onsite care: can this strategy change your health care game?
DESCRIPTION
Onsite care programs are rapidly gaining popularity, both as a mechanism to control costs and to increase the value of benefits offered to employees. Employees love onsite clinics for the convenient access to care they provide — and employers are eager to realize cost savings, enhance worker productivity, and tout the value of the offering to attract and retain talent.TRANSCRIPT
ONSITE CARE: CAN THIS STRATEGY CHANGE YOUR HEALTHCARE GAME?
March 20, 2014
HOUSEKEEPING
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TOPICS COVERED TODAY
• Intro
• Who’s a Good Fit and How to Build an Onsite Program
• Cost Structure and Payment Methods
• Keys to Onsite Success
• Client Stories
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INTRO
Why are companies considering onsite care?
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Employers are frustrated with the
amount of waste we’re seeing in
our health care system.
How big is it?
That’s…
33-52% of a total health care spend of $2.6 trillion
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WASTE IN THE US HEALTHCARE SYSTEM
THE CONSUMER
THE SYSTEM
HIGH COST OF ILLNESS
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“Unscheduled absences can cost employers $3,600 a year per hourly worker, so helping your employees stay healthy and on the job is smart business whether you have two employees or 200.”
—Kaiser Permanente
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REASONS FOR ESTABLISHING AN ONSITE CLINIC
ADDITIONAL CONSIDERATIONS
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• Experiencing High Absenteeism
• Low Utilization of Primary Care
• Quality of Local Providers
• Needs of the Population
Photo via Wikipedia
INCREASED EMPLOYEE DEMAND
• Employees view this as a benefit!
• Clinics have become common in the workplace
• By 2015, onsite clinics are expected to serve more than 13 percent of the under 65 population in the US compared to 4 percent in 2008*
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*Massachusetts Research Company
PATIENT-CENTERED HOME
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http://youtu.be/btsGDHO_4lU Patient-Centered Medical Home via Spectrum Health
WHO’S A GOOD FIT & HOW TO BUILD A PROGRAM What types of companies can make onsite care work? How does onsite care work, exactly?
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ONSITE CLINIC MODELS
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• Traditional Clinic o Near Site or Shared Clinics
• Direct Primary Care • Limited Service Clinic • Mobile Medicine
TRADITIONAL SERVICES
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• Occupational Health • Acute Care • Preventive Care • Wellness • Chronic Care and Disease Management
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ADDITIONAL SERVICES • Physical Therapy and Chiropractics • Radiology • Dermatology, Orthopedics, Pediatrics • Dentistry • EAP – Behavioral Health • Laboratory • Travel Medicine • Minor Procedures
Photo by Joe Goldberg via Flickr
TRADITIONAL ONSITE CLINIC
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• Hire third-party vendor • Employ all clinic staff and management • Hybrid — employ clinic staff but managed by contracted physician • Contract with local providers to operate the clinic • Shared clinics
Towers Watson
DIRECT PRIMARY CARE
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It’s retainer primary care practice. Basically, you get a company doctor, and your employees are VIPs (very important patients).
DEFINITION
DIRECT PRIMARY CARE
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EXAMPLE
Characteristic Traditional Practice Direct Primary Care Practice
Panel size 2,000-3,000 < 500
Provider incentive Volume-based Quality-based
PT access to MD Through call center 24/7 access to MD cell phone/email
PT appointment scheduling Weeks out Same day/next day guaranteed
Appointment length Appointment times < 10 min Appointment times > 30 min
Waiting room times Often > 1 hour No waiting
Annual exam Brief, it at all Comprehensive with lab work
Care Location MD office MD office, patient home, workplace, cell phone/email
Care coordination Minimal Complete
LIMITED SERVICE CLINIC
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Nurse Practitioner or Physician Assistant
Photo via Wikipedia
MOBILE MEDICINE
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Transporting the office to the patients to diagnose, monitor, and treat health conditions.
DEFINITION
MOBILE MEDICINE
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http://youtu.be/p8jbV1rugyc UnitedHealth Group: Connected Care Telehealth Video via Connecting Care
TELEMEDICINE AND KIOSKS
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INTEGRATION • Collaborate with other health plan programs, e.g. care management • EAP • Workers comp • Safety (OSHA ) • Onsite fitness • Pandemic planning
Photo by Liza via Flickr
COST STRUCTURE & PAYMENT METHODS How do we pay for onsite care?
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ACCESS AND ELIGIBILITY Who can use the clinic? • Employees • Dependents • Limit to those in the health plan • Shared facilities with other employers • General public
Hours of operation • Shifts of employees • Anticipated utilization • Flexibility of staff • Coordination with other providers
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Photo by Enrico Donelli via Flickr
VENDOR PAYMENT METHODS
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• Direct costs plus a management fee • Per member per month • Monthly flat fee
Photo by Andrew Magill via Flickr
START-UP COSTS
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• None — Built into vendor fixed rate • Small initial investment in an exam room • Clinic build out
o 500 to 2,000 square feet o $50 to $100 per square foot
• Start with basic services and add over time
START
OPERATING COSTS
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• 70% to 80% labor Family Practice Physician: $170,000 Nurse Practitioner; $94,000 Physician Assistant: $90,500 Registered Nurse: $65,000 Certified Nursing Assistant: $42,000 Physical Therapists: $83,000
• 20% to 30% supplies Immunizations Medications Minor Equipment Laboratory
EMPLOYEE INCENTIVES AND OUT OF POCKET EXPENSES
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• Most have low or no copays to encourage utilization • Services may be provided at cost with no markup e.g. immunizations, minor equipment (crutches) • Equipment could be loaned
COPAY NO -or- LOW
HEALTH BENEFIT DESIGN
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Core Plan
• Deductible - $3500 per individual
• Coinsurance
– Preventive Care – 100% (all providers)
– All other services including Rx - 80% benefit in-network
• Maximum Out-of-Pocket - $6350 per individual
HEALTH BENEFIT DESIGN
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Choice Available
• Option 1:
– $1000 company contribution to Health Savings Account
– No access to On-Site Clinic/DPC model for non-preventive
care
-OR-
• Option 2:
– $0 co-pay for primary (non-preventive) care at on-site
clinic/DPC provider
– Selection of Option 2 disqualifies access to HSA funding
KEYS TO ONSITE SUCCESS
How do I comply with regulations?
What are best practices?
How do I measure performance?
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HSA RULES AND WORKPLACE CLINICS
• HSAs are tax-exempt accounts that must be linked to health plans with high deductibles
• Under IRS rules, enrollees in HSA-eligible plans must pay full market value for medical care until they have met the entire deductible
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ERISA
• Narrow exemption exists for certain clinics
• Treatment of minor injuries or illness or rendering first aid in case of accidents occurring during working
• If the clinic does not fall within this definition, it is considered a welfare plan is needs to comply with ERISA
• ERISA claims and appeals procedures
• Plan Document, SPD, Form 5500, Summary Annual Report are all required
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ACA COMPLIANCE
• Must include clinic in the cost of coverage reported on the W-2 if COBRA premium is charged
• Value is included in the cost of employer coverage when performing Cadillac tax calculations
• Must comply with wellness rules
• Other mandates such as 100% preventive care, emergency care, etc.
• Additional guidance regarding ACA impact on on-site clinic would be welcome
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ADDITIONAL REGULATORY CONSIDERATIONS
• State corporate practice of medicine laws
• Fraud and abuse Laws
• HIPAA
• Medical malpractice
• Rules for nondiscrimination in favor of highly compensated employees
• Accreditation and licensure
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AVAILABILITY BY EMPLOYER SIZE
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# of Employees Full Service
Onsite Clinic Limited Service Onsite Clinic
Mobile Medicine
Direct Primary Care
Mid-Size (<200) n/a X X x
Larger (200+) X X x x
SUCCESSFUL PROGRAM BEST PRACTICES
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Essential • Leadership Support • Continual Communication • Patient Medical Home • Providers that Fit
BEST
MEASURES OF SUCCESS
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• Savings — direct and downstream • Operational — attendance, wait times, etc. • Satisfaction — employer and employee • Utilization — physicals, visits • Clinical outcomes
RETURN ON INVESTMENT
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• T&W — Over half do not track savings • Not tracked because
o Complex o No access to past claims o Difficult to measure cost avoidance o Catastrophic events can skew results o Higher use due to incentives or lower costs
• Hard ROI • Soft ROI • Most studies estimate the ROI between 2 to 3 years
SUCCESSFUL PROGRAM OUTCOMES
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• Coordinated Care • Control Downstream • Transparency and Consumerism • Promote Wellness
SUCCESS STORIES
How have other firms made onsite care work?
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SUCCESS – TRADITIONAL CLINIC
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OUTCOME: Integrated diabetes management program into primary care model for 2.4 ROI.
MANUFACTURER WITH 1,000 EMPLOYEES
SUCCESS – DIRECT PRIMARY CARE
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OUTCOME: The strategy yielded 9.2% reduction in first year health care costs.
MANUFACTURER WITH 550 EMPLOYEES
SUCCESS – LIMITED SERVICE CLINIC
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OUTCOME: Detected several serious health problems and connected employees with primary care physician.
Photo via Wikipedia
MANUFACTURER WITH 80 EMPLOYEES
QUESTIONS
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