1. Enhancing Care Management of the Chronically Ill Through Medication Management and Adherence Harry Leider, MD, MBA, FACPE Chief Medical Officer XLHealth and Care Improvement Plus

2. 2 Background on XLHealth Founded in 1998 as a DM company focused on diabetes Participated in BIPA and MHS CMS DM demos In 2006, launched a Chronic Care Special (C-SNP) Needs Plan pilot in Maryland –Traditional health plan structure, plus Part D, plus DM programs In 2007, withdrew from DM vendor business and launched Chronic Care Special Needs Plans in 6 states –65,000 seniors –All have either: heart failure, diabetes, COPD, ESRD We now have full financial risk for each member –Averages $15,000 per member

3. 3 Leveraging medication data and use is a critical part of our business 1.Our members average 6 chronic medications 2.Medication spending is over 18% of our total medical spend 3.Providing access to key meds is a important aspect of our health plan value proposition to seniors 4.Achieving adherence with key medications drives outcomes in our DM programs

4. 4 Objectives 1.To provide an overview of how chronic care plans can use medication “benefit design” to improve enrollment and DM outcomes 2.To examine how medication utilization data can be leveraged to improve DM outcomes 3.To examine new technology-based tools for improving medication adherence 4.Questions and Discussion!

5. 5 Plan Formulary Design: Our Concept of “Tier 5” drugs While we do have traditional co-pays in our Part D plan Our member have access to our “Tier 5 drugs” at zero cost through the “donut hole” Examples include: –Beta-blockers (brand), TZDs, spironolactone, nsulin, diuretics, ACE The objective: improve access and adherence A growing concern about shifting costs of drugs to patients and reducing access….

6. 6 The Value of Drug Utilization Data 1.To enhance patient identification 2.Basic risk stratification for DM Programs 3.More sophisticated predictive modeling 4.Targeting opportunities for care management

7. 7 The Value of Drug Utilization Data 1.Patient Identification/basic risk stratification for DM Programs Spironolactone: severe Heart Failure Oral Steroids in adults with COPD

8. 8 The Value of Drug Utilization Data 2.Basic Risk Stratification Principle: Patients with chronic illness who are not on key medications have an increased risk of hospitalization and death…..

9. 9 Medication Management in Diabetes: 7-Year Outcomes Adapted from Haffner SM, et al. N Engl J Med. 1998;339:229-234. Relative 25% 25% 20% 20% 15% Risk Diabetes + prior MI Diabetes w/o prior MI 45% 14% 6% 20% 0 10 20 30 40 50 No RxStatinHTNASAFibrate TZD Metformin Glucose Control CVD Mortality

10. 10 The “Quick Hits” in Diabetes ASA Lipids ACE/ARBs BP control Beta-blockers in patients with prior MI Glycemic control in patients with HgbA1C > 9 or 10*

11. 11 Is it all about “Better Living Through Chemistry?” What about changing lifestyle issues? These issues are important BUT are very hard to change! Getting patients to diet, lose weight, exercise, and stop smoking after MANY years of bad habits is very difficult! Strategy: –Focus first on the quick hits! (mostly medications) –Then work on lifestyle issues

12. 12 3.Medications and Predictive Modeling

13. 13 Archimedes TM : Predictive Model Based on 18 high quality diabetes outcomes studies Predicts 30 year risk of heart attacks, strokes, kidney failure, amputations, eye disease Model requires –Demographics information –Risk factors –Lifestyle issues –Some physical measurements (BP) –Some lab data (LDL, HDL, total cholesterol, alb/creat) –Meds for diabetes, hypertension, and hyperlipidemia You can change risk factors and see the impact on risk of a future outcome!!! www.diabetes.org/diabetesphd/default.jsp

14. 14 Patient Profile: Harry 2 74 y.o. black male, obese, Type II DM, hypertensive (not controlled), moderately elevated lipids

15. 15 Health History Risks in addition to demographics, BP, and Lipids

16. 16 Current Meds for DM, HTN, Lipids (insulin added to the model)

17. 17 Overview: 30 Yr. Risk of Major Health Outcomes

18. 18 Heart Attack risk (baseline): 45% over 10 years (on ACE already)

19. 19 Impact of Aggressive Lipid Management and Aspirin Risk over 10 years reduced from 45% you 25% !!!!

20. 20 Additional Impact of Control of Moderate Hypertension Minimal additional impact of control of moderate hypertension after ASA and lipid control

21. 21 Impact of Increased Glycemic Control MI risk decreased further from 25% to 20% over 10 years

22. 22 Impact of smoking cessation (after other risk factors modified) Risk of MI reduce >5% by smoking cessation even after lipid and HTN control, use of ASA and tight glycemic control

23. 23 Improving Adherence and Outcomes Medications are the most powerful interventions in many chronic conditions Two key drivers of outcomes –Putting patients on key drugs –Optimal levels of adherence Key barriers to adherence: –Patient’s can’t afford the medications –Failure to take the medications regularly

24. 24 Health Care Costs Negatively Impact Adherence

25. 25 Generics Can Reducing Drug Costs and Improve Adherence

26. 26 IVR Generic Switching Outreach End of Campaign Summary January 2008

27. 27 Goals  Encourage members to switch to a generic alternative/equivalent of the drug they have been prescribed Targets  XLHealth members who are currently taking either a cholesterol drug or PPI Generic Switching Outreach

28. 28 Generic Switching Outreach Outreach Process Overview  Confirm target member  Explain that there are low cost alternatives for current medications  Review specific savings with members who allow IVR to mention the name of drug they are taking  Review general savings with those members who do not allow the script to mention the names of the drug they are taking  Review the generic alternatives/equivalents for the drug the member is currently taking  Offer to transfer the member to a representative for more specific information regarding available savings

29. 29 Generic Switching Outreach Key Outcomes: Total Population: We received 16,105 records; 4.43% of records were scrubbed, leaving us with a Target Population of 15,391 members to reach out to. Targets Reached: We were able to reach 58% of target members. Typically, we see about 50% for a campaign with two rounds of outbound calls. Yes to Continue: Close to our benchmark of 75%, 70% of the target members reached asked to continue with this call, showing the great interest in hearing more information about savings Hang Up Rate: At 5%, as compared to our benchmark of 10% or less, we feel that this, once again, shows a strong member affinity towards XLHealth and Care Improvement Plus.

30. 30 ♦ Simple - used successfully by Seniors with 5 th Grade Education ♦ Manages 25 medications per patient and delivers education, questionnaires, behavioral prompts, reminders ♦ Branching logic captures critical health information ♦ Customized – Web-based individualized care plan ImforMedix Med-eMonitor

31. 31 Confidential and Proprietary XLHealth/InforMedix/ADT Workflow Process

32. 32 Confidential and Proprietary Remote Monitoring Process:

33. 33 Summary Medications play a critical role in a chronic care SNP (and in all DM programs) A specific opportunity in the C-SNP model is innovative benefit design to reduce co-pays and improve access “Driving” patients to generics is important to increase adherence and reduce costs Drug data can help identify and risk stratify patients for DM programs New technologies are showing promise for improving medication therapy and adherence

34. 34 Discussion and Questions?