# Presentation: 211194

## An Overview of Alere’s 
     Personal Health Support
	  for AHIC Chronic Care Workgroup

***     ******Personal Health Support***
**	****  ****for AHIC Chronic Care Workgroup**

**Sept. 27, 2007**

**Gordon Norman, MD, MBA**
**EVP, Chief Science Officer**

##  Alere: the Meaning, the Mission

- CARING
- Professionalswho use evidence-  based medicine to educate patients about their illness and treatment

-                    CONNECTING
-                   Objective findings,        patient symptoms,                              and multiple data points                               (PBM, care gaps, lab data)                         using  proprietary technology

- EMPOWERING
- Developing self-management skills to help individuals lead healthier and more satisfying lives

*** ******Alere: the Meaning, the Mission***

***a•lere (************lere) v.******	***
**“****To support” or “ to nourish” **

**Dedicated to improving health and supporting a population’s health needs**

## Company Overview

- Leading provider of disease management services designed to improve health, productivity, and wellness of its participants
- Cover over 25 million commercial and 2 million Medicare lives
- Company’s strategic success reflected in our dynamic growth
- 2003-2007E Revenue CAGR 50%, Employee CAGR 42%
- Currently 5th largest independent DMO in U.S.
- Transitioning to a full Personal Health Support company
- Chronic condition management with remote monitoring
- Prevention, wellness, health coaching, risk reduction
- Disability & absence management, EAP integration
- Support of clinicians & medical home
- Personal Health Record for participants, clinicians

## Alere’s Initial Focus

**5% of people**
**generate 50% of costs**

***Alere’s Initial Focus***

- Reference: EW “Chronic Care Model”

- Healthy/Low Risk

- At Risk

- High Risk

- Chronic
- Disease

- Complex &
- Catastrophic

**Chronic Condition Management**

- Reference: EW “Chronic Care Model”

**CHF, CAD, COPD, asthma, ****diabetes**

## Our Pursuit of Excellence

**1996**

**2002**

**2003**

**2004**

**2005**

**ALERE Medical founded**

**Started monitoring heart failure patients**

**Transformed to a ****pure play disease management company**

**Acquired DM programs of National Jewish**

**WHARF trial published **

**2006**

**1999**

***Our Pursuit of Excellence***

**DayLink****®**** Monitor 100**

**DayLink****®**** Monitor 112**
**(multi-condition)**

**Partnered with Joslin Diabetes Center **

**DayLink****®**** Monitor**
**110**

**2007**

**Company buyout by **
**TA Associates**

**Providing integrated population health management programs**

**2008**

**2000**

**Third party HF outcomes validation**

**DMPC recognizes Alere’s Pacificare results for plausibility**

## Our National Presence

**50 States**
**>100,000 Patients Actively Engaged**
**>25 Million Covered Lives / >2 Million Medicare Lives**

**Reno (Corp HQ)**

**Columbus**

**Irvine**

**Denver**

**San Antonio**

**Chicago**

## Alere Clients

## Data Driven Interventions

- Effective incorporation of multiple data points
- Claims, PBM, lab, biometric, symptoms
- HRA data, behavioral readiness to change
- Real-time access to patient specific information for
- Risk stratification
- Validation, interpretation and patient coaching
- Alere serves as the “eyes and ears” of the physician for each patient transmitting “just-in-time” critical information for the physician’s intervention

## Data Driven Interventions

***Data Driven Interventions***

## Allegro Proprietary DM System

- Integrated, scalable platform for candidate acquisition, program enrollment, patient engagement, clinical intervention and outcomes reporting
- Powerful features include the ability to:
- Electronically collect patient specific data
- Graphically display key data over time
- Reprioritize patients throughout the day
- Alert nurses to changing clinical conditions
- Alert patients by phone and physicians by fax
- Monitor and adjust to open workflow tasks based on volume and available resources
- Scale to accommodate increased patient volume, client
- 	acquisition and client customization

## Identification & Stratification

- Approach
- Use best tools and methods for client-specific goals, population
- Apply to historical claims to conduct formal opportunity analysis to advise clients, recommend tailored programs, and set expectations
- Tools
- Alere Identification System (SAS/SQL)
- Internally developed analytic platform for very large datasets
- Proprietary criteria developed & refined for multiple conditions at population level or select risk subsets
- Impact ProTM Suite (Ingenix)
- Uses ETGs for episode identification, PRGs for pharmacy-based predictive modeling and EBM Connect for profiling of conditions, gaps in care
- Pharmacy Risk GroupsTM (PRGs)
- Pharmacy-based predictive modeling system that uses pharmacy data alone to assess prospective risk in individuals

## Acuity Prioritization System

- We use 2-3 dozen data parameters to recompute an acuity score for every participant every 1-2 hours through the day
- These scores determine sequencing of outbound contacts to those participants at greatest risk
- Contacting highest risk participants early in the day allows us to connect them to their physicians that same day if warranted
- This “intelligent targeting” of outbound contacts contributes to program effectiveness and efficiency
- To achieve similar outcomes without remote monitoring and data-driven prioritization would drive significantly higher costs for additional manpower and higher contact frequency
- We can also reassess status and acuity following all ER and admission events with client-supplied daily census file and patient contact within 2 days following such events

## Enrollment & Engagement

**Eligible Members from Customer**

**Stratification**

**Data Loaded into Alere Call Queues**

**Welcome Packet**

**Motivational interviewing techniques by Certified Enrollment Service Reps**
**IVR System Call Recording**
**Logic Driven System Embedded Call Scripting**
**System Requeuing**
**Performance Standards Management**
**Call Quality Monitoring**
**No “Talktime Restraints”**

**Language Translation**
**Device Troubleshooting**
**Installation Assistance**

## Nursing Assessment

- Health history
- Hospitalizations & procedures
- Medications
- Disease & condition knowledge
- Vaccinations
- Co-morbidities

## Risk & Depression Screening

- Routine screening for depression & risk for falling
- Referrals to appropriate resources (healthplan, provider, etc.)

## Medication Adherence

- Assess & intervene for class drug usage
- Monitor medication adherence

## Patient Monitoring — Rx Claims

- PBM data

- Enrolled patients with selected Rx

- Routine program follow-up

- Match against PBM Rx data

- Coach Rx compliance call

- Filled

- Encourage Rx refill

- Enter new Rx information

- Call back

- Not filled

- MD change

- No MD change

- Yes

- No

## Patient Monitoring — Device

**Home Biometric****DayLink****® Monitor ****110 / 111 **
**(Heart Failure Program)**

**Home **
**Biometric****DayLink****® **
**Monitor**** 112**

- Symptoms + / - Precise electronic scale up to 475 lbs.
- Easy installation
- Requires < 2 minutes for patients to complete
- > 95% compliance
- Transmits data over phone line to Alere’s toll-free number

- Biometric data collection for multi disease states
- Expanded capabilities to incorporate peripheral devices
- Glucose readings
- Blood Pressure, Pulse Oximetry
- Expanded questions and reminders
- Wireless devices allows for “plug and play” setup

## Heart Failure Biometric Monitoring

- Daily weight and symptom monitoring via DayLink® Monitor in patient’s home
- Data transmitted over phone line
- 95% patient compliance

##  COPD Biometric Monitoring

- Daily symptom data via DayLink® Monitor in patient’s home
- Adherence reminders
- Data transmitted over phone line

##  Diabetes Biometric Monitoring

- Bi-weekly blood glucose and symptom data via DayLink® Monitor in patient’s home
- Data transmitted over phone line

## Clinician Communications

- Our management team, mostly clinicians themselves, appreciates the realities of busy office practices
- Communications to clinicians must be patient-specific, timely, actionable, brief, and highly relevant to be value-adding
- Our goal is parsimonious reports that can be scanned and digested in <1 minute, and identifies important information that impacts clinicians’ treatment plan & patient management
- Our reports provide data that most physicians do not routinely receive or may be time-consuming to check, such as all Rx from all clinicians, treatment adherence information from claims and self-report, latest key lab tests and results, etc.
- We can send reports electronically if desired, yet nearly all physicians still prefer fax; PHR integration is underway

## Clinician Reports

***Clinician Reports***

**PRE-VISIT REPORT**

**ALERT REPORT**

**Alert Report – HF / COPD**
- Faxed to physician when urgent patient problem needs to be reported to physician
- 24-hour response expected
- 95% physician compliance

**Pre-visit Report – CAD / Diabetes**
- Faxed to physician 1 to 2 days prior to scheduled appointment
- Provides between visit summary of relevant clinical data

## Data Rich, Easily Interpreted

## Evidence-Based Pt. Education

- Disease & symptoms
- Medication use & compliance
- Diet & nutrition
- Exercise & lifestyle
- Depression
- Self-management

## Outcomes Approach

- Alere believes the industry is strengthened by more standardized, rigorous, and ultimately, comparative outcomes
- Leading role in DMAA’s industry standardization process
- Immediate Past Chair of DMAA’s Q&R Committee
- Start by doing Opportunity Analysis from historical claims
- Allows program customization, aligns mutual expectations
- Utilize industry standard outcomes measures/methods
- Alere’s methods consistent with DMAA, Volume I & II Guideline reports
- Multiple correlating measures reinforce plausibility of results
- Transparent evaluation of program performance
- Expect clients to replicate evaluation with matching results
- Independent review or audit of outcomes welcomed

## Outcomes Accountability

- Pioneer in use of independent third party experts to validate DM outcomes
- Tillinghast Towers-Perrin, 2000
- Recognition by DM industry for its leading outcomes
- Methods certified by Disease Management Purchasing Consortium
- One of two DMPC-certified entities to demonstrate reduction in utilization per plausibility measure (per Al Lewis, DMPC President)
- Consultant to DMAA for standardized outcomes methods/measures
- NCQA consultant for public, comparative DM outcomes reporting
- Consultant to Munich Re American Healthcare for DM partnering
- Independent research results support Alere programs
- WHARF trial, L. Goldberg, U.Penn, Am. Heart Jl., 2003
- RPM study, H. Krumholz, Yale, Circulation, 2007

**Notes:**
Gordon, please cut words or Emily, you can take a pass at cutting this down/making less wordy

GN 110606: trimmed down

## Outcomes Measures

- If an equivalent control group is available we base analysis on comparison of intervention group to control group
- Absent equivalent control group, we use a pre/post framework to analyze change in total medical expenditures for the DM eligible population compared to baseline
- We then look for key utilization metric confirmation
- All-cause hospital admission rate for eligible population
- Disease-specific hospital admission rate for entire insured population (“plausibility measure” per Disease Mgt Purchasing Consortium)
- We expect clinical quality and functional status measures to parallel economic measures
- Experience of care coordination assessed for participantsand providers via third party satisfaction survey

## HF Outcomes

***Reduction in Paid $ PMPM (Commercial)***

**Annual Outcomes Analysis Performed by Alere’s Client**
**Total Health Care Cost Per Patient Per Month**

*Data Source:  Client outcomes database:  Commercial Population     *

***34%***

***70%***

## HF Outcomes

***Reduction in Hospitalization Rate (Commercial)***

*Data Source:  Client outcomes database:  Commercial Population*

**Annual Outcomes Analysis Performed by Alere’s Client**
**All-cause Hospital Admits Per 1,000 Patients Per Year**

***27%***

***67%***

## CAD Outcomes

***Cardiac Risk Management***

*Data Source:  Alere Outcomes Database*

**Program Effect On Engaged Patients With Higher Risk Score**

_**Risk Score Reduction**_

_**Cardiac Risk Score by Baseline Score**_

***12%***

***22%***

***8%***

- *

- *

**  p<0.05*

## CAD Outcomes

***Reduction in Utilization and Costs***

*Data Source:  Medical Claims Data from Client A (2/1/04 to 5/31/06)*
*Annual cost trend applied*
*Annual Stop-loss not applied*

**All-cause Inpatient Admit Rate (PTMPY)**

**Total Health Care Costs (PPPM)**

**20%**

**7%**

**15%**

**10%**

**14%**

**2%**

## Diabetes Outcomes

*** ***

**Total Health Care Cost Per Patient Per Month**
** ****(Preliminary analysis based on 6-month program evaluation period –**
**randomized control / interventions groups)**

*Data Source:  Client’s Claims Database 2005-2006*

**40%**** **

**  p<0.05*

*****

- n = 70

- n = 190

- n = 425

## Diabetes Outcomes

***Diabetes Outcomes***

*** ***

**Cost Per Patient Per Month by Type of Service**
** ****(Preliminary analysis based on 6-month program evaluation period)**

*Data Source:  Client’s Claims Database 2005-2006*

- n = 70

- n = 190

- n = 425

## Quality of Life Outcomes

**Improvement in Mental & Physical Component Scores Over Time**

*Data Source:  Alere Outcomes Database *
*                       **Patient self-reported QOL data 2005*

***SF-12:  Average PCS Score***

***SF-12:  Average MCS Score***

*Response Rate: 40%*

- *

- *

- *

- *

- *

- *

- *

- *

- * p<0.05

## Clinician Satisfaction Outcomes

*Data Source:  Serial Alere provider satisfaction survey data from The Olinger Group*

*95% Confidence Interval: Varies by question, by year, but typically in range of 6-12%*

## Alere’s Present Focus

**50+% of employees**
**generate 90% of direct and indirect health related **
**costs**

***Alere’s Present Focus***

- Reference: EW “Chronic Care Model”

**Intensive Case Management**

- Healthy/Low Risk

- At Risk

- High Risk

- Chronic
- Disease

- Complex &
- Catastrophic

**Disease Management**

**HRA**

- Reference: EW “Chronic Care Model”

**Health**
**Coaching**

**Wellness**
**Programs**

## Total Health Management Needs

***Total Health Management Needs***

- Reference: EW “Chronic Care Model”

- Reference: EW “Chronic Care Model”

- Healthy/Low Risk

- At Risk

- High Risk

- Chronic
- Disease

- Complex &
- Catastrophic

**Workplace**
** ****Health**

**Disability / **
**Absence Mgmt**

**Health **
**Advocacy**

**Medical Home Support**

***Behavioral Health / EAP Integration***

## Relevant Decision Support Today

| What Clinical Decision Support Should Provide Clinicians | What Alere’s PHS Platform Provides Clinicians Today |
| --- | --- |
| Identification and stratification of population under care for those at risk for avoidable morbidity and mortality, delineation of those risks | For clinicians without registries (most), we do monthly population analysis to identify and track patients at greatest risk for avoidable morbidity |
| Predictive modeling tools to extend risk assessment beyond observable clinical characteristics to include prior diagnoses, labs, procedures, events, drugs, self-reported data | We integrate a large number of clinically-relevant variables that are beyond the usual scope of the community practitioner to find high risk patients who might not present for care until much later |
| Workflow tools, processes to routinize the oversight of at risk and chronically ill populations when out of sight from clinicians | Our Alere platform provides integrated workflows to track and intervene when needed, and can be used by our clinical staff or 3rd parties as needed |
| Regular recurring contact and data collection (daily, if warranted) to monitor risk status and refer patients with imminent threat of morbidity in time to MD to intervene effectively and efficiently | Daily remote monitoring of symptoms and select biometric parameters for highest risk cohorts allows more efficient and effective identification of those in need of acute clinician intervention |
| Timely clinician notification and suggested interventions to avoid morbidity that fit into current practice ecology without reengineering | Our usual clinician communication is by fax and phone, similar to current workflow for lab results, imaging, other routine clinical communiqués |

***Relevant Decision Support Today***

## Personal Health Support

***Personal Health Support***

**At any given time, a given person may need one or more of these forms of personal health support – and we will be there ****to provide it!**

**Person-Centric, Needs-Based, Data-Driven, Clinician-Connected**