Impact of Convenient Care in the Healthcare Industry May 20, 2008 Sandra F. Ryan, Chief Nurse Practitioner Officer Take Care Health Systems, LLC Co-Chair Clinical Advisory Board CCA

Agenda Evolution of an Industry Current Landscape CCA: Driving Quality Care The Future of Convenient Care: The Take Care Health Model

Evolution of an Industry The first Convenient Care Clinic (CCC) opened in clinics operated by over 20 companies Increased shortage of primary care physicians and will get worse in future 35% of current physicians are nearing retirement. Fewer than 30% of current medical students say they intend to be primary care physicians. Significant annual increases in health insurance deductibles and co-pays Growing popularity of ‘consumer driven’ health plans (CDHPs) Rapid growth of uninsured population that now includes nearly 47 million people Increasing time pressure on consumers How can Convenient Care impact healthcare moving forward?

Current Landscape and Scope of Practice Acute, Self-limiting conditions Limited Scope of Services Bronchitis, common colds, coughs, ear infections, flu, laryngitis, sinus infections, sore throat, strep throat, upper respiratory infections Bladder infections, diarrhea, nausea and vomiting, early lyme disease, fever, head lice, skin rashes, mononucleosis, eye infections, seasonal allergies, swimmer’s ear Minor Injuries Abrasions, minor burns, splinters, sprains/strains, staple/suture removal Other Services Include vaccinations, screenings, and administrative physicals

Current Synergies with the Medical Community Overflow outlet for Busy provider practices Evening/weekend/holiday coverage Overburdened emergency rooms Quality access to healthcare Electronic prescribing Regulatory compliance Peer and CP Review Evidence-Based practice that follow AMA and AAFP guidelines Easier access to healthcare Particularly for those individuals without a PCP, without insurance, and/or in underserved areas Connects individuals without a PCP to a health care home Earlier access to healthcare Reduces illness severity and spreading of infections Encourages preventive care Reduces overall health care utilization

Current Synergies with the Medical Community An April 2007 study* by a market research company found that 18% of convenient care clinic users were referred to another health care provider for additional treatment at the end of their visit. 60% of those people who required referrals were able to schedule the referral on-site at the convenient care clinic before the end of their visit. 27% of all referrals were directed to family physicians/primary care providers. Only 7% of CCC users were referred to the emergency room for care, suggesting that CCCs are helping to reduce unnecessary ER use by providing the right level of care, in the right place, at the right time. *Market Strategies Inc., ‘Retail Clinics: Health Care Evolution or Revolution?’, April 2007.

The Convenient Care Association: Driving Quality Care Association Goals: Develop common standards of operation to ensure the highest quality of care Unite behind one voice to advance the needs of CCCs and their customers Streamline marketing efforts to promote the concept and respond to questions about this evolving industry Reach out to the existing medical community and creating new partnerships Build synergies with traditional medical service providers

CCA Standards CCA standards adopted in March 2007 Thorough credentialing for licensure and experience Quality monitoring, including but not limited to: peer review; collaborating physician review; use of evidence-based guidelines; collecting aggregate data on selected quality and safety outcomes; collecting patient satisfaction data. Relationships with traditional health care providers and hospitals Encouraging patients to establish a relationship with a primary care provider, and to making appropriate referrals for follow-on care. Compliance with applicable OSHA, CLIA, HIPAA, and ADA standards. All CCA Members follow CDC guidelines for infection control through hand- washing.

Quality and Safety Standards Provide health promotion and disease prevention education Use of Electronic Health Records (EHR) to ensure high-quality efficient care and promote continuity. Commitment to sharing health record with providers Provide an environment conducive to quality patient care and meet standards for infection control and safety. Establish emergency response procedures and develop relationships with local emergency response service providers. Empower patients to make informed choices about their health care. Prices should be transparent and accessible.

Practice Guidelines and Certification Best Practice document developed for members as a guideline Recommendations for the delivery of high quality, affordable, convenient healthcare Provides policy recommendations CCA Certification Review Process Department of Health Policy at Jefferson Medical College Review of policies and procedures to ensure compliance with CCA quality and safety standards

High-quality Health Care Clinics Professional exam rooms; some clinics have exam tables Rooms meet OSHA, CLIA, HIPAA, and ADA standards Running water for hand-washing in room or near by; appropriate sanitation in room EMR technology

Commitment to Quality Collaborating physician review, peer review and compliance auditing Referral process and integration Patients referred to primary care provider and/or CP for follow-on care (up to 20%) Patients do not have healthcare home (up to 30%) Patients would have gone to the ER, Urgent Care or not sought treatment (Over 40%) CCCs strive to monitor quality and practice standards Practice guidelines based on widely accepted professional standards Most CCCs advocate or conduct CME’s, Grand Rounds for their providers

Data: Evidence of Quality American Journal of Medical Quality reported that retail clinics provide “exceptionally high-quality care” for acute pharyngitis (sore throat) when practitioner training is combined with EMR support tools* Among 39,350 cases indicating a negative rapid strep test result, MinuteClinic nurse practitioners and physician assistants adhered to clinical guidelines in percent of patient visits by not prescribing unneeded antibiotics. Among the 13,471 cases with a positive rapid strep test result, percent received an appropriate antibiotic prescription. The combined guideline adherence rate for both positive and negative results was percent. *Represents a one-year study of acute pharyngitis that analyzed 57,331 patient visits at 28 MinuteClinic health care centers in Minneapolis and Baltimore between September 2005 and September 2006.

Data: TCHS Evidence of Quality Preliminary quality data from Take Care Health Systems shows that appropriate antibiotic usage far exceeds national benchmarks – up to 50%. Significantly better than NCQA standards: Utilization of RAPID strep tests Appropriate antibiotic prescribing for bacterial strep infections Appropriate treatment of pediatric age upper respiratory infections and adult bronchitis

The Future of Convenient Care: The Take Care Health Model

Future Impact of Convenient Care Public Health and Safety First-line management of National Emergencies Chronic Disease Management & Health Promotion Infusions Lab Services Education Convenient ED concept Absorb non-emergent patient visits Educate patients about healthcare home Refer into hospital provider base Improve patient satisfaction Corporate On-Sites

A healthier workforce costs less and is more productive. A Kaiser study found that only 24 percent of costs associated with illness resulted from direct medical costs. Almost 70 percent were related to absenteeism or employees working while ill and unable to fully perform. A comprehensive wellness program is necessary to control ancillary costs. A 2004 study by CCH and Harris Interactive found that the annual costs of employee absenteeism can range from $60k for smaller employers to $1M for large companies. Access to quality, affordable and convenient healthcare near at work Provide large company employees and health plan members seamless access to health centers and pharmacies at worksites and in the community after-hours and on weekends Potential to Offer: Health Promotion Occupational Health Disease Management Risk Management

Created March 17, 2008 Announced intent to acquire I-trax/CHD Meridian Healthcare and Whole Health Management, two leading providers of workplace-based healthcare Acquisitions will complement May 2007 acquisition of Take Care Health Systems, leading manager of convenient-care clinics With retail pharmacies, Walgreens will have nearly 7,000 points of care Acquisitions bring more than 500 health centers, including Take Care Health Clinics Adds thousands of healthcare professionals to Walgreens, including physicians, physician assistants, nurse practitioners, and nurses Walgreens Health and Wellness Division: Creation

Walgreens Health & Wellness Division I-trax/CHD Meridian Healthcare Provides worksite health services, including: Acute care/Primary Care Wellness & disease management services Pharmacy Health and fitness programming 160 employers including: BMW, Disney, Eastman Chemical, Gillette, Goldman Sachs, Horizon Blue Cross Blue Shield of New Jersey, Lowe’s, and Toyota Whole Health Management Provides: Primary Care Urgent Care Wellness Programs Health coaching Occupational Health Services 69 worksite health centers for 27 clients, including Continental Airlines, Florida Power and Light, Harrah’s Entertainment, Scotts Miracle-Gro, and Sprint

I-trax/CHD Meridian, Whole Health, Take Care Health Systems Overlap ©2008 Walgreen Co. All rights reserved. 20

Market Landscape 45% 37% 17% Service provided by in-house clinicians No service provided in workplace Service provided by 3 rd party vendor 7,600 corporate campuses of 1,000 employees, plus families and retirees 2,836 (37.3%) do not provide work-site healthcare 3,446 (45.3%) internally provide work-site healthcare 1,321 (17.4%) use a third party to provide work-site healthcare The number of companies with on-site clinics is projected to increase by 26% in 2008 – Watson Wyatt 2007 survey

Health and Wellness Division: Objective and Vision Expand healthcare beyond traditional retail sites Provide large-company employees and health plan members seamless access to quality, affordable, and convenient healthcare near home and at work Access to health centers and pharmacies at worksites and in the community after-hours and on weekends Non-worksite employee population–including dependents and retirees–can access care in retail locations Continue expansion of Take Care Health Clinics ® Create value for employers and health plans by lowering costs and improving outcomes Focus on enhancing productivity and a healthier workforce

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