While Hillary and Obama are debating how to save health care and we all rail against the drugstore clinics, a quiet revolution in primary care delivery is happening right under our noses.
I’m talking about employer-based health clinics. In-house clinics operated on site at the job, usually staffed by mid-level practitioners and maybe a doc, sometimes including a pharmacy.
What got me thinking about workplace clinics?
Well, a few days back, a young patient who I had not seen in 3 years arrived for an appointment, abnormal pap smear in hand, requesting a coloposcopy. She had been referred back to me by the nurse practitioner at her job, where she had been getting free pap smears since I had last seen her.
That same day, I hear that Walgreens has bought both I-Trax, Inc (CHC-Meridian) and Whole Health Management, two of the county’s largest operators of workplace health clinics.
“These announcements mark an important strategic initiative for us,” said Walgreens Chairman and CEO Jeffrey A. Rein. “Walgreens Health and Wellness division will marry our store clinics and pharmacies with worksite health centers and pharmacies. Our unique offering will allow large employers and health plans to provide care to employees and plan members at their worksites, and to dependents and retirees through our Take Care Health Clinics at local Walgreens drugstores.”
Are you thinking what I’m thinking?
Two Ways to Look at it
Now, there are two ways to looks at the situation. The first is to believe all the press releases and see this as a win – win for both patients and employers. Employees get inexpensive, on-site, convenient health care. There is opportunity for development of long term relationships with patients, which enhances interventions to treat chronic diseases, especially those that have a lifestyle component. Combine this with on-site fitness centers such as those offered by I-Trax and Whole Health, and you have a model for the development and maintenance of a healthy workforce.
Of course, the cynical way to look at it is to say that Walgreen’s acquisition of employer-based clinics is just another way for them to capture the prescription drug market. In this regard, it will be very interesting to see if Walgreen’s keeps I-Trax and Whole Health’s employer-based fitness center products as part of their business model. I suspect that they may not. A recent survey of employer based clinics found that while older clinics were more likely to include physical therapy and mental health benefits, newer ones were more like to to offer pharmacy benefits.
Workplace-based clinics have the potential to destroy ongoing doctor-patients relationships that employees may have outside the workplace (as happened to my patient and myself). Not to mention that they are gleaning the healthier patients, leaving the community-based docs to deal with the sickest patients while losing the revenue generated from primary and acute care.
One might also argue that this is more of what NHS Blog doctor calls the “dumbing-down of health care” – the shift away from highly trained and experience doctors towards lower level, cheaper providers. Because the truth is that most workplace clinics are staffed by mid-level practitioners “supervised” by an MD, who may or may not be on site. Thus, in return for convenience, employees will receive the bulk of their primary care from someone other than a doctor. Of course, that’s the way it is anyway in most managed-care primary practices these days (except of course, Dinosaur Doc’s ), so maybe this will be nothing new.
How big is the movement to employer-based clinics?
According to a recent article in the Milwaukee Sentinal, 23% of 600 large companies surveyed reported that they were providing health care on site for their employees. These include companies like Sprint/Nextel, Qualcomm and Pepsi, just to name a few.
Walgreen’s is not the only company getting in on Employer-Based Clinics. Some medical centers offer on-site care to large employers, guaranteeing their continued place in the provision of primary care and a nice referral base for their hospital and specialists. Individual physician practices may also contract with local employers to provide on site care.
What happens next?
Something tells me that pharmacy run employer-based health care is fraught with conflict of interest that may not necessarily be aligned with those of the employers or employees. But I think the business model is making sense for employers, at least from what I’ve gleaned in my readings on the topic. And if I were a medical center, or a primary care practice in an area with a big employer, I’d be thinking about scrambling to get those employer contracts for myself before Walgreen’s snatches them all up.
As for my patient, I was more than happy to do her colposcopy, and she decided she would stay with me rather than go back to her employer for follow up.
Still, I called her workplace nurse practitioner, gave her the biopsy results and sent her some of my cards. I figured at least I might be able to get a few more referrals before she puts me out of business.
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Other Blog reactions to Walgreen’s announcement
Healthbeat Blog – “Health care is a public good, and as such, should be delivered by non-profit organizations overseen by government organization that reviews quality and is accountable only to the public.”(via Kevin, MD)
Brian Kleppert – if the physician community remains scattered and dis-united, it could spell the end of medicine as a cottage industry, and the next big phase of true corporate medicine in America.”
Listen to an NPR story on Employer based clinics
I guess I am a bit of a cynic. I think having a work-place health care provider really has potential for invasion of privacy, even with HIPAA. Especially with how nosey people can get.
Besides, it would be awfully hard to fake a dr’s appt to play hookey when the doc is on-site.
I’ll still go see my own doc.
I have worked in a company that provided a clinic that was staffed with nurses and doctors for both Occupational Health programs as well as clinic services.
It’s convenient and weird all at the same time.
Let’s cover convenient. When I went to get married and needed a blood test, it was so easy to go to health services, let them draw the blood and run the syphilis test. It was free and I had results in a day. HOWEVER, if I were in a position to NEED a syphilis test, my employer would be the LAST PLACE ON EARTH that I would turn to.
I am confident that the results would not be maintained in a confidential way (based on past experience of this occurring), and if I should ever have a dispute of any sort with my employer, I would not want them to have direct access to such immensely personal information.
The docs that were there serously lacked credentials. Granted, they are more than qualified for a prescrition for a Z pack for strep throat, but I wouldn’t want them to mess with my BP meds – or for them to know that I was on them.
I just think it is really invasive if your company is providing your primary care. I can’t believe that someone would have a pap done at work. To me, this is when the company really owns you. When I worked at this firm, I could get my dry cleaning done there, buy cards and gifts (nice ones too), have all my meals there – including dinners – have the car detailed, have the car oil changed, do all of my banking there…you get the drift. They make it easy for you to live your life there so you can work more hours. Is it convenient? Yes. But it is convenient for the company too.
I collect a check so I can go off and live my life. Seeing my doctor is very much a part of that…
I do admire companies that are trying to get more affordable healthcare to the masses, but people need to draw the line someplace.
In what way was your relationship with this patient destroyed? Was it personal, that you were hurt that she’d gone somewhere else for her care? Was it medical, in that you didn’t know or have access to the records of how she’d been treated in the intervening years? Or both, or something else entirely?
It’s always fascinating to me to hear from docs about the demise of the doctor-patient relationship, because as far as I can tell, outside of rural areas, the doctor-patient relationship for the kinds of interactions that would take place at these workplace clinics, or the walmart/walgreens/etc. clinics, doesn’t exist. Perhaps for pediatrics, if you’ve had the same pediatrician since your child/children were small, you may have some relationship since you had the frequent well-child visits in which to build one. If you have a baby, you get to know your OB pretty well because of the frequent appointments, but even there everyone I know sees the nurse practitioner more than they see their OB. My GP doesn’t know me from Adam (Eve?) and most of the time I end up seeing one of the revolving door of nurse practitioners anyway since I dont want to wait three weeks to get a throat culture or an inhaler refill.
Managed care further compounds the problem by requiring specialized care to be within the medical group, so if you actually have a health problem, you may have to change medical groups to get good care right at the time when continuity with primary care would be highly beneficial.
As far as I can tell workplace clinics and pharmacy/big box store-based clinics are a symptom of the breakdown of health care provision, not a cause.
Anonymous #1 – Agree, the potential is there for loss of privacy, as apparently Schruggling found out.
Schruggling –
Your results were not confidential? Tell us more…That is quite concerning.
Anonymous#2-
I would say that if a patient leaves my practice and goes elsewhere to get her medical care, then that doctor-patient relationship no longer exists, wouldn’t you? It’s not personal, my feelings are not hurt, but it is a matter of fact.
As to the nature of my relationships with my patients, they are as varied as the patient. Some see me once a year for a quick visit, others come more often because they have problems or issues. Some pour their hearts out to me, others are more guarded. Some see me once a year and call me once a month (a relationship that I would call high maintenance…)
But what all of them have in common the simple fact that I am their doctor. That if they call me with a problem, I will see them. That I know their history, and place my treatment in that context. That I take responsibility for their healthcare.
If the relationship you have with your primary is what you describe then an employee-based clinic probably won’t seem any differnt for you, as I alluded to in my post.
Totally agree with your last statement.
Peace,
TBTAM
One of the things I like about reading blogs is that I get a little insight into how other people’s lives work. So, I almost laughed aloud when I read that some of your patients call you once a month. I just can’t even imagine. It’s so out of my realm of what I would do, you know?
And then my brain goes all, “Hi, TBTAM, just thought I’d call to tell you that I tried that fig recipe you posted tonight!” At least that would be bettter than “Hi, TBTAM, just calling to let you know that I have cramps and took a couple aspirin.”
(I’m sure my reaction sounds mean to someone who’s really sick and calls about real things, but my experience is so different that my brain doesn’t go there right off.)
I imagine for lots of relatively healthy people who see a doctor every year or less, there doesn’t seem to be much of a relationship so an easy clinic makes sense. (My doctor seems perfectly pleasant, but I’m very happy with our minimalist once a year relationship.)
Workplace clinics, like doctors and doctor offices, come in all shapes and sizes. The mature services available through employers who have chosen this form of benefit delivery are the rival of any good physician office.
We have been working with this “new trend” for twenty years and our clients continue to outpace local physician practices in service, technology, effectiveness and quality. Simply put, the “workplace clinic done right” recognizes access, quality, privacy, information technology and the health status of the employee base as high priorities for their health benefit dollar.
As an example, QuadGraphics has had this in place for the last sixteen years and they have HEDIS scores that rank aboce any HMO in the country. This ia a company that has been on the Forbes “best Places to Work” list 15 of the last 20 years and which is deploying its second EMR (electronic medical record) at a time when most physican offices and hospital clinics are “thinking about” their first. They implemented HIPAA standards (patient privacy) when hospitals and doctor groups were still whining about an extension. Again, this is a printing plant that chose to implement good ideas rather than wait to see if they were adopted by the rest of the herd.
Walgreens? I have no idea where they will go with this. The most insightful blog is that of Dr. Klepper and I would urge readers to click on his URL contained in this thread to read about his take on the whole Walgreen’s acquisition and what it may mean.
Employers are studying and adopting this moodel all over the country. Our most recent installation is the Toyota Family Medical Center in San Antonio at their newest production facility. Trend? For San Antonio it is. Many doctors and hospitals are awaking to a health system in transition and this transition is being designed and developed by the employers who feel they have not not received value for thier health care dollars.
Mike LaPenna
Bardiac –
Clearly, you are of the “low maintenance” patient type. And you are right – for an annual well woman visit, workplace clinics can do well, as they did for my patient for 3 years.
AM Lapenna-
Thanks for your comments, they have added much to the discussion.
A good medical practice is a good medical practice, whether it is located in the workplace, the hospital or the corner. I suspect workplace medicine is here to stay, and can only hope that as it expands, it works as well as the examples you have described. GIven Walgreen’s success in other areas, if any of the chains were to do this, I would have chosen them. However, I still have an inherent problem with pharmacies running clinics. And am surprised that they are allowed to, given the restrictions that are placed on phycsicians self-referring to laboratory or radiology businesses that they may also own. All of which speaks to the lobbying power of large corporations, and the relative powerlessness of physicians in the marketplace.
Thanks for reading!
my experience with confidential information leaking out in the work place is that this occurred often, and in a gossip type manner.
Keep in mind that this was a huge pharma company, and the clinic and staff were high end like am Iapenna is describing. The docs were mostly military trained, and admitted that they preferred occupational health and non-relationship oriented practice.
I was responsible for the accident prevention program at work. Therefore, I had to interact with the docs on injuries and illnesses and make a determination if it were work related or not.
In the course of having these discussions, the docs would REGULARLY discuss with me the other conditions that were in the records. For example, one guy was complaining about back strain, and the person related it to his job activities. The doc shared with me that this man had chronic prostatitis, and that could be what the back ache was from. This is one of MANY examples. I was told about substance abuse issues, about family situations such as divorce, etc. All completely inappropriate, but shared freely. I was very young, and looking back I can see that the gossip did in fact influence my decisions about making assessments on whether or not illnesses and injuries were work related – in particular for the cases that were in a very gray area (back injuries, aches, pains, strains, etc).
In addition, my earlier comment about the docs not being so qualified was also experiential. More often than not, patients were sent out for consultations should something occur that was not routine. I can recall at least 15 cases where I had to over turn a work related/not work related categorization based on what came back from outside docs. Not because they more accurately diagnosed something, but becaue simple histories were not taken accurately in the work clinic. This was over a 2 year window of time – so it happened very often.
Sorry, but for me, a relationship with your physician is critical, and should not be influenced by your workplace.
My husband works for a very large oil & gas/engineering firm. Last year they implemented an on-site clinic. Last month, during the craziness of the flu/allergies/upper respitory crisis going on – I got really, really sick and my asthma symptoms began acting up after years of having no problems. My doctor, who we have seen for many years, could not work me in for 2 days. Because my husband’s employer has an on-site clinic (staffed by real MD’s, etc.) I was able to get in and get the medical attention I needed – with a suggestion that I follow up with my regular doctor (which I did).
While I think the on-site clinics are great for situations like the one I recently had – I cannot imagine substituting this for the relational care I get from my doctor – the history we have with him is priceless.
Great post, by the way!
Schruggling –
Wow – Scary stuff, that. I wonder if these were pre-hipaa days if things are better now. Or with the EMR, worse….
Kelly –
You’ve pointed out the reasons why drugstor clinics and on-site clinics may just take away the primary care business from us docs – if we can;t get patients in for urgent care, someone else will.
Thanks for reading.
I don’t know about in the US, but workplace clinics are brilliant things in the third world, where the average family can’t make it to the public clinics/hospitals without saving up for transport, and where the public healthcare is iffy in general.
In the first world, I guess a lot of the privacy rights would come down to who owns the charts. In Canada, there are pretty clear laws about this, and so, even if the clinic was owned by the workplace, the employer would never have access to medical information other than that which is released by the employee. And protecting that information would be part of the duty of care of the physician.