The Web and blog-o-sphere are filled with news of health care reform, but most of it is reporting on standard insurance issues.  There are still areas of great concern for the self-funded firm that is offering robust health care on-site.  This topic was addressed in detail by Ms. Sarah Bassler Millar of Drinker Biddle.  Some of the material that she reported is still so far away (2018?) that we have to remember that it is TWO Presidential elections away.  That gives allot of time for politics, legislative bodies, and the courts to impact upon the reform that is now on the books (describing the structure under which we are all going to be operating).

Ms. Millar did reflect on important issues such as the valuation of health care plans and the concept of thresholds for the definition of "Cadillac offerings."  I would not want to attempt a synopsis here of the issues on which she offered opinion, but I did add her contact information to the Web site (www.onsiteclinics.org) and I suggest that you pose the following questions to your own counsel (or vendor or consultant):

1.  What services can we offer on a gratis basis for employees?

2.  How will we "value" on-site offerings for the employees and rank the benefits against thresholds defined in the Reform Act?

3.  How does the on-site program articulate with our consumer-directed savings plan?

4.  What ERISA issues arise if we are using plan funds for the provision of health care services?

5.  How can preventive and wellness services, and safety and first aid programming, be delineated from primary and secondary care?

In some cases, she stressed that we are awaiting further guidance and clarification on some important factors related to what constitutes health care and the way in which benefits provided directly to employees and their beneficiaries might be defined.  These issues will not deter firms that are committed to a healthy workforce and the many benefits that can be derived from it; but "lack of definition" may put firms that are on the fence, more firmly in the "wait and see" category.

Roundtable Discussion Topics

When we got to the discussion topics posed by the participants, a few new ones emerged.  I have listed some of the issues that were addressed and the comments offered.  Remember, this is a roundtable and the comments are offered by on-site clinic providers to their peers, not from a podium to an audience.  This is just a sample of what was discussed.

Q.  Do the on-site programs have to be filed as separate health care plans under ERISA?   A.  It all depends.  The answer is different for municipalities, and it also depends upon the breadth of services offered.

Q.  How does a program manage around the requirement of billing deductibles and co-pays?  A.  Many programs don't "manage around" these at all.  They address them head on and bill co-pays just as if they were a "plan provider."  Again, structure and program design dictates the answer here.

Q.  What are the pros and cons of partnering with other companies in the provision of on-site services?  A.  The "pros" are the obvious - more visits and more patients yield less cost per service unit.  The cons are the cost allocation methodologies that are necessary to set these arrangements in motion.  Few, if any, good examples were offered with the exception of the collaboration that Quad/Graphics has in Milwaukee between their program and Miller Brewing and Briggs & Stratton. 

Q.  How do on-site clinics relate to ACO's and value based contracting?  A.  There is no real definition of an ACO (accountable care organization) as of yet.  This is likened to a fictional animal that is often reported but never photographed.  However, if it becomes the mechanism for the provision of true value in the marketplace, then on-site programs will be able to contract with them right along with any other interested health care purchaser.  As for the idea of "value-based" contracting, there is no reason not to move forward on that front right now.  Call it value-based, or outcomes-driven, or whatever you think fits.  The idea has merit and seasoned providers of on-site services know that this is the way to save on costs and improve beneficiary service and quality.  Hint: Don't wait for ACOs.

Q.  Should an on-site clinic offer biometric screenings in combination with HRAs?  A.  HRAs (health risk appraisals) are not universally offered by providers and sponsors of on-site programming, but when they are, they are thought of as positive additions.  Answers ranged from: "We don't provide them" to "This is an integral part of our programming."

Q.  How do you re-evaluate vendor contracts, and what are the implications of "switching" vendors?  A.  Contracts should be reviewed every couple of years and the transition from one vendor to another requires that the contracts assure that there are no barriers for the transition of intellectual property, patient lists, patient records, service contracts, etc.  Also, there is a need to make sure that employees do not have restrictive convenants that would preclude them from accepting a position with another company while maintaining their site-of-service at the employer's location.  Contract evaluation and renegotiation is becoming more important as the programs mature.

The group consisted of several standard employers.  But there was also active participation by one of the major insurance companies that has its own clinics and which is positioning itself to start them for their clients. There were also three universities in attendance.  The colleges seem to be looking at this with a level of interest that is growing.  We now know of at least ten that have on-site employee health access programs and many more that are studying them.  Municipalities were represented along with some significant hospital systems.  One national consulting group offered up ideas that they had from their program demonstrating that some consultants don't just tell clients how to do it, they demonstrate it and take some of their own advice.

I hesitate to name names, because all of the roundtable members were open and sharing in their comments.  I also do not want to inadvertently assign any comment that I might make to the group in a fashion that might make an individual feel that a confidence had been betrayed. In all, the group was not your normal set of players, and the dialogue reflected some refreshing new slants on the issues and challenges related to on-site health programming.