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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
Copyright (c) NAWHC 2016 2
} 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
Copyright (c) NAWHC 2015 4
} 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
5
} 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
Copyright (c) NAWHC 2016 6
} 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 8
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
Copyright (c) NAWHC 2016 10
} 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
Copyright (c) NAWHC 2016 11
} 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
Copyright (c) NAWHC 2016 12
Copyright (c) NAWHC 2016 13
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
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} 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
Copyright (c) NAWHC 2016 15
} 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
Copyright (c) NAWHC 2016 16
} 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
Copyright (c) NAWHC 2016 17
} 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
Copyright (c) NAWHC 2016 18
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} Conditions treated: ◦ State dependent ◦ Acute ◦ Workplace injury ◦ Chronic disease management ◦ Cold and flu ◦ Dermatological ◦ Conjunctivitis ◦ Ear irritations ◦ Sore throat ◦ Urinary tract infections ◦ Vaccinations ◦ Pharmacy
Copyright (c) NAWHC 2016 20
} Minimal upfront costs } No capital investment } Payment flexibility } Tracking and reporting of service utilization } Quality tracking and reporting } Vendor coordination
Copyright (c) NAWHC 2016 21
Copyright (c) NAWHC 2016 22
0% 5%
10% 15% 20% 25% 30% 35% 40% 45% 50%
<1000 1000-10K >10K
Copyright (c) NAWHC 2016 23
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
<1000 1000-10K >10K
Copyright (c) NAWHC 2016 24
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
<1000 1000-10K >10K
Copyright (c) NAWHC 2015 25
Employer self-
managed, 38%
Onsite vendor managed,
54%
Local health provider
managed, 8%
Copyright (c) NAWHC 2016 26
0% 2% 4% 6% 8%
10% 12% 14% 16% 18% 20%
Mobile van Telemedicine Multi-employer clinic
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} 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
Copyright (c) NAWHC 2016 28
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Copyright (c) NAWHC 2016 31
Copyright (c) NAWHC 2016 32
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
Copyright (c) NAWHC 2016 34
} 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
Copyright (c) NAWHC 2016 37
Copyright (c) NAWHC 2016 38
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
Copyright (c) NAWHC 2016 39
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
Copyright (c) NAWHC 2016 40
} Larry Boress ◦ lboress@worksitehealth.org ◦ 312-372-9090 x 101 ◦ www.worksitehealth.org ◦ NAWHC LinkedIn Group
Copyright (c) NAWHC 2016 41
Legal and Tax Issues Impac1ng On-‐Site Health Clinics
March 17, 2016
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Ann Murray, Partner ann.murray@nelsonmullins.com 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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Group Health Plan Requirements
Laws That May Apply to Group Health Plans • ERISA • COBRA • MEWA rules • ADA
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Group Health Plan Requirements
ERISA Compliance
• Summary plan descripPon • Fiduciary duPes • Claims procedures • Exclusive benefit requirements • ERISA bond • Annual reporPng (Form 5500)
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Group Health Plan Requirements
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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Group Health Plan Requirements
Are you sponsoring your clinic with other employers?
*******************************
Consider MulPple Employer Welfare Arrangement (MEWA) requirements
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Group Health Plan Requirements
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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Privacy and Security Laws
Who has the responsibility for maintaining paPent
medical records?
Are paPent medical records kept separate from employee personnel files?
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Privacy and Security Laws
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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Privacy and Security Laws
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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Privacy and Security Laws
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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Privacy and Security Laws
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.
• DIVERSITY. We offer the strength and resources of diverse alorneys and professional staff experienced in a range of industries.
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