DPCA: DIABETES PREVENTION AND CONTROL ALLIANCETM

JW TERRILL SEMINAR SERIES

Presentation to

DIABETES PREVENTION AND CONTROL ALLIANCE April 25, 2012

AGENDA The Epidemic Trio: Diabetes, Prediabetes and Obesity Introduction to the Diabetes Prevention and Control Alliance (DPCA) Diabetes Prevention Program (DPP) for Prediabetes Diabetes Control Program for Diabetes Management The NOT ME DPCA Brand Testing Event Overview: DPCA Critical Success Component

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AGENDA

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Diabetes Prevention and Control Alliance Not Business as Usual

Diabetes & Prediabetes US Adult Prevalence

1. Division of Diabetes Translation, www.cdc.gov 2. American Diabetes Association 3. Huang, Diabetes Care 32.12 Dec 2009 4

Missouri Adult Diabetes

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Overweight in the Show-Me State Diabetes problems follow closely behind

Missouri Adult Obesity / Overweight

Since 1990, the obesity rate has more than doubled1

As of 2010, 30.5% of Missouri adults were obese

25% percent of Missourians engage in no leisure time physical activity

1CDC's Behavioral Risk Factor Surveillance System 2 Reidhead, M. The Economic Burden of Diabetes Mellitus Among Missouri Adults, 2006. Part One: Direct Costs. Missouri Department of Health and Senior Services. Diabetes Prevention and Control Program, Jefferson City, MO, 2008. 3“Combined State Sheets”. Juvenile Diabetes Research Foundation.

Diabetes Prevalence 1995: 4.1% of Missouri adults had diabetes 2012: Prevalence more than doubled to 9.4%1

Annual Cost of Diabetes: Estimated direct costs (medical care) for diabetes = $2.72 billion2

Estimated indirect costs (inability to work, death) > $850 million3

Total direct and indirect costs = $3.57 billion

Diabetes has a firm grip on Missouri: For the last 16 years it has remained the 6th or 7th leading cause of death

6 1. UnitedHealth Group’s commercial book of business, 2008 / 2. UnitedHealthcare 2008 analysis for Diabetes Health Plan for several large employers; Medical only (no Rx) / 3. American Diabetes Association

Increased treatment costs: • $6,663 PMPY average cost increase for diabetes • $889 PMPY average cost increase for prediabetes

Costs directly related to progression in severity; a non-compliant individual with diabetes and related complications has potential to cost 9Xs more than a non-diabetic individual 1

10 year NPV of avoiding diabetic conversion - $55K Progressive Cost of Diabetes Per Member Per Year2

$2,784 $3,673

$4,592 $5,595

$6,195

$13,093

$17,762

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

No diabetes Diabetes / no complications

Diabetes non-compliant w/hypertension

Diabetes non-compliant w/CVD

Prediabetes Diabetes compliant w/hypertension

Diabetes compliant w/CVD

The Toll of Diabetes on US Health Care Potential to Bankrupt the Heath Care System

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What is Prediabetes?

A medical condition, impaired glucose tolerance, in which your blood glucose (sugar) is higher than normal but not yet at the level of diabetes (Fasting Blood Glucose = 100 – 125 mg/dl / A1c = 5.7% – 6.4%)

The primary causes of this condition are obesity and inactivity There are no symptoms for prediabetes; 90% of individuals with

prediabetes do not know they have the condition If healthy lifestyle changes are made, the condition can be reversible Annually, 10% of individuals with prediabetes will convert to diabetes

predia betes n. pree-dahy-uh-bee-tis. Noun - pathology

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DPP Target Population

U.S. Prediabetes Overview Diabetes Prevention Program Challenge

Definition: Blood glucose levels are higher than normal, but not high enough to be irreversible

Culprit: Obesity and Inactivity

Goals: Modify participant behavior, affect lifestyle change, help participants lose weight

Ideal: Reduce diabetes conversion

1. Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393-403, 2002 2. Ackermann and Marrero. Adapting the Diabetes Prevention Program Lifestyle Intervention for Delivery in the Community. AADE 2007.

Diabetes Prevention Program (DPP) Evidenced-based Intervention for Prediabetes

Study Diabetes Prevention Program Deploy2

Sponsor(s) National Institutes of Health Centers for Disease Control & National YMCA

Methodology Randomized Control Trial

(Lifestyle/drug/control) 27 sites, 3,234 prediabetics ages (>25) and various ethnicities

Pilot-cluster Randomized Trial (Lifestyle / Control)

Interaction 1:1 PhD-level Clinician (long-term maintenance, consistent training)

Group YMCA Lifestyle Coach (long-term maintenance, consistent training)

Frequency 16 Sessions (with optional year-long monthly follow-up)

Content

Welcome & Getting Started ▪ Be a Fat & Calorie Detective ▪ Ways to Eat Less Fat & Fewer Calories ▪ Healthy Eating ▪ Move Those Muscles ▪ Being Active: A Way of Life ▪ Tip the Calorie Balance ▪

Take Charge of What’s Around You ▪ Problem Solving ▪ Four Keys to Healthy Eating Out ▪ Talk Back to Negative Thoughts ▪ The Slippery Slope of Lifestyle Change ▪ Jump Start Your Activity Plan ▪

Make Social Cues Work for You ▪ You Can Manage Stress ▪ Ways to Stay Motivated

Goals 7% weight loss <25% fat calories 1200-1800 calories/day >150 minutes weekly physical activity

Results 5% weight loss 58% reduction in diabetes conversion 6% weight loss

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DIABETES PREVENTION PROGRAM (DPP) Lifestyle Management and Weight Loss

People diagnosed with prediabetes can slow and even prevent the onset of type 2 diabetes through weight loss and lifestyle management. Participants are guided in group sessions by specially-trained health coaches. DPP Overview

16 core 1-hour small group sessions, then monthly follow-up for one year Recognized by Centers for Disease Control and Prevention (CDC) Preventive benefit; no copayment for participants Sustained weight loss in 40 % of participants at 10 year follow up Adult risk of developing type 2 diabetes reduced by nearly 60%; in adults

age 60+, the reduction is 70% Program lifestyle changes proven to be more effective than medication Regular communication provided to physicians

Diabetes Prevention Program (DPP) Delivered via Local Health Coaches

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DPP at a Glance

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DPP Member Experience

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Current St. Louis Locations Y-USA Listings & Map

We will continue to add locations based on enrollment growth

West County Branch YMCA 16464 Burkhardt Place Chesterfield Jefferson County YMCA 1303 YMCA Dr Festus Wildwood Family YMCA 2641 Hwy 109 Wildwood Four Rivers Area Branch YMCA 400 Grand Ave Washington Marquette Branch YMCA 304 N Broadway St. Louis Downtown Branch YMCA 1528 Locust St St. Louis Carondelet Park Rec Complex 930 Holly Hills St. Louis Monsanto Branch YMCA 5555 Page Blvd St. Louis Webster Groves Branch YMCA 226 E Lockwood Ave Webster Groves Kirkwood Branch YMCA 325 North Taylor Avenue Kirkwood South County Branch YMCA 12736 Southfork Rd St. Louis Emerson Family YMCA 3390 Pershall Rd St. Louis South City Family YMCA 3150 Sublette Ave St. Louis Mid-County Branch YMCA 1900 Urban Dr Brentwood Edward Jones Family Branch YMCA 12521 Marine Ave St. Louis O'Fallon Family YMCA 3451 Pheasant Meadows Dr O'Fallon St. Charles Branch YMCA 3900 Shady Springs Lane St. Peters Tri-County YMCA 5293 Quail Ridge Pkwy Wentzville

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Diabetes Prevention Program Current Pricing

Average payer cost per participant = $450 Claim payment is progressive and based on outcomes (not a PMPM) Expected ROI estimated at 3.0 : 1

Metric Definition Claim Payment

Cumulative Payment

Engagement Enrolls in DPP and attends at least one of the 16 sessions $50 $50

Participation Enrolls in DPP and attends at least four of the 16 sessions $100 $150

Completion Enrolls in DPP and attends at least nine of the 16 sessions $235 $385

Performance 1 Enrolls in DPP and attends at least nine of the 16 sessions and loses >= 5% within 60 days of class completion $165 $550

– OR –

Performance 2 Enrolls in DPP and attends at least nine of the 16 sessions and loses >= 9% within 60 days of class completion $205 $590*

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DCP Target Population

U.S. Diabetes Overview Diabetes Control Program Challenge

Number: 26 million individuals / 1 in 10 adults

Definition: Can’t process glucose (blood sugar) normally

Culprit: Lack of control for BP, LDL, glucose, weight

Goals: Increase ADA standards compliance, monitor medications and control BP, cholesterol, HbA1c

Ideal: Avoid complications, delay disease progression

1. Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393-403, 2002 2. Ackermann and Marrero. Adapting the Diabetes Prevention Program Lifestyle Intervention for Delivery in the Community. AADE 2007.

Diabetes Control Program (DCP) Evidenced-based Intervention for Diabetes

Study The Pharmacy Care Program The Diabetes Ten City Challenge

Sponsor(s) City of Asheville NC & NC Association of Pharmacists

HealthMapRx & American Pharmacists Association

Methodology Ashville city employee diabetes management

program to demonstrate the value of pharmacist-directed care management

Duplication of the Pharmacy Care Program by observational analysis & pre/post comparison

with 573 employees at 10 US locations

Interaction 1:1 ▪ Individual & Pharmacist (health care education and compliance)

Frequency 4 Quarterly Consultations

Content

Baseline Diabetes Assessment (height, weight, waist circumference, BP, diabetes medical history ) ▪ HbA1C, Total cholesterol, LDL, HDL, TG lab reviews ▪ Medication Review ▪ Goal Setting ▪ ADA Exam Schedule ▪ Flu and pneumonia shots ▪ Participant Reminder Calls ▪ Primary Care Provider Updates ▪ Diabetes Self-management Education: Understanding Diabetes ◦ Nutrition & Meal Planning ◦ Medications ◦ Physical Activity ◦ Acute Complications ◦ Chronic Complications ◦ Monitoring Blood Glucose ◦ Health & Behavior Change ◦ Psychosocial Issues & Concerns)

Goals A1c < 7.5% LDL < 100 Systolic Blood Pressure < 130 Weight/BMI < 25

Results > 50% participants’ A1c level

Annual direct medical costs $1,200 - $1,872 Estimated annual productivity of $18,000

Influenza vaccination rate 33% Eye exam rate 24% ▪ Foot exam rate 40%

7.2% annual total health care costs

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DIABETES CONTROL PROGRAM (DCP) Medication Management and Disease Control

Less than 2% of individuals diagnosed with diabetes are in control of their disease.1 The four additional annual touch points with a specially trained pharmacist supports the PCP’s treatment plan and provides participants with additional health resources. DCP Overview

4 quarterly core 1:1 consultations in a private setting No copayment for program services Convenient pharmacist-monitored care includes meds, BP, weight, labs Proven to identify early signs of debilitating complications & improve outcomes Coordination with participant’s primary care physician Every % in A1C = 40% risk of eye, kidney, nerve disease complications Every 10 mm Hg in SBP = diabetes-related complications by 12% Improved LDL control may reduce cardiovascular complications by 20-50%

Diabetes Control Program (DCP) Delivered via Local Pharmacists

1 Source: National Health and Nutrition Examination Survey, National Center for Health Statistics, Centers for Disease Control and Prevention Beckles et.al. Population-based assessment of the level of care among adults with diabetes. Diabetes Care 1998 Sep;21(9):1432-8.

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DCP at a Glance

Current St. Louis Locations Shop N Save Pharmacy Listings & Map

We will continue to add locations based

on enrollment growth

Address City 1253 Watertower Place Arnold 7909 Highway N Dardenne Prairie 15446 Manchester Road Ellisville 45 Gravoi Bluffs Plaza Drive Fenton 49 N Florissant Road Ferguson 1275 N Truman Blvd Festus 175 Flower Valley Shopping Center Florissant 196 Mayfair Plaza Shopping Center Florissant 2183 Charbonier Road Florissant 1023 Crossroads Place High Ridge 10461 Manchester Road Kirkwood 7355 Manchester Road Maplewood 9521 Lewis and Clark Blvd. Moline Acres 1421 Mexico Loop Road East O'Fallon 4447 Natural Bridge Ave Saint Louis 10634 St Charles Rock Rd St Ann 9070 St Charles Rock Rd St John 3865 Gravois Ave St Louis 7057 Chippewa St St Louis 100 Jungermann Road St Peters 3740 Monticello Plaza Drive St. Charles 60 Harvester Square St. Charles 1032 Lemay Ferry Road St. Louis 10805 Old Halls Ferry Rd St. Louis 4660 Chippewa St St. Louis 500 Highway 50 W Union

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Average payer charge per participant for all claims is ~ $750 – First visit = $125 cost of entire intervention / Subsequent visits = $89 cost of entire intervention – Labs = $60/quarter (includes mailing, test, phys order, results review and data transfer) – Performance metrics = $90 each:

Pricing and underlying reimbursement tied to participant outcomes (not PMPM) Reduction in specialist referrals (expected but not included in ROI) Reduction in trend tied to improved compliance Expected ROI estimated at 3.5 : 1

Metric Definition Additional Requirements

Claim Payment

A1c < 7.5%

If < 7.5%, participant must maintain – OR– If > 7.5%, a reduction of at least 10% – OR– final A1c < 7.5%.

1. At least three measurements within the participant’s program year

2. Two of those measurements at least 180 days apart must be in control per guidelines

3. All measurements match a visit date

$ 90

LDL < 100

If < 100, participant must maintain – OR– If > 100, a reduction of at least 50% – OR– final LDL < 100

$ 90

SBP < 130

If < 130, participant must maintain – OR– If > 130, a reduction of at least 20% – OR– final SBP < 130

$ 90

BMI < 25

If < 25, participant must maintain – OR– If > 25, a reduction of at least 10% – OR– BMI < 25

$ 90

Diabetes Control Program Current Pricing

Current & Scheduled DPCA Markets * Indicates a 2012 Market

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Market Rollout Schedule through 2013

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DPCA ACTIVE MARKETS Albuquerque NM DCP Mid-Atlantic market

+ Baltimore & DC metro + Northern & Fairfax VA + Suburban Maryland

BOTH Annandale NJ DPP

Atlanta GA BOTH

Birmingham AL DPP Milwaukee WI BOTH

Bloomington IN DPP Minneapolis & St Paul MN BOTH

Boise ID DPP New York City Metro + Surrounding Boroughs + Northern NJ + Fairfield County CT

BOTH Boston MA DPP

Buffalo NY DPP

Cincinnati OH & No KY BOTH Oklahoma City OK DCP

Columbus OH BOTH Orlando FL BOTH

Dallas/Ft Worth/Arlington TX BOTH Phoenix AZ BOTH

Dayton OH BOTH Pittsburgh PA DPP

Eugene OR DPP Providence RI (entire state) DPP

Fort Wayne IN DPP Rochester NY DPP

Houston TX BOTH Savannah GA DPP

Indianapolis IN BOTH Seattle WA DPP

Jacksonville FL BOTH Spokane WA DPP

LaCrosse WI DPP St. Louis MO BOTH

Las Vegas NV BOTH Tampa FL BOTH

Lexington KY DPP Tucson AZ BOTH

Louisville KY DPP Venice FL DPP

Marshalltown IA DPP Wilmington DE (entire state) DPP

DPCA SCHEDULED 2012 MARKETS Albany NY May-Aug Philadelphia PA Jul

Asheville NC May-Aug Plattsburgh, NY May-Aug

Binghamton, NY May-Aug Salem OR Mar

Burlington VT May-Aug Springfield MO May-Aug

Charlotte, NC May-Aug St. Petersburg FL May

Clearwater FL May Stevens Point WI Apr

Cleveland OH Jul Sycamore IL May-Aug

DeLand FL May-Aug Syracuse NY May-Aug

Evansville IN May-Aug Tacoma, WA May-Aug

Itasca MN May-Aug Watertown NY May-Aug

Las Vegas NV Mar Wenatchee WA May-Aug

Marquette MI May-Aug Wichita, KS Jan

Middletown, NY May-Aug

DPCA PENDING MARKETS San Antonio TX TBD 2012

Austin TX TBD 2012

Denver CO TBD 2012-2013

Providence RI (entire state – add DCP) TBD 2013

San Diego CA 2013 Q1

Greensboro NC 2013 Q1

Orange/Ventura Counties CA 2013 Q1

New Orleans LA 2013 Q1

Chicago IL 2013 Q1

Diabetes Prevention and Control Alliance (DPCA)NOT ME Brand

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DPCA Consumer Brand

Bold and engaging with a strong call-to-action Mindset transition from “It can’t happen to me” to “I won’t let it happen to me” Relevant across full concern / hope / pride spectrum; meets people where they are

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Employee Communication Tools

Comprehensive view of employee population – demographics, psychographics, lifestyle and behaviors Communication plan for diabetics (DCP)

and prediabetics (DPP) – Direct mail letters – Outbound phone calls by a

DPCA representative – Newsletter articles – Internal communications – Employer campaign kit

Ongoing support for continued maintenance and improvement

DPCA will work with you to reach your members through multiple touch-points to maximize enrollment

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Sales & Marketing Tools

Proposal template with strong visuals and descriptive tables

Presentation template to customize to your needs

Employer kit tools to ensure successful testing event / health fair / etc.

– Program brochures describing each condition and program success credentials

– Vivid, descriptive and challenging posters that issue calls to action

– Email series to educate members and inform of program or event details

– Newsletter template to provide a comprehensive overview for employer internal communications

A proprietary – and unique – model for diabetes risk identification

Uses the industry’s largest database of medical facts and demographics to provide unparalleled accuracy

OptumInsight Impact Suite Reveals Members Who Need Testing, Enrollment

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What They Don’t Know Can Hurt Them

Why are testing events so critical?

26 million (11.5%) US adult diabetic individuals 1; 7 million (27%) are undiagnosed 79 million (35% )US adult prediabetic individuals1; 67 million (85%) are undiagnosed

and have NO symptoms2

The extra step to “go get tested” is a behavior change barrier that an onsite event could overcome

Traditional “you may be at risk” letters with follow-up phone calls has proven to be ineffective

The cost of waiting is conversion to diabetes

Almost 10% of prediabetic individuals will convert to diabetes annually

Increased average annual medical spend $5,7743 – $3,673 PMPY increase for prediabetes – $9,447 PMPY increase for diabetes with/without complications – The 10 year NPV of an individual converting to type 2

diabetes is $55K

1. American Diabetes Association Source for statistics 2. The Lewin Group 3. UnitedHealthcare 2008 analysis for Diabetes Health Plan for several large employers; Medical only (no Rx)

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Testing Event Member Benefits

Instant results “Teachable moment” that is hopeful Excellent on the spot enrollment results Most had no idea Some have been told since they were

not diabetic “everything was fine” Most health fairs don’t see prediabetes

as a red flag

Facts about identification and testing: – Results are immediate – Only 1-2% will show up as already diagnosed prediabetic – Approximately 30% of adult members appear in “undiagnosed but at risk” – Over 40% of “at-risk” will test positive for either prediabetes or diabetes – Over 80% of those who test positive will enroll immediately following

the screening event

This is the population we

need to get tested!

Testing Event Member Experience

Member arrives for their appointment at a given time and is checked in by staff from DPCA or Wellness Inc.

Member fills out release forms for Wellness Inc. A1c or Fasting Blood Glucose test is administered

– Test usually takes five minutes for results – Tester hands results to member with no consultation

Member checks out and based on results is either free to leave or is directed to Y table for consultation

– A1c results 5.7 – 6.4 of FBG 100 – 124 = DPP – A1c results 6.5+ or FBG 125+ = DCP

Typical consultation should take 5-10 minutes DPP members will leave feeling “signed up”

for a class while DCP members will leave with doctor referral form

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Event Details Finalized

DPCA Contacts Identified Employees

Additional Participant Employees

Employees Register

STEP WEEK 4 WEEK 5 WEEK 3 WEEK 1 WEEK 2 WEEK 6

SCREENING EVENT

DPCA Screening Event Value of DPCA logistics expertise

Location, date and time established Event data loaded into MYnetico At-risk participants identified

Employers promote event attendance DPCA Supplies the email blast Engagement Specialists begin outbound calls

Participants call to RSVP and ask questions

Fulfillment file loaded and sent to RR Donnelley Participant letters mailed Auto-dialer file prepared and sent

• Event Coordination • Identifying only at Risk participants •Outreach via Mail and Call Center outbound calls •Web link for participants to choose an exact time •DPCA will be onsite during the event to discuss the programs and enroll participants • Call Center to handle incoming calls

DPCA’s Turnkey Testing Event

Solution:

Employees that Test Positive

Enroll

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DPCA TIMELINE QUICKLY REACHING YOUR AT-RISK EMPLOYEES

Program Confirmed

Benefit Confirmed

Contract Executed

Content Provided

Participants Identified

Participants Entered

Communications Sent

Telephonic Outreach

Client eligibility and claim data collected/sent through DPI process to identify known / at-risk employees

Identified known and at-risk employees loaded into MYnetico

DPCA sends targeted letters to identified employees to begin

Confirm that CPT codes used for DPCA services are covered under client's preventive benefits.

client reviews, signs and returns

documents and member communication samples to client

Client agrees to move forward with DPCA; determines effective date, markets, applicable employee population and chosen programs

DPCA sends administrative

Contract delivered to client;

STEP WEEK 4 WEEK 5 WEEK 3 WEEK 1 WEEK 2 . . .

DPCA call center begins calling campaign to engage identified employees

QUESTIONS?

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