Company care: Employers turn to on-site clinics

Large corporations are finding that putting physicians on the payroll can keep workers at work by preventing injuries and promoting wellness. And offering work-site clinics saves money.

By Mark Moran, amednews correspondent. April 1, 2002.

W hole Health Clinic, for employees of Continental Airlines at Cleveland's Hopkins Airport, has the look and feel of a doctor's office anywhere: waiting area, receptionist's window, exam rooms. And on a recent morning, Stephen Weirich, MD, a family physician and corporate medical director at Whole Health, prepares to treat complaints familiar to any primary care practice.

But Dr. Weirich's work at the clinic also has taken him out of the confines of the office and into some places the average family doctor never ventures -- such as the cramped baggage compartments of airplanes where some Continental employees work loading and unloading luggage.

That's the kind of firsthand experience a physician needs when 80% of his patients present with work-related injuries or illness. "There are some real ergonomic issues there," Dr. Weirich said.

Then there's the framed poster in the clinic that reads: "Rule No. 1: If the customers don't like it here, they'll go someplace else."

The sign would appear to be something more than a platitude, since the patients who visit the clinic are insured under conventional employer-sponsored health insurance. Sidestepping managed care plans, Cleveland-based Whole Health Management Inc. contracts directly with the employer to provide a service that complements those plans; employees come to the Whole Health clinic because they incur no cost and no co-payment, because it is conveniently located at the airport or because they like it there -- but if they don't like it, they do have other choices.

In these and other ways, the clinic at Continental Airlines is neither your typical primary care clinic nor a conventional practice in occupational medicine.

One clinic provider offers 150 work-site facilities in 30 states.

Instead, leaders at Whole Health say the Continental site and 35 others around the country represent a new version of an old model of care -- the work-site medical clinic -- retrofitted to the realities of a 21st-century American health care market.

Among others, the company's clients include Nissan Motors, USA Today, American Airlines and several federal agencies. While the Continental clinic treats only employees, some of Whole Health's 35 other sites around the country also treat dependents.

Wedding an orientation toward prevention and "wellness" with a focus on job-related health and illness, Whole Health and similar companies offering work-site medical practice strive for a hybrid of conventional primary care and occupational medicine conveniently located where people spend the majority of their lives.

In so doing, they hope to eliminate the distinction between work-related injuries and nonwork-related health conditions.

"It is clear to us that those are not entirely separate entities," said Bruce Sherman, MD, vice president for medical affairs. "Employers are starting to realize that whether the employee is injured or ill, on or off the job, the lines are blurring between work and nonwork. What we offer is a more integrated perspective on health."

Creative alternative

Companies offering work-site practice say they can reduce employer health care costs by preventing injuries and reducing claims, promoting health and wellness, and decreasing absenteeism.

"With the specter of health care costs back in the double digits, businesses are looking for a creative alternative to get a better return in terms of access, quality and cost," said Michael Hardies, MD, chair and chief medical officer at CHD Meridian Healthcare of Nashville, Tenn., a pioneer in work-site medical practice.

CHD Meridian has 150 sites in 30 states, largely serving employees of Fortune 500 companies and government agencies and -- in some cases -- their dependents. The company's clinics may be located on-site in offices or plants or may exist as stand-alone buildings near the work site.

In addition to the convenience of on-site care, the clinics also offer employees discounted co-pays, Dr. Hardies says.

The amount of discounts vary from employer to employer, as does staffing. Clinics range in staff size from a single half-time physician to 10 full-time physicians with a support staff of a hundred people. They offer primary care along with services traditionally performed by occupational and environmental health professionals, such as ensuring work-site compliance with regulations of the Occupational Safety and Health Administration.

Dr. Hardies says many sites also have pharmacies writing as many as 1,000 to 1,400 prescriptions a day. "In the last five years, our growth has been meteoric," he said. "This year, it is expected that we will bring on another 20 or 30 sites, and as many or more next year."

Dr. Hardies and Dr. Sherman both say their companies prefer to hire primary care physicians and train them to deal with occupational issues, rather than the other way around.

And both agree that today's work-site clinics are newly attractive to physicians fed up with the hassles of private practice.

"What we offer physicians is the ability to do what they do best -- practice medicine," Dr. Hardies said. "Much of the paperwork is handled for them, and they are paid a straight salary, with performance requirements, that is equal to or greater than what is offered in the community."

At the Whole Health Continental clinic, Dr. Weirich concurs. "I don't have to worry about beefing up my patient load to meet payroll or overhead. I can focus on practicing medicine."

Wave of the future?

Advocates of work-site medical practice believe the model has the potential to become a staple of health care delivery. "If people step back and look at the power of the model we are creating, it really is the wave of the future," said Whole Health CEO and founder Jim Hummer.

Hummer says the impetus for the new model grew out of the misaligned incentives of employers and health care professionals that characterized fee-for-service medicine and that contributed to the rise of managed care. But where managed care has failed to fulfill the promise of prevention and long-term health promotion -- because of rapid member turnover in health plans -- the model of work-site medical practice has staying power.

Health care industry analysts agree that employers are seeking new ways to cope with the resurgence of medical costs and that the model represented by Whole Health and CHD Meridian is part of that trend.

But Kenneth Abramowitz, a health care analyst and managing director of the Carlyle Group, says it is liable to remain a specialized opportunity for select companies rather than an encompassing answer to rising health care costs. "The impact on [overall] costs is going to be modest because the highest percentage of health care costs is not in primary care."

Rather, the great bulk of health care costs are related to care of patients with multiple, chronic conditions -- many of whom are retired or not employed. "Twenty percent of the patients make up 80% of the total costs," Abramowitz says.

Constance Hanna, MD, MPH, corporate director of health services at Honeywell International in Morristown, N.J., says the convenience of work-site primary care makes it attractive to employers. Honeywell has considered outsourcing primary care -- but not traditional occupational health care -- to an on-site provider.

"Nowadays when employees go to primary care for acute episodic care -- colds, flu and the like -- our feedback is that it takes days or weeks to get an appointment, by which time they are well," she said. "Minimizing time away from work is a major issue for employers, especially when a lot of that time is spent not in actually getting care, but waiting for it."

But Dr. Hanna said that unless the return on investment is measurable -- in terms of reduced absenteeism and other factors -- companies that contract for on-site medical care while also providing group health insurance might not know whether they are double paying for health care.

And she suggested that ideally the on-site medical clinic would be a part of the employer's health plan. "If the on-site clinic is truly the employee's primary care, it allows physicians to know their patients and manage complicated conditions over time."

Dr. Hanna thinks that if on-site medical care is not part of the company's health plan, it is best confined to acute care. "The management of chronic disease states needs to be done in the context of a long-term relationship with a primary care physician."

Similarly, she said she would question the wisdom of outsourcing management of occupational concerns traditionally handled by in-house occupational health staff.

"If you outsource the whole package, including occupational health, they may not have the expertise on the occupational side -- especially for companies that have complicated issues around chemical exposure -- to provide the support you need, plus do primary care well," she said.

That for-profit companies offering work-site medical practice are thriving today underscores the obsolescence of "corporate practice of medicine" laws, passed by a number of states early in the 20th century. In many locations, those laws have been amended to allow for care by professional practice entities -- aligned with corporations -- in which medical decisions are made entirely by physicians.

But the potential dilemmas that gave rise, in part, to those laws adhere to today's work-site primary care practices: To whom does the work-site physician owe primary allegiance -- the contracting employer or the patient?

Who's the boss?

Because of the need to demonstrate cost savings, work-site physicians acknowledge they must walk a straight and narrow line between the two. "We really need to define ourselves as being right in the middle," Dr. Sherman says. "Although we are hired by the employers, we have the same level of responsibility to the patients."

In this regard, that poster in the halls of the Whole Health Clinic -- "Rule No. 1" -- resonates. "We clearly need to do our job well, otherwise the employer won't keep us, but we also need to honor requests of the employee, or they will stop using our clinic," Dr. Sherman says.

More than 70 years after businesses began offering group health insurance to workers, the resurgence of work-site primary care practice would seem to signal a new level of intimacy between work and the provision of American health care.

Says Dr. Sherman: "We are offering convenience to the patient, such that this is a place to establish a more involved relationship between doctor and patient, with an emphasis on prevention and health promotion that the current reimbursement system doesn't reward."