the value of onsite & near-‐site clinics

THE VALUE OF ONSITE & NEAR-‐SITE CLINICS MARCH 17, 2016

HOLIDAY INN AT THE UNIVERSITY OF MEMPHIS

THANK YOU TO OUR SPONSORS

Larry Boress Executive Director

National Association of Worksite Health Centers

Copyright (c) NAWHC 2016 1

}  The nation’s only non-profit association supporting employer and union sponsors of onsite, near-site, mobile health, pharmacy, fitness and wellness centers

}  Assisting employers in developing and expanding the capabilities of onsite centers into primary care and wellness centers

}  Offering educational programs, networking, benchmarking and advocacy for the worksite health center employer and vendor communities

}  Website offers NAWHC membership information and resource materials on worksite health and fitness centers, on-site pharmacies and wellness centers

}  www.worksitehealth.org -- NAWHC LinkedIn Group }  Oct. 25th Chicago 4th Annual Forum


}  Treatment of Injuries ◦  First aid ◦  Acute/urgent care

}  Occupational health ◦  OSHA exams, drug testing ◦  Physicals/RTW ◦  Travel medicine ◦  Disability mgmt

}  Identification of risks ◦  Health risk assessment/screenings

}  Prevention of illness ◦  Immunizations

}  Health and Benefits Education ◦  “Lunch and Learn”/health fairs ◦  Online health portal

}  Chronic Disease Mgmt ◦  Health/disease mgmt coaching ◦  Case mgmt

}  Worksite Wellness Programs ◦  Weight management/coaching ◦  Fitness programs/challenges ◦  Incentive-based activities ◦  Smoking/tobacco cessation ◦  EAP/lifestyle coaching/stress mgmt

}  Primary care/care coordination ◦  Health advocacy ◦  Telehealth

}  Ancillary Services �  Pharmacy services �  Lab/x-ray services �  Physical therapy �  Vision services �  Dental services �  Chiropractic services �  Massage therapy �  Acupuncture 3

}  Coordinate care for patients }  Consolidate data from internal and external sources with

health center’s EMR }  Improve visibility and access to services }  Track patient use of service and referrals }  Collaborate care management }  Provide improved support for patient self-management }  Get cross referrals between contracted vendors }  Make greater utilization onsite fitness centers }  Provide easy access to all services }  Collect and measure performance


}  Offering employees the tools and resources they need to live healthy and productive lives and to cope with health issues is core to effective health and productivity programs

}  Comparisons of low vs. highly successful companies found one key differentiator is high performers offer easy access to preventive and other health care services*

}  Metro Nashville Public Schools found its onsite clinics and associated programs not only generated savings of $2.8 million, it has shown a correlation between teacher wellness ratings and student scores on ACT national tests**

*Towers Watson-NBGH Staying@Work Report ** IBI Case Study 2015

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}  Today, around 30% of companies offer some form of onsite, near-site or mobile health services to employees, dependents, retirees and others – 16% offer onsite pharmacy services

}  Approximately 67% of employers have some form of onsite fitness programs and centers

}  While many vendors recommend at least 1000-1500 employees in a single location to support center, many employer-sponsors of centers have smaller populations

}  Centers range from one day a week operations, led by NP/PA, to 5-7 day a week centers, open evenings and weekends, primarily staffed by physicians


}  Employers with locations having 500 or more employees }  Geographic areas facing primary care shortages }  Locations with barriers to reaching external care settings (e.g.,

remote locations, long commutes, heavy traffic) }  Low utilization by employees/dependents of existing primary

care, preventive, screening and condition management programs and services

}  High emergency room utilization for non-emergency conditions }  High absence and lost time for unscheduled medical issues }  Industries with low-turnover, long-term employees }  Older populations with high utilization of services }  Younger populations without primary physicians and with

limited time

Source: Towers Watson 7

Copyright (c) NAWHC 2016

}  Manufacturing (30%) }  Financial Services (12%) }  Health Care Services (12%) }  Government (8%) }  Consulting/Business services (5%) }  Retail (5%) }  Communications and Technology (5%) }  Others industries mentioned:

�  Education �  Entertainment �  Food �  Hospitality �  Non-profit �  Wholesale

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}  Early Programs: ◦  Occ health clinics deal with a few relatively straight-forward

services: First aid, Absence Management, Foreign Travel Preparation, On-site PT, Acute (Non-emergent) Medical Triage

}  Today’s programs: ◦  Primary care centers offering adult medicine, pediatrics,

OB-GYN, geriatrics. specialty services, pharmacy services, physical and other therapies, lab services, wellness programs, health coaching, chiropractic, acupuncture and massage services


}  Objectives }  Population to be served }  Self-manage or contract out }  Type of services to be provided }  Include or exclude workers comp }  Size and layout }  Staffing }  Hours }  Cost-sharing }  Information technology }  Ancillary services }  Measurement areas }  Onsite, near-site or mobile location


}  Employer operates the center itself, hiring the staff as its own employees

}  Employer manages the center and contracts with a provider group for staffing

}  Employer contracts with vendor/health plan to build, manage and staff the center

}  Property owner operates center for tenants }  Multiple employers share center, located either on one

employer’s location or centrally located, owned by the employers or the employers could contract with a provider or outside vendor to run it

}  Key is employer needs to remain engaged in center oversight, strategic and policy direction



0% 10% 20% 30% 40% 50% 60% 70% 80%

Within worksite Nearby, <2 miles from worksite

Nearby, >2 miles from worksite

Within an industrial park

with shared access

<1000 1000-10K >10K

}  The vast majority of US firms have less than 500 workers in a single site – considered a minimum by many to support an onsite clinic

}  Several vendors specialize in this approach }  Local providers often offer to set up dedicated centers for

area employers or designate time slots in existing clinics for employers

}  These can be set up in industrial parks, like fitness centers to serve multiple employers


}  NOT an either or scenario }  A combination offers greater access }  Economics and access drive decision making }  Connectivity to TPA/carrier }  Billing }  Data sharing }  Where are they? – You need to be where you members already

are }  Who are they? }  Trust factors }  Scheduling considerations }  Scope of Service offerings }  All should connect with patient’s personal physician


}  Onsite clinic vendors will usually charge: ◦  PMPM, ◦  Hourly or ◦  Cost-sharing agreement

}  Near-site or multi-employer clinics often bill clients based on: ◦  The number of hours the clinic is operational or the

portion of the schedule set aside for each employer’s workers ◦  The number of employees that are seen from each

participating employer by the health professionals ◦  A membership or subscription fee per employee


}  Sponsors: ◦  Health systems ◦  Big box stores: Walmart ◦  Pharmacies: CVS

Caremark ◦  Grocery stores

}  Services: ◦  Acute ◦  Primary ◦  Preventive ◦  Injury

}  Access: ◦  Hours vary

}  Staff: ◦  Physician ◦  Nurse Practitioner/

Physician Assistant }  Cost: ◦  Free ◦  Cost-sharing


}  Conditions treated: ◦  State dependent ◦  Acute ◦  Workplace injury ◦  Chronic disease management ◦  Cold and flu ◦  Dermatological ◦  Conjunctivitis ◦  Ear irritations ◦  Sore throat ◦  Urinary tract infections ◦  Vaccinations ◦  Pharmacy


}  Minimal upfront costs }  No capital investment }  Payment flexibility }  Tracking and reporting of service utilization }  Quality tracking and reporting }  Vendor coordination



0% 5%

10% 15% 20% 25% 30% 35% 40% 45% 50%

<1000 1000-10K >10K


0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

<1000 1000-10K >10K


0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

<1000 1000-10K >10K


Employer self-

managed, 38%

Onsite vendor managed,

54%

Local health provider

managed, 8%


0% 2% 4% 6% 8%

10% 12% 14% 16% 18% 20%

Mobile van Telemedicine Multi-employer clinic

}  Services offered: ◦  Physicals ◦  Lab work ◦  Vaccinations ◦  Acute care ◦  Screenings ◦  Follow-up care for those with chronic disease ◦  Dental care ◦  Lifestyle and wellness coaching

}  Vans can be scheduled to visit different locations/employers in same geographic area

}  Scheduled and same day appointments


Telemedicine now seen as: ◦  Remote monitoring �  Devices used to monitor patients,

chronic diseases, record vital signs and improve medication adherence

◦  Interactive services �  Real-time interaction between provider and patient, via

phone, video chat, text �  For diagnosis, consultation, treatment, education and care

management ◦  Store-and-forward �  Transmission of medical data, such as images, to a

physician for assessment

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}  Clinics use it to expand their reach to distant or remote sites }  It can be run by clinic staff, telehealth vendor or local provider }  Services provided: ◦  Injury/Illness ◦  Chronic disease management ◦  Travel medicine ◦  Tele-Derm ◦  Tele-Behavioral health

}  Access: ◦  Smartphones ◦  Kiosks ◦  Computers ◦  Pop-ups/carts


}  Towers Watson & Co. found: ◦  75 percent of employers anticipate offering

telemedicine services by 2018, at a potential health care cost savings of $6 billion a year. ◦  15 percent of primary-care visits, 15 percent of

emergency room visits and 37 percent of urgent-care visits could have been solved effectively and at a lower cost via telemedicine.

}  Researchers at Rand have said telemedicine could reduce the demand for physician services by as much as 25%.

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}  There are third-party vendors and some physician practices that offer to send doctors to the worksite when contacted by an employee

}  This can be paid for on a per encounter basis or the employer covers the cost



0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Integration of health

mgmt

Improved worker health

Increased access to medical & wellness services

Increased effectiveness

of health promotion

efforts

Increased employee

engagement in health

management programs

Increased employee

satisfaction

Increased productivity,

reduced absenteeism

Managed accidents

<1000 1000-10K >10K


0% 10% 20% 30% 40% 50% 60% 70% 80%

Reduced hospital

admissions

Reduced medical costs

Reduced pharmacy

costs

Reduced time off to

visit medical

providers

Reduced use of ER

Reduced use of outside

anciallary services

Reduced use of outside med.

Specialists

<1000 1000-10K >10K

}  You need a great provider staff that cares }  Promote confidentiality and privacy }  Offer services for free or lowers than outside services }  Use a vendor with state of the art ROI tools }  Set expectations of senior management – cost savings and

behavioral change could take 3-5 years }  Ensure clinic activities are integrated with all wellness programs

and vendors work together }  Pharmacy has proved a very effective engagement tool }  Promotion and visibility is key }  Clinic can offer providers that young employees often don’t

have }  Focus on prevention and close management of illnesses


}  Larry Boress ◦  [email protected] ◦  312-372-9090 x 101 ◦  www.worksitehealth.org ◦  NAWHC LinkedIn Group


Legal and Tax Issues Impac1ng On-‐Site Health Clinics

March 17, 2016

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Ann Murray, Partner [email protected] 404-‐322-‐6603

Legal Compliance

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Legal Compliance

•  Group Health Plan Requirements

•  ACA Impact

•  Privacy & Security Laws •  Other Laws •  Vendor Compliance

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Group Health Plan Requirements

On-‐site clinics might be regulated as a group health plan

under ERISA

***************************************

Does my clinic go BEYOND first aid? Is health care available to former or non-‐employees?

Are employees charged for use of the facility?

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Laws That May Apply to Group Health Plans •  ERISA •  COBRA •  MEWA rules •  ADA

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ERISA Compliance

•  Summary plan descripPon •  Fiduciary duPes •  Claims procedures •  Exclusive benefit requirements •  ERISA bond •  Annual reporPng (Form 5500)

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COBRA

•  Must the clinic be offered as a separate COBRA elecPon?

•  Will a separate premium be charged? •  If there is a separate COBRA premium, how will it be

calculated? •  Will there be safety or morale concerns if former

employees are allowed to access the worksite for clinic visits?

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Are you sponsoring your clinic with other employers?

*******************************

Consider MulPple Employer Welfare Arrangement (MEWA) requirements

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COMPLIANCE STEPS

§  Consider whether to treat your clinic as a component of your group health plan

§  Streamline compliance, including combined plan document, SPD, and Form 5500 filing

§  Adopt policies and procedures to address legal requirements

ACA Impact

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ACA Impact

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•  Most clinics should be exempt from the ACA's eligibility and coverage mandates

•  Most clinics will not saPsfy employer shared responsibility rules

•  ACA's W-‐2 reporPng requirements – discussed later as part of Tax Compliance

Privacy & Security Laws

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Privacy & Security Laws

•  HIPAA Privacy and Security •  Worker's CompensaPon

•  State Law Requirements

•  OccupaPonal Health/Leave Management

•  GenePc InformaPon NondiscriminaPon Act (GINA)

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Privacy and Security Laws

On-‐site clinic may qualify as a covered provider or business associate subject to HIPAA's privacy and security

regulaPons

***************************************

Does my clinic provide healthcare services?

Does my clinic exchange healthcare info electronically in connecPon with covered transacPons, such as billing or

care coordinaPon?

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Who has the responsibility for maintaining paPent

medical records?

Are paPent medical records kept separate from employee personnel files?

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Worker's Compensa1on Ensure worker's comp records and other work-‐related info are kept separate from employee medical records,

INCLUDING on-‐site clinic records

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Some states impose: •  addiPonal privacy and data security requirements,

•  record retenPon requirements, and

•  obligaPons to provide individual noPficaPons if inappropriate access occurs

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Occupa1onal Health/Leave Management

Privacy and recordkeeping requirements may apply

***************************************

Does my on-‐site clinic assist with? •  Eligibility determinaPons under FMLA or state

leave laws •  Reasonable accommodaPon assessments under

the ADA or similar state laws

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Gene1c Informa1on Nondiscrimina1on Act (GINA)

GINA limits when employers and group health plans may acquire info about family medical history and other genePc informaPon

IMPORTANT:

Implement policies and procedures to ensure genePc informaPon is not inappropriately shared

Other Laws

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Labor Laws

Are any of your employees unionized? If yes: confirm whether the establishment of an on-‐site clinic is a mandatory subject of bargaining

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Workplace Safety/OSHA

•  Include your on-‐site clinic in your OSHA compliance process. • Conduct a thorough hazard assessment of the clinic to determine and provide for: –  the full scope of your OSHA compliance and reporPng

obligaPons –  the safety & protecPon of employees working at

or visiPng the clinic

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Drug and Alcohol Tes1ng

Will your clinic handle this tes1ng? • Clinic tesPng must comply with federal, state, and local laws, including: – noPce requirements, and – administraPve safeguards

• NOTE: Some jurisdicPons prohibit on-‐site drug or alcohol tesPng

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Vendor Compliance Ensure Third-‐Party Vendor Compliance:

•  Licensure/accreditaPon •  Premises liability •  Scope of provided benefits •  Claims determinaPon processes •  Medical malpracPce liability and insurance issues •  IndemniPes •  Privacy, storage, security, processing & exchange of medical info •  CoordinaPon with other benefit plans

Tax Compliance

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W-‐2 Repor1ng

(1)  Aggregate cost of employer-‐sponsored health coverage must be included in the W-‐2 reporPng. -‐ What is the value of the clinic?

(2) Medical services and supplies that are not otherwise

excludable under IRC secPon 105 or 106 must be reported on Form W-‐2 as taxable and are subject to withholding

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HSA Ineligibility

Employees eligible to use the clinic on a subsidized basis may become ineligible to contribute to an HSA (their spouse may also lose HSA eligibility)

•  Verify if rule applies

•  NoPfy/warn employees

•  Consider internal protecPons

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Cadillac Tax

On-‐site clinic health benefits could be included in cadillac tax calcula1on

•  IF clinic provides more than first aid or other minimal services

•  See IRS NoPce 2015-‐16

•  Stay tuned for more guidance

Ques1ons?

Thank you for your Pme!

This presentaPon is for informaPonal purposes only and does not consPtute specific legal advice or opinions. Advice and opinions are provided by our firm only upon engagement with respect to specific factual situaPons.

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About Nelson Mullins

•  Founded in 1897 •  More than 500 alorneys and government relaPons

professionals •  More than 45 diversified pracPce areas •  Fimeen offices, including Atlanta, Boston, HunPngton,

Jacksonville, Nashville, New York, Tallahassee, Washington, D.C., and throughout the Carolinas

•  Alorneys have tried cases in 45 states, argued before the U.S. Supreme Court and most U.S. Circuit Courts of Appeals, are mulPlingual and represent mulPnaPonal companies in over 30 countries worldwide

•  In most current ranking by The American Lawyer, 111th largest law firm in the naPon based on gross revenue

How is Nelson Mullins Different?

•  LESS LEVERAGE. Nelson Mullins is commiled to less leverage, more partner involvement.

•  COORDINATION. Our client-‐first commitment and our service model are based on responsible client-‐partner coordinaPon and simplifying contacts and the management of malers.

•  COST EFFICIENT. We strive to have a lower-‐cost infrastructure than many of our compePtors and, when appropriate, we uPlize technology to deliver efficient and cost-‐effecPve legal services including legal project management and knowledge management systems.

•  CORPORATE EXPERIENCE. Many of our alorneys have in-‐house experience, which gives us an understanding of corporate culture and experience that extends beyond the private pracPce of law.

•  FLEXIBILITY. We have the depth and breadth of a large firm, but our flexible structure allows a personal and entrepreneurial approach to serve our clients.

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the value of onsite & near-‐site clinics

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