Solving for Type 2 Diabetes in the Workplace

TEXAS BUSINESS GROUP ON HEALTH Solving for Type 2 Diabetes in the Workplace Bharath Thankavel, MD Medical Director, Value Based Care Blue Cross and Blue Shield of Texas @BCBSTX Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Types of Diabetes Type 1 Type 2 Characterized by lack of insulin Autoimmune disease Usually diagnosed in children Characterized by insulin resistance A syndrome, not a disease Usually diagnosed in adults Characterized by insulin resistance A syndrome, not a disease Usually diagnosed in adults 5% Type 1 PREVALENCE 95% Type 2 2

Projecting the Future Diabetes Population: The Imperative for Change 35.0 30.0 28.7 29.6 31.4 32.7 U.S. Population with Diabetes (%) 25.0 20.0 15.0 10.0 14.5 17.5 20.4 23.2 25.6 5.0 0.0 2010 2015 2020 2025 2030 2035 2040 2045 2050 BOYLE JP, ET AL. POPUL HEALTH METR. 2010;8(29):1-12. 3

Impact on Your Bottom Line In a U.S. company of 1,000 employees: 120 have diabetes 34 are undiagnosed 370 have prediabetes $4 million is spent on insurance (on average, for people with diabetes and prediabetes) $751,682 is the annual increase in cost (if 25% of employees with prediabetes develop diabetes) SOURCE: AMERICAN DIABETES ASSOCIATION, MARCH 11, 2016 4

Employer Challenges in Dallas Dallas County SOURCE: BCBSA COMMUNITY MANAGEMENT HUB. JUNE 22, 2018. 5

Employer Challenges in Houston Harris County SOURCE: BCBSA COMMUNITY MANAGEMENT HUB. JUNE 22, 2018. 6

Employer Challenges in San Antonio Bexar County SOURCE: BCBSA COMMUNITY MANAGEMENT HUB. JUNE 22, 2018. 7

Top 5 Most Expensive Chronic Conditions Oncology Diabetes Musculoskeletal Health Conditions Respiratory Heart

BCBSTX Claims $3.6 Billion $5.4 Billion Diabetes without complications is so prevalent, it has become our highest driver of claims cost. $3.5 Billion $3 Billion $2.7 Billion $2.6 Billion $2.5 Billion $2.4 Billion Diabetes with chronic conditions is less prevalent but still a top driver of costs $2.3 Billion $2.2 Billion Source: TX Claims Data 2015 SOURCE: BCBSTX CLAIMS DATA, MARCH 2016. NUMBERS ARE ROUNDED.

Diabetes with Chronic Complications is Trending Up 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18 May-18 Jul-18 Sep-18 Nov-18 Jan-19 Mar-19 May-19 If trend continues looking to 7% prevalence rate SOURCE: BCBSTX CLAIMS DATA, MARCH 2016. Source: BCBSTX Claims data, March 2016

Our Diabetes Health Care Costs Diabetes Health Care Costs (PMPM) BCBSTX members residing in Texas (all ages) Diabetes without Complications $1,719 Price Per Member Per Month Diabetes with Chronic Complications $2,419 Diabetes with Acute Complications $4,419 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 $4,500 $5,000 Health Care Costs (PMPM) Source: BCBSTX Claims data, March 2016 SOURCE: BCBSTX CLAIMS DATA, MARCH 2016.

The Cost of Complications END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, STAGE 5 $28,234 $25,185 CHRONIC KIDNEY DISEASE, STAGE 4 $7,296 DIABETES WITH ACUTE COMPLICATIONS $4,449 End Stage Renal Disease is rare, but it averages $28,234 per member per month. Prevalence.04% 6.55% DIABETES WITH CHRONIC COMPLICATIONS $2,419 DIABETES WITHOUT COMPLICATIONS $1,719 SOURCE: BCBSTX CLAIMS DATA, MARCH 2016.

TEXAS BUSINESS GROUP ON HEALTH Proactive Approaches for Employers Empowering Through Prevention

A MODERN APPROACH TO HEALTH AND WELLBEING BLUE CARE CONNECTION WELLBEING MANAGEMENT Utilization Management (UM) fixed UM expansion variable options Separate programs for disease management and case management supported by different clinicians Holistic Health Management supported by a multidisciplinary team Telephonic lifestyle management program Tobacco cessation and weight management support via Well ontarget Limited digital, self-management wellness content and coaching Extensive digital, self-management wellness content and coaching via Well ontarget Telephonic engagement Multi-channel engagement (telephonic, email, secure messaging, click to schedule a call) Cost avoidance Near-term, hard-dollar cost savings 14

15 Client Example Annual Wellness Exam Incentive To increase annual wellness exam compliance, this client increased participation by offering an incentive in the form of a premium reduction. 30,000 Eligible Members 21,900 (73%) Members took their annual wellness exam 15,330 (70%) of these Members did not have an annual exam 1 year prior 13.6% of Members were diagnosed with a new condition following the exam.

Prevention Works Diabetes Prevention Program Research Group 3,234 people with prediabetes assigned to one of three groups Placebo Metformin Lifestyle management 150 minutes exercise per week Weight loss of 7%

Prevention Works SOURCE: NEW ENGLAND JOURNAL OF MEDICINE. 2002 FEB 7; 346(6): 393 403.

Integration with DIGITAL HEALTH PARTNERS Metabolic Syndrome Reversal Program Lose weight. Not pleasure. Obesity-related Chronic Disease Prevention Solutions Healthy habits, built over time Diabetes Management Effectively manage diabetes 18

Weight Loss Program Airline Client Results 2015-2018 8 Classes 21,786 Participants 80%+ Completion Rate >155,000 lbs Lost So Far 9 lbs Avg 10-Week Weight Loss >10,000 participants lost more than 5% body weight 65% Lowered Diabetes Risk 39% Metabolic Syndrome (MetS) Reversal

Weight Loss Program Real world clinical results with employers, published in two peer-reviewed journals Journal of Metabolic Syndrome and Related Disorders 1 Journal of Occupational and Environmental Medicine 2 Metabolic Syndrome -50.7% Type II Diabetes Risk -55% Blood Pressure Risk -50% Losing 5%+ of bodyweight -44% 1. Evaluation of a Voluntary Work Site Weight Loss Program on Metabolic Syndrome. Conrad P. Earnest, PhD; Timothy S. Church, MPH, MD, PhD. October Issue 2015 (N=3880) 2. Evaluation of a Voluntary Work Site Weight Loss Program on Hypertension. Conrad P. Earnest, PhD; Timothy S. Church, MPH, MD, PhD. December Issue 2016 (N=5988)

Consider Covering Bariatric Surgery Total diabetes medication costs decreased significantly among surgery patients. Courcoulas, JAMA Surgery 2015 Bariatric surgery with lowlevel lifestyle intervention resulted in more disease remission than did lifestyle intervention alone. KLEIN, OBESITY VOLUME 19 NUMBER 3 MARCH 2011 21

Healthy Kids Healthy Families 2017-2018 Grantees

Stay informed. @BCBSTX

Impact of Type 2 Diabetes on Texas Employers Comparing Dallas/Fort Worth, Houston, and San Antonio July 12, 2018 Marianne Fazen, Ph.D. President & CEO, Texas Business Group on Health Richard Frye, Ph.D. CEO, Managed Care Digest Series 1 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Learning Objectives Following the session, participants will be able to: 1 2 3 Discuss Type 2 Diabetes Patient Variation Across 3 Texas Markets Review How Those Differences May Translate into Variations in Type 2 Diabetes Care Understand How Those Variations Might Impact Outcomes for Texas Type 2 Diabetes Patients 2 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Diabetes Claims Dataset Data are derived from health care professional (837p) and institutional (837i) insurance claims, representing nearly 11.7 million unique patients nationally in 2017 with a diagnosis of Type 2 diabetes. Of these, nearly a million (998,282) were diagnosed in Texas. Diagnosis data are integrated with prescription activity from the National Council for Prescription Drug Programs (NCPDP) and lab results from a national provider. Includes data from physicians of all specialties and from all hospitals. HIPAA-compliant patient identifier methods allow tracking of diseasespecific diagnosis and procedure activity across the various settings where patient care is provided. Claims Data + RX Activity + Lab Results 3 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Age 65+ Share of Type 2 Diabetes Patients Is Highest in San Antonio Percentage of Commercial Type 2 Diabetes Patients, by Age, 2017 1 1 The percentages are representative of the universe of Type 2 diabetes patients on whom claims data have been collected in a given year. Includes HMOs, PPOs, point-of-service plans, and exclusive provider organizations. NOTE: Throughout this presentation, the Dallas/Fort Worth market includes Arlington; the Houston market includes The Woodlands and Sugar Land; the San Antonio market includes New Braunfels. 4 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

More Than One in Four San Antonio Type 2 Diabetes Patients Is Obese; Houston s Ratio Is Nearer to One in Five Percentage of Commercial Type 2 Diabetes Patients, by Select Comorbidities, 2017 1 MARKET Depression Hyperlipidemia Hypertension Obesity Dallas/Fort Worth 9.7% 63.5% 82.3% 23.4% Houston 7.9% 66.0% 83.3% 21.5% San Antonio 8.5% 58.4% 80.3% 25.9% Texas 7.9% 67.2% 81.0% 20.4% Nation 10.2% 65.8% 80.7% 25.5% 1 A comorbidity is a condition a Type 2 diabetes patient may also have, which is not directly related to the the diabetes. Comorbidities were narrowed down to a subset of conditions which are typically present in patients with Type 2 diabetes. Comorbidities of Type 2 diabetes include, but are not limited to, depression, hyperlipidemia, hypertension, and obesity. 5 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Dallas Share of Type 2 Diabetes Patients with Well-Controlled A1c Levels ( 7.0%) Is Highest; San Antonio s Is Lowest Distribution of Commercial Type 2 Diabetes Patients, by A1c Level Range, 2017 1 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentages of Type 2 diabetes patients who have had at least one A1c test in a given year. 6 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Among Texas Markets Shown, Dallas Had the Highest Share of Type 2 Diabetes Patients Receiving Any Insulin; San Antonio Had the Lowest Percentage of Commercial Type 2 Diabetes Patients Receiving Various Insulin Therapies, 2017 1 MARKET Any Insulin Products Long-Acting Basal Category 1 Long-Acting Basal Category 2 Rapid-Acting Insulin Mixed Insulin GLP-1+Long-Acting Insulin (Fixed Ratio) Dallas/ Fort Worth 34.0% 19.0% 7.5% 16.0% 3.0% 0.8% Houston 32.1% 18.5% 6.8% 15.0% 2.3% 0.5% San Antonio 29.7% 16.7% 7.3% 13.4% 2.0% 0.7% Texas 33.0% 18.6% 7.5% 15.5% 2.5% 0.6% Nation 34.4% 20.4% 5.8% 17.4% 2.3% 0.4% 1 Patients who filled prescriptions for only insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. NOTE: Throughout this presentation, Category 1 refers to long-acting basal insulins approved through 2014 and follow-on long-acting insulins approved after 2014. Category 2 refers to non-follow-on long-acting basal insulins approved in or after 2015. 7 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Share of Type 2 Diabetes Patients on Any Non-Insulin Antidiabetic Product in San Antonio Exceeds Those of All Other Markets Shown MARKET Percentage of Commercial Type 2 Diabetes Patients Receiving Various Non-Insulin Antidiabetic Therapies, 2017 1 Any Non-Insulin Antidiabetic Product Biguanides DPP-4 Inhibitors GLP-1+Long- Acting Insulin (Free Ratio) Insulin Sensitizing Agents SGLT-2 Inhibitors Sulfonylureas Dallas/Fort Worth 85.8% 54.6% 10.1% 4.2% 6.6% 15.8% 24.6% Houston 88.0% 59.2% 10.5% 4.2% 6.0% 15.0% 24.6% San Antonio 88.8% 57.3% 10.4% 4.3% 6.9% 16.6% 20.9% Texas 86.7% 56.9% 10.4% 4.2% 6.4% 15.1% 24.0% Nation 85.5% 60.6% 11.0% 3.6% 5.1% 12.2% 26.4% 1 Patients who filled prescriptions for only insulin products may have also filled prescriptions for products in the non-insulin category, and vice versa. 8 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

San Antonio Lags Other Texas Markets and the Nation in A1c Testing Among Type 2 Diabetes Patients in 2016 Percentage of Commercial Type 2 Diabetes Patients, by Service, 2016 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentages of Type 2 diabetes patients who have had at least one A1c test in a given year. 9 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Nephropathy, Neuropathy, and PAD Rates Are Higher Among San Antonio Type 2 Diabetes Patients Than Those in Dallas or Houston Percentage of Commercial Type 2 Diabetes Patients, by Select Complications, 2017 1 MARKET CV Disease Nephropathy Neuropathy PAD Severe Hypoglycemia Dallas/Fort Worth 32.8% 37.9% 36.6% 15.1% 3.8% Houston 35.4% 36.4% 36.7% 14.1% 3.9% San Antonio 29.3% 39.3% 38.9% 22.6% 2.9% Texas 33.4% 36.7% 35.9% 15.8% 3.5% Nation 36.9% 32.9% 36.2% 15.4% 3.7% 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, cardiovascular (CV) disease, nephropathy, neuropathy, peripheral artery disease (PAD), and severe hypoglycemia. 10 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

In All Texas Markets, Emergency Department Professional Charges Were Higher for Type 2 Diabetes Patients With A1c >9.0%, and Highest in Houston in 2017 Average Annual Emergency Department Professional Charges for Commercial Type 2 Diabetes Patients, Overall vs. Commercial Type 2 Diabetes Patients With an A1c >9.0%, 2017 1,2 1 The A1c test measures how much glucose has been in the blood during the past 2 3 months. Figures reflect the percentages of Type 2 diabetes patients who have had at least one A1c test in a given year. 2 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 11 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

In All Texas Markets, Emergency Department Professional Charges Were Higher for Type 2 Diabetes Patients with Severe Hypoglycemia, and Highest in Houston in 2017 Average Annual Emergency Department Professional Charges for Commercial Type 2 Diabetes Patients, Overall vs. Commercial Type 2 Diabetes Patients With a Complication of Severe Hypoglycemia, 2017 1,2 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, atherosclerotic cardiovascular disease (ASCVD; includes patients with ACS, AMI, stroke, and other cardiovascular conditions), cardiovascular (CV) disease, nephropathy, neuropathy, peripheral artery disease (PAD), retinopathy, severe hypoglycemia, and stroke. 2 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 12 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Inpatient Professional Charges Were Also Elevated in Houston vs. the Other Texas Markets, Especially for Type 2 Diabetes Patients with Severe Hypoglycemia Average Annual Inpatient Professional Charges for Commercial Type 2 Diabetes Patients, Overall vs. Commercial Type 2 Diabetes Patients With a Complication of Severe Hypoglycemia, 2017 1,2 1 A complication is defined as a patient condition caused by the Type 2 diabetes of the patient. These conditions are a direct result of having Type 2 diabetes. Complications of Type 2 diabetes include, but are not limited to, atherosclerotic cardiovascular disease (ASCVD; includes patients with ACS, AMI, stroke, and other cardiovascular conditions), cardiovascular (CV) disease, nephropathy, neuropathy, peripheral artery disease (PAD), retinopathy, severe hypoglycemia, and stroke. 2 Professional charges are those generated by the providers delivering care to Type 2 diabetes patients in various settings. 13 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774

Methodology IQVIA generated the Type 2 diabetes data for this presentation out of health care professional (837p) and institutional (837i) insurance claims, representing nearly 11.7 million unique patients nationally in 2017 with a diagnosis of Type 2 diabetes (ICD-9 codes 249.00 250.92; ICD-10 codes E08, E09, E11, E13). IQVIA also gathers data on prescription activity from the National Council for Prescription Drug Programs (NCPDP). These data account for some 2 billion prescription claims annually, or more than 86% of the prescription universe. These prescription data represent the sampling of prescription activity from a variety of sources, including retail chains, mass merchandisers, and pharmacy benefit managers. Cash, mail-order, Medicaid, and third-party transactions are tracked. Proprietary lab data derive from one of the largest independent commercial lab companies in the U.S. Patient information is de-identified, matched, and linked with other patient data assets (e.g., medical claims data). The most common attributes used are the de-identified patient ID, observation date, diagnosis, test name, test code, and test result. DATA INTEGRITY Data arriving into IQVIA are put through a rigorous process to ensure that data elements match to valid references, such as product codes, ICD-9/10 (diagnosis) and CPT-4 (procedure) codes, and provider and facility data. Claims undergo a careful de-duplication process to ensure that when multiple, voided, or adjusted claims are assigned to a patient encounter, they are applied to the database, but only for a single, unique patient. Through its patient-encryption methods, IQVIA creates a unique, random numerical identifier for each patient, then strips away all patient-specific health information protected under the Health Insurance Portability and Accountability Act (HIPAA). The identifier allows IQVIA to track disease-specific diagnosis and procedure activity across the various settings where patient care is provided (hospital inpatient, hospital outpatient, emergency rooms, clinics, etc.), while protecting the privacy of each patient. Limitations This is an administrative-claims-based data set, with potential biases secondary to coding variation and missing data. Administrative claims data have been used successfully in many published studies to examine patterns, effectiveness, and gaps in quality of care, and to assess outcomes in care. Although this data set focuses on patients with Type 2 diabetes, there are limitations in the granularity of ICD9-CM/ICD10 codes used for billing. There were unmeasured factors that predict hospital readmission (e.g., quality of inpatient care and discharge planning, race, education, smoking, wellness program utilization) that were not controlled for in the multivariate analyses. 14 Managed Care Digest Series, 2018 sanofi-aventis U.S., LLC. A SANOFI COMPANY Data Source: IQVIA 2018 SAUS.105.18.03.1774