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REDESIGNING CARE FOR THOSE WHO NEED IT MOST…

Our Mission

To address the complex problems of aging while protecting the precious financial resources of our members and the federal government.

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Las Vegas

3,852

Tucson8,682

Nevada

Arizona

San Jose3,425

Modesto3,828

San Bernardino3,328

LA/OC38,035

A Deployable Model Wrapped in Health Plan

Our Markets

Riverside875

Phoenix3,849

Source: Management estimates for membership for the year ending 12/31/11

California

CONFIDENTIAL MATERIAL

Virginia

Richmond

2013 Expansion

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Our Philosophy of Health Care Older patients require overtly coordinated care with a care path that takes into account their multiple conditions and treats them simultaneously A physical and human locus of care is required to create care coordination and a setting where care habits of patients can be sustained. Clinicians in key roles must be confident generalists, persistent and deliberate, with competence as clinical decision makers, communicators and team players. All providers of service have a buy-in for the system of care, not just their individual capabilities. A complete care continuum requires equal attention to medical, social, psychological and pharmacological needs of the patient. An explicit approach to care is required for each chronic condition, for high-frequency acute episodes, and for end-of-life. An obsessive attention to detail in both micro matters (individual care) and macro matters (care programs) permits optimal outcomes A willingness to thoughtfully challenge the status quo provides windows of insight into clinical innovation and care pattern redesign which can optimize patient health and comfort, and conserve financial resources.

Challenging the Status Quo Health care systems should be about improving quality, not maintaining it At least 35% of health care costs for the chronically ill can be avoided Prepayment (Capitation) is freedom, not risk Primary Care is a “team sport” not an “individual sport” For aging adults, Primary Care should be an outbound activity, not an inbound

activity A high percentage of physician services can be provided by non-physician

clinicians Benefit design should lead with patient access and compliance considerations,

not actuarial risk considerations Patient compliance is more our problem than the patient’s We have a responsibility for the financial well-being of our physician and

hospital partners Many patients fare better with less complex health care interventions

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The CareMore Model

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Healthcare cost and quality problems are concentrated….not widespread

Healthy Stable Sick Sickestmostly 1 + Chronic Illness mostly 3 + Chronic Illness

Progressive Illness2010 MedicareSpending Projection = $522 B46 Million BeneficiariesSpending Per Beneficiary = $11,347

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

Annu

al Co

st/Be

nefic

iary 23 Million Beneficiaries

- Spending $1,130 each- Total Spending = 5%

($26 B)

16.1 Million Beneficiaries- Spending $6,150 each- Total Spending = 20%

($104 B)

7 Million Beneficiaries- Spending $55,000 each- Total Spending = 75%

($391 B)

AverageSpending

CHF, DM

85% of Beneficiaries = 25% Spending 15% of Beneficiaries = 75% Spending

ESRD, CANCER

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Non-Frail Population

CareMore’s system functions in parallel with community physicians

Primary Care

Physicians

Extensivists

Member Services

Continuous Frailty Assessment Tools

Provider Relations

CareMore Care

Centers

CareMoreExtensivist

CareMore Care

Centers

Home Based

ServicesSpecialists

Case Managers

Primary Care Physicians

Close monitoring of non-frail members to proactively identify at-risk members and aggressive management of chronic conditions to prolong the onset of frailty

Intensive management of frail and chronically ill members, identified through predictive models, data scans, PCP referrals or member self-identification

Frail & Chronically Ill Population

The essentials of CareMore’s model

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Chronic Care Management

Acute CareManagement

Predictive Modeling & Early

Intervention

Redefining Primary Care

Operating Principles Clinical Control - CareMore extensivists

determine when a patient requires proprietary services and programs

Speedy Deployment - Proprietary services and programs can be deployed within minutes

Efficient Allocation of Clinical Resources - The model replaces physician labor with skilled, allied health professionals such as NPs, MAs, therapists and dieticians

Early Intervention - Proprietary resources and predictive modeling allow for early intervention to prevent acute episodes

Secondary Prevention

Redefined Acute Care Episode

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CareMore solution – new model of care

Predictivemodeling

Integrated IT infrastructure

Longitudinal patient record

Point-of-care decision support

Evidence-based protocols

Extensivist Manageme

nt Strength Training

Fall

Coumadin

Exercise

Foot care

Nutritionist

Monitoring

Diabetes

ESRD

COPDCAD

CHF

Palliative Care

Hospice

Mental Health

Social Workers

Pre-Op

Case Manager/

NP

Extensivist

ClinicalCare Centers

(CCC)

PCPEnd of Life Care

Social / Behavioral

Support

Secondary Prevention

Risk Event Prevention

Chronic Disease Support

Frailty Support

Healthy Start

Wound Clinic

Results of the CareMore Model

Primary care physician value proposition

CareMore programs provide the PCP with resources that enable better clinical care

Medical Home (CCC) Chronic programs Preventive care programs

Technology Communications tools

Increase PCP Compensation

Medicare FFS pays the PCP $67 per visit (CPT code 99213) -- an average of $480 patient / year (assuming 7.2 patient visits a year)

CareMore guarantees the PCP $480 ($40 PMPM) but visits are only 4.5 per year and we pay $107 per visit

Increases PCP Schedule Capacity

Better Patient Care

CareMore clinicians and programs relieve PCPs of their most complex chronically ill and frail patients

Increases PCP capacity by 20% to 30% -- can add more patients to increase pay

More resources used to support the PCP funded by CareMore prepayment

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Unique PCP value proposition has served CareMore well in new markets

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The CareMore model produces dramatically improved outcomes for several costly chronic diseases and conditions

Many patients with out-of-control diabetes were not brought in control through insulin use. Common wisdom was that inability to correctly self administer or improper dosing were driving results. Further, insufficient support in the areas of nutrition and exercise were observed

Established insulin “starts” and insulin “camps”. At the “start” day, patient is trained in all aspects of self-administration of insulin. At “camps”, patients are brought to the center for a full day to observe all of their behaviors and monitor glucose levels at all points of self care. A personal nutrition counselor was assigned

Average HbA1c for those attending our diabetic clinic is 7.08, with 7.0 being considered good control. Patients in the clinic are referred for poor control

50% reduction in hospital admission rate in 5 months42% fewer admissions than the national average

Established a dedicated case manager and nurse-practitioner who receive referrals from centers in lieu of ER referral. Primary/preventive care is provided and all patients are in the diabetic management program, receiving monthly preventive access line inspection and, if needed, cleaning

Half of all ESRD Admissions were the result of either poor hygiene, poor diabetic control or vascular access limits/clogs. Dialysis centers provided no primary care and patients were referred to the ER. Most ER visits resulted in an admission

56% reduction in hospital admission rate in 3 months

Equip each patient with a wireless scale that sets off alerts if weight gain is 3 lbs overnight or 1 lb per day for more than 3 days. Same-day visit with clinician if alert is triggered. Proactive hospice planning with changes in condition

PCPs were not collecting daily weights, a leading indicator of change of condition. Self-reported weights were inaccurate. PCPs were not adequately responsive to immediate care needs of patients who require intervention within a few hours of onset of symptoms

Diabetes ESRD CHF

Status quo Status quo Status quo

CareMore Redesign CareMore Redesign CareMore Redesign

Result Result Result

The CareMore model produces dramatically improved outcomes for several costly chronic diseases and conditions (cont’d)

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70% of hypertensive patients do not have adequate blood pressure control. This leads to increased stroke (and other cardiovascular) risk. Blood pressures checked in PCP offices frequently are inaccurate.

Equipped patients with labile HTN with wireless blood pressure cuff. CareMore NPs monitor blood pressure & make appropriate changes according to JNC guideline.

• 48% of patients had >10mmHgs drop in blood pressure

• Patients with SBP>160 or higher had average SBP drop of 23 mmHg

• Patients with SBP b/n 150-160 had average SBP drop of 19mmHg

Diabetic amputation rate for CareMore members is 60% lower than the national average.

Designed a wound clinic, staffed with wound-certified CareMore NPs.

PCPs have inadequate time/resources to deal with diabetic wounds, which results in specialty (surgical) referrals that delay treatment, increases cost and increases chance of amputations.

Early diagnosis and then intervention at CareMore’s mental health centers(19% of screened)

All new CareMore members receive a comprehensive health exam that includes PHQ-9 & dementia screen.

Depression is a underdiagnosed problem in seniors. Underdiagnosed depression leads to a variety of health problems and costs including ER visits & unnecessary tests.

System Failure System Failure System Failure

Result Result Result

CareMore RedesignCareMore Redesign CareMore Redesign

Stroke Prevention Amputations Depression

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Inactivity and some staffing issues (one monthly visit/60 days), lack of primary care in facilities resulted in wound development or exacerbation (for example bed sores)

Deployed nurse practitioner teams to nursing homes weekly to proactively tend to skin or create early intervention in patients likely to develop wounds

The CareMore model produces dramatically improved clinical outcomes for several costly chronic diseases and conditions (cont’d)

CareMore sends a nurse practitioner to the nursing home once a week to keep patients stabilized. If an acute event emerges, an NP is available 24x7 for telephonic consultation and in-person visits if needed

Patients in institutional settings were being hospitalized at a rate of 5x the general populations for untreatable conditions, largely because nursing homes do not have skilled clinical staff to make timely interventions

CareMore assembled a team of clinical social workers, mental health professionals, lawyers, physicians and NPs who assume a home-based multi-disciplinary care approach for these patients

A small fraction of the Medicare population are hospitalized >10 times per year because of lack of home-based or social support resulting in falls, malnutrition, dehydration. Most live alone and suffer from dementia or other mental illnesses

Wounds Institutional CIT1

Status quo Status quo Status quo

CareMore Redesign CareMore Redesign CareMore Redesign

The usual rate per year for development of pressure ulcers for nursing home patients in California is 13% Only 4% of CareMore’s institutionalized patients developed pressure ulcers

Preventive intervention resulted in reduction in bedsores and reduction in falls. Hospital admission rates are 80% less than national norms

Reduced hospital and SNF admissions by 60%. Resulted in placement rate of >30% for participants

Result Result Result

1 CareMore Intervention Team, which includes the Company’s expert team of providers

Sharing the CareMore Model

PCP Capitation

Variable-Cost BasedHospital per Diem

All else actual cost

Physician Services

Hospital Services

Market Branding

MA License & Marketing

Chronic Care Infrastructure

Existing Membership

Presbyterian Community Hospital (Whittier CA) Experiment

Results sharing with hospital and physicians

10-Year Contract

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Lowest Medicare Variable CostReduction in Surgical ComplicationLowest rate of Death-in-Hospital

4% better readmission rate7 minute response-time

Joint Steering Committee

CareMore Supplies the Architecture to Succeed in Risk Based Environment

Creates Primary Care Capacity

Enables Primary Care Profitability

Improves clinical outcomes in chronic care management

Improves hospital quality

Lowers hospital variable costs

Embraces transition to risk-based payments

Supports Evidence-based documentation

Partnering, Sharing the CareMore Model

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CareMore

CareMore Inside

CareMore Essentials

• Transference of care delivery competency

• Provide enabling infrastructure

• Share in HCC savings

• Direct care delivery• High risk populations• HCC savings accrue to

client• Fee-based structure

Patient Care

Disease Mgmt

Data Integrati

on

Clinical Protocols

Risk Coding

Analytics

Reporting

Payment Models

Case Mgmt

Predictive

Modeling

Quality Initiative

s

Training

Realizing Value From Your Integration Journey• Vision of Improving the Health of Your Communities• Proactive and Targeted Population Health Initiatives• Turning a Health Improvement into an Accretive Event• Seeing Capitation as Freedom, Not Just Risk• Imagine a Delivery System that Creates Value From:• Better Management of Chronic Conditions• Better Quality of Life for Your Frail Aged Community• Better/Safer Care• Rethinking How You Measure Market Share• % of Volume?• % of Population Under Your Care?

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