Strategies for Navigating the New Medicaid

1. Strategies for Navigating the New Medicaid The Third National Medicaid Congress Sam WillcoxonCEOFidelis SeniorCare

2. Challenge The Challenge: • How to manage the growing cost and improve the quality of care in the most expensive Medicare beneficiaries: the most functionally impaired frail elders. The Demographics: • The institutionalized frail elder comprise a significant portion of the Medicare population. Today: • 3.5% of the Medicare population resides in a nursing facility - 1.6 million beneficiaries • 1.5% of the population resides in assisted living - 800 thousand beneficiaries • Up to 3 million beneficiaries with similar levels of impairment still reside in the community many receiving inadequate care. • The nursing facility population has a life expectancy of 18 – 24 months, and consumes the most significant resources • Medicare annual expenditures of $30 Billion • Medicaid annual expenditures of $65 Billion • The frailest-of-the-frail, those 85 years old and older, will double in population from 4.7 million today to 9.6 million by 2030. The Thesis: • Highly focused care, applied to discrete segments of the Medicare beneficiary population, dramatically improves both the cost and quality of care

3. Solution • Change the paradigm. Encourage the growth and adoption of companies such as Fidelis, that; • Manage Medicare resources on a risk basis; thus reducing Medicare expenditures • “Marry” expert physicians practicing evidence based medicine to a care management model; thus improving the quality of care. • Partner with those physicians to deliver demonstrably better care at lower cost to high risk population. • Allow companies that prove this paradigm to expand into the community, overlay comparable clinical models on institutional status members living outside of traditional nursing facilities, thus preventing migration of these individuals into increasingly more expensive sites of residence and service.

4. Outcomes • Median age 82 • 9% < 65 years old • Low income (97.2% Medicaid) • Multiple overlapping chronic diseases • 84% of our members have 5 or more active chronic disease conditions • Of these; the most common chronic disease conditions • 72% have Dementia • 54% suffer from major psychiatric disorder such as Depression • 39% have had Strokes • 39% have had Diabetes • 38% have had a previous Heart Attack and 34% suffer from Congestive Heart Failure • 26% have chronic respiratory disease such as COPD or Asthma • Activity of Daily Living (ADL) Impairments: • 91.3% impaired in more than 2 ADL’s • 33.3% impaired in more than 4 ADL’s • Average Medicare risk score of 2.1 The typical Fidelis Member reflects population of institutionalized Medicare beneficiaries

5. Fidelis Model at a Glance • A Medicare Advantage Special Needs Plan that: • Partners with expert geriatricians within a market • Focuses on detailed, individualized care planning for each patient which includes family members, physicians, facility team and Fidelis • Ensures a minimum metric of 5 team visits (physician, extender, Fidelis) per patient, per month. Members are seen more often (frequently daily) as warranted by their clinical need. • Treats change of condition in the member’s home, the nursing facility, where clinically appropriate • Frequently communicates with family members

6. Long Term Care Facility Resident with Multiple Chronic Conditions Clinical Status Time Fidelis Care Model Comparison The Fidelis Nursing Facility (NF) experience demonstrates the results of superior clinical care USUAL NF CARE MODEL Lack of early diagnosis and treatment results in deterioration, eventual hospitalization Delirium, confusion from transfer results in chemical or physical restraints Inevitable second hospitalization exacerbates problems (high-tech medicine has poor risk/benefit ratio) Accelerated deterioration to end-stage disease, death FIDELIS CARE MODEL Condition deteriorates from baseline; diagnosed immediately on-site Stable for several months; gets skilled services on-site Aging/progressive deterioration over time; BUT remains comfortable and cared for on-site End-stage disease; receives comfort, care until death

7. A Snapshot of Fidelis Quality Indicators # of Medications Baseline: various, Medicare FFS data

8. Lessons & Implications • Highly focused care applied to discrete segments of the Medicare beneficiary population dramatically improve both the cost and quality of care. • Solutions, like Fidelis SeniorCare, when more broadly applied across the continuum, could have significant impact on Medicare and Medicaid budgets. • How?

9. Fidelis Value to Medicaid • Today… • Reduction in Medicare Copayments/Coinsurance • Skilled Nursing Care – covered 100% • Primary Care Services – covered 100% • Transportation Benefit – accompanied transportation as needed for outside clinical services • Basket of services – Dental, Vision, Hearing – provides additional services beyond Medicare and Medicaid • Clinical Value • Reduced Hospital stays – reducing copayment amounts covered by Medicaid • Reduced Prescription Drug use – less drug interaction, lower overall costs. • Overall better quality of life – lower overall service utilization

10. Medicaid and Fidelis Integration Opportunities • Today/Tomorrow… • Capitation for Current Medicare Products • Medicaid currently covers Coinsurance/Copay for Medicaid recipients enrolled in Fidelis Medicare product • Capitation for those services would benefit Medicaid • Decrease administrative burden of paying claims • Normalize cost of services for those enrolled in the program • Support Aging in Place Efforts • Diversion Programs • Where waivers exist, Fidelis can be the Medicare alternative for Medicaid enrollees • Currently offered in Nursing Facilities and Assisted Living Facilities • Fully Capitate for All Medicaid Services • Inclusive of all amounts paid for housing • Utilize current eligibility criteria • Allow Fidelis to place the individuals in the housing most appropriate for their condition, • Reducing housing costs • Clinical program ensures higher quality care in the most appropriate setting

11. Medicaid HMO’s and Fidelis • Fidelis has significant clinical expertise in Nursing Facilities • Those members that are sent to Skilled Nursing Facilities for short term stays can be managed by Fidelis onsite clinicians • Pro-active post acute/rehab management through Fidelis Physicians and team vs. telephonic case management • Improves outcomes • Reduces length of stay • Members Resident in Assisted Living Facilities • Fidelis provides onsite care • Willing to accept risk based payments