1. Achieving the Lowest Overall Cost and the Most Engaged Consumers
NASCHIP
Andrew Krueger, MD, Accordant Medical Director
October 16, 2008

2. Accordant® Health Services Who We Are
Decade of Experience managing common and rare chronic conditions
28 conditions with full NCQA accreditation
URAC case management accreditation
CVS / Caremark – Parent Company
Industry-leading size, longevity, and expertise
Excellent financial stability, reliability
State-of-the-Art nurse call centers
Employ over 500 healthcare professionals
Dedicated Medical Director
Nurses Licensed in 50 States
Clinical Social Workers
Medical Advisory Board – Condition Specific
Serve more than 150 health plans and employers

3. Total Population Health Management
Engagement
Cost
Total Population Health Management
$6,000
$5,520+
$5,000
$4,000
$3,460
$3,039
Annual Health Care Cost PMPY
$3,000
$2,199
$2,000
$2,199
$2,199
Maintain
Improve
Manage
$1,000 $0
Well
At Risk
Chronic
Complex
We deliver the broadest, most frequent interaction with consumers, providing personalized coaching at each interaction to:
Reverse the migration from left to right
Best support those living with chronic/complex conditions
Add info about excess costs, also discuss groups.
Early identification and treatment of diabetes reduces progression by 60% and cost by 82%
Source: Derived from Eddington, AJHP 2001; 15(5):

4. Leading the Industry with 28 Conditions
Rare Chronic Programs:
Amyotrophic lateral
sclerosis (ALS)*
CIDP*
Crohn’s disease*
Cystic fibrosis*
Dermatomyositis*
Gaucher’s disease*
Hemophilia*
Lupus*
Multiple sclerosis*
Myasthenia gravis*
Parkinson's disease*
Polymyositis*
Rheumatoid arthritis*
Seizure disorders*
Scleroderma*
Sickle cell anemia*
Common Chronic Programs:
Asthma (adult)*
Asthma (pediatric)*
Chronic Obstructive Pulmonary Disease COPD*
Coronary artery disease*
Depression
Diabetes*
Heart failure*
Hypertension
Low Back Pain
Metabolic Syndrome
Migraine
Peptic ulcer disease
*22 full NCQA patient and provider accredited programs!

5. Managing Complex Conditions
Rare Disease Management

6. Rare Chronic Programs Amyotrophic lateral sclerosis (ALS)
Chronic Inflammatory demyelinating polyradiculoneuropathy (CIDP)
Crohn’s disease
Cystic fibrosis
Dermatomyositis
Gaucher’s disease
Hemophilia
Lupus
Multiple sclerosis (MS)
Myasthenia gravis
Parkinson's disease
Polymyositis
Rheumatoid arthritis
Seizure disorders
Scleroderma
Sickle cell anemia

7. The Unique Nature of Chronic, Complex, Progressive Conditions
Low prevalence, high average costs, and distinct disease-specific characteristics
Necessitates access to specialized expertise and support to prevent crises
Emphasis on member self-management
Includes wide range of complications requiring numerous and dynamic interventions
Inpatient hospital utilization represents largest cost component
High and increasing utilization of expensive specialty drugs
Conditions are progressive and, therefore, more expensive over time
Lack of disease-specific information and national medical guidelines

8. Accordant’s Medical Advisory Board
Strong academic backgrounds
Hold positions in patient foundations
Remain in “active” clinical practice versus isolated scientific research
Endorse population management
and its key principles…
High quality
Best cost
Serve as ongoing consultants
to nurses and physicians
A few words about our MAB. We have well known and well respected experts in specialties that support each and every one of our programs on both the common and rare sides. Our MAB plays a critical role in our processes throughout our DM offerings from development to day to day consultation. They practice their craft and hold appointments at well known universities and foundations. (Northwestern, Duke, Tufts, BI Deaconess, U of Az…) and are well known in their field.
Now let’s talk about some of the elements of program development.
The Medical Advisory Board plays a critical and central role with program development and ongoing support. We rely on their expert input to develop a disease profile. Our development staff gathers the best information available in the published peer reviewed literature ands that to the most current guidelines available from the germane organizations such ADA, AHA, GOLD, NHLBI etc… We ask our experts to review this info and help interpret it for the purposes of DM and focus on the most important elements. As the disease profile is being built we will need to be clear about the disease etiology, natural history, risks, clinical features, complications, treatment, and opportunities. Gathering, reviewing, and distilling the latest information results in a program that fundamentally evidence based and targeted at to address the most important aspects of care.
We also rely on the MAB on a day to day basis as cases come up that are confusing or complex or there may be a co-morbidity or problem that has arisen. For instance, as the nurse is talking with a participant and she/he finds out that the diabetes treatment is unusual she can reach out to a MAB for advise on what could be done. Another example might be an MS patient that has been on IVIG but not an ABC drug. Other examples include drug safety and drug interactions, these to will trigger a referral for opinion to a MAB.
I use them regularly as well for things such as to discuss drugs in the pipeline, or other treatment updates. I work with them on provider communications, I can have them available to providers to discuss individual cases or with health plans to discuss biotech drugs or benefit designs as necessary.
We meet with them regularly individually and as a group. We invite them onsite to meet staff and provide continuing education to staff.

9. Managing Chronic Conditions
Common Chronic Health Management

10. Common Chronic Programs
Asthma (adult)*
Asthma (pediatric)*
Chronic low back pain
Chronic obstructive pulmonary disease (COPD)*
Coronary artery disease*
Depression
Diabetes*
Heart failure*
Hypertension
Metabolic Syndrome
Migraine
Peptic ulcer disease
*Full NCQA Patient and Provider Accreditation

11. The Power of Pharmacy Data Pharmacy Event Calls
Goal is to provide early intervention to participants experiencing exacerbations or changes in their condition prior to their next scheduled call
Call is immediately scheduled upon receipt of certain prescriptions
Examples:
Regranex prescription (foot ulcer)
New nebulizer medication (adult & pediatric asthma)
New steroid inhaler (COPD)
New Insulin prescription for patients previously taking oral medications (diabetes)
Relevant education and support provided by nurse at a teachable moment

12. Outcomes & Reporting
Rare & Common DM Programs

13. The Depth And Breadth of A&O
Over 250 analytic and IT analytic resources dedicated to support CVS Caremark clients.
Over 40 analytic resources dedicated to the AHS and specialty health management suites.
Substantial analytical and clinical resources support ongoing research initiatives and leveraging our longitudinal experience.
Analytical support has led to key, actionable information as well as publications for peer-review.
Research objectives support clinically diverse and timely interests.

14. DMAA and Our Industry Collaborations with DMAA Industry Expectations
Participated in DMAA’s Outcomes project
Member of the DMAA Outcomes steering committee and workgroups
Risk Adjustments / Trends
Small Populations Analyses
Medication Adherence
Selection Criteria
Continuously evaluate new DMAA recommendations and modify as appropriate
Industry Expectations
Financial ROI alone does not represent the complete picture
Need to focus upon other metrics such as clinical, process and satisfaction
Need to focus upon overall health care trend impact

15. 2007 Book of Business Program Results: Common & Rare DM Programs
Source: Accordant data.

16. Data Source for Member Identification
Medical claims
Pharmacy claims
Health Risk Assessment questionnaire
Physician referral
Case manager referral
Disability referral
EAP referral
Self-referral

17. Measuring Clinical Effectiveness
Clinical indicators measured and tracked according to NCQA and other authorities
Utilization trends
Place of service cost drivers
PMPM trends
Quality of life scores
Satisfaction survey administered by external vendor

18. Stratification – Determining Risk and Devising a Course of Action
Registered nurse initial assessment
Member response to quality of life survey
Resource utilization survey
Disease symptoms
Functional status
Support systems
Education needs
Medication utilization including OTC
Co-morbidities

19. Predictive Modeling and Stratification
Predictive Model (PM) scores are run for entire eligible population using Symmetry Pharmacy Risk Group (PRG) score. Episode Treatment Group (ETG) to be implemented Q
For Common Chronic, the PM score is used in segmenting a population and also for stratifying a participant.
Segmenting Eligible Population
Stratifying At Risk Population
*PM Score + Utilization
*PM Score + Utilization
+ Clinical
+ QOL
40% - Low risk Level 2
50%
Minimal Risk
Level 1
50%
At Risk
30% - Moderate risk Level 3
30% - High risk Level 4
*Segmentation and Stratification scoring performed at a participant level

20. Comprehensive Reporting - Rare
Quarterly Activity Reports
Provides detail on program activity and enrollment
Quarterly Utilization and Clinical Reports
Provides a quarterly view of clinical performance and utilization trends
Participant Satisfaction
Provides results from annual participant satisfaction survey
Annual Reconciliation
Provides total savings, ROI, utilization analyses, and clinical performance measures
Ad Hoc Requests
As stipulated by the terms of the contract

21. Measuring Success Through Clinical Indicators - Rare
Multiple Sclerosis
% Experiencing Flares in Past Three Months
% Able to Repeat Warning Signs of Infection
% With Bladder Issues Where MD is Addressing
% With Stable EDSS
Parkinsons
% With Two or More Falls
% PD Reporting No Medicine Wear-Off
Rheumatoid Arthritis
Mean HAQ Score for Mbrs With Initial Score of At Least 7
% Reporting GI Disturbances
% Reporting Problems With Pain in Last Three Months
Sickle Cell Anemia
% With Aplastic Crisis in Past Three Months
% Aware of Need for Hydration
Scleroderma
% Able to Repeat BP Values
% With Well-Controlled Blood Pressure
Lupus
% Reporting Urinalysis in Past Six Months
% Able to Repeat Symptoms of Infections
ALS
% Comfortable with Feeding Tube Management
Cystic Fibrosis
% Performing Daily Airway Clearance
% Reporting Annual Blood Sugar Test
CIDP
% Maintaining Independence per Rankin Score
% With Two or More Falls
Myositis
% With EKG in Past Year
Gaucher
% With Bone Crisis in Past Three Months
Hemophilia
% Aware of Early Bleeding Symptoms
Myasthenia Gravis
% With Stable Respiratory Status
% Carrying AHS Medication List
Seizure Disorder
% Reporting A Seizure in Past Three Months

22. Rare: Sample MS Clinical Metric
Rationale: MS patients are at increased risk for infections and complication due to infections. Awareness of early signs of infection can assist with early, proactive clinical interventions to help avoid deterioration.
LOTIP: “Length of Time in Program” Response Measurement

23. Rare: Sample MG Clinical Metric
Rationale: Cost-driver analysis and clinical input reinforce that MG respiratory status is a component of the disease that is especially subject to deterioration and may be either a harbinger of impending crisis or the result of a crisis with a potential for a high cost IP admit. Early recognition of deterioration in respiratory status can assist with early, proactive clinical interventions to help avoid such deterioration.
LOTIP: “Length of Time in Program” Response Measurement

24. Rare: Average Change in Managed Per Member Per Month Costs
Based on AHS Book of Business Results
Decrease in Average Managed Costs of 9%
Approx. ½ attributable to decrease Inpatient & Emergency Room Utilization Costs
Tracked in Quarterly Reports (Plan-Specific as Compared to AHS Book of Business)

25. Rare: Average Change in Utilization Results for Managed Members
Based on Average of AHS Book of Business Results for Inpatient Admissions
Average 4% decrease from qtr to qtr
Approximately 20% decrease over 2 yrs for Managed Members
9% Decrease in Days/1000
Average LOS is 3.5 Days

26. Rare: 2007 Member Satisfaction

27. MCHA Specific Financial Results July 1, 2006 through June 31, 2007
Annualized gross savings per participant per year (PPPY) of $3,498 (16%)
Note: Trend rate of 10.50% applied to Baseline Cost PPPY to arrive at Trended Baseline Cost PPPY for Period 4.

28. Common Comprehensive Reporting
Our comprehensive reporting package provides quarterly participation rate and summary statistics
Annual
Data Source
Clinical indicators
Plan participant reported, medical and Rx claims
Quality of life
Plan participant reported
Plan participant satisfaction
Medical utilization
Medical claims
Direct medical costs
Reports
Activity/utilization, medical claims

29. AccordantCare™ Clinical Indicators/ Screenings /Vaccinations - Common
Wellness General Health Indicators
Smoking / Non-Smoking COPD
Exercise
Body Mass Index
Cholesterol / LDL
Blood Pressure
Flu/Pneumonia Vaccinations
Asthma Clinical Indicators
Written Action Plan
Appropriate Short-Acting Therapy (SABA)
Appropriate Maintenance Therapy (LABA)
Flu Vaccination
Cardiac Clinical Indicators
ACE-I/ARB Medication
Aspirin/Antiplatelet Medication
Beta-Blocker Medication
Blood Pressure Measurement
Diuretic Medication
Lipid Therapy
COPD Clinical Indicators
Action Plan
Appropriate Pharmacological Therapy
Flu/Pneumonia Vaccinations
Diabetes Clinical Indicators
Eye Exam
Foot Exam
Cholesterol Test
Lipid Therapy
HbA1c Test
Urine Protein Test
Blood Pressure Measurement
ACE-I/ARB Medication
Aspirin/Antiplatelet Medication
Sick Day Plan

30. Asthma Clinical Indicators 2007 Common Chronic Total Population
Source: 2007 Annual Outcomes Report for AccordantCare™ Common Chronic Population

31. CAD Clinical Indicators 2007 Common Chronic Total Population
Source: 2007 Annual Outcomes Report for AccordantCare™ Common Chronic Population

32. Diabetes Clinical Indicators 2007 Common Chronic Total Population
Source: 2007 Annual Outcomes Report for AccordantCare™ Common Chronic Population

33. Heart Failure Clinical Indicators 2007 Common Chronic Total Population
Source: 2007 Annual Outcomes Report for AccordantCare™ Common Chronic Population

34. General Health Indicators 2007 Common Chronic Total Population
Source: 2007 Annual Outcomes Report for AccordantCare™ Common Chronic Population

35. Changes in Rates Per 1000 Pre vs. Post Enrollment
Changes in Utilization Rates - Summary 2007 Common Chronic Total Population
Changes in Rates Per 1000 Pre vs. Post Enrollment
*Presenteeism questions not asked for Ulcer Program
Source: 2007 Annual Outcomes Report for AccordantCare™ Common Chronic Total Population

36. Common: 2007 Member Satisfaction

37. The Future of Disease Management

38. Accordant’s View of the Future of Disease Management
Healthcare continues to be impersonal, fragmented, inefficient, expensive, and often not consistent with evidence based care
Accordant’s DM can support all these problems
Improve satisfaction with healthcare leading to better compliance
Provider support
Science of behavior change
Health literacy
Adherence to complex treatments
Positive outcomes
Reduce healthcare costs