2. Pilgrimage Healthcare Patients Deserve More Options…

3. Integrated Delivery Network of Five Not-for-Profit Hospitals 15 Out-patient Centers 1.6 Million yearly patient encounters $1.7 Billion yearly revenue 12,000 Employees 600 Employed Providers 2,000 Physician Medical Staff 1,857 Licensed Beds 60,000 Admissions/year Norton Healthcare

6. Who is Accountable for Care? Autonomy versus Paternalism “Flu Shot”

7. ACO Current State Accountability is an Action… Not an Organization ACA has pushed organizations to compete on quality and price rather than fee-for-service. Currently 5% of Medicare Beneficiaries in an “ACO” 89 initial CMS approved ACOs – only five with both upside and downside risk

8. ACCOUNTABLE CARE ORGANIZATION Manage population health Patient attribution Community outreach Training and education Behavior and change management Segmentation and risk factor capabilities Marketing Cost and Efficiencies Effective Health Management Coordinate Items and Services Manage to Quality Standards Manage Costs and Efficiencies Manage to Quality Standards Coordinate Items and Services Components of an ACO Quality management (definition by population, not event or episode-driven) Quality standards reporting Disease management Data management and analytics Business intelligence management of clinical, operational and financial data Effective Health Management Risk management Finance and accounting Disease management Measurement of clinical, operational and financial key performance indicators Preventive care Medical management Telemedicine Funding administration Supply chain Participation in Health Information Exchanges (HIEs) Employers Patients Hospitals Acute, sub-acute and long- term care providers Ambulatory care centers Pharmaceutical companies Medical device manufacturers Care Givers (physicians, nurses, home health, clinical social worker, clinical psychologist, and other ancillary providers) Payors Federal government The Players Used with Permission KPMG HEALTHCARE

9. Initiated as part of Brookings – Dartmouth Commercial Pilot in 2009 Future plans for other manage care providers as model develops. Patient population – 1.24 million in community Current included groups: NHC employees/Humana employees – 10,000 Approximately 300 physicians included —Primary Care and Specialists Consideration to expand into other reimbursement partnerships —Bundled Payment —Shared Risk (smaller employers) Journey for Accountable Care

10. Strategy for Success Accountability is an Action Manage the Patient Through the Care Continuum Patient and Community Engagement and Accountability Transparency Data Infrastructure Management and EMR Patient, Provider, Payer, and Employer Partnerships Change is Hard Decrease Variation – Increase Personalization

11. Learning Improving Predicting Evolution of Analytics WHAT happened? WHY it happened? WHAT WILL happen and WHEN?

14. Year 1 Financial Data Norton Year 21.7% Reduction below target PMPM Humana Year 214.9% Reduction below target PMPM Norton Healthcare – Humana Accountability Pilot Clinical Results: Aggregated Commercial ACO-Utilization/Quality/Overuse Metrics Inpatient days/1000Down 29% ER visits/1000Down 46% Physician visit within 7 days dischargeUp 14.6% Diabetes A1c testingUp 6.1% Cholesterol Management - DiabetesUp 8.6% Appropriate Imaging – Low Back PainUp 13.9% Avoidance of Antibiotics w/Acute BronchitisUp 32%

15. Norton Healthcare Accountability Pilot 15 Dartmouth – Brookings ACO PilotPerformance Measurement Quality Measure (for all, higher %s represent better performance) 2009 HEDIS PPO Norton Baseline Norton Year 1 Change Diabetes – A1c Management (testing) 83.3%87.7%93.4%5.6% Diabetes – Cholesterol Management (testing) 78.6%83.9%91.8%7.9% Use of Appropriate Medications for People with Asthma 92.8%96.2%82.8%-13.4% Cholesterol Management for Patient with Cardiovascular Conditions (testing) 80.2%88.9%89.5%0.6% Use of Imaging Studies for Low Back Pain 72.7%65.2%56.3%-8.8% Avoidance of Antibiotic Treatment for Adults with Bronchitis 22.6%12.2%16.7%4.5% Persistence of Beta Blocker Treatment After Heart Attack 69.6% Cervical Cancer Screening 74.6%77.9%78.2%0.3% Breast Cancer Screening 67.1%79.9%81.6%1.7% Annual Monitoring for Patients on Persistent Medications 77.0%83.7%88.6%4.9% Too few eligible cases.

16. Anti-Infective Purchasing/QTR/Patient Day

17. Total Joint Replacement (Per Case) Absolute Impact% Impact Direct Variable Cost($665)-8.0% Length of Stay(0.27)-9.5% COPD Initiative (Per Case) Absolute Impact% Impact Direct Variable Cost($400)-13.1% Length of Stay(0.37)-7.5% CHF Initiative (Per Case) Absolute Impact% Impact Direct Variable Cost($243)-6.8% Length of Stay(0.01)-0.2% Clinical Effectiveness ESRD Initiative (Per Case) Absolute Impact% Impact Direct Variable Cost($1094)-9.4% Length of Stay(0.75)-8.7%

18. The Future of Clinical Re-Engineering Improved care coordination and communication Improved access – physician extenders – email – phone call etc. Prevention and early diagnosis ED and Immediate Care Center visits Increase generic medication utilization Hospital re-admissions and multiple ED visits Improved management of complex patients – Manage the Top 100 – Care Coordination and High Resource Utilizers

19. Evidence or Bias?

20. Disruptive Innovation Future of Healthcare

21. Think Differently – Treat Differently Future of Healthcare *The Volume-To-Value Revolution. Oliver Wyman

22. Resource Management

23. Questions Steve.Hester@NortonHealthcare.org