1

Cleveland, OhioJune 17, 2008

Delivering Health in Cuyahoga CountyThe Plain Dealer Editorial Board

The following report is proprietary information of the MetroHealth System and should not be disclosed in whole or part to any external parties without

the express consent of the MetroHealth System.

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Mission

Academic Health Care System

Committed to Community

Saving Lives, Restoring Health, Promoting Wellness

Outstanding, Life-long Care

Accessible to All

The MetroHealth System

Owned by Cuyahoga County

400+ bed Acute Care Medical Center

Physicians on CWRU School of Medicine Faculty

Complete Specialist Coverage

Nationally Recognized Quality

Nursing Magnet Status

County’s Only Level I Trauma & Burn Center

Largest Local ED with 100,000 Visit Capacity

Nine Community Health Centers

New Senior Health and Wellness Center in Old Brooklyn

Skilled Nursing

Significant Clinical/Behavioral Research

6,500 Employees

3

Serving Cleveland’s urban core

44107

44116

4413544126

44140

44114

4411344102

44111

44115

44103

44106

44108

44110

44127

44128

4402244124

44137

44120

44125

44118

44122

44112

44119

44121

44117

44105

44144

44129

44142

44130

44070

4413144134

44143

44136

44040

44011

44017

44056

44023

44012

44146

44138

44133 44141

44139

44123

4413244094

44236 44241

Clev eland

Lakewood

RockyRiv er

FairviewPark

N Olmsted

Bay Village

Cleveland

Shaker Hts

Univ Cir

Cleveland

Collinw ood

Solon

GarfieldHts

Bedford

Beachw ood

ClevelandHts

Chagrin Falls

Lyndhurst-Mayfield

S EuclidE Cleve

Euclid

Independence

Parma Hts

Brook Park

MiddleburgHts

Parma

Clev elandNorth Ridgeville

RichmondHts

Berea

Avon

Chagrin Falls

Avon Lake

Gates Mills

StrongsvilleN Royalton

Olmsted Falls

BrecksvilleBroadview

Hts

Novelty

Chesterland

Macedonia

Hudson Streetsboro

Willoughby

Cuyahoga

Lorain

Geauga

Lake

Summit

MASCMASCMASCMASCMASCMASCMASCMASCMASC(Outpatient (Outpatient (Outpatient (Outpatient (Outpatient (Outpatient (Outpatient (Outpatient (Outpatient Surgery)Surgery)Surgery)Surgery)Surgery)Surgery)Surgery)Surgery)Surgery)

West Park West Park West Park West Park West Park West Park West Park West Park West Park (Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)

PrentissPrentissPrentissPrentissPrentissPrentissPrentissPrentissPrentiss(Skilled Nursing)(Skilled Nursing)(Skilled Nursing)(Skilled Nursing)(Skilled Nursing)(Skilled Nursing)(Skilled Nursing)(Skilled Nursing)(Skilled Nursing)

McCaffertyMcCaffertyMcCaffertyMcCaffertyMcCaffertyMcCaffertyMcCaffertyMcCaffertyMcCafferty(Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus 4 Specialties)4 Specialties)4 Specialties)4 Specialties)4 Specialties)4 Specialties)4 Specialties)4 Specialties)4 Specialties)

Asia PlazaAsia PlazaAsia PlazaAsia PlazaAsia PlazaAsia PlazaAsia PlazaAsia PlazaAsia Plaza(Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus 3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)3 Specialties)

Buckeye Buckeye Buckeye Buckeye Buckeye Buckeye Buckeye Buckeye Buckeye (Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus(Primary Care plus8 Specialties)8 Specialties)8 Specialties)8 Specialties)8 Specialties)8 Specialties)8 Specialties)8 Specialties)8 Specialties)

J. Glen Smith J. Glen Smith J. Glen Smith J. Glen Smith J. Glen Smith J. Glen Smith J. Glen Smith J. Glen Smith J. Glen Smith (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus (Primary Care plus 2 Specialty)2 Specialty)2 Specialty)2 Specialty)2 Specialty)2 Specialty)2 Specialty)2 Specialty)2 Specialty)

The Courtlands(2 Specialties)

Park East(6 Specialties)

Lee-Harvard (Primary Care plus 8 Specialties)

Broadway(Primary Care plus5 Specialties)

Old Brooklyn(Primary care, Skilled Nursingand 9 Specialties)

Brooklyn(Primary CarePlus 5 specialties)

Strongsville(Primary Care plus5 Specialties)

MHMHMHMHMHMHMHMHMH

44026

44028

44039

44067

44087

44092

44104

44145

4414744149 44202

Columbia Station

Northfield

Tw insburg

Wicklif fe

Westlake

Aurora

Brunsw ick

2006 MH Market Share

20.0% +

10.0% to 19.9%

< 9.9%

The MetroHealth System

Community Health Center

MetroHealth Main Campus

Outpatient Medical Center

Skilled Nursing

CG 6/08CG 6/08CG 6/08CG 6/08CG 6/08CG 6/08CG 6/08CG 6/08CG 6/08Planning and Market ResearchPlanning and Market ResearchPlanning and Market ResearchPlanning and Market ResearchPlanning and Market ResearchPlanning and Market ResearchPlanning and Market ResearchPlanning and Market ResearchPlanning and Market Research

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Safety net for the citizens of Cuyahoga County

Note: IP - Market and MH are Cuyahoga residents onlySource: CDC NHAMCS; OHA Inpatient and Outpatient Data, 2006; MH Internal Data, US Statistical Abstract

2916

45

24

21

47

513

0%

20%

40%

60%

80%

100%

Cuyahoga County MetroHealth

Commercial Medicare Medicaid Uninsured

25K206K

Inpatient Discharge Distribution by PayorAll Cuyahoga Providers vs. MetroHealth, 2006

Inp

atie

nt

Dis

char

ges

by

Pay

or

60%

33

15

14

8

32

38

21

38

0%

20%

40%

60%

80%

100%

Cuyahoga County MetroHealth

Commercial Medicare Medicaid Uninsured

78K505K

ED Visit Distribution by PayorAll Cuyahoga Providers vs. MetroHealth, 2006

ED

Vis

its

by

Pay

or

76%

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Long-term decline in regional economy

Source: US Census Bureau; US Decennial Census; American Community Survey; Consumer Price Indexes, Bureau of Labor Statistics; Booz & Company Analysis

1,6481,721

1,4981,412 1,392

1,309

477506574

751876

444

0

400

800

1,200

1,600

2,000

1960 1970 1980 1990 2000 2006

Cuyahoga County (-0.5% CAGR) Cleveland City (-1.5% CAGR)

Total Population 1960 – 2006Cuyahoga County and City of Cleveland

Total Pop. (000s)

National and Cuyahoga Median Household Real Income (2006 Dollars) 1969 - 2006

$41,522$47,396$46,489

$50,008

$55,036

$48,451

$50,816$48,865

$46,765$46,615

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

1969 1979 1989 1999 2006

Cuyahoga County United States

Median HH Income

Cuyahoga HH Income to US HH Income Ratio

118% 107% 95% 93% 86%

(1) Data for 1969, 1979, 1989, and 1999 has been sourced from US Decennial Census; Data for 2006 has been sourced from American Community Survey

(2) Census questionnaires request for income for the previous financial year; Census conducted every decade (e.g., 2000) therefore reports income for the prior year (e.g., 1999)

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Increased need for health safety net

6%

9%

5%

6%

16%

13%

0%

5%

10%

15%

20%

2000 2001 2002 2003 2004 2005 2006

Unemployment Rate 2000-2006

Cleveland Cuyahoga National

Un

insu

red

Rat

e (a

s %

of

Civ

ilia

n W

ork

forc

e)

Source: Ohio Department of Jobs and Family Services; Census ACS Survey; Ohio Medicaid Reports (2000-05)

209237

138128

53

17

0

50

100

150

200

250

300

350

400

450

2000 2006

Medicaid Uninsured Eligible, not Recipient

418

364

Cuyahoga Uninsured and Medicaid Population (<65)

Cu

yah

og

a C

ou

nty

Po

pu

lati

on

(00

0s)

<200% FPL 29% 33%

14.8%

5.1%

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Managing in a constrained environment

MetroHealth Operating and Net Income/Loss

Source: MetroHealth audited financial statements and 2008 budget

($80)

($60)

($40)

($20)

$0

$20

2003 2004 2005 2006 2007 2008Budget

Operating Loss Excess Revenue Over Expenses

MetroHealth Charity Care and Subsidies

$ m

illio

ns

$ m

illio

ns

Budget

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

$100

2007Uncompensated

Care Cost

GovernmentSubsidies

Funding Gap

$94M

County Subsidy

$40M

HCAP

$15M

Gap

$39M

Note: $9.6M is also received from UPL as a Medicaid Supplement

Budget

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MetroHealth’s priorities

Expand service selectively

– The Center for Community Health

– Senior Health and Wellness Center

Implement screening exams to improve patient experience

Launch revenue and operational upgrades

Capture immediate budget opportunities

Improve

Today Tomorrow

Improve public health

Implement new care model for the uninsured

Attract patients with affordable quality

Reinvent

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Other communities are progressingIncremental levels of sophistication/progression

11 22 33

Service EnhancementsService Enhancements Care Delivery Management InitiativesCare Delivery Management Initiatives Patient Centered CarePatient Centered Care

Execute targeted initiatives to address utilization of high-cost services

Enroll uninsured in “program” designed to manage care delivery most efficiently

Adopt a patient-centric approach to health care

Open access formats/extended hours clinics to increase access for non-emergent care – e.g., Hudson River HealthCare (NY)

Increased urgent care clinics and enhanced nurse triage to alleviate ER non-emergent care – e.g., Harborview Medical Center (WA)

“Frequent user” case management including high cost utilization analysis and intense follow-up – e.g., “Frequent Users of Health Services Initiative” (CA)

Robust program for management of care delivery (a ‘virtual insurance’ model) – e.g., “Carolina Access”

– Utilization and Care Management across services

– Appropriate authorization of services

– Referral management

Expanded chronic disease management – e.g., “Voices of Detroit Initiative” (MI)

Assignment of medical homes to help coordinate care and information across care continuum – e.g., San Francisco Universal Access Program

Integration across care continuum, easily accessible including well located primary care sites, access to specialty care – e.g., Kaiser Permanente CA

Support for patients beyond basic medical care including patient navigators, social workers, transportation – e.g., MD Anderson Navigators

Community outreach to proactively target underserved

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MetroHealth leadership in the community

Extensive community-based services through MetroHealth’s Center for Community Health

Extensive research on care delivery in underserved populations

– Proven outcomes in the management of chronic disease

– Center for Reducing Health Disparities• $6 million NIH grant focused on hypertension

and kidney disease• Novel community-based research programs

– Center for Health Care Research and Policy• Robert Wood Johnson Foundation initiative

Full service specialty/ tertiary care medical center