Piece of Work

The workplace can double as a medical home, say advocates of worksite clinics

Healthcare today is being delivered in many sites other than the hospital, as Journal of Healthcare Contracting readers are well aware. Add the workplace – office building, factory, etc. – to the list.

Work is where people congregate during the day. They spend many of their waking hours there, they interact with the same group of people, day after day. Work is where bad health habits can fester – and where good ones can be nurtured and spread. So why not bring healthcare there?

The case for worksite clinics is strong, according to advocates. The employer wins, with increased productivity, reduced absenteeism, quicker return to work for employees, etc. And the patient wins too, as healthcare providers – doctors, nurse practitioners, physician assistants and others – work with employees to coach them on better health.

“We use illness to find wellness,” says Edward Schwartz, M.D., chief medical officer, CIGNA Onsite Health. An employee who comes in with a sore throat may get asked about his or her sleep habits, eating habits, etc. “We’re trying to go back to a holistic delivery system.

“Seventy to 80 percent of chronic conditions are lifestyle-related,” he says. “[Worksite clinics] offer a huge opportunity to not only prevent, but to sometimes reverse [chronic conditions]. It’s a fascinating dynamic.”

Market’s growing
“Demand is exploding right now,” says Stuart Clark, president, CHS Commercial Services, Reston, Va., which operates about a hundred worksite health centers. The company responded to 35 requests-for-proposal in 2009, and 58 in 2010. As of May of this year, CHS had already responded to 25. “Ten years ago, there were seven competitors; today, there are 35.” Private equity firms, health plans, healthcare providers and others are entering the market.

In February 2010, CIGNA Onsite Health – then just two years old – acquired Kronos Optimal Health to expand its worksite program, says Schwartz. “We had developed our own biometric testing capabilities, but we never realized how successful we were going to be. And we didn’t have the ability to provide services to everyone who was asking.” Based in Phoenix, Kronos focused on lifestyle management programs, face-to-face coaching, biometric screenings and health education programs.

Thirty-one percent of large employers offer a medical clinic at or near their workplace, according to a 2009 Mercer employer study. While most still use such clinics for occupational health services (which is where many got their start), 11 percent of large employers provide a clinic for primary care services and 10 percent of all employers surveyed are considering offering a primary care clinic this year. The Midwest Business Group on Health reports that 62 percent of workers are interested in their company offering onsite medical clinics to better manage their health, according to recent employee focus-group research.
In most cases, employers that are self-insured express the strongest interest in worksite clinics. They typically have a thousand employees or more in any one geographical region. However, smaller employers are banding together to create “near-site” clinics to serve their collective employees.

What’s driving them?
Healthcare reform is one factor driving interest in worksite clinics, says Patricia Berger-Friedman, senior consultant, Towers Watson, a New York-based benefits-consulting and financial management firm. With an estimated 30 million formerly uninsured people anticipated to gain access to care, employers are concerned that their employees and families may lack access to good medical care when they need it, she says. Another driving force is the employer’s desire to make itself an employer of choice as well as an employer known for creating an atmosphere in which wellness and health is promoted.

Start-up costs can be substantial, depending on the scope of services offered. And it is unrealistic to expect that once the clinic is opened, employees will embrace it. In fact, they may be suspicious of the employer’s motives, according to a December 2010 report by the Center for Studying Health System Change.

“This tends to be an issue particularly when there has been a history of adversarial relationships between management and labor.” Employees may fear that their personal medical information will be shared with their employer and have negative consequences. “Experts emphasized that employers need to expect these concerns and work with vendors to ensure that the handling of confidential employee data fully complies with federal and other regulations, and then communicate clearly with employees about these protections,” according to the study.

The players
Employers considering workplace clinics have three options: They can hire a third-party vendor (e.g., CHS, Take Care Health, CIGNA Onsite Health) to set up, staff and operate the clinic; they can contract with a local hospital system to do so; or they can do it themselves.

Most employers outsource clinic operations through so-called turnkey operations. But a few, including Sussex, Wis.-based Quad/Graphics and Chicago-based Boeing, have grown their own clinics. A few companies (such as Quad/Graphics) have gotten so good at running their clinics, they have launched clinic businesses of their own.

Aurora Health Care in Milwaukee, Wis., had attempted to set up and operate worksite primary care clinics for local employers, says Mary Jo Capodice, DO, MPH, medical director, occupational health and wellness. It no longer does that, but the IDN does place caregivers onsite to help employers enhance the health of their workers, to help control workers compensation costs, and to control short-term disability claims. In addition, Aurora creates what Capodice calls “virtual clinics” for employers. Physicians and mid-level providers from a nearby Aurora clinic are assigned to a particular employer. They get to know the employer and employees. And while they continue to see other patients, they become the company’s primary care provider.

The promise
One of the most promising aspects of worksite clinics is their potential to transform the delivery of wellness, disease management and primary care by developing a relationship between the patient and the trusted clinician, who may be a primary care physician or other health provider, according to the Center for Studying Health System Change. Through longer, more frequent face-to-face encounters that emphasize holistic rather than acute, episodic care, this model distinguishes itself from most community-based care.

“We remove barriers,” says Schwartz. “We’re convenient, because we’re at the employer’s location. We’re usually very affordable – in most cases, free, or [available to the employee] for a small co-pay. And we’re adding the quality element.

“Everybody wants to be healthy, look good, feel good,” adds Schwartz. “But people need someone to guide them, to be the cheerleader and trusted advisor.” Patients get individual attention over a prolonged period of time, something they can’t get from other healthcare providers. “And we try to change the culture of the group, focusing on lifestyle changes and wellness,” he says.

“About a third to a half of the workforce – especially males – do not visit a primary care doctor on a regular basis,” says Clark. This is particularly true among young people. “While we say we are there to support the family doctor in the community, the reality is, we become the family doctor for them.” The role of the worksite clinic becomes even more crucial as the workforce ages, he continues.

Over the last five to seven years, worksite clinics have emerged as coordinators of the employer’s overall healthcare strategy for their workers, he says. Clinic staff members can help coordinate the employee’s care among community-based doctors and specialists, and they can direct employees to employer-sponsored wellness plans, health-risk-assessment programs, etc.

The long-term presence of the worksite clinic doctors, nurse practitioners or physician assistants, and their familiarity with employees is the key to improved health, says Clark. “The healthcare industry has not provided a real solution to changing patient behavior over the long term,” he says. Even financial incentives have failed to work. “There has to be enough time spent with the patient so he or she understands what it takes to change [their behavior].”

“We find that our clinicians spend two to three times the amount of time with each patient that you would normally see in the community,” says Gabe Weissman, spokesman for Walgreens and its Take Care Health Employer Solutions business. The business offers worksite occupational health, primary care, pharmacy, fitness and health promotion services.

In the Take Care model, the employer pays the company to set up the center and to staff it. “So no longer is that clinician saying, ‘In order to meet my numbers, I have to drive 25 patients a day,’” says Weissman. “We’re saying, the way to showcase [the employer’s] investment in the clinic is to produce the best outcomes. That creates a situation where coaching can take place. So the patient visits the clinic for strep throat, and while they’re there, the [provider] says, ‘I notice your blood pressure is 135 over 90; let’s talk about that.’ All those conversations are more likely to happen because of the way reimbursement is driven.”

Supply chain considerations
Worksite clinics are becoming more sophisticated in the care they provide. “Among our client population over the past two years, we’ve seen a 25 percent increase in the number of clients offering full primary care services, vs. the legacy of occupational health,” says Weissman.

Adds Clark, “We can provide 300 different treatments that we feel fall within the clinical scope of a physician.” In fact, CHS has 300 evidence-based clinical guidelines and treatments for physicians to follow. In clinics without MDs, that number drops a bit.

In the end, though, the care provided is at the discretion of the employer. An employer whose people travel extensively might need an expert in travel medicine (vaccines, etc.), for example, while another might need little more than a small office in the corporate center staffed by a nurse practitioner, says Weissman. “Some of our largest sites have radiology and lab onsite,” he says. But those support very large populations, that is, as many as 15,000 to 20,000 people.

Just as each clinic is tailored to the specific employer, so too do their supply chain needs differ. “If they’re seeing patients, you’ll see things like otoscopes, stethoscopes, bandages, etc.,” says Capodice. “It runs the gamut of supplies.” But if the caregivers at the clinic are primarily coordinating employees’ care with other providers, the clinic might need little more than pen, paper and a computer.

“Typically, they’ll run some waived tests, then send out the rest,” says Berger-Friedman. They might have basic imaging equipment, such as X-ray units, particularly in clinics that support workers compensation programs and occupational health.

Employers who run their own sites may purchase their own supplies and equipment, according to experts. But those who outsource their sites tend to leave purchasing to the vendor. “We’re a huge buyer of medical supplies and equipment,” says Clark. “It’s all done through headquarters.”

What’s ahead
Healthcare reform or no healthcare reform, operators of worksite clinics believe they have a bright future ahead of them. “Large, self-insured employers will still be on the hook” to provide care for their employees, says Clark. Worksite clinics can help them do so efficiently and affordably.

“We are as busy as all can be, because there’s a realization that healthcare expenditures are continuing to go up,” says Schwartz. “Employers are saying, ‘If we do nothing to change the delivery system to our employees, we know healthcare will be more expensive year over year.’

“It’s a time that’s ripe for innovation. And employers are the best place to start.”