The Value of On-site Health Centers Society for Human Resource Management

Transcription

1 May 26, 2010 The Value of On-site Health Centers Society for Human Resource Management Bruce Hochstadt, MD

2 On-site clinic resurgence, evolution and prevalence

3 The Next Wave Factors driving the resurgence of on-site clinics Contributors to the popularity of on-site clinics Turnkey solutions for employers Increasing employee out-of-pocket costs Employees face heavy, stressful workloads Less willing to leave worksite Providers are hurried, distracted The 5-10 minute office visit Limited access to care, shortages of PCPs Non-compliance approaches 50% (NEJM 2003) The sick-care delivery system Incentives poorly aligned 2

4 Evolution of On-site Health Services First aide kits to multi-specialty centers High On-site total comprehensive health center e on cess ings) otal Value ential impact, safety, proc ncies and savi To (Pote health efficien Low Occ-Health Focused Ltd primary care Near-site clinics, incl retail settings - in most states Low intensity Near-site retail or shared PC clinic Mid-level (RN/PA) staffing Basic PC services Moderate intensity Integrated Occ-Health PC clinic w/ pharmacy MD/DO expanded PC, chronic and semiacute care High intensity Evolutionary path 3

5 How Common are On-site Clinics? 70% employees 60% 50% 1,000-4,999 employees 5,000 + employees Health care 40% Manufacturing 30% Financial services 20% Government Wholesale/Retail trade 10% Services 0% By employer By industry Transportation/Communication/ Utilities Source: National Survey of Employer-Sponsored Health Plans

6 On-site clinic considerations and decision points

7 On-site Clinic Objectives What are employers hoping to achieve by opening a clinic? Improve access and convenience Save money moderate trend, lower spend Reduce lost time and absence, improve productivity Improve health outcomes individually and in aggregate Promote wellness and importance of screening and preventive services Provide a higher quality of care (than that received in the community) Boost employee retention, recruitment and morale Redirect care from expensive, sub-optimal and time consuming settings Serve as the primary locus of care delivery for workers and dependents 6

8 On-site Clinic Considerations Key decision points in assessing the feasibility of an on-site health clinic Who should be eligible to use the clinic? What costs underlie an on-site clinic? Should patients be charged for services? What services should the on-site clinic offer? How should the clinic be staffed and managed? Where should the clinic be located? Should it be a dedicated on-site facility or shared with other nearby employers? What are the benefits of an on-site clinic and how should they be measured? What IT infrastructure is needed to support operations and ongoing reporting/evaluation? How will risk management, legal and regulatory issues be managed? 7

9 On-site Clinic Eligibility Who can use the clinic? Onsite clinics do not need to be restricted to just employees at the site. Other parties who might use the health clinic may include: Employees from other locations (presumably nearby) Covered dependents Children will depend on whether pediatrics is offered Retirees, who live locally Employees of nearby employers Either on a fee-for-service or fixed fee basis Structuring the clinic as a shared facility amongst employers Worksite safety and security issues will influence this decision point Employers can open the clinic with limited access And expand to other groups over time 8

10 The Costs of On-site Clinics Start up and operating costs Onsite clinic costs will be a function of the scope of services offered, the upfront build-out required and the staffing model contemplated Build-out usually does not require bricks and mortar, but rather remodeling of existing space This can range from $ per square foot for modest build-out to as high as $ per square foot for extensive remodeling 75% of operating costs are staffing related, which will reflect the population size, scope of services offered and anticipated utilization A single mid-level practitioner (nurse practitioner or physician s s assistant) with a receptionist who can also serve as a medical assistant will translate into operating costs of roughly $350,000 per year Clinics that have full-time physicians and offer additional ancillary services, e.g. lab, X-ray, pharmacy, vision, physical therapy, can cost considerably more 9

11 Charging for Use of the On-site Clinic A key consideration Employers must decide whether to charge members for the use of the clinic and, if so, what to charge This will impact clinic utilization and adoption rates Today, more and more employers are requesting a modest co-pay for the use of an on-site clinic Typically tiered below the plan design copays to see a physician through the health plan network, e.g. $5-10 vs. $15-20 for primary care Some may waive the co-pay as an initial promotional offer during the first few months of clinic operation to encourage employees to try the clinic A modest copay may also serve as a potential deterrent to those workers who may over-utilize or abuse the clinic as a way to avoid work Many employers maintain policy of not charging workers for use of the clinic Preferring to have no economic barrier to workers seeking care on-site IRS requires employers to charge workers with account-based plans (eg HSA) for some on-site services 10

12 On-site Clinic Services What to offer and how to position Treat primary and urgent care needs to reduce costs and absenteeism, and improve productivity Traditional occupational health services to manage work-site injuries, illnesses and exposure On-site Pharmacy, Mini-dispensary Health Promotion and Wellness Referrals to high quality community physicians and specialists when outside care is required Workers Comp Disease Mgmt Drive preventive health and wellness programs to manage health risks and maximize member benefits On-Site Provide health coaching and care management to Clinic serve as on-site info/education center, incl HRA review Disability Basic Medical Care Dispense commonly prescribed prescription drugs to improve generic use and formulary compliance Employee Assistance Programs Travel Medicine Provide initial on-site mental health triage, counseling and integration with EAP services Administer travel medicine program to provide vaccines and prophylactic medications to overseas travelers 11

13 On-site Pharmacy Services Rx options for employers 1. Comprehensive pharmacy Comparable inventory and staffing to a retail pharmacy (>3,000 lives) 2. Mini-dispensary Stock of the most commonly prescribed medications 3. Dose or starter pack dispensary 2-3 or 3-5 day supply of medications prescribed by clinic staff Initial doses until patient can visit retail pharmacy or receive mail order 4. Concierge service On-site delivery arrangement with local retail pharmacy 12

14 On-site Occupational Health Services For worksite injuries and exposures and more Evaluation, documentation, management, triage To appropriate providers and care settings Emergency / crisis response (CRT) Pre-employment physicals and drug testing DOT requirements OSHA regulations Worksite surveillance/compliance Travel Medicine policies and programs Disability-related medical exams and referrals Return-to-work (RTW) programs Family Medical Leave Act (FMLA) administration 13

15 Staffing and Managing an On-site Clinic Predominant management models In-House The clinic is managed directly by the employer and clinic staff are hired and paid by the employer as its employees Hybrid The employer contracts medical services from a local clinic or health care institution but manages business operations itself Outsourced The entire enterprise is outsourced to a third-party vendor or management company that controls all clinic operations and employs all clinic personnel When choosing a model, consider what makes sense for you and the risk your organization is willing to absorb 14

16 Vendor Profiles Many started in occ health and have expanded to non-occ Vendor Size Services/Distinctive Characteristics ti 700+ locations in the US Comprehensive set of services (GMC, occ. health, DM/wellness) Largest manager of worksite health and wellness centers 324 near site, 270 Three-pronged business: health services, network services, case management services onsite clinics i Primary business in near site occ. health clinics; onsite services are secondary 150 clinics in 43 states GMC, wellness, case management, 24/7 phone triage, retail clinic manager for providers Transitioned from niche player in occ. health to GMC and now even retail clinics 25 clients, 80 Three divisions: Work Site Clinics, contracted provider network, med. readiness teams clinics Clinics offer GMC, DM/wellness, pharmacy services; CHS specializes in national med. exams 80 clients in 24 states Provides basic medical care with emphasis on preventive care (no occ. health) Operates a clinic for BCBS of NC; showed interest in partnering with a health plan provider 32 clinics, mainly in the Southeast GMC, occ. health, DM/wellness; 1/3 clinics are still occ. health only Acquired by healthcare IT company Cerner in early clients across different states GMC, DM/wellness, occ. health, pharmacy Integrated web-based technology platform includes a personal health record 10 clinics in 4 states Created in 1990 as a subsidiary of printer Quad/Graphics Focus on population health management 500 locations in 25 states Subsidiary of CVS Caremark Corporation Traditionally offer a fee-for-service model for employers 15

17 On-site Clinic Location Where should the clinic be situated? Location options Size Within the building On campus Near-site, e.g. nearby employer Dependent on projected utilization, staffing levels, scope of services and available space Clinics range from 200 to over 25,000 sq ft Most are 500 to 2,000 sq ft Considerations Ease of access and high visibility drives higher utilization Existing facilities (minor interior remodeling vs. extensive: walls, floors, plumbing) Separate door to the outside for sick employees and dependents Security and safety concerns for non-employees being on-site Private, professional setting employees expect privacy and frown upon co-workers seeing them at the clinic i 16

18 On-site Health Services Potential benefits from employer on-site clinics Reduced lost work time and absenteeism Avoidance of higher cost and time consuming settings (e.g., ERs) Reduced referrals to and use of costly services from specialists Lower workers compensation as well as non-occupational disability costs When combined with an on-site pharmacy, improved medication compliance, generic and therapeutic substitution and formulary adherence Lower medical spend amongst users of the on-site clinic through greater utilization of screening and preventive services, and more timely care access Improved employee morale, retention, loyalty and productivity as well as a recruitment and retention inducement 17

19 On-site Clinic Legal and Regulatory Issues Understanding the risks and staying in compliance Design considerations affecting compliance Compliance issues ERISA COBRA HIPAA portability HIPAA privacy and security HSAs Wellness and compliance HIPAA nondiscrimination rules Genetic Information Nondiscrimination Act (GINA) ADA State laws Taxation 18

20 Recent trends and developments in employer-based on-site clinics

21 Shared Near-site Clinics Enabling mid-sized employers to offer this benefit An employer opening its on-site clinic to nearby company employees Assuming no security or safety issues tied to industry (eg defense contractors, technology), toxic exposure (chemical plant) or physical location Neighboring employers banding together to establish a communal employee health facility To collectively achieve a critical employee/member threshold to drive adequate capture Joint venture or other formal arrangement to structure clinic ownership, financing and management Landlord or property p manager providing this amenity For tenants in a multi-tenant office building, office park or manufacturing facility/park Comparable to on-site health/fitness club, dry cleaning or cafeteria either exclusively for tenant companies or for the general public on membership and/or fee-for-service basis 20

22 On-site Wellness and Health Promotion More than just a clinic Employers are increasingly positioning their on-site clinics as far more than just treatment centers. They are seeking the clinic to serve as a: On-site center or store front for health promotion and wellness Driver of risk reduction, screening and prevention Opportunity to promote healthy behaviors and lifestyles Numerous clients have branded their clinics as Wellness Centers, Healthy Living Institutes or Health & Fitness Centers Clinics can leverage existing health management programs with feet on the ground Clinic-offered Biometric testing HRA completion and review Face-to-face health coaching and chronic disease management Medical home annex as applicable 21

23 The Virtual Waiting Room Taking efficiency and privacy to the next level Employee reticence due to concerns over privacy and confidentiality Clinic and waiting room locations that are exposed leaving employees to feel as though their privacy is invaded Co-workers who are treating them and sitting nearby in the lunch room Real-time notification when the clinician is ready to see them To greatly reduce or even virtually eliminate waiting time for an on-site clinic Like shopping at the mall while waiting for your table to be ready An employee can leave her desk or job-site upon notification that the nurse (or PA/ physician) is finishing up with a patient currently 22

24 Hey - What About Us? Provider groups emerging as attractive clinic partners In many markets, local and regional provider groups have developed go-tomarket solutions for staffing and also managing employer on-site clinics Such provider groups include forward-thinking integrated delivery networks, hospital systems, multi-specialty clinics and local medical practices Many now view worksite clinics as an opportunity to extend their practice reach, generate downstream referrals, and re-engineer their approach to care delivery This is in contrast to just a few years ago when worksite clinics were perceived as much more of a threat than an opportunity Established local groups often are viewed by employees as being of high quality Proven clinicians with strong credentials Separation from the employer, ie big brother Coordination with off-site care and referrals However, the clinic must offer an efficient delivery model and not simply py be an outpost or satellite office for an inefficient practice 23

25 On-site Clinic Right-sizing and Pragmatism Matching budgets with ambitions Manage operational costs and fully utilize staff Cost factors include scope of services, facility size / location, staffing model Realistic expectations: generating an ROI takes time (1-3 years) ROI is a function of not only savings (direct and indirect) achieved, but also costs (initial build-out and ongoing operating) The timeline for success and a favorable ROI is mainly dictated by how rapidly employees adopt the clinic and utilize its services Ideally each unit of service offered should be delivered at a lower cost basis than those procured externally In a challenging environment, we often recommend that an employer pursue a phased approach to clinic implementation Start with a small staff delivering a finite scope of services in a relatively compact space (but leaving room for expansion) As employee utilization ramps, the clinic and its services, staffing and space can be added We have reviewed many proposals from vendors detailing expansive (if not lavish) facilities, with equally lofty budgets We have usually recommended d scaling back and letting employee capture and demand dictate future plans for clinic expansion 24

26 If You Build It, Will They Come? Critical success factors for on-site clinics Clinics require ongoing efforts to ensure their success. A common source of onsite clinic disappointment is low employee utilization or capture. In our experience, key success factors include: Effective communication / broad awareness Privacy and confidentiality assurances Strong executive support / involvement Superior service delivery Enthusiastic clinicians Attractive plan design / incentive Appealing clinic location / layout 25

27 On-site clinic scenarios, feasibility, and measurement and evaluation

28 On-site Clinic Candidates Characteristics of employers likely to benefit from a clinic Facilities with more than 750 or more employees Geographic areas facing primary care shortages Locations where workers spend hours traveling to and from external care settings (eg remote locations, long commutes, heavy traffic, etc.) Low utilization of proactive primary care services, related to screening, prevention and risk reduction High emergency room (ER) utilization, esp. for non-emergent medical conditions High absence and lost time, especially for unscheduled medical-related issues High retention / low turnover companies and industries in which workers tend to remain for many years, e.g. governmental agencies Older populations, which consume greater levels of care in general Conversely, younger populations in need of wellness and preventive services, as well as young families with increasing demands on their time 27

29 On-site Clinic Scenarios and Consulting Services Common employer stages 1. Employers without an existing on-site clinic But contemplating whether establishing one makes sense and, if so, how strong the business case may be 2. Employers with an existing on-site clinic(s) But seeking to optimize its impact, eg expanding or contracting services, hours, locations, staffing, eligible participants, etc. and adjustment to align with best practices 3. Employers with a recently opened clinic or planning to open in the near future (approval in place) Install independent monitoring and reporting processes of clinic operations, impact and vendor performance 28

30 On-site Clinic Product/Service Offerings 1. Employers without an existing on-site clinic Feasibility studies - to qualify potential clinic viability, calculate projected ROI Analytic Approach Paid claims data to identify prevalence and costs of conditions and services amenable to on-site clinic provision ER visits that likely were not true emergencies and whose point of care can be safely shifted Cost avoidance models to estimate savings (time and money) from outside services that could be avoided through the use of an on-site clinic compared to emergency room, urgent care, office visit Sensitivity analysis to forecast potential clinic volume based on population-specific conditions and encounters Formulate assumptions as to the percentage of members inclined to use an on-site facility Low, moderate, high adoption levels and rates over time The impact of OOP cost and incentives on clinic utilization On-site per-visit savings 80% 60% 33% Adjustments for induced demand created by the clinic ER UC Office visit 29

31 On-site Clinic Feasibility How savings are identified Step 1. Identify claims that could be serviced in an on-site clinic setting Total Claims Step 2. Develop model and associated costs to deliver those services on-site Step 3. Compare projected external delivery of those services to delivery on-site Cost of External Providers Eligible to be serviced in a clinic Eligible to be serviced in a clinic Model Services Staffing Location Build-out Costs Medical Rx Lost Time Utilization vs. Cost of On-site Clinic 30

32 On-site Clinic Feasibility Savings Opportunities Onsite Clinic Encounters Lead to savings Workers Medical Cost Rx Compensation Lost Time Utilization Reduction Disability 31

33 Cost/Savings Analysis Re-directing non-emergent ER visits Medical Cost Sampling of ER claims analysis yellow highlights indicate suspect nonemergent claims that might be handled in an onsite clinic Cause Detail Diagnosis Code Description Number of Claimants Total Net Paid Accident AMPUTATION FINGER 1 $ Accident CONTUSION OF TOE 1 $93.00 Accident 8260 CONTUSION OF CHEST WALL 1 $ Accident 9352 SPRAIN OF FOOT NEC 1 $ General Sickness CONJUNCTIVITIS NOS 1 $ General Sickness 75 2 ND DEGREE BURN HAND 1 $1, General Sickness 6039 HEADACHE 1 $ General Sickness 3129 BACTEREMIA 1 $

34 On-site Clinic Service Utilization Differential levels and sequential adoption rates Adoption Rate Service Year 1 Year 2 Years 3+ Low Gyn Exam 5% 10% 20% Moderate Yearly Physical 20% 30% 40% High Allergy Shots 40% 50% 60% 33

35 On-site Clinic Feasibility Study Modeling the reduced lost time savings from off-site redirection Lost Time In this example, average commute time is 20 minutes or a distance of 12.5 miles Lost time and improved productivity impact Each clinical encounter shifted from community settings to on-site is estimated to save 2 hours of lost time The average salary & benefits translate into an hourly cost for time spent away from the worksite If workers clock out, direct absenteeism costs may not be experienced Projections do not include savings from reduced presenteeism Employers may or may not wish to include replacement labor, overtime, or impact on production and profitability Eligible claims for lost time savings based on services to employees working only during traditional primary care hours Community Setting On-site Setting Office visit 150 minutes 30 minutes ER visit 270 minutes 30 minutes Pharmacy visit 45 minutes 15 minutes Lab visit 75 minutes 15 minutes Estimates shown include travel, wait and treatment times 34

36 Expanding an On-site Clinic In a challenging, budget-constrained environment Traditional Occupational Health Clinic Expanding beyond traditional occ health and disability/workers comp Adding non-occ basic medical services (primary care), low acuity urgent care in a phased part-time manner To gauge employee receptivity and utilization Non-Occupational Primary Care Clinic (with or without Occ Health) Adding and/or formalizing screening, prevention, health coaching services and programs Drive preventive health and wellness programs to manage health risks and maximize member benefits Provide direct health coaching and care management to position the clinic as an on-site info/education center, incl HRA review Attempt to sequence in additional services as staffing/budget neutral Capitalize on slack resources, existing staff downtime Part-time time service hours, adjusted staffing mix as needed 35

37 On-site Clinic Measures of Success Tracking comprehensive value & ROI metrics Dashboard Process Measures Operational Staffing reliability attendance, punctuality Service levels waiting time minimums Audit findings adherence to policies / procedures and evidencebased guidelines Reporting delivered on timely and regular basis containing agreed upon metrics Efficiency Actual utilization or volume by service type vs. expected targets (visits/1000 members/year) Utilization as a percentage of capacity Year-over-year comparison / trend of clinic volume by service type, including specific screening / prevention GYN, Flu Shot, PE Referrals to other employer-sponsored programs, including health plan-based or carved-out Wellness, DM, CM/UM, EAP, etc. Satisfaction Surveys of employee users on perceived service, efficiency, quality and overall experience Employer satisfaction based on customer service levels, employee receptivity and value received Savings Direct savings from lower per visit costs vs. off-site primary care Re-directed care from higher cost, time consuming settings, e.g., by capturing reductions in ER/UC utilization Estimated lost time reduction per visit per location as calculated by geography-specific g p distances, traffic patterns and commutes Downstream utilization reduction based on earlier access to care and higher screening / prevention rates Cost Considerations Direct Clinic Costs build-out, implementation and ongoing operating cost (staffing, supplies, management fees, etc.) Incremental utilization spike due to increased access and convenience Outcomes Improved compliance with screening, follow-up and prescribed therapy, e.g., diabetes and Hgb A1c testing Utilization metrics that suggest improved health status and absence of complications, e.g. fewer ER visits in asthmatics Condition-specific adherence to evidence-based guidelines Disposition by service type (treated in house, Rx written, consult) and by referral destination (RTW, home, PMD, ER) 36

38 Case studies

39 Case Study 1 Global Financial Services Company Organization profile Consumer Financial Services Company $18.5B in revenue Operating in 130 countries worldwide 66,000 full-time employees Clinic Offerings Acute and emergency care by an RN Advanced medical care provided by a NP or Physician Business travel consultation and immunizations Allergy shots under the direction of the employee s allergist Blood drawing services as ordered by personal physician Ergonomic evaluation and treatment of medical conditions related to repetitive movements Evaluation, treatment and reporting of work-related injuries Review disability cases as it relates to ADA Provide medical consultation to staff groups on such issues as IAQ, drug testing, fitness for duty, etc. Annual GYN exam with age and risk-appropriate education Wellness and screening programs (84 events with 17,000 employee s participating in 2008) Results Key Statistics On-site domestic clinics serve 50% of US employees (no dependents) Hybrid clinic models with both in-sourced and outsourced clinics and staff Operating 10 clinics in the United States (3 in Phoenix) 20% of US employees are based in Phoenix Program Goals Reach 20% of US employees and create a platform by which to showcase new Health and Wellness strategy Introduce new high touch programs locally at major Phoenix sites Provide more holistic approach to diabetes and other chronic condition management Expand on-site clinic staff and service mix to include preventive care, GYN services/screenings, nutrition counseling and wellness coaching/health education Deploy fully outsourced on-site health services through partnership with bestin-class third party vendor. Leverage relationship with current clinic partner to efficiently implement on-site clinic options for long-term health and wellness strategy. Run fully outsourced clinic model concurrently with the existing hybrid model in other locations to compare and share best practices of both operations While negotiating vendor management contract, identified unnecessary operational expenses which were removed from the contract Negotiated best practice performance guarantees for customer service, compliance, attendance, auditing, and reporting New staff members hired to deliver expanded GYN, nutrition counseling and wellness coordination capture for the first six months included: 192 women had their yearly y preventive screening at one of the three wellness centers 574 employees completed an initial visit with a Dietician 439 employees completed an initial visit with a Health Coach Evaluated EMR carve out vendors against incumbent s technology offering to identify opportunity for improved capability and/or reduced cost 38

40 Case Study 2 County government Organization profile Southeastern US county government with 4,000 active employees Risk management department sought to expand provision of medical services at existing occupational health clinic Current clinic offerings Occupational health Disability management Worksite injury/exposure Return to work Health screening Ambulatory primary care Mini-pharmacy Employee Demographics Aging workforce of teachers, sheriffs and fire depts., maintenance and administrative staff with high retention/low turnover Diabetes and hypertension found to be highly prevalent per claims analysis, exceeding industry and national benchmarks Two conditions accounted for disproportionate share of medical resources and costs Key Activities With PBM, designed disease-specific programs for diabetes and hypertension Clinical pharmacist deployed to the on-site clinic to work with diabetic and hypertensive employees Patient incentives offered: waiver of co-payment for formulary- preferred hypertension and diabetic medications and supplies Dedicated physician added to mid-level clinic staff to provide expanded primary care and chronic disease management Patient-specific data on diabetes, hypertension and cholesterol was recorded into an EMR Clinical deficiencies were addressed with focused education and behavior modification interventions Results Patients were assigned individual health goals during each visit with an emphasis on disease state self-monitoring Enrollment within first 12 months was 829 diabetic and hypertension patients For the most at-risk group, results included: 1.7% average reduction in Hemoglobin A1c (diabetes) and 33.9/11.2 average lowering of blood pressure leves 39

41 point-of-view and clinic consulting services

42 On-site Clinic Experience Team depth and point-of-view s experienced multi-disciplinary on-site clinic consulting team applies a data-driven solution set to help clients rationally address this timely topic in health benefit design and cost management We consult to employers considering i introducing i on-site clinics i or seeking to optimize i existing ones We have performed on-site clinic projects for over 25 clients in 2009 including 10 Fortune 500 s Our services include strategy development, financial and feasibility modeling, vendor selection, implementation oversight and performance assessment through audits and measurement & evaluation The team includes specialists (MDs, PharmDs, JDs, OT) experienced in employer on-site health services such as on-site pharmacy, total health management, legal and compliance issues such as ERISA, HIPAA, COBRA and ADA We view on-site health as an attractive ti option to help overcome issues of access, affordability, non-compliance and limited follow-up On-site clinics provide convenience and savings compared to community-based care, enabling employers greater direct control over the health benefit and health of employees There is a natural linkage with absence and productivity both from lost time seeking care off-site and first-hand knowledge of worksite and clinically-based limitations We have proactively encouraged clients to position on-site clinics as more than just treatment centers Our clients have leveraged their clinics to serve as on-site hubs of health promotion and wellness intended to drive risk reduction and prevention and to promote healthy behaviors and lifestyles 41

43 Employer On-site Health Clinics Product/Service s Employer On-site Health Clinics solution set Target Segments Self-funded employers with greater than 500 employees Description s on-site clinic team consults to employers who are considering adding on-site clinics or looking to optimize and expand existing clinics. Our services include strategy development, financial modeling, vendor selection, and performance assessment through audits and measurement and evaluation. The team includes clinical resources experienced in employer on-site health services including onsite pharmacy, total health management, measurement and evaluation, audits and legal, and compliance issues such as ERISA, HIPAA, COBRA and ADA. Value to Employer Clients s experienced multi-disciplinary team provides effective guidance by applying a data-driven driven solution set designed to help clients rationally address this timely topic in health benefit design and cost management. Internal Contacts Bruce Hochstadt, MD (Chicago), National Team Lead Bruce.Hochstadt@mercer.con con David Keyt, MS (Chicago) david.keyt@mercer.com Service/Offering Define strategy, set goals: Strategy session to define and prioritize health care and benefits issues an on-site clinic would be expected to address. Frame key considerations and decision points to use in modeling clinic feasibility. Feasibility analysis: Feasibility studies with ROI forecasts of contemplated on-site clinic. Summary assessment of business case for an on-site clinic for a given population based on parameters defined during strategy review. RFP/Vendor selection: For outsourced and hybrid clinic models, identify suitable vendor partner candidates. Design or modify RFP to reflect desired clinic features and goals. Analyze proposals and assist with finalist vendor selection, negotiation and contracting. ti Implementation oversight: Assist with clinic implementation, communications strategy/ delivery, integration, and vendor management against predetermined deliverables & timelines. Clinic M&E: Independent, valid measurement and evaluation of direct clinic i impact (financial, i clinical, i l operations, satisfaction and vendor performance). Establish dashboard of reporting metrics and measure outcomes against existing performance guarantees. Negotiate or revise PGs as needed. Audit/Assessment: Review of clinic operations, eg services, staffing, utilization, outcomes, satisfaction, integration, data capture. Deliver comparison to best practice, opportunities for improvement and action plan for modifications. 42

44 Services provided by Health & Benefits LLC