Opening & Managing a Healthcare Clinic Jeff Reagan, Senior Consultant Glen Volk, FSA. MAAA
Clinic Discussion Overview Why Consider an Onsite Medical Center Onsite Medical Center basics to know (a Consultant s perspective) How to get started, evaluating a clinic and does it makes sense (an Actuary s perspective)
Lots of Noise & Unsubstantiated Claims Onsite Clinic Vendors Selling hard Don t have credible experience on scalable models Don t have predictive data tools or integration Very little communication with the carrier Poor reporting Smoke & Mirrows Brokers / Consultants Unable to appropriately evaluate IF onsite makes sense No skills to manage an onsite medical center once it is in place Not getting the credit from the marketplace when implemented
Projecting Sustainable ROI Organizations with similar geo/demo, etc, and participation may produce different ROI Risk Pools are different ROI is based on what the risk of the population is for that employer The real long term challenge needs to focus on improving the general health conditions of your population
Key Questions Regarding an On-site Will there be buy-in from all stakeholders? Will there be ease of access? Is your plan self-funded? Are your benefits a clinic fit? Can your carrier receive patient data and utilize it? Will your on-site help you contain costs against future network increases?
On-site Medical Center Basics
On-site Medical Center should.. Lower cost for Primary Care (PCP) Avoid unnecessary specialty care Health coaching for future high risk Disease management compliance Referral to high performance network Generic drug utilization
On-site Medical Center Clinic must be managed / It will not run by itself Running vs. Managing a Medical Center Doing basic operations Missed appointments Generic management Ex: Plavix / Lipitor My On-site Medical Center
The focus has shifted for employers with On-site Medical Centers CURRENT FOCUS Illness / injury treatment Single risk factors Disease conditions Medical costs Absenteeism Uncoordinated programs ILLNESS WELLNESS DESIRED OUTCOMES Prevention orientation Whole person management Optimal health Quality outcomes Enhanced performance Employee-centered solutions WELLNESS ILLNESS 9
On-site Clinic Must Haves: Integrate health related information to all carriers/administrators Connect EMR with outside providers Manage referral process (two-way) Focus on Wellness and Preventive Provide online self care, ehealth, appointment booking and messaging
Ongoing Needs for Employer Clinic utilization data that s usable What services are being provided Inventories of drugs / other operational requirements Claims spend and savings accrued Ongoing review of population health status Staff Member productivity review
Strategic Considerations
Objectives of an On-site Health Medical Center Control escalating medical plan cost Improve access to medical care Provide employees with quality health care Improve the overall health of the employee population Reduce large claims through wellness engagement Better utilization of health care benefits Encourage prevention of disease Increase Productivity Decrease absenteeism and presenteeism Increase generic Rx usage
Step 1: Examine Your Culture Are you willing to create meaningful incentives to have members seek care from your clinic? Total BUY-IN from all constituents (sr. management, employee groups/unions and dependents)
Step 2: Understanding Influencers Healthcare providers in the marketplace Carrier/Vendor ability to coordinate with On-site On-site Medical Center capabilities/logistics Employee perception and concerns
Step 3: Understand the impact of ACA What it means to you? Must have a financial model that shows the total overall assessment Cost of Center Total Cost of Both Impact of HCR Double Expense that you would not normally have
Step 4: Feasibility Study Must review Healthcare Reform financial projections Must review current utilization and claims Must define what services and the model you are targeting Must understand how much onsite medical center utilization steerage you will need What are your ROI targets?
On-site Medical Clinic Feasibility Study
Feasibility Study The Process Goal is to estimate savings that a clinic could generate and compare savings to cost of establishing and operating the clinic Estimating the cost of the clinic is relatively easy (vendor proposals for other clients, RFIs) Estimating clinic-driven savings is not as straightforward Should consider at least 2 to 3 year measurement period 19
Feasibility Study Cost of Clinic Operation Cost components of operating a clinic include: Mix and cost of clinic staff (e.g. physician, nurses, PAs, medical assistant, x-ray technician) Administrative expense (IT, reporting, staff management, licensing, insurance, clinic vendor fees, etc.) Occupancy cost (e.g. rent/lease expense, maintenance expense, cleaning, etc.) Build-out costs + medical equipment Promotional activities Materials and supplies (e.g. generic drugs, Medical supplies, lab fees) 20
Feasibility Study Cost of Clinic Operation Most significant variable is the estimate of required clinic capacity, which depends on: The number of eligible employees The geographic concentration of employees (access) The scope of services to be covered at the clinic Potential utilization If occupational health and/or employment physicals will be included Consider the potential need for one or more clinic locations and the size of each location. Required capacity will also depend on the utilization rate the % of visits that will move from other locations to the clinic. 21
Feasibility Study Cost of Clinic Operation We like to see multiple scenarios. Assume the clinic utilization will increase over time so start with less capacity and assume an increase in years 2 and 3. Required capacity will drive the hours of clinic operation Typically expressed in # of hours per week Professional time (physicians, nurses, PAs) is charged back to the sponsor on an hourly basis OR set as a PEPM.
Feasibility Study Cost of Clinic Operation There are several different clinic staffing and pricing models Some models have a physician on site at all times. Others are based on a PA or nurse as the primary provider, with physician supervision. Others offer off-site contracted facilities such as a Doc-N-The-Box Choice of model will affect cost and possible savings AND level of utilization We prefer to model a range of potential costs (high/low)
Feasibility Study Cost of Clinic Operation If study is performed in conjunction with an RFP, you can use actual vendor proposals If study is performed without an RFP, you should estimate vendor costs based on experience from other similar groups Either way, you end up with a cost model that includes sensitivity analysis for: Level of clinic utilization Level of assumed clinic operating expenses Typical annual cost per full time location is from $750K to $1.5 million depending on model and targeted capacity
Feasibility Study Claim Savings Generally focus on hard dollar savings Immediate savings associated with moving services from physician s office or other outpatient setting to the clinic Long-term savings associated with health improvement of employee population Vendors will also promote soft dollar savings Reduced absenteeism Presenteeism Improved employee retention Soft dollar savings may well have value, but the value is difficult to quantify with any confidence.
Feasibility Study Claim Savings Sources of immediate hard dollar savings: PCP office visits Specialist office visits and associated diagnostic tests Lab services Prescription drugs (increase generic utilization and reduce overall utilization) Routine x-rays (if x-ray equipment included) Occupational and/or Employee Physicials
Feasibility Study Claim Savings Sources of long-term hard dollar savings Increased participation in health risk assessments and other screenings provided at the clinic Improved compliance with treatment plans Increased participation in disease management programs Increased participation in wellness programs More difficult to predict the value of these items
Feasibility Study Claim Savings Estimating Immediate Hard Dollar Savings Need detailed historical utilization and cost of services that are expected to be affected by the clinic Need to estimate what portion of those services will be redirected to the clinic Generally look at a range of levels (high/low) Usually expect clinic utilization to increase over time Biggest factor is the portion of PCP visits that are redirected to the clinic (most other services will be related to PCP visits)
Feasibility Study Claim Savings Other Immediate Hard Dollar Savings: May see small decrease in ER and Urgent Care visits (clinic is not a substitute for ER) In the short term, clinic is unlikely to affect inpatient utilization Vendors will suggest additional savings, but we are skeptical
Feasibility Study Claim Savings Estimating long-term hard dollar savings: Generally related to improved health of the population Need to consider the current disease burden and how it might be affected by a clinic Should only give credit to the extent that a clinic is expected to drive more improvement than could be obtained through existing programs Model impact of gradual changes in health risk: Reduce risk for chronic conditions Reduce movement from healthy to chronic state Lower medical trend
Feasibility Study Putting It All Together Analysis creates a number of scenarios High/Low clinic operating costs High/Low utilization (affects cost and savings) Assumed utilization changes over time Assumed health improvement over time Most appropriate scenario depends on the plan sponsor Quality of facility/location Commitment to driving clinic utilization Commitment to health improvement
Feasibility Study What Have We Seen? Results will vary by employer, but Most consistent finding is that the pure redirecting of services to a clinic does not generate large savings when the cost of the clinic is factored in To the extent clinics can be used to improve overall employee health, more significant long term savings are possible Reducing medical trend in future years is the real key
On-site Medical Clinic ROI Analysis
Measuring A Clinic s ROI This is still a developing science with no standard method Common Vendor method is to count appointments and services and apply average cost to each to calculate savings. A (very simple) example: 5,000 visits recorded for a year Average all in cost for an office visit is $250 Clinic saved 5,000 x $250 = $1,250,000 Vendors also like to include soft-dollar savings
Many problems with this method: Measuring ROI 5,000 clinic visits does not mean 5,000 doctor visits were avoided (probably closer to 3,000 at best) Doctor visits avoided will be of lower intensity than a usual visit. Average cost will be lower Must also factor in impact of waiving employee co-pays Soft-dollar savings are not completely invalid, but they are very difficult to quantify with any level of confidence and are long-term
Measuring ROI Preferred method is to look at actual change in utilization and cost under the plan YOY For those services that can reasonably be expected to be affected by a clinic, how many were done, and at what net cost, prior to the clinic and after the clinic Also look at change in Rx generic utilization and costs Still have issues addressing random fluctuation in utilization from year to year
Measuring ROI In general, the services that are mostly affected by a clinic are the least costly services under any health plan If a clinic costs $1 million to operate, it takes a whole lot of these small dollar savings to break even Clinics can be effective, but it is not an automatic and results usually are long-term The real opportunity for savings is in employee health improvement and reducing medical trend
ROI Questions Address access to care Address quality of visit and treatment Establish and maintain Evidence Based Practice standards Informatics to evaluate care / treatment (HPPN?) Greater provider / health coaching and engagement Fully integrate carrier-based DM / Health Management tools Improve community relationships Improve specialty referrals (HPPN?)
Reasons Not to Get into Medical Centers Could be a huge financial liability Getting into the business of providing healthcare Cannot get buy-in from all constituents Not willing to change your benefits program Not willing to provide significant incentives to seek care from onsite Not willing to commit to Wellness and/or Health Management as a priority of your benefits program
Next Steps Q&A Thank you!