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An Intensive Medical Home for Patients with Chronic Disease Presented to the National Academy of Medicines Value Incentives and Systems Innovation Collaborative meeting December 18 th , 2017 Lawrence R. Kosinski, MD, MBA, AGAF, FACG Why


  1. An Intensive Medical Home for Patients with Chronic Disease Presented to the National Academy of Medicine’s Value Incentives and Systems Innovation Collaborative meeting December 18 th , 2017 Lawrence R. Kosinski, MD, MBA, AGAF, FACG

  2. Why Crohn’s Disease? A “High Beta” Illness with a Significant Opportunity to Bend the Cost Curve Payer provided us with claims • Medical and pharmacy claims on 21,000 patients with Crohn’s disease during 2010-2011 • Average cost of Crohn’s disease: $24,000 per patient per year Expense Breakdown • > 50% of all expenses incurred were for hospital inpatient services • 17% Hospitalization Rate due to high complication rate • Biologics account for a growing % of total expenditures • Physician payments represent < 4% of overall costs Patient Engagement • Over 2/3 of patients hospitalized for a serious complication did not have any physician interaction in the 30 days prior to inpatient admission • Deterioration in symptomatology often unrecognized by patients A Sonar System is needed to engage patients between face to face visits • 2 Proprietary

  3. Project Sonar Pilot - 2013 Data 50 Crohn’s patients • Not randomly selected • No particular phenotype CDS Tools Deployed • Assessments Physicians Order Sets • Patients • Based on AGA CDCP •CDS Tools • Alerts •Portal-based • Risk Assessments Performed •Guidelines • Guidelines Tools •Risk End Points • Reports •Nurse Care Assessments • Algorithms Manager • Hospitalization Rate • ER Visits Results • Hospitalization Rate cut by >50% Data ER Visits cut by > 50% • 3 Proprietary

  4. Project Sonar Timeline June 2015 Dec 2014 Jan 2012 May 2012 Mar 2013 Oct 2013 Feb 2014 Apr 2014 Sep 2014 Agreement signed with Received large Presented concept Meeting at BCBSIL to Final Agreement signed Final patient Go live on financial Began meeting with LOI signed between Takeda and Xcenda to shared savings period BCBSIL to obtain database from BCBSIL of Project Sonar to discuss structure and BCBSIL and IGG with BCBS attribution list validate platform with cost data on BCBSIL data provided cost data on Crohn’s 21,000 patients 2012 2013 2014 2015 AGA Crohn’s Disease Care Pathway Data Analysis Patient Enrollment Live Project Sonar Testing July 2012 Jan 2014 Aug 2014 Dec 2014 Jan 2013 Mar 2014 June 2015 Began developing CDS tools Early Data showing AGA Crohn’s Dis Care Financial Data available Deployed Project Sonar on 50 Meeting with Takeda to SonarMD Web and patient engagement tools LK patients decrease in discuss data Pathway published on patients APP/Platform Deployed hospitalization Proprietary Proprietary

  5. The SonarMD Process Attribution Enrollment Hovering Data Analytics Patient Attribution Patient Enrollment Patient Hovering Data Analysis The payer attributes the The patient undergoes an Patient receives text message Payer provides quarterly patient with the chronic enrollment visit which with secure hyperlink claims data to SonarMD disease includes: Patient completes disease SonarMD provides •Identification of Goals, Barriers The practice engages the specific questionnaire performance reports to •Depression Screen patient practice Sonar Score is calculated by •Nutritional Assessment •Explains the program platform •Sonar Ping response rate •Action Plan •Schedules Supervisit with Nurse •Average Sonar Score by practice, •Consent Forms Immediate feedback is Care Manager provider and NCM •Signoff by all provided to the patient •May schedule concurrent provider •Average Sonar Slope by practice, Enrollment in SonarMD visit if indicated provider and NCM Sonar Score is sent to NCM Platform •BCBS Provides Claims Data on each •Cost Analysis patient quarterly NCM interprets score based •Initial Manual Ping upon algorithm •Initial Sonar Score •Risk Assessment NCM communicates with provider if necessary SonarMD receives monthly claims Practice and SonarMD receive Practice receives Payment Practice receives PMPM Payment data and provides Data Analytics to Attribution List Practices Proprietary

  6. Risk Assessment Risk Factors Comorbidity Risk Advanced Medical Therapy Comorbidity Risk Prior Surgery Dis Burden Risk Stricturing Inf Burden Risk Anemia Comorbidity Risk Abcess Inf Burden GI Bleeding Inf Burden Risk Fever Inf Burden Risk Cutaneous Signs Dis Burden Risk Ulcers Dis Burden Risk Perianal Disease Inf Burden Risk Localized Tenderness Comorbidity Risk Perianal Abcess Inf Burden Risk ESR 0 0.5 1 1.5 2 2.5 3 Cost Factor Proprietary Proprietary

  7. Web-based Patient Engagement Tools Crohn’s Disease Activity Index (CDAI) Algorithm for automated CDAI = Sum(2S+5P+7G+20 Σ C+30D)* responses drives behavior What patients tell you (subjective) is different from what really happens (objective) reporting Portal response rate 27% and application response rate 80% *S = number of liquid or soft stools each day for 7 days; P = abdominal pain (graded from 0–3 on severity) each day for 7 days; G = general well being, subjectively 7 assessed from 0 (well) to 4 (terrible) each day for 7 days; C = presence of complications, 1 point each for each set of complications; D = taking Lomotil or opiates for diarrhea. Proprietary Proprietary

  8. Project Sonar: Process Overview Develop the Algorithm Assess the Risks Project Engage the Patient Sonar Develop Predictive Analytics Manage the Care Analyze the Payer Data 8 Proprietary

  9. Change in Crohn’s-related Normalized Payments From Baseline (Digestive Disease Week, May 2016) 20% Percentage Change From Baseline 8.97% 10% 0% -10% -9.87% -20% -30% -24.50% -40% -50% -60% -53.28% -57.14% -70% Total Inpatient Emergency Department Infusable Biologics Injectable Biologics Proprietary Proprietary

  10. Enhanced Patient Engagement = Cost Savings “ To date, we see medical savings trending at $6,000 for each “pinger”—patients using the technology—compared with other patients. This rate has resulted in almost $500,000 in savings for the 81 pingers in the initial program.” HFMA Journal February 2017: Care Not Just for Primary Care Practices See more at: http://www.hfma.org/Leadership/Share_Your_Story_Blog/2017/February/Value-B ased Care Not Just for Primary Care Practices Comparison against a Control Group All Services Total Control Study Pingers Nonpingers Savings against Control Savings % Patients 1049 864 185 111 74 Inpatient Cost $ 1,476,937.77 $ 1,261,079.67 $ 215,858.10 $ 77,949.06 $ 137,909.04 Inpatient Cost/PT $ 1,407.95 $ 1,459.58 $ 1,166.80 $ 702.24 $ 1,863.64 $ (757.34) -52% Total Outpatient Cost $ 6,096,846.84 $ 5,073,329.16 $ 881,270.68 $ 517,382.29 $ 500,344.39 OPT Cost per patient $ 5,812.06 $ 5,871.91 $ 4,763.63 $ 4,661.10 $ 6,761.41 $ (1,210.81) -21% Total Savings $ 7,331.49 $ (1,968.15) -27% 10 Proprietary

  11. Ping Response Rate Drives Cost Savings 11 Proprietary

  12. Performance Update: HCSC Data Results: Comparison against Matched Controls Medicare Normalized Data Study Matched Control Savings Metrics 2016 2016 Patients Count 185 864 % of Male 47.6% 45.0% Patient Age 46 46 Concurrent Risk Score, First Quarter 2016 2.868 2.703 Concurrent Risk Score, Whole Year 2016 2.635 2.925 Crohn's Related Services Inpatient Cost $94,122 $887,381 Inpatient Cost/PT $509 $1,027 ($518.29) Total Outpatient Cost $358,813 $2,209,751 Outpatient Cost/PT $1,940 $2,558 ($618.05) Proprietary Proprietary

  13. Patient Experience (TS) 43 year old female with Crohn’s Ileocolitis 2011: Stable on medical therapy but desired pregnancy • 6MP Discontinued at recommendation of OB • Successful pregnancy in 2012 2013: Placed on Pilot of Project Sonar August 2014: Disease Flare – Detected by Rising Sonar Scores Patient seen in office • Flexible Sigmoidoscopy Performed – Active Colitis • Diagnosed • Medications adjusted – Medication change – Clinical Improvement April 2015:Rising Sonar Score/Persistent symptoms • Fe Def Anemia/Iron Infusions added • Biologic initiated – Humira No hospitalization or ER Visit June 2015: Poor response to Humira • Dose increased to weekly • Skin Rash on hands – side effect of Humira Sept 2015 Persistently high Sonar Scores • Humira discontinued • Entyvio started Stabilized Sonar Scores • Flex Sig April 2016 – endoscopic improvement 13 Proprietary

  14. PTAC Update Announcement: The Physician-Focused Payment Model Technical Advisory Committee (PTAC) has completed its two-day public meeting to deliberate and vote on three proposals for physician-focused payment models. The full Committee voted to make the following recommendations to the Secretary of the Department of Health and Human Services (HHS): • Project Sonar submitted by the Illinois Gastroenterology Group and SonarMD, LLC: recommend for limited-scale testing • The COPD and Asthma Monitoring Project (CAMP) submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group Inc. (PMA): do not recommend • The ACS-Brandeis Advanced APM submitted by the American College of Surgeons: recommend for limited scale testing The next step is for PTAC to draft its report to the Secretary transmitting its recommendations and rationales for those recommendations. The Secretary will post his response to PTAC’s recommendations on the CMS website. 14 Proprietary

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