Com­pany doc­tor­ing

More em­ploy­ers of­fer on-site clin­ics to re­duce work­ers’ health costs

Modern Healthcare - - NEWS - By David Royse

Laitram Ma­chin­ery, the world’s largest man­u­fac­turer of shrimp-peel­ing ma­chines, sits along the Mis­sis­sippi River un­der the Huey P. Long Bridge, just out­side of New Or­leans. It’s a suit­able lo­ca­tion for a com­pany as­so­ci­ated with a food prod­uct that’s cen­tral to southern Louisiana’s cel­e­brated Cre­ole and Ca­jun cui­sine.

But there’s a health down­side to that rich cul­ture. “In New Or­leans, you can find ways to not eat well and not drink well,” said Franck LaBiche, the com­pany’s hu­man re­sources di­rec­tor.

Let­ting les bons temps rouler­wasn’t just bad for the com­pany’s work­ers. It also was rough on its fi­nances. “We were look­ing at a monthly health­care pre­mium curve for employees that showed a 40% in­crease over six years,” said LaBiche, whose com­pany has a self-in­sured health plan.

One con­cern for em­ploy­ers open­ing on-site clin­ics, par­tic­u­larly in smaller com­mu­ni­ties, is up­set­ting in­de­pen­dent physi­cians and other providers in the com­mu­nity who may worry about los­ing pa­tients to work­site providers.

In 2012, Laitram joined a grow­ing list of large U.S. em­ploy­ers that have opened on-site health clin­ics in an ef­fort to con­trol the ris­ing costs of their health ben­e­fit pro­grams. Nearly 30% of com­pa­nies with more than 5,000 work­ers now have on-site or near-site clin­ics offering some type of pri­mary care, up from 24% in 2013, ac­cord­ing to a sur­vey this year by ben­e­fits con­sul­tant Mercer. In ad­di­tion to serv­ing employees, some clin­ics also treat work­ers’ fam­i­lies. Many of th­ese fa­cil­i­ties in­clude fit­ness cen­ters with ex­er­cise equip­ment. Th­ese ser­vices of­ten are pro­vided with­out charge to employees.

This has pro­duced a growth mar­ket for com­pa­nies that op­er­ate clin­ics for emp loy­ers, in­clud­ing Health­stat, Marathon Health, Premise Health, and QuadMed. Health sys­tems also have jumped into the mar­ket, op­er­at­ing about 18% of work­site clin­ics, ac­cord­ing to ben­e­fits con­sul­tant Tow­ers Watson, which sur­veyed firms with clin­ics this year. Down­ers Grove, Ill.based Ad­vo­cate Med­i­cal Group has a di­vi­sion called Ad­vo­cate at Work that op­er­ates work­site clin­ics for about 120 com­pa­nies, in­clud­ing fi­nan­cial ser­vices firm North­ern Trust and the Chicago Tri­bune.

“Be­ing the largest in­te­grated de­liv­ery sys­tem in the area, it was a nat­u­ral fit for us to fig­ure out how to lever­age our ex­per­tise for the ben­e­fit of th­ese com­pa­nies,” said Dr. Pren­tiss Tay­lor Jr., Ad­vo­cate At Work’s cor­po­rate med­i­cal di­rec­tor.

Ac­cord­ing to Tow­ers Watson, 64% of em­ploy­ers with an on-site clinic con­tract the work to a ven­dor, while 23% are op­er­ated di­rectly by the em­ployer.

Em­ploy­ers say th­ese clin­ics pro­vide pri­mary and pre­ven­tive care, and en­cour­age ex­er­cise, thus keep­ing work­ers health­ier, re­duc­ing ab­sen­teeism and cut­ting ben­e­fit costs. They say the on-site cen­ters re­duce the amount of time work­ers spend away from work vis­it­ing off-site health­care providers. In ad­di­tion, the cen­ters can help com­pa­nies iden­tify oc­cu­pa­tional health and safety risks, such as poorly de­signed work­sta­tions that re­sult in back and neck prob­lems.

Be­cause they be­lieve in the cost-saving po­ten­tial of on­site clin­ics, many em­ploy­ers plan to con­tinue in­vest­ing in them even though the cost will likely be in­cluded in calcu- lat­ing the Af­ford­able Care Act’s Cadil­lac tax on high-value health plans start­ing in 2018. Ear­lier this year, the In­ter­nal Rev­enue Ser­vice said spend­ing on on-site clin­ics would be con­sid­ered in the tax cal­cu­la­tion un­less the clin­ics of­fered only “de min­imis” care.

Two-thirds of large em­ploy­ers with on-site health fa­cil­i­ties say they plan to ex­pand such fa­cil­i­ties, ac­cord­ing to the Tow­ers Watson sur­vey. “That’s val­i­da­tion of their be­lief that the clin­ics are re­duc­ing cost,” said Al­lan Khoury, se­nior health man­age­ment con­sul­tant at Tow­ers Watson.

But Vi­vian Ho, a Bay­lor Univer­sity health econ­o­mist, ques­tioned whether th­ese clin­ics will yield sig­nif­i­cant cost sav­ings. The employees most likely to use the clin­ics are those who al­ready are the most health con­scious, while the un­health­i­est and most ex­pen­sive employees will still be un­likely to get needed pre­ven­tive care, she said. Be­yond that, the pay­off from pre­ven­tive medicine of­ten comes years later, per­haps af­ter the employees have left the com­pany.

In ad­di­tion, she said employees may be re­luc­tant to use work­place clin­ics be­cause of con­cerns about pri­vacy. Many employees al­ready fear their em­ploy­ers will use their health in­for­ma­tion against them. “I think th­ese are le­git­i­mate wor­ries,” she said.

Work­place clin­ics are ac­tu­ally an old con­cept. Decades ago, some in­dus­tries with high oc­cu­pa­tional in­jury rates em­ployed com­pany doc­tors and nurses to treat work­ers. Kaiser Per­ma­nente grew out of em­ploy­er­spon­sored clin­ics to pro­vide care for work­ers in ship­yards and steel mills be­fore World War II.

In more re­cent years, ris­ing costs have prompted em­ploy­ers to look be­yond tra­di­tional oc­cu­pa­tional health to of­fer broader pri­mary care for of­fice and in­dus­trial work­ers, said Larry Boress, ex­ec­u­tive di­rec­tor of the Na­tional As­so­ci­a­tion of Work­site Health Cen­ters and CEO of the Mid­west Busi­ness Group on Health.

Th­ese newer em­ployer-spon­sored clin­ics typ­i­cally have nurse prac­ti­tion­ers or physi­cian as­sis­tants on staff, though some also have full-time or part-time physi­cians. Some fea­ture spe­cialty providers such as phys­i­cal ther­a­pists and nu­tri­tion­ists. About half of­fer phar­macy ser­vice. The on­site health clinic at Face­book’s cor­po­rate head­quar­ters in Menlo Park, Calif., has a chi­ro­prac­tor. Many also in­clude fit­ness cen­ters.

The scope of ser­vices of­fered varies, with most offering at least ur­gent care but many pro­vid­ing broader ser­vices. Many of­fer flu shots, and some can even take X-rays. Some of­fer healthy cook­ing classes. United Air­lines, which has

clin­ics for its employees at air­ports in Chicago, Hous­ton and Newark, has doc­tors and phys­i­cal ther­a­pists at each, in ad­di­tion to nurse prac­ti­tion­ers and physi­cian as­sis­tants.

For some employees, the on-site clin­ics may pro­vide their only reg­u­lar health­care. For work­ers who do have a reg­u­lar provider, em­ploy­ers want the work­place clinic to com­ple­ment rather than re­place those providers. At Laitram, for ex­am­ple, employees can sign a con­sent form al­low­ing the on-site clinic to share med­i­cal records with out­side clin­i­cians.

One con­cern for em­ploy­ers open­ing on-site clin­ics, par­tic­u­larly in smaller com­mu­ni­ties, is up­set­ting in­de­pen­dent physi­cians and other providers in the com­mu­nity who may worry about los­ing pa­tients to work­site providers. But Boress said 40% to 60% of peo­ple who go to on-site clin­ics don’t have a per­sonal doc­tor. Laitram’s LaBiche said that the com­pany clinic some­times sends pa­tients to a lo­cal health sys­tem with which it has an agree­ment, and that the sys­tem may end up get­ting more pa­tients.

Some clin­ics, such as Laitram’s, pro­vide ser­vices with­out charge to employees cov­ered by the com­pany’s health plan. Those who aren’t cov­ered pay a fee. Some­times the fit­ness cen­ters also are free, though some charge a small mem­ber­ship fee on the be­lief that peo­ple who pay for a gym mem­ber­ship are more likely to use it.

LaBiche said the com­pany’s health clinic, op­er­ated by Wi­nooski, Vt.-based Marathon Health, and its fit­ness and nu­tri­tion cen­ter, run by LifeS­tart Well­ness Net­work, are im­prov­ing em­ployee health and re­duc­ing the com­pany’s health ben­e­fit costs. Em­ployee vis­its to hos­pi­tal emer­gency rooms have dropped 26% since 2010, and nearly 8 in 10 work­ers have seen im­prove­ment on at least one mea­sure of health, such as blood pres­sure, choles­terol or body fat per­cent­age, he said. The com­pany’s health ben­e­fit costs were flat be­tween 2012 and 2014, though they in­creased about 5% this year.

Still, there’s not much hard data on re­turn on in­vest­ment for em­ploy­ers, aside from anec­do­tal in­for­ma­tion from com­pa­nies such as Laitram. Tow­ers Watson’s sur­vey found that more em­ploy­ers are now mea­sur­ing ROI, though only 12% have com­mis­sioned in­de­pen­dent analy­ses. Khoury said the ACA’s Cadil­lac tax will force em­ploy­ers to take a harder fi­nan­cial look at the clin­ics. “The ex­cise tax will put a lot of fo­cus on whether they ac­tu­ally are re­duc­ing cost,” he said.

Ad­vo­cates of work­place clin­ics say they can be use­ful in im­prov­ing oc­cu­pa­tional health and safety for a com­pany’s work­force. If a sig­nif­i­cant num­ber of work­ers are re­port­ing back and neck pain, the com­pany can con­duct an er­gonomics as­sess­ment of employees’ desk and seat­ing ar­range­ments and make mod­i­fi­ca­tions, said Daniel Lord, a chi­ro­prac­tor who heads phys­i­cal medicine at Face­book’s health cen­ter.

United Air­lines uses data on the types of in­juries the clin­ics are treat­ing to spot trends and im­prove its safety train­ing. “We can see what body parts to fo­cus on out on the ramp,” said Terry Wer­ber, the air­line’s man­ager for the on-site clin­ics.

More than a dozen com­pa­nies have started work­site clin­ics for em­ploy­ers. Marathon Health now op­er­ates 140 on-site clin­ics in 38 states. An­other large firm in this niche is Brent­wood, Tenn.-based Premise Health, cre­ated last year by the merger of Wal­greens’ Take Care Em­ployer So­lu­tions di­vi­sion and CHS Health Ser­vices. It op­er­ates more than 500 on-site health clin­ics, phar­ma­cies and fit- ness cen­ters in 46 states. Char­lotte, N.C.-based Health­stat has more than 300 fa­cil­i­ties in 32 states. An­other com­pany, Sus­sex, Wis.-based QuadMed, runs more than 100 clin­ics in 20 states.

Hos­pi­tals and health sys­tems have taken no­tice of the in­dus­try’s growth and have launched ini­tia­tives. Ad­vo­cate Med­i­cal Group’s Ad­vo­cate at Work op­er­ates work­site clin­ics for about 120 com­pa­nies, and serves the 32,000 employees of its par­ent com­pany, Ad­vo­cate Health Care. Tay­lor said be­ing part of a large health sys­tem such as Ad­vo­cate ex­tends the value of the clinic, be­cause it can help pa­tients nav­i­gate the broader health­care maze, in­clud­ing spe­cial­ist re­fer­rals. “We in­ter­act with the en­tire health­care sys­tem for the ben­e­fit of the em­ployee,” he said.

One worker who at­tests to the value of an on-site clinic is Gregg Schenck, an in­for­ma­tion tech­nol­ogy de­vel­oper at Laitram. He said hav­ing the health­care providers and fit­ness and nu­tri­tion spe­cial­ists at his work­place and get­ting to know them made it eas­ier for him to seek care.

Schenck weighed 350 pounds when he went in for a health con­sul­ta­tion and a weight-loss pro­gram. He worked with staff at the fit­ness cen­ter, which he started us­ing reg­u­larly since it was so con­ve­nient. He was mo­ti­vated by the sup­port of co-work­ers, who praised his progress as he lost 110 pounds.

“The doc­tor has taken me off the diabetes med­i­ca­tion, the acid re­flux has gone away, and my blood pres­sure has come down,” Schenck said. “I really see it as a saving grace.”

“The doc­tor has taken me off the diabetes med­i­ca­tion, the acid re­flux has gone away, and my blood pres­sure has come down. I really see it as a saving grace.” Gregg Schenck, an in­for­ma­tion tech­nol­ogy de­vel­oper at Laitram

Laitram Ma­chin­ery’s on-site health­care providers and fit­ness staff in­clude, from left, Nina Davis, med­i­cal as­sis­tant; nurse prac­ti­tion­ers Emily Davis and Anna Bruno; Kristin King, reg­is­tered di­eti­tian and health coach; Christina Franko, per­sonal trainer; and fit­ness di­rec­tor Pa­trick Holmes.

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