POPULATION HEALTH MANAGEMENT Volume 17, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/pop.2013.0095

Worksite Primary Care Clinics: A Systematic Review Victoria Shahly, PhD,1 Ronald C. Kessler, PhD,1 and Ian Duncan, FSA, FIA, FCIA, MAAA 2

Abstract

Despite levels of health spending that are higher per capita and as share of gross domestic product than any country worldwide, the US health care system is fragmented, technology and administration heavy, and primary care deficient. Studies of regional variations in US health care show similar ‘‘disconnects’’ between higher spending and better health outcomes. Faced with rising health benefit costs and suboptimal workforce health amid economic downturn, concerned US employers have implemented innovative payment and health care delivery strategies such as consumer-driven health plans and targeted prevention programs. The former may impose undue cost shifting, prohibitive out-of-pocket expenses, and health literacy challenges, while the latter have shown inconsistent near-term economic returns and long-term clinical efficacy. Employers have begun exploring more comprehensive health delivery platforms such as integrated worksite primary care clinics that have potential to cost-effectively address several pressing problems with current US health care: the growing primary care physician shortage, poor access to routine care, lack of coordinated and patient-centered treatment models, low rates of childhood immunizations, and ‘‘quality-blind’’ fee-for-service payment mechanisms. Such on-site medical clinics exploit one of the rare comparative strengths of the US health care system—its plentiful supply of highly skilled registered nurses—to offer workers and their dependents convenient, high-quality, affordable care. A relatively recent health care paradigm, worksite clinics must yet develop consistent reporting strategies and credible demonstration of outcomes. This review explores available evidence regarding worksite primary care clinics, including current rationale, historical trends, prevalence and projected growth, expected health and financial benefits, challenges, and future research directions. (Population Health Management 2014;17:306–315) Background and Purpose

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t is well known that the US health care system faces twin challenges of rising costs and declining access to care. Although US health spending growth remained below 4% in 2011 for the third consecutive year, total annual expenditures nonetheless reached $2.7 trillion, nearly 18% of gross domestic product.1 Escalating health care costs, inferior population health system performance, and suboptimal health and risk profiles of employees on the jobsite combine to drive up costs for US employers who fund the majority of health benefits for employees and their families. Historically, many employers have offered on-site occupational health services to treat work-related illnesses and injuries. In an effort to support workforce health and productivity more broadly and contain health-related expenses without undue cost or responsibility shifting, some em-

ployers have begun to expand former occupational worksite clinics to include more comprehensive primary care and pharmacy services. Such clinics have the potential to address several serious problems in the US health care system, including lack of coordinated and patient-centered treatment models, low immunization rates, high pharmaceutical pricing, and fee-for-service payment mechanisms that are indifferent to quality. The 2012 Towers Watson Onsite Health Center Survey2 of 74 companies offering or planning to offer worksite health centers reported that over 60% of respondents offer some form of primary care, and 66% offer occupational health. Almost all offer vaccinations and biometric screening. Many offer wellness coaching to help employees reverse lifestyle risk factors. Worksite health centers also may help offset the growing primary care physician shortage by exploiting the plentiful US supply of highly skilled registered nurses3 in order to offer workers

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Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. Department of Statistics and Applied Probability, University of California Santa Barbara, Santa Barbara, California. At the time of writing, Mr. Duncan was employed in Clinical Outcomes and Reporting at Walgreen Co., Deerfield, Illinois. 2

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and their dependents quality and affordable health care, conveniently located at the worksite. Worksite clinics are limited to employees, eligible retirees, and dependents, and should not be confused with freestanding centers for the public operated by physician groups or hospitals or with retail clinics that are increasingly open to the public inside stores and pharmacies. Worksite clinics frequently offer a full range of primary care and occasionally offer specialist care as well, while retail clinics generally are limited to acute episodic services and physical examinations. Some vendors that provide both clinic models, such as Walgreens, are integrating their retail and worksite clinic networks to provide broader access. Given the relative recency of worksite clinics, credible evidence of their prevalence, utilization, or cost benefits is scarce. The literature examining health and cost outcomes of worksite clinics is much less developed than comparable research on worksite health promotion. Not only are the majority of worksite data focused narrowly on targeted risk reduction programs, but the majority of pertinent juried publications on worksite clinics are confined to a single journal (the Journal of Occupational and Environmental Medicine). Most accessible information on the health and economic outcomes associated with worksite clinics is based on anecdotal industry case studies, external accounting audits, and benefits consultancy reports that lack articulated methods, nationally representative sampling frames, validated metrics, effect sizes, or even quantifiable outcome data.4,5 This review explores available academic data on US worksite primary care clinics published in English from the inception of several electronic databases to present, and summarizes the less systematic information found in media and industry reports. Topics include the current rationale for worksite clinics, historical trends, prevalence and projected growth, expected health and financial benefits, evaluation challenges, potential drawbacks, and suggestions for future research directions. Methods

A systematic search was conducted for original studies, meta-analyses, and literature reviews published in English and pertaining to worksite medical clinics. Six academic electronic databases were searched from their dates of inception to May 15, 2013: CINHAL ( January 1, 1982–May 15, 2013), EBSCO ( January 1, 1980–May 15, 2013), EMBASE ( January 4, 1980–May 15, 2013), Global Health ( January 1, 1960–May 15, 2013), PsychINFO ( January 1, 1960–May 15, 2013), and PubMed ( January 1, 1960–May 15, 2013). The following keywords were used singly or in combination: work*, onsite, in-house, employer-sponsored, primary care, clinic, center, efficacy, quality outcome, clinical outcome, economic, return on investment (ROI), ROI cost, claims, value*, measure*, method*, productivity loss, absenteeism, presenteeism, and disability. In contrast to the comprehensive literature on worksite health promotion activities, few academic papers on worksite clinics were identified. For instance, the PubMed search on health efficacy or quality of care returned 335 general references for workplace health promotion but no relevant citations for worksite clinics. Similarly, a PubMed search of academic publications during the last decade concerning financial returns on investment yielded 225

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general references for workplace health promotion but only 2 relevant papers on clinics.4,5 Given the research team’s interest in more inclusive whole health worksite clinics, publications relating exclusively to occupational medicine, or to health risk assessment (HRA), health promotion, or wellness programs were excluded. The full electronic search strategies are available upon request. A search of bibliographies from retrieved papers was then conducted for additional references and expanded to Google Scholar and then Google in order to identify government agency, trade, and media Web sites or articles of interest. The Corporate Snapshot—Health Care Costs for Employers

Several economic factors are implicated in rising health care expenditures, including the rapid aging of the US workforce and increased burden of illness. In 2007, 39% of the working-age population had at least one chronic condition, up from 35% in 2003, and an estimated 65% of these chronically ill adults or 46.6 million Americans were privately insured.6 Problems with the primary care system compound escalating health care costs and the greying of the population. Primary care visits generally are constrained by daytime and weekday hours of operation, and recent declines in the supply of primary care physicians7 have contributed to long scheduling delays and wait times.8 Moreover, reimbursement cuts have forced many physicians to shorten average appointment length.9 Hospital emergency rooms manage a growing proportion of primary care cases10 even among insured populations, complicating follow-up, especially for complex conditions. One solution to both the nation’s rising health care costs and fragmentation of care involves extending comprehensive primary care options beyond customary institutional walls.8,11 As typical full-time workers spend approximately half their waking hours at work12 and most workplaces offer ample opportunities for employer incentives and peer networking, the workplace is increasingly considered a valuable site for wellness promotion, intervention, and integrated primary care delivery.13,14 Approximately 62% of American workers receive employer-sponsored health benefits,15 although this number is depressed by the large number of employees at small firms that are less likely to offer health insurance. Growth in health costs has been shown to adversely impact the economic performance of US industries.16 In a 2012 national benchmark employer survey of 2121 randomly-selected, nonfederal public and private US firms, employer premiums for annual family health coverage averaged $15,745 per worker.17 Although the 4% increase in family insurance premiums from 2011 to 2012 observed in the 2012 benchmark employer survey is modest by historical standards, it still outpaced growth in workers’ wages by 1.7% and general inflation by 2.3%. Barring major unanticipated health reforms, it is estimated that employers will pay an average $28,000 per worker by 2019.18 Direct medical costs, however, account for only a portion of all corporate healthrelated expenditures as employers also must absorb substantial indirect costs associated with compensated sick leave, limited or modified duty, and work presenteeism.19

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The Corporate Snapshot—Health Care Costs for Workers

Rapid growth in the costs of health benefits have prompted employee cost shifting in the form of higher insurance premiums, coinsurance, and co-pays, posing serious burdens for workers. Consensus data from current US population surveys indicate that health care inflation has caused increases in outof-pocket medical expenses to grow disproportionately faster than workers’ wages.20 Average annual family insurance premiums have increased 97% over the decade since 2002, while workers’ wages increased 33% and inflation increased 28%.21 Although such burdens are obviously industry specific, in 2007 total average health spending for a family of 4 represented almost 58% of hotel cleaning and maintenance workers’ average annual earnings.22 Trends in Worksite Medical Clinics: Moving From Occupational Health and Minor Acute Care to Prevention Programs and Primary Care

Although larger companies have routinely sponsored onsite occupational health clinics equipped to manage workplace injuries, preemployment exams, safety and substance compliance, and return-to-work functional testing, a gradual decline in manufacturing hazards has led to many such clinics being closed or repurposed to treat minor acute conditions instead.8,23 Over the past 2 decades, employers have steadily shifted their focus from occupational and/or acute episodic care to in-house programs targeting specific modifiable health risks and unhealthy lifestyles that may undercut a productive workforce. The Web-based 2007/ 2008 National Business Group on Health (NBGH) Onsite Health Center Survey of human resources and health benefits managers at 84 US companies with 1000 + employees (totaling over 2.3 million workers) found that 75% of clinics established before 2000 (early adopters) concentrated on occupational health and safety, compared to 37% of those established after 2000 (recent adopters).24 Health promotion activities were sponsored by nearly two thirds of employers with at least 50 employees by the mid-1980s, and are nearly universal among large employers now.25 Numerous onsite wellness initiatives have been explored, including HRAs, health risk reduction programs, nurse help lines, behavioral counseling, health coaches and fitness programs, and smoking and nutrition clinics.4,12,26 The breadth of care provision offered in worksite clinics varies widely. Although the most ambitious clinics are staffed by multidisciplinary teams (eg, physicians, nurses, physical therapists, x-ray technicians, pharmacists), the treatment scope is highly variable and may include:   

 

Physical and wellness exams (eg, HRA follow-up, biometric screenings, blood work, electrocardiograms); Compliance exams (eg, drug screening); Occupational health (eg, treatment of work-related injuries, employee screenings, travel medicine, dispensing safety and protective gear, compliance with federal workplace safety regulations); Acute care (eg, treatment of minor acute episodes such as sore throats or sprains); Preventive care (eg, allergy shots, influenza vaccines, immunizations);

  

Employee assistance programs and other counseling; Chronic disease management; and Select specialty care (eg, dental, vision, audiology, dermatology, physical therapy, orthopedics, surgery, obstetrics-gynecology, pediatrics).

Larger and more comprehensive clinics are developing into full-scale patient-centric medical homes with integration into full service medical neighborhoods. Although the management of common acute conditions such as ear infections and respiratory problems at worksite clinics could greatly relieve overburdened US emergency departments, and clinicwide immunization could help reduce infectious diseases, surprisingly little is known about actual worksite clinic services and outcomes. Available data on the distribution of services rely entirely on business coalition and media sources. According to the 2007/2008 NBGH survey cited above, most clinics provided immunizations and screenings (81% and 83%, respectively) and urgent care and chronic disease management (62% and 64%), while far smaller proportions offered laboratory or radiographic services (32% and 36%) and therapy (physical or mental health/employee assistance program counseling, 23%).24,27 As expected, targeted prevention and wellness initiatives were reported in the survey to be much more prevalent than comprehensive onsite medical clinics, with 81% of companies offering flu shots and 66% offering HRAs, nurse lines, and/or disease management programs.28 Recent data suggest that integrated worksite pharmacy services may offer a particularly important avenue for improving employee health and reducing employer medical expenses by emphasizing treatment adherence. Pharmacy claims data comparing medication adherence of worksite-treated employees with those of community pharmacy users show significantly improved medication adherence for workplace pharmacy users.29 Growth, Services, and Satisfaction with Primary Care Worksite Clinics Growth

Available evidence indicates that worksite clinics are expanding rapidly,30 with annual US growth variously projected between 11%31 to 20%.32 Possibly 10% of all general medical care for adults ages 65 and younger may be provided at a worksite clinic by year 2015, compared to 4% in 2008. Assuming average campus employee/dependent utilization rates of 60%, the on-site clinic market could serve 13% of working Americans by 2015,32 although the average utilization rate of worksite clinics has not been reliably documented and may be considerably lower than 60%.32 In terms of clinic prevalence, comparable data are scarce, with the majority of figures based on industry or business coalition reports that are rarely evidence based or peer reviewed.5,23 Pertinent studies generally contain only minimal information on survey design, sample selection, or response rates. Industry figures using broad definitions indicate that between one quarter and one third of midsize and large employers sponsor some sort of worksite clinic on site or near site.9,24,27,33 Mercer’s 2008 Survey on Worksite Medical Clinics, the most widely cited source, reports that of the 345 (200 + employees) US public and private companies assessed, 100 (34%) had worksite clinics on site or near site,

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mostly restricted to occupational health services. Narrowing the definition to primary care worksite clinics reduced the estimate to 13%. Mercer’s more recent 2012 Survey on Worksite Medical Clinics, based on a smaller sample (131 companies) of somewhat larger companies (with 500 + compared to 200 + employees in the 2008 report), is not directly comparable to the older survey that reports that 37% of employers with 5000 or more employees operated occupational health clinics, while 15% sponsored an on-site clinic currently, with another 11% considering establishing one within 2 years. Among those with functioning primary care clinics, 82% cited reducing presenteeism as a primary motivator, while 75% cited reducing overall costs and 73% cited managing employee health risks and chronic conditions as other important factors. A 2008 Hewitt Associates survey focusing on medical worksite clinics among 248 midsize and large companies (500 + ) found 19% offering on-site medical programs and 11% offering worksite pharmacies.34 A health tracking household survey carried out at about the same time found 8% of American families had at least 1 family member using a worksite clinic in the past year. This population-based estimate of clinic use is predictably lower because many adults are employed in small and midsize companies that are not feasible sites for worksite clinics.23 Nurse management and services

Perhaps one of the greatest strengths of the worksite primary care clinic design is its heavy reliance on nurse practitioners, with physicians providing consultation. Nurses represent the single largest group of health care workers in the United States, with about 3.1 million nationwide in 2012 (more than 10 times the number of practicing primary care physicians).35 In contrast to the low US population density of primary care physicians relative to other Organisation for Economic Co-operation and Development countries, the United States has the highest population density of nurses (10.8/1000) and highest nurse-to-physician ratio.36 In many worksite health centers, primary care is delivered by physicians and nurse practitioners, with the latter representing about 3.5% of all nurses in the United States. Registered nurses also are employed to provide care, education, and preventive services. Although large self-insured employers with low employee turnover and high concentration at worksites are more inclined to fund the initial capital investments and ongoing operational costs necessary for full-service on-site clinics, smaller employers have begun partnering with nearby companies to operate ‘‘near-site’’ clinics as well.23,37 Larger national employers tend to contract with national worksite vendors who have the advantage of serving many employer sites and practicing nationally with consistent standards of care and quality. Although overall only 11% of employers share clinics with nearby employers, this percentage increases to 65% among small employers (200–999 workers),32 although employers with worksites in rural communities tend instead to contract with local providers such as physician groups and local hospitals because of limited availability of managed care networks and third-party vendors. Management models range from direct employment of clinic staff to contracting with third-party vendors or external health care

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providers to operate the clinics. As medical care and data confidentiality are remote from their core competencies, most companies choose to outsource clinic operations.23 Regardless of management model, the employer wishing to establish a new worksite clinic must first address medical, labor, and data security regulations at both federal and state levels. Federal regulations guarantee the privacy of employee health records and govern health savings accounts. State and local regulations govern the licensure of health care facilities and medical providers, medical data privacy and access, biomedical waste disposal, handling and storage of laboratory specimens, and pharmaceutical control. Although different regulatory environments may complicate oversight and credentialing for employers with clinics across multiple states, some standardization is nonetheless possible across sites. An employer wishing to establish a worksite clinic must navigate a complex regulatory environment from regulations governing professionals and the practice of medicine, to regulations covering corporate, labor, privacy, and data security matters at both the federal and state levels. Because the breadth of services provided at a workplace clinic varies greatly and there is a heavy reliance on nurse practitioners to provide such services, careful attention must be devoted to ensuring that the nurse practitioner is operating within his or her scope of practice. This includes ensuring that tasks are appropriately delegated by a supervising physician, that standing orders are utilized appropriately, if necessary, and ensuring that the nurse practitioner has authority to dispense and prescribe prescription medications. Similarly, state laws may dictate how the workplace clinic must be structured from a corporate perspective and also whether employers operating a workplace clinic can directly employ the physicians and potentially other providers at the clinic. Many states recognize the ‘‘corporate practice of medicine’’ doctrine prohibiting a physician from being employed by a ‘‘lay person’’ or by a corporate entity that is not itself licensed to provide professional services. When establishing a workplace clinic in a state that recognizes the ‘‘corporate practice of medicine,’’ a ‘‘friendly’’ or ‘‘controlled’’ professional corporation structure may need to be utilized in order to employ the physicians providing services at the workplace clinic. Such a structure involves forming a professional corporation (PC) or limited liability company (LLC) whose shareholders and officers are all physicians in order to comply with the corporate practice prohibition. The PC or LLC would employ the physician providing services at the workplace clinic and additional controls may be included in the physician’s employment agreement. Although compliance with federal and state data security and privacy regulations can be challenging given the myriad participants and wide range of organizational structures in the ‘‘typical’’ workplace clinic, compliance with federal and state data security and privacy regulations is critically important. The services provided at each workplace clinic range from flu administration and vaccinations to primary care, and a health care provider’s ability to disclose a patient’s clinic health record is restricted by Health Insurance Portability and Accountability Act and state privacy laws unless an exception applies. Whether a certain type of record is considered ‘‘occupational health’’ will dictate whether this information may be disclosed. Because different

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types of occupational health records are governed by different laws (eg, Occupational Safety and Health Administration, Department of Transportation, Family and Medical Leave Act, workers’ compensation laws), there is not a universal scheme that standardizes these disclosures. Rather, there are a variety of laws and regulations at play, the applicability of which may depend on the nature and purpose for the underlying health service. Finally, at an operational level, workplace clinics must comply with federal and state regulations related to biomedical waste disposal, handling and storage of laboratory specimens, and pharmaceutical control and adverse reporting requirements. Notwithstanding the different regulatory landscapes that may complicate oversight and operations for employers with clinics across multiple states, some standardization is possible across sites. Employee fees, utilization, and satisfaction

According to Mercer, about 41% of employers charge employees nominal co-pays ($5–$10 per visit) for workplace clinic services.9 Cost sharing is becoming an increasing reality though, and although 70% of early clinic adopters still provide free services, only 56% of recent adopters do.24 Reported utilization rates vary widely by source, ranging between 25%–60%. Half of the midsize and large companies (200 + ) in Mercer’s 2008 study reported only 25% of eligible employees using clinics in the past year, while one quarter said that 50% or more did.9 The Hewitt Associates 2009 survey on health care trends found 27% of eligible employees using clinic services over the past year.28 The range of company sizes sampled was unreported. The NBGH survey of large companies (1000 +) estimated that, on average, health clinics are used by 50% of active employees on campus.27 There are scant data on employer or employee satisfaction with clinic performance. In their dedicated study of worksite clinics, Hewitt Associates found that 81% of employers were satisfied with clinic performance.34 However, in a health care industry in which satisfaction is often well above 90%, such results may indicate problems. Results were more detailed in their larger health care trends survey, in which 35% of employers were highly satisfied with their on-site clinics, 50% were satisfied, 13% were somewhat satisfied, and zero were not satisfied. Information on employee satisfaction was limited to incidental and selective disclosures from industry or media sources. For example, although reporting a breakeven on operating costs for their new Arizona worksite clinics, the director of Intel’s global benefits design commented that patient satisfaction was nonetheless 98% in January 2011,40 while QuadMed’s medical director said the proportion of employees with chronic conditions reporting ideal care rose by 14% from 2006 to 2008.41 According to the NBGH, although the majority of clinics serve employees actively enrolled in the health plan (whether on or off shift), 87% also serve regular benefit-eligible employees, 71% serve part-time employees, 25% serve covered dependents, and 20% serve retirees.24 Challenges associated with treating dependents and retirees include adequate capacity, access, security, and safety, especially in settings of government defense or heavy industry.23

SHAHLY, KESSLER, AND DUNCAN Benefits of Worksite Primary Care Clinics Outcomes

Though limited in scope, workplace-directed interventions and health promotions have been evaluated most often along specific dimensions such as rates of alcohol or tobacco use, biometric changes, pain intensity, and functional status. Strong correlational data indicate that multiple risk factors and high self-reported stress are linked to higher healthrelated employer costs,42–44 and that health promotion improves employee health and reduces direct medical costs and/ or indirect sickness-absence costs.43,45–57 However, although reviews and meta-analyses provide guarded support for both their positive health58–60 and economic outcomes,58,59,61–64 formal outcome studies have been limited to freestanding worksite programs and have been dogged by multiple methodological problems including small sample sizes, convenience samples, selection bias, skewed data, weak evaluation metrics, and lack of complete integrated data.13,25,26,65–68 Furthermore, rigorous attempts to specify benefit-cost ratios have yielded inconsistent findings. For example, nutrition and exercise promotion showed reduced direct and indirect costs according to non-randomized designs, but not randomized controlled trials,69 or using either design type in conjunction with some outcomes (eg, physical activity, musculoskeletal) but not others (eg, fatigue).70 In contrast, randomized-controlled trials of workplace screening and depression outreach programs found robust direct and indirect financial yields at 6 and 12 months71 and 5 years.72 Data on the time course of ROI are even weaker and less widely available, as few controlled evaluations follow samples long enough to provide accurate estimates of expected time to achieving a positive ROI.71,73 Whether such health promotion programs would yield more robust results if couched within comprehensive worksite clinics equipped to track and treat emerging chronic conditions remains untested. Benefits for employers

Worksite clinics offer employers better control over direct medical spending than comparable fee for services in the community. Predictable near-term savings, sometimes referred to as ‘‘hard ROI,’’ are generated by avoidance of needless emergency department visits and hospital admissions, direct contracting for inpatient and specialty services with community providers willing to exchange discounts for volume,14 and conversion of nongeneric prescriptions. Reduced employee travel, release, and wait time is another source of quantifiable savings, yielding approximately 3 hours more productive on-the-job time versus communitybased appointments.14 Many companies also have ‘‘virtual waiting rooms’’ that exploit technologies such as mobile texting, instant messaging, and e-mail to permit real-time notification of workers when clinicians become available, further enhancing employee productivity.74 Longer term savings or ‘‘soft ROI’’ may result from improved workforce health secondary to rapid response to industrial injuries and minor acute ailments, prevention or early detection of serious diseases and chronic conditions, and deterrence of disability and liability claims.4,23 Less tangible but significant rewards may include improved staff morale or loyalty and enhanced perception as an ‘‘employer of choice.’’14,23

WORKSITE PRIMARY CARE CLINICS Benefits for employees

Advantages of worksite clinics are not limited to employers. It is estimated that only one third to one half of the US workforce receives regular medical attention.9 The on-site clinic provides convenient access to a range of providers, minimizes employees’ time and travel barriers to care, and promotes positive health behaviors. More specifically, on-site clinics may reduce existing socioeconomic and racial health disparities by improving general health care access.75,76 The convenience of on-site services with the possibility of offhours service may improve personal on-the-job productivity and reduce job strain. Fewer scheduling delays, more physician ‘‘face time,’’ coordinated referrals to contracted highperformance networks of specialists and local hospitals, and integrated wellness promotion and health educational components may all enhance clinical outcomes. Most employees also have reduced out-of-pocket expenses by way of minimal or waived co-pays, and may enjoy other incentives such as lower insurance premiums or financial contributions to health savings plans.25,77,78 The Economic Argument for Worksite Primary Care Clinics

In keeping with much of American health care, little proactive, data mining-based outreach is undertaken in worksite clinics (although they are ideally situated to do so).79 NBGH estimates that 41% of recent clinic adopters and 58% of early adopters do not link on-site health center data with medical claims.24 An additional 19% of recent clinic adopters and 16% of early adopters do not even store data electronically.24 Reporting, particularly of outcomes, also is frequently inadequate: in the NBGH survey, 45% of employers with on-site clinics self-reported a lack of adequate performance measures.24 The Hewitt Associates survey of health care trends found 58% of employers relying on basic trade measures such as medical cost trend reduction, while 57% relied on program utilization metrics.24 Hewitt Associates comment, however, that although utilization rates are easily measured, they generally provide insufficient basis for evaluating outcomes and program effectiveness.28 Only 38% of employers measured participant satisfaction, and fewer than 20% considered participants’ behavioral changes.28 No credible systematic information was located on cost offsets or avoidance related to clinic impact on absenteeism or presenteeism. Worksite clinics generally have not been integrated with community providers, either clinically or in terms of data exchange, although this constraint is rapidly changing. Lack of complete administrative data makes it necessary to estimate the effectiveness of the clinic indirectly by comparing population health status, health risk factors, costs of clinic services vs. community cost (for the same services), comparing projected health care costs versus actual costs after clinic implementation, and comparing health care costs after clinic implementation versus those of other companies in the community or in the same industry or versus other campuses in the same company without clinics.23 Methods for economic evaluation and standard reporting measures enabling comparisons have yet to be systematized within the industry.15,80–83 Historically, worksite clinics have operated on a fee-forservice (cost-plus) basis. However, financial pressure and the

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development of alternative financing methods for employer health care (such as pay for performance, medical homes, and accountable care organizations) are stimulating interest in at-risk financing methods among sponsoring employers. Evidence-based data on the timeline of investments and returns also are minimal.73 NBGH estimates that most companies with on-site clinics realize a positive ROI within 1 to 2 years of start-up.27 Examples of such quick returns are common on industry Web sites. For example, the worksite clinic operated by the city of Port St. Lucie, Florida reports a 6-month 3:1 ROI with lower outpatient drug, lab, X-ray, occupational health costs, and absenteeism.84 QuadMed reports a 1-year ROI of $2 million associated with early disease detection and reduced emergency visits at its parent company QuadGraphics.41 Other sources, however, suggest that 2–5 years to achieve breakeven may be more realistic.23 Challenges for Worksite Primary Care Clinics

Although a major challenge of existing primary care worksite clinics is the absence of a standardized methodology to assess and quantify ROI,85 regulatory compliance and patient safety also remain important concerns. A comprehensive literature review of compliance concerns and administrative risks associated with worksite clinics from 2000 to 2010 yielded only 22 publications in industry databases, professional Web sites, and journals, none of which reported study designs or quantifiable outcome data.5,85,86 Although the on-site clinic may improve workforce productivity and contain health-related employer costs, there are some potential challenges such as patient privacy,39 conflicts of interest, corporate paternalism, and ability to treat the entire family (not just the employee on site).31,84,87,88 Although workplace screening and outreach programs are highly effective,71,72 the integration of onsite primary care with coexisting health promotion programs also is inconsistent, limiting clinical results and economic returns.24,27,32 NBGH estimates that 19% of employers fail to integrate medical services with other company health and productivity programs, while another 17% fail to establish connections with local specialty providers.24 Worries about privacy also have been managed concretely. Disney, for instance, equipped their $6 million worksite clinic with patient pagers, white noise machines, and privacy doors.84 Legal liabilities are possible, but likely reduced in management models relying on third-party vendors or existing community health providers.89 Noncompliance with federal or local health regulations may result in direct employer costs by way of penalties, civil actions, licensure loss, or criminal charges; and indirect costs by way of employee mistrust and avoidance of clinic services.86 Media sources have questioned whether the rapid growth of on-site clinics might shift the residual patient mix in the community toward less lucrative Medicare, Medicaid, and self-pay cases.90 It has been countered, however, that worksite clinics would relieve community physicians rather than rob them of patients given current shortages of primary care physicians, a situation that doubtless will increase as the Affordable Care Act produces additional demand for services.41 Summary of Findings and Future Directions

The US health care system is fragmented, technology and administration heavy, and primary care deficient. Cross-

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national and regional US studies show ‘‘disconnects’’ between higher spending and better health outcomes. Faced with the escalating cost of health benefits and suboptimal workforce health amid economic downturn, concerned US employers have implemented innovative payment and health care delivery strategies such as consumer-driven health plans and targeted prevention programs. The former, however, may impose undue cost shifting, prohibitive outof-pocket expenses, and health literacy challenges, while the latter may fail to demonstrate convincing near-term economic returns or long-term clinical efficacy. Progressive employers have begun exploring possibilities of whole health medical delivery with the ‘‘captive audience’’25 of workers at the jobsite. The worksite primary care clinic is an ambitious health delivery platform with potential to directly and cost-effectively address several pressing problems with current US health care.67 The worksite clinic paradigm (broad office hours, low wait time, long appointment time, personalized and skilled nursing care, on-site pharmacy) has particular promise to offset the growing US primary care physician crisis, lack of patient-centered care, and current ‘‘technology heavy’’ treatment models. Worksite primary care clinics are relatively new developments within the more established occupational health system. Although clinics with a narrow occupational emphasis can prevent episodic injuries from escalating into chronic disabilities, more substantial clinical benefits and cost savings are obtained using primary care models that influence broader practice and prescription patterns, facilitate early detection and treatment of serious conditions, and avert emergency visits and hospitalizations.23,27 Market pressures, dynamic changes in the demographics of the US workforce (increased age and morbidity), and major health reforms all underpin the recent expansion of worksite clinics. Reported benefits include reductions in both direct and indirect health care costs, with reductions in workers’ compensation, disability, and life insurance claims; employee turnover; absenteeism; and presenteeism. Although credible, peer-reviewed cost-benefit evidence is scarce, reported financial returns range from 10% to 30% savings off total health care expenditures, an estimated $7 to $20 billion savings for the roughly 1200 employers currently operating them.32 Nonetheless, the broad consensus of available published sources within the last decade is that worksite clinics provide convenient and high-quality health care for employees and produce prompt and stably positive ROI for employers.4 The well-administered worksite clinic may offer employees a comprehensive patient-centered ‘‘medical home’’ that provides accessible team-based, preventionfocused primary care,77,79,91 reduces socioeconomic health inequalities, and offsets physician shortages in the community. Future research on worksite primary care clinics must develop standardized methods to quantify and report both health outcomes and ROI.85 Supporting the refinement and validation of outcome metrics, future reports must conform to scientific conventions when reporting data, articulating methods, and specifying sampling frames and effect sizes. Although the impact of worksite primary clinics on the local economies of host corporations is important, an equally vital project is a broader examination of their potential impact on the national economy and health care crisis.

SHAHLY, KESSLER, AND DUNCAN Author Disclosure Statement

Drs. Kessler and Shahly and Mr. Duncan declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Support for Drs. Kessler and Shahly was provided by a grant from the Walgreen Company to Harvard Medical School, Department of Health Care Policy. Mr Duncan is an employee of Walgreen Company. The authors thank Thomas Parry, PhD, Bruce Sherman, MD, and Jennifer McMurray, PharmD for valuable comments on an earlier draft. References

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Address correspondence to: Ian Duncan, FSA, FIA, FCIA, MAAA Dept. of Statistics and Applied Probability University of California Santa Barbara Santa Barbara California 93106 E-mail: [email protected]

Worksite primary care clinics: a systematic review.

Despite levels of health spending that are higher per capita and as share of gross domestic product than any country worldwide, the US health care sys...
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