The following is excerpted from a panel discussion held during RYAN Associates’ recent seminar on Profiting from Product Line Diversity: Integrating Urgent Care and Occupational Health Services. The panelists are:
Q: What is your background and the nature of your organization’s mixed-use clinic model?
Dr. Thomas: I started out in academic medicine with training in internal medicine and a sub-specialty in infectious diseases. I taught for about a dozen years, wound up in private practice for a while, and then started doing urgent care/occupational medicine with OH+R in the Nashville area (OH+R was acquired by Concentra Health Services in 2005). I like the mix. The addition of urgent care is a relatively new development for Concentra, and in some ways, we are still learning how to do it. I believe the blended model is here to stay because a lot of your occupational medicine patients will need personal medical services at some time. If you can provide those services, they can simply go from one set of paperwork to another set of paperwork.
Dr. Cranfield: I decided to try urgent care starting in 1985 after serving as a flight surgeon in the Air Force. I have always worked with the blended model and have never known another way for it to be. About 70 percent of our practice is urgent care and 30 percent is occupational medicine. It’s a hybrid system. We do have an onsite presence, and I encourage other providers to look into that. It has been a long road and I have seen a lot of changes in the field. Urgent care started out as a substitute for the emergency department. It has gone through a transition and has become its own “specialty.”
Ms. Brock: Our hospital-affiliated program has been providing occupational medicine since 1994 on the Tennessee/Kentucky line, balancing different state regulations and laws. It is a rural area without a lot of industry, so we have had to add some service lines (to keep it viable). In 1998 we started phasing in a rehab component (PT/OT/speech therapy) and have done well with that. We moved the occupational medicine practice to the hospital diagnostic center in 2005. In January 2010 we moved into a new building offering urgent and episodic care and follow-up, occupational medicine, rehab, a full lab, and a diagnostic center with CT scanning capabilities. Next month we are adding primary care.
“The paperwork for workers’ compensation is very different, but a patient is still a patient.”
Q: Our urgent care clinic is preparing to phase in occupational medicine services. What do you recommend we offer and build on?
Dr. Cranfield: If you are providing urgent care services and trying to incorporate occupational medicine, it is going to be easiest to add the injury care component first, because you already do that for your urgent care patients. Drug screening is another service you probably have to be able to offer. That requires additional expertise other than just collecting urine for a urinalysis. There is a lot to it.
Dr. Thomas: Occupational medicine is not as simple as folks would like to make it out to be. Get a feel for the companies around you and what their needs are. You may want to start with the small to mid-sized companies first, then develop your services so you could go into a larger company later. Get your processes down. The paperwork for workers’ compensation is very different, but a patient is still a patient. That is how I look at it. We are trying to satisfy their need and return them to a sense of well-being. More specifically, you may also want to incorporate some Department of Transportation (DOT) medical exams in your practice. The rules are important. It would be useful for your provider to attend a DOT medical examiner’s course.
Ms. Brock: If you start with injury treatment that automatically will grow into drug screening and/or physicals.
Q: What can we do to manage the lack of occupational medicine provider experience in the urgent care realm?
Dr. Cranfield: Again, start with the little things. You don’t necessarily want to say, “I have got my doctor who has been practicing occupational medicine for 30 years and now I am suddenly going to open the doors to people with a fever of 102 and lower abdominal pain.” Set parameters for the types of patients you are comfortable seeing in the clinic. Then, as a provider learns more, you can expand from there. About 75 percent of what we see in urgent care is upper respiratory infections, runny noses, coughs, earaches, and sore throats. Those are pretty easy to manage; most of them get better whether you do anything or not. You may want to limit yourself to that – like what the Minute Clinics do–before you start expanding.
Dr. Thomas: I agree – you can set parameters. A lot of doctors aren’t comfortable dealing with children. You can cut it off at a certain age and stick with it. As you know, the number of trained occupational medicine physicians in this country is dropping. They are not as readily available as they used to be. So, you are going to have to depend on physicians with family, emergency, or internal medicine training. It is not that difficult a transition, but I think it is more difficult for the occ med physician to see urgent care than the opposite.
Q: How do you recommend handling different levels of comfort with different patient populations among practitioners in a blended practice?
Dr. Cranfield: As long as it is not something that has to be handled acutely if you have two providers with different comfort levels and they don’t work at the same time, you can have cross-referrals – tell the patient to come in when this doctor is here. In any case, we have established a standard: When we hire a doctor they go through a credentialing process in which they have to agree to demonstrate a certain level of proficiency before we will hire them. Our preference is that our clinicians have a certain comfort level from the start.
Ms. Brock: When we started our occupational medicine program, we did not have access to an occ med physician. We contracted with a board-certified occupational medicine physician to educate our medical director and affiliated family practice and emergency physicians. Later, it was relatively easy for us to transition into urgent care because we were staffed by family practice and emergency physicians.
Q: How can we best satisfy the expectations of multiple constituencies?
Dr. Cranfield: You have to realize that when you are dealing with an injured employee you don’t just have the employee as a client, you also have the employer as a client, and the employer has needs that may make you think about that patient in a little bit different way.
Ms. Brock: There are a lot of regulations, guidelines, and national standards out there. Do your homework and make sure you are meeting that standard of care and offering the correct quality to the employer and the patient.
Dr. Thomas: There are more layers of people involved in occupational medicine than there are in urgent care. Not only do you have the injured person, but you also have to deal with the employer, adjusters, and nurse case managers…you have to make an effort to satisfy all of them at some level, even though the treatment may be no different from what you would provide to any other patient.
“Set parameters for the types of patients you are comfortable seeing in the clinic.”
Q: Using DOT physicals as an example, how would you handle an examinee with high blood pressure or diabetes? Would you refer him or her to a primary care physician for follow-up? What if the examinee does not have his or her own doctor?
Dr. Thomas: You can handle that a couple of ways: I usually try to get them set up with a primary care physician. If they want to see me they have to come to me as an urgent care patient; I can’t mix the two entities. If a driver’s blood pressure is not too bad, you can give him up to 90 days to get himself together before coming back for a re-check. He is likely to be motivated; if he is not driving he is not making any money.
Dr. Cranfield: For those people who come in with uncontrolled diabetes or high blood pressure, regardless of whether you are going to start treatment today or send them to a primary care physician, the fact is they are not going to get a full DOT card at that time. They may fail completely to get their card initially. As a practical matter, we don’t send them out to sign them back in again. If we take the examinee as a patient rather than just a DOT physical, he or she has to be logged in differently. I have my staff get the information we need and try to make it as seamless as possible.
Ms. Brock: If they have a primary care physician, we get on the phone and try to get them in to see their own doctor as quickly as possible. If they do not, our provider will see the employee and start whatever process they need. We provide follow-up visits, so they would come back for monitoring until they got to the point where they could qualify.
Q: Some employers in our market are asking for primary care services for their workforce. What is the difference between primary care and urgent care?
Dr. Cranfield: With urgent care, you have episodic care and with primary care you are also going to be getting into managing the people with diabetes and high blood pressure and heart disease and making sure they are maintained on their medicine, getting their annual checkup, annual blood tests and that type of thing. There are some urgent care centers that do that. Our model is not to do chronic care; we send those patients to the family doctors. We have enough people who want to see us for their acute care needs that we don’t have to do that. There are a lot of physicians who bill themselves as urgent care providers when their goal is to open a practice, get patients to come in without appointments until they build up their practice, and then switch over to family care.
Dr. Thomas: If you get patients who like the provider (in a blended clinic), they will try their best to attach themselves to that provider and will come back no matter what you do. You can get them set up with an internist or a family practitioner, but they just keep coming back. What I have done is tell them, “We do not do primary care management. I am happy to serve you when you come in, but I am telling you upfront I am not your primary care physician and I do not see myself that way.”
Dr. Cranfield: There are certain people who use you routinely and consider you as their primary care physician, even though you really are not. We may give those people a 30-day supply of medication to give them enough time to get them back to their primary care doctor or to find someone to help manage their chronic condition.
Dr. Thomas: The first time they can’t get an appointment with their PC they will be back.
Q: Do you recommend having the capability to offer in-office medication dispensing?
Ms. Brock: We had to deal with that issue in our rural area when we extended our hours to 10 p.m. All of the pharmacies within a 40-mile radius of our clinics close at 6, or even as early as 4 or 5 p.m. So, we dispense some specific medications. We are not keeping any kind of scheduled drugs, just a minimal amount of antibiotics to get them through a day or two. It is not a profit center; it is a value-added service.
Dr. Thomas: The reimbursement you would get from dispensing would be negligible. There is also the hassle factor.
Dr. Cranfield: We can still do it for occupational medicine patients, but it is not as easy on the urgent care side, primarily because most insurance plans include a pharmacy. Unless you have a pharmacy with pharmacists on staff and have signed up with that insurance plan to dispense, you are not going to get a lot of that business. It used to be really big, but it has tapered off quite a bit.
Q: What have you found is the most effective way to market your centers?
Ms. Brock: One of the first things we learned when we added urgent care was there was a lot of confusion in the market as to what we had become: “Are you seeing primary care?” “Can I bring the kids over?” We thought we had marketed it very well. Our mistake was that it was not a clear, consistent message, and I don’t think we did enough marketing, either. We did a massive marketing campaign when we first opened. Then we just assumed that because we
had been there for so long, everybody would know who we were originally. We found that was not so.
Dr. Cranfield: It seems as if it is still the roadside sign, word of mouth, and the Yellow Pages, believe it or not, that bring people in. My office is located just south of Hendersonville, which is a rapidly expanding community. Five years ago, in order for people to get the things they needed, they had to come down to my part of the woods. When Hendersonville got its own (major chain stores), it kept people there up to a point. We ended up using a strategically placed, visually appealing billboard right at the cutoff point. Another thing we have found to be successful is television ads. I am usually the one who speaks in them. You get groupies who say, “I saw you on TV!” even long after the ad stops running.
Dr. Thomas: Our surveys show a lot of the public doesn’t understand what urgent care means. If you tell them walk in, that means one thing. Some of them think of urgent as more for emergencies. You have to realize that when you do your advertising and marketing, it is helpful to have your provider involved in the marketing, particularly in occupational medicine. Having the provider involved in what you are trying to do to promote your facility is important to your survival and success.
“We learned there was a lot of confusion in the marketplace as to what we had become.”
Q: When Concentra was marketing itself as a pure-play occupational medicine specialty practice and then converted to the blended model, how did you deal with the switch from a marketing perspective?
Dr. Thomas: The trick is for a company that has been a pure-play model with a directed focus to get the providers to switch directions. For me it was not a problem because I was used to seeing sick people – that was my background. For some physicians it is almost as if they have to go back to medical school, in their minds at least, to accept it.
Q: What is your best piece of advice for operators of mixed-use clinics or those who are considering introducing the blended model?
Dr. Cranfield: I didn’t start skiing until I was 34 years old. I started on the bunny slope and quickly moved up the mountain. Don’t be afraid to try something new. It is going to be hard when you first start, but once you learn how to do it, it will be easy to ski down the slope after that. You have to start on the baby slopes but don’t wait too long to get to the top of the mountain.
Ms. Brock: Either you control the day or the day controls you. Given the nature of the competition and what is happening to our profession, I would rather be at the forefront and controlling my own destiny than have someone do it for me, even if I am speeding down the ski slope. Move forward. Even if you fall on your face, you are still moving forward. Go with it.
Dr. Thomas: Try to know where you have been before you try to know where you are going. Have a feel for what has happened in the past in your area. Get a feel for the landscape. Pick a path, start on that path, and stick with it. Don’t deviate too much from the original plan for your journey.
