Well Meds Patient Centered Medical Home STFM Conference

Well. Med’s Patient Centered Medical Home STFM Conference December 5, 2010 George Rapier, MD - Chairman & Chief Executive Officer

Company Overview • Founded in 1990 in San Antonio, Texas by Dr. George Rapier • Well. Med 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

Company Overview • Two Lines of Business – Physician Management Operations (“PMO”) • At-risk integrated medical services provider, fully capitated and delegated for UM, credentialing, and claims payment – Physicians Health Choice (“PHC”) • Medicare Advantage HMO • Leverages PMO medical-risk management model • Industry leading medical management metrics for higher than average risk members

Clinic Model • 30 clinics in San Antonio, Austin, Rio Grande Valley, Florida Treasure Coast • 80 + Providers • Full Service (in house lab, x-ray, pharmacy at larger locations) • Family Practice and Internal Medicine Doctors • Serving over 70, 000 patients, including 27, 000 Medicare Advantage Members

IPA Model • 120 IPA Contracted Physicians in San Antonio • 100 IPA Contracted PCP’s in Central and East Florida • Service Medicare Advantage Contracts • Base PCP cap or FFS • Upside only risk pool sharing • 15, 000 Medicare Advantage Members

Physicians Health Choice • Physicians Health Choice (“PHC”) holds a full service HMO license in Texas, New Mexico, Arkansas and Florida • Current patient enrollment approximately 40, 000 as of April 2010

Utilization Management Program Overview

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 Manager Outpatient Services referred to Specialist and Facilities – supported by Referral Coordinators

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

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 Self Referral Management Physician Notification 90% of referrals (Green) Prior authorization Required quorum of 3 PCPs (Red) • 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 < $300. 00 • Non-Contracted or Non-Covered Services • P. E. T • Elective Plastics • Chiro/Endo/Pain Mgt. • Home Health > 9 visits • Physical Therapy > 6 visits • Cardiac/Pulm Rehab • DME > $300. 00 UM Committee Medical Director Review (high cost/catastrophic or case mgmt required) • Non-Contracted or Non-covered services approved at PCC • Experimental/New Technology • Acute inpatient rehab or LTAC • DME > $1000. 00 • Neurosurgery Referrals • Brilliant CT/CTAs • EP Studies/Cardiac Ablation • Cardiac Implants • Hyper Baric Oxygen Therapy • IMRT

Weekly PCC Meeting • Hospital Review • Complex Care Patient Care Plans • ER Patients • Referral Authorizations and Denials

Monthly Reporting Package • Clinic Financials • UM Metrics • Quality Metrics • High-Risk, High-Cost and Complex Patients • Hospital and ER Patients

2009 Quality and Process Metrics

Quarterly Strategic Planning Meeting • Set goals for the year (Max 3 goals – i. e. reduce readmissions for CHF) • Review financial and UM data • Review reporting on goals • Adjust action plan for strategic goals

Clinic Operations Overview • Mission Statement • Philosophy, Coordination, Continuity • Patient Touch • Circle of Care story • Disease Management Programs • Social Services • Value-Added Benefits • Part D Assistance

Well. Med’s Mission Statement “Our name, Well. Med is a daily reminder of our objectives as a medical group. Our goals are to help the sick become well and to help patients understand control their health in a lifelong effort at wellness. ”

Well. Med’s Philosophy Well. Med’s goal is a personal health care team committed to treating our patients with a level of care, service and services they need… AND deserve. • Our patient’s well-being is our central focus. • We value our patients and understand their challenges in receiving the best health care. • Maintain continuous communication between our patients and our health care team. • Our goal was to find a better way to help patients and to provide them with MORE services.

Patient First Touch • New members are called to setup a Patient First Touch Appointment. • All patients are called to confirm appointments. • Almost all of our patients wait no longer than 20 minutes before seeing their PCP. • Patients are not “cattle” called from doorway; staff approaches patient, introduces themselves and escorts patient to back area. • All patient receive either a post appointment call or letter with lab/radiology results.

Patient Service • All patients receive a post appointment call inquiring: How are you doing? How was our service? • Designated reserved Senior Same Day Urgent Care appointments. • Morning to morning and afternoon to afternoon return calls. • On site pharmacy, lab, and x-ray available at most clinic locations. • Almost all of our clinics are on the ground floor with easy access to parking.

Well. Med Surrounds You… the Patient

Value Added Services Medication Voucher Program (MVP) Co-payments on 90 Disease Management related prescription drugs are covered and coverage is extended through the donut hole

Social Services Assistance in applying for Medicare Savings Programs Designed to provide assistance to Medicare Beneficiaries to help them apply for Medicare Savings Programs available through the State of Texas. • Social Services team members help fill out proper forms and submit them to the State on patients behalf. • The State will determine if Medicare Beneficiaries qualify for assistance. • Qualifying beneficiaries can receive $93. 50 in their social security checks.

Value Added Services Comfort Care Transportation Services – Free non-emergency transportation to and from doctor visits, hospitals and/or skilled nursing facilities – Available for qualified patients Silver. Sneakers® – Customized group fitness program designed to increase strength, flexibility and energy for qualified patients

Value Added Services As a Well. Med Patient, our patients receive more than just health care. • Dental Benefits – Free annual cleaning, exam and discounts on restorative work • Vision Benefits – One comprehensive eye exam every 12 months and a vision allowance up to $300 every 24 months towards the purchase of glasses and frames through contracted providers • Hearing Aid Benefits – 35% discount plus an additional $400 discount on custom hearing aids every three years

Value Added Services As a Well. Med Patient, our patients receive more than just health care. • Medical Care Band – Portable Personal Health Record • Social and exercise facilities as part of clinic

Well. Med Provides a Higher Level of Care At Well. Med, we will work to help you live a healthier and happier life. We care about your health.

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

The purpose of Health. Right 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.

Disease Management Chronic Disease Management Continuum W E L L P A T I E N T S H I G H R I S K Sick and Do Not Know It 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

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

Disease Management • 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.

2007 -2009 Transition to the CCM Well. Med Vision. . . Change the Face of Healthcare Delivery for Seniors. • Industry leader in innovative healthcare practices • Set the standard versus meet the standard • Passionate about quality and continuous process improvement • Leader in evidence-based clinical practices • Begin the next generation care model for patients with chronic disease • Economic Imperative with changes in MA reimbursement

Chronic Care Model VS Acute Care Model

Results Pre-2008 DM Program Candidates and Enrollees Diabetes IHD CHF Process Measures Outcome Measures 1. A 1 c < 7 1. LDL < 70 1. ACE/ARB 1. LDL <70 32% 49% 34% 92% 2. LDL 89% 65% 2. LDL < 70 31% 89% 2. LDL 86%

Economic Imperative for Improved Clinical Outcomes • Diabetes Margin by Hb. A 1 c Well. Med 2006 • 150% Variation in net revenue between patients with Hb. A 1 c < 7 and those > 10 • $199 PMPM Net Revenue differential

Economic Imperative for Improved Clinical Outcomes • IHD Margin by LDL level – Well. Med 2006 • 128% Variation in net revenue between patients with LDL <70 and those > 130 • $112 PMPM Net Revenue differential

The Chronic Care Model

First Implementation 2008 & 2009 • Developed implementation plan • Implemented at most clinics in a 2 -3 week time span • Less than satisfactory buy-in by physicians and staff • Less than satisfactory results • SO!!!!!

Breakthrough Series

Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation

History of the “Chronic Care Model” § The Chronic Care Model (CCM): - developed by the Mac. Coll Institute for Healthcare Innovation in the early 1990’s - designed using evidence-based change concepts § Improving Chronic Illness Care (ICIC): - a national program of the Robert Wood Johnson Foundation launched in 1998 - an organization dedicated to bettering the health of chronically ill patients through implementation of the Chronic Care Model (CCM) - www. improvingchroniccare. org

Chronic Care Model • Self Management Support • Delivery System Design • Decision Support • Clinical Information Systems • Informed Activated Patient • Prepared Proactive Practice Team

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

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.

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.

Well. Med Chronic Care Collaborative Utilize Health Coach for Goal Setting Use a planned agenda (CHF, Transitions) Use a checklist or Protocol Engine Team Huddle at End of Day Improved Evidence-Based Outcomes: Diabetics with A 1 C <7 Diabetics with BP < 130/80 IHD with LDL < 70 CHF on ACE/ARB

“Do the Chronic Care Model” Process Measures Agenda Protocol Engine or Checklist Self Management Goal End of the Day Huddle Target (a) (a) (b) (a) present in every visit (b) held every day, all visits reviewed Goal: All four present for 90% of CC visits

Process Metrics and Follow-Up • Each clinic keeps and tabulates their 4 process metrics and reports them every 2 weeks on a group conference call • Every other 2 weeks, have small group conference call with Mentors (Physician, Health Coach and Administrator) • Share results and best practices

Process Results • Way too many 100%’s – Takes a while for teams to get an understanding of what and how they should be measuring – Need to develop tools to help them, i. e. draft agendas, measurement tools, reporting tools

e. Physician Resources Gateway • Access to Information

e. Member Resources Gateway • Care Bracelets