Prevention in Medicare Managed Care Plans

2. Session Outline Background Medicare Medicare Managed Care Performance of Managed Care Overview of Prevention Highmark Strategies for Prevention

3. 1945 - President Truman proposed a National Health Program 1965 - President Johnson signs Medicare Bill 1945 - President Truman proposed a National Health Program 1965 - President Johnson signs Medicare Bill

4. An acute care model for care.An acute care model for care.

5. 1965: People aged > 65 who are eligible for  Social Security. 1972 Social Security disabled population Most People with End Stage Renal disease (Note: populations covered by Social Security have been increasing over time; i.e. state employees 1965: People aged > 65 who are eligible for Social Security. 1972 Social Security disabled population Most People with End Stage Renal disease (Note: populations covered by Social Security have been increasing over time; i.e. state employees

6. 1965 elderly 35.2% in poverty compared to below 65 17% One in seven is member of a racial or ethnic minority and visits to doctors 4.8 and by 1971 7.3 ESRD and those with disabilities 1965 elderly 35.2% in poverty compared to below 65 17% One in seven is member of a racial or ethnic minority and visits to doctors 4.8 and by 1971 7.3 ESRD and those with disabilities

8. Medicare Managed Care Definition Corporate or organizational involvement in the financing of healthcare delivery In western PA managed care began in 1995 with the SecurityBLUE product 20% of seniors enrolling in SecurityBLUE did not have Medigap coverage. This represents a different demographic group In western PA managed care began in 1995 with the SecurityBLUE product 20% of seniors enrolling in SecurityBLUE did not have Medigap coverage. This represents a different demographic group

9. HIGHMARK BLUE CROSS BLUE SHIELD Pennsylvania-based nonprofit corporation Provides a range of insurance products to its approximately 4 million members in the state and across the nation One of the nation�s largest Blue Cross Blue Shield plans 40 counties 93 hospitals Over 200 SNF Over 3600 PCP For 65 years, serving seniors and started serving in 1965 local plan had 250,000 and result was switchboard flooded No computers, claims and payment on IBM punch cards Covered 40 hospital deductible, Part B co-payments and SNF co-payments. HIGHMARK BLUE CROSS BLUE SHIELD Pennsylvania-based nonprofit corporation Provides a range of insurance products to its approximately 4 million members in the state and across the nation One of the nation�s largest Blue Cross Blue Shield plans 40 counties 93 hospitals Over 200 SNF Over 3600 PCP For 65 years, serving seniors and started serving in 1965 local plan had 250,000 and result was switchboard flooded No computers, claims and payment on IBM punch cards Covered 40 hospital deductible, Part B co-payments and SNF co-payments.

10. Medicare Managed CareSuccess or Failure? Success* High member satisfaction with costs Lower hospital admission Shorter length-of-stay Less use of expensive test and procedures Greater use of preventive services Clinical care quality and outcomes for several conditions equal or better than fee-for-service Several cancers diagnosed at earlier stage Failure* Does not control cost No difference in clinical outcomes Stroke care and outcome better in fee-for-service Provider and member dissatisfaction with utilization management

11. Medicare Managed CareSuccess Clinical Outcomes Less likely to have breast cancer diagnosed at late-stages Earlier diagnoses of cervix and colon cancer, and melanoma Hypertensives received better care in MCO than FFS AMI care and outcome better in MCO UPMC researchers found mortality found to be lower across admission types for those covered by MCO Additional primary care visits in MCO residents in long-term care reduced emergency room utilization All compared to FFSAll compared to FFS

12. The Highmark Experience Success when compared to FFS or Competitors! High member satisfaction Low disenrollment Network quality Greater % of board certification physicians Utilization of preventive care such as mammography Plan outcome experience reported in aggregate with HCFA (now CMS) Better than FFS over multiple conditions* Similar functional status and readmission rates after hospitalization*

16. Quality Adjusted Life Years

17. Part B benefits 1981 PAP, MMR, Immunizations 1997 Elimination of the co-pay significantly increase flu immunizationPart B benefits 1981 PAP, MMR, Immunizations 1997 Elimination of the co-pay significantly increase flu immunization

18. Highmark Medicare Advantage Cover all Medicare preventive services Additional services* or frequency**, less cost sharing Routine vision care* Exam and corrective lenses Dental Care* Oral exam and cleaning q 6 months Routine hearing services and care* Annual hearing exam Allowance for hearing aids Broader immunization coverage* Abdominal aortic aneurysm screening for males* Annual wellness physical examination** Annual gynecologic examination** Cost sharing is minimized compared to FFSCost sharing is minimized compared to FFS

19. Cost of Preventable Diseases Obesity is quickly catching up with tobacco as the leading cause of death in the United States. (Washington Post, March 10, 2004) Treating these conditions is costly to everyone involved. In 2002, Highmark spent more than $1.1 billion in in-patient and out-patient costs for only 10 of 29 co-morbidities closely associated with obesity. Nearly 28 percent of those costs in the chart in Figure A are attributable to being overweight. Obesity is quickly catching up with tobacco as the leading cause of death in the United States. (Washington Post, March 10, 2004) Treating these conditions is costly to everyone involved. In 2002, Highmark spent more than $1.1 billion in in-patient and out-patient costs for only 10 of 29 co-morbidities closely associated with obesity. Nearly 28 percent of those costs in the chart in Figure A are attributable to being overweight.

20. Preventive Health Gaps in Care 2005 JAMA Pham, et al. Concluded the delivery of routine preventive services is suboptimal for Medicare beneficiaries Diabetic eye exam 43-48.9% HgA1C 48.4-61.2% Colon cancer screening 8.5-10% Influenza vaccination 39.2-52.1% Pneumococcal vaccination 6.4-8.2% Consistent with findings of landmark Community Quality Index study by Rand Corp 2003 NEJM �Delivery of Preventive Services to Older Adults by PCPs��Delivery of Preventive Services to Older Adults by PCPs�

21. On the continuum, the least clinical or less hands-on approach includes Internet and Telephonic programs where people may participate on their own time and at their convenience�at home, at work, etc. The mid-range focus is Worksite Wellness and community-based programming. Highmark�s comprehensive worksite wellness program provides Sales staff with an advantage over many other insurer�s products because it is a tool employers can use to manage their health care costs over the long term. The intense approach involves the expertise of clinical staff, such as dietitians or exercise physiologists, to administer the program. (HOPE, Ornish) Highmark utilizing a programatic approach to address: nutrition, exercise, stress management and smoking cessation. Highmark will work towards preventing the chronic diseases that affect our members the most (cancer, coronary artery disease, obesity, etc.) On the continuum, the least clinical or less hands-on approach includes Internet and Telephonic programs where people may participate on their own time and at their convenience�at home, at work, etc. The mid-range focus is Worksite Wellness and community-based programming. Highmark�s comprehensive worksite wellness program provides Sales staff with an advantage over many other insurer�s products because it is a tool employers can use to manage their health care costs over the long term. The intense approach involves the expertise of clinical staff, such as dietitians or exercise physiologists, to administer the program. (HOPE, Ornish) Highmark utilizing a programatic approach to address: nutrition, exercise, stress management and smoking cessation. Highmark will work towards preventing the chronic diseases that affect our members the most (cancer, coronary artery disease, obesity, etc.)

22. Highmark Resources Supporting Seniors Preventive Health Services SilverSneakers Program Chronic Condition Management Quality Management Department Care and Case Management SecurityBLUE Medical Director Geriatric Advisory Board

24. Highmark Osteoporosis Prevention and Education (HOPE) Program is a 6-week program developed in 1999 to reduce fracture risk and improve quality of life through lifestyle modification Participants meet one day/week for 2 hours Program focuses on strength training exercise, nutrition and medication counseling, social support and stress management Team members include: registered dietitian, exercise physiologist, group support facilitator, program administrator, medical director and pharmacist Eight Week Outcomes for the First 17 Cohorts (n=375) March 10, 2004 Knowledge Assessment Strength Flexibility (inches) Balance Fitness Nutrition Mins Aerobic Exercise Time per Wk Strength Training % Recommend Calcium % Recommend Vitamin D Average age 67 for results accumulated 9/04 to 6/05 86 participants Chair Stands in 30 Sec Arm Curls in 30 Sec Eight Week Outcomes for the First 17 Cohorts (n=375) March 10, 2004 Knowledge Assessment Strength Flexibility (inches) Balance Fitness Nutrition Mins Aerobic Exercise Time per Wk Strength Training % Recommend Calcium % Recommend Vitamin D Average age 67 for results accumulated 9/04 to 6/05 86 participants Chair Stands in 30 Sec Arm Curls in 30 Sec

25. Essentially non-smokers with CHD or CHD equivalent 1998 JAMA study, quantitative coronary angiography showed reduction of stenosis compared to control group where progression was noted. Essentially non-smokers with CHD or CHD equivalent 1998 JAMA study, quantitative coronary angiography showed reduction of stenosis compared to control group where progression was noted.

27. The "reversal" diet is a whole foods vegetarian diet high in complex carbohydrates, low in simple carbohydrates (e.g. sugar, concentrated sweeteners, alcohol, white flour), and very low in fat (approximately 10% of calories). Those few plant-based foods that are high in fat are excluded, including all oils (other than 3 grams per day of flaxseed oil or fish oil to provide additional omega-3 fatty acids), nuts, and avocados. The diet consists primarily of fruits, vegetables, grains, and beans (including soy-based foods) supplemented by moderate amounts of nonfat dairy and egg whites. The "reversal" diet is a whole foods vegetarian diet high in complex carbohydrates, low in simple carbohydrates (e.g. sugar, concentrated sweeteners, alcohol, white flour), and very low in fat (approximately 10% of calories). Those few plant-based foods that are high in fat are excluded, including all oils (other than 3 grams per day of flaxseed oil or fish oil to provide additional omega-3 fatty acids), nuts, and avocados. The diet consists primarily of fruits, vegetables, grains, and beans (including soy-based foods) supplemented by moderate amounts of nonfat dairy and egg whites.

29. For those with CHD, baseline utilization was similar for the intervention group ($5378) and the matched control group ($5344). For the next three years, the utilization for the intervention group decreased 8.7% to an average of $4911, while the utilization for the control group increased 47.2% to an average of $7867, an average reduction of $2956 per patient per year (p<.009). For those with only risk factors, baseline utilization was similar for the intervention group ($2302) and the control group ($2305). For the next three years, the utilization for the intervention group increased 55.0% to an average of $3568, while the utilization for the control group increased 131.3% to an average of $5330, an average reduction of $1762 per patient per year (p<.06). For those with CHD, baseline utilization was similar for the intervention group ($5378) and the matched control group ($5344). For the next three years, the utilization for the intervention group decreased 8.7% to an average of $4911, while the utilization for the control group increased 47.2% to an average of $7867, an average reduction of $2956 per patient per year (p<.009). For those with only risk factors, baseline utilization was similar for the intervention group ($2302) and the control group ($2305). For the next three years, the utilization for the intervention group increased 55.0% to an average of $3568, while the utilization for the control group increased 131.3% to an average of $5330, an average reduction of $1762 per patient per year (p<.06).

30. CMS includes the program elements bundled as cardiac rehabilitation.CMS includes the program elements bundled as cardiac rehabilitation.

31. The SilverSneakers� Fitness Program A unique physical activity, lifestyle, and social oriented health and wellness program specifically designed for Medicare-eligible members of all fitness levels 1.9 million eligible older adults Over 34,000 participants per day The SilverSneakers� Fitness Program: Show Clip here? Since 1996 when the program first became available, SilverSneakers has grown to cover over 1.9 million older adults through more than 50 health plans in 41 states (will be 44 by Jan 2006 plus Puerto Rico). Medicare Advantage in 1996 and Medicare supplemental in 2001. Highmark: 120,00 Medicare Supplement and 193,000 Medicare Advantage (through Oct 2005). Vendor Selection Criteria: Program consistency�in delivery, marketing, quality, and focus. Ability to develop a network and reach more members. Win-win arrangement with partners Affordability for health plan and member Safe, accessible, and attractive venues Programming designed for older adults Strategies for engaging members Program deliverables The SilverSneakers� Fitness Program: Show Clip here? Since 1996 when the program first became available, SilverSneakers has grown to cover over 1.9 million older adults through more than 50 health plans in 41 states (will be 44 by Jan 2006 plus Puerto Rico). Medicare Advantage in 1996 and Medicare supplemental in 2001. Highmark: 120,00 Medicare Supplement and 193,000 Medicare Advantage (through Oct 2005). Vendor Selection Criteria: Program consistency�in delivery, marketing, quality, and focus. Ability to develop a network and reach more members. Win-win arrangement with partners Affordability for health plan and member Safe, accessible, and attractive venues Programming designed for older adults Strategies for engaging members Program deliverables

32. Member Engagement Strategies  Fitness center membership at no cost Easy enrollment with no fees or contract SilverSneakers classes taught by certified instructors Direct marketing to the member Clinician referrals Special outreaches Enrollment in the program is easy. Members are required to complete an Activity Readiness Assessment prior to exercising, and are referred to their provider for clearance if necessary. ( 3% of members enrolled to date required a clinician�s release for exercise � may be understated.) Each site offers SilverSneakers group exercise classes designed exclusively for the older adult to increase strength, flexibility, balance, and energy. Staff at each location are trained to adhere to the program�s quality assurance and senior-focused standards. In addition, each site designates a senior advisor to provide the members with information and personalized service. SilverSneakers marketing materials are sent to the general health plan membership to engage them in the program as well as specialized messages to reach specific risk groups, like diabetics for example. Enrollment in the program is easy. Members are required to complete an Activity Readiness Assessment prior to exercising, and are referred to their provider for clearance if necessary. ( 3% of members enrolled to date required a clinician�s release for exercise � may be understated.) Each site offers SilverSneakers group exercise classes designed exclusively for the older adult to increase strength, flexibility, balance, and energy. Staff at each location are trained to adhere to the program�s quality assurance and senior-focused standards. In addition, each site designates a senior advisor to provide the members with information and personalized service. SilverSneakers marketing materials are sent to the general health plan membership to engage them in the program as well as specialized messages to reach specific risk groups, like diabetics for example.

33. Highmark Member Participation 41,291 Highmark members are enrolled in the SilverSneakers Fitness Program as of January 2006 - 13.1% of membership. 17,138 members actively participated in the fitness centers in January 2006 accumulating 130,158 fitness center visits - average of 7.6 fitness center visits per participant. An additional 790 Highmark members are enrolled in the SilverSneakers Steps Program. The Steps program is an option that is used when members are farther than 15 miles from a fitness center. There has been tremendous growth in fitness centers in the area (from 123 to 150 (22% increase) as of Nov 2005), thus reducing the need for members to use this option. The number of Steps enrollees has declined (from 1,243 a year ago). The Steps program is an option that is used when members are farther than 15 miles from a fitness center. There has been tremendous growth in fitness centers in the area (from 123 to 150 (22% increase) as of Nov 2005), thus reducing the need for members to use this option. The number of Steps enrollees has declined (from 1,243 a year ago).

34. Highmark�s Member Profile Average age: 70.9 years (12% are 80+) Gender: 41% male Multiple chronic conditions: 72% Exercising < 3 times per week: 54% Sedentary lifestyle: 29% Overweight or obese: 69% Smokers: 3% No prior fitness center membership: 74% We started offering the program to our members in January of 2004 with a lead time of only 3 months. So far we�ve had tremendous success in getting more than 37,000 members to join. Note: The profile data shown on this slide represents members as they look when they first enroll. - exercise < 3 times per week � prior to joining SilverSneakers (54%) - sedentary lifestyle � prior to joining SilverSneakers (29% � based on 0 or 1 time per week of exercise). - overweight � prior to joining SS. - smoking � before joining, members smoking was 3%; only 2% reported still smoking after 1 year (from the 2004 HSS Yr 1 cohort follow up). - prior fitness membership � hasn�t changed. The members who join look similar to those of the other Blues plans (from HCD other Blues profiles). - Average age: 73 years (13% are 80+) - Gender: 43% male - Multiple chronic conditions: 67% - Exercising < 3 times per week: 49% - Sedentary lifestyle: 30% - Overweight or obese: 68% - No prior fitness center membership: 72% The program is attracting members who can certainly benefit from more physical activity � members who may already have health risks from sedentary lifestyles or chronic disease � and it�s engaging members who haven�t previously used fitness centers. We started offering the program to our members in January of 2004 with a lead time of only 3 months. So far we�ve had tremendous success in getting more than 37,000 members to join. Note: The profile data shown on this slide represents members as they look when they first enroll. - exercise < 3 times per week � prior to joining SilverSneakers (54%) - sedentary lifestyle � prior to joining SilverSneakers (29% � based on 0 or 1 time per week of exercise). - overweight � prior to joining SS. - smoking � before joining, members smoking was 3%; only 2% reported still smoking after 1 year (from the 2004 HSS Yr 1 cohort follow up). - prior fitness membership � hasn�t changed. The members who join look similar to those of the other Blues plans (from HCD other Blues profiles). - Average age: 73 years (13% are 80+) - Gender: 43% male - Multiple chronic conditions: 67% - Exercising < 3 times per week: 49% - Sedentary lifestyle: 30% - Overweight or obese: 68% - No prior fitness center membership: 72% The program is attracting members who can certainly benefit from more physical activity � members who may already have health risks from sedentary lifestyles or chronic disease � and it�s engaging members who haven�t previously used fitness centers.

35. Reasons for Joining SilverSneakers Members joining an exercise program do so primarily to improve their health and fitness. Recommendations and referrals from their health care provider play an important role in their adoption of a new exercise program. The new HEDIS measure is all the more reason to support that. Members joining an exercise program do so primarily to improve their health and fitness. Recommendations and referrals from their health care provider play an important role in their adoption of a new exercise program. The new HEDIS measure is all the more reason to support that.

36. SilverSneakersProgram Measurement Plan Program utilization Physical activity behavior change Acquisition and retention of members Health maintenance/improvement over time Health care utilization and claims cost savings Value of media exposure We are ready to begin our third year offering SilverSneakers and we�ve been surveying our members to track changes in their physical activity behaviors and functional health status. Our IT and Health Economics staff have been designing a claims study to evaluate cost savings that result from physical activity changes. We�re using our risk profiling software to compare the SilverSneakers claims costs with similar members not enrolled in the program. These other measures will help round out the picture in terms of the overall value (return on investment) such a program brings to the health plan. (The gentleman pictured on this page is 77 years old.) We are ready to begin our third year offering SilverSneakers and we�ve been surveying our members to track changes in their physical activity behaviors and functional health status. Our IT and Health Economics staff have been designing a claims study to evaluate cost savings that result from physical activity changes. We�re using our risk profiling software to compare the SilverSneakers claims costs with similar members not enrolled in the program. These other measures will help round out the picture in terms of the overall value (return on investment) such a program brings to the health plan. (The gentleman pictured on this page is 77 years old.)

37. Results to Date High member satisfaction (97%) 84% report overall health improvement 94% reduction in high risk sedentary behavior Avg. 2 days/week increase in physical activity by 50% of enrollees Acquisition impact reported by 30% of new health plan members Early claims study findings demonstrate short-term positive impact on health care costs We are ready to begin our third year offering SilverSneakers and we�ve been surveying our members to track changes in their physical activity behaviors and functional health status. Members are very satisfied with the program and reporting overall health improvements. More importantly, we�ve seen a 94% drop in the number of members who say they are exercising less than once a week. Half of the enrollees are reporting being more active than before they joined SilverSneakers � on average, they�ve added 2 days of exercise per week. We�ve conducted outreach phone calls to 714 new health plan members to date, with 30% of these members saying that SilverSneaekrs was one of the reasons they joined Highmark. Our IT and Health Economics staff have performed a preliminary claims study to evaluate cost savings that result from physical activity changes. We�re using our risk profiling software to match SilverSneakers members with members not enrolled in the program by age, sex, conditions, risk score, and baseline health care costs. 30% claim cost reduction in a cohort of members match similar controls. We are ready to begin our third year offering SilverSneakers and we�ve been surveying our members to track changes in their physical activity behaviors and functional health status. Members are very satisfied with the program and reporting overall health improvements. More importantly, we�ve seen a 94% drop in the number of members who say they are exercising less than once a week. Half of the enrollees are reporting being more active than before they joined SilverSneakers � on average, they�ve added 2 days of exercise per week. We�ve conducted outreach phone calls to 714 new health plan members to date, with 30% of these members saying that SilverSneaekrs was one of the reasons they joined Highmark. Our IT and Health Economics staff have performed a preliminary claims study to evaluate cost savings that result from physical activity changes. We�re using our risk profiling software to match SilverSneakers members with members not enrolled in the program by age, sex, conditions, risk score, and baseline health care costs. 30% claim cost reduction in a cohort of members match similar controls.

38. Results Continued An analysis of 814 Highmark SilverSneakers participants who completed a baseline and one-year follow-up health status survey shows improvement in how they feel about changes in their health since the previous year. 46% responded that they felt much better or somewhat better. 46% responded that they felt much better or somewhat better.

39. Results Continued An analysis of 814 Highmark SilverSneakers participants who completed both a baseline and one-year follow-up health status survey revealed that: Greater physical health status was maintained than would be expected for this group based upon age and chronic conditions. While there is a decline in mental health status, Highmark SilverSneakers participants scores remain higher than seniors nationally Research by the Medicare Outcomes Trust shows that a one point per year decline in physical health status occurs with aging in the absence of disease. When chronic conditions are present, the expected decline is greater. An analysis of 814 Highmark SilverSneakers participants who completed both a baseline and one-year follow-up health status survey revealed that: Greater physical health status was maintained than would be expected for this group based upon age and chronic conditions. While there is a decline in mental health status, Highmark SilverSneakers participants scores remain higher than seniors nationally. Research by the Medicare Outcomes Trust shows that a one point per year decline in physical health status occurs with aging in the absence of disease. When chronic conditions are present, the expected decline is greater. An analysis of 814 Highmark SilverSneakers participants who completed both a baseline and one-year follow-up health status survey revealed that: Greater physical health status was maintained than would be expected for this group based upon age and chronic conditions. While there is a decline in mental health status, Highmark SilverSneakers participants scores remain higher than seniors nationally.

40. Results Continued In a longitudinal study of Highmark SilverSneakers members who screened positive for depression at baseline using the SF-36� tool: - One year later, these members� scores were an average of 8.60 points higher - SF-36� literature reports an average improvement of 3.86 points for older adults screening positive for depression

41. Impact on Highmark Members� Lives �I�ve noticed my physical strength increasing. After each session, twice a week, I leave enjoying a great sense of well being.� � I have noticed a change in my body since I came to the program. I really feel good about myself. Being a diabetic, my doctor always encourages me to exercise. My blood tests this past 3 months have been fantastic. I have also lost 7 pounds since I began the program.� � SilverSneakers has reawakened the �me� in my life. How lucky I am to be a senior eligible for this program.� � I want to thank Highmark for offering this program to we who are kind of over the hill in body, but very much of the mind to stay healthy and prevent the opposite state.�

42. Health Dialog�s support for the �coachable� high needs of individuals and families extends across a broad range of healthcare needs, and includes Chronic Condition Management and Decision Support. The term �coachable� is used to combine two concepts: the extent to which a condition (or conditions) can be positively influenced by telephonic Health Coaching support and the individual�s receptivity to this kind of support. Chronic condition management covers major chronic medical conditions such as asthma, diabetes, CAD, CHF, and COPD, and the co-morbid conditions frequently associated with these chronic conditions. Decision support extends to many other healthcare issues a member may face, including significant medical conditions (back pain, prostate cancer, benign uterine conditions, etc.), symptom management for minor medical events, and help with understanding health information. Health plans find that the Decision Support component is one way Health Dialog�s Collaborative CareSM program is differentiated from other disease management programs and traditional nurse triage lines. It is fully integrated into the disease management component, resulting in a �whole person� approach with greater impact. Health Dialog�s support for the �coachable� high needs of individuals and families extends across a broad range of healthcare needs, and includes Chronic Condition Management and Decision Support. The term �coachable� is used to combine two concepts: the extent to which a condition (or conditions) can be positively influenced by telephonic Health Coaching support and the individual�s receptivity to this kind of support. Chronic condition management covers major chronic medical conditions such as asthma, diabetes, CAD, CHF, and COPD, and the co-morbid conditions frequently associated with these chronic conditions. Decision support extends to many other healthcare issues a member may face, including significant medical conditions (back pain, prostate cancer, benign uterine conditions, etc.), symptom management for minor medical events, and help with understanding health information. Health plans find that the Decision Support component is one way Health Dialog�s Collaborative CareSM program is differentiated from other disease management programs and traditional nurse triage lines. It is fully integrated into the disease management component, resulting in a �whole person� approach with greater impact.

44. Member are encouraged to participate in their health care and take advantage of their Personal Health Coach who provides individualized support and customized follow-up based on need 10,000 calls a month and 25% are inbound Member are encouraged to participate in their health care and take advantage of their Personal Health Coach who provides individualized support and customized follow-up based on need 10,000 calls a month and 25% are inbound

45. Significant Improvement on Many Clinical Measures (Medicare population) 2004 results2004 results

46. Quality Management MCO Preventive Health Activities Annually Preventive Health Schedule Preventive Health Committee Geriatrics Advisory Board SecurityBLUE Medical Director HEDIS� Quantitative Analysis Qualitative Analysis Practitioner-led committees Service Quality Access and availability CAHPS

49. Diabetic Retinal Examinations

50. Quality Management Accomplishments Achieved 90th percentile in 7 of 14 HEDIS measures for Medicare HMO product (statistically significant improvement in 4 measures) HEDIS � Measures: Beta Blocker Treatment after Heart Attack Comprehensive Diabetes HbA1c testing LDL screening Controlling hypertension Follow-Up after Hospitalization for Mental Illness Follow-up 30 days Follow-up 7 days Advising Smokers to Quit

51. QM Accomplishments (continued) SecurityBLUE ranked 5th out of 131 of the best Medicare plans in the U.S. News & World Report/National Committee for Quality Assurance article titled �America�s Best Health Plans 2005� Based on clinical performance, member satisfaction and NCQA accreditation scoring Received national recognition from CMS for participation on the National Health Plan Learning Collaborative to Reduce Disparities and Improve Quality

52. Websites http://www.ahrq.gov http://www.ahrq.gov/clinic/pocketgd.pdf http://www.medicare.gov/health/overview.asp http://www.cms.hhs.gov/ccip/ http://www.hospitalcompare.hhs.gov/ https://www.highmark.com/hmk2/index.shtml https://www.highmarkbcbs.com/ https://www.highmarkblueshield.com/