Company Overview SENIORS

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3 Company Overview Founded in 1990 in San Antonio, Texas by Dr. George Rapier WellMed is a medical management company Specializes in managing medical services for SENIORS through full risk capitation contracts with CMS and Medicare Advantage ( MA ) plans Primary-Care, Physician-Centric Two Lines of Business Physician Management Operations ( PMO ) At-risk integrated medical services provider Physicians Health Choice ( PHC ) Medicare Advantage HMO Leverages PMO medical-risk management model Industry leading medical management metrics for higher than average risk members

4 Clinic Model 24 Clinics in San Antonio and surrounding towns and 7 Clinics in Florida 90 + Providers Full Service (in house lab, xray, pharmacy at larger locations) Family Practice and Internal Medicine Doctors Serving over 70,000 patients, including 25,000 Medicare Advantage Members

5 IPA Model 50+ IPA Contracted Physicians in Texas, development stages in Florida Service Medicare Advantage Contract Base PCP cap or FFS Upside only risk pool sharing 8000 Medicare Advantage Members

6 Physicians Health Choice Physicians Health Choice ( PHC ) holds a full service HMO license in Texas and New Mexico, Florida and Arkansas and currently has operations in Austin, Corpus Christi, El Paso, Amarillo, Rio Grande Valley and Las Cruces New Mexico. To start operations in Ft Lauderdale, Fl. And Little Rock, Ar. in 2008 Launched MA health plan for Austin and Corpus Christi markets in September 2005 Current aggregate patient enrollment exceeds total of more than 12,500 as of June, 2008 Added Chronic disease special needs plans beginning 2007

7 Utilization Management Program The PCP, physician manager, has a designated panel of members and is responsible for directing health care services in accordance with CMS guidelines. Case Management services related to hospitalization and skilled nursing facilities supported by RN Case Managers Primary Care Physician Physician Manager Outpatient Services Services referred to Specialist and Facilities supported by referral coordinators

8 Utilization Management Committee Health Plan UM Committee Patient Care Committee PCP MS Health Plans delegate the responsibility of implementing and evaluating of the UM program to the UMC. The UMC is a quorum of medical directors who monitor the effectiveness of the plan. CMS Guidelines UMC implements and revises the UM program in accordance with CMS UMC makes determines medical necessity and benefit coverage per CMS UMC, as Sr. management, supervises the UM Program to ensure equitable administration of benefits. Medical Directors The UMC consists of a quorum of at least 3 medical directors. The UMC meets weekly to discuss: - UM issues, updates and CMS announcements - review requests for medical appropriateness - evaluate reports for UM trends for process improvement Annual Evaluation An annual assessment of the UM program is evaluated to ensure appropriateness of criteria and utilization of services UM reporting is supported by Qlikview for immediate access to financial and utilization information The effectiveness of the UM program is reported to Sr. mgmt annually

9 Primary Care Physician (PCP) PCPs are the healthcare managers and are responsible for making medical necessity determinations in accordance to CMS guidelines. Primary Care Physician directs and authorizes all healthcare services PCP Responsibilities PCPs provide access to healthcare services for Medicare Advantage members to ensure appropriate utilization of the following components: Primary Care Services Hospital coverage (PCP/hospitalists) Annual physical exams Access for post discharge follow ups Preferred Specialty Network Routine follow up care Case Management: PCPs are the principal authority of the case management program. RN Case Managers act as agents of the PCP to provide: Appropriateness of benefit coverage Medical indication of criteria Post hospital follow up care Placement of custodial living

10 Case Management CMS Health Plan UM Committee Patient Care Committee PCP Case managers provide concurrent, prospective, and post services review of hospital and skilled nursing facility admissions. The CM collects data for entry into the Hospital Visit Tracking system (HVT). Hospital Services Outpatient Services Reporting CMs provide onsite daily review of hospital and skilled nursing patients OBS vs. DRG review Discharge planning and post discharge follow up care Referrals for disease mgmt Custodial placement RNs are clinical resources to referral coordinators for criteria and benefit coverage Patient Care Committee resource for utilization review of outpatient services Referral to social worker for social issues, hospice, and placement Daily census reporting to PCP and UM staff Data collection of hospital & skilled nursing utilization Cost containment and appropriate direction of financial responsibility: Hospice 3rd Party Liability Health Plan Risk CMS

11 Outpatient Referral Management PCPs provide ongoing review of ambulatory referrals, home health services, and elective admissions. The referral management program objectives are the review of referral requests for medical necessity based on coverage guidelines. Referral Management Program services are designated at multiple levels of review from self referral to medical director review Specialist providers and members request referrals from the primary care physician Referral coordinators are designated as referral support to the PCP in verifying eligibility, gathering supporting information, criteria, and benefit guidelines Online website with auto authorization available to providers Referral coordinators and case managers provide physician and member notification of authorized services

12 Outpatient Referral Management UM Delegation is a series of program components providing authorization authority to the physicians at stratified levels with consideration to diagnosis and service. Member PCP Patient Care Committee UM Committee Self Referral Management Physician Notification 90% of referrals (Green) Prior authorization Required quorum of 3 PCPs (Red) Medical Director Review (high cost/catastrophic or case mgmt required) Annual GYN Exam Mammogram Routine Radiology Optometry Flu Vaccine Virtual Colon screening Hospitalizations CT/MRI approved by PCP Non-invasive Radiology Specialty visits Home Health X 9 Physical Therapy X 6 DME < $ Non-Contracted or Non-Covered Services Elective Plastics P.E.T Chiro/Endo/Pain Mgt. Home Health > 9 visits Physical Therapy > 6 visits Cardiac/Pulm Rehab DME > $ Non-Contracted or Non-covered services approved at PCC Experimental/New Technology Acute inpatient rehab or LTAC DME > $ Neurosurgery Referrals Brilliant CT/CTAs EP Studies/Cardiac Ablation Cardiac Implants Hyper Baric Oxygen Therapy IMRT

13 Utilization Reporting Qlikview reports data for financial reporting, utilization & pharmacy management trends and enrollment in disease management programs.

14 UM Metrics employed physicians

15 UM Metrics contracted physicians

16 Gary Piefer, MD, MS, FACPE, FAAFP Senior Vice President Medical Affairs Richard Manning Senior Vice President of Services Michelle Henry, MSN, RN Director

17 MISSION The purpose of HealthRight is to identify patients with chronic diseases, to manage these conditions more effectively through education and care coordination, and to decrease, prevent, or reverse the progression of chronic diseases thereby reducing potential healthcare costs.

18 Disease Management Continuum Chronic Disease Management Continuum W E L L P A T I E N T S H Sick and Do Not Know I It G H Sick and Do Not Know R It I S K Traditional Disease Management Patients Four Major Disease Groups CHF IHD COPD Diabetes C O M P L E X C A R E H O S P I C E C A R E

19 Disease Management Current programs include: Diabetes Congestive Heart Failure (CHF) Ischemic Heart Disease (IHD) Chronic Obstructive Pulmonary Disease (COPD) Pre Disease Management Complex Care Wound Care

20 DataRAP Audit Patient Identification All charts are audited by nurse auditors assisted by data mining Patients become automatic potential candidates in our system Potential patients are identified by other claims data, and hospital admissions data Direct referrals are received from Primary Care Physicians and Case Managers

21 What happens during a Disease Management visit?

22 Patient Visits in Clinic Initial (1 hour) and follow-up (30 min.) education sessions conducted in the clinic by Registered Nurses. All patients return to the clinic for follow-up education and repeat laboratory testing. Additional telephone contacts made in between visits as indicated by Disease Management protocols for reinforcing compliance and for monitoring signs and symptoms.

23 Disease Management Clinical Guidelines and Outcomes

24 CHF/IHD CHF/IHD % on combo therapy CHF/IHD % on statin only CHF/IHD % on ACE/ARB CHF/IHD % on BB CHF/IHD % on ASA CHF/IHD contra % CHF/IHD % with LDL in 12 mos. Avg LDL CHF % echo CHF/IHD BP <130/80 Diabetes DM % on combo therapy DM % on statin only DM % on ACE/ARB DM % on ASA DM contra % DM % with LDL in 12 mos. Avg LDL DM % A1c in 12 mos. Avg A1c DM % eye exams DM % foot exams and shoes

25 ENROLLED NOT ENROLLED # OF DAYS CONGESTIVE HEART FAILURE D/1000 SNF A/1000 SNF ENROLLED NOT ENROLLED

26 ENROLLED NOT ENROLLED # OF DAYS DIABETES D/1000 SNF A/1000 SNF ENROLLED NOT ENROLLED

27 ENROLLED NOT ENROLLED # OF DAYS COPD/ASTHMA D/1000 SNF A/1000 SNF ENROLLED NOT ENROLLED

28 ENROLLED NOT ENROLLED # OF DAYS ISCHEMIC HEART DISEASE D/1000 SNF A/1000 SNF ENROLLED NOT ENROLLED

29 Before and After enrollment DM

30 Before and After enrollment CHF

31 Before and After enrollment IHD

32 DATA HVT Lab Data Paid Claims/ Referral/ UM EMR data Pharmacy claims Data Warehouse QV Reporting emrg eprg Protocol Engine

33 QV Reporting

34 e PRG

35 e MRG

36 Care Band

37 Protocol Engine

38 Chronic Care Model VS Acute Care Model

39 Total lives lost per year 100,000 How Hazardous Is Health Care? DANGEROUS (>1/1000) HealthCare (Leape) REGULATED Driving ULTRA-SAFE (<1/100K) 10,000 1, Mountain Climbing Bungee Jumping Chemical Manufacturing Chartered Flights Scheduled Airlines European Railroads Nuclear Power ,000 10, ,000 1,000,000 10,000,000 Number of encounters for each fatality

40 Our Results Pre 2008 DM Program Candidates Diabetes IHD CHF Process Measures Outcome Measures Process Measure Outcome Measures Process Measures Outcome Measures 1. A1c 1. A1c < 7 1. LDL 1. LDL < 70 1.ACE/ARB 1.LDL <70 92% 65% 89% 32% 49% 34% 2. LDL 2. LDL < LDL 89% 31% 86%

41 Economic Imperative for Improved Clinical Outcomes Diabetes Margin by HbA1c WellMed % Variation in net revenue between patients with HbA1c < 7 and those > 10 $199 PMPM Net Revenue differential $600 $400 $200 HbA1c < 7 HbA1c > 7 HbA1c > 8 HbA1c > 9 HbA1c > 10 $0

42 Economic Imperative for Improved Clinical Outcomes IHD Margin by LDL level WellMed % Variation in net revenue between patients with LDL <70 and those > 130 $112 PMPM Net Revenue differential $600 $500 $400 $300 $200 $100 $0 1st Qtr LDL < 70 LDL > 70 LDL > 100 LDL > 130

43 The Chronic Care Model

44 Chronic Care Model Self Management Support Delivery System design Decision Support CIS Informed Activated Patient Prepared Proactive Practice Team

45 Essential Element of Good Chronic Illness Care Informed, Activated Patient Productive Interactions Prepared Proactive Practice Team

46 What characterizes an informed, activated patient? Informed Activated Patients They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it.

47 What characterizes a prepared practice team? Prepared Proactive Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care.

48 Improved Outcomes from Improved Systems Other System Measure Before After HbA1c under 7% 1999: 42% 2001: 70% HbA1c checked twice a year Foot exams with monofilament testing Annual urine protein measures ACE inhibitors with positive urine protein 1997: 67% 2001: 90% 1997: 61% 2001: 78% 1997: 52% 2001: 78% 1999: 38% 2001: 80% Premier Health Partners - Dayton, Ohio (A.C.T. Report)

49 Scheduled Visits Foundation of Productive Interactions

50 CCM Team and Visits Pilot Project, one clinic with 5 providers, ½ day CCM visits per week Weekly meetings to integrate principles of Rapid Cycles of Change The Team roles were identified by the group The Team determined a process flow template for visits The Team created a CCM Checklist for tracking process and outcome measures

51 CCM Team and Visits The Team worked collaboratively and each member s feedback contributed to the final process The Team conducted patient surveys to obtain valuable feedback: no one has ever asked me what I wanted before what took you so long to do this

52 CCM Roles Support Specialist Introduces patient to the CCM Schedules patient for pre-clinic labs and CCM visit Medical Assistant Collects all needed data (last lab, med list, last flu shot, etc.) for the team on a CCM Checklist Prepares patient and checks VS upon arrival

53 CCM Roles PCP Facilitates collaboration within the team Creates the Plan of Care Ensures all interventions are ordered to complete process outcome compliance Shares the Plan of Care with the patient and the team Conducts a team huddle before visits to prepare team and after visits to determine what worked, what didn t work, how to improve process

54 CCM Roles DM Nurse (Self-Management Support) Coaches the patient to create a self-management goal and Action Plan Communicates patient needs to the PCP Ensures all process outcome measures are complete on the CCM checklist Provides focused education for specific needs Identifies additional resources for patient support (Referral to the MVP, Social Worker or Pharmacist)

55 CCM Roles Clinic Administrator Supports CCM team with logics, staffing, problem-solving Supervises Med. Asst., receptionist, medical records Receptionist Greets patient Generates and processes fee ticket Informs Med. Asst. of patient arrival

56 Next Steps Integrate the CCM visit schedule and process for each provider everyday Fully implement the CCM process into all of the WellMed clinics

57 IHD Patients

58 IHD Patients in Chronic Care Model

59 IHD Patients

60 IHD Patients in Chronic Care Model

61 Diabetic Patients in Chronic Care Model

62 Diabetic Patients in Chronic Care Model

63 That s All Folks