Worksite Primary Care: An Assessment of Cost and Quality Outcome Metrics

To the Editor: The health care reform legislation is not likely in the near term to impact health care delivery in the United States, which is broadly considered to be expensive, imperfect, and ineffective. It is responsible for ∼60% of personal bankruptcies.1 It now consumes 17% of the nation's economy and will reach 21% by 2020, if trends continue.2 Relative to effectiveness, the United States is ranked number 37 in the world by the World Health Organization.3 The costs associated with health care rank with the price of energy, a broken tort system, and the excessive corporate taxes in creating a major disadvantage for American businesses. The World Health Organization's 2008 statistics demonstrate the significant gap that exists between the U.S. private sector spending on the per capita cost of health care relative to other major industrialized countries such as Germany, Canada, Japan, and the UK, an average of about six-to-one. When comparison is made with such developing economies as China and India, the differences can reach orders of magnitude (Fig. 1).4 Because >60% of Americans get their health insurance coverage through their employer,5 transforming health care is critical for American businesses to achieve global competitiveness.FIGURE 1.: United States versus selected countries private sector health care spending.Many large and mid-sized U.S. employers (1000 or more employees) have considered the opportunity to offer worksite primary care as a means to not only control the costs of health care but also to improve the effectiveness of care and to enhance human performance. In general, worksite primary care can impact health care costs through the following mechanisms: Diagnosis and treatment can be performed at lower unit costs compared with community providers. The proper alignment of provider incentives through evidence-based treatment guidelines can increase the likelihood of quality outcomes. The easy accessibility to on-site treatment can limit unnecessary visits to emergency departments and to inappropriate and multiple providers. Early intervention by on-site providers may limit the duration of absence and enhance productivity. There exist several possible staffing strategies for worksite primary care. These include hiring a medical staff or building a primary care program around existing clinical personnel, contracting directly with local health care providers, or working with a vendor to provide worksite medical services. Developing the program internally gives the employer the greatest latitude in design, creates the most favorable opportunity to align incentives, and supports health improvement and injury and illness management along the continuum of prevention and risk reduction strategies to evidence-based medical and disability management. In addition, worksite primary care has been documented to provide a favorable return on investment.6,7 This letter outlines the worksite primary care program developed internally by a mid-sized Midwest manufacturing company and provides further evidence that such programs can deliver superior clinical outcomes with a favorable benefit to cost ratio. BACKGROUND Faced with unfavorable health care costs, the senior management of a Midwest manufacturing firm of ∼3500 employees agreed in 2004 summer to a proposal to hire a nurse practitioner and the necessary support staff to develop an on-site primary care practice within the context of a well-established traditional occupational medicine program. The strategy was to impact health care costs by focusing on prevention with adherence to evidence-based medical guidelines. Services were free to employees, to spouses, and to retirees who participated in one of the company's health plans, which included examinations, laboratory studies, radiology, and consultants, such as dietitians and behavioral therapists. Employees were encouraged to use the clinic for all acute and chronic health care needs as a full replacement for their community provider; any testing or subspecialty referrals beyond the capabilities of the workplace clinic were managed within the context of the company's health plans. Hospitalizations were handled through an arrangement with a hospitalists' group practice. A maximum of three clinic visits were scheduled each hour to provide ample “face time” with the employee to address not only the chief complaint but also to promote a thorough investigation of individual health risks and to promote preventive health strategies. Clinic enrollees reflected the makeup of the plant; 85% hourly and 15% salaried, with ∼55% being men. METHODS The key measures that were tracked were employee satisfaction, clinical results, and financial outcomes. Surveys were developed to assess satisfaction with services and to identify opportunities for improvement. Selected Healthcare Effectiveness Data and Information Set (HEDIS) effectiveness of care measures were used to track preventive screening rates and clinical outcomes, and the company's data warehouse vendor mapped clinic patients separately from those using community providers to permit comparative estimates of the per capita costs of health care and savings to cost estimates. RESULTS Employee Satisfaction The proportion of responses rated “very good” or “excellent” was 89% for being seen within 15 minutes or less and 96% for the medical professional spending sufficient time with the patient. The average wait time was 8.2 minutes, and the average total time that elapsed from registration to the completion of the examination and discharge from the clinic was 36 minutes for primary care visits and 28 minutes for all other visits. Ninety-five percent of respondents indicated that they would recommend the worksite clinic to their coworkers, and 96% of respondents indicated that they would return to the worksite clinic for future care. Clinical Results Tables 1 and 2 provide outcomes for selected HEDIS effectiveness of care measures, showing comparisons not only with commercial health plans but also in the case of diabetes management, to providers within the local community. Hemoglobin A1C testing was accomplished in accordance with the HEDIS standards in 100% of the diabetic patients affiliated with the worksite clinic compared with only 31% in those using community providers. Similarly, ophthalmologic examinations and screening for microalbuminuria were being done at a rate of 76% and 92%, respectively, within the worksite clinic for diabetic patients compared with only 40% and 12%, respectively, with local community providers.TABLE 1: HEDIS Effectiveness of Care MeasuresTABLE 2: Diabetes HEDIS StandardsFinancial Outcomes The company's data warehouse vendor was able to map worksite clinic patients separately from those who used community providers for primary care services. Figure 2 demonstrates the differences in per capita costs for all primary care services obtained from October 2004 through September 2005 for worksite clinic patients compared with community clinic patients. The data were adjusted by age, sex, and costs net of $30,000 to provide a more realistic basis for comparison. Worksite clinic patients demonstrated a per capita cost that was 42% less than that achieved by patients seeking care from community providers.FIGURE 2.: A comparison of the per capita spending for all categories of primary care services among patients being seen predominately through the on-site clinic versus community providers.A separate analysis for cost effectiveness was performed. Six months of clinical data were evaluated for the services delivered in the worksite clinic. That data were adjusted for health plan costs and discounts as well as employee copays to give a conservative estimate of the cost of these services they had been delivered by community providers. The actual costs to deliver these services at the worksite were computed based on laboratory charges, radiology costs, and the additional headcount necessary to provide these services. The annualized difference ($775,000) represented the cost avoided by providing the services on-site; the health care savings-to-cost ratio was ∼7:1, or a savings of $1.00 for every $0.15 spent. DISCUSSION On-site primary care fulfills the components of the Patient Centered Medical Home model, ie, accessible comprehensive primary care, a team-based approach, coordination of care, a focus on quality and safety, and a health information technology platform to support the successful achievement of population-level health outcomes. The Patient Centered Medical Home model allows the provider to be proactive in managing the population of patients they serve, including laboratory studies as in the case of diabetic patients, or by ensuring that preventive services are being offered. Thus, by integrating effectiveness of care metrics, costs, and patient satisfaction data as shown in this study, one is able to assess the total value of health care investments. The time return on an investment of this nature would be expected to stable, given that the primary care staff was added to an existing occupational medicine department and program costs would change only incrementally over time. The probability exists, however, that as more employees availed themselves of the clinic services, the cost savings would improve over time, given the lower per capita health care costs associated with the on-site clinic population compared with those using community health care providers and the increasing economies of scale. In addition, the results obtained for this Midwest manufacturing firm would be expected to be similar across different industries given that the prevalence of chronic disease and underlying health risks in this cohort were comparable with the general population. David E. Turner, MD, PhD, MPH Primecare Corporate Health Solutions Washington, DC