Enhanced Urgent Care

1. Enhanced Urgent Care Reducing Healthcare Costs

2. Current situation- Nationally • Chronic Disease Population • 30 million chronically ill nationwide • Cost of health care for people with chronic diseases account for 75% of the nation’s total health care cost. • Growing aged and chronic disease population Current situation-in the health system • Limited patient understanding of disease education. • Lack of integrated care post-discharge with gaps. • Non-compliance with plan of care

3. Emergency room treatment for non-emergency medical conditions is a major contributor to the rising cost of health care. Building a relationship with a primary care physician and seeking treatment for routine conditions in a doctors office instead of an emergency room is an efficient way to keep healthcare affordable. ER Overuse

4. 55% of the 114 million visits to hospital emergency rooms in a given year are for non emergencies. Even patients judged their conditions as non-urgent.  A 2006 survey of California hospitals found that nearly half of ER patients thought they could have resolved their medical problem with a visit to their doctor,  but they were unable to obtain timely access to care. Patients who seek non-urgent care in the hospital emergency room waste significant resources because the ER is one of the most costly ways to obtain routine treatments.

5. EMERGENCY DEPARTMENT SUMMARY, 2008 The Florida Center for Health Information and Policy Analysis (FCHIPA) within the Agency for Health Care Administration (AHCA) began the collection of Emergency Department (ED) data for the State of Florida in 2005. In 2008, there were 5,943,820 visits to the Emergency Departments that did not result in admission to the hospital. This reflected an increase of 195,445 visits since AHCA started collecting data in 2005 (5,748,375). There was also an increase of patient visits in this year which resulted in an inpatient admission for a total of 1,448,180. The number of visits for 2005 that resulted in admission was 1,353,336. The total ED patient visits to the emergency departments in 2008 was 7,392,000, an increase of 94,844 visits since 2005 (7,101,711).

6. Facts About Florida's Health Care System November 2009

7. 1.7% 1.5% 0.4% 8.3% 22.9% 46% 4.2% 14.9%

8. Total charges for 2008 hospitalizations were over $90 billion dollars.Medicare, Medicare HMO or Medicare PPO accounted for over half of the total charges at 51.5%. Commercial insurance accounted for the second largest amount of charges with 25.6%. Workers’ Compensation had the highest average charge ($49,376.09)

9. Trends in Avoiding Potentially Unnecessary Hospitalizations and Costs To address the population perspective of avoiding potentially unnecessary hospitalization, data on ambulatory-care-sensitive conditions are summarized here using the AHRQ Prevention Quality Indicators (PQIs). While not everyone of the hospitalization tracked by the AHRQ PQIs is preventable, ambulatory-care-sensitive condition are those for which good outpatient care can prevent the need for hospitalization or for which early intervention can prevent complications or more sever disease.

10. RESULTS • By tracking daily vital signs we are able to monitor and adjust patients treatments and medications to affectively keep them from returning to the hospital. • This in turn cuts down cost in readmissions and costly unnecessary ER visits.

11. GOALS • Create a series of Elite Urgent Care Centers that would cover the county, thereby providing the health plans with a planned first response other than the Hospitals Emergency Department. • Get the HMO’s to direct most patients to our Urgent Care Centers rather than the hospitals. This will only happen after the county is covered by our centers. ( • Work with the at risk provider’s hospitalist programs to admit patients to the health-plan’s preferred hospitals, bypassing the emergency room whenever possible.

12. Dade County HMO facts: • Dade County has the greatest percentage of HMO patients in the state of Florida. • Dade County receives the highest, per member, per month Medicare reimbursement to healthcare plans in Florida. • The largest HMO in the county is Humana. • The two of the largest Medicare plans in the county are: • CarePlus & Leon Medical Centers • Humana has the highest number of at risk providers in the County, many of these are independent doctors, many in Hialeah.

13. Hialeah Professional Building Project & Future Expansion 590 East 25th Street Hialeah, Florida

14. One of the most strategic locations in Dade County. • Landmark building which is well known. • Other medical offices in the building (mostly specialists) • Located across from the hospitals Emergency Department. • Former site of a very successful urgent care when CAC (a former HMO) was in the building.(CAC is now CarePlus and they bought and built their own building next door – never re-instated after hours urgent care) • Centrally located in the county with great access from many different locations. • View from Hospital ER where waiting is average 5 – 6 hours.

15. Hialeah Hospital ER Leon Medical Center (MSO - HMO) CarePlus Clinic (Humana HMO)

16. Leon Medical Center east Hialeah ER CarePlus Clinic (Humana HMO) 590 Building • East 8th avenue is the same as LeJeune Road (42nd Ave) and connects with Coral Gables in 15 minutes. • East 25th street is the same as NW 79th street and connects all the way to Miami Beach in 30 minutes.

18. CarePlus Clinic (HMO) Leon Medical (HMO/MSO) URGENT CARE CLINIC URGENT CARE CLINIC These are not the actual signs, but are representative of the signage area designated to us by the building landlord.

19. CarePlus Clinic 590 Building All parking lots belong to the 590 building ER 40 meters

20. 27,000 cars per day (2007 stats) Population within 5 mile radius 376,639 Median Age 41.2 years old Median household income $35,000 p/yr Zip Codes - 33013, 33002, 33011, 33017, 33012, 33147, 33010, 33166, 33167, 33054, 33014, 33142, 33168, 33016, 33122 Hialeah 590 Site Facts:

21. 5,300 square feet (first floor). Already 90% built out. Present monthly rent $8,600.00 Building available for sale asking $10 million. Leased Space:

22. The present first floor has been partially built-out with leaded walls etc for the imaging. (previously planned for SPECT/CT and PET now can be converted to CT and X-Ray)Will require removal of SPECT/CT. (no cost) There is a space in the SW of the first floor that should be made bigger. That entails removing 4 walls. Estimate from contractor was approx. $8,000.00 Already installed is a PACS/RIS system, an EMR billing system and a laser printer. (cost equipment lease $111K) 4 slice CT scanner (if we decide to put one in) $155K X-Ray system with CR plates $50K Stretchers and misc Urgent Care equipment ($20K) Staffing – covered on next slide Investment to open:

23. There are two models of staffing this UC center. The first would be with a low cost solution: Use a GP or Internist doctor that would supervise a Physician Assistant or Nurse Practitioner. There would only be an X-Ray system in place.(no ultrasound or CT) Front desk manned by a Paramedic. Only two people on shift (Paramedic and MD or PA or NP) This would get us only the standard Urgent Care contracts. Standard contracts are from $80 to $150 per patient all inclusive. Staffing:

24. This is the model that Humana liked and therefore developed a special contract for us. This model assumes an ER doctor and diagnostic services (Labs, CT, Ultrasound, X-Ray). Basically an alternative ER outside of the hospital. ER Physician (Board Certified or Board eligible) Emergency Medical Technologist Receptionist If we are very busy we would add a nurse. Per case on-call contracted technologists for X-Ray, CT and Ultrasound. Staffing (model II)

25. 3/21/10 Non-Stated Meeting Goals • Examine the Building leases and space needed (Shah/Raja – Fernandez) • Assess Advantages to the 590 Building • Explore the different projects synergies • Define tasks and course of work timetables • Determine list of tasks and follow-up assignments

26. Key Project Components • Strategic Location • Knowledgeable Physicians • Head Physicians to be Board Certified or Board Eligible and have business sense. • Physician workers to be patient friendly and bi-lingual. Diligent workers that like and know their jobs. • Knowledgeable Management and Administration • Efficient well known Marketers • Key Strategic Hospital Alliances

27. 590 Building Advantages (Relevant/Immediate) • Location • Close to some of the biggest HMO’s • Across the street from the Hialeah Hospital ER • Photon has a large base of cardiologist clients nearby • First Floor Target Space (split between two businesses) • Dedicated PET Scanner Imaging • Enhanced Urgent Care (Including CT, X-Ray, Ultrasound & Labs) • Fifth Floor Target Space (split between two businesses – maybe 3) • Research Facility • Level Two Lab • Possible future Women’s center (to enhance research & attract business)

28. 590 Building Advantages (Future/Tactical) • Location (same as Immediate) • Second Floor Space (Large Clinic Operation) Options • Mt. Sinai expansion Clinic • Citrus health plan and Community Health Center • A Health Care plan that does not have coverage in the immediate area • Large Multi-specialty group (preferably one that has oncologist and cardiologist) • Third Floor Space • Cardiologist Offices & Internal Medicine Office • Fourth Floor Space (more physician offices hopefully specialists)

29. Building Occupancy • Building Occupancy after Present leases start • 6th Floor No Occupancy • 5th Floor (Lab & Research would take 60% of space)Approximately 40% of space available • 4th Floor 100% of Space available Best suited for two large practices possibly one large & two smaller • 3rd Floor 50% of space available • 2nd Floor 100% of space available • 1st Floor No Occupancy – Two Businesses • Enhanced Urgent Care (CT/Ultrasound/X-ray/Labs/PACS/RIS/EMR) • Dedicated PET (Cardiac PET Imaging)

30. Local Area Health Care Facts • South Florida controlled by Managed Care • Managed Care is very attuned to “Bottom Line” • Major Costs to Managed Care • The Number one expense is ER Costs (30%-40%) Yet 60% to 80% of ER daily visits are non-emergent visits and could be handled outside an ER. • Pharmaceutical costs (20%-30%) • Direct Admissions Hospital Costs • Home Health & DME • Laboratory costs are among some of the lowest costs • Regular Urgent Care (reimbursement $80 - $150) • Regular doctor internist/ or general practitioner ) • No diagnostics or stat lab work

31. Managed Care ER Cost Estimates Approximately $600M Expensed to Hospital ER 10% Savings by EUC is $60 Million • Assumptions: • The Managed Care enrollment numbers are estimated not precise • Monthly government revenue given to HMO per patient is $1,400.00 • Estimated ER Costs generated as 30% of Gross Revenue

32. Enhanced Urgent Care (EUC) • Enhanced Urgent Care is almost a hospital ER • Physicians are Board Certified or Board Eligible ER doctors • EUC has advanced diagnostics and therefore provides diagnostic results there avoiding referring the patient to the hospital for a diagnosis. EUC diagnostic tools are: • CT • Ultrasound • Digital X-Ray • Labs • PACS/RIS & EMR • Enhanced Urgent Care (EUC) contract: • $250 for Basic consult (Includes Basic Labs and X-Ray) • $400 if there needs to be an ultrasound done • $550 if there is a CT scan done

33. Assets, Partials & Needs • Marketing • Equipment • Contracts (Multiple) • Build-Out Modification • Legal Questions • Physician Owned • Non-Physician Owned • Affiliation • Ownership • Referring Physicians • Location • Damien CEO • Dr. Aparna Raja COO • Location • Build-Out 90% • Humana Contract • Management Team • Management Team • LSO PET Scanner • Location

34. Urgent Care & Cardiac PETTask List – To Do List • Lab Team To Do List: • Educate EUC team of what would be needed from them for the Lab work that is obtained from a typical ER room lab. • Lab Team needs to develop a basic description of who they are and services rendered so that Photon management can integrate them into the business plan and the marketing plan for the project. • Photon/EUC/Pet To Do List: • Meet with local doctors to get them to commit • Prepare B-Plan for each of the two entities: • Enhanced Urgent Care • Cardiac PET • Landlord (Richard Fernandez): • Get Contract to Lab Team