On Site Health Clinics: Effectively Managing Initial Costs and Incorporating Innovative/Effective Programs

On Site Health Clinics: Effectively Managing Initial Costs and Incorporating Innovative/Effective Programs

Health Plan Overview: Where We Were In 2009/2010 Fully Insured through BCBS of Florida Covered 8,200 employees and 10,000 total members Total medical and prescription Claims of $49,300,000 Employee co pay structure Primary care $20 $30 (Depending on Plan Selected) Specialist $35 $50 (Depending on Plan Selected) Generic Rx $10 Preferred brand Rx $25 Non preferred brand Rx $40 Plan utilization 115,000 prescriptions filled annually 183,000 medical claims processed annually

Health Plan Overview: Where We Were Headed $50,000,000 health plan budget that was increasing at a rate of 9 12% annually. Annual plan changes were shifting more costs to employees and their families. The District had just entered a budget crisis, as state and local revenues were down due to the recession/depression that would last almost 6 years. Traditional wellness and cost containment efforts were becoming less and less effective. Large scale solutions were needed due to the plan size and enrollment counts.

Medical/Prescription Claims and Expected Liability Increasing 9% $90,000,000.00 $80,000,000.00 $70,000,000.00 $60,000,000.00 $49,204,426.00 $58,459,778.53 $53,632,824.34 $82,520,748.30 $75,707,108.50 $69,456,062.87 $63,721,158.60 $50,000,000.00 $40,000,000.00 $30,000,000.00 $20,000,000.00 $10,000,000.00 $ 2010 2011 2012 2013 2014 2015 2016 Projected Health Plan Costs without Care Here

Our Strategic Solution Change from full insured to a self insured plan with stop loss coverage. BCBS remained as our third party administrator. Bring comprehensive primary care services within the District by opening Employee Health and Wellness Centers (EH&WC). Started with three centers, and have since opened 2 additional facilities. Leverage plan specific data to address our cost drivers and develop a comprehensive plan with the use of data analytic services. Integrate wellness and primary care services. Integrate occupational services, and drug/alcohol testing programs (federal OTETA and reasonable suspicion) Change pharmacy benefit manager. Moved from Medco (AWP +/ model) to Envision (pass through pricing).

Employee Health and Wellness Center Services Primary care with family practice/internal medicine focus Acute care Chronic care X Ray Prescription dispensing Health risk assessments, biometric screening, and lab draws Disease management and wellness programs Occupational/workers compensation services OTETA physicals and reasonable suspicion drug/alcohol testing Pre employment post offer physicals

How Did We Drive Employees from the Medical Plan to the Health and Wellness Centers? No co pays for office visits Free generic prescription medication Free wellness services and programs Financial incentives for health risk assessments and follow up Convenient locations geo access analysis Telephone and on line appointment scheduling Early, late, and weekend appointment availability True 20 minute appointments with treating provider Little to no waiting for appointments Benefits Team contacts newly eligible employees (new hire or newly benefit eligible) within 30 days of becoming benefit eligible. Video tutorials: How to Register for an HRA and What is an HRA?

Health and Wellness Center Staff Physicians augmented with mid level providers Nurses MA/PT Wellness/disease management team Registered dietician Exercise physiologist Social worker Smoking cessation facilitator Wellness coach/nurse Hours 8:00am 5:00pm standard for most centers Early start and late close days are scheduled each week Saturday hours are 9:00am 1:00pm

Employees and eligible plan members still have a choice with respect to treatment, but the outcomes are not the same.

Health and Wellness Center Top Diagnosis Hypertension Bronchitis Vitamin Deficiencies Hyperlipidemia Acute Pharyngitis Lumbago Impaired Fasting Glucose Esophageal Reflux Maxillary Sinusitis Obesity Allergies

Employee Health and Wellness Center Locations

Employee Health and Wellness Center Utilization 80000 564 70000 678 755 11328 60000 50000 425 344 10575 11201 40000 30000 140 3793 6802 10017 46540 48532 58898 20000 32177 35299 10000 22213 0 2011 2012 2013 2014 2015 2016 Medical Ancillary Occupational

12,000 EH&WC: Unique Patient Participation 10,000 8,000 6,000 4,000 2,000 0 Jan11 Dec11 Jan11 Dec12 Jan11 Dec13 Jan11 Dec14 Jan11 Dec15 Jan11 Dec16 Retiree 86 121 153 164 218 296 Dep Child 120 167 225 273 342 427 Dep Spouse 120 194 256 333 397 452 Employee 3550 5420 6698 7841 9027 10277

Total Medical Claims Processed by Health Plan 200000 180000 160000 140000 120000 100000 186592 80000 60000 150509 154168 137649 156146 152345 128590 40000 20000 0 2010 2011 2012 2013 2014 2015 2016 Health Plan

Prescription Utilization Medical Plan and Health and Wellness Centers 140000 120000 100000 0 15471 23950 27542 36929 39945 46553 80000 60000 114924 103311 90926 91733 89552 90871 89455 40000 20000 0 2010 2011 2012 2013 2014 2015 2016 Health Plan H&WC

Medical/Prescription Claims and Expected Liability vs. Actual $9,000 $8,000 $5,799 $6,321 $6,890 $7,510 $8,186 $8,922 $7,000 $6,000 $5,000 $4,000 $3,000 $5,799 $6,018 $6,429 $6,566 $6,713 $6,997 $2,000 $1,000 $0 Baseline 2011 2012 2013 2014 2015 Actual plan trend has been an average of 4.13% vs. 9% projected. Plan Costs with Care Here Projected Health Plan Costs without Care Here

Savings to the District Projected Cost of Medical and Rx Claims at 9% Actual Cost of Medical and Rx Claims w/ Care Here Cost Difference Per Employee Contract Per Year Average Number of Employee Contracts Total Net Savings (Cost Avoidance) 2011 $6,320.90 $6,017.60 $303.30 8527 $2,586,239 2012 $6,889.78 $6,429.38 $460.40 8200 $3,775,280 2013 $7,509.86 $6,565.93 $943.93 8110 $7,655,272 2014 $8,185.74 $6,702.36 $1,483.37 8210 $12,178,535 2015 $8,922.46 $6,996.81 $1,925.65 8298 $15,979,044 Total Since Inception $42,037,608

Employee Savings Medical Co Pay Savings Prescription Co Pay Savings Totals by Year 2011 $444,260 $213,887 $658,147 2012 $643,540 $331,229 $974,769 2013 $705,980 $386,438 $1,092,418 2014 $930,800 $510,728 $1,441,528 2015 $970,640 $552,439 $1,523,079 Totals $5,689,941

Employee Wellness Programs and Initiatives Free health risk assessments Comprehensive Follow Up Programs Cholesterol Management Diabetes Management Weight Management Beginners Exercise Healthy Eating Tobacco Cessation Hypertension Stress Management Active wellness committee with employee, health partner, and community involvement.

Employee Incentive Program and Program Engagement Employees receive $150 per year for completion of an annual health risk assessment Employees can receive an additional $50 per year for completion of a health and wellness follow up program aligned with their individual health needs. Max incentive per employee is currently $250 per year For plan year 2014, the District had 2,683 employees complete a health risk assessment and initiate a health and wellness follow up activity.

Pasco School s Honors and Distinctions 2012 Tampa Bay Business Journal Healthy Employer (1500+) 2013 Florida Worksite Wellness Award Tampa Bay Business Journal Healthiest Employer (1500+) 2014 35 th Healthiest Workplace in America Tampa Bay Business Journal Healthy Employer (1500+) American Heart Association Fit Friendly Platinum Award 2015 Wellness Council of Tampa Bay We in Wellness Recognition Florida tobacco Cessation Alliance Silver Level Award The American Diabetes Association Organization Health Champion 2016 Florida Healthy Districts Health School District The American Diabetes Association Organization Health Champion 2017 34 th Healthiest Workplace in America

Moving Forward: Medical Tourism and Personal Importation Specialty Pharmacy and Personal Importation The average cost per Rx per employee has risen 38% in the past 3 years, due almost entirely to the increase in specialty drugs hitting the market for conditions like Hep C, MS, etc. Looking at marketing a targeted mail order program. High Cost Chronic Conditions and Medical Tourism The District is looking for a way for employees to obtain a clinical review and prescribed medical regimens at significantly reduced costs. Initial focus will be MS, Cancer, RA, HIV, Hep C

Medical and Rx Cost Increases 7000 Almost 3.5% Per Year Average 6000 5000 $1,398.53 $1,397.17 $1,182.79 $1,345.33 $1,457.11 $1,637.65 $1,739.46 4000 Less Than 1% Per Year Average. 3000 2000 $4,381.73 $4,168.19 $4,605.31 $4,528.50 $4,401.71 $4,422.72 $4,656.00 1000 0 2010 2011 2012 2013 2014 2015 2016 Medical Claims Cost PEPY Rx Claims Cost PEPY

Prescription Spend by Type (Specialty vs Non Specialty) $16,000,000 $14,000,000 $12,000,000 $10,000,000 $8,000,000 $6,000,000 $4,000,000 $2,000,000 $0 $13,589,198 $10,668,680 $11,879,524 $2,588,940 $3,490,901 $5,346,093 $8,079,740 $8,388,623 $8,243,105 2013 2014 2015 Non Specialty Rx Specialty Rx *SPECIALTY Rx defined by prescriptions with an average cost over $3,000 Specialty prescriptions with an average cost over $3,000 each is the primary cost driver to the plan. These primarily include the treatment for conditions like Cancer (Oncology), Hep C, MS, Rheumatoid Arthritis, HIV 24

Personal Prescription Importation FDA Allowances: If you still choose to import prescription medications from outside the United States, be aware that FDA inspectors are allowed to use enforcement discretion to permit the importation of certain unapproved prescription medications for personal use, but that discretion includes these stipulations: The product is for personal use (90 day supply or less). The intended use is for a serious condition for which effective treatment may not be available domestically. There is no known commercialization or promotion to U.S. residents by those involved in the distribution of the product. The product does not represent an unreasonable risk. The individual seeking to import affirms in writing that it is for the patient s own use and give the name of the U.S. physician caring for them or that the therapy is a continuation of therapy begun by a foreign physician.

Program Excluded Prescriptions Narcotics and any other Controlled Substance as defined by the FDA Antibiotics or other Non Maintenance Medications including Stat Orders Stat Order: Immediate fill and initiation mandatory in Attending Physician s opinion) Biologics include but are not limited to a wide range of medicinal products such as vaccines, blood and blood components, allergenics, somatic cells, gene therapy, tissues and recombinant therapeutic proteins created by biological processes (as opposed to chemical). Drugs where frequent blood levels are required for titration with respect to narrow therapeutic ranges allied with close clinical observation. Drugs that require cold chain custody / refrigeration to preserve therapeutic efficacy, or any other drug that is supplied in a vial or includes hardware such as needles or syringes for administration Any Drug that is the subject of current or future FDA Consumer Safety Alerts or a Department of Homeland Security Alert or Process Change

March 2015 Clinical Pharma- Travel Program Welcome to World Class, Destination Healthcare

Clinical Pharma-Travel Program Pharm Travel is a program designed for individuals to obtain a clinical review and prescribed medical regimens for significantly reduced cost. Patients who want to or need to reduce the cost of their prescription medications patients who require expensive medications for chronic illness and long term treatment. patients who require as needed medications or a one time dose. Initial focus will be MS, Cancer, RA, HIV, Hep C 29

Clinical Pharma-Travel Program 1. Health City has an initial assessment process that qualifies each candidate for the program, and ensures that the medications are available. When potential patients are recognized as a candidate and medications are secured, patients are sent formal invitations for participation. 2. Once accepted into the program the patient travels to HCCI with their U.S. M.D. s issued prescription(s) to meet with an HCCI specialist 3. HCCI specialist reviews the patient s recent lab work and provides consultation, physical exam if required, any additional screening determined necessary to complete the process, collaborates/acknowledges the appropriateness of the medication and provides a 3 month prescription 4. Rx is filled at HCCI and brought back to the U.S. by the patient. 5. The patient travels to HCCI quarterly for subsequent RXs if needed. 30

Clinical Pharma-Travel Program: Hepatitis C Treatment Health City Cayman Islands is a state of the art tertiary care hospital located in the heart of the Caribbean. HCCI believes no one s socio economic status should determine their access to healthcare. In line with this vision and mission, HCCI is now offering the new medical treatment for Chronic active Hepatitis C, at a fraction of the US cost. Pasco School District has had at least 7 members supported by Hep C treatment at a cost of over $400,000 31

Week 1: 2 Night Stay Clinical Pharma-Travel Program: Hepatitis C Treatment 28 Days Later: 1 Night Stay 28 Days Later: 1 Night Stay HEP C Package : $25,000 Package Inclusions: Hotel Stay (5 6 Nights Total $400 USD per night) Air Fare Round Trip (Estimated Max of 1000 per round trip) Drugs, Consultation, and related lab investigations Within 1 Month after completing 12 weeks regime: Final Review: 1 2 Night Stay Does not include cost of treatment for any unrelated diagnosis or complications In the event lab investigations are not conducted at HCCI price of the package will be reduced by $1000 32

Clinical Pharma-Travel Program: Hepatitis C Treatment Traditional PBM Example of 90 days of treatment for Hepatitis C Non Traditional PBM Contract (PCSD Current PBM) $92,000 $62,000 $25,000* Designated Medical Destinations *includes initial assessment and consultation with physician, medication, lab work, hotel, air travel 33

Other Continuing Challenges and Opportunities Moving Forward Increase health risk assessment and wellness program participation further Continue to balance available Health and Wellness Center capacity with employee utilization and demand Further partnerships with other governmental agencies in Pasco (recently partnered with the Pasco Sherriff s Office) Continue to push education of employees about the costs associated with the District s health plan and the impact that healthy choices can have

Any Questions? Kevin Shibley, Esq. Assistant Superintendent for Administration 813 794 2853 kshibley@pasco.k12.fl.us