Southwest Health Alliance SWHA

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2. Southwest Health Alliance Southwest Health Alliance (SWHA) An Employer Coalition created to bring Value-based Purchasing opportunities to its members: Avnet City of Chandler Maricopa County City of Glendale Affiliate Members Schering International HSAG

3. Southwest Health Alliance SWHA Business Strategy Best Practices Business Model for All Products and Services Focused on: Clinical Quality Improvement in Health Care Employee Productivity Research Strategic Business/Information Support Tools Consumer/Employee Education Price and Service Value Contracting Not available To Individual Employers Fully Disclosed Expenses In All Contracting Broker and Consultant Friendly Product Offerings Contracting that includes performance criteria and financial participation from vendors

4. Southwest Health Alliance SWHA Best Practices Products Next Wave Health Plan Management Strategies: HealthEOS

5. Southwest Health Alliance SWHA Information and Support Services Common RFI Collaborative Contracting Tool Plan Specific Claim History For Employer Members Market-wide Quality Performance Reporting Individual, Patient-Focused Providers Quality Checks National Research Productivity Research Publications and Forums Industry Segmented Productivity Benchmarking Surveys Personal/Employee Health Profiling and Management Tools

6. Southwest Health Alliance Research Initiatives For Members Burden of Disease on Cost and Productivity (Self-report Survey, Tampa Coalition) Best Practices (Cost and Quality)for Treating Asthma and Allergy, Hepatitis C (SWHA and EHA)

7. Southwest Health Alliance

8. An Employer-Based Solution�

9. Southwest Health Alliance Has Your Managed Care Plan Performed?

10. Southwest Health Alliance Risk and Alternatives Continue to Pay Double Digit Increases to MCOs Eliminate Health Care Coverage Move To Defined Contribution Evaluate Limited Self-funded Health Plan

11. Southwest Health Alliance Recommended Strategy Examine self-funding options Focus on improved care delivery and cost reduction Obtain health plan data Partner with vendors that will address these concerns � HealthEOS, TPA, Reinsurance

12. Southwest Health Alliance HealthEOS Components HealthEOS Care EngineSM System Health Plan and Provider Performance Measurement Local and National provider networks Aggressive provider discounts Claims Re-Pricing Utilization Review/Case Management Coalition Membership

13. Southwest Health Alliance Performance Measurement �You can�t manage what you don�t measure.� Employers will have data for determining best value for their health care dollars Most efficient hospitals Highest quality doctors Employees will be able to choose providers based on value Data analysis will drive quality improvement initiatives throughout the community�s health care system

14. Southwest Health Alliance

15. Southwest Health Alliance Broad-based Local Network 1,194 facilities in Arizona (55 acute care hospitals) 6,400 providers (physicians, therapists, etc.) National Network Coverage Over 3,000 acute care facilities; 53,000 ancillary facilities Over 410,000 physicians and specialists Aggressive Discount Pricing

16. Southwest Health Alliance Premier System Technology Superior Claims Processing Technology Re-price Claims off Payor Eligibility Develop And Maintain Multiple Network Configurations Reduction Of Paper Claims Ability To Receive Claims EDI From Providers (HIPAA Compliant) Ability To Transmit Re-priced Claims Edi to Payors (TPAs) Data capture/data warehouse

17. Southwest Health Alliance Utilization Review / Management URAC Accredited Case Management Services Disease Management Services Enhanced Electronic Treatment Authorization for Providers (E-Auto-Auth)

18. Southwest Health Alliance CareEngineSM Services Software developed by physicians and healthcare consultants A patient-centric approach using a series of over 1000 healthcare algorithms and logic matrices. Staff physicians assisted by specialist consultants at major universities

19. Southwest Health Alliance What does the CareEngineSM do? Finds individuals in a population who are at clinical risk in current time and continually monitors their clinical situation. Passes data on to the treating physician. Assists in the healthcare management of a population - one person at a time.

20. Southwest Health Alliance Care Engine Service Delivery Process

21. 5 patients, a,b,c,d,e. The care engine looks at pieces of data and finds for patient A, an odd lab value. Patient B, a claim..maybe for something indicating a heart attack, patient C nothing unusual, patient D a utilization management note that indicated something unusual, patient E, some drug issue that needed looking into. The Care Engine pulls all the data in for this one patient and looks for any piece that says, �This may be a problem�look further�. 5 patients, a,b,c,d,e. The care engine looks at pieces of data and finds for patient A, an odd lab value. Patient B, a claim..maybe for something indicating a heart attack, patient C nothing unusual, patient D a utilization management note that indicated something unusual, patient E, some drug issue that needed looking into. The Care Engine pulls all the data in for this one patient and looks for any piece that says, �This may be a problem�look further�.

22. Let�s follow patient A through the Care Engine process. WE FOUND PATIENT A BECAUSE OF THAT ONE COMPELLING PIECE OF LAB DATA. In this case, a Cholesterol > 240. This needs to be looked at. Maybe diet and exercise will help. Maybe pA already is taking medicine for it. But, now the care Eng looks at all the data for patient A. It builds a whole record for Patient A and finds that not only is the Cholesterol high, but A has also had a heart attack (claim data). Consulting Umnotes, see that the Blood Pressure is high and there are reports of shortness of breath, And, A has diabetes. Now, its not just high cholesterol. But looking in the context of all the data, the care engine can identify a number of potential drug / disease issue. 1)High Cholesterol -No evidence of treatment w/drugs(Statins).Considering the hx of ht disease and diabetes, unless there is good reason not to be on statin (like liver disease) should be. 2) HT Attack: HEDIS measure, if an MI, should be on a Beta Blocker w/in 7 days. Person also has multiple episodes of syncope(fainting). After a HT attack, this waves a flag. No evidence that this had been worked up. Evidence would have been the use of a Holter monitor, for ie. 3) High Blood Pressure and SOB. Care Engine infers that Maybe person has some congestive Ht failure, even though there is no evidence of this diagnosis on a claim. Based on that, thedrug patient is taking to lower their bld pressure, (verapamil) is very bad (is is a Ca Channel Blocker and can weaken ht muscle�which is a bad thing for someone with congestive heart failure. There are lots of other BP drugs. Also, probably should be taking an Ace Inhibitor�which are also known to be good for Diabetics. 4) Diabetes: Good News - Hemoglobin AIC is being monitored. (amt of glucose Red blood cells carry) Typical is 7-8. This person it is 11. HEDIS measure has this monitored every 6 months. Bad News - Hemoglobin AIC is significantly elevated. Means the diabetes is not being well controlled. Patient is on a very tiny dose (5 mg) of glucatrol (pill to control diabetes). May need larger dose. May need insulin therapy. WE FOUND THIS PERSON BASED ON THIS ONE COMPELLING LAB EVENT AND SURFACED issues on drugs shouldn�t beon, drug dosage that needs adjusting, possible omission of care, the need for futrher monitoring. SO WHAT NOW?Let�s follow patient A through the Care Engine process. WE FOUND PATIENT A BECAUSE OF THAT ONE COMPELLING PIECE OF LAB DATA. In this case, a Cholesterol > 240. This needs to be looked at. Maybe diet and exercise will help. Maybe pA already is taking medicine for it. But, now the care Eng looks at all the data for patient A. It builds a whole record for Patient A and finds that not only is the Cholesterol high, but A has also had a heart attack (claim data). Consulting Umnotes, see that the Blood Pressure is high and there are reports of shortness of breath, And, A has diabetes. Now, its not just high cholesterol. But looking in the context of all the data, the care engine can identify a number of potential drug / disease issue. 1)High Cholesterol -No evidence of treatment w/drugs(Statins).Considering the hx of ht disease and diabetes, unless there is good reason not to be on statin (like liver disease) should be. 2) HT Attack: HEDIS measure, if an MI, should be on a Beta Blocker w/in 7 days. Person also has multiple episodes of syncope(fainting). After a HT attack, this waves a flag. No evidence that this had been worked up. Evidence would have been the use of a Holter monitor, for ie. 3) High Blood Pressure and SOB. Care Engine infers that Maybe person has some congestive Ht failure, even though there is no evidence of this diagnosis on a claim. Based on that, thedrug patient is taking to lower their bld pressure, (verapamil) is very bad (is is a Ca Channel Blocker and can weaken ht muscle�which is a bad thing for someone with congestive heart failure. There are lots of other BP drugs. Also, probably should be taking an Ace Inhibitor�which are also known to be good for Diabetics. 4) Diabetes: Good News - Hemoglobin AIC is being monitored. (amt of glucose Red blood cells carry) Typical is 7-8. This person it is 11. HEDIS measure has this monitored every 6 months. Bad News - Hemoglobin AIC is significantly elevated. Means the diabetes is not being well controlled. Patient is on a very tiny dose (5 mg) of glucatrol (pill to control diabetes). May need larger dose. May need insulin therapy. WE FOUND THIS PERSON BASED ON THIS ONE COMPELLING LAB EVENT AND SURFACED issues on drugs shouldn�t beon, drug dosage that needs adjusting, possible omission of care, the need for futrher monitoring. SO WHAT NOW?

23. Southwest Health Alliance Identified Care Considerations Ranked by severity 1, 2, or 3. Reviewed by physicians and possibly specialists Appropriate recommendations communicated to the treating physician Recommendations accompanied by current supporting medical literature A Clinical Level One Recommendation is communicated by a Clinician to Clinician phone call.. Supporting evidence is provided. Might the case of a direct drug to drug interaction. A Clinical Level II Recommendation may prompt a phone call or a fax to the treating physician. Like an elevated PSA test result that doesn�t seem to have been followed up on. A Clinical Level II Recommendation is communicated by a fax or letter, but always with the supporting documentation.A Clinical Level One Recommendation is communicated by a Clinician to Clinician phone call.. Supporting evidence is provided. Might the case of a direct drug to drug interaction. A Clinical Level II Recommendation may prompt a phone call or a fax to the treating physician. Like an elevated PSA test result that doesn�t seem to have been followed up on. A Clinical Level II Recommendation is communicated by a fax or letter, but always with the supporting documentation.

24. Southwest Health Alliance Rapid Deployment of Medical Knowledge A summary of New England Journal of Medicine January, 2000, article showing the prescription medicine Ramipril significantly reduces strokes, myocardial infarctions, and death in a broad range of high-risk patients, is sent to treating physicians of identified high risk patients.

25. Southwest Health Alliance Care EngineSM Services For Whom? Employers Health Plans/TPA�s Medicaid State/Federal Governments Medicare Supplement/Risk

26. Southwest Health Alliance Unique Competitive Position SWHA Exclusive Independent Control of all claims data Advanced reporting capabilities One-stop shop for your health plan needs

27. Southwest Health Alliance Unique Competitive Position URAC accredited pre-cert/UR/Case and Disease Management Specialty managed care products Internet Custom Directories Geo Access Capabilities Aggressive Fee Schedules

28. Southwest Health Alliance Questions

29. What does all this mean? How will the CareEngineSM impact my Health Care Plan?

30. Southwest Health Alliance Care EngineSM Service Often Reduces� Misdiagnoses Ineffective drug prescriptions Adverse drug interactions Unneeded lab tests Unnecessary treatments Length of recovery Costly repeat visits to the doctor

31. Southwest Health Alliance Return on Investment (ROI) Merrill Lynch found high cost claims (>$50,000) fell from 3.3/1000 in 1995 to 2.2/1000 in 1999 Wall Street Journal, May 23, 2000 Merrill Lynch per employee health cost is now 24% below the national peer group average Wall Street Journal, May 23, 2000 Can you afford Not to do this? Can you afford Not to do this?

32. Southwest Health Alliance The ROI Impact of

33. Southwest Health Alliance The ROI Impact of

34. Southwest Health Alliance The ROI Impact of

35. Southwest Health Alliance The Difference Focus on Effective Delivery of Health Care Affordable Prices Satisfied Employees Predictable Costs

36. Southwest Health Alliance The SWHA Advantage Employer Driven Solutions Exclusive HealthEOS product offering Near and long-term cost savings Focus on improved employee productivity Constant flow of employer-sponsored innovation Purchaser-direct dialogue with health care suppliers

37. Southwest Health Alliance The Southwest Health Alliance To Join SWHA and Price HealthEOS Contact: Peter Cerchiara, Jr., Board Chair (peter.cerchiara@swhealthalliance.org) Tom Sawyer, President (tom.sawyer@swhealthalliance.org) Phone: 480-970-1724 www.swhealthalliance.org