Risk Appraisals to Identify Early Risk Before Medical Claims and Health Coaching 63% 25% 12% After +10% -5%

9. 9 9 Results from Health Savings and Reimbursement Plans, Plus Disease Management, Provider Transparency, and Health Coaching Use of preventive care increased  First year visits increased  Second year visits remained higher than traditional Use of Evidence Based Medicine was similar to traditional plans Increase in use of maintenance medications that support chronic conditions Total medical cost trends were lower for both first year and second year CDHP members Member out-of-pocket costs were similar  First year members similar out-of-pocket costs  Second year CDHP out-of-pocket costs reduced for both HRA and HSA members

10. 10 Highlights 2005 vs. 2006 Findings: Health Reimbursement Accounts and Health Savings Accounts 20052006 Preventive Care Visits12% higher12% higher Evidence based medicine96%97% (% Same or better) First year medical savings16%12% Member cost share19%/16%13%/13% (Traditional vs. HRA/HSA)

11. 11 Barriers or Accelerators Barriers – Legislation or regulation that stifle transparency and disclosure of consumer health information – Legislation or regulation that caps MLR (medical loss ratio) that prevents health plans from performing added value services – Limitations to the ability to offer wellness incentives Accelerants – Comparative effectiveness legislations – Multi-stakeholder data aggregation and profiling efforts – Health information exchange within HIPAA’s privacy and security protections – A pathway for generic biologics and specialty drugs – Initiatives to encourage value-based purchasing within public payors

12. 12 Discussion