Robin Barca, RN Senior Vice President, Chief Operating Officer, Baptist Health

1. A Care Management Business Model for the Uninsured Robin Barca, RNSenior Vice President, Chief Operating Officer, Baptist Health Pamela Newman, MT Care Advisor and Laboratory Director , Baptist Health

2. Uninsured statistics are staggering • 89.6 million – Number of Americans under 65 without health insurance for some or all of the two-year period from 2006-2007 • More than one in three Americans (34.7 percent) under the age of 65 were uninsured part-time or full-time during 2006-2007 • 17 million - Number of additional uninsured Americans at some point during 2006-2007 compared to 1999-2000 • 20– Number of states where more than one-third of the people under 65 went without health insurance for some or all of the two-year period from 2006-2007

3. Who are the uninsured? • Four out of five uninsured are from working families • 40% earn more than $50K per year • 4.2% uninsured are looking for work • 80% are U.S. citizens Uninsured by race & ethnicity, 2006-2007 Uninsured by age, 2006-2007

4. The uninsured turn to health systems for care Uncompensated care by type of provider 19% 63% 18% Source: Hadley and Holahan. Health Affairs (2003)

5. Many uninsured have chronic diseases that need medical care Source: A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults. Annals of Internal Medicine, August 2008

6. Five disease categories drive half of all healthcare spending • Heart disease • High blood pressure • Diabetes • Asthma • Mood disorders Healthcare expenditures 49% Source: Agency for Healthcare Research and Quality – Medical Expenditure Panel Survey

7. A care management alternative for the uninsured with chronic diseases Chronically ill and uninsured Medical care in the hospital “as-is” Better way Outpatient primary care Identify the chronically ill and their medical needs Address barriers Identify barriers to care

8. Care management infrastructure and a care team are required Hospitals Physicians Care managers Analytics, other infrastructure Pharmacists Social workers

9. Analytics Medical Home Pharmacy Assistance Four foundations for success Ongoing Care Management

10. Analytics drive patient identification and selection of interventions • Total uncompensated care population analysis • Total cost of care • Cost per patient • Demographic distribution/patient segmentation • Population identification • “Frequent Flyers” identification • Readmissions assessment • Percent of patients with a medical home • Encounter analysis • Condition prevalence, respective cost, utilization distributions • Patients with chronic conditions analysis • Identification of chronic patients • Stratification of patients exceeding high-cost benchmarks • Cost distribution across the chronically ill population • Patient identification

11. Baptist Health witnessing rapid escalation in uncompensated costs 38% y-o-y

12. Age distribution of costs reflects young uninsured population The average billed amount per person is $5,553 across the whole population. The average billed amount per person is $5,553 across the whole population.

13. Youthful distribution extends to patients with top 5 chronic diseases The average billed amount per person is $5,553 across the whole population.

14. Cost concentration exists for uncompensated with chronic diseases Note the 80/20 rule is closely obeyed, and that the top 1% are one-fourth of total billed.

15. Readmission rate high but not unexpected due to no primary care access

16. Inpatient costs showed rapid growth Billed Inpatient dollars are increasing at a higher rate than billed EDdollars

17. Financial measures in South ED facility reduced ED visit frequency, not admissions Inpatient frequency is increasing at a higher rate than ED frequency

18. Overview of the pilot

19. Overview of the pilot • Population to be managed • Uninsured patients with the five chronic diseases • High utilization over a twenty-four month period • Four hundred potential patients identified to be managed • Delivery of care • Primary care residency program to deliver primary care services • Pharmacy leverages 340B program in place • Access to care • Transportation • other community assistance

20. Baptist Health Program Care Advisor program began August 2008 • Purpose: Reduce avoidable hospital inpatient admissions Reduce inappropriate use of ED with RN case management Improve patient knowledge of disease, medications and diet. • Populations served: CHF, COPD, CAD, Diabetes, Asthma, Hypertension • Criteria for admission • 3 or more inpatient hospital stays in 1 year • No Medical Home • No Insurance • Goals • Provide Medical Home • Provide Medications • RN and Social Work Case Management • Eliminate barriers to healthcare

21. The medical home offers a stable, consistent source for required care • Montgomery Family Residency Program becomes the Medical Home • Care Advisor staff collaborates with MFPRP Clinic to schedule patient’s initial appointment • RN Case manager attends initial visit with patient to collaborate the health risk assessment and establish relationship with patient

22. Providing required medications to patients is necessary for success • Medication formulary approved by Program Medical Director and Pharmacy Director – strickly enforced • All medications provided at Baptist Outpatient pharmacy • 340B Drug Pricing Program allows certain federally-funded programs, safety net healthcare providers medications at significantly reduced prices • Manufacturer pharmacy assistance programs for special circumstances

23. Ongoing care management to support the complex needs of the chronically ill • Care management services aimed at resolving identified risks, barriers to care and chronic condition • Disease-specific education and materials to patients • Medication and diet education • Readmissions management, including appropriate use of Emergency Department • Social work case management to identify patient needs and eligibility for coverage with Medicaid or SSI. Cell phones provided as needed

24. 2011 Return on Investment -141 patients in program for 1 year

25. Outpatient management of uninsured with chronic diseases can yield great value • Shift uninsured patients with chronic diseases from the facility to outpatient primary care • Improve quality of medical care • Reduce total costs • Open capacity for reimbursable care for hospitals with capacity issues • Deliver attractive return-on-investment to the health system • Impact future healthcare costs through chronic disease control today

26. 2010 Introduction of Community Care Management Patients are Insured and have a Medical Home Initial focus with CHF patients SERVICES 30 Day Supply of new medications by Baptist Pharmacy upon at discharge Telephonic education on disease management , medications, diet, and weight by Nursing Case Manager Social Worker Care Management Expanded to included management of COPD and Pneumonia patients in May 2011 CareAdvisor created an infrastructure for reducing readmission in all payor classes

27. Patient Identification Inpatient clinical pathway developed for CHF including consults for CCM program Targeted inpatient case managers to introduce program to patient prior to discharge OUTCOMES CMS Core Measure Group CHF Readmission Rate for 2010 is averaging 20%. National Average is 22% Reported Thomson-Reuters Data for BMCS CHF Readmission Rate for Medicare has averaged 12%for year. July Data had 8.3% readmit rate for Medicare patients CHF Readmission RateDecrease is Encouraging

28. Sickle Cell Disease Management • GOALS • Decrease ED utilization for crisis management • Decrease number of Inpatient visits • Decrease LOS • Program Elements • Outpatient clinic opened March 2011 for consistent disease management • Scheduled transfusions in Hospital OP visit to prevent crisis • Outcomes for 27 patients in program for 1 year • Decrease by 137 inpatient visits after being managed in Sickle Cell program. • The length of stay decreased an average of 1 day per visit

30. Program Volumes September 2011

31. Lessons learned Witnessing significant impact to managed patients • Financial impact on patients managed by the program is significant and likely to be sustainable Lower than expected enrollment • Inherent challenges contacting targeted uncompensated patient population • A belief that hospital is collecting debts • Patient information issues • Initially we were too conservative in approaching the population • We did not want to interfere with even loosely established patient/physicians relationships

32. Lessons learned, cont. Processes and adherence are key elements of program success • Program awareness and education across all health system constituents are key for program success • Strong client program lead/champion is fundamental for building excitement, auditing health system processes • A defined generic medications list is necessary to control pharmaceutical cost. Tracking and periodic audits are required

33. In conclusion • The problem of the uninsured needs attention today, despite the efforts of the current administration toward universal coverage • Health systems are facing unsustainable uncompensated cost increases that need relief today • Much of the cost of the uninsured is borne by patients with common chronic diseases • An outpatient care management program may prove to be a win-win for health systems and the uninsured • The lessons learned managing the uninsured are applicable to paying populations today and will likely be more relevant with healthcare reform

34. Baptist Health Mission Statement As a witness to the love of God through Jesus Christ, Baptist Health exists as a voluntary, not-for-profit organization to promote and improve the physical, emotional, and spiritual well-being of the people and communities it serves through the delivery of quality health care services provided within a framework of fiscal responsibility