By Isabelle T. Walker
Running a pure-play occupational health clinic isn’t the straightforward endeavor it was two decades ago when workplace injuries, drug screens, Department of Transportation (DOT) exams, physicals, and on-site prevention kept providers busy and ledgers in the black. With fewer manufacturing jobs in the U.S., a business sector still smarting from the recession, and better injury prevention programs in place, occupational medicine clinics need a competitive edge.
For many programs, adding urgent care to their menu of services has become a popular solution. Concentra (http://www.concentra.com), the nation’s largest occupational medicine provider, added fuel to this strategy in 2008 when its 320-plus clinics began offering varying levels of urgent care services, including the trademark conveniences that urgent care clinics are known for . . . walk-in appointments and extended hours. In late 2010, when the health insurance giant Humana bought Concentra for $790 million, industry leaders realized the trend was converging with the new and unfolding needs of a rapidly changing healthcare system.
Meanwhile, from the other direction, more and more of the nation’s approximately 9,300 urgent care clinics have been recognizing the business opportunities that occupational medicine programs can bring to their practices.
Michael Rothwell, M.D., president and CEO of Tennessee-based Smoky Mountain Urgent Care, said that in 2010, his company was doing just a limited amount of occupational medicine including pre-employment physicals and drug screens––to fill up slow times. But then area employers began asking for more services, such as wellness and episodic care. By April 2011, the center was beginning to bundle employer services to market packages of care for a monthly fee.
“The blended clinic model is what the employer is looking for more and more,” Dr. Rothwell said. “Urgent care centers are set up to be efficient models of healthcare, and employers are looking for that.”
Whether you are coming from the occupational health side or the urgent care side, expanding to a blended clinic invariably presents challenges. But with the coverage expansion that the Affordable Care Act (ACA) is about to trigger, and the growing focus on cost control, many experts think multi-service walk-in clinics with a community focus are going to be extremely attractive to consumers, employers, and third-party payers.
“I do not think you have a choice today,” said Donna Lee Gardner, R.N., M.B.A., senior principal at RYAN Associates. “If you are an urgent care, if you don’t provide occupational medicine and look to blended services, you are going to lose out in your market. And if you are a stand-alone hospital occupational health program, you would be foolish not to get into the community focus of a blended clinic, because your market is going to demand it.”
In the NAOHP’s 2012-13 national member survey, 16 percent of responding programs––or 28 of 175––reported having one or more blended clinics. Of the remaining 84 percent, 18.3 percent, or 32 programs, planned to add one this year. Another 26 percent were considering it. Steve Schumann, M.D., medical director of occupational health at the Doctors on Duty clinic in Salinas, California––one of the chain’s 11
Central Coast sites––said in many cases it is the employers who urge their occupational medicine provider to add on urgent care services. Today, pure-play occupational medicine clinics are burdened by lagging reimbursement rates, paperwork, and reports, he said. “It’s so much easier to do urgent care.”
At Dr. Schumann’s Salinas clinic, occupational health comprises 50 percent of the care provided. His patients derive largely from the surrounding agriculture industry––fieldworkers, truckers, and machine operators among others.
Alan Ayers, M.B.A., vice president of strategy at Dallas-based Concentra Urgent Care, said when one of their clinics has a lease up for renewal, the company examines where its occupational medicine clients come from. If they can move the clinic within one to three miles, and retain all of its occupational medicine clients while also appealing to residents who want the convenience of a retail location, business can grow, Mr. Ayers said.
“With the flow of urgent care patients, we get a location that is easier to find, that is nicer, better and more efficient, with better flow and better aesthetics,” he said. Ultimately, that appeals to employers too. At some Concentra clinics, 95 percent of the business is occupational medicine, at others, it is evenly split between the two.
A July 2013 survey by The Center for Studying Health System Change (www.hschange.com/CON-
TENT/1367) found hospitals and health plans optimistic that urgent care centers could improve access and reduce emergency department visits in coming years. With the rollout of the ACA (www.hhs.gov/opa/affordable-care-act/index.html) set for January 1, 2014, and the anticipated surge in demand for primary care providers that will follow, general practices could see longer wait times for appointments. With multi-service walk-in clinics poised to catch the overflow, health plans continue to recognize opportunities for efficiency.
In 2012, Wellpoint (http://www.bizjournals.com/philadelphia/blog/peter-key/2012/07/wellpoint-llr-invest-in-physicians) invested in the 20-clinic chain Physicians Immediate Care (www.physiciansimmediatecare.com) and Blue Cross/Blue Shield of North Carolina invested in FastMed (www.fastmed.com), a network of physician-owned urgent care centers.
The two models have many similarities, according to Ms. Gardner. Both are customer service oriented; the practicalities of the care provided are similar too. As Ms. Gardner puts it, “A stitch is a stitch, a cut is a cut.” However, in an urgent care setting, the patient is always the customer. In occupational medicine, the patient is the customer and the employer is also the customer. It is a different mindset that takes getting used to.
“In occupational medicine, there can be a mindset that the patient isn’t the person paying, the patient is not the one deciding to use the center, therefore [he is] someone who gets acted upon,” said Mr. Ayers. “Urgent care is really a retail business. Patients have to choose to go to the facility, and you need them to have a good experience so they can tell others.”
In addition, occupational medicine is regulation-based. Clinic managers need a full understanding of workers’ compensation, OSHA regulations, the Americans with Disabilities Act (ADA), and more. Urgent care centers bill private insurance, Medicare, and Medicaid, and their providers are specifically credentialed for those plans. Occupational medicine clinics bill employers and workers’ compensation carriers, sometimes receiving pay out of pocket at the time of service. Electronic Medical Records (EMR) systems must be chosen with care to ensure that they can handle both urgent care and occupational medicine IT needs. According to Ms. Gardner, managers and owners need to understand the scope of practice laws in the state(s) they are operating in. Such practice laws will dictate which staff members can perform which duties.
In 2005, Scott Burger, M.D., partnered with a college roommate and another friend to found the Doctor’s Express urgent care center in Towson, Maryland, with an eye on establishing a nationwide franchise. Two years into operation, they added occupational medicine services to their menu of services. In 2009, when the company began selling franchises, they suggested all their new franchises do the same.
“In terms of the logistics, (for) the workers’ compensation [billing], there was a learning curve,” recalled Dr. Burger. “Getting paid at first was a challenge. I’m not sure you are ever 100 percent smooth, [but] it’s going fine. It gives you another opportunity to engage patients you might not otherwise encounter.”
“The demand from patients and the demand from employers going forward in medicine is a comprehensive care place for the patient,” said Dr. Rothwell of Smoky Mountain Urgent Care. “And if you are not at least thinking about it and planning towards it, you are going to be outdated and left behind.”
