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7789 - Amendment 2 Executed DocuSign Transmittal Coversheet File Name Purchasing Contact Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 Ginny Brummett 7789- Clinic Operations & Management Service-Amendment 2 1 FIRST AMENDMENT TO HEALTH SERVICES AGREEMENT This First Amendment to Health Services Agreement (the "Addendum"), dated as of the latest of the signatures below (the “Effective Date”), is made by and between Marathon Health, LLC and City of Denton, Texas (“Client”). RECITALS WHEREAS, Marathon and Client entered into that certain Health Services Agreement, dated as of March 22, 2022, for certain preventive, wellness, disease management, health consultation, occupational health and/or primary care services (as amended, the "Agreement"); and WHEREAS, the Parties desire to amend the Agreement to modify the performance guarantees applicable to the remainder of the Initial Term of the Agreement, effective as of November 1, 2023. NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, and intending to be legally bound, the Parties agree as follows: 1. Amendment and Restatement of Performance Guarantees. The Parties agree that the Performance Guarantees shall be amended and restated as set forth in Attachment 1 of this Addendum, to be effective beginning November 1, 2023. 2. Miscellaneous. This Amendment is made under and incorporates the terms and conditions of the Agreement. The terms and conditions set forth in this Amendment are in addition to and not in substitution of any terms or conditions set forth in the Agreement. Except as specifically modified by this Amendment, the terms and conditions of the Agreement remain in full force and effect. IN WITNESS WHEREOF, each of the parties hereto has executed this Amendment as of the Effective Date. CITY OF DENTON, TEXAS MARATHON HEALTH, LLC By: By: _____________________________ Name: ___________________________ Name: __________________________ Title: Title: Date: Date: Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 SVP 10/23/2024 Val LeyderGinny Brummett 10/25/2024 Buyer 2 Attachment 1 Performance Guarantees At-Risk Amount. Marathon provides performance guarantees based on achievement of key metrics covering the four dimensions of the optimization of healthcare delivery and overall health of a population (the “Quadruple Aim”). Ten percent (10%) of the aggregate Annual Fees remitted by Client for each 12-month period (“At-Risk Amount”) beginning November 1, 2023 and November 1, 2024 (“Year 2” and “Year 3”, respectively) are “at-risk” until the third anniversary of such Start Date and will be subject to Client credits as detailed below in the event that the following Quadruple Aim metrics are not met, allocated as indicated for each year: Year 2 Year 3 Member Engagement 2.5% 2.5% Member Experience 2.5% 2.5% Health Outcomes 2.5% 2.5% Client Savings 2.5% 2.5% Total At-Risk 10% 10% MEMBER ENGAGEMENT MEMBER ENGAGEMENT Marathon’s Performance Following each of Year 2 and Year 3, Marathon will calculate the Engagement Targets set forth in the table below as indicated in the table. Category Definitions Measurement Engagement Target Utilization Unique eligible employees that have used any of the following services in person or via telephonic or virtual means (“Utilization”): visit with a medical assistant, nurse, health coach (RD, CDE, BHS) or provider; biometric screening; wellness programs (activity, webinar, etc.) Numerator: Unique eligible employees with Utilization during the applicable 12- month period Denominator: Unique eligible employees with at least 6 months eligibility during the applicable 12-month period and eligible at the end of such period 50% Engagement Unique eligible employees that have an appointment with a provider or health coach (RD, CDE, BHS) in person or via telephonic or virtual means (“Appointment”). Numerator: Unique eligible employees having an Appointment Denominator: Unique eligible employees with at least 6-months eligibility during the applicable12-month period and eligible at the end of such period 40% Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 3 High- Chronic Engagement Unique eligible employee who are identified as high-chronic that have an Appointment. Numerator: Unique eligible employees who are identified as high-chronic having an Appointment Denominator: Unique eligible employees who are high-chronic (Marathon Health Proprietary High-Risk Algorithm) with at least 6-months eligibility during the applicable 12-month period and eligible at the end of such period 60% Fee Credits The portion of the At-Risk Amount attributable to Increasing Member Engagement (indicated in the table above) will be credited back to the Client in accordance with the following scale: # of Engagement Targets Met % of At-Risk Amount 2 of 3 0% credited to Client 1 of 3 50% credited to Client 0 of 3 100% credited to Client MEMBER EXPERIENCE Marathon’s Performance Following each of Year 2 and Year 3, Marathon will calculate the Experience Targets set forth in the table below as indicated in the table. Category Definitions Measurement Experience Target Patient Satisfaction % of survey respondents who indicated they were 'satisfied' or 'very satisfied' with Marathon Health in patient satisfaction surveys with a 5-point response scale - satisfied, very satisfied, neutral, dissatisfied, and very dissatisfied Respondents who indicated they were 'satisfied' or 'very satisfied' – minimum sample size of 50 responses 90% Net Promoter Score (NPS) Survey respondents on a scale of 0-10 answering the question – how likely is it that you would recommend Marathon Health to your friends, family or business associates NPS calculation – minimum sample size of 50 responses 70 Repeat Patient Utilization Rate Repeat employee Utilization Numerator: Unique eligible employees who had at least two instances of Utilization during a 12-month period Denominator: Unique eligible employees who had at least one instance of Utilization, with at least 6-months eligibility during the applicable 12-month period and eligible at the end of such period 50% Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 4 Fee Credits The portion of the At-Risk Amount attributable to Member Experience (indicated in the table above) will be credited back to the Client in accordance with the following scale: # of Experience Targets Met % of At-Risk Amount 2 of 3 0% credited to Client 1 of 3 50% credited to Client 0 of 3 100% credited to Client HEALTH OUTCOMES Marathon’s Performance Following each of Year 2 and Year 3, Marathon will calculate the measurements indicated in the table below for Members with at least 6 months of eligibility during the applicable 12-month period who have had at least one preventive provider visit during such period (note exception for mental health screening which requires a physical or comprehensive health review). Measurement targets are set based on attainment of the HEDIS 67th and 75th percentiles Years 2-3 where applicable. Where no HEDIS benchmark applies, target is based on internal benchmarks. The minimum sample size for inclusion of a metric is 20 members. In the event one or more metrics are not included in the total points calculation due to insufficient sample size, the total achievable points for such year shall be decreased by the number of excluded categories and the target points pro-rated accordingly. Category Guidelines Class Measurement Targets Years 2-3 Weighting Top Cost Drivers Cancer Breast Cancer Screening (Mammogram) Adult Preventive Care Guidelines Measure identifies women 50 through 74 years of age during the reporting period who had a mammogram to screen for breast cancer within the past 24 months, with a 3 month grace period HEDIS® 67th/75th percentiles 0.33 Cervical Cancer Screening 21-64 Adult Preventive Care Guidelines Measure identifies female patients 21 through 64 years of age who have had a cervical cancer screening – look-back period varies with test type HEDIS 67th/75th percentiles 0.33 Colorectal Cancer Screening Adult Preventive Care Guidelines Measure identifies patients 45 through 75 years of age who received a colorectal cancer screening – look-back period varies with test type HEDIS 67th/75th percentiles 0.33 Circulatory BP Control (140/90) Adult Preventive Care Guidelines Measure identifies patients 18 years of age and older whose most recent blood pressure is less than 140/90 (within the past 12 months) HEDIS 67th/75th percentiles 0.50 Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 5 TC : HDL Ratio – Improvement of High / Very High Risk Adult Preventive Care Guidelines Percent of patients who are high or very high risk for TC : HDL ratio who had two measurements and were eligible for at least 75% of the measurement period and improved to a lower risk category 30% / 35% 0.50 Key Comorbidities / Risk Factors Mental Health Screening for clinical depression and follow-up Adult Preventive Care Guidelines Measure identifies patients 12 years of age and older who have been screened for clinical depression using a standardized depression screening tool, and it positive, a follow-up plan is documented. Pertains to patients with an annual physical or comprehensive health review. 60% / 70% 1.00 Diabetes Percent at SOC – at least 5 of 8 met 70% / 75% 1.00 BP Control in Diabetes (140/90) Diabetes Guidelines Measure identifies patients 18 years of age or older with diabetes whose most recent blood pressure is less than 140/90 HbA1c Process (1x year) Diabetes Guidelines Measure identifies patients 18 years of age or older with diabetes who have had a hemoglobin A1c screening HbA1c Control <8% Diabetes Guidelines Measure identifies patients 18 years of age or older with diabetes whose most recent hemoglobin A1c value is less than 8% Statin Use Diabetes Guidelines Measure identifies patients 40 through 75 years of age with diabetes who have an active statin prescription Comprehensive Diabetic Foot Exam Diabetes Guidelines Measure identifies patients 18 years of age or older with diabetes who received a diabetic foot exam Lipid Control (less than 100) Diabetes Guidelines Measure identifies patients 18 years of age or older with diabetes whose most recent LDL-C value is less than 100 mg/dl Nephropathy Screening Diabetes Guidelines Measure identifies patients 18 years of age or older with diabetes who have had a nephropathy screening or evidence of nephropathy Pneumonia Vaccination Diabetes Guidelines Measure identifies patients 18 years of age or older with diabetes who received 23-Valent Pneumococcal Polysaccharide Vaccine Tobacco Cessation Tobacco Cessation Counseling Adult Preventive Care Guidelines Measure identifies patients 18 years of age or older who are identified as current tobacco users and received tobacco cessation counseling or therapy HEDIS 67th/75th percentiles 1.00 The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA. Marathon may update guidelines within the clinical areas above to remain current with evolving care standards. Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 6 Annual Fee Credits The portion of the At-Risk Amount attributable to Health Outcomes (indicated in the table above) will be credited back to the Client in accordance with the following scale: # of Points Achieved % of At-Risk Amount < 2 100% credited to Client 2.0-2.99 75% credited to Client 3.0-3.99 50% credited to Client 4.0-5.00 No refund CLIENT SAVINGS Marathon’s Performance The portion of At-Risk Amount attributable to Client Savings will be credited back to the Client in accordance with the following scale: Year 2 Year 3 Scoring Achievement of Net ROI 1.5 : 1.0 2.0 : 1.0 >90 & <100% of target = 25% refund >75 & <90% of target = 50% refund <75% of target = 100% refund Calculation Methodology: • Client’s expected medical and Rx plan paid PMPM claims costs for November 1, 2022 through October 31, 2023 (“Year 1”) for the eligible population, excluding high-cost claimants of $100,000 or above, are calculated using a 7% medical inflation rate and 11% Rx inflation rate • Expected Year 2 PMPM costs are computed by increasing expected Year 1 costs by 7% for medical inflation and 11% for Rx inflation • Expected Year 3 PMPM costs are computed by increasing expected Year 2 costs by 7% for medical inflation and 11% for Rx inflation • Gross savings is calculated by comparing actual plan paid spend to projected spend as illustrated below • ROI is calculated by dividing grossing savings by the annual service fee; the resulting ratio must meet or exceed targets above Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 7 Average Enrolled Pop.PMPM Excl. Outliers > $100K Total Plan Paid Excl. Outliers Baseline 2,000 300.00$ 7,200,000$ Comparison Trend - 7% Inflation 2,000 321.00$ 7,704,000$ Actual Plan Paid - Measurement Year 2,000 286.00$ 6,864,000$ Actual vs. Comparison Trend (Gross Savings)(840,000)$ Marathon Health Annual Service Fee 500,000$ Est. Savings : Cost Ratio (ROI)1.68 Cost Savings Calculation Illustration • Claims and plan eligibility data must be received in the format and within the timeframe specified in this Agreement to complete this analysis • Unforeseen macro-economic events may require an adjustment of the comparison trend and the Parties will negotiate such adjustments in good faith if such unforeseen events occur. Requirements of Client Notwithstanding the above, if the following requirements are not met during a given year for the indicated dimension, then no fee credit will be due to the Client for that dimension for such year: Member Engagement: 1. A minimum of 40% of the eligible employee population must participate in a biometric screening or annual physical during each contract year. If an outside vendor is utilized for biometric screening, Client will ensure that the patient data is provided to Marathon. 2. For use of the health center, if Client requires high co-payments (>$50), limits employee access during work hours, locates the health center offsite, or has other significant restrictions on health center use, then a minimum of 50% of the eligible population must have at least one provider visit in the health center during each contract year. 3. Client must utilize Marathon branded or co-branded material in the development and execution of member communications as described in Exhibit B. 4. Client must provide an employee incentive of $250-$500 or more which promotes Utilization of the health center. Client Savings: Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 8 1. Client must provide information on PMPM medical and pharmacy claims cost and high-cost claimants of $100,000 or above for at least the last 2 years immediately preceding Year 1 of the Agreement. 2. Client must provide the expected PMPM medical and pharmacy claims cost, net of and high-cost claimants of $100,000 or above, for Year 1, reflective of the impact of any health plan design changes for that year. 3. Client must provide information on PMPM medical and pharmacy claims cost and high-cost claimants of $100,000 or above within 90 days of the end of each contract year. 4. The medical claims, pharmacy claims and membership data referred to in Section 6.6 and Section 6.7 of the Agreement must be received as scheduled. 5. Client must have named an Executive Sponsor for the health center. Results Summary Annual results will be calculated following 90 days of claims run-out with final results available within 180 days. Categories % of Fee at Risk Results Member Engagement 25% 2 of 3 met = no refund Member Experience 25% 2 of 3 met = no refund Health Outcomes 25% 4.0 – 5.00 met = no refund Client Savings 25% 100% of target = no refund Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 CONFLICT OF INTEREST QUESTIONNAIRE CONFLICT OF INTEREST QUESTIONNAIRE - FORM CIQ For vendor or other person doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local government entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. 2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information in this section is being disclosed. Name of Officer This section, (item 3 including subparts A, B, C & D), must be completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor? Yes No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity? Yes No C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership of one percent or more? Yes No D. Describe each employment or business and family relationship with the local government officer named in this section. 4 I have no Conflict of Interest to disclose. 5 Signature of vendor doing business with the governmental entity Date Docusign Envelope ID: D3D006EF-FE38-44C9-B64F-D56F0D55FE27 Marathon Health, LLC 10/23/2024 Valerie Leyder Certificate Of Completion Envelope Id: D3D006EFFE3844C9B64FD56F0D55FE27 Status: Completed Subject: ***Purchasing Approval***7789- Clinic Operations & Management Service-Amendment 2 Source Envelope: Document Pages: 10 Signatures: 3 Envelope Originator: Certificate Pages: 6 Initials: 3 Ginny Brummett AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-06:00) Central Time (US & Canada) 901B Texas Street Denton, TX 76209 Ginny.Brummett@cityofdenton.com IP Address: 198.49.140.10 Record Tracking Status: Original 10/22/2024 11:35:18 AM Holder: Ginny Brummett Ginny.Brummett@cityofdenton.com Location: DocuSign Signer Events Signature Timestamp Ginny Brummett ginny.brummett@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Completed Using IP Address: 198.49.140.10 Sent: 10/22/2024 11:38:23 AM Viewed: 10/22/2024 11:38:33 AM Signed: 10/22/2024 11:38:39 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign Lori Hewell lori.hewell@cityofdenton.com Purchasing Manager City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 10/22/2024 11:38:41 AM Viewed: 10/22/2024 11:59:48 AM Signed: 10/22/2024 1:39:15 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign Marcella Lunn marcella.lunn@cityofdenton.com Senior Deputy City Attorney City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 10/22/2024 1:39:17 PM Viewed: 10/22/2024 6:56:59 PM Signed: 10/22/2024 6:59:35 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign Val Leyder valerie.leyder@marathon.health Sr Vice President Security Level: Email, Account Authentication (None)Signature Adoption: Drawn on Device Using IP Address: 174.195.115.32 Sent: 10/22/2024 6:59:37 PM Viewed: 10/23/2024 4:55:12 PM Signed: 10/23/2024 4:55:37 PM Electronic Record and Signature Disclosure: Accepted: 10/23/2024 4:55:12 PM ID: 22b29b44-6dcf-4714-bc3b-6b21d861c809 Signer Events Signature Timestamp Megan Gilbreath Megan.Gilbreath@cityofdenton.com HR Director City of Denton - Human Resources Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.104 Sent: 10/23/2024 4:55:40 PM Resent: 10/24/2024 4:59:01 PM Resent: 10/25/2024 11:44:32 AM Viewed: 10/25/2024 1:07:06 PM Signed: 10/25/2024 1:07:10 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign Ginny Brummett ginny.brummett@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.104 Sent: 10/25/2024 1:07:13 PM Viewed: 10/25/2024 1:09:05 PM Signed: 10/25/2024 1:09:16 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Cheyenne Defee cheyenne.defee@cityofdenton.com Procurement Administration Supervisor City of Denton Security Level: Email, Account Authentication (None) Sent: 10/25/2024 1:09:18 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign Misty Hambright misty.hambright@cityofdenton.com Total Rewards Manager City of Denton Security Level: Email, Account Authentication (None) Sent: 10/25/2024 1:09:19 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 10/22/2024 11:38:23 AM Envelope Updated Security Checked 10/24/2024 4:58:50 PM Certified Delivered Security Checked 10/25/2024 1:09:05 PM Signing Complete Security Checked 10/25/2024 1:09:16 PM Envelope Summary Events Status Timestamps Completed Security Checked 10/25/2024 1:09:19 PM Payment Events Status Timestamps Electronic Record and Signature Disclosure ELECTRONIC RECORD AND SIGNATURE DISCLOSURE From time to time, City of Denton (we, us or Company) may be required by law to provide to you certain written notices or disclosures. 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