Payment and Delivery Reform

1. Payment and Delivery Reform Steve Arner Senior Vice President / Chief Operating Officer June 6, 2013

2. Carilion ClinicWho we are(FY 2012) Physicians 592 Hospitals 8 Employees 11,300 Admissions 50,300 Revenue $1.3 B

4. Vision 2017 We are committed to a Common Purpose of Better Patient Care, Better Community Health and Lower Cost

5. Challenges with Today’s Care Model • High prevalence of chronic disease and mental illness • Health care cost growing; burden to business • Shortage of healthcare professionals • Overuse; volume “treadmill” • Inconsistent care; fragmentation • Lack of coordination • Payment models at odds with countering rising costs

7. Affordable Care Act 2700 pages and virtually nothing about payment reform

8. OutcomesCost Value =

9. Cost in Health Care HealthEpisodes Per Person ProcessesPer Health Episode CostPer Process x x Transformational Management Operational Excellence Increased Productivityand Quality & Lower Unit Cost

10. Changing the Value Proposition • Reducing the number of “Health Episodes per person” • Case Study: Congestive Heart Failure

11. Action Team 5/08: • Cardiologists • Nursing leaders • Hospitalist • Palliative Medicine • Case Management • Home Health • Primary Care • IT

12. Action Timeline • EPIC order sets, CPGs & best practice alerts (late ’07- early ‘09) • Medical Director (Steve Phillips MD) 2/09 • Program Co-ordinator (Mary Davis RN) 2/09 • Outpatient CHF clinic 8/09 • Dedicated inpatient unit 11/09 • “Transitions of Care” program (late ’09 – present) • Home health – use of Telemedicine link 1/08 • Began JCAHO DSC for Heart Failure process 10/10 • JCAHO DSC for CHF Accreditation 8/11 • Broad Education Initiatives ’09-present

13. Steady improvement has placed us in the top 10 percentCarilion Medical Center – Heart Failure Readmission Rate CMC 30 Day Readmission Rate (All Cause) for Medicare Patients with Heart Failure Diagnosis

14. Changing the Value Proposition • Reducing the number of “Health Episodes per person” • Case Study: Congestive Heart Failure • Other focus areas: • Reduce Waste • Prevention • Patient Involvement

15. Risk Sharing in the Future is a Must • Partnerships between providers and payers is critical

16. Accountable Care • 575 employed Carilion physicians are Doctors Connected ACO participants. Medicare Strategy Commercial Strategy Carilion Clinic Support • Key Facts: • MSSP Participant, start date 1/1/2013 • Shared savings based upon achievement of quality benchmarks and cost reduction • 46,400 beneficiaries • Qualitative application process; Carilion medical home strategies very helpful for questions regarding quality, care coordination, beneficiary engagement, evidence-based medicine, and reporting. • Key Facts: • ACO product with Aetna, start date 1/1/2012 (in addition to collaboration on Medicaid, Medicare Advantage, and Employee programs) • Participating in other payers’ shared savings initiatives (Anthem PC2 for example) • Key Facts: • Dedication of senior leadership to ACO strategy and development. • Recruitment of a Chief Strategy Officer • Development of a comprehensive enterprise data warehouse (EDW) for integration of EMR data and healthcare claims. • Creation of a Transformation Oversight Committee of senior leadership to develop care delivery strategies for key disease states (CHF, COPD, Diabetes).

17. What is Population Health Management? • Goal is optimal patient health • Healthcare, not sick care • Proactive, not reactive • Align care team resources to meet the needs of different patient segments and personalized to the patient. • Reduce the need for higher cost services (ED, hospitalizations, imaging tests, etc)

18. Medicaid Expansion • Why it is important to business