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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.
