HealthAdvocate. Abbie Leibowitz, MD Co-founder, EVP and Chief Medical Officer Copyright 2011, Health Advocate, Inc.

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1 HealthAdvocate Abbie Leibowitz, MD Co-founder, EVP and Chief Medical Officer

2 HealthAdvocate The nation s leading independent health advocacy and assistance program Offered by more than 7,800+ clients nationwide Serving more than 22 million Americans Covers the employee, spouse, dependents, parents and parents in-law An expert staff of healthcare and insurance professionals A strong and recognized brand enjoying a reputation for being objective and well-respected A privately-held company founded in 2001 Financially strong, profitable, funded by the original founders and friends-and-family, and debt-free

3 Obama Health Initiatives American Recovery and Reinvestment Act Project Cost Comparative Effectiveness Research $ 1.1 Billion COBRA Continuation $ 24.7 Billion Depts of Defense and Veterans Affairs $ 1.4 Billion Health Information Technology $ 19.2 Billion Health Resources and Services Admin $ 2.5 Billion Medicare- Hospitals, Hospice, LTC $338 Billion Medicaid and State Programs $ 87 Billion NIH $ 10 Billion Prevention and Wellness $ 1 Billion Public Health and Social Services $ 0.5 Billion This is in Addition to $32 Billion Over 4 Years to Expand the CHIP Program Funded by a $0.62 Per Pack Increase in the Federal Cigarette Tax and Other Tobacco Taxes R. Steinbrook, MD, NEJM, March 12, 2009

4 Making Up For Medicare and Medicaid

5 Public Opinion Tracking Poll

6 National Health Expenditures Levels of National Health Expenditures, , and Projected Levels, , According to Type of Funding Lee P et al. N Engl J Med 2010;362:3-5

7 Per Capita Total Current Health Care Expenditures, U.S. and Selected Countries, 2006 Australia Austria Belgium Canada Denmark Finland France Germany Iceland Ireland Italy Japan Luxembourg^ Netherlands Norway Sweden Switzerland^ United States $2,960 $3,462 $3,326 $3,505 $3,643 $2,546 $3,353 $3,247 $3,285 $2,945 $2,520 $2,529 $3,391 $3,075 $4,223 $4,233 $4,311 $6,567 ^OECD estimate. $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 Notes: Amounts in U.S.$ Purchasing Power Parity, see includes only countries over $2,500. Total Current Expenditures on Health is defined by the OECD as the sum of expenditures on personal health care, preventive and public health services, and health administration and health insurance; it excludes investment. United Kingdom not included because it does not provide a breakdown of Total Health Expenditures into Current and Investment expenditures; the Total Health Expenditure Per Capita for the UK in 2006 was $2,760. Source: Organisation for Economic Co-operation and Development. OECD Health Data 2008, from the SourceOECD Internet subscription database updated October Copyright OECD 2008, Data accessed on 11/12/2008. Copyright 2010, 2011, Health Advocate, Health Inc.

8 Cumulative Changes in Health Insurance Premiums, Inflation, and Workers Earnings, 140% % 120% 100% 80% 60% 40% 20% 0% 38% 28% Health Insurance Premiums Note: Due to a change in methods, the cumulative changes in the average family premium are somewhat different from those reported in previous versions of the Kaiser/HRET Survey of Employer-Sponsored Health Benefits. See the Survey Design and Methods Section for more information, available at Workers' Earnings Overall Inflation Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), ; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, (April to April).

9 Projected Health Insurance Premiums for Family Coverage, Assuming Average Growth Rates, from and $35,000 $30,803 $30,000 $28,337 $26,069 $25,000 $20,000 $15,000 $10,000 $15,803 $13,375 $14,539 $15,057 $14,191 $13,375 $17,178 $15,975 $18,673 $20,297 $16,949 $17,983 $23,983 $22,063 $21,479 $19,080 $20,244 $22,789 $24, (8.7%) $5, (6.1%) $ Note: Health insurance premiums projected for assuming (1) that the average growth in premiums between 1999 and 2009 (8.7%) continues or (2) that the average growth in premiums between 2004 and 2009 (6.1%) continues. Source: Kaiser Family Foundations projections based on data from Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

10 Average Percentage of Premium Paid by Covered Workers for Single and Family Coverage, * Estimate is statistically different from estimate for the previous year shown (p<.05). Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

11 Percentage of All Firms Offering Health Benefits, *Estimate is statistically different from estimate for the previous year shown (p<.05). Note: Estimates presented in this exhibit are based on the sample of both firms that completed the entire survey and those that answered just one question about whether they offer health benefits. The percentage of firms offering health benefits is largely driven by small firms. The reason for the increase in 2010 is unclear, but it is primarily driven by a 13 percentage point jump in the percentage of firms with 3 to 9 employees offering coverage, from 46% in 2009 to 59% in We have seen some fluctuation in this category in the past but never of this magnitude. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

12 Firm Health Insurance Take-Up Rate by Percentage Contribution For Single Coverage Take-Up Rate 89% 88% 84%* 82%* 78%* 77%* 68%* to to to to to 36.9 Annual Worker Contribution Percentage 37.0 and above *Percentages in categories 3 through 7 different than first category (89%) at p<.05. Source: Pooled data from 2005 and 2006 Kaiser/HRET Annual Employer Health Benefits Surveys. Percentages weighted by number of workers in responding firms.

13 Percent of Total Health Care Spending Concentration of Health Care Spending in the U.S. Population, % 96.8% 80% 64.6% 73.7% 80.3% 60% 49.7% 40% 20% 0% 23.4% 3.2% Top 1% Top 5% Top 10% Top 15% Top 20% Top 50% Bottom 50% ( $43,290) ( $14,099) ( $7,629) ( $5,275) ( $3,887) ( $776) Percent of Population, Ranked by Health Care Spending (<$776) Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population, including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and pharmacies; health insurance premiums are not included. Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2005.

14 Percent of Total Health Care Spending Concentration of Health Care Spending in the U.S. Population, % 96.8% 80% 60% 49.7% 64.6% 80.3% 73.7% Put another way, 50% of Americans spend less than $776 a year in healthcare costs 40% 20% 0% 23.4% 3.2% Top 1% Top 5% Top 10% Top 15% Top 20% Top 50% Bottom 50% ( $43,290) ( $14,099) ( $7,629) ( $5,275) ( $3,887) ( $776) Percent of Population, Ranked by Health Care Spending (<$776) Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population, including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and pharmacies; health insurance premiums are not included. Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2005.

15 Percentage of Covered Workers Enrolled in a Plan with a General Annual Deductible of $1,000 or More for Single Coverage, By Firm Size, *Estimate is statistically different from estimate for the previous year shown (p<.05). Note: These estimates include workers enrolled in HDHP/SO and other plan types. Because we do not collect information on the attributes of conventional plans, to be conservative, we assumed that workers in conventional plans do not have a deductible of $1,000 or more. Because of the low enrollment in conventional plans, the impact of this assumption is minimal. Average general annual health plan deductibles for PPOs, POS plans, and HDHP/SOs are for in-network services. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

16 Percentage of Covered Workers Enrolled in a Plan with a General Annual Deductible of $2,000 or More for Single Coverage, By Firm Size, *Estimate is statistically different from estimate for the previous year shown (p<.05). Note: These estimates include workers enrolled in HDHP/SO and other plan types. Because we do not collect information on the attributes of conventional plans, to be conservative, we assumed that workers in conventional plans do not have a deductible of $2,000 or more. Because of the low enrollment in conventional plans, the impact of this assumption is minimal. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

17 Harris Poll National Quorum telephone survey of 1,008 U.S. adults 18+ yrs. Sept 29 Oct. 4, 2010 The Challenge of Paying Medical Bills Those with incomes < $100,000 we more likely (~25%) to pay bills late than those with incomes > $100,000 (9%)

18 Cost Containment Strategies Estimated Cumulative Percentage Changes in National Health Care Expenditures, 2010 through 2019, Given Implementation of Possible Approaches to Spending Reform Hussey P et al. N Engl J Med 2009;361:

19 Where Do You Start?

20 HEALTH ADVOCATE A Truly Integrated Care Model Health Information Health Risk Appraisals Online Medical Info Self Care Tools Cost Information Provider Quality Info Personal Health Record HEALTH ADVOCATE Patient Physician Relationship Individual Health Interventions Wellness Programs Decision Support Disease Management Case Management Nurse Triage Line HEALTH ADVOCATE HEALTH ADVOCATE Provider Network Member Service Health Benefits Claims Admin

21 HealthAdvocate s Core Program Personal Health Advocate - RN s supported by Medical Directors and claims and benefits experts Care Locator - Nationwide service, network coordination, common care needs, DME, Dental Services Advocates of Excellence - Centers of Excellence, complex care, coordination, 2 nd opinion service Health Advocate CareCoach - Medical information using the HealthWise database, pricing tools Benefits Advantage - Claims, referrals appeals, grievances, paperwork Help Health Advocate CareQuest - Additional outside services and resources

22 SOLUTIONS 22 Copyright 2011, Healt Advocate, Inc.

23 Engage Health Solutions Core Advocacy Wellness Advocate Prevention & Chronic Care Messaging Benefits Gateway & Dashboards Nurse Line EAP & Work Life MedChoice Support Pricing Tools & Medical Bill Saver

24 HealthAdvocate Utilization Summary Most Common Health Related Reasons for First Call Book of Business Specialty Care Locator 5% Routine Care Locator 3% Health Information 6% Care Coordination 2% Rx Advocate 4% Mind Matters 2% Most Common Administrative Related Reasons for First Call Book of Business Benefits Education 31% Claims Assistance 10% Enrollment Support 7% Eligibility 4% Coverage Advantage 2% Appeals Assistance 1%

25 Clinical Utilization Distribution Development 3% January December 2010 Rheumatology 1% ElderCare Serious Injury 2% 1% ENT 5% Podiatry 1% Orthopedics 14% Cancer 6% Pregnancy 3% Prevention 17% Mental Health 11% Neurology 6% Dermatology 3% Dental 8% Gastrointestinal 6% Gynecology 6% Cardiovascular 6%

26 Access to Care Average US Wait Times for an Appointment 81% New Zealand 63% 61% 56% 47% 36% Germany Britain Austrailia U.S. Canada Ability to be seen by a Primary Care Physician within 48 hours for an acute problem Cardiology = 15.5 days Dermatology = 22.1 Days OB/GYN = 27.5 Days Orthopedics = 16.8 Days Family Practice = 20.3 Days Boston Has the Longest Average Wait Times for an Appointment at 49 Days. Wait Times in Boston Increased After Massachusetts Enacted Universal HealthCare Business Week, July 9 & 16, 2007

27 HealthAdvocate Pricing Tools Health Cost Estimator Pre-service pricing decision support tool Part of Core Health Advocate service Based on zip code analysis of Healthcare claims Grouped into consumer-friendly Episodes of Care No Additional Cost Medical Bill Saver Post-service / Post-claim pricing review service Optional service at an additional cost or Free Specialized internal unit to negotiate specific claims Can save member and employer significant $$$ Typical discount = 60%+

28 MedChoice Support Program Preference-Sensitive Coaching

29 Among Firms Offering Health Benefits, Percentage Offering a Particular Wellness Programs to Their Employees, by Firm Size, % 93% All Small Firms (3-199 Workers) 90% All Large Firms (200 or More Workers) 80% 79% 70% 60% 50% 57% 63% 61% 59% 53% 47% 40% 30% 20% 10% 34% 27% 28% 34% 24% 19% 12% 36% 0% Offer at Least One Wellness Program* Web-based Resources for Healthy Living* Gym Membership or Exercise Facilities* Smoking Cessation* Wellness Newsletter* Weight Loss Programs* Classes in Nutrition/ Healthy Living* Personal Health Coaching* *Estimate is statistically different within type of wellness program between All Small Firms and All Large Firms (p<.05). Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2009.

30 HealthAdvocate s Wellness Program Core Health Advocate + Wellness Advocate

31 Wellness Program Components A Personal Wellness Coach is the Focal Point for Participants Online, Personalized Web Portal Health Risk Assessment Immediate Results Health information and Interactive tools Unlimited Chat and Telephonic Coaching Push and Pull interactions Incentive Management Complete communications program Management Reports Add-On Options : Workplace Programs (i.e., biometric screening, on-site coaches, etc.)

32 Number of Deaths (thousands) US Deaths Related to Behavior Sexual Behavior Alcohol Motor Vehicle Guns Drugs Obesity Smoking Schroeder, NEJM 357;12, September 20, 2007

33 The Cost of Obesity Extra Lifetime Medical Costs Attributed to Obesity for 20-year Olds Who Are About 30 to 69 Pounds Over A Healthy Weight White Men: $16,490 Black Men: $12,290 White Women: $21,550 Black Women: $5,340 Extra Lifetime Medical Costs Attributed to Obesity for 20-year Olds Who Are Roughly 70 Pounds Over A Healthy Weight White Men: $16,720 Black Men: $14,580 White Women: $29,460 Black Women: $23,750 Source: Eric Finkelstein, Economist for RTI International: The Journal of Obesity As Reported in USA Today, June 10, 2008

34 Tobacco Cessation Program Low-cost, 13-week program tailored to an individual s health status and needs Unlimited telephone and /text access to a trained Coach who stays with the member through the whole program Uses evidence-based techniques including readiness-to-change assessment, continuous support Engages spouse in coaching for additional support Discounted program for employer-based nicotine replacement therapy Provides affidavit for alternative methods to quit e.g., acupuncture, hypnosis Comprehensive reports document participation and outcomes at 3, 6 and 12 months

35 Promoting Awareness

36 Benefits Gateway and Dashboards Single point of access for easy use Low cost and costeffective The ultimate integration and engagement tool Motivates actions at the point of engagement Maximizes the value from all associated programs Reduces medical costs and improves clinical outcomes 36

37 Health Information Dashboards 37

38 A Complementary Solution Health Information Dashboard HEALTH INFORMATION DASHBOARD 38

39 A Complementary Solution Health Information Dashboard HEALTH INFORMATION DASHBOARD 39

40 A Complementary Solution Health Information Dashboard HEALTH INFORMATION DASHBOARD 40

41 A Complementary Solution Health Information Dashboard HEALTH INFORMATION DASHBOARD 41

42 Chronic Disease Costs Average Annual Per Capita Spending for Patients with Different Numbers of Chronic Conditions Bodenheimer T and Berry-Millett R. N Engl J Med 2009;361:

43 Preventive Care Messages Data driven using eligibility and claims data matched to evidence- based guidelines and plan coverage Increases adherence 15% - 20% over baseline Smart referrals to Core Advocacy, Wellness and Chronic Care programs based on need and participation data

44 Chronic Care Messages Reaches all employees due for recommended chronic care services Directs employees to their personal physician and Health Advocate s Personal Health Advocates (PHAs) and Coaches PHAs and Coaches encourage completion of important tests, provide guidance to evidencebased care, promote wellness/ lifestyle changes and medication compliance

45 D. Wessel. WSJ2/4/2010 The Cost of Doing Nothing CMS Forecasts that Healthcare Costs Will be 19.3% of GDP By 2019 In the Urban Institute s Best Case Scenario the Number of Uninsured Americans Will Increase to 57 Million (20.1% of the Population) From 49.1 Million (18.4 % of the Population) in 2009 The Proportion of Americans on Medicaid and CHIP now at 16.5% Will Increase to Between 16.5% and 18.3% In 2010 Medicare and Medicaid will Cost Nearly $725 Billion, About 50% More Than Congress Appropriates for All Domestic Agencies From the National Park Service to K-12 Education. By 2014 the Cost will be $950 Billion! Employer Costs for Healthcare Will Increase 64% (or More) Over the Next Decade

46 Regional Variations in Care Proportion of Higher Regional Medicare Spending Attributable to Differences in Race, Income, Health Factors, and Regional Factors Sutherland J et al. N Engl J Med 2009;361:

47 Weinstein J. N Eng. J Med 2009;361: Regional Variations in Care Ratios of Medicare Vertebroplasty Rates to the U.S. Average, According to Hospital Referral Region ( )

48 Costs for End-Of-Life Treatment Total Medicare spending in the last two years of life UCLA Medical Center: $93,842 Johns Hopkins Hospital: $85,729 Massachusetts General Hospital: $78,666 Cleveland Clinic: $55,333 Mayo Clinic, Rochester MN: $53,432 The difference in the last six months of life is even more striking UCLA Medical Center: $52,911 Mayo Clinic: $28,763 Yet the outcome is the same! Pear, R. New York Times. April 7, 2008

49 Thank You! 49