1. Corporate Healthcare Ideas: Thinking Outside the Box with Employer Sponsored Clinics WAHU John Neuberger Vice President Operations September 19, 2008

2. The Problem Healthcare Cost and Quality CRISIS

3. PCP Specialist A Lack of Coordination & Integration A Crisis in Healthcare

4. Our Healthcare System Costs $7,000/person, twice as much as other industrialized countries spend to cover every citizen 30% of dollars and up to half of doctors and nurses time spent on paperwork Only 1/3 of time is evidence-based medicine practiced Healthcare costs to businesses up 140% in the last 10 years, 5x wage growth But primary care real incomes are down

5. Overstressed PCP No System Integration No Universal EMR No Financial Incentives Lack of Care Coordination A Crisis in Healthcare

6. One Employer’s Solution to the Healthcare Crisis

7. Who is Quad/Graphics? Founded in 1971 The world’s largest privately held printer of magazines and catalogs 10 printing plants in 6 states International partnerships with printers in Poland, Argentina and Brazil More than 10,000 employees $2.0 billion in annual sales

8. A Sample of Quad/Graphics Clients Advertising Age Cargo Entertainment Weekly Elegant Bride Golf Digest Health JC Penney Life National Geographic Newsweek People Self Time Inc. U.S. News & World Report Victoria’s Secret Williams-Sonoma

9. Why Is Quad/Graphics In The Health Care Business? Control costs by providing a full range of healthcare services Focus on wellness and preventive medicine Enhance quality through best practice guidelines and Evidence-Based Medicine Offer benefits that attract, retain staff Maintain flexibility in benefit design Improve patient access with onsite facilities

10. Who Is QuadMed?

11. Quad Med – A Medical Subsidiary of Quad Graphics Opened first clinic in 1990 Currently manages 8 clinics –5 Quad Graphics –2 Briggs & Stratton (2002 & 2004) –1 Miller Brewing Company (2005) In 2007 Quad Med Provided –120,500 Clinic Visits –122,100 Prescriptions –21,800 Dental Visits –17,600 Rehab Visits –230,000 Adjudicated Claims

12. Briggs & Stratton Health Center

13. Miller Health & Fitness Center

14. Comprehensive integrated on-site services: Requires balance Risk Management Medical Management Health Transformation/ Population Management OSHA Reporting Acute care Injuries and Illness Workers Compensation Disability Management Absence Management Case Management Primary Care Referral Management Health Advocacy Wellness/ Prevention Chronic Disease Management On-site pharmacy

15. QuadMed Strategy Provide onsite primary care & selected specialty care Focus on prevention and wellness Restructure the delivery of primary care –Focus on patient centered care –Salaried providers, not “production” based reimbursement –Incentives based on quality – customer satisfaction, adherence to guidelines, preventive services, collegiality, committee participation –Provide ample “face time” with patients –Provide resources supporting quality care Provide specialty care & hospital care through direct contracting “Narrow Networks” Remove waste and improve quality - LEAN Integrate workers’ compensation into primary care services

16. The Power of Integration & Coordination Health Plan Design Workers Compensatio n Occupational Health On-Site Primary Care Clinic Pharmacy Prepackaged meds Prevention & Wellness Fitness Centers Physical & Occupational Therapy EAP & AODA Counseling TPA Case Management Disease Management Electronic Medical Record Direct Contracting High Performance Networks Data Warehouse

17. The Savings of Employer Managed Healthcare

18. QuadMed Track Record Average healthcare cost per employee

19. Actuarial Study Quad/Graphics’ healthcare costs are consistently below the benchmark, when adjusted for demographics and benefit design: 18% below in 1998 19% below in 2000 17% below in 2002 26% below in 2004 32% below in 2006

20. Potential Savings for an On-Site Clinic and Pharmacy Onsite care can provide the following additional savings Lab – 94% Savings Rehab – 54% Savings Pharmacy- 8% Savings Direct Contracting – 11% Savings

21. Average Healthcare Cost Trend 2000-2007 per employee per year 4.9%

22. Briggs & Stratton Per Employee Cost Comparison

23. Steinhafels Experience at Quad PHCS VS Quad shows 16% savings per month per participant Based on 2007 Data

24. The Health Plan

25. Preferred Quad/Clinics 400 Specialists 9 Hospitals $6 Co-Pay $30 Co-Pay $25-200 Co-Pay 100%84% Network98 Hospitals 6,650 Doctors $300/500 $2,300 max 80%9% Nonnetwork$400/80070%7% Power Of Benefit Design Weekly Premium of $11 per single, $22 per couple, $32 per Family ProvidersDeductible/ Copay CoverageDollars Spent

26. Quality of Care Measures

27. Quality of Care – Reporting Tools Satisfaction Surveys –Patient –Staff –Provider Data Warehouse (Ingenix) –Key Indicator Report – Comparative Activity Report –Evidence-Based Medicine Report –Ad Hoc Reports EMR/PM (GE Centricity) –Focused EBM Reports – Individually Actionable

28. Key Indicator Report – National Experience

29. Evidence-Based Medicine Compliance ConditionWI Compliance RateNational Compliance RateBenchmark Depression84.4%84.3%88.7% Diabetes Mellitus74.1%55.6%56.0% Epilepsy82.4%53.9%69.4% Hyperlipidemia93.6%71.3%74.9% Hypertension89.2%73.0%75.8% Obesity75.5%46.1% Ingenix Database

30. Quality of Care Analysis - EMR Immunizations Up-to-date on all immunizations at age 2 QuadMed - 98% NCQA - 68% Up-to-date at age 13 QuadMed - 88% NCQA - 50%

31. In Summary QuadMed has developed a program that has been successful in controlling cost and improving quality of care for QuadGraphics. The program focuses on: –Patient Centered Care –Empowered Primary Care –Wellness and Prevention –Practice of Evidence-Based Medicine –True Integration of Healthcare Across Disciplines The program can be successfully implemented at a myriad of industries and organizations with similar results.