The role of primary care and wellness in reshaping health care economics

• Some primary care practices are bringing wellness services directly to the workplace to meet an increasing desire by employers to reduce their healthcare costs.

• Even if your practice is not focused exclusively on wellness, numerous wellness services allow you to improve patient health and increase your revenues.

Billions of dollars could be shaved from the nation's annual $2.5 trillion healthcare bill with a greater focus on disease prevention, in forms such as tobacco cessation; alcohol abuse screening; reduction of weight, blood pressure, and cholesterol risk factors; and the encouraging of daily aspirin use.

As part of its 2011 National Prevention Strategy report, the National Prevention Council found that:

• a 1% reduction in weight, blood pressure, glucose, and cholestorol risk factors would save $83 to $103 annually in medical costs per person;

• annual healthcare costs are $2,000 greater for smokers, $1,400 for people who are obese, and $6,600 higher for individuals with diabetes than are costs for individuals without those conditions; and

• medical costs are reduced by about $3.27 for every dollar spent on workplace wellness programs.

Those statistics, combined with continuing increases in healthcare costs, have sparked greater interest among the nation's employers in wellness services for their workers. In response, some primary care practices are expanding beyond their office walls to bring services directly to the workplace.

Although original workplace clinics provided more occupational health or urgent care services, the trend is moving toward wellness and primary care services. The option provides convenience for the employee and delivers a happier, healthier, and more productive workforce for the employer.

A MODEL PROGRAM

Dartmouth Health Connect is turning the practice of primary care on its head through its new delivery model that promotes wellness. The primary care practice opened in February in conjunction with Dartmouth College in Hanover, New Hampshire, Dartmouth-Hitchcock health system in Northern New England, and Iora Health, a Cambridge, Massachusetts, healthcare company founded by Rushika Fernandopulle, MD, MPP, who serves as chief executive officer.

The practice-which is not a walk-in clinic-includes two Dartmouth-Hitchcock Medical Center physicians, a nurse, a practice coordinator, and several health coaches. The primary care practice offers physicals, vaccines, sick visits, prescriptions, and ongoing care to Dartmouth College employees.

Instead of the usual fee-for-service model, Dartmouth pays Iora Health a monthly per-patient fee, providing an incentive to focus on patient health, Fernandopulle says. Enrollment is voluntary, but more than 650 patients have signed on to the new program.

Iora Health, the successor to Fernandopulle's Renaissance Health, already runs similar practices in several other locations, including in Nevada and New Jersey, where the focus is on casino union workers, and in Seattle, which caters to Boeing employees. He plans to open additional practices in 2013 in Brooklyn, New York, and Boston, Massachusetts. Fernandopulle says the model produces an average net healthcare spending reduction of 20%.

"Our model is, employees don't pay anything out of pocket. It's completely free to them," Fernandopulle says. "We get paid per employee, but unlike concierge care, the employer is paying that. They are the ones who will benefit when dollars are saved.

"We are outside the insurance system. We do an end-run around the insurance company. We directly contract with the employer."

PUTTING IT ALL TOGETHER

Fernandopulle says that to change the model of primary care, it is imperative to start from scratch. Iora Health designed the practice space to meet the needs of Dartmouth Health Connect, hired a new team, trained health coaches, and even designed its own information technology system, which alerts the practice when patients are having health problems and allows patients to view and enter information in their own medical records.

"People feel it's a better service," he says.

When first starting out, Fernandopulle says, he tried what other practices sometimes do: running a standard primary care practice while adding corporate wellness programs at different locations. He says it didn't work and became a logistical and ethical problem as he realized physicians ended up treating people differently.

"You act differently if you're paid a fixed amount and are trying to keep people out of trouble," he says, adding that physician might think twice about ordering lab tests if there is no payment attached to the action. "Our doctors, we get paid for everything. Fee-for-service is not paid for everything."

Although he doesn't begrudge companies that offer workplace wellness clinics, he says they are not transformational and offer services more akin to occupational medicine or urgent care.

TO MARKET...OR NOT

S. Steve Samudrala, MD, medical director of America's Family Doctors (AFD), says AFD Primary Care Clinics of Tennessee began offering wellness services about 6 months ago after patients and local companies began asking for them. AFD has done everything from biometrics screenings to onsite flu clinics and tuberculosis skin tests to annual physicals. The clinics recently began offering bioidentical hormone replacement therapy after patients complained about the cost of seeking it elsewhere.

But Samudrala says the tests and services it provides are not money-maker for the practice, and AFD-comprised of four physicians, five physician assistants, and one nurse practitioner-doesn't market its services.

"If we're lucky, we'll break even," he says. "It's more just a service we offer. If you want to do a good job, you have to spend more time with your patients. If we break even, I'm comfortable with that.

"It's a patient-driven thing. If we want to expand, we'll have to invest in marketing, and we don't want to do that. Word of mouth is always the best."

Samudrala, who says he believes in growing a business organically, says he'd love to be able to expand into weight loss and smoking cessation programs at local companies. The venture would allow the practice to expand without the expenses associated with adding l bricks and mortar. He adds that some companies might be hesitant to work with an individual doctor's office, but he says a practice can offer personalized service and ensure provider consistency.

"We aren't a shift-based clinic," he says. "If you're doing to do company wellness, you want continuity of care. You find that in private practices."

Paul Ehrmann, DO, a family physician in Royal Oak, Michigan, has offered corporate wellness programs for years, including flu vaccination fairs and free health lectures. Ehrmann left his private practice after 28 years to join St. John Providence Health System of Detroit, Michigan, a division of Ascension Health in St. Louis, Missouri, to engage in workplace wellness.

"My passion is preventive health, weight management, public health, and sports medicine," he says.

He does most of his marketing through free preventive and sports medicine lectures at community venues, high school physicals, and through his local chamber of commerce. He says whenever he does give a talk, he likes to keep it positive. And he says a connection he makes today might not turn into a new patient visit for a year or two, but people remember him from his wellness initiatives.

"You have a bigger crowd when you talk about health and wellness than Alzheimer's disease," he says. "I've got a very nice rapport with the business community and want them to think of us. We're available, and our hours are convenient."

RETURN ON INVESTMENT

David Roddenberry, co-founder of HealthyWage in New York, New York, says workplace wellness began primarily with larger businesses focused on containing healthcare costs through preventive health programs. Small businesses also are interested in corporate wellness programs as a perk and tend to offer employees incentive to keep them happy, engaged, and healthy. The need is enticing more primary care physicians to fill that niche, offering a consistent and more holistic approach to care.

"An employer is really looking for the return on investment," Roddenberry says, adding that behavior change is difficult and can take a long time to see a return on investment. "The other thing they are looking for is early detection of problems, and also focusing on high-expense, high-risk problems-like stillborn pregnancy-and avoiding the ticking time bomb medical problems that wind up being huge costs."

Attracting patients to a workplace wellness clinic can be challenging if employees fear their information will be shared with their employer. Strategies to bring people through the doors include preventive screening reminders, health risk assessments with follow-up health coaching, and flu vaccinations.

Fernandopulle says the Iora Health model is improving health outcomes and saving employers healthcare costs by keeping people out of the emergency departments and hospitals. The vast majority of healthcare costs, he says, are helping people navigate the system, such as helping someone manager diabetes.

At Boeing, Fernandopulle says, the company's healthcare costs were about equal with its output for steel. Soaring healthcare costs harmed the cost differential for Boeing's products, affecting its competitiveness in the market. That led the company to Fernandopulle for a strategic transition to a new health plan for its employees.

"A few companies discovered an opportunity at the workplace to transform how all healthcare is delivered. We're taking on trying to help those people navigate the whole health system," Fernandopulle says. "That requires being willing to leave their current source of care and come to us. The employer needs to be willing to make that argument to people."

Rodenberry says there is a growing recognition that society has some serious health-related problems and that many people are trying to trade up to healthier options.

"I think it's analogous to Whole Foods and how they've grown from nothing to represent a healthier, cultural undercurrent," he says.

Wellness in every practice

Even if your practice is not exclusively focused on wellness, you may be missing out on revenue by not providing wellness care to your patients.

"The greatest area of missed revenue I have seen is not billing for all the preventive services Medicare will pay for," says Virginia Martin, CMA, CPC, CHCO, CHBC, of Healthcare Consulting Associates of N.W. Ohio, Waterville, and a Medical Economics editorial consultant.

If a mid-sized practice has 6,000 patients, 30% of whom have care covered by Medicare, then 1,800 patients in the practice are eligible for these services, Martin says. "Just considering the initial preventive physical examination, if 50% of the practice's Medicare patients were seen, that represents $144,000 in bottom-line revenue," she adds.

Martin says that every large practice in which she has performed reviews lately is charging only some of the G codes for these exams, losing out on much potential revenue. "They don't understand that they can bill and evaluation and management (E/M) service in addition to the wellness visit (usually a low-level one), therefore combining the wellness and a routine monitoring visit on the same day," she says. (See the list "Other wellness and ancillary services" and the "Wellness services" chart for more information on codes for such services.)

One way for practices to achieve success in the area of routine wellness care is to hire a nurse practitioner whose sole responsibility is to conduct wellness visits and provide related services, perhaps taking care of an acute visit occasionally, Martin says. Another way is to increase patient visits by promoting the fact the some wellness services involve no out-of-pocket costs for patients.

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