1. © 2003 Mercer Human Resource Consulting Arnie Milstein, MD, MPH Pacific Business Group on Health Mercer Human Resource Consulting Disease Management in Transition: Benefit Plan Purchasers Awaken May 13, 2003

2. 1 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Process Perfection Performance Assessment: (Results) Performance Assessment: (Best Practices) Purchasing of Activity Customer Understanding Vocabulary Enrootment Benefits Management Innovation Cycle: Chronicling Disease Management Labeling 1985 ~ 1990 ~ 2010 ~ 2002 ~ 1995 ~ 2000 ~ 2005 & 2015

3. 2 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Disease Management Lineage Second wave of re-thinking health care Catalyzed by Breslow observation that health outcomes primarily determined by patient behavior and patient environment Most MDs and hospitals do not yet feel responsible for these two determinants Initially delivered by separate “backstage providers,” but next equilibrium is unpredictable

4. 3 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Today’s Benchmark “Backstage” Providers Health promotion Major behavioral risk reduction Minor illness coaching Disease and case management Major decision support Utilization review and case management Hospitalists Managed Rx

5. 4 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Important Distinguishing Characteristics for all Backstage Providers Integration with frontstage providers Psychological mindedness Focus on manageability of elevated risk Use of statistical process control

6. 5 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Prior to Process Perfection Early Impact on Care Costs is Variable Estimated Percentage Point Premium Reduction 1. Health Promotion0.1%1.7%5.2% Low Performance Middle Performance High Performance 2. Behavioral Risk Reduction-1.0%0.7%3.4% 3. Self-care / triage-0.1%0.2%1.2% 6. Decision-support0.1%0.4%1.0% 4. DM — major event prevention-0.1%0.2%0.8% 5. DM — ongoing symptom mgmt-0.1%-0.0%0.2% Total-0.3%5.2%16.3% 7. UM / Case Management0.0%0.4%1.4% 8. Hospitalists0.8%1.6%3.1%

7. 6 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting The Pivotal 2002-2006 Period Purchasers and consumers in financial pain IOM blows whistle on care discontinuities and “quality chasm” Herd leading purchasers, awaken and set new course

8. 7 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Continued tepid incrementalism Exhortation of professionals Government as purchaser or regulator Boost market sensitivity to plan performance Boost market sensitivity to performance of providers and treatments Options For Chasm Crossing

9. 8 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Gear consumer decision support and incentives to drive selection of better-performing providers, including “backstage providers,” and treatments (AKA “Consumerism”) Expand performance-based provider payment via gain-share when performance improvement hurts all providers’ margins (P4P) Boost Market Sensitivity to Performance of Providers & Treatments

10. 9 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Performance Disclosure: The Critical Path from Disclosure to Performance Breakthrough Performance comparisons for providers & Tx  Market sensitivity to performance Clinical re- engineering by providers Q 50 ppts $ 40 ppts Value of Health Benefits Key Evolutionary Steps High Low 2002 2012 Performance Disclosure Consumerism & P4P Chasm Crossing Americans

11. 10 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting CARE SYSTEM RE-ENGINEERING IMPERATIVES Redesigned care processes Effective use of information technologies Knowledge and skills management Development of effective teams Coordination of care across patient conditions, services, and settings over time Use of performance and outcome measurement for continuous quality improvement and accountability CARE SYSTEM Supportive market environment Safe Effective Efficient Personalized Timely Equitable 1 Adapted from Crossing the Quality Chasm, IOM, 2001. Organizations that facilitate the work of patient- centered teams High performing patient-centered teams EMPLOYERSOUTCOMES GOVT & PLANS The National Academy of Science’s More Detailed Map

12. 11 Pacific Business Group on Health© 2003 Mercer Human Resource Consulting Closing Thoughts on Disease Management and Chasm-Crossing The question is how soon, not whether Poverty of ambition is the enemy Economic downturns permit bolder strokes Performance breakthrough requires leadership