Raymond Fabius, MD Workplace Health Centers: Driving employee wellness and productivity through integrated workplace Health, wellness and fitness President & Chief Medical Officer CHD Meridian Healthcare

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 2 Presentation overview There is a competitive advantage to having a wellness and fitness center at the workplace in the quest to create healthier, more productive workforces. In this presentation we will address workplace health and productivity and describe how integrating workplace health centers, wellness programs and fitness centers can create a competitive advantage by producing a fit, healthy and productive workforce. Learning objectives: 1.Understand the advantages gained from collaboration of health centers, pharmacies, and wellness and fitness centers at the workplace. 2. Describe how workplace health, wellness and fitness centers benefit employees and their families. 3. Gain an appreciation of the outcomes possible from workplace health, wellness and fitness centers through a brief review of relevant published research. 4. Recognize how the current obesity epidemic makes employer commitment to workplace health, wellness and fitness centers particularly important today.

Brief workplace health update

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 4 PRIMARY SERVICES Occupational Health Acute/ Extended Episodic Care Primary Care Pharmacy Prevention/ Wellness Fitness ADDITIONAL SERVICES Physical Examinations Disease Management Disease Management Wellness Care Coordination Health Screening Health Fairs Health Coaching Health Advocacy Compliance: OSHA, AED, CLIA and VIS Medical Surveillance Workplace Safety Return to Work Program Ergonomics Pharmacy Concierge Services Specialty Pharmacy Services Integrated PBM/ Mail Order Services Physician Referral Network Disaster Management Travel Medicine Disability Management, Including STD, LTD & FMLA Physical Therapy Laboratory Services Specialty Services Rotations Woman’s Health Medical Emergency Services Substance Abuse Testing Global Medical Leadership/ Direction Creating integration & synergy with existing programs: Adding wellness to workplace health centers scope of services

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 5 “Migration & Integration” of workplace health services: Yielding great improvements in productivity Risk ManagementMedical Management Population Management 25%75% Medical Surveillance Exams Injuries & Illness Workers Compensation Ergonomics OSHA Reporting Disability Management Case Management Absence Management Wellness/ Prevention Primary Care Health Advocacy Disease Management Referral Management Pharmacy % of Employer Healthcare Costs Travel Medicine Urgent Care Emergency Preparedness Emergency Response EAP Behavioral Health Fitness Dental Physical Therapy

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 6 Patient satisfaction Access Availability Wellness programs Trusted relationship Medical surveillance Injury & illness Return to work Ergonomics Metric driven Clinical excellence Total population health External accreditation Direct medical Cost avoidance Reduced lost time Health advocacy Measurable ROI Employer of Choice Worker Safety Cost Savings Quality Care The value propositions of workplace health

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 7 SourceDescription Site Experience HEDIS commercial CES 3rd Line Antibiotics Utilization (appropriateness) Threshold 90% 89%N/A CES Pharyngitis Treatment 82% Peds, adults 73% Peds CES Outcomes DB Diabetics: HbA1c < 7.5 (threshold 50%) HbA1C < 7 72% 64% N/A 42% Outcomes DB Hypertension: BP < 140/9069%60% CES Outcomes DB Hyperlipidemia: Cholesterol: < 200 (threshold 50%) LDL: < % 53% (all HL dx.) N/A 57% (only CV dx.) CES Preventive Care Screening – Women Cervical, breast, colon, and others (threshold 80%) 69% composite Breast: 70% Cervical: 81% Colon m&f: 54.5% CHD Meridian / HEDIS Scorecard

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 8 Patients at locations where CHD Primary Care and Pharmacy is available cost on average $ per year less* than similar patients at locations where CHD Primary Care and Pharmacy is not available regardless of whether they use onsite medical services Patients who use worksite primary care cost on average $ per year less* than patients at the same locations who use community primary care only Worksite primary care and pharmacy delivers real savings Risk adjusted* cost savings for patients who use Worksite Primary Care (PC/Rx locations only) Risk adjusted* cost savings for patients at 4 CHD-PC/Rx locations versus 4 similar locations without CHD-PC/Rx Preliminary Results

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 9 Comprehensive ROI analysis of Goldman Sachs Continues to be Refined) ( Continues to be Refined)

Workplace Health Opportunities for Integration

Integration with Occupational Health & Environmental Health & Safety

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 12 Optimizing the health of the employer community: Partnering with health and safety and medical leadership Medical Surveillance exams Diagnostic testing Acute care H & S Exposure management Industrial hygiene Workplace safety Regulatory compliance Ergonomics Injury documentation Accident investigation Responding to the needs identified by Client’s H&S and Medical Leadership to deliver the highest level of medical compliance and protect every worker from occupational illness and injury

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 13 Treating workplace illness & injury Key principles Assist employees in obtaining appropriate medical service as quickly as possible Select and monitor specialty physicians to ensure efficiency and communication Educate employees, their treating providers and plant supervisors regarding available modified or restricted duty programs Reduce absenteeism and disability related costs by facilitating an employee’s early return to work Track workplace injuries & illnesses to develop preventive programs Assess job functions and worksite ergonomics to identify safety issues Assure that employees receive their entitled absence benefits

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 14 Reducing the impact of worker’s compensation Total Incurred CostsSeverity Rates Lost Time DaysLost Time Accident Rates

Integration with Wellness & Fitness

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 16 Workplace Safety Ergonomics Fitness Personal Trainer Work Hardening Physical Therapist Work Readiness Occupational Therapist Injury at Work Physician / Nurse Return to Work Disability Management Workplace fitness & health: Minimize days away from work

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 17 Outcome Measure Low-Risk (N=671) Medium- Risk (N=504) High-Risk (N=396) Excess Cost Percentage Short-term Disability $120$216$33341% Worker’s Compensation $228$244$49624% Absence$245$341$52729% Medical & Pharmacy $1,158$1,487$3,69638% Total$1,751$2,288$5,05236% Wright, Beard, Edington. JOEM. 44(12): , 2002 Association of risk levels with several corporate cost measures

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 18 Deaths Attributable to Various Causes Fatal 5 and the Impact of Obesity/Poor Diet 1990 vs 2002 USA 400, , , , ,000 80,000 90,000 76,000 55,000 60,000 # of deaths and %   8%  25%  (20%)  (16%)  (8%) Mokadad, A Jama 2004; 291:

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 19 Greatest Cost Savings Opportunity Getting the Obese Group to Exercise BMI, Physical Activity, and Health Care Costs; Wang et al; JOEM :Vol. 46, No. 5, May 2004, pp A Study done comparing HRA self reported data to claims information following over 20K ee’s in a manufacturing environment that including GM. $500

Integration with Absence Management

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 21 Medical Drug testing Disability mgmt Acute care HR Hiring & training Work-life balance Benefit design Wellness & Health promotion Return-to-work Absence management Responding to the needs identified By Human Resources and Medical Leadership to optimize employee health and productivity Optimizing the health of the employer community: Partnering with human resources and medical leadership

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 22 NEW SCHOOL: The Skill & The Will & NOT ILL Health is Not a Cost! It is an Investment into Human Capital

Integration with Disease Management

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 24 CHD-Meridian/Goodyear; and Lynch, et al. JOEM 2006;48: To be Published The power of integration: Healthcare center drives improved engagement & retention rates

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 25 Chronic illness is better managed: Workplace care vs. Community care Study Design – control vs. study groups Primary Care/ Rx Site Chronically ill patients 4X more likely to use CHD Meridian for primary medical care Chronically ill patients who utilize the Medical Center for primary care exhibit: –More primary care visits - 24% more total office visits per year –Less hospitalization - Inpatient admission rate reduced by 50% –Less ER/hospital use - Hospital outpatient visits reduced by 42% –Less need for referral - Community office visits are reduced by 36% –Less prescriptions/More use of mail order - PBM scripts are reduced by 61% Medical claims costs reduced by 32% Pharmacy claims costs reduced by 17% Total medical and Rx costs reduced by 29%

Integration with Consumerism & Health Advocacy

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 27 Consumers need health advocacy: Even presidents have difficulty selecting providers Higher quality lowers cost Many consumers do not realize some doctors/hospitals are better than others Pareto Rule : 20% of covered lives spend 80% of the dollars and have choices By steering to high performance providers, costs will decrease and quality will increase President Clinton could have benefited From a trusted clinician’s guidance! Hospital Risk-Adjusted Mortality Rate (RAMR) Beth Israel2.67 Columbia Presbyterian3.93* Lenox Hill2.26 Mount Sinai2.81 NYU Hospitals Center1.95 Weil Cornell – NYP0.95* Westchester Medical Center3.27 SurgeonRAMR State Total2.25 Smith, C4.15 Bill Clinton to have scar tissue removed Six months after undergoing heart bypass surgery, former US President Clinton will return to the hospital this week to have a rare buildup of fluid and scar tissue removed from his chest.

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 28 Identifying best specialists & hospitals and directing employees to them Toyota presentation to IHPM 10% 0.00% The CHD specialty referral rate is 40% lower than the community referral rate. 4.00% 6.00% 8.00% 2.00% 10.00% 6% 2007 Actual Billed Charges Paid January thru June 2007 Actual Billed Charges Paid January thru June %Using Best Hospitals 2006 vs 2007 %Using Best Specialists 2006 vs 2007

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 29

Integration with Workplace Primary Care & Pharmacy

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 31 Integrated primary care and pharmacy: Greater Use of Generics Much higher Generic Dispensing Rate for PC/ Rx Above industry average/ retail-PBM average Affects COMMUNITY providers as well Each % point of GDR ~ $100-$200K/ year incremental savings (depending upon volume)

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 32 Better Care – and a Potential Savings of $1.5 Million for Antibiotics Alone Evidence-based prescribing practices generate value (recently published article in Journal of Health & Productivity – March 2007)

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 33 15% Greater medication adherence CHD primary care & pharmacy users versus community care patients

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 34 Medication patient safety: Significantly better than retail pharmacy (Based on 1 million prescriptions filled over 5 year contract) With a retail error rate recently reported in USA Today of 1/ Expect 1000 errors At $2000 per ADE (IOM) = $2 Million 4 Hospitalizations at 10,375 each (IOM) 24 ER visits at $ 1444 each (IOM) With our error rate of 3/10000 (prior to implementation of new IT platform) -Expect less than 300 = $600K -1 Hospitalization PATIENT SAFETY COST SAVINGS = 1.4 Million 2% of all hospitalizations are due to medication misadventures

Copyright © 2008 CHD Meridian Healthcare, LLC - All Rights Reserved 35 Integrating Care at the Workplace Leveraging the “Trusted Clinicians” Physicians, Pharmacists, Nurse Practitioners, Nurses, Therapists, Sports Physiologists, Health Coaches, Care Managers, Personal Trainers Wellness Screenings Immunizations Health Coaching HRA Illness Drug Management Behavioral Health Disease/Case Management Environment Smoking Ban Traditional Occ Health Safe Workplace Cafeteria Managing the Medical Community Specialists Tests Hospitals Treatment Options Fitness Work Readiness Ergonomics Work Hardening Return to Work