Employers must offer health insurance to their employees. The requirement is a legal mandate and a competitive necessity.  Healthcare costs continue to rise because complexity and lack of transparency undermine consumerism.  With so much confusion and obfuscation, the healthcare industry delivers unnecessary services and products to consumers who don’t know better and who don’t feel directly the true costs of their healthcare.  Lack of accountability for poor health behaviors and their long-term costs adds fuel to the fire.  What is to be done?

There is no universal remedy for this healthcare dilemma, but there are solutions that can help employers take more control. Take the example of Futura Industries (Clearfield, UT), who in 2007, paid $100.23 per member per month (PMPM) for healthcare (167 empl). Eight years later, Futura’s PMPM cost was $95.70. It’s estimated that they saved $2.5 million during those years, even as their employee patient population aged almost a decade. How did they do it?  With a workplace clinic.

Workplace primary care clinics provide the means of eliminating incentives for unnecessary services, increasing consumerism, and engaging employees in taking more responsibility for long-term health.  Here are three problems a workplace clinic can address and four criteria with which to evaluate onsite clinic options.

High Deductible Health Plans (HDHP) and Health Savings Accounts (HSA)

To control rising costs, employers have used cost-shifting (employees pay more), either through premium-sharing or through HDHP’s.  Limiting benefits and creating narrow networks of providers have also been tried.  HSAs have been widely adopted as a means of blunting these “take-aways” and for trying to foster consumerism, but with limited success.

A major unintended consequence of HDHPs has been the suppression of primary care visits and chronic disease management.  Multiple studies have show that patients, if paying themselves, will just stop going to the doctor.  With the adoption of an HDHP, one study estimated a 10% drop in preventive care and an 18% drop in physician visits, the highest drop occurring in the sickest quartile of patients.[1]  Even services covered at 100% by the plan are only used approximately 18% of the time, as patients fear being charged for additional services that must be paid out-of-pocket. With the cost of healthcare now consuming 23% of take home pay, one can understand why consumers avoid the healthcare system.

Onsite clinics can be offered as a free benefit to employees or at a much reduced cost.  Because the clinic is free or very-low-cost, utilization is high.  Employees’ incentives to go to the doctor are restored.  Employees with chronic conditions, a primary source of healthcare costs, especially benefit themselves and their employer, avoiding more complex health problems down the road.

Reimbursement Incentives

Traditional payment amounts for medical services are established by insurance companies and providers. Anyone with an employer health plan has experienced that, for the same office visit or procedure, there can be wildly different reimbursements based on which provider the patient visits.  When a provider is in vs. out of network, discounts apply so that out-of-network care is much more expensive.

The more extensive an office visit is, the higher the billings and reimbursement.  Providers and care teams are often incentivized to expand the scope of patient visits in order to generate higher fees.  Some providers increase their paychecks by sharing in the overall profits from ancillary tests done within their organization and through hitting certain benchmarks for referred care.  In this environment, is it any wonder that providers may come to see patients as virtual ATMs?  One study calculated, that in a health system, every $1 primary care revenue generates $6 in downstream revenue.[2]

Each of these problems points to a HUGE mal-alignment of incentives between the people paying for services (employers and employees) and healthcare providers.  Workplace clinics change this alignment.  The workplace clinic primary care provider works on a “capitated” basis, not charging or being paid by visit or by procedure, but simply providing all of the primary care needed for the population. This model motivates the provider to focus on preventing care rather than multiplying it, lowering employer costs.  Because of their knowledge, the clinic doctor can advocate for that patient in seeking the lowest-cost, highest quality specialty care.  Workplace clinic providers regularly prevent unnecessary emergency or urgent care visits.

Medical Home and Patient Accountability

Turn-and-burn primary care clinics provide an average visit time of 7.2 minutes.  There is no time for conscientious care, wellness plans, and health “coaching.”  Workplace clinics become a patient’s “medical home” where the primary care provider coordinates all the patient’s healthcare needs.  Proximity and convenience make it simple.  Aligned incentives put the clinic provider in the patient’s corner.  Employer-provided incentives in exchange for free primary care, provide a “soft accountability” for employees to take more responsibility for healthy behaviors.  Wellness programs can be coordinated with or run directly from the clinic so that follow-up doesn’t fall through. Employees become more informed, more health-conscious and cost-conscious through an effective onsite clinic.

If a workplace clinic seems a compelling option to consider, be aware that not all solutions are created equal.  Here are four criteria to consider in evaluating options:

• Capitation – Focuses providers on wellness, disease prevention and early treatment.  Clinic costs will be transparent and predictable.  Any and all clinic revenue will be returned to the employer.

• Independence – The clinic should have no obligations other than to the employer.  Ensure the clinic vendor is not aligned with any health system  incentivized to “feed the beast”-- a hospital, sub-specialists, or ancillary care services.  Such alignments may not be explicit but cannot be easily removed.  Many health systems operate primary care clinics at break-even or loss so that they gain access to all of the costly and profitable downstream care to which employees will surely be referred. 

• Patient Centered Medical Home – Employees need longer visit times and coordinated wellness. The employer should be involved in clinic staffing decisions.  The clinic should have population health analytic tools and be willing and able to process and analyze claims, whether self-funded or fully-insured. Chronic disease management will be an important capability of the clinic provider.

• Physician Led – Look for a supplier who understands the healthcare system, has lived in it and practiced in it.  A company with a clinical paradigm will be more capable of understanding and addressing your employee population’s unique needs.  They will be more successful at finding the right doctor for each company’s culture.

The workplace clinic model works because primary care is the gateway to all healthcare costs and the driver of patient experience.  When the provider is compensated independently of fee structure, they no longer view patients as medical ATM’s but rather as partners for improving health.  Additional benefits observed include improved employee morale, productivity, retention, recruitment, as well as reductions in absenteeism, presenteeism and workers compensation claims.

For health plan consultations, and to learn more about Onsite Care Clinics, wellness programs, near-site clinics and occupational medicine, contact  Bruce Bartholomew, Business Development Officer, bbartholomew@onsitecareclinics.com, 801-206-9443, onsitecareclinics.com.