Employer Sponsored Health Clinics

1. Employer Sponsored Health Clinics How to Develop and Maintain an On-Site Health Clinic with Excellence

2. The Question… Why?

3. Value Propositions of On-Site Health Centers • Recruitment and Retention Tool Healthcare Industry Broken Quality Care Savings • Emerging Benefit Expectation • Happier and Healthier Employees • Builds Employee Trust • Builds Desirable Company Culture • Shortage in Primary Care Physicians • Unsustainable Rising Costs • Non-Transparent • Complex and Confusing • Governmental Requirements (Meaningful Use) • Patient-centric • Outcomes and Evidence-driven • Referral Network • Health Coaching • Case Management • Prevention • Acute Care • Occupational Health • Fewer Admissions, ER Visits and Specialist Visits • Lower cost Labs, Imaging and Medications • Improved Productivity • Reduced Lifestyle Risks • Lower Work Comp Claims

4. The Process • Financial Feasibility • Management Planning and Vendor Selection • Implementation Planning • Assessments and Audits

5. Financial Feasibility

6. Financial Feasibility – Scope of Services Impact Savings Opportunity Patient Centered Medical Home Occupational Health Acute Episodic Care Wellness—HRA, screening, lifestyle coaching Primary Care $Savings Opportunity $$$ Non-Occupational Care and Emergency First Aid

7. Financial Feasibility – Perform the Analysis Preferred characteristics • 2,000+ employee lives in a location (1,000 minimum) • Older workforce with significant health issues • Gross medical/Rx cost over $8,000/employee/year • Current, well-managed benefits environment • Streamlined health vendor configuration • High medical cost environment

8. Management Planning and Vendor Selection

9. Management Planning - Models

10. Management Planning - Regulatory and Compliance Considerations Federal Local State • ERISA • COBRA • HIPAA • Certain IRS provisions • Americans’ with Disabilities Act • Occupational Safety and Health Administration standards • Corporate Practice of Medicine • Licensure of facilities and providers • Credentialing and oversight requirements for mid-level providers • Data privacy and access • Disposal of biomedical waste • Handling and storage of laboratory specimens • Prescription drug dispensing • Health department rules • Health department rules • Laws regulating laboratories and specimen handling • Laws applicable to medications and handling biologicals Legal Counsel In sponsoring onsite health centers, employers have to navigate a complex array of government regulations to assess impact on ownership, staffing, data management, operations, etc.

11. Management Planning – Corporate Practice of Medicine Laws A business corporation may not practice medicine or employ physicians or other health center personnel to provide professional medical services. The objective is to prevent non-physicians and non-physician-owned business entities from influencing treatment decisions. • California is commonly regarded as among the most aggressive of CPOM states. Others include: Arizona, Arkansas, Colorado, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Jersey, New York, North Carolina, North Dakota, Ohio, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Washington, West Virginia, and Wisconsin • Ownership is an indicator of the following: • Control of a patient's medical records and should be retained by a state-licensed physician • Selection, hiring/firing (as it relates to health center competency or proficiency) of physicians, allied health staff and medical assistants • Setting parameters under which physicians will enter into contractual relationships with third-party payers • Decisions regarding coding and billing procedures for patient care services • Approving of the selection of medical equipment and medical supplies for the medical practice • Ownership Options: • Select physician to “own”, incorporate and operate a professional medical corporation (PC) • Select physician to “own” and incorporate a PC, and establish contractual relationship with a management services organization (MSO) • Outsource the operation, contract with an existing PC

12. Management Planning - Summary of Federal Law Considerations IRS – HDHP/HSAs • Employees cannot contribute to an HSA if they have medical coverage other than through a qualified high-deductible health plan (HDHP). HSA/HDHP participants cannot receive subsidized services from health center (other than preventive services) before reaching minimum deductible. • An employer-sponsored onsite health center has three options: • Limit the health care services to permissible coverage that qualifies as preventive care and not significant medical benefits—free screening tests, flu shots, and treatment of accident-related injuries • Require employees with the HDHP/HSA option to pay for the full value of the services provided to them by the on-site health care facility until the individual satisfies the minimum deductible • Eliminate the HDHP/HSA option HIPAA As a group health plan and a provider, health center must comply with HIPAA Privacy and Security rules. HIPAA and Nondiscrimination provisions may also apply.

13. Management Planning - Summary of Federal Law Considerations ERISA • On-site health centers that provide medical care and not just treatment of minor injuries or work accidents are group health plans subject to ERISA. • If an on-site facility is considered a group health plan under ERISA, the facility will be subject to the following reporting and disclosure requirements: • Plan document • Summary Plan Description (SPD) • Form 5500 filing • Summary Annual Report (SAR) • Summary of Material Modifications (SMM) • Claims and Appeals

14. Management Planning - Summary of Federal Law Considerations COBRA • COBRA does not have to be offered for an on-site facility if: • Health care is primarily first aid provided during working hours to treat issues that arise during working hours; • Health care is available only to current employees; and • Employees are not charged for the use of the facility • Need COBRA rates for employees who are not plan participants. For group health plan participants, COBRA rates can be structured as: • 1) One COBRA rate that includes group health plan coverage and health center access or • 2) separate COBRA rates for each • COBRA requirements: • Enrollment and election notice • Required for all employees with access to the health center • COBRA rates are 102% of cost of coverage • Options must be offered for COBRA participants during OE • Security/access for terminated employees electing COBRA

15. Vendor Selection • Knowledge & Expertise • Facility architectural design and space planning expertise • Guidance on federal, state and local regulatory concerns to ensure compliance • Vendor contracting, revenue cycle, operations management • Follow rigid quality measures for health center care delivery, customer experience, and account management • Care planning within health center and between health center, community and vendor partners • Held accountable for patient outcomes, wait time, referrals, patient satisfaction, and return on investment • Quality of Care • Best-in-Class Technology • Sophisticated employer-sponsored health center systems (i.e. EMR, practice management, and patient portal) • Reporting and analytics • Frequent updates and review of tools to drive innovation and enhance provider and patient experience • Technology (software and hardware); • Furniture and equipment; and medications with established ordering and billing procedures • Low cost or no cost employee communication materials to introduce the service and reinforce awareness • Purchasing Power • Insurance coverage for malpractice, Workers’ Comp, unemployment, general liability, etc.   • Vendor accepts all responsibility • Risk Management • Staffing and Health Center Operations • Candidate selection, vetting process, and continuing education and training • Part of bigger community of onsite health center providers to regularly share information, experiences and learnings • Immediate access to back-up staff for unplanned events

16. Vendor Selection – Ideal Insurance Coverages Legal Counsel Legal Counsel

17. Implementation Planning

18. Implementation Planning Population Access Scope of Services • Employees • Spouses • Dependents • Children 5-18 • Children <5 • Local retirees • Contractors • Union members • Employees from other locations • Employees of nearby employers • Acute Episodic • Primary care • Nutrition • Pharmacy • Dental • Health Coaching • Physical Therapy • Occupational Health • Safety • Wellness Programs • Laboratory • Health Advocate • Case Management • Telemedicine • Imaging • Massage Therapy • Acupuncture

19. Implementation Planning Staffing Plan Design Hours of Operation • Medical Director • Primary Care Physician • Nurse practitioner • Operations Manager • Medical Assistant • RN/LPN • Specialists • Dieticians • Pharmacist • Case Manager • Health Coach • Receptionist • Flexible • Monday-FridayShift hours • Evenings • Weekends • 24/7 Coverage • After Hours • Self-funded vs. fully insured plans • No copayments for PPO • Meet regulatory copayment amount for HDHP with HAS • ERISA • COBRA • Square footage estimates • Location • Layout • Parking • Public Access

20. Assessments and Audits

21. Assessment Determine metrics and sources up front and communicate results frequently to stakeholders • Operational • Reporting • Utilization • Capacity • Type, duration and frequency of visits • No-show and cancellation rates • Patient wait times • Cross-referrals • Budget • Compliance with evidence-based medicine guidelines • Credentialing, certification and licensing of health center staff • Quality Assurance (chart review) • Case management measures • Patient satisfaction • Quality • Outcomes • Compliance with age-gender screening tests • Generic substitution rates • ER visits and inpatient admissions • Productivity and absenteeism • Claims trend • Risk reduction

22. Assessment Quantitative Qualitative • Health Center users vs. non-health center users cost comparison • Report on total cost per medical claimant (health center users vs. non-users) in total and for the following categories: primary care, OBGYN care, specialty care, hospitalizations, PBM prescription drugs, laboratory and imaging • Compare health center users with non-users by defined chronic health categories,such as diabetes, hyperlipidemia, and hypertension • Compare average costs of a “routine exam” or common procedures provided in the health center vs. community • Review average cost per day supply by NDC filled at on-site health center vs. external pharmacies • Track absence data and short-term disability data over time and compare results to Official Disability Guidelines (ODG) benchmarks • Health Center users vs. non-health center users utilizationcomparison • Examine following utilization metrics per medical claimant (health center users vs. non-users): inpatient admissions per 1,000 members, average length of stay, physician office visits per 100 members, emergency room visits per 100 members, retail prescriptions per member, brand prescriptions per member • Health Center users vs. non-health center users quality of care comparison • Review evidence-based adherence rates to evaluate extent to which each comparison population is following established quality of care guidelines and identify additional services required at health center • Health Center users vs. non-health center users health risk comparison • Establish and compare illness burden for the health center user and non-user populations • Assess changes in risk over time by using self-reported results of HRA survey *Health Center users can be defined as individuals having had at least two on-site health center visits during study time period

23. Audits