Telehealth Management: Can a new paradigm in managing chronic illness control costs and improve quality?

1. presented by Maria Lopes, MD, MS Doreen Salek, BS, RN, CCS/CPC Telehealth Management:Can a new paradigm in managing chronic illness control costs and improve quality? October 26, 2010

2. Speaker Bios Maria Lopes, MD, MS, Chief Medical Officer Dr. Lopes is an OBGYN by training, but has been serving in senior medical management positions in managed care since 1996. Prior to joining AMC in 2008, she spent 4 years as Senior Vice President and Chief Medical Officer for GHI, New York State’s then largest commercial payor, and before that served in senior positions for 7 years at Horizon Blue Cross Blue Shield of New Jersey. Dr. Lopes received her MD from The University of Connecticut School of Medicine, and an MS in Administrative Medicine from The University of Wisconsin. Doreen Salek, BS, RN, CCS/CPC Ms. Salekis the Director of Business Operations of Health Services for Geisinger Health Plan in Danville, Pennsylvania.  She is responsible for leading business planning and Health Services innovation project teams with medical home, medical management, care coordination, quality improvement and clinical reporting as well as strategic implementation and evaluation of outcomes.  In her current role she is focused on transitions of care across the continuum, as well as strategies around enhancing quality and reducing readmissions, including telemonitoring. Ms. Salek earned her BS from Colorado State University and nursing diploma from the Geisinger School of Nursing. She holds certifications as a Certified Coding Specialist and Certified Professional Coder.  2

3. What is TeleHealth? • Remote Telemonitoring or Telehealth: • theprocess of collecting daily biometric and other health-related information from where patient is and transmitting data to clinicians who manage care • Two forms of data collection • “Hard” biometric data • “Soft” self-reported symptom information • “Telemedicine” has become a universal term for industry 3

4. Evolution • Telemedicine has been around since early 60’s when NASA developed monitoring methods for the space program • The majority of activity described as “Telemedicine” surrounds two-way televideo for clinical consultation • In the last 10 years remote physiological monitoring from the home has become a recognized and affordable component of chronic care 4

5. How It Works: Data Collection and Integration Data integration platform captures timely information from patients when they cannot be physically in front of clinicians Self-reported symptom information via IVR “Live” virtual diagnostic assessment via televideo Medication compliance data via dispensing/reporting appliances Biometric information via telemonitoring devices AMC collects, sorts and verifies raw data and presents it as critical, actionable information on the secure web portal 5

6. The Problem Telehealth Seeks to Address • Acute exacerbation occurs outside clinical scrutiny. It is often preceded by incremental and insidious deterioration whose expression occurs in the home, away from clinical eyes. • Existing information systems do not cross boundaries of care settings • Electronic Health Records (EHR’s) illuminate what wasdone to patients (i.e. tests ordered, hospitalizations, Rx written, etc.) but don’t clarify the outcome. • “Are their biometrics improving? Are they at reduced risk because of these actions? Are their medications having the right effect? Have barriers to compliance been identified?” • As a result, care is often duplicated, applied too late, or in the worst setting due to incomplete clinical information 6

7. How TeleHealth is Advancing Patient Care • Knowingwhat is going on with a patient’s course of illness, in between visits, when he or she cannot be physically in front of the clinician • Detecting pre-acute conditions early enough to bring resources to bear before the patient clinically decompensates • Not waiting for the call from the ER before knowing that a patient is trending in the wrong direction 7

8. Not Traditional Disease Management • Telemonitoring uses real-time information from the patient’s home to empower them with knowledge of how they are progressing in the context of their personal disease progression and care plans, and how their behaviors are indeed affecting their health • Thus, unlike traditional DM, which can educate a patient about what can and usually happens, telemonitoring can tell them what is happening, and how they—and their doctors and caregivers—can react to these events to change course if necessary 8

9. Value Proposition Clinical: Improve outcomes 9

10. Support for Medical Home • Empower the clinician through technology provide critical information to electronic health records (EHR’s) • Through daily data collection, PCP can continually monitor patient between doctor visits increases efficiencies in care by allowing PCP to be alerted when intervention is most needed • Greater frequency of targeted patient education continual data collection provides physician with real-time quality measures for benchmarking and improvement 10

11. Challenges “There is a tendency to overemphasize the technological aspects of telehealth and indeed to equate it with its technology … Telemedicine is not software or hardware, although it employs both. Nor is it ‘clinicianware’ or ‘econoware’ despite its value to clinicians and administrators and payors. When it’s all said and done, it is ‘patientware’, as it should not be defined in terms of its technical components but in terms of utility in reinforcing the clinician-patient bond.” – Jay Sanders, MD, former President, American Telemedicine Association 11

12. Challenges (continued) • It can never be about the technology: • This has to be about putting accurate and meaningful information in front of the clinician, regardless of the means of collection • Must be seamlessly embedded into a care management workflow to maximize efficiency • Data must be timely, meaningful and actionableand not simply contribute to the ‘noise’ 12

13. AMC-Geisinger Strategic Partnership PCMH & Telehealth Platform Evolution AMC Health: Telemonitoring And IVR Services Real-time Data & Clinical Decision Support Tools Geisinger: Subject MatterExpertise for Predictive Analytics Clinical Content & Decision Support A mutual investment to strategically impact and enhance each other’s core competencies and business models 13

14. AMC’s Telehealth program doubled the ratio of CHF Patients that Geisinger Case Managers were able to cover in complex case management: • Geisinger Health Plan Outcomes • Track patients in real-time • Uncover proactive intervention opportunities • Receive unbiased, reliable patient data • Reduce the need for clinicians to initiate outreach 96%of Geisinger Case Managers reported AMC technology improved efficiency in monitoring HF patients 85% of Geisinger Case Managersreported telehealth solution prevented patient hospitalization 14

15. Looking Forward New technologies are constantly being assessed for integration potential Motion Analysis and Access Detection Technologies GPS Tracking and Communications Exercise Monitoring Wearable Sensors for Recording Events Over Time Bringing the Lab Home SmartBandagesand Clothing 15

16. Synthesis with New HIT Priorities Thread telehealth technology unobtrusively into best-of-breed care coordination models that best fit each unique structure, including: Data Mining and Population Analytics • Comprehensive, cross-setting, interdisciplinary care coordination models that utilize Extended Care Pathways • ACO models • Less comprehensive care management models housed within the payor or community-based care entity Data Collection Technologies Webportal for Shared Reporting & Analytics Patient at Home Telecare Management Nurse Call Center 16

17. The Goal: Open-Ended Integration Universally-Accessible Webportal with Decision-Support Analytics PBM & Other Pharma Data Claims External Care Management Data Telehealth Data EHR’s 17

18. Outcomes Impact of Telecare Management (TCM) on Medicare Advantage (MA) Members after 8 months: • Study Parameters: Results: • TCM Intervention Group N=69 • 8 Month Period • Random Selection • Intervention and control cohorts had • similar claims histories • CHF, Hypertension, Diabetes, • COPD, CAD , Atrial Fibrillation • 66% >3 diagnoses ROI 3:1 If ESRD is included, 43% reduction in total costs compared to control represents ROI 6:1 18

19. Outcomes Impact of Telecare Management (TCM) on MA Members after 8 months (continued): Comparison of Total Costs (8 Months) Care Management vs. Care Management + Telemonitoring* PMPM * MEMBER MONTHS:Control Group – pre: 5,106, post: 4,698 , Telemonitored Group - pre: 538, post: 543 19

20. Outcomes Impact of Telecare Management (TCM) on MA Members after 8 months (continued): • Majority of non-diabetics reached BP goals, as did nearly half the diabetics • Improvement in BP translates into 29% reduction in risk of cardiacevents and 21% reduction in risk of stroke • 83% of diabetics reached blood glucose targets • Average blood sugar reduction equates to a 1.7 point drop in HbA1c: • 63% reduction in risk of microvascular complications • 73% reduction in risk of peripheral vascular disease 20

21. Outcomes Impact of Telemonitoring Combined with Home Care Case Management (Medicare Advantage Plan): • Study Parameters Results • N = 47, • Intervention period > 12 months • Longitudinal • Primary Dx CAD, CHF, COPD • or DM • Control members in Case • Management without • Telemonitoring 21

22. Outcomes Impact of Telemonitoring Combined with Home Care (cont.) * MEMBER MONTHS:Control Group - pre 1644, post 853 , Telemed Group - pre 586, tele 219 22

23. Outcomes Impact of Telemonitoring Combined with Home Care (cont.) * MEMBER MONTHS:Control Group - pre 1644, post 853 , Telemed Group - pre 586, tele 219 23

24. Outcomes Impact of Telemonitoring Combined with Home Care (cont.) Pre-Intervention Levels * MEMBER MONTHS: Telemed Grouptele 219, post 107 24

25. Outcomes Value of Telemonitoring in Achieving A1c and Blood Pressure Goals in Medicaid Managed Care Population • N= 440 on telehealth for a minimum of 40 days • Identified through outpatient clinics Results • For the 21% with no glycemic improvement, 66% of those hypertensive at baseline improved by an average of 5mmHg diastolic 25

26. Outcomes Value of Telemonitoring in Achieving A1c and Blood Pressure Goals in Medicaid Managed Care Population (cont.) Of the group with improvement, the higher the baseline HgA1c, the greater the improvement: • For the subset of members with a minimum of 12 mos of claims both pre-telemonitoring and for 12 mos of telemonitoring (n=77): • 36% reduction in hospitalization • 47% reduction in emergency room visits 26

27. Outcomes Impact of Telemonitoring (TM) Post-Discharge from Acute Care Setting Fee-for-Service Medicare Home Care: • Study Parameters • Pre/Post intervention study • N = 1,451 for 2 years • Results: • Subsequent Controlled Study: • N= 510 for 18 months • Result: ↓34% reduction in 30-day readmission compared to control RN Weekly Visits ↓50% Cost/ Home Care Episode ↓ $750 ER Visits ↓ 40% 27

28. Impact of Telecare Management on Biometric Outcomes – 1st 90 DaysMedicaid (SSI, non-Medicare Eligible) Diabetes Pilot • Outcomes • Average PMPM costs prior to pilot: $1,943 • Reductions in average blood pressure: • 17% reduction in risk of cardiac events • 12% reduction in stroke risk • Blood sugar reductions for 25% most severe at baseline = 2 pt reduction in HbA1c: • 10% reduction in overall health care costs • 80% reduction in risk of eye, kidney and nerve disease complications* * Source: National Diabetes Clearinghouse 28

29. Impact of Telecare Management on Biometric Outcomes – 1st 120 DaysMedicaid (SSI, ABD & Medicare Eligible) Telehealth Pilot • Outcomes • Average PMPM costs prior to pilot: $2,893 • High risk, rural population • COPD, Diabetes, Heart Failure, Hypertension, Renal Failure • : • Reductions in average blood pressure for 25% most severe non-diabetics: • 43% reduction in risk of cardiac events • 27% reduction in stroke • Blood sugar reductions for 25% most severe at baseline = >1.2 pt reduction in HbA1c: • 24% reduction in overall health risk  for Sources: Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913 and Heart Disease and Stroke Statistics – 2007 Update Dallas, TX: American Heart Association 2007. e million adults in 29

30. Case Study Metoprolol 30