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The Medtronic ™ Care. Link Network (and Heart Failure Device Patients) Presented By: Will The Medtronic ™ Care. Link Network (and Heart Failure Device Patients) Presented By: Will Au-Yeung John Curtis Susan Malaret 3/15/2018 MEDTRONIC CONFIDENTIAL 1

Agenda • Converging Forces Increasing Heart Disease o Industry & IT Trends o • Agenda • Converging Forces Increasing Heart Disease o Industry & IT Trends o • Care. Link Technology • Reference Case • Cost Effectiveness Discussion 3/15/2018 - page 2

Advancing technology creates opportunity Increasing Life Expectancy & Heart Failure Macro-Trends Industry Trends Care. Advancing technology creates opportunity Increasing Life Expectancy & Heart Failure Macro-Trends Industry Trends Care. Link 3/15/2018 - page 3

What is Heart Failure? • Heart Failure is NOT a heart attack! • Heart What is Heart Failure? • Heart Failure is NOT a heart attack! • Heart failure is a condition that develops when the heart’s muscle becomes weakened after it is injured from something like a heart attack or high blood pressure, and loses its ability to pump enough blood to supply the body’s needs. • Effect on Body Not enough blood circulating o “Congestion” or fluid build up o 3/15/2018 - page 5

Heart Failure Prevalence • 4. 8 million Americans suffer from congestive heart failure • Heart Failure Prevalence • 4. 8 million Americans suffer from congestive heart failure • 250, 000 deaths each year caused by heart failure • 500, 000 new cases diagnosed each year, expected to double within 5 years • Americans have a 1 in 5 lifetime risk of developing this condition Source: National Health and Nutrition Examination Survey 3/15/2018 - page 6

Heart Failure Occurs in Old Age Percentage of total population by age group 3/15/2018 Heart Failure Occurs in Old Age Percentage of total population by age group 3/15/2018 - page 7

Heart Failure Costs • $40 billion is spent each year in managing heart failure* Heart Failure Costs • $40 billion is spent each year in managing heart failure* • Hospital charges for heart failure management were approximately $10, 000 per discharge, based on a mean length of stay of 6. 3 to 7. 7 days. ** • HF patients average 3. 4 office visits per year, at a cost of $13 billion** • Average cost per office visit- approximately $800/visit. *Medtronic website **O’Connell, JB, “The Economic Burden of Hearth Failure, ” Clinical Cardiology, 2000. 3/15/2018 - page 8

s Quickly Approaching Capacity Constraints 1250 D 750 ev ic e The number of s Quickly Approaching Capacity Constraints 1250 D 750 ev ic e The number of cardiac device patients is expected to soon exceed clinics’ capacity 1000 Patients pa tie nt 1500 250 clinic capacity 0 1998 2000 2002 2004 2006 2008 Implantible cardiac defibrillators (ICDs) are increasingly used for heart failure therapy. 3/15/2018 - page 9

Industry Macro-trends Patients demand: • Greater responsibility for managing their health • Convenient and Industry Macro-trends Patients demand: • Greater responsibility for managing their health • Convenient and consistent care delivery • Increased family involvement Clinics face: • Escalating volumes • Pressures for time, ROI, staff recruitment/retention • Disruption to continuity of care 3/15/2018 - page 10

Device Follow-Up: Today Total Time: 20 -30 minutes Receptionist Admin/Technician • Pulls schedule and Device Follow-Up: Today Total Time: 20 -30 minutes Receptionist Admin/Technician • Pulls schedule and • Greets patient • Collects co-pay, patient file if applicable 1 2 Nurse/Technician • Escorts patient to • Interrogates device room and checks • Inquires about meds, thresholds when appropriate 4 3 10 -15 mins Receptionist • Schedules next appointment Doctor • Sees patient if necessary 5 Nurse/Technician • Completes paperwork 6 Doctor • Over-reads paperwork 7 8 Administration • Billing submitted • Reimbursement filed 9 5 mins 3/15/2018 - page 11

Solution: Medtronic Care. Link Network 1 Patient holds the antenna over her device for Solution: Medtronic Care. Link Network 1 Patient holds the antenna over her device for interrogation. The Monitor automatically dials a toll-free number and transmits the data over a standard phone line. 3 Clinic can view patient data and reports on a secure website 2 Data is automatically sent to a secure server 3/15/2018 - page 13 4 Patients and their families can access extensive materials about living with their ICD

Medtronic Care. Link™ Monitor Portable device used by patients to send data • Routine Medtronic Care. Link™ Monitor Portable device used by patients to send data • Routine follow-up • Symptomatic episodes • Post-shock events A standard telephone line is the only requirement • Connect from home or while traveling (within the United States) 3/15/2018 - page 14 Medtronic Care. Link Monitor

Clinician Website • Interrogation capabilities comparable to in-office follow-up • All vital information provided Clinician Website • Interrogation capabilities comparable to in-office follow-up • All vital information provided in familiar, easy-to-read format • Review information any time, anywhere • Connect using personal computer with standard Internet access 3/15/2018 - page 15

Patient list • The first screen the clinician sees upon entering the Care. Link Patient list • The first screen the clinician sees upon entering the Care. Link Clinician site • Sort by date/time, patient name, and physician • Allows quick triage of patients, based on alerts • Detailed information on patients or transmissions is one click away 3/15/2018 - page 16

Quick Look™ • All vital device information provided in a familiar, easy-toread format • Quick Look™ • All vital device information provided in a familiar, easy-toread format • Comparable to the Medtronic programmer 3/15/2018 - page 17

10 Second EGM Determine appropriate sensing and pacing characteristics Patient’s presenting rhythm is captured 10 Second EGM Determine appropriate sensing and pacing characteristics Patient’s presenting rhythm is captured at time of transmission 3/15/2018 - page 18

Cardiac Compass Report • One of the most important patient monitoring tools • Same Cardiac Compass Report • One of the most important patient monitoring tools • Same format as the Programmer • Can be viewed on-screen first and then printed on 8 ½” x 11” paper 3/15/2018 - page 19

Workflow with Care. Link Total Time: 4 -8 minutes Admin/Technician • Pulls patient file Workflow with Care. Link Total Time: 4 -8 minutes Admin/Technician • Pulls patient file • Prints Reports • Schedules next appointment Nurse/Technician • Checks device and completes paperwork 2 Doctor • Over-reads paperwork Administration • Paperwork to Billing • Billing submits claim 4 3 1 4 mins 3/15/2018 - page 20

The solution. ICD Follow-up Example Medtronic ICD Clinic Example • Increases the number of The solution. ICD Follow-up Example Medtronic ICD Clinic Example • Increases the number of patients clinics can see today without investing in new staff or facilities • Limit staff and facility investments tomorrow 3/15/2018 - page 21 M Ca edt re ro Li ni nk c The Medtronic Care. Link Solution:

Cost Effectiveness 3/15/2018 - page 22 Cost Effectiveness 3/15/2018 - page 22

Cost Effectiveness = (Cost of intervention – costs averted by intervention) Benefits of intervention Cost Effectiveness = (Cost of intervention – costs averted by intervention) Benefits of intervention 3/15/2018 - page 23

Cost Effectiveness Costs of Intervention By Payor: • Reimbursed same as office visit By Cost Effectiveness Costs of Intervention By Payor: • Reimbursed same as office visit By Provider: • Medtronic bills monthly fee based on number of patients enrolled (about $17. 50 per patient, per month) • Cost of nurse, technician, and/or physician to review reports • Some training required By Patients: • No fee to Medtronic for monitor or basic patient website access • Patient co-pays are equivalent to in-office visit • Some training required 3/15/2018 - page 24

Cost Effectiveness Costs averted by intervention For clinics: • Reduced cycle time for follow-up Cost Effectiveness Costs averted by intervention For clinics: • Reduced cycle time for follow-up visit- “ 5 minute check vs. 20 min check. ” By patients: • Transportation costs and lost time 3/15/2018 - page 25

Cost Effectiveness Costs averted include transportation time for patients and reduced cycle time for Cost Effectiveness Costs averted include transportation time for patients and reduced cycle time for follow-up checks for clinics. Current Follow-up Work flow: Admin/Technician • Pulls schedule and patient file Receptionist • Greets patient • Collects co-pay, if applicable Nurse/Technician • Escorts patient to room • Inquires about meds, Nurse/Technician • Interrogates device and checks thresholds when appropriate 10 -15 mins Doctor • Sees patient if necessary Receptionist • Schedules next appointment Nurse/Technician • Completes paperwork Doctor • Over-reads paperwork 10 mins Total Time: 20 -30 minutes 3/15/2018 - page 26 Administration • Billing submitted • Reimbursement filed

Cost Effectiveness Work flow with Care. Link: Admin/Technician • Pulls patient file • Prints Cost Effectiveness Work flow with Care. Link: Admin/Technician • Pulls patient file • Prints Reports • Schedules next appointment Nurse/Technician • Checks device and completes paperwork Doctor • Over-reads paperwork 3 mins Administration • Paperwork to Billing • Billing submits claim 4 mins Total Time: 4 -8 minutes Time savings with Care. Link: 12 -26 minutes 3/15/2018 - page 27

Cost Effectiveness Benefits of Intervention Clinic Benefits: • Better patient care: Allows continuity of Cost Effectiveness Benefits of Intervention Clinic Benefits: • Better patient care: Allows continuity of care, which may lead to improved patient compliance and satisfaction. • Improved access to patient data: Comprehensive device data and patient diagnostics are available when and where needed. • Improved clinic operations: Current clinic customers report being able to dramatically decrease the time for each device check. Patient Benefits: • Convenience: routine device checks can be done from the convenience of the patient’s home. • Freedom to travel: patients can transmit data from anywhere in the 50 states • Peace of Mind: patients and their families have peace of mind by being remotely connected to clinics. 3/15/2018 - page 28

Cost Effectiveness Total Cost Effectiveness Net costs of intervention: • Increased cost to clinic Cost Effectiveness Total Cost Effectiveness Net costs of intervention: • Increased cost to clinic for Care. Link service approx. $210 per patient per year. Care. Link reader provided to patient free of charge. • No net change for equipment at clinic. • Cost savings from decreased cycle time potentially $400 per visit, or $1360 per patient per year based on 3. 4 visits per year. • Net savings potentially $1150 per patient per year. Change in Quality Adjusted Life Years (QALY’s) • Undetermined: net change in health status likely to be negligible due to equivalence to office visit. • Potential gains: decrease in disease affecting work and social activities due to travel time to office visits. • Potential losses: increased complexity of care. Potentially cost saving, but more studies need to be completed. 3/15/2018 - page 29

Cost Effectiveness of Similar Technologies “Preliminary findings suggest that using this technology would result Cost Effectiveness of Similar Technologies “Preliminary findings suggest that using this technology would result in an annual savings of $515 per patient and a 26% reduction in Medicare costs. Investigators also postulate that if all 500, 000 Americans with pacemakers switch to remote monitoring, the technology could save Medicare $210 million a year in direct healthcare costs. ” Quality, Patient Safety & Cost Effectiveness through Leadership and Health Information Technology “The benefits of e. Health enabled chronic care have been established by leading health care institutions including the Dept. of Veterans Affairs, which recently published results from over 2 years of demonstration projects showing 63% reduction in hospital admissions and a significant improvement in quality of life. “Published results from studies involving over 1000 patients with HF, diabetes and chronic respiratory diseaseshowed a 40% reduction in emergency room visits, 63% reduction in hospital admissions, 60% reduction in hospital bed days of care…. and significant improvement in quality of life. Remote monitoring of ICDs July 2003 by National Horizon Scanning Centre. Cost effectiveness study carried out in France- A follow-up cost for non home monitoring patients was compared to the expected follow-up cost of patients with home monitoring of ICDs. For each visit, the cost for transportation was $128 US and medical costs were $94 leading to a total cost of $222. Over 5 years, the reduction in costs for follow-up visits was estimated at $2, 200 if the number of visits is reduced from 4 to 2 and $3, 300 if reduced to 1 visit per year. Healthcare: Harness the Power of the Internet e-Commerce and e-Care by Douglas E. Goldstein, Aspen Publishers 3/15/2018 - page 30

Reimbursement - Existing Codes • CMS Carrier (WPS) Medical Director has agreed to allow Reimbursement - Existing Codes • CMS Carrier (WPS) Medical Director has agreed to allow use of existing codes • Use codes o 93741 • Single-chamber ICD check without reprogramming o 93743 • Dual-chamber ICD check without reprogramming • No additional paperwork require • Approximate Medicare reimbursement in Chicago/Illinois = $75 - $85 3/15/2018 - page 31

Reimbursement 3/15/2018 - page 32 Reimbursement 3/15/2018 - page 32

Conclusions • Cost effectiveness of telemedicine is hard to prove o Claims data is Conclusions • Cost effectiveness of telemedicine is hard to prove o Claims data is minimally useful • Uses current codes- difficult to differentiate from reference case • Patients are sick! A lot of comorbidities. • Cost-savings for provider is not clear o Time savings? Prevention of hospitalization and follow-ups? • Patient Benefit is Unclear o Convenient but does it impact the QOL score? • Further Study Clinical studies to identify any changes in QALYs o Verification of decreases in cycle time and associated costs. o 3/15/2018 - page 33

Questions? 3/15/2018 - page 34 Questions? 3/15/2018 - page 34

The Future of Follow-Up Care • Cardiac patients send comprehensive device data from the The Future of Follow-Up Care • Cardiac patients send comprehensive device data from the comfort of their homes. • Electrophysiologists view and analyze data using the Internet. • Patients may view an educational website designed exclusively for them. • Referral physicians benefit from timely feedback from the EP about the patient’s condition. 3/15/2018 - page 35

Patient Prevalence (000’s) The Numbers… Only 34% of VT/VF patients indicated for ICD therapy Patient Prevalence (000’s) The Numbers… Only 34% of VT/VF patients indicated for ICD therapy receive the device today* *Ruskin, N. J Cardiovascular Electrophysiology, 2002; 13: 38 -43. **1) AHA 2002 Heart and Stroke Statistical Update. Dallas, Tex. : AHA 2001. 2) Brehens, S. PACE. 2002; 25: 545. 3) Reek S et al. PACE. 2002; 24: 527. *** Abraham W, Fisher W, Smith A, et al. N Engl J Med. 2002; 346: 1845 -1853. 3/15/2018 - page 36

A growing population s ICD Follow-up Clinic Example 750 tie pa ev ic e A growing population s ICD Follow-up Clinic Example 750 tie pa ev ic e Patients 1000 The number of cardiac device patients is expected to soon exceed clinics’ capacity 500 250 Fact: The number of patients indicated for ICD therapy has doubled. * D 1250 nt 1500 clinic capacity 0 1998 2000 2002 2004 2006 2008 * ACC/AHA/NASPE 2002 guideline update. 3/15/2018 - page 37

Impact to Your Clinic 3/15/2018 MEDTRONIC CONFIDENTIAL 38 Impact to Your Clinic 3/15/2018 MEDTRONIC CONFIDENTIAL 38

Patient Adoption 3/15/2018 MEDTRONIC CONFIDENTIAL 39 Patient Adoption 3/15/2018 MEDTRONIC CONFIDENTIAL 39

Patient benefits Convenience: Routine device checks can be done from the convenience of the Patient benefits Convenience: Routine device checks can be done from the convenience of the patient’s home. Freedom to travel: Patients can transmit data when they travel within all 50 states (USA only). Peace of mind: Patients and their families have peace of mind by being remotely connected to the clinic. 3/15/2018 - page 40

Reimbursement 3/15/2018 MEDTRONIC CONFIDENTIAL 41 Reimbursement 3/15/2018 MEDTRONIC CONFIDENTIAL 41

NASPE Consensus and Guidelines for Regular ICD Evaluations • One-to-four month intervals • More NASPE Consensus and Guidelines for Regular ICD Evaluations • One-to-four month intervals • More frequently if o ICD therapy occurs in absence of premonitory symptoms • To ensure no false sensing or breach of electrode integrity has occurred • As battery end-of-life approaches 3/15/2018 - page 42

Pricing and Billing 3/15/2018 MEDTRONIC CONFIDENTIAL 43 Pricing and Billing 3/15/2018 MEDTRONIC CONFIDENTIAL 43

Pricing • For clinics Monthly fee based on number of patients enrolled (~$17. 50 Pricing • For clinics Monthly fee based on number of patients enrolled (~$17. 50 pppm) o No up-front fees; 30 -day notice to terminate o Invoiced per patient per quarter o Sign. Up! Program applies with 10 or more patients per quarter o • For patients o No fee to Medtronic for monitor or basic patient website access • Patient co-pays equivalent to in-office visit 3/15/2018 - page 44

Clinic Fee Supports Many Services • Clinician Website • Monitor (shipping, storage, and replacement) Clinic Fee Supports Many Services • Clinician Website • Monitor (shipping, storage, and replacement) • System Maintenance • System Updates • Data Storage • Security • Unlimited Clinic Users • Implementation Support (including materials, training, etc. ) • Technical Support • Account Management 3/15/2018 - page 45

Sign up. Enroll patients. Save. • Introducing… • Enroll 10 or more patients on Sign up. Enroll patients. Save. • Introducing… • Enroll 10 or more patients on the Medtronic Care. Link Network in a calendar quarter and receive a rebate---resulting in savings of approximately 25% 3/15/2018 - page 46

Care. Link Network Economic Advantages • Snowbirds • Episode Patients who go to the Care. Link Network Economic Advantages • Snowbirds • Episode Patients who go to the ER • Referrals and Outreach • Marketing Leadership • Time – Reallocate to Higher Value Activities • Potential Savings in Satellite Expenses 3/15/2018 - page 47

Why clinics buy Care. Link: • Low Risk Business Model and Contract No upfront Why clinics buy Care. Link: • Low Risk Business Model and Contract No upfront costs – unlimited users – complete service o Upgradeable to new technology o 30 day anytime out of the contract o Maintain current reimbursement o • Care. Link is cash flow neutral • Not a cherished revenue/profit center (non-material) • Perceived Value of Technology is a new option to manage clinic growth o CL competes well with current cost of running a clinic o Improve workflow – “The 5 minute Check vs. the 20 minute check”. o “Patients are asking for Care. Link”. o 3/15/2018 - page 48

Implementation and Account Management 3/15/2018 MEDTRONIC CONFIDENTIAL 49 Implementation and Account Management 3/15/2018 MEDTRONIC CONFIDENTIAL 49

Medtronic Patient Management Provides Comprehensive Account Management • Implementation and Ongoing Service • Partner Medtronic Patient Management Provides Comprehensive Account Management • Implementation and Ongoing Service • Partner with Customer to Achieve Care. Link Objectives o Best Practice Development and Sharing • Respond to Service Requests and Information Needs • Represent Customer in Product Enhancement Planning “Our Goal: Customer Satisfaction and Retention” 3/15/2018 - page 50

Medtronic Care. Link Network Questions? ? 3/15/2018 - page 51 Medtronic Care. Link Network Questions? ? 3/15/2018 - page 51

3/15/2018 - page 52 3/15/2018 - page 52