Advances in Alignment, Measurement, and Performance MY 2017 Results Highlights

Align. Measure. Perform. (AMP) Programs Launched in 2003, VBP4P is a statewide performance improvement program and one of the nation s largest Alternative Payment Models (APM). IHA information demonstrates the care delivered by integrated physician organizations outperform non-integrated networks by an average of 48% on quality and 5% on cost. 2018 Integrated Healthcare Association. All rights reserved. 2 2

Program Governance Committee Structure for Health Plan & Physician Organization Involvement Governance Committee Technical Payment Committee Contracting, Actuarial, and Medical Economics Experts Technical Measurement Committee Clinical and Data Reporting Experts IHA Staff Partners 2018 Integrated Healthcare Association. All rights reserved. 3

Parag Agnihotri, MD Medical Director, Population Health & Post-Acute Care Sharp Rees-Stealy Medical Group IHA Technical Measurement Committee Chair Anil Keswani, MD Corporate Vice President, Scripps Health Chief Medical Office, Scripps Health Plans and ACOs IHA Technical Payment Committee Chair 2018 Integrated Healthcare Association. All rights reserved. 4

Commercial Insurance Exhibits Wide Clinical Quality Variation Between Regions - 10 to 47 percent points! Average of 25 percentage points across the 19 geographic regions * Lower is Better 2018 Integrated Healthcare Association. All rights reserved. 6

Physician Organization Rate (%) Physician Organization Performance Against Atlas 100 41,463 More Diabetic Patients with Blood Sugar Controlled 90 80 70 60 31.9% difference 50 AMP Commercial HMO PO Average: 55.7% 40 30 20 Commercial PPO Average: 23.8% 10 0 2018 Integrated Healthcare Association. All rights reserved. 8

AMP Commercial HMO Measures in Atlas Measurement Year 2015 Results Diabetes Care: Blood Sugar Control <8.0% Diabetes Care: Blood Sugar Control <9.0% Diabetes Care: Kidney Disease Monitoring Breast Cancer Screening Colorectal Cancer Screening Cervical Cancer Overscreening Cervical Cancer Underscreening Appropriate Use of Imaging Studies for Low Back Pain AMP Commercial HMO PO Average Commercial PPO Average

Common Measure Set Clinical Quality Patient Experience Advancing Care Information Appropriate Resource Use Total Cost of Care Process and outcomes measures focused on six priority clinical areas: Cardiovascular (5) Diabetes (8) Musculoskeletal (1) Prevention (7) Patient ratings of five components, including care overall: Provider Communication Care Coordination Office Staff Overall Ratings of Care Ability to report selected e- measures (2) Utilization metrics spanning: Inpatient Stays Readmissions ED Visits Outpatient Procedures Generic Prescribing Average health plan and member payments associated with care for a member for the year, adjusted for risk and geography Respiratory (3) Access to Care 2017 Integrated Healthcare Association. All rights reserved. 11

Measures with Greatest Improvement Measures 1. Childhood Immunization Status: Combo 10 2. Statin Therapy for People with Cardiovascular Disease: Adherence 3. Appropriate Testing for Children with Pharyngitis Percentage Point Change +4.72% +4.37% +3.85% Estimated Impact 3,708 more children immunized 1,228 more patients adherent with statin meds 997 more children dispensed an antibiotic were appropriately tested 4. Diabetes Care: HbA1c Control <8.0% +3.26% 5. Optimal Diabetes Care: Combination +2.90% 15,476 more diabetic patients had blood sugar controlled 13,754 more diabetic patients received right combination of care The following measures was excluded due to a break in trending: Immunizations for Adolescents: Combo 2 2018 Integrated Healthcare Association. All rights reserved. 12

Measures with Least Improvement Measure Percentage Point Change 1. Patient Experience: Access Composite -0.45% 2. Patient Experience: Overall Ratings of Care Composite 0.05% 3. Statin Therapy for People with Diabetes: Statin Adherence 80% 0.15% 4. Controlling Blood Pressure for Non-Diabetic People with Hypertension 0.25% 5. Patient Experience: Provider Communication Composite 0.32% The following measure was excluded due to a break in trending: Asthma Medication Ratio 2018 Integrated Healthcare Association. All rights reserved. 13

Measures with Most Variation Measure Standard Deviation 1. Diabetes Care: Blood Pressure Control <140/90 mm Hg 28.67 2. Controlling Blood Pressure for Non-Diabetic People with Hypertension 26.74 3. Childhood Immunization Status: Combo 10 21.46 4. Appropriate Testing for Children With Pharyngitis 19.40 5. Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis 18.57 2018 Integrated Healthcare Association. All rights reserved. 14

Measurement Year 2018 Measure Set Clinical Quality Patient Experience Advancing Care Information Resource Use Measure Commercial HMO Commercial ACO Medi-Cal Managed Care Medicare Advantage Concurrent Use of Opioids & Benzodiazepines Baseline Testing Baseline Use of Opioids at High Dosage Baseline Testing Baseline Controlling Blood Pressure for People with Hypertension X X Controlling High Blood Pressure Baseline Baseline Baseline Baseline Proportion of Days Covered by Medications: RAS Antagonists X X X Proportion of Days Covered by Medications: Statins X X X Statin Therapy for Patients With Cardiovascular Disease X X X X Diabetes Care: Combo X X Diabetes Care: Blood Pressure Control X X X Diabetes Care: Eye Exam Baseline X Baseline X Diabetes Care: HbA1c Control X X Diabetes Care: HbA1c Poor Control X X X X Diabetes Care: Medical Attention for Nephropathy X X X X Proportion of Days Covered: Oral Diabetes X X X Statin Therapy for Patients With Diabetes X X X Use of Imaging Studies for Low Back Pain X X X Breast Cancer Screening X X X X Cervical Cancer Overscreening X X X Cervical Cancer Screening X X X Childhood Immunization Status: Combo 10 X X X Chlamydia Screening in Women X X X Colorectal Cancer Screening X X X X Immunizations for Adolescents: Combo 2 X X X Appropriate Testing for Children With Pharyngitis X X X Asthma Medication Ratio X X X Avoidance of Antibiotics of Adults with Acute Bronchitis X X X Encounter Rate by Service Type X X Info Only Initiation & Engagement of Drug Dependence Treatment Testing Statin Use in Persons with Diabetes X Prenatal & Postpartum Care Testing Disease Modifying Anti-Rheumatic Drug Therapy for RA X Osteoporosis Management in Women Who Had a Fracture X Adult BMI Assessment X Weight Assessment & Counseling for Children/Adolescents Testing Access Composite X X Care Coordination Composite X X Office Staff Composite X X Overall Ratings of Care Composite X X Provider Communication Composite X X e-measure: Controlling High Blood Pressure e-measure: Screening for Depression & Follow Up Plan X X Acute Hospital Utilization X X All-Cause Readmissions X X X Info Only Ambulatory Care: ED Visits X X X Emergency Department Utilization X X X Frequency of Selected Procedures Info Only Info Only Generic Prescribing X X Inpatient Utilization X X Outpatient Procedures Utilization X X Cost Total Cost of Care X X X 2018 Integrated Healthcare Association. All rights reserved. 18

Clinical Quality Diabetes Measurement Year 2018 Measure Set Measure Domain 11. Measure Name Diabetes Care: Blood Pressure Control <140/90 mm Hg Measure Steward NQF Endorsed Commercial HMO Commercial ACO Medicare Advantag e Medi-Cal Managed Care NCQA Yes 0061 X X X 12. Diabetes Care: Eye Exam NCQA Yes 0055 Baseline X X Baseline 13. 14. Diabetes Care: HbA1c Control < 8.0% Diabetes Care: HbA1c Poor Control > 9.0% NCQA Yes 0575 X X NCQA Yes 0059 X X X X 15. Diabetes Care: HbA1c Testing IHA-NCQA Yes 0057 Retired Retired 16. 17. 18. Diabetes Care: Medical Attention for Nephropathy Proportion of Days Covered by Medications: Oral Diabetes Medications Statin Therapy for Patients With Diabetes NCQA Yes 0062 X X X X PQA Yes 0541 X X X NCQA No X X X 19. Statin Use in Persons with Diabetes PQA Yes 2712 X 2018 Integrated Healthcare Association. All rights reserved. 19

Highlights from Proposed Measure Set Changes Advances ACO developmental measures Encounter data measurement expanded to include facility and planned for incentive payment New blood pressure specifications Retires Use of Imaging Studies for Low Back Pain Public Comment Period Open through Oct. 5! VBP4P staff review every comment and take this feedback to the VBP4P Committees governing the program 2018 Integrated Healthcare Association. All rights reserved. 20

Preview of ACO Performance From MY 2015 Atlas Highlights Broad Variation Avoidance of Antibiotics for Adults w/acute Bronchitis Breast Cancer Screening Cervical Cancer Overscreening Cervical Cancer Screening Colorectal Cancer Screening Use of Imaging Studies for Low Back Pain Diabetes Care: Blood Sugar Control < 8.0% Diabetes Care: Blood Sugar Control <9.0% PPO Diabetes Care: Kidney Disease Monitoring HMO 2018 Integrated Healthcare Association. All rights reserved. 22

AMP Commercial ACO Measure Set Clinical quality, patient experience, utilization, and cost YEAR 1 MEASURES (MY 2017) 1. Asthma Medication Ratio 2. Breast Cancer Screening 3. Cervical Cancer Screening 4. Cervical Cancer Overscreening 5. Colorectal Cancer Screening 6. Controlling High Blood Pressure 7. Statin Therapy for Patients with Cardiovascular Disease 8. Comprehensive Diabetes Care 9. Statin Therapy for Patients with Diabetes 10. Use of Imaging for Low Back Pain 11. Appropriate Testing for Children with Pharyngitis 12. Antibiotic Avoidance in Adult Acute Bronchitis 13. Childhood Immunization Status 14. Chlamydia Screening in Women 15. Immunizations for Adolescents 16. All Cause Readmissions 17. ED Visits 18. Total Cost of Care DEVELOPMENTAL MEASURES (MY 2018 and beyond) 19. Initiation of Alcohol and Other Drug Dependence Treatment 20. Persistent Beta Blocker After Heart Attack 21. Avoidable ER Visits 22. Prenatal and Postpartum Care 23. Preventative Care & Screening: Tobacco Use 24. AHRQ Prevention Quality Indicator #90: Ambulatory Sensitive Admissions 25. Use of Opioids at High Dosage OR Concurrent Use of Opioids & Benzodiazepines 26. Weight Assessment & Counseling for Children/Adolescents 27. CG-CAHPS (ACO) 28. Patient Reported Outcomes 29. Flu Vaccinations for Adults 18-64 30. Adult BMI Screening & Follow Up 31. Depression Remission at 6 months 32. Screening for Depression & Follow Up Plan 33. Ischemic Vascular Disease: Aspirin Use 34. Optimal Diabetes Care Combination 35. NTSV C-Section 2018 Integrated Healthcare Association. All rights reserved. 23

Measure Development Leverages and Builds Upon Established Collection Processes Easier Harder Curren t state Greatest Impact Test Develop/Adapt Specs New Data Source Electronic Clinical Data Patient Reported Outcomes DEVELOPMENTAL MEASURES 19. Use of Opioids at High Dosage OR Concurrent Use of Opioids & Benzodiazepines 20. Initiation of Alcohol and Other Drug Dependence Treatment 21. Persistent Beta Blocker After Heart Attack 22. Prenatal and Postpartum Care 23. Weight Assessment & Counseling for Children/Adolescents 24. AHRQ Prevention Quality Indicator #90: Ambulatory Sensitive Admissions 25. Avoidable ER Visits 26. CG-CAHPS (ACO) 27. Flu Vaccinations for Adults 18-64 28. NTSV C-Section 29. Preventative Care & Screening: Tobacco Use 30. Adult BMI Screening & Follow Up 31. Ischemic Vascular Disease: Aspirin Use 32. Optimal Diabetes Care Combination 33. Screening for Depression & Follow Up Plan 34. Depression Remission at 6 months 35. Patient Reported Outcomes 2018 Integrated Healthcare Association. All rights reserved. 24

Common Incentive Myths Myth #1: Plan says they have adopted the value-based design, but model is different Myth #2: Quality performance doesn t matter in the value-based shared savings design Myth #3: Shared savings are based on Total Cost of Care performance, so my organizations cost structure makes earning incentives impossible Myth #4: Payments for IHA results have decreased under value-based design 2018 Integrated Healthcare Association. All rights reserved. 26

Greater Alignment in Health Plan Value-Based Incentives Myth #1: Plan says they have adopted the value-based design, but model is different Reality: Most plans have aligned their programs to the recommendations, differences usually result from messaging, incentives for full risk groups, or timing of adoption MY 2013 MY 2014 MY 2015 MY 2016 MY 2017 MY 2018 MY 2019 Blue Shield Cigna United Aetna Anthem Sharp Western Health Care1st (Medi-Cal) Health Net Kaiser N/A N/A N/A N/A N/A N/A N/A 2018 Integrated Healthcare Association. All rights reserved. 28

Share of Savings (PO Keeps) Quality as Eligibility Gate & Incentive Adjustment Myth #2: Quality performance doesn t matter in the value-based shared savings design Reality: Quality is an eligibility requirement and provides for a two-fold difference in the amount of any shared savings your physician organization keeps Quality Adjustment to Share of Savings 70% 60% 50% Maximum Share of Savings: 67.5% 40% 30% 20% 10% 0% Did Not Pass Gate Not eligible for incentive QCS < 7 Below 10th Percentile Minimum Share of Savings: 32.5% QCS = 7 10th Percentile QCS = 10 20th Percentile QCS = 12 30th Percentile QCS = 16 40th Percentile QCS = 21 50th Percentile QCS = 26 60th Percentile QCS = 34 70th Percentile QCS = 41 80th Percentile QCS = 50 90th Percentile MY 2017 Quality Composite Score 2018 Integrated Healthcare Association. All rights reserved. 30

Shared Savings Opportunities based on Utilization Management Myth #3: Shared savings are based on Total Cost of Care performance, so my organizations cost structure makes earning incentives impossible Reality: Shared savings are based on net performance for 5 resource use measures Resource Use Increase Resource Use Saved Overall: Net Resource Use -35.7% 64.3% All-Cause Readmissions -51.4% 48.6% Inpatient Bed Days -44.8% 55.2% Outpatient Procedure Utilization -43.2% 56.8% ED Visits -39.7% 60.3% Generic Prescribing Rate: Overall -6.1% 93.9% -60% -40% -20% 0% 20% 40% 60% 80% 100% 2018 Integrated Healthcare Association. All rights reserved. 32

Average Payments ($ PMPM) Payments for all IHA Results Increased Myth #4: Payments for IHA results have decreased under value-based design Reality: Average PMPM payments for IHA results are consistent with peak 2006 levels, however, commercial HMO enrollment is a smaller proportion of many groups patients and individual PO earnings vary to a greater extent $1.00 $0.80 $0.60 $0.40 $0.20 $- Health Plan Payments Using IHA Results $0.96 $0.95 2006 Measurement Year 2016 2018 Integrated Healthcare Association. All rights reserved. 34

Disentangling Plan Variation & Maximizing Your Incentive Quality is a requirement and input for all health plan incentives Improve performance on clinical quality and patient experience Payments in shared savings designs rely on resource use performance Shared risk POs: Prioritize strategies that impact hospital, ED, outpatient, and pharmacy utilization All plans use measures that rely on risk adjustment Improve the completeness and accuracy of your encounter data especially important for full risk POs 2018 Integrated Healthcare Association. All rights reserved. 35

Risk Score Professional Encounter Rate Ties Strongly with Risk Score Encounter data matters. A lot. For all IHA stakeholders. IHA encounter measurement is expanding and will play a more direct role in health plan incentive payments especially for full risk physician organizations 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 Encounter Rate by Risk Score, MY 2016 y = 0.1428x + 0.047 R² = 0.6818 0.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Overall Encounter Rate 2018 Integrated Healthcare Association. All rights reserved. 36