Tuesday, February 23, 2016

Employer-Sponsored Comprehensive Primary Care

Patients need doctors that take time to listen which means a limited number of patients under care. Employers need programs that reduce costs and ideally improve the health of their staff. These apparently disparate needs can come together in a new model for effective company-sponsored primary care programs.

Those of you who have followed this series know that I am an advocate for PCPs finding ways to have a smaller patient panel so that each patient can receive more time for comprehensive primary care. When properly designed, company-sponsored primary care clinics can do just that.

Some employers are turning to outside firms such as QuadMed to initiate care models that can serve both smaller patient panels yet reduce their total costs toward healthcare. Although there are many such firms (or local practices) that will take on the role, real success hinges on a program that is well organized and allocates adequate time for the PCP to give truly comprehensive primary care. It also means that the employer has accepted the concept that it is no longer just trying to hold the line on healthcare costs but is actually looking at employee health as a strategic business imperative.

Successful programs tend to include not only PCPs, NPs, nurses and other providers but, if the employee base is large enough, a pharmacy, laboratory, and radiology suite. Other key resources are health coaches and nutritionists to maintain wellness and reduce risk factors. The typical employer in these arrangements is generally self-insured, has a large enough employee base to justify the clinic resources and is committed to employee health and wellness while wanting to reduce its total costs of health care.

A full service primary care clinic is funded by the company at or very near to the employer’s site of business. Services include routine episodic care but also extensive preventive care, intense management of those with chronic illnesses and care coordination when a patient does need to visit a specialist and sufficient time with the provider that trust can develop; in other words, this is comprehensive primary care not just limited function urgent care centers.

Employees are informed that they are welcome but not required to utilize the clinic and do so at no cost or perhaps a modest fee per visit. Some but not all employers make the clinics available to family members. Each participating individual is assigned a primary care physician (PCP) or in some cases a nurse practitioner or physician assistant. The PCP/NP/PA is paid by salary by the vendor company, not fee-for-service. In the programs that truly develop comprehensive primary care, the PCP/NP/PA has a limited number of patients in his or her panel, does a full initial evaluation usually lasting 60 minutes or more and then sees the individual thereafter as often as necessary for as long as necessary.

The expectation is that the patient and PCP/NP/PA will develop a long term trusting relationship just as they would in a private office setting. Individuals can schedule appointments often on the same or next day and there may be extensive use of mobile technologies, an electronic medical record, telemedicine and other advanced techniques. For those individuals with a chronic illness, the clinic nurses often work with the PCP to coordinate care and (often and hopefully always) the PCP communicates directly with any specialist before referring and after the visit.

The clinic manages wellness and preventive programs with health coaching and lifestyle behavior management. This might include but is not limited to nutrition counseling, fitness counseling, stress management and smoking cessation. It depends on the provider company selected to develop and manage the clinic, but if the employer already has an effective wellness program ongoing with another provider, the primary care company may agree to partner with that wellness provider to create seamless programs. It can thus be an employer wellness program and a comprehensive primary care program rolled into one. It may even be population health to the extent that the PCP and the team proactively interact with each participant to address risk factor and incipient chronic illnesses rather than waiting for an employee/patient to call or visit with a problem. To repeat, a very key ingredient is assigning no more than a reasonable number of employees and family members to each PCP/NP/PA. What is “reasonable”? – it depends – on average age, whether many individuals have chronic illnesses, etc.

Some provider companies such as WeCare TLC call their model “medical risk management,” a term generally thought of in medicine as programs and policies to reduce the potential for malpractice claims. Here however it has a completely different meaning. It is called medical risk management because the driving principle is identification and management of ongoing medical problems while at the same time addressing potential health risks for the future. It is really an employer-sponsored (although not directly involved) companywide approach to population health management. It is taken from the concept of enterprise risk management which seeks to identify and mitigate corporate risk as a strategic advantage. It is management of risk not just from a downside perspective but from an upside or positive perspective as well. The employer therefore needs to be thinking about health risk management as a strategic perspective, not just as a tactical effort. In other words, a healthy workforce is available to be productive and a healthy workforce creates a very substantial savings in medical costs for both the company and the employee.

Note that it is not just “episodic” visits but rather comprehensive primary care in a medical home type model with proactive population health concepts.

The provider company and the employer usually agree up front to a set of performance measures such as utilization/penetration of the clinic (are employees actually using it), patient satisfaction (do they like what they get), quality outcomes (standard measures used nationally such as blood pressure control, diabetic control, immunizations up to date, etc.) and of course functioning within budget and a return on the employer’s investment at a pre-agreed level. Companies that engage in these clinics, provided that the services are actually comprehensive in nature as described, tend to find that their return on investment very good.

Since in these models of comprehensive primary care where the employer fully pays for the primary care services, there can be a significant savings for the employee (patient) and family members.  Importantly, the employer pays the bills, perhaps offers incentives for participating but is otherwise kept at a distance. The PCP and other staff members work for the provider company, not for the employer, and cannot be expected to share patient information. The employee gets quality healthcare with a strong emphasis on maintaining wellness, active prevention and on chronic illness early detection, management and care coordination. The result is a healthier workforce leading to greater productivity, greater workforce satisfaction, reduced or no employee costs for primary care and reduced or at least limited health insurance cost increases for both employers and employees.  Definitely a triple win.

But there are potential downsides to consider. Some KevinMD readers will certainly comment that it is best to keep the employer completely out of healthcare. Another downside would be if the employer wanted to be intrusive and learn medical information about individuals. A third would be the loss of a trusted PCP when a person leaves the company for other employment. So in the end, each person offered the option needs to make an informed decision.

Note: I have interviewed principals at both QuadMed and WeCare but have no financial or arrangements with either. They are used as examples only; their use does not represent an endorsement.

Wednesday, February 3, 2016

Reducing Healthcare Costs Through Company Wellness Plans

Employers have seen their health care costs rise dramatically over the years. To compensate, they have expected employees to pay an increasing portion of the healthcare insurance premium, expected employees to pay significant co-pays with each physician visit and have purchased policies that restrict individuals to a narrow network of doctors and hospitals. Largely these have not worked. They have offset some of the expenditures but it has not done much to slow the inexorable rise of health care costs. The reason is because they attack the wrong “problem.” What is needed is to institute approaches to improve health and maintain wellness of the employee (and the employee’s family) and to assure that the employee (and family) get outstanding primary care including proactive population-style health care. Add to this patient engagement – a stake in the financial arrangement. That combination will reduce costs considerably. Here is one approach that progressive companies are following.
Large companies such as General Mills and Safeway have demonstrated the utility of wellness programs. Employees are invited to voluntarily participate in company sponsored programs that are designed for behavior modification such as nutrition, fitness, chronic stress reduction and smoking cessation. The employee (and sometimes the employee’s family members) who participate are rewarded with a reduction in their share of the health care premium. Given that employers are continually increasing employee share, this reduction can be a real benefit to a person’s paycheck. Large corporations often create these programs in house but smaller and many larger companies can turn to wellness companies such as Orriant that will do a turnkey approach for a single larger company or a group of smaller companies in a defined geographic region. Workplace wellness programs logically should improve employee health but until now results were mostly anecdotal; there was no definitive proof. Now, evidence has been published in the International Journal of Workplace Health Management that an opt-in program encompassing biometric testing and a personal wellness profile to guide individualized telephonic health coaching combined with financial incentives led to improved health parameters, improved health age and reduced healthcare costs. The authors concluded that “health coaching effectively improved biometric scores among high-risk individuals and narrowed the difference between current health age and achievable age, more so among those with the greatest health risks at baseline.”

Here are some of the specific findings: Compared to nonparticipants, the participant’s claims paid increased at a lower rate and they had fewer claims per person. For those with elevated blood pressure, the average systolic pressure was 170 mmHg which was reduced by 34 over the three year study; for diastolic it was 105 down by 18 mmHg. For those with elevated glucose the starting average was 164.4 and dropped by 31(58%) over the three years. Those at the greatest risk for cancer improved their lifestyle score by nearly 32 points, or 41%.

According to those in the company wellness field, there are few key ingredients that make for a successful wellness program. The majority of employees (and spouses) need to be working one-on-one with a health coach to develop their own self-directed plan for behavioral improvement. Individual care and concern by the health coach is the most effective intervention. Employees need to like their coach (which I interpret to mean they trust their coach.) Coaches need to be well trained with a significant healthcare background. Individual accountability needs to be an integral part of the program. This implies that the participant needs to call the coach; not the other way around. That is part of accountability. The focus needs to be on those with health risks, which most Americans have. Getting the men in the company involved is important; women are more likely to volunteer early so there has to be extra effort to attract the men.

Some readers will not like the idea of health coaches “meddling in their affairs.” But no
one is obliged to join into the wellness plan; it is always an option although for
sure the employer often offers a financial incentive to do so. Whether in a
wellness plan or affiliated with your PCPs office, health coaches (when properly trained and focused) have been found to be powerful advocates for improved health.

Major health risks from life style factors are being overweight (two thirds of the American population), lack of adequate exercise (probably more than half of people), chronic stress (it seems like everyone is stressed today) and smoking (still about 20%.). High blood pressure can be in part lifestyle directed as is obesity. These in turn lead to chronic illnesses such as heart disease, stroke, chronic lung and kidney disease – just the diseases that account 75-85% of all claims paid by healthcare insurance.

The cost of wellness programs, whether done in house or with a consultant, can be self-funding, i.e., those who opt in get lower premiums and those that do not have higher premiums. But the larger more valuable benefits accrue to both the employer and employee. Staff become healthier – that is good for them. But healthier employees use less total healthcare resources. This in turn lowers company insurance costs or at least slows the growth of premiums, often dramatically. The employee benefits from better health, will likely be more productive, will have less absenteeism and will have greater job satisfaction. That is a win-win for employee and employer alike.

My next few blogs will relate what some companies are doing to offer a complete package of wellness, prevention, consumer-directed insurance, on site primary care clinics, prefunding a HSA or HRA, price transparency and more to manage costs while improving employee health.

[Note: A look at the Orriant web site will show that I am quoted. I am a proponent of wellness programs but I have no financial or other association with the company. If you go to the link for the article on wellness plans noted above you will find that you need to pay to read more than the abstract. I read it and thought it was useful information which why I used it here. You can also find the details on the Orriant web site. As with any study there can be criticisms but I think it was pretty well done. The graph is  claims paid per participant]

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).