Melissa Welch, MD, MPH Regional Medical Director, Aetna

1. Taking Action Together to Prevent Heart Attacks and StrokesReaching 90th Percentile Targets: Medical Directors Report on Health Plan Strategies, Programs, Plans, and Achievements 3rd Annual Dean’s Right CareCardiovascular and Diabetes Leadership Summit Melissa Welch, MD, MPH Regional Medical Director, Aetna October 1, 2010  U.C. Berkeley

2. Commercial HMO Demographics Aetna Health of California, Inc. • Number of Commercial HMO enrollees: 389,755 • Demographic profile of enrollees: • Male: 50.3% • Female: 49.7% • Age of enrollees: • 0-19: 26.3% • 20 – 49: 53.1% • 40 – 79: 20.6% • Over 80: 0.045% • Race/Ethnicity of enrollees (voluntary, self-identified – 59%) • African American (3.1%) Asian/Pacific Islander (14.5%) • White (45.5%) American Indian/Alaskan (0.3%) Latino (23.4%) Other (13.2%)

3. 2009 HEDIS® Data Aetna Health of California, Inc. • HMO profile (based on eligible HEDIS population): 1. Number with Heart Disease: 617 • Percent with blood pressure controlled: N/A • Percent with cholesterol controlled: 63.53% 2. Number with Hypertension: 8,169 • Percent with blood pressure controlled: 62.59% 3. Number with Diabetes: 8,269 • Percent with blood pressure controlled: 65.11% • Percent with cholesterol controlled: 46.80% • Percent with HbA1c > 9: 29.98%

4. Aetna Health of California, Inc.HEDIS® 2010 Rates vs. Goals* *Aetna’s goal is to achieve National HEDIS® 90th Percentile for all HEDIS® measures

5. Aetna Quality Management Clinical Improvement Strategy • Each year, Aetna Quality Management forms work groups for targeted HEDIS®Clinical Measures in order to: • Review current Aetna data and review current literature; • Conduct barrier/root cause analysis; • Measure the impact of previous clinical improvement activities; and • Plan, design and implement new clinical improvement activities. • In 2009, target areas included: • Diabetes Eye Care (outreach calls, Member educational DVD’s, Provider outreach); • Heart Care for Life - Persistent Beta-Blocker Initiative. √ • In 2010, targets include: √ • controlling high blood pressure; • cholesterol management; and • diabetes management.

6. Aetna Clinical Improvement Activities – Member Focus • “Numbers To Know®” Hypertension & Cholesterol Management Member Health Education Newsletter • mailed to Aetna members on May 17, 2010 (Handout). • The goals of the hypertension and cholesterol reminder mailing is to promote screening and control of high blood pressure and screening and control of cholesterol levels. • “Know Your Cholesterol” Cholesterol Management Member Health Education Newsletter • mailed to Aetna member or sent via Aetna Quality e-Messages email on August, 16, 2010 (Handout). • The goals of the cholesterol member health education newsletter is to promote screening and control of cholesterol levels.

7. Aetna Clinical Improvement Activities - Member Focus • “Know Your Blood Pressure and Your Medicine” Hypertension Management Member Health Education Newsletter • mailed to Aetna member or sent via Aetna Quality e-Messages email on August 19, 2010 (Handout). • The goals of the hypertension reminder mailing is to promote screening and control of high blood pressure.

8. Aetna Encourages Member Self-Management of Diabetes • Aetna Provides Complimentary Blood Glucose Monitors to Eligible Members with Diabetes!

9. Aetna Clinical Improvement Activities: Member/Provider Focus • Diabetes Targeted Member and Provider Outreach with Follow-Up • Initial member health education letter with copy to his/her primary care physician (PCP) of record was mailed on May 24, 2010 (Handout) and follow-up member outreach was conducted on June 15, 2010 (Handout). • The two goals of the member/provider reminder mailing are to: 1. Improve compliance with three diabetes screenings (i.e. HbA1c, LDL-C, and eye exam) as recommended by the current American Diabetes Association (ADA) guidelines. 2. Indentify any due or missing screenings based on the frequency recommended by ADA guidelines.

10. Aetna Clinical Improvement Activities - Provider Initiatives • “Provider Cholesterol Management Resource Kit” • Goal: To support providers in identifying members who may benefit from cholesterol screening. • A cover letter explaining the purpose of the mailing and a “Provider Cholesterol Management Kit” was mailed on September 1, 2010 (Handout) to Aetna family practitioners, internists and cardiologists. • The “Provider Cholesterol Management Resource Kit” contains: • Program goals and description; • Provider desk reference guide; • Individual provider reports of their Aetna patients who have suffered a cardiac event or who have Ischemic Heart Disease (IHD) and no claims evidence of cholesterol testing; • Chart Reminder Stickers for recording services rendered; • Resource Sheet for patients with websites and telephone numbers to obtain additional information.

11. Aetna Clinical Improvement Activities - Provider Initiatives “Diabetes and Heart Disease Management Resource Kit” • Goal: To encourage all providers to access the American Diabetes Association (ADA) website to obtain a comprehensive toolkit of reproducible patient education handouts on topics related to diabetes and heart disease. • A cover letter explaining the purpose of the mailing and a description of the “Diabetes and Heart Disease Management Resource Kit” developed by the ADA, American College of Cardiology and Preventive Cardiovascular Nurses Association was emailed on April 19, 2010 to all Aetna participating primary care providers (Handout). • The resource kit covers 29 topics, and is available in both English and Spanish.

12. Aetna Clinical Improvement Activities - Provider Initiatives • “Diabetes Clinical Performance Report Initiative” • Goal: to improve provider performance with regard to compliance with the recommended diabetic screenings which include: Diabetes Annual Retinal Exam, Diabetes Annual Lipid Testing, Diabetes Annual HbA1c Level Testing and Diabetes Annual Medical Attention for Nephropathy. • A cover letter explaining the purpose of the mailing and a provider specific “Diabetes Clinical Performance Report” which contains member specific data to construct performance rates for each of the above diabetes measures based on 2009-2010 encounter data was mailed to all providers who had treated at least 4 diabetic members in the designated time frame on August 23, 2010 (Handout). The mailing also included tools to assist in improving diabetes screening rates. • Tools: • Provider Access to NaviNet in order to obtain lists of their members who are in need of diabetes services. • Aetna electronic ‘Care Consideration’ alerts on NaviNet to assist providers in improving diabetes outcomes.

13. CommunityEngagement Aetna Awards $25,000 Grant To Central American Resource Center In San Francisco • 2010, Aetna Foundation, grant of $25,000 awarded to the Central American Resource Center (CARECEN) to support its "Preventing Obesity and Diabetes Among Latinos in San Francisco" program. • Established by Salvadoran refugees in 1986, CARECEN is an immigrant family wellness and empowerment center committed to providing needed services while building community leadership to effect long-term change. • Program's objectives: to help Latino youth in San Francisco avoid obesity and diabetes by instilling in them good nutritional habits and a love for physical exercise. The program also educates participants' parents on cooking, nutrition and health; thus, engaging parents to become strong supporters of the program. Furthermore, this program is set to train eight community-based health promoters on diabetes and obesity prevention, benefits of exercise and best practices for community health promotion to recognize diabetes symptoms and ill effects and when to refer individuals for treatment, as well as conducting culturally appropriate diabetes and obesity prevention and referral. • An example of Aetna’s outreach to improve member health and to close the gap on disparities in medical care in minority communities.

14. Aetna Pharmacy Solutions “Heart Care for Life”- Persistent Beta-Blocker Initiative (2007 – Present) • Description: • To encourage long-term compliance with medication therapy following an heart attack or acute myocardial infarction (AMI).  • Member Mailings over 3 months including treatment information, resources, reminder cards. • Provider email and mailings with links to the medication adherence poster and medication adherence assessment form. • Initiative Goal: • To reinforce the importance of medication adherence and provide comprehensive educational information for members recovering from a heart attack. • Target Population: • Members 18 years and older newly identified via claims data with a discharge for heart attack or AMI within the last 90 days.

15. Aetna Pharmacy Solutions “Super Value Diabetes Care Program (DCP)” • Description: • Group or One-to-One Member Education Program consisting of a comprehensive diabetes self-management training by a Diabetes Care Program (DCP) Professional. Program directed by specially trained pharmacists in 15 states. • Individual Baseline Assessment: Insulin-administration education on an individual basis. • Follow-up assessment of established goals at six (6) month to twelve (12) month intervals on a group or individual basis. • Classes are limited to not more than twenty (20) participants which also includes significant others. Provider tracks Member attendance and provide follow-up opportunities for enrolled participants to make up missed sessions. • Initiative Goals: • Improve member education related to diabetes and the management of co-morbidities related to diabetes. • Empower members who have diabetes to take an active role in the management of their disease. • Increase accessibility to diabetic education services. • Target Population: • Members 18 years and older newly identified via claims data with a diagnosis of diabetes within the last 90 days.

16. Results & Lessons Learned Describe lessons learned from evaluation of the process and outcomes and Barriers to decreasing heart attacks, strokes and complications of diabetes: • Health Plan physicians, appropriately, do not render care • Member non-compliance with medication, diet and exercise. • Provider non-adherence to accepted professional clinical practice guidelines. • Lack of communication between providers. • Lack of provider access to complete patient medical records via electronic medical records of prescriptions, medical visits, lab tests, etc.

17. Results & Lessons Learned What is working? What isn’t? Why? What changes are being made? Aetna supports: • Motivational Interviewing techniques and coaching to address member non-compliance. • Wellness Programs and consumer-directed Benefit Plan design to encourage healthy choices. • 100% coverage of preventive care • Pay For Performance programs to help address provider non-adherence with professional clinical practice guidelines. • Community outreach efforts and educational programs • Provider electronic medical records adaptation

18. Resources Needed • Barriers to achievement that the Right Care Research team may be able to assist with meeting (performance at or above the 90th percentile ranks nationally) in heart disease, hypertension and diabetes. • Moving forward, what additional resources (e.g., increased funding for CQI, information, support, or collaborative action) does your plan need to achieve or exceed the 90th percentile targets? • What activities can health plans take among themselves and/or with medical groups and /or vendors to move your health plan’s performance into the 90th percentile ranks nationally?