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Written by: Bruce Hochstadt , David Kaplan , David Keyt
Employers across the globe have strived to effectively manage rising health care spend by encouraging employees to understand and improve their health situations. A number of strategies − from plan designs to communications to worksite-based health and wellness initiatives − can reinforce employee engagement. One very visible reinforcement resource has been the resurgence of onsite health centers.
Many legacy worksite clinics were created to deliver occupational health services to treat and manage worksite injuries, exposures and illnesses. Over time, many expanded to include acute care services as a way to utilize excess capacity more fully and to provide basic, convenient, accessible care for minor health conditions.
Historically, onsite health centers have enabled employers to:
Recently, there has been a surge of interest in onsite health resources fueled by:
This surge of interest is not just in the traditional onsite clinic/health center approach. Rather, employers are experimenting with new models for reaching their employees in smaller and more remote locations, focusing on the chronically sick/highest-risk members and positioning clinics as onsite hubs or “ambassadors” to a company’s full range of health- and wellness-related offerings. Many employers have combined flexibility and innovation in the way they approach and leverage these centers. The following are examples of some emerging practices, along with a brief description and information related to results or potential impact:
Shared or multi-employer near-site clinics – These clinics serve as a way for an employer to share the cost/responsibility related to an onsite clinic, especially if a single employer’s headcount at a given location may not generate clearly sufficient volume on its own.
Comprehensive onsite wellness centers – Some employers position traditional occupational and even nonoccupational primary care clinics to be more than just treatment centers. Many employers are setting up their clinics and the variety of resources housed on site as organizational “store fronts” or hubs for health promotion and wellness programs. Services provided may include biometric testing, health risk assessment completion and review, face-to-face health and lifestyle coaching, as well as employee assistance plan services and chronic disease management programs. In some cases, such onsite-based programs are supplementing and in other cases, replacing telephonic programs.
Virtual waiting rooms – More and more employers are seeking to achieve greater time efficiency at their onsite health centers. Unlike at traditional community-based clinics and medical practices, where extended wait times are expected, onsite clinics have begun to leverage technology (such as mobile texting, instant messaging, email, etc.) to enable real-time notification of employees when the clinician is available to see them. This concept can greatly compress and in some settings, “virtually” eliminate clinic waiting times – universally a major source of frustration for patients.
Local provider-managed clinics – Most employers have implemented outsourced clinic models (clinic staffed and managed by an external third party) for their populations. The significant growth in this niche has spurred the recent entrance of vendors, many of whom can offer near-turnkey onsite clinic solutions. Health care providers have also jumped on this bandwagon, attracted by the movement of employers to add health services to the worksite. Similar to outsourcing with a national (or regional) commercial vendor, in these situations staffing and management are provided via a local (or regional) health system or provider group. This is a growing concept, as more and more providers are interested in piloting the accountable care organizations defined in the Patient Protection and Affordable Care Act, as well as extending their practice reach to the worksite.
Established, respected local or regional provider groups can often offer employees the advantage of increased independence and quality, as well as greater separation from the employer (allaying concerns about potential privacy and confidentiality violations). This arrangement can also create improved coordination and integration with offsite care and referrals.
A major risk to guard against when partnering with health delivery systems is the potential for them to generate excessive referrals of costly services (specialists, diagnostic testing and procedures) to its offsite community-based facilities. Performance guarantees tied to referral volume and steerage can help prevent this untoward outcome.
Medical home linkages – An onsite clinic can support an employer’s population-specific medical home program by focusing on the most at-risk members (those with diabetes, coronary disease, emphysema, etc.). These members often require regular monitoring (for example, blood sugar, glycosylated hemoglobin and urinalysis for diabetes). The onsite resources can provide this clinical surveillance in close coordination with members’ primary care physicians, providing important services on a regular – and, in some cases, daily − basis in a convenient, cost-effective setting. This leads to better management of the condition, better treatment compliance and a reduction in time away from work.
In addition, the type of face-to-face interaction and coaching that can be delivered in this setting is far more effective than traditional telephonic methods. Positioning an onsite health center as an extension or “annex” to a patient-centered medical home model offers a valuable, additional set of “eyes and ears” for the primary care physician responsible for managing the care of high-risk, high-cost members.
Telemedicine – Telemediated consultations is increasingly being considered for smaller employee locations that lack the headcount number needed to justify a dedicated onsite health center. Telemedicine may also be appropriate for remote locations with significant access shortages (of both primary care and specialties) or where employees may need to drive long distances (sometimes in excess of 50 miles) to see physicians.
Expanding global footprint
Onsite medical facilities offer special opportunities for employers across the globe. The opportunities are largest in countries where governments have mandates for onsite medical clinics. These mandates vary by country, employer industry and employer size. Countries with broad mandates include the Philippines, India, China and Mexico. In other countries, mandates are narrower, but onsite facilities represent a prevalent practice.
For employers that have already made the financial commitment to onsite facilities, there is a significant opportunity to increase the value of that investment. This can be achieved by broadening the scope of service at underutilized facilities to include activities that cover the unmet health needs of local employees. Examples include care for episodic illness or management of chronic diseases.
Mercer’s experience from auditing onsite health centers in both Asia and Latin America shows that the health centers are often underutilized and the providers spend significant portions of their days not addressing employee health care. There is great potential for employers to leverage an existing investment to meet general health and wellness needs by shifting the focus to their employees.
Another area of significant opportunity for employers is in improving the reporting from the onsite health centers. It is essential to protect employee privacy, and the medical data from individual employees should not be accessible to employers. However, there is great power in aggregated data, which can be used to help employers identify health risks for their populations. An understanding of these risks can guide the appropriate deployment of wellness and risk-mitigation programs.
Looking at trends on a more regional scale, Mercer has identified some opportunities for employers in the onsite health center space.
The mandates in the Philippines for onsite health centers are among the most rigorous in the world. The proscribed staffing ratios almost guarantee that the physicians will have a great deal of free time. The mandated annual testing is relatively simple, with a physical and five mandated tests including a chest x-ray, complete blood count, urinalysis, stool test and body mass index. Often, there is no follow-up for any abnormalities found in the exams or testing.
A number of vendors operate in the market, but they have weak quality assurance processes, have trouble recruiting quality providers and rarely provide service-level agreements or performance guarantees.
Like many countries in Asia, the Philippines is seeing a significant increase in chronic illness manifesting at younger ages. Some of this is thought to be related to lifestyle changes. Using excess capacity in onsite clinics to begin to manage some of these conditions allows employers to leverage their existing investment to address new health issues.
China has several unique health challenges that can be at least partially addressed by onsite health centers. China lacks a coherent system of primary care. When an individual is ill, he or she goes to the local hospital to be seen in a clinic for that illness. Access is generally good and the cost is quite low. But the process, which includes queuing in a line to pay for the visit, then waiting for the visit, queuing again to pay for any tests or prescriptions and then again waiting for the tests or at the hospital pharmacy, makes a simple visit take the better part of a day.
Some employers have found that having an onsite clinic that provides care for simple illnesses can significantly reduce the time employees are away from work. This leverages the investment already made in the provision of occupational health care services.
The other unique challenge in China is that to fill the gap in primary care, many employers fund an annual health check for employees. This is a comprehensive check-up including an examination, blood work, x-rays and often a dental exam. The health check generally takes place in specialized check-up facilities and, afterward, the employee is sent a copy of the findings.
Given the lack of a primary care infrastructure, following up on the results of these health checks is difficult. The employee may not understand the findings or know what type of physician he or she may need to see. Employers invest a significant amount of money in these health checks and without follow-up, the value is unclear. Utilization of onsite clinics to review health check results with employees and clarify best next steps can make the check-up program more effective.
The vendor market for onsite services in China continues to grow, with a few progressive providers looking at expanding their scope of services. Some employers hire their own clinical staff to run their health centers.
India is a growing market for onsite health centers. There are government mandates in place and many unmet health needs. Many of the branded hospital systems in India are entering the onsite health center vendor space.
These hospital systems are held in high esteem and may be able to attract a more qualified group of providers to the onsite space. The challenge for employers is that these brand-name hospitals view the onsite clinics as sales channels. There could be a significant cost impact if all follow-up care and testing were referred to these very expensive facilities.
In many of the large cities in India, overwhelming traffic makes even short journeys a multi-hour proposition. An employee who has to leave work for a medical appointment is usually gone for most of the day. Onsite health centers offer a time-efficient alternative that increasing numbers of employers are embracing. In addition, the increase in cardiac disease and diabetes among younger workers creates an opportunity for the onsite health center to provide a platform for education and lifestyle management initiatives to both help prevent and treat these conditions.
Employers in Mexico have embraced onsite health centers to both comply with government mandates and offer expanded services to their employees, in some cases to compensate for other benefit cuts. Progressive employers have integrated the health centers with physical fitness centers, quiet rooms for stress reduction, private rooms for nursing mothers and health education programming.
Vendor quality is highly variable, and service providers often lack basics such as policies and procedures and important tools like electronic medical records. Reporting is very rudimentary, and employers do not receive much aggregated data.
Site-based health centers and local health resources are becoming a critical part of many employers’ future health and wellness strategies. Although historically the focus of these resources has been in the delivery of a finite set of medical services, many employers are now positioning their health centers for employees as a single point of entry into wellness resources, programs and education. This approach will directly affect the health of the workforce and provide a more scalable approach across smaller locations.
Employer-sponsored onsite health is increasingly being viewed as an attractive option to help overcome issues of access, affordability, non-compliance and limited follow-up. Onsite clinics can provide convenience and savings compared to most community-based care, while contributing to the health of employees. Furthermore, there is a natural linkage with absence and productivity both from lost time seeking off-site care and first-hand knowledge of worksite and clinically-based limitations.
Mercer encourages employers to position onsite clinics to employees as more than just treatment centers. Many employers have successfully leveraged their clinics to serve as onsite hubs of health promotion and wellness intended to drive risk reduction and prevention and to promote healthy behaviors and lifestyles.
About the authors
+1 312 917 0716
Dr. Bruce Hochstadt is a Partner and National Onsite Health Lead in Mercer's Total Health Management Practice. Based in Chicago.
+1 415 743 8716
Dr. David Kaplan is a physician and Global Leader for Clinical Solutions at Mercer. Based in San Francisco.
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David Keyt is a Senior Associate in Mercer's Total Health Management Practice with extensive onsite health project management experience. Based in Chicago.