Pharmacy Medication Adherence and Condition Monitoring Program © 2009 Pharmacy Solutions, LLC. All Rights Reserved. Rx MedAL Medication Adherence for Life

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, To provide hospitals, patients, practitioners, payers, and home health care professionals with products and services with a proven process to reduce health care cost and improve patient outcomes through condition monitoring and medication adherence in chronic disease.  Congestive Heart Failure  Diabetes Mellitus  Hypertension  Chronic Obstructive Pulmonary Disease (COPD)  Chronic Autoimmune Disorders (e.g. multiple sclerosis)

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, ADHERENCE FACTS:  The #1 problem in treating illness today is patients' failure to take prescription medications correctly, regardless of patient age.  32 million Americans are taking three or more medications daily.  Approximately 125,000 deaths occur annually in the United States because of non-adherence with cardiovascular medications.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, The Evidence:  Medication Adherence Rates are Low  Averaging only 50 – 65% The Result:  Symptoms and Complications Worsen  Utilization of Inpatient Medical Services Increases  Total Health Care Costs Increase

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, *US patients take less of their medication than is prescribed.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  A 2009 study 1 found that the cost of drug-related morbidity, including poor adherence (not taking medication as prescribed by doctors) and suboptimal prescribing, drug administration, and diagnosis, is estimated to be as much as $289 billion annually, about 13% of total health care expenditures. 1 New England Healthcare Institute, Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease (August 2009)

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, The barriers to medication adherence are many:  Cost  Side effects  Difficulty of managing multiple prescriptions  Patients’ acceptance and/or understanding of their disease, forgetfulness, cultural and belief systems  Imperfect drug regimens  Patients’ ability to navigate the health care system  Cognitive impairments, and  Reduced sense of urgency due to asymptomatic conditions.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Adherence Management System:  Patient in-home biometrics are saved to a database, with alerts and messages possible.  Biometric data can be transmitted to the patient, doctor or other locations with ease.  Medications are reviewed and evaluated for fulfillment and adherence with prescribed regimens.  Motivational Interviewing principles are applied:  Adherence intent is assessed and monitoring plans developed to achieve desired outcomes.  Patient feedback and adherence coaching is provided as appropriate.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  A secure online database collects relevant data and gives clinicians the ability to assess patient adherence by monitoring the plan of care for the patient.  Clinicians can access a condition scoring system, that provides a basic snapshot of the patient’s overall adherence.  Biometric data and adherence scores provide clinicians with an evaluation tool and a basis for motivational interviewing and intervention.  The web portal may be used to review patient care notes, biometric data, historical trends to assist in making adherence assessments.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  A condition scoring system has been developed for three major disease states and is adaptable to other chronic conditions: 1. Congestive Heart Failure 2. Diabetes Mellitus 3. Hypertension  The condition scoring system is an indicator of adherence and is used to target areas of concerns and for improvement within each disease state. o Numerical scoring based on the familiar grading system. This system is easily recognized and understood.  Motivational interviewing techniques are applied to improve scores and outcomes. o Increasing adherence scores are associated with increased cost savings and reduced hospitalization risk.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  The unique adherence scoring system is calculated based upon individual biometric data, patient responses, and medication history.  Each patient receives an individualized adherence plan targeted to achieve persistence and optimal outcomes.  These scores can be used to trend adherence over time for each patient and trend adherence over time for patient populations.  These trends are also compared against baselines and goals associated with optimal outcomes.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  As adherence scores increase health care costs and hospitalization risk decrease 1 1 Michael C. Sokol, MD, MS, Kimberly A. McGuigan, PhD, Robert R. Verbrugge, PhD,and Robert S. Epstein, MD, MS, Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost, Medical Care Volume 43, Number 6, June 2005

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  In another study 1 hospital re-admission rates for congestive heart failure patients dropped 57 percent through the use of wireless technology to monitor their weight and blood pressure. 1 MemorialCare Health System, Laguna Hills, CA,, A Study of Rehospitalization Rates for Congestive Heart Failure Patinents Receiving Remoted Patient Monitoring Technology, May, 2009.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  Glucometer  Heart Rate and Blood pressure cuff  Weight Scale  Pulse Oximeter  Fully integrated patient information systems and medication databases

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Patient takes real- time information using blue tooth devices Data is transmitted to the secure online database Feedback to patient, physician, case manager, caregiver

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Phase I – Patient Enrollment: Identification of patients with specific disease (e.g. Diabetes, CHF, hypertension) and program assignment. Identification from Pharmacy Data Provided or Post Discharge Information. IVR or Call Center Calls for Enrollment and Initial Coaching and Compliance Assessment. Phase II – Ongoing Patient Monitoring: Patient data and compliance scores are monitored according to the individual adherence plan assigned to the patient. Alerts, messages, and questionnaires are used to facilitate communication and direct appropriate actions or interventions. Based on the alert system, direct intervention is triggered by a adherence coach for further assessment and escalation as appropriate. Phase III – Feedback and Reinforcement: On a monthly basis, patients receive feedback and motivational interviewing based on the results of their adherence scores. Adherence Intent and motivational interviewing is used to recognize, reinforce, problem solve, and educate. Phase IV – Monthly Results Reporting: Adherence scores are tracked, trended, and reported. Hospitalization rates, home health visits, and other metrics are tracked.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  Adherence Assessment  Motivational Interviewing  Condition Monitoring  Improved Adherence  Customer Value  Optimal Patient Outcomes  Reduced Health Care Costs  Return on Investment

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Expected Adherence based on Program Results   Claims cost data   Hospital Admission/Re-admission Rates   Objective data and statistical reporting  Retention Rates   Program Evaluation and Patient Satisfaction  Documented Cost Savings through Improved Adherence

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Transition, Implementation, and Ongoing Monitoring  Admission and Data Interchange  Equipment Set-Up and Validation  Initial Adherence Coaching  Ongoing monitoring and intervention  Program Cost offset through Cost Savings

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Customer Value Improved Adherence Optimal Clinical Outcomes  Care Planning and Real Time Monitoring  Patient Coaching and Motivational Interviewing  Medication Adherence  Condition Monitoring  Reduced Costs from Improved Adherence and Outcomes  Reduced Hospital Readmissions } = ROI

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  There are approximately 5.3 million people suffering from congestive heart failure (CHF) in the United States.  The lifetime risk of developing heart failure at the age of 40 is 20%  Approximately 380,000 people above the age of 65 will be diagnosed with CHF annually

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  A great cause for concern has been the increasing number of patients being hospitalized with CHF.  The number of patients with CHF discharged from the hospital rose from 400,000 in 1979 to over 1 million in  Within 4-6 months after discharge 47% of the patients are likely to be readmitted.  The five year mortality rate for patients with CHF was 48% from

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  The estimated total of direct and indirect cost of heart failure in the United States for 2008 is $34.8 billion with the greatest share being hospitalizations.  In the commercially insured, Medicare and Medicaid populations, the single largest health expenditure is inpatient utilization (nearly 33% in 2005) with 13.3% of all emergency department visits associated with a hospital admission.  The average cost associated with a CHF hospitalization is $10,000.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  The estimated total of direct and indirect cost of heart failure in the United States for 2008 is $34.8 billion with the greatest share being hospitalizations.  In the commercially insured, Medicare and Medicaid populations, the single largest health expenditure is inpatient utilization (nearly 33% in 2005) with 13.3% of all emergency department visits associated with a hospital admission.  The average cost associated with a CHF hospitalization is $10,000.  Approximately 14% of Medicare beneficiaries have heart failure, they account for 43% of Medicare spending

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  Reduction in Re-Hospitalizations 1  Over a three month period realize up to a 57% decline in hospital re- admissions, or a 27% hospital admission rate for CHF.  Program Cost  $750 per patient, initial three months.  $150,000 per 200 patients.  Cost savings  Over a three month period, pre-program admission costs are $1,260,000 per 200 patients.  After enrollment in the program, the cost for total admissions is $540,000 per 200 patients  Resulting in cost savings of $636, MemorialCare Health System, Laguna Hills, CA,, A Study of Rehospitalization Rates for Congestive Heart Failure Patinents Receiving Remoted Patient Monitoring Technology, May, 2009.

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions,  Program Savings/Program Cost  ($636,000/$150,000)  $4.24 for every $1 invested Putting ROI into Context

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Complete Continuum of Care Patient Assessment and Training Condition Monitoring Motivational Interviewing and Adherence Coaching Optimal Patient Outcomes Reduced Health Care Costs Return on Investment

© 2009 Pharmacy Solutions, LLC. All Rights Reserved. Pharmacy Solutions, Next Steps ? Meeting to discuss and refine the demonstration project proposal in terms of:  Final study design and methodology  Presentation to Senior Management Teams  Identify and allocate resources  Develop business plan and proformas  Establish organization and work flows  Training and implementation  Patient selection  Program monitoring  Results reporting