1. Tariq Abu-Jaber, MA, MPH, Staff VP Clinical Informatics, EIM, WellPoint, Inc. Praveen Soti, MD, MBA, Principal, Healthcare Consulting, Infosys Technologies Enterprise Data Management as a Health Plan Quality Improvement Strategy The Quality Colloquium, Harvard University August 21, 2007

2. 2 Data Management to Improve Care Quality Thesis: Enterprise Data Management Enables Integrated Care Coordination Across Products, Time and Services, Leading to Better Quality of Care and Therefore Health Outcomes Value Proposition Industry Experience Measuring Outcomes Implementation Challenges Recommendations

3. Value Proposition

4. 4 Value Proposition for Data Integration For Health Plans … For Groups/Members … “Direct” Improvements Medical, pharmacy and specialty cost reduction Coordinated prevention, diagnosis and treatment of conditions “Indirect” Benefits Absenteeism, disability, family med leave, worker’s comp, “presenteeism” Intangible (pain, psychosocial costs, etc.) Note: Productivity Costs usually 1- 3x Direct Medical Costs Revenue & Membership Growth Increased penetration through integrated medical, behavioral health, specialty and clinical programs Lower cost of care Industry Leadership Meets customer needs to manage overall expense Sets improved standard for quality of care

5. Industry Experience

6. 6 Cost of Care From: “Steps to a Healthier US Workforce”, Goetzel R., NIOSH background paper, 2004

7. 7 Integration Opportunity From: “Steps to a Healthier US Workforce”, Goetzel R., NIOSH background paper, 2004 The sum of the median 1998 HPM opportunity costs across programs was $2,562 per eligible employee, a 26% reduction opportunity in total per employee HPM costs

8. 8 8 Savings Opportunity From Integrating Medical & Short-Term Disability Data & Care DiseasePrevalence (%) Differential Medical Costs Differential STD Costs Potential Opportunity /1000 ee’s Arthritis9-22%$1,382$616$435,477 Asthma4-7%$1,117$373$73,001 Cancer1-2%$4,210$558$52,457 Depression2-5%$2,453$539$83,785 Diabetes4-7%$3,346$971$258,996 Cardiac2-7%$4,372$1,029$334,888 Migraines4-18%$1,510$366$84,441 From: Musich, Schultz, Burton and Edington, Disease Management and Health Outcomes, 2004

9. 9 WellPoint: 360º Health ® Program Integration Integrated program to manage the whole member and every member, across all levels of illness/risk, across all WellPoint health programs, via integrated database: Health Coaching 24/7 Nurseline Worksite Wellness Healthy Lifestyle Future Moms ComplexCare NICU Pharmacy Behavioral Health Integrated Disability Management MyHealth Advantage (therapeutic alerts) Condition Care (DM): Asthma Diabetes CAD CHF COPD 4 Vascular at Risk programs Low Back Pain Musculoskeletal Oncology ESRD

10. 10 : Comprehensive Suite of Services  Pre-Certification  Utilization Management  ComplexCare Catastrophic Care Management  Centers of Clinical Excellence Transplants Bariatric Cardiac Oncology/Radiology  Condition Care Asthma, Diabetes, CAD, COPD, CHF Low Back Pain, Oncology, Musculoskeletal, Vascular, Depression  Advanced Care Management  MyHealth Advantage Early Risk Management Therapeutic Alerts  Neonatal Intensive Care Unit Health Management Health Management and Coordination  24/7 Nurseline  Predictive Modeling  Condition-Specific Education  Decision Support  Hospital Quality Comparison Tool  Procedure Decision Support Tool  MyHealth Record  Pre-populated personal health record (PHR)  Health Coaching  Member/Family advocate  Dedicated RN’s  High Engagement  Future Moms Maternity Management  Special Offers  Discount programs  Health Portals  Condition Centers  Physician Pre-visit Questionnaire  Health Quotient  Nutrition Center  Prevention Reminders  Immunizations  Cancer Screenings  InTune Living  Wellness incentive program  Worksite Wellness On- Site Screening and Seminar Programs  Health Portals  Drug Interaction Alerts  Children’s Health  Men’s Health  Women’s Health  Daily Health Tips  Alternative Medicine  Audio Tape Library  Online Preventive Guideline Health Resources Health & Wellness Health ExtrasHealth Guidance Health Support/ Advocacy Health Incentives Tools & Discounts

11. 11 Advantages of Enterprise Data Integration Consolidated, integrated data: 1 member = 1 record across time, providers, events “Single source of truth” – clinical and financial Facilitates coordination of care, avoids errors Improves predictive modeling across data sources Allows health plan to personalize member experience Enables member <> plan <> provider communications One face to the customer Administrative efficiencies Comprehensive ROI assessment resulting from integration of data, programs and products

12. 12 Employer Costs of Lost (% of Payroll) ProductivityDirectIndirectTotal AON4-6%8-12%12-18% Towers Perrin8-12%4-6%12-18% Watson Wyatt6.1%2-4 x direct costs12-30% Mercer4.4%½-4 x direct costs 7-22% Industry Experiences – Cigna Illustration Around $6,000 Actual Cost Per Employee Per Year Averages 15% Of Payroll Premium Costs = Only 1-2% of payroll Inefficiencies largely driven by non-integration of data, services Illustration

13. 13 Key Cigna Findings Most top cost drivers are the same for disability & medical Disability claimants with chronic conditions experience longer durations whether or not the disability was primarily due to the chronic condition Claimants involved in integrated STD and Healthcare management (having both Disability and Healthcare coverage) have 12% Shorter STD Durations and 6% Higher Return to Work Rates Behavioral health conditions associated with a medically related disability result in poorer outcomes (durations 28% longer; incidence rate 7% greater) Employees engaged in Cardiovascular Disease and Low Back Pain disease management programs experience shorter disability durations & lower incidence of STD Illustration

14. Aetna’s Integrated Health and Disability (IHD) Common Platform Real-time, shared data enables improved outcomes Service efficiencies from availability of information Real-time data integration Enables predictive modeling for medical events and disabilities to facilitate coordinated care management Combined reporting helps customers recognize total cost of conditions, provides focus for prevention efforts Proactive case management Data availability provides opportunities for early intervention Earlier member outreach and program referral may reduce disability risk Illustration

15. IHD Results: Reduced STD Duration Source: March 2006 Aetna Integrated Informatics ® study of claims incurred between 4/1/2003–1/31/2005. A group of 5,546 claimants were split evenly between members with Aetna disability only and members with Aetna medical and disability (IHD). Claims include members who returned consent and those who did not. Days 52.5 48.0 Aetna’s IHD STD claims were 4.5 days shorter than those with only Disability coverage Illustration

16. 16 Other Results in the Literature Johnson & Johnson: After integrating health and disability management with a common data store and common processes, Johnson & Johnson realized medical cost savings of $225 per employee per year. Pitney Bowes: After integrating disease and disability data and management, Pitney Bowes found a 32% decrease in average duration of disability, and an 11% reduction in absenteeism. From: “Integrating Disease Management and Disability Programs Results in Great Rewards,” Managed Health Care Executive, Sept. 2003. Illustration

17. Measuring Outcomes

18. 18 Measurement Components Target Acceptable Questionable = Actual Health Insurance Unscheduled Absence Employee Satisfaction Non-occup Disability Turnover Workers’ Comp Disease & Demand Mgmt. Establishing benchmarks across all programs, products and interventions is essential to measuring comprehensive effectiveness

19. 19 Criteria Used to Track Improvements Direct Medical Cost Reductions Group Health Costs Occupational Disability Costs Workers Compensation Costs Disease Management Savings Indirect Productivity Improvements Unscheduled Absentee Rates Paid Sick Leave Employee Turnover Rates Employee Assistance Occupational Safety Claims Employee Satisfaction Non-occupational Disability Worker's Compensation Short Term/Long Term Disability

20. Recommendations

21. Process of Building an EDM as Quality Strategy - Based on our Scars and Stars  Define data domains across time, members, providers, events products and services: Involve all the operational departments 21  Define a robust Data Model (Dimensional &/or Relational) to support analytics and decision making and integrate it with Enterprise Warehouses  Gather learnings and then define an Enterprise wide roll-out  Define a common vocabulary, infrastructure, analytical tool set and robust analytics processes to identify deviations from standard thresholds  Pilot the program in 1 region with 1 employer group with 1 product  Have Enterprise Information Management group become a facilitator for this program  Enable a single distribution point for Organizational information: internally and externally

22. 22 The Basis of Improved Outcomes In an article on the evolution of care management programs, Al Lewis stated that a newly emerging model “works because it is vastly more inclusive… doesn’t just involve chronic diseases… combines wellness, 24/7 nurse line, preference-sensitive conditions, complex case management and care coordination…” How does the new model achieve its results? 1.Consolidation of data in a common store 2.Touching more people by combining programs 3.Coordinating care by combining intervention data 4.Measuring results across all members & products

23. Sample Illustration 23 Clinical Informatics – Care-Based UseClinical Informatics – Reporting & Extracts Warehouses Laboratories Pharmacy/PBM Plans and Purchasers Member Portals Source Data from different feeder systems from healthcare entities Accounts and External Reporting Pay for Performance Refining Medical Policy Disease and Care Management Health IT Initiatives Personal Health Record, EPrescribing External PBM UM/CM Ops Systems EIM Repository Clinical Information Based Business Services EIM Repository serves as the source of Information for Business Functions Claims Ops Systems Providers Patient’s Condition Comprehensive services provided elsewhere Complete Medication history Utilization & Adverse Effect Reporting Laboratory Results data Medical History & Examination