OnSiteClinics.Org

Robert Wood Johnson Takes Note of Workplace Health

Review:  Issue Brief No. 17, The Center for Studying Health System Change: Workplace Clinics:  A Sign of Growing Employer Interest in Wellness.

This is a product of a grant by one of the most prestigious organizations operating in the health care space today.  When the RWJF takes note of something, it becomes important.  Actually, to the millions of workers and beneficiaries who receive high quality care and to the firms who provide that care — this is already an important subject.

This is a study conducted by researchers, Ha T. Tu, Ellyn Boukus, and Genna R. Cohen.  It should be noted that The Center itself receives funding from the Robert Wood Johnson Foundation and many other sources.   Their goal is to conduct research and publish results with a focus on “. . . how local and national changes in the financing and delivery of health care affect people.”

The Brief in question was published just last month, and we admit to being involved as one of the interviewees.  We feel that the 24-page report stops short of its potential.   The research was minimal – the Brief states that literature reviews were conducted (however, reviews cited in the Brief included only six  published articles) as well as “more than 35 telephone interviews with workplace clinic industry experts and representatives of benefits consulting firms, clinic vendors and employers sponsoring onsite clinics” (again, this seems like a relatively small number overall).

Overall, the Brief does do a good job of describing the scope of services being provided across the nation, some of the challenges in setting them up and maintaining their operation, as well as some of the regulatory issues (which are usually completely foreign to the employer).  However, the Brief takes a couple of positions which we feel are, at the very least, insufficiently developed and which some might consider inaccurate.

First, with regard to return on investment, throughout the Brief the researchers indicate that ROI is hard to calculate and frequently overstated.   Our experience is much to the contrary (except when sales literature is the source of the information).  Those employers who have had years of experience in providing on-site care have a wealth of credible, hard data which demonstrate the significant positive return on investment that is possible.  To quote John Torinus, Jr. from his recent book on employer-managed healthcare, “It doesn’t take an act of faith for a company to go this route.  The audited numbers at QuadMed, gathered over two decades, prove beyond any reasonable doubt that primary care should be the pivotal platform for value-based medicine.  Effective primary care saves huge sums of money.”  We have numerous other employers who have likewise produced credible data which show well-respected returns on their investment.  This type of anecdotal research and comment reflects poorly on the impact that employer-managed healthcare through the provision of on-site clinics can actually have – at a time when the cost of healthcare is literally breaking the bank at every level of our economy.  ROI – challenging to define but not impossible.

Second, the research Brief provides the following opinion:  “Workplace clinics that provide primary care have the potential to improve access to care for eligible employees and dependents, but some observers have expressed concern about the potential aggregate impact that clinics may have on community-based primary care in the surrounding areas.   If onsite clinics continue to grow and a greater portion of primary care for well-insured patients continues to shift to the workplace, their concern is that primary care practices in the community will be left with increasingly less viable payer mix.  This is an issue for policy makers to be aware of as they consider whether to actively encourage the growth of workplace clinics.”

Our problem with this statement:   Primary care medicine has been less and less attractive as an alternative specialty for physicians for more than a decade.  Fewer and fewer residents are choosing primary care.  Why?  Because they have to see too many patients every day to make a living.  Primary care is not procedure-driven.  It is patient-driven. High volumes of patient visits equate higher income.  So, the perverse nature of the reimbursement structure (fostered by all insurance carriers, including government payers like Medicare and Medicaid) is that to earn what they feel they need to as physicians, family practitioners, pediatricians, internists, must focus on volume – to the absolute detriment of the health of the patient.  The visits get shorter and shorter, there is no focus on preventive medicine or managing the overall health of the patient.   The day is long, jam-packed with patients, and the reimbursement per patient is low.  So, no one wants to be an FP.   On-site clinics have figured out that the best solution is to pay those primary care physicians for providing good quality care, not for how many visits they do in a day.  So, existing primary care physicians are allowed to practice the type of medicine they have been trained to provide – high quality, focused on the whole patient, back to basics, developing a real relationship with the patient  and his/her family.   Government should be promoting the development of these clinics, by employers, and, dare we say it, for Medicare and Medicaid recipients.  We can’t imagine blaming employers for “stealing” away PCPs for their on-site services.  Or, even more absurd – penalizing them for it, or regulating their ability to do so because it hurts “the system”.  There is no way these employer-managed plans hurt anyone, they help, and should be encouraged, not stifled.

In fairness to the sources, they are proponents of “health system change” and we are all proponents of changing the health system — one company and one program at a time.  We conducted a survey of companies over two years ago and (with 60 respondents representing tens of thousands of employees served by on-site programming), the most often voiced reason for providing the service was to assure their employees access to primary care.  This reasoning in our limited sample beat “cost” by two-to-one.  The researchers are right except that they think access could be a problem — employers and consumers already know it is a problem.

The Brief presents comments based on 35 interviews.  It could be that we are actually fortunate that RWJF and the researchers have begun the discussion at this level.  We need inspection and introspection.  We need to publish hard data and not merely opinions from a small group of sampled individuals when presenting on this topic.  Let’s focus on facts and not on focus groups.

Read the issue paper and let us know your comments.