OnSiteClinics.Org

Working with Local Providers – a Monograph

Working  with Local Providers (La Penna Presentation to MBGH Spring Meeting: Employer Worksite Healthcare Conference, Chicago, April 2011)

Background

Every employer and every “employer health care program” co-exists and is interdependent on local health care providers and support systems.  These are the same providers that “constructed” the present system of care and cost that the employer is trying to replace or improve upon with their on-site programming.  It is counterintuitive to think that the environment that caused the problems in which the employer is suffocating is going to provide solutions to these same problems.  However, there are ways that on-site programs can use and apply local resources in ways that are different than those employed in the past to improve care, cost, and access – if there is some element of planning and design.

First, recognize that the local provider systems come in four categories:

• Hospitals and health systems
• Physicians and other care providers
• Consumer and retail outlets
• Support system providers and ancillary services

Each is different, and each is somehow either competitive to the project at the worksite or complementary to it.  Each could be a resource if it is part of an overall strategy.  Each will be no better than it has been in the past, if it is not controlled and managed.

Planning is the Key

First, the employer must plan their own program from the inside-out.  This should be done with the employee (beneficiaries) as the central factor and with factors such as cost, quality, and service as pre-determined standards.  Planned for, measured and achieved – not measured and benchmarked against failure.

Then, the vendor should be enlisted as a partner in the process.  They will not come to this as their own solution.  This has to be defined for them – contracted and specified.  If the plan is clear, the contract that aligns the vendor goals with the plan will also be clear.  If there is not any effort at this stage, there is no sense in trying to coordinate local resources.  Control first the issues that you can control as an employer.

• Control Benefit Design
• Control the Beneficiary Information Channels
• Control the On-site Vendor Contract Process
• Control Feedback Loops and Performance Standards

Start with the Hospital

It is true that a hospital seems to contain all of the components of a successful on-site clinic deployment strategy.  Ask the local hospital, and it will tell you that it can deliver the necessary staffing, data services, ancillary programming, and inpatient resources.  It knows the appropriate specialists, and it has a management team that is used to handling these factors of production.  However, a hospital is not focused on the needs of the firm; it is focused on survival and on the needs of the community in which it exists.  It is a provider of commodity goods – not boutique services.

What it can do for you is defined, first and foremost, by what your needs are and what you wish to have the hospital provide.  It also depends on the hospital.  Some health systems around the country are actively pursuing partnerships with local employers to implement on-site programming, and most hospitals have the interest.  The challenge is to distinguish between the “desire” of the health system relative to its actual capabilities as the firm moves forward with programming, since there are many areas of opportunity for articulation with local health systems, and an on-site project cannot ignore the need to work with them.

A successful model for working with a health system is generally constructed after the firm does its own planning and defines its own goals and objectives.  A health care system, like most successful entities, is a “learning enterprise” and, when challenged, can adapt to meet almost any service line need.  However, most hospitals are politically and functionally challenged to meet any objective that ranks any particular provider over any other.  Even though there are many doctors who might distinguish themselves within an institution, the hospital itself conducts business as a democratic organization of equals.

What are the options and services that a health system can provide?

• The hospital can be a “vendor” just like any other.  If so, it should be treated like any other vendor.

Is the hospital prepared to submit a formal response to the same RFP that is being developed for other vendors?

Can the hospital contract for full services at the site and manage it as a truly independent contract, or do they conceive it being part of a larger program?

Can the hospital service contract be inclusive to other community health care providers (perhaps including some who are competitors)?

How will the program be managed?  Who will be the one person in charge?

What is the hospital’s track record with key program components—like an electronic medical record, continuous quality improvement, performance- based provider contracting, and the Patient-Centered Medical Home?

• The hospital can provide support services.

This includes all categories of on-site staffing support – not just physicians.

They may facilitate special access and inpatient coverages that would otherwise not be possible.

Hospitals do have talent pools and can be used for consulting advice relating to ambulatory care issues or regulatory and licensing issues.

Hospitals have specialized maintenance and support functions that might be contracted.

The hospital is the place to go for program support and after-hours coverage.  They have paging systems and existing linkages with local community service agencies.

Hospitals might be able to facilitate contracts with “hospital-based specialists” like radiology, anesthesia, critical care units (intensivists), laboratory, and the emergency department.

• Hospitals might be a source for information and linkages and facilitation of other functions.

Identification of specialists for “narrow network” or “high-performing” network services related to the specialists.

Enhanced and coordinated registration processes.

Support for care management, case management, or coaching (or whatever it is called).

Linkages to clinical “systems” — inpatient EMR, lab, imaging, discharge reporting, etc.

Coordination with national coverage programs, centers of excellence, and other insurance products.

The most mature programs will pick a hospital system as a partner and not treat it as a vendor.  It is impossible to make any generalization about a hospital except that the local hospital has a stake in what is occurring at a health care site in a community in which they provide services.  It can also be said that most hospitals enjoy some level of community support, and most are seen by consumers as credible.  The word to stress here is “most.”  In a town where there are many hospital choices, there are generally some which stand above the others in any survey of local health care consumers.  Your beneficiaries, as a matter of fact, have already chosen a local industry leader.

The process of choice starts with a review of the claims file and an understanding of what is being spent in the local health care community.  Before the employer approaches a hospital or health system, they should know what they have traditionally spent on health care and what their “spend” is worth.  This will allow a meeting that is collaborative and productive where the opportunities for steerage or selection that might be achieved by a partnership can be appreciated by both parties.

The employer is well-advised to meet with the local hospital and explain the goals of on-site programming so that there is an understanding of the ground rules and the stakes in this health care initiative.  The employer is not competing with the hospital as much as it is attempting to continue a competitive advantage in its own competitive arena of services and products where health care costs are production costs.

Considerations with Local Physicians

Local doctors are traditional, fee-for-service, health care providers, and on-site programs are based on a different business model.  Community-based physicians are based at their office, and there is a reason that the care is being relocated to the worksite.  Generally speaking, these factors are not compatible to good program planning, but nothing is impossible if goals can be aligned in some way.

Some reasons to work with local providers seem obvious.  First, they are local and at hand.  Second, they already are connected to existing health resources.  Also, they are generally anxious to provide some form of a solution.

Some of the problems are not so obvious.  They are generally at or near capacity.  They are already connected to existing health resources (less flexible in changing referral targets).  They are invested in the status-quo.  Generally, speaking there should be a gut-check on these points before the discussions are engaged.

There are also a few obvious issues that might not seem so obvious at the start of the process.  The employer should keep in mind that local doctors are not able to generally access patient records for on-site care of their own patients on a casual basis.  It is true that some patients already go to the doctors as family physicians, but not everyone does.  New patient visits at the worksite will have to be carefully registered to assure that confidentiality and recordkeeping is kept in appropriate buckets.  This may seem incongruous, but the records at the work site are important to define in the original program as being part of the workplace process (even if primary care is part of the equation) and not part of a private medical record in the community, and vise-versa.  The dictates of the program are more important in defining this issue than the dictates of the private practitioner.

The level of primary care at the work site will also define how a care event is constructed.  Hopefully, if the Patient-Centered Medical Home Model is elected, each primary care event will encompass a health status check and a review of basic personal health planning criteria.  This will mean an investment of time that is three or four times as long as a standard primary care appointment, and it will be very different than the care normally available in a community-based practice.  Other program features such as consumer satisfaction and benchmarking are difficult to design within a practice that is being arranged through another practice originally formed around traditional physician and provider contracts.

Forgetting the Barriers, the Advantages Seem Obvious

Programming has to start someplace, and there is a common feeling expressed by many employers that the best way to engage in the on-site experience is to take a path of “least resistance” with the local medical community.  Another argument often expressed is that this is a “starting point” and that, as the program, it can be shaped with the local providers becoming more fully engaged in the “vision.”  This is a doubtful result but often heard as a reason to “think big” and “start small.”

Whatever the arguments, there are key issues that will need to be addressed with any local provider group.  The listing is offered as a starting point to promote some level of clarity in the planning process:

Will care be delivered “on-site” or at a facility that has been traditionally associated with the local provider?  If the services are provided at the workplace, who will “manage” the contracted physicians and employed staff?

Which components will be owned and operated by the employer and which, if any, by the provider group?

Employer owns and manages the facilities and purchases equipment and supplies.

Employer hires support staff and non-providers and contracts with a local entity to provide the physicians and licensed providers.

Employer hires support staff and contracts with a national vendor with the direction to incorporate local providers as part of their staffing solution.

Employer uses a contract management approach to have an outside consulting group oversee the sourcing of staff, providers, equipment, facility, etc. as an “owner’s representative” and pass-through entity.

If one single contracting entity is chosen as a provider (or provider-manager), the contract form could be cost-plus or fee-for-service, capitated, or a combination of methods.  Actually, pricing may be one advantage that an employer might gain in using a local provider that cannot be easily achieved when contracts are approached through intermediaries.

Some nagging questions remain (and must be solved).  Who owns the medical records, and how can they be transferred in the case of a transition?  Who owns the intellectual property associated with the program?  Can employed physicians shift from one vendor to another if the program goes through a transition?

Issues and challenges related to the utilization of local practitioners include a few things that might not be evident until the process of development begins, but the result can be rewarding if the original program planning concepts are kept in sight.  The incorporation of trusted local physicians, local brands, and trade names does signal support from the medical community for the employer’s programming.  Local physicians already have credentialing completed with local hospitals and managed care programs.  If there is a high performing network that is part of the program, the local doctors can bring some level of “intelligence” to the contracting process in order to develop it quickly. Home town providers might also have a good sense of specific resources for disease state management.

Don’t Forget Ancillaries and Retail

Primary care is emerging in any number of different forms.  Communities now have retail outlets doing consumer medicine, and this is a factor that can also complement – or compete with — a workplace program.  Usually, these are located at pharmacy locations and are staffed by mid-level providers, but they are also cropping up in malls, convenience centers and other locations that are frequented by the same beneficiaries that are being covered by the plan the employer sponsors.  They provide consumer access, after hours care and some incidental pricing advantage, but they lack (for now) any real integration with comprehensive primary care.

Some points to remember include the fact that “urgent care” is not “primary care,” and the convenience clinic that has a shift worker for a provider is not going to articulate with a fully- developed EMR.  However, it will link with the other provider sites within its own chain of retail outlets.  This is focused on consumer convenience and symptomatic relief rather than comprehensive medical care.

There is nothing inherently wrong with these services, and they should be considered when forming program goals, but like any program trade-off, there is no one right answer, and the retail-provider-community is in a state of rapid development and change.  As long as the overall principles of the program are maintained, even a local retail outlet can be part of the solution.

Summary

There is no “one right way.”

The only mistake is to have an “unplanned” approach.

The environment is constantly shifting, and providers are eager to be involved.

Local providers have lots of resources and lots to offer.

A provider-designed program will look a lot like the program that you are trying to replace.

Successful programs are ones that continue to transform and take advantage of the arbitrage opportunities that the system continuously offers to alert employers.