1. Ronald J. Shumacher, MD FACP CMD Chief Medical Officer, Optum Complex Population Management ©AAHCM

2. Ronald J Shumacher MD has the following financial relationship to disclose:  Employee of: Optum Services, Inc. ©AAHCM

4.  An average of 8+ conditions  An average of 10+ medications  Most members have both functional impairment plus chronic medical conditions  Frequent ambulatory visits, emergency room visits (3 plus/ year)  Require an extremely high level of care, attention and time  Do not regularly engage with doctor or look to payer for health support/ management 5% of the population drives 50% of the medical spend Stanton MW. The High Concentration of U.S. Health Care Expenditures. Research in Action, Issue 19. AHRQ Publication No. 06-0060, June 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html ©AAHCM

5.  Medically complex members frequently present with multiple chronic conditions, associated cognitive issues and psychosocial complications that render them high-risk  Multiple providers and medications produce disjointed, confusing and sometimes contraindicated care plans  Traditional in-office medical care delivery is insufficient — in time and quality — to establish the patient insight and relationship depth that medically complex members uniquely require  Under the current care delivery model, primary provider and specialist practices are not structured or equipped to provide the urgent, 24/7 response proven to be critical in preventing chronic illness escalation and exacerbation  The accompanying gaps in care — along with a common lack of patient adherence — leave members vulnerable to frequent escalations and exacerbation; these, in turn, devolve into excessive medical crises requiring ER visits, acute hospitalizations, readmissions and unnecessary medications ©AAHCM

6. Bridges gaps in care after discharge from hospital Readmission rates typically >17% for Medicare Advantage Readmissions often result from poor communication, non- compliance, etc. Transition program can reduce avoidable hospital readmissions by 30 – 45% Post-Acute Transitions Use predictive modeling to identify highest risk patients Longitudinal care and care management improves self- care and better manages triggers Care is coordinated with PCP Prevents avoidable ER visits and hospitalizations by 50 – 65% Chronic Care Management ©AAHCM

7.  Reduces overall health costs, including reduced hospitalization/re-hospitalization rates, emergency department (ED) visits and costs associated with end of life  Supports accurate diagnosis resulting in appropriate coding  risk adjusted payments and MA plan revenue  Supports quality metrics, including Star ratings and HEDIS  Guides patients into right care at right time  Improves quality of life and satisfaction  Decreases caregiver burden while retaining involvement  Enables home situation and safety assessment 7©AAHCM

8.  A house call program with 91 clients in a Nevada Social HMO produced a 62% reduction in hospital days and savings of $439,825 per year in acute, skilled and sub-acute days, with net savings of $261,225 1  A randomized controlled trial explored in- home, post-discharge care for the elderly showed 65% reduction in hospital days and 50% cost savings 2  One study of post-hospital care for high-risk CHF patients produced 50% reduction in rehospitalization when in-home, multidisciplinary program implemented 3 1 Phillips SL, et al. Chronic home care: a health plan’s experience. Annals LTC. 2004. 2 Naylor MD, et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA. 1999;281:613-620. 3 Rich MW, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333:1190-1195. 4 Costs and cost-effectiveness of home medical care. AAHCM. Accessed online: http://go.nationalpartnership.org/site/DocServer/Costs_and_Cost_effectiveness_of_home_medical_ care.pdf?docID=6850 http://go.nationalpartnership.org/site/DocServer/Costs_and_Cost_effectiveness_of_home_medical_ care.pdf?docID=6850 ©AAHCM

9. Months 9 Optum CarePlus outcomes study on dual skilled nursing population’s inpatient admissions compared to actuarial equivalent matched cohort (n=15,000 members), Jan. 2008 – Jul. 2008. Arizona health plan. Data compiled by Optum Data Analytics. ©AAHCM

10. 10 Markets Optum CarePlus outcomes study for high-risk Medicare Advantage health plan members (n=20,000 members), Jan. 2007– Dec. 2008. Florida Medicare Advantage health plan. Data compiled by Optum Data Analytics. ©AAHCM

11. Optum CarePlus outcomes study: cost of high-risk Medicare Advantage members (2+ chronic conditions and 1+ hospital admission) during the first six months of the program inception compared to the previous six months (n=35,000 members), Jan. 2009 – Dec. 2010. Alabama Medicare Advantage health plan. Data compiled by Optum Data Analytics. ©AAHCM

12. Optum CarePlus outcomes study: cost of high-risk Medicaid members (2+ chronic conditions and 2+ inpatient admissions) claims during the CarePlus program (n=20,000 members), Jan. 2008 – Dec. 2009. Tennessee health plan. Data compiled by Optum Data Analytics.

13. 13 Month 1Month 2Month 3 Month 4Month 5 Month 6 $ 4,000 $–$– $8,000 $12,000 $16,000 $ 20,000 $2,042 $2,662 $3,826 $4,323 $2,491 $2,172 $5,316 $3,142 $2,691 $3,400 $3,391 $5,412 $3,845 $7,449 $4,665 $11,037 $10,104 $17,559 All Medicare Medicare High Risk Home-care managed Outcomes study: cost of members during the last six months of life measured against both an actuarial equivalent cohort and the average medicare advantage costs in the Michigan and Alabama Medicare Advantage health plans (n=70,000 members; 35,000 members), Jan. 2010 – Aug. 2010. Data compiled by Optum Data Analytics.

14.  In-home visits have huge impact downstream on HEDIS/Stars and quality outcomes  Screening, tests, vaccinations, management of chronic conditions can all be influenced by home-based provider  Robust outcome studies not performed but many MA plans leveraging home provider visits to augment Star strategy ©AAHCM

15.  Patients highly satisfied with in-home medical care/perception of improved quality of life  High levels of provider satisfaction with home care delivery models  Enhances reputation for caring and compassion  Medicare Advantage Star ratings driven by CAHPS, HEDIS and HOS patient satisfaction survey measures ©AAHCM

16.  Address patients without visits  Must be based on face to face encounter with provider (physician, NP, or PA)  Must be documented in medical record  Requires monitor, evaluate, assess, or treat  At least annually  Highest level of specificity (training is critical)  Main reason for visit and coexisting conditions are documented  Much more effective than network based physician coding ©AAHCM

17. Ronald J Shumacher, MD FACP CMD Chief Medical Officer, Optum Complex Population Management rshumacher@optum.com ©AAHCM