1. V alue B ased I nsurance D esign and Low Wage Workers April 24, 2008

2. It’s Time for Comprehensive Health Care Reform  The efforts of HCAT to improve the health of our low wage worker members are patches on a dysfunctional system still leaving them underinsured  Employer sponsored coverage falls short for these members and many other Americans  Only through a reform plan that ends the fragmentation in our medical system leading to overuse, misuse and underuse can we begin to match the general health care outcomes and realize similar savings as the other industrialized nations

3. GENERAL INFORMATION  More than half of employees or their dependents have a chronic health condition that will require ongoing care 1 – Chronic illnesses drive approximately 75% of health care costs 2  Wellness is increasingly important in fighting obesity, which is associated with a 35% increase in spending on health care services 4 – Estimates of ROI for obesity wellness programs is up to 1:54  Preventive health screenings continue to play an important role in managing health costs – About ⅓ of diabetics do not know they have the disease 3 – A 10% reduction in cholesterol levels can result in a 30% reduction in the incidence of heart attacks and strokes 5 Sources: 1) Hewitt Associates Research, April, 2008 2) American Medical Association, “Strategies to Address Rising Health Care Costs”, 12/07 3) “Weights and Measures: What Employers Should Know about Obesity”, The Conference Board, 2008 4) Centers for Disease Control and Prevention (CDC), “Preventing Diabetes and Its Complications” 5) Cohen, JD. “A Population Based Approach to Cholesterol Control,” American Journal of Medicine, 1997, as reported by the CDC What We Know

4. SEIU Health Care Access Trust A Taft-Hartley Plan  Set up to take in newly organized low wage workers – Child Care – Home Care – Janitors  Average income before organizing – Janitors and Home Care workers – minimum wage – $6.50 – Child Care Workers – $9.00 to $20.00 per child care day

5. Health Care Access Trust Members OUR MEMBERS’ PROFILE  45 – 48 years old  80 – 90%+ female  Largely Latino, African, African- American, Rural Caucasian  Inconsistent or no previous health care  Multiple untreated chronic diseases  Have learned how to use the ER as their doctor

6. Why There Will Be High Cost in the Future THESE MEMBERS HAVE SERIOUS UNTREATED ILLNESSES  In one bargaining unit 45% of the members surveyed self-identified as having one or more chronic diseases – mostly high blood pressure and diabetes  They are likely to have undiagnosed acute problems such as cancers and serious heart disease  Members tend to have multiple jobs and serious economic strain leading to high stress  Members usually do not have leave to take care of their health without losing income

7. Why Are These Members Low Cost Today?  Employers are unwilling or unable to provide adequate funding for health care: – Little or no money in early contract years – Tend to favor high deductible/high co-insurance plans  Therefore members are at best underinsured  If they have insurance – Cannot afford the co-pays and co-insurances for necessary services – Are constantly afraid of high bills if a doctor finds something wrong

8. Sources: *2006 Center for Disease Control, **UnitedHealth Claims Data, 2007 Opportunity for Greater Engagement THE PARADOX  How much to spend preventing future expenses and how much to spend controlling today’s highest costs? 59% of future high cost population comes from today’s low cost population* 95% 70% Claims Costs ** 20% of Members 5% of Members

9. Recognize you can’t do it all with $175 pmpm Try to get chronic disease treated Make it easy to see the doctor Have at least some drug and diagnostic covered Short change hospitalization and hope you can find community resources to help Our Philosophy

10. Walking the SEIU Talk in Our Own Sponsored Plans IF WE ARE WALKING THE TALK We have to look seriously at evidence-based medicine We have to encourage personal responsibility We have to address chronic disease more creatively We have to realistically address smoking and weight control

11. V alue B ased I nsurance D esign WHY TRY IT?  VBID overlays a quality of life calculation on evidence based medicine  It differentiates copayment rates based on the value of the medical service to the individual and to the system  It drives patients into essential services by eliminating financial barriers to those services – critical to low wage workers

12. University of Michigan Department of Public Health Dr. Mark Fendrick UnitedHealth Care Value Based Insurance Design Team SEIU Locals 1 and 26 Milwaukee and Minneapolis Janitors Respectively Our Partners

13. VBIDVBIDVBIDVBID alue ased nsurance esign Challenges to Implementing VBID for Low Wage Workers  Our members are on limited plans due to financing from employers  Some of our employers do not see it as their responsibility to improve their employees' health or explore new avenues for health care provision  Our members have little or no experience with the health care system  A challenge to insurers even with ASO contracts  Incentives – how do we do that in a Taft-Hartley?

14. OTHERS SEIU HCAT APPROACH Plan design ensures access for targeted clinical services Whole person approach:  Ensure access via plan design  Education and engagement via integrated care/coaching programs  Incentives for success: Healthy actions and outcomes FOCUS Chronic population and Rx costs Encourage prevention and compliance across broad population  Unique strategies for high/low cost populations  Reflects all costs of maintaining health CONSUMER ENGAGEMENT Pharmacy gaps, care management Consumer level – customized communications, retail marketing approach How Is This Different? VBIDVBIDVBIDVBID alue ased nsurance esign

15. Implementing a VBID Plan IDENTIFYING HEALTH ISSUES  Health Risk Assessment  Biometric Screening  Age appropriate physical exams GETTING MEMBERS TO THE RIGHT PROGRAM  Healthy and want to stay that way  Smoking and weight issues  Chronic disease issues  Acute illness VBIDVBIDVBIDVBID alue ased nsurance esign

16. Benefit Design and Incentives  Enrollment Options with additional options for those with identified chronic conditions – Option 1 – Preventive – Option 2 – Weight and/or smoking cessation – Option 3 – Chronic disease control  Eliminate Barriers to Care – to the extent possible zero co-pays for necessary services and drugs  Incentive Plans that are clear and actionable by members – if you do this, you get that VBIDVBIDVBIDVBID alue ased nsurance esign

17. Care and Coaching Programs  Enhancements to existing disease management programs based on voluntary enrollment using incentives  For selection of program option – “best fit” review of care based on Biometric Screening, Health Assessment, prior claims VBIDVBIDVBIDVBID alue ased nsurance esign

18. Value Based Insurance Design THE QUESTIONS WE ARE ASKING  Will the Local leadership be receptive?  How will the members receive these kinds of plans and how do we make them understandable?  Will the employers be willing to work with us on implementing these plans?  How do we implement this kind of plan for workers who have very limited coverage?  Will the insurers we work with be able to administer this kind of program?  Could VBID actually help this population control its chronic disease?

19. PREVENTIVE CARE PROGRAM WELLNESS LIVING WITH CHRONIC DISEASE ACCESS Utilization Data HEALTH LITERACY Survey SELF- EFFICACY Survey OUTCOMES HRA Evaluation of the Program

20. Optimal Results  Positive member experience  More engaged, knowledgeable members  Richer, more effective but still affordable benefits package  Maximize SEIU HCAT’s member and employer health investment

21. What About VBID for Excellent Comprehensive Plans THE BENEFITS  Should reduce acute incidences due to chronic disease – good for the system and the patient  Provides better value for the health care dollar – financial drivers move patients to high value services THE CHALLENGES  Is seen as a reduction in benefits because of added cost to low value services  Requires commitment on the part of employers to having a healthy workforce, not just saving money VBIDVBIDVBIDVBID alue ased nsurance esign

22. Health Care Access Trust