Service Line Strategy Advisor

1. Service Line Strategy Advisor Women’s Health Trends Ready to Use Presentation Slides Prepared July 2014

2. Technology Service Line Strategy Market Forces Evaluating Opportunities in Women’s Health Growth and Financial Outlook

3. Market Forces Reshaping Women’s Services Strategy Four Trends Shifting Competitive Dynamics Source: Service Line Strategy Advisor research and analysis. Market Forces Impacting Women’s Health 1 2 3 4 Increasingly Savvy Patients Focus on Health and Wellness Continued Economic Challenges Emphasis on Patient Loyalty • Patients first looking to online sources for information on health condition, rather than relying solely on physicians • Direct to consumer marketing inspiring patients to approach physicians on new procedures or techniques • Incidence of chronic disease, multiple comorbidities rising • Keeping patients out of EDs to decrease overcrowding • Hospital payment at-risk for unnecessary readmissions • Insurers incentivizing patients to take a greater role in personal health • Many patients continue to experience economic hardship with many having lost insurance • Patients moving to high deductible plans making them wary of elective procedures, imaging • Increasing number of patients qualify for Medicaid decreasing per-case profits • Hospital mergers creating larger systems with more insular referral networks • New payment models place risk on hospital for all care received, regardless of institution • Word-of-mouth advertising remains a primary method for determining provider of choice Consumerism Population Health

4. Research Points to Key Differences in Women Symptoms and Treatments Vary By Gender Source: Service Line Strategy Advisor research and analysis; “Women and Men: 10 Differences that Make a Difference” SWHR, available at: http://www.womenshealthresearch.org/site/PageServer?pagename=hs_sbb_10diff (accessed September 21, 2011) Emergence of Gender-Based Medicine Identifying Differences in Women’s Health

5. Definition of Women’s Health Extends Beyond OB/GYN Demographic Shift Driving Demand For New Services Source: Service Line Strategy Advisor research and analysis; HealthLeaders Media, “A Comprehensive Women’s Health Service Line: Lessons From North Shore–LIJ,” available at: http://www.healthleadersmedia.com/rounds/rounds_detail.cfm?content_id=281516, accessed September 17, 2012.. Aging Population Women’s Orthopedics MFM ” Behavioral Health The percentage of women aged 40-45 will increase by 85% across the next decade Home Health Women’s Cardiovascular Normal and High-Risk OBGeneral Gynecology Osteoporosis Screening Breast Health Urogynecology Elevated Purview of Women’s Services “It’s a major priority for us as an organization because we have to get way, way beyond thinking of women’s health as being limited to pregnancy and delivery. It’s not an easy thing to do because women’s health, in many ways, is almost everything.” Michael J. Dowling, President & CEO, North Shore-LIJ Health System “A Comprehensive Women’s Health Service Line: Lessons From North Shore–LIJ”

6. Shift To Population Health Source: Service Line Strategy Advisor research and analysis. Catering to Different Stages of Life Allows Targeted Approach to Women’s Competitive Programs Reach Across Continuum Spectrum of Services Required Across Life Stages Service Opportunities Across All Life Stages • Primary Care • Behavioral Health • Sexual Health Young Women Service Opportunities Mid-life and 65+ Service Opportunities • Gynecologic Health (including office visits, screening exams) • Obstetrical Care • Infertility Services • Sports Medicine • Urogynecology • Breast Health • Osteoporosis • Digestive Health • Heart Health 1 in 3 75+ Women in their 40’s have need for service Pediatrics 13-17 18-40 40-55 55-75

7. Utilization is Greater Among Women Childbirth and Longer Life Lead to Higher Proportion of Inpatient Stays Healthcare Consumerism Number of Hospital and Non-Hospital Visits Advisory Board Company Estimates 2013 Estimates Healthcare Utilization Over Time Healthcare Cost and Utilization Project Percent of All Hospital Discharges, 2009 Source: Service Line Strategy Advisor research and analysis; Advisory Board Company Inpatient and Outpatient Market Estimators; Databases and Related Tools from the Healthcare Cost and Utilization Project (HCUP). Fact Sheet. AHRQ Publication No. 10-P009-EF, March 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/data/hcup/datahcup.htm

8. Pressure to Establish Patient Loyalty Providers Using Many Strategies to Lock in Women Source: Service Line Strategy advisor research and analysis; Marketing and Planning Leadership Council interviews and analysis. Healthcare Consumerism • Patient Navigation • Educates about services and conditions • Schedules appointments and follow-up care • Provides counseling, helps to establish health goals • CollaborativeSpecialty Care • Multidisciplinary team creates comprehensive care plan across providers • Coordinated across continuum • Personalized Primary Care • Team available to patient for access, education, decision support • Focus on both chronic and preventive services • Incorporates health activities • Patient Access to Information • Convenient access to personal health information, and scheduling appointments • Reliable and comprehensive sources to support patient engagement Female Consumer • Convenient • Sites of Care • Available when and where patient needs care • Easy to find, low-acuity options • Outcomes-Driven • System Activation • Sensitive to minor changes in individual health status • Tracking to identify target groups for prioritization, targeted community needs • Community Partner • Collaborative with employers, community groups • Ongoing education • Target underlying drivers of population health

9. Technology Service Line Strategy Market Forces Evaluating Opportunities in Women’s Health Growth and Financial Outlook

10. Softening Demand in Labor and Delivery Demographics Changing the Median of Demand Source: Service Line Strategy Advisor research and analysis; Advisory Board Data and Analytics Group; Marketing and Planning Leadership Council interviews and analysis; Centers for Disease Control and Prevention, National Center for Health Statistics, VitalStats, available at: http://www.cdc.gov/nchs/vitalstats.htm, accessed May 24, 2011; Sutton, Paul, “Recent Trends in Births and Fertility Rates Through June 2010,” available at: http://www.cdc.gov/nchs/data/hestat/births2010/births2010.pdf, accessed May 24, 2011; Centers for Disease Control and Prevention, Infertility FAQs, available at: http://www.cdc.gov/reproductivehealth/infertility/, accessed August 14, 2012; Demographics Shifting Demand Outpatient Market Projections National, All-Payer National, All-Payer Inpatient Market Projections Total Births Per 1,000 Persons (Total Population) • 1999-2012 5-Year Growth Rate 7% Opportunities for Women’s Midlife Health Care • Mammography and subsequent procedures for breast cancer • Menopause and associated care including hormone replacement therapy • Incontinence and pelvic floor disorders • Weight-loss management • Depression screening • Cardiovascular screening • Colonoscopy • Osteoporosis management 9%

11. Subspecialties Poised for Growth Source: Service Line Strategy Advisor research and analysis; Marketing and Planning Leadership Council interviews and analysis. Demographics Shifting Demand Five-Year Inpatient Growth 2013-2018 Five-Year OutpatientGrowth 2013-2018 Specialty Assessment • Underutilized services with good payer mix • Marketing/education needed to overcome stigma and embarrassment 7% 9% Urogynecology • Shortage of trained specialists, potential overlap with general oncologists and RT • Opportunity to highlight expertise through women’s services 0% 28% Gynecologic Oncology • Significant investments made already to differentiate • Tomosynthesis foothold increasing, disrupting volumes - 9% Women’s Imaging • High paying service, however high cost • Coordination with prenatal programs to capture high-risk cases early 0% - Neonatology • Increased incidence in diabetes, obesity, etc. driving complex pregnancies • Opportunity to use telemedicine -3% 9% MFM • Demand driven by women delaying pregnancy • Success rates on interventions improving • More states covering services - 12% REI

12. Advisory Board Company 2012 National Outpatient Service Line Statistics Gynecologic Oncology: only includes Gynecologic Surgical Oncology sub-service line Inpatient Services Outlook Source: Service Line Strategy Advisor research and analysis; Advisory Board Company Inpatient Estimators. OB Still IP Volume Driver Despite Slowing Growth Growth Prospects Market and Finances Volume Mix Estimated Growth Rate, 2013-2018 Medical Gynecology 2013 Volume Gynecologic Surgery 498K Gynecologic Surgery MFM 324K Neonatology General Gynecology 61K Obstetrics 1.2M Neonatology 67K Gynecologic Oncology 3.9M Obstetrics 596K Urogynecology 71K Breast Health

13. Outpatient Services Outlook Advisory Board Company 2012 National Outpatient Service Line Statistics Source: Service Line Strategy Advisor research and analysis; Advisory Board Company Outpatient Estimators. Significant OP Opportunities Across Sub-Specialties Growth Prospects Market and Finances Volume Mix Estimated Growth Rate, 2013-2018 Obstetrics 2013 Volume Gynecologic Surgery Obstetrics 1.3M 7.7M General Gynecology Urogynecology 1.5M Gynecologic Surgery General Gynecology 2.9M MFM 40M Women’s Imaging 7.6M Urogynecology 2.6M Breast Health Women’s Heart 36.5M REI 1.4M Women’s GI 10.2M Gynecologic Oncology 2K

14. Technology Service Line Strategy Market Forces Evaluating Opportunities in Women’s Health Growth and Financial Outlook

15. New Growth Objectives for Women’s Programs Source: Service Line Strategy Advisor research and analysis; Marketing and Planning Leadership Council interviews and analysis. Redefining Women’s Health for Value-Based Compensation 1 2 3 Competing for Share Ensuring Patient Retention Activating Patients in Health Outcomes • Competing for share of profitable volumes • Establishing high-end subspecialty niche • Investing in new technology for advanced treatment modalities • Increasing access, convenient sites of care • Brand awareness and continuity • Care coordination, collaborative specialty care • Strengthening referral network integrity • Continuing patient, provider education • Wellness and prevention services • Community engagement and needs assessment • Offering technology platforms for self monitoring

16. Redefining Women’s Health for Value-Based Compensation Source: Service Line Strategy Advisor research and analysis. Coordination Infrastructure Critical for Success Four Key Components of Service Line Strategy Comprehensive Offerings Care Pathway Development and Planning Centralized women’s health offerings retain patients seeking care across different life stages, and promote multidisciplinary care Patient satisfaction improved by smooth care pathway and protocols more easily followed with standardized care Referrals Management Physician Engagement Streamlined referral pathways incentivize providers to keep patients in the system Strong relationships between physicians and administration enhances communication and increases likelihood of success of new programs

17. Variety of Models Deliver Comprehensive Offering Selecting Model That Complements Available Resources Cross-Continuum Service Line Models Source: Service Line Strategy Advisor research and analysis. • Virtual Women’s Center • Co-Located Providers • “One-Stop Shop” Day Clinic • “Gateway” Provider Most services housed under non-women’s outpatient clinics Procedures, consults coordinated by nurse navigators or dedicated schedulers, who may also be involved in patient education Low-cost option for providing women’s services and minimize duplication Requires concerted marketing efforts Single provider conducts initial patient education assessments Refers patients to specialists as appropriate Often an OB/GYN, nurse, or nurse practitioner with interest in women’s midlife care Using a midlevel provider mitigates “turf wars” Co-located providers at either an on-campus or off-campus facility Appointments booked either independently or with assistance from a clinical coordinator Emphasis on branding midlife center important to make program more than just a building Multiple, coordinated appointments with physicians in the same facility, on-campus or off “One stop shop” day clinic differentiates itself from simply co-locating providers by seamlessly integrating appointments Novel offerings include spa-like amenities and architecture, resource library, health coach Program Comprehensiveness Ease of Implementation Decentralized Models Single-Site Models

18. Source: Service Line Strategy Advisor research and analysis. Service Line Leadership Models Purview Can Extend Well Beyond OB/GYN Combination of Direct Reporting and Coordination Representative Service Line Structure These services typically report to the women's service line leader through a matrix reporting structure. Whether or not pediatrics is included in the Women’s Service Line depends on the strategic goals and level of care of the institution. Traditional Service Line Comprehensive Service Line Progressive Service Line

19. Leadership Role Merging Business Development and Care Coordination Service Line Leadership Models Source: Service Line Strategy Advisor research and analysis; Marketing and Planning Leadership Council interviews and analysis. Role Merges Strategic Planning and Care Coordination Four Key Responsibilities of Women’s Program Leader 1 2 3 4 Service Line Innovation Program Visibility CareProcess Patient Engagement Sample Job Description for Women’s Health Services Director • Subspecialty development • Volume and margin performance • Clinical quality • Care coordination • Health education • Patient compliance • Brand/service awareness • Community partnerships • Background • 5-10 years experience in women’s health, preferably nursing or clinical background • Knowledge of health care trends, financial regulations, society guidelines • Experience with marketing services, developing a budget, business planning • Demonstration of effective leadership skills

20. Service Line Leadership Models Source: Service Line Strategy Advisor research and analysis; Marketing and Planning Leadership Council interviews and analysis. Balance Direct Oversight With Collaboration Successful Clinical and Administrative Partnerships Required • Direct Oversight Over Core Women’s Services • Obstetrics • Gynecology • Pelvic Floor • Infertility • Community Education • Patient Navigation Clinical Programs Administrative Functions • Cardiology • Oncology • GI • Orthopedics • Behavioral Health • Strategic Planning • Marketing • Physician Outreach • Administrative Partnerships • Joint planning for strategic marketing • Coordinated initiatives for promoting services • Clinical Partnerships • Shared goals and for quality and satisfaction • Defined patient pathways for care coordination

21. Nurse Navigators Drive Network Referrals, Improve Patient Satisfaction Care Coordination Source: Service Line Strategy Advisor research and analysis. Women’s Navigator Essential in Care Pathways Women’s Navigator Responsibilities Manage Patient Expectations Improve Physician Alignment Direct Patient Flow • Involve multiple providers in program development • Reduce communication barriers and inefficiencies • Offer opportunities for provider feedback • Lead comprehensive wellness classes • Inform patients of care pathway • Help patients develop own goals and to be own care advocates • Operate along entire care pathway including post-discharge • Direct pre-surgery screening process • Develop discharge plan for efficient patient transition

22. Navigators’ Characteristics Include Empathy, Creativity, and Availability Care Coordination Source: Service Line Strategy Advisor interviews and analysis. Role Varies Based on Program Needs Ideal Qualifications for Women’s Health Navigators Three Roles of Women’s Navigators • Background • 3-5 years experience in women’s health or OB/GYN, preferably nursing background • Knowledge of women’s health issues, insurance regulations, clinical guidelines • Experience with marketing services, developing education sessions • Ideal Qualifications, Characteristics • Ability to work with varied members of local community including physicians (affiliated and non-affiliated), vendors, and media • Compassionate personality and ability to engage with patients • Experience in running and managing local, community health initiatives • Prefers to work in team environment • Creative event planning • Active listening skills, ability to earn patients’ trust Educator Build awareness of women’s health issues and services available Clinician Assess patient needs and triage to appropriate care Patient Advocate Guide patients through treatment decisions and follow up care

23. Physician Engagement Physician Alignment Drives Programmatic Success Source: Service Line Strategy Advisor research and analysis. Weighing Health System and Physician Demands to Promote Integration System Demands Physician Demands • Clinical Leadership & Integration • Strong physician leadership at all levels (service line, hospital, regional, corporate) • Improved quality, efficiency, income, and reduced costs, with ultimate aim of market dominance • Strong physician loyalty and some control of pay-for-performance incentives • Physician Employment • Improved risk management, physician loyalty as means to optimize market capture, financial gain while meeting community’s medical needs • Strategic Partnership • Expanded market capture, improved brand awareness, potential access to capital, quality and efficiency gains • Clinical Leadership & Integration • Role in decision-making process, leadership position if benefits accompany it • Improved quality, efficiency, income, and reduced costs, with ultimate aim of practice growth • Strong personal, hospital, and system reputation stemming from consolidation • Physician Employment • Improved lifestyle, income stability stemming from system’s organizational structure without significant loss of autonomy or changes to practice style • Strategic Partnership • Expanded income streams, improved brand awareness, potential access to capital, quality and efficiency gains

24. Physician Engagement Key Alignment Models by Degree of Risk and Impact Source: Service Line Strategy Advisor research and analysis. Application for Women’s Low Risk and Low Impact High Risk and High Impact

25. Technology Service Line Strategy Market Forces Evaluating Opportunities in Women’s Health Growth and Financial Outlook

26. Few Marquee Technologies Needed Clinical Innovation Increasing Trend Toward Minimally-Invasive Procedures Women’s Services Technology Adoption Outlook Many Capital Technologies Restricted to Progressive Programs Source: Service Line Strategy Advisor research and analysis. Fetal MRI Fertility Preservation for ART2 IVF1 ECMO3 Fetal Genomics AirStrip Fetal Monitoring Amniocentesis Fetal Surgery Women’s Heart Program Cordocentesis Women’s GI Program 2-D US PBC Chorionic villus sampling Doppler US 3D/4D US Botox Hysterectomy Myomectomy MRgFUS6 GEA4 LAVH Robotic Myomectomy Robotic Hysterectomy UFE5 Breast Tomosynthesis FilmMammography Full-Field Digital Mammography Radiofrequency Tissue Remodeling Electrical Nerve Stimulation Urodynamic Testing System Pelvic Floor US Robotic Sacrocolpopexy POP Repair Kit Biofeedback TOT Sling PEM8 Breast US Breast MRI (coil) MBI7 Automated Breast US

27. Technology Pipeline for Women’s Health Services Source: Service Line Strategy Advisor research and analysis. Clinical Innovation Urogynecology Breast Imaging Gynecology OB/MFM Alternative Procedures to be Used Prior to Surgical Intervention Breast Imaging Techniques to Reduce Recall Rates Move Towards Less Invasive Treatments Although Invasive, Early Intervention Can Save Fetal Lives • Percutaneous Tibial Nerve Stimulation (PTNS): • OAB treatment ideal for those who experience adverse side effects to anticholinergics, or lack therapeutic response, can also be applied to treat FI • PTNS is more cost effective than other minimally invasive therapies • Digital Breast Tomosynthesis (DBT): • Improved visualization increases radiologist confidence in reading • Reductions in recall rate possible leading to fewer unnecessary biopsy procedures • However, higher equipment costs with incremental payment to be determined makes financial viability a challenge for many hospitals • Fetal Surgery • Program is comprised of a multidisciplinary team of physicians, ancillary staff, technology, and protocols capable of diagnosing prenatal conditions that can be corrected for in the prenatal state • Fetal intervention is typically the terrain of large academic medical centers with only 20 centers in the U.S. able to accommodate these patients • MRgFUS • MR Guided Focused Ultrasound utilizes high-intensity ultrasound energy to ablate uterine fibroids under the guidance and imaging of MRI technology • Fibroid ablation via noninvasive ultrasound waves is a less severe treatment for fibroids than hysterectomy or myomectomy, reducing length of stay and recovery times

28. Reduced Recall Rate Demonstrated Across Studies Clinical Innovation Source: Service Line Strategy Advisor research and analysis.; Skaane P., Et al. Comparison of Digital Mammography Alone and Digital Mammography Plus Tomosynthesis in a Population-based Screening Program, Radiology 2013 DBT Likely to Become Screening Standard-of-Care DBT in Addition to 2D vs. 2D Mammography Alone in Screening Patients Cancer Detection Rate per 1,000 Patients n = 12,631 400-500 Units Nationwide tomosynthesis unit install base Mid-2013 7% Screening and Diagnostic Mammography Projected 5-Year Growth 2 2D+3D vs. 2D Alone 15% 27% 40% Increase in detection of both invasive and in situ cancers Reduction in false positives Increase in detection of invasive cancers

29. Improves Efficiency by Uncoupling Image Acquisition from Interpretation Clinical Innovation ABUS Aids Screening for Dense Breasted Women Source: Service Line Strategy Advisor research and analysis; Advisory Board Company Outpatient Estimators; http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm320724.htm. Breast UltrasoundNational Estimate Diagnostic Yield Per 1,000 Studies 7.2 5-Year Growth Rate 14% 3.6 Reimbursement Rates 75-90 Units Nationwide U-Systems ABUS unit install base as of early 2013

30. Technology Service Line Strategy Market Forces Evaluating Opportunities in Women’s Health Growth and Financial Outlook

31. A Comprehensive Solution for Your Women’s Health Strategic Needs Enhancing Women’s Service Line Strategy Service Line Strategy Advisor 1 2 3 • Service Line Assessment • Current and future service line performance evaluation to pinpoint growth and development opportunities • Unique insights based on market dynamics to drive fine-tuned recommendations • Strategic recommendations on clinical asset deployment and competitive strategy based on current system structure • Tactical recommendations for service investments and distribution • Technology and Service Business Plans • Comprehensive market and financial analysis to determine investment decisions • Concrete plans and prioritization accounting for institutional priorities, budget, and goals System Service Rationalization

32. Custom Research Case Study: Investing In Automated Breast Ultrasound Evaluating an ABUS Investment Can be a Challenge SLSA Recommended Hospital X Not Invest in ABUS, Due to Member’s ask… • 2. Significant effort required to build awareness around technology • As a relatively new technology, breast centers need to make an effort to build awareness in both the patient and referring physician community. If the technology went underutilized because of a lack of interest or awareness, Hospital X would risk losing considerable revenue. • 1. High charge to patient limits impact on community • ABUS is currently reimbursed at the same rate as a standard handheld ultrasound. The investment at Hospital X would not yield a positive NPV without charging an extremely high fee to the patients, due to the high margin per exam expected by their radiologists. Should We Take the Plunge and Invest in an ABUS Unit? • Can we breakeven on this investment without a dedicated CPT code? 1 • Do other breast centers charge an additional fee, and how does it impact the investment? 2 • How will ABUS affect the operations of our breast center? 3 Instead, they plan to first focus on raising awareness amongst their dense breasted, higher risk patients on the benefits of such technology. Using our analyses and research, Hospital X was able to recognize the financial risk of this investment without receiving incremental reimbursement. SLSA was able to save Hospital X a total of $300,000. • Will this technology best serve our dense-breasted population? 4