Opening Keynote “Population Management: The CareMore Experience" David Ramirez, MD, Chief Quality Officer, CareMore Health Plan

1. Population Management:
The CareMore Experience
David Ramirez
Chief Quality Officer

2. Fact Base: Medicare Only
2
• 15% of beneficiaries account for 75% of total cost of care
• Approximately 250 APK per year
• 20% of admissions are readmitted within 30 days of discharge
 Nearly ¾ of them could have been prevented
• Patients experience the following during hospitalization:
• 50% of acute admissions die or are readmitted within a year of discharge
Sources: Center for Medicare and Medicaid Services, Kaiser, Institute of Medicine, Center for Disease Control and Prevention
 > 50% have medication discrepancy  20% experience delirium
 30% have functional decline; only
50% return to prior baseline
 Decubitus ulcer (pressure sore) occurs
within hours of immobilization
 5% will have hospital acquired
infections
 Weight loss, nutritional decline, loss
of muscle strength

3. Health Spending & Chronic Disease
• 15% of the population spends 70% of the dollars
(Kaiser Permanente)
• 70% of all healthcare dollars are spent on chronic
diseases (Agency for Healthcare Research and Quality)
• Five chronic diseases make up the vast majority of this
category*
- Diabetes
- Congestive Heart Failure
- Coronary Artery Disease
- Asthma
- Depression
* Hypertension contributes to complications

4. Healthcare cost and quality problems are
concentrated….not widespread
Healthy Stable Sick Sickest
mostly 1 + Chronic Illness mostly 3 + Chronic Illness
Progressive Illness2010 Medicare
Spending Projection = $522 B
46 Million Beneficiaries
Spending Per Beneficiary = $11,347
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
AnnualCost/Beneficiary
23 Million Beneficiaries
- Spending $1,130 each
- Total Spending = 5%
($26 B)
16.1 Million Beneficiaries
- Spending $6,150 each
- Total Spending = 20%
($104 B)
7 Million Beneficiaries
- Spending $55,000 each
- Total Spending = 75%
($391 B)
Average
Spending
CHF, DM
85% of Beneficiaries = 25% Spending 15% of Beneficiaries = 75% Spending
ESRD, CANCER

5. Community physicians work in parallel with
CareMore Extensivists to provide a cohesive,
comprehensive solution

6. The CareMore model: an innovative healthcare approach that
proactively addresses the complex problems of aging
 “Extensivists” care for the
most ill and frailest patients
 NPs in neighborhood Care
Centers provide support
and care for the chronically
ill and frail
 Care delivery is coordinated
across all sites (PCPs,
hospitals, LTC, specialists)
 Proprietary resources and
programs are deployed
within minutes (not hours
or days)
 Efficient allocation of
clinical resources allows all
to practice at the highest
level of license
 Proprietary predictive
modeling and condition
identification allows us to
intervene early, often

7. CareMore’s operating principles and enabling capabilities
coalesce to form a highly effective model of care
Operating Principles
 Clinical Control - CareMore Extensivists determine when a patient requires proprietary services and
programs
 Speedy Deployment – Proprietary resources and programs must be available to adequately intervene and
be deployed within minutes (not hours or days)
 Efficient Allocation of Clinical Resources – Some types of physician labor is replaced with skilled, allied
health professionals such as NPs, MAs, therapists and dieticians
 Early, Proactive Intervention - Proprietary predictive modeling and condition identification resources allow
us intervene early and often to prevent acute episodes and sentinel events
 Intimacy of Contact – Management of complexity requires constant knowledge of the health condition
Key Enabling Capabilities
7
Predictive
Modeling
Integrated IT
Infrastructure
Longitudinal
Patient Record
Point-of-care
Decision
Support
Evidence-based
Protocols
Advanced
Training

8. CareMore offers a broad range of SNPs
geared toward the frail and elderly
ESRD
Chronic SNP
DIABETES
Chronic SNP
CONNECT
Dual Eligible
SNP
TOUCH
Institutional
SNP
BREATHE
Pulmonary
Chronic SNP
HEART
Cardiovascular
Chronic SNP

9. CareMore COPD Program
• Dedicated Nurse
Practitioner lead
• Team approach coordinated
with other providers
• Holistic management and
education
• Protocols based on national
clinical practice guidelines
9%
16%
18%
CareMore In
Program
CareMore Not In
Program
Medicare Average
COPD Readmissions

10. CareMore Wireless Monitoring
Present State
• CHF: Wireless Scales
• HTN: Wireless BP Cuffs
• Benefits: Patient Compliance, Data
Acquisition, Rapid Intervention
• Challenges: Patient Selection, False Alerts,
Data Volume, Segmented Care

11. CareMore Wireless Monitoring
Future State
• Integrated monitoring across disease states
• Selection of optimal patients
• Data management
• Provider alert management

12. CareMore – Sentrian COPD Program
• Identify-Monitor-Analyze-Act Model
• 1000 intervention patients over 12 months
• Use existing data to select optimal patients
and wireless monitoring options
• Integrate monitoring across chronic diseases
• Continuous risk stratification
• Create rules for alerts

13. 10,000 Member Initiative
• Goal = Proactively manage top 10% highest
risk CareMore members
• Intervention = Early identification and referral
to CareMore programs
• Approach = Develop inclusion/exclusion
criteria, generate list from EDW, apply risk
stratification criteria, prioritize outreach

14. Technology
EDW
FACETS
Rules Engine
(SAS, SQL,
etc)
Criteria,
Diagnostic Codes,
Risk factors,
Episodes, etc.
Criteria
Trigger List
Data Analytics
Analytics Overview

15. Population Management Overview
Chronic:
Care
Management
Disease
Management
Preventative:
Member Services
Clinical Outreach
Pharmacy Outreach
Med Therapy Mgmt
CCC/ PCP visit
Sales/Marketing/ Townhalls
Patient Education
Episodic:
PCP visit
CCC visit
ER/Inpatient visit
Meds Reconciliation
Oversight:
HEDIS QM
submission
STARs submission
CAHPS HOS surveys
Appeals Grievances
ACTIVITIES
Coordination
1.
2.
3
Prioritize
1.
2.
3
Categorize
1.
2.
3
Analyze
Departments
Programs
MultipleTouchpoints
CRM
Integration Coordination
Risk
Patient
Experience
Resource
Management
Service Coordination List

16. CareMore Values
• Accountability
• Coordination
• Urgency to match care desired with care
received