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The American Journal of Managed Care July 2015
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Worksite Medical Home: Health Services Use and Claim Costs
Christopher Conover, PhD; Rebecca Namenek Brouwer, MS; Gale Adcock, MSN, RN, FNP-BC, FAANP; David Olaleye, PhD, MSCe; John Shipway, BS; and Truls Østbye, MD, PhD
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Worksite Medical Home: Health Services Use and Claim Costs

Christopher Conover, PhD; Rebecca Namenek Brouwer, MS; Gale Adcock, MSN, RN, FNP-BC, FAANP; David Olaleye, PhD, MSCe; John Shipway, BS; and Truls Østbye, MD, PhD
This study examined the relationship among availability of an on-site, employer-provided primary care medical home, and health services use and health plan costs.
HCC casual user spending was $482 higher than that of HCC major users (P <.01), with most of the difference ($263) attributable to increased pharmaceutical expenses. Costs associated with HCC major users were statistically lower than both other groups for preventive care (P <.001) and lower than HCC casual users for acute/chronic care (P <.05). Pharmaceutical costs were significantly higher in both the HCC casual-user group (P <.001) and HCC major user group (P <.01) relative to the non-user group. Employee HCC major users had significantly lower claims costs related to preventive care than did both comparison groups (P <.001).

Health Services Use by Dependents

In adjusted analyses, for dependents, lower encounter rates for HCC major users were observed for all outpatient use relative to the HCC casual users (P <.001) (Table 2b); and HCC nonusers (P <.001). This pattern and level of significance held true for both preventive and acute care encounters. Hospital admissions were significantly higher for dependent nonusers compared with major users (P = .003). Otherwise, dependents mirrored patterns seen in employee utilization. There was no difference across groups in hospital days per 1000.

Standardized Claim Costs for Dependents

Dependents in the HCC major user group had claim costs that were approximately $600 lower than those in the HCC casual user group and $330 lower than those in the HCC nonusers (P <.001 and P <.01, respectively). Outpatient health claim costs accounted for most of the difference. As they were for employee HCC major user, outpatient costs were lowest for dependent HCC major users, which were significantly different from those of HCC casual users (P <.001) and HCC nonusers (P <.001). Pharmaceutical expenses were significantly lower for dependent nonusers relative to major users (P = .02). As they were for employee HCC major users, preventive care claims costs were lower for dependent HCC major users relative to both comparison groups (P <.001)—a finding repeated for acute care claims (P <.001).

DISCUSSION

Both employee and dependent casual users of the SAS Health Care Center had higher annualized claims costs than HCC major and nonusers. This finding was likely driven by high pharmaceutical expenses in HCC casual user employees and by acute and chronic care encounters in dependents. Employee and dependent HCC major users had significantly lower claims costs than the other groups for outpatient claims, including those related to preventive care services.

Health services use by employee and dependent HCC major users was significantly lower than comparison groups for external encounters (P <.001), and as expected, significantly higher than comparison groups for HCC encounters (P <.001). HCC casual users, both employees and dependents, had the highest number of external encounters—accounted for principally by more preventive encounters—compared with employees and dependents in other groups. Dependent HCC major users showed significantly fewer hospital admissions compared with nonusers, but this result was not found in employees.

Others have also found lower use of health services outside the workplace when there is a clinic available on site. Turner found that primary care costs for patients seeking care from a worksite medical home were 42% lower than for patients seeking care from community providers.7 Furthermore, in a cost-effectiveness study for another North Carolina employer, Syngenta’s worksite clinic was found to provide its employee healthcare services 66% less expensively than it would have cost to provide similar healthcare services off-site.18

An important limitation of comparing only actual health services use and health plan claims costs to demonstrate differences between the groups is that it accounts only for “hard return on investment (ROI)” (savings in direct health plan costs), and ignores both the cost of running the on-site clinic and “soft ROI” (which includes productivity gains accrued through less time away from work for provider visits, fewer sick days, company loyalty, increased employee satisfaction, and lower turnover).

Examples of companies that have experienced soft ROI include Southwire, Mead Corporation, and SAS Institute—all of which experienced cost savings (inclusive of some soft ROI) when providing on-site healthcare to employees in their larger locations.16,19 Others have investigated productivity gains: Syngenta, for example, found that the on-site health clinic averted the loss of 3028 work hours (for 725 employees) in 1 year.18 This 4 hours per year per  employee would translate into savings of $50 to $300 depending on employee salary. SAS estimates a minimum of 2 hours of work time saved with each employee visit and includes that savings in its ROI calculation. Similarly, Pachman et al found that an on-site corporate medical clinic reduced absenteeism by 3.3 days per employee per year, which again could translate into hundreds of dollars depending on the employee’s compensation.20 They also investigated whether the availability of on-site healthcare encouraged “frivolous” use, and found that for all the healthcare visits provided on-site, 69% of employees reported that they would have sought care elsewhere.

Limitations and Strengths

Our study has several important limitations. First, we examined only costs associated with the health plan use, not costs incurred by SAS in its operation of the HCC. The use of health services shows that HCC users to a large extent receive their services from the HCC instead of from the outside, although there is not a full substitution. We did not attempt to assess the total costs to SAS of external services covered by the health plan and the costs of the services provided through the HCC. Second, we have not included any indirect benefits (such as productivity gains, employee satisfaction, and company image) associated with the SAS HCC. This study examined only a single employer in 1 location, albeit a large employer. Analyses were adjusted by group; however, employees may self-select for themselves and their dependents based on factors (such as preexisting conditions and lifestyle behaviors) for which we were not able to control. Finally, the employee population consists largely of professional/managerial positions.

The study also has considerable strengths. First, it examines well-documented outcomes from a large number of employees and dependents who received comprehensive coverage over the course of several years. Our analysis adjusted for many potential confounders. Finally, the evaluation team was strengthened by the inclusion of both internal and external team members.

These analyses provide comparative results that may be of interest to SAS and other employers, and they also represent analyses that may be possible to conduct for other employers with relative ease. The evaluation also illustrates the use of integrated SAS Analytics, SAS’s own data management and analysis package, which facilitated the analysis of this relatively complex database.

CONCLUSIONS

In summary, in this evaluation of a medical home embedded in a large workplace, health plan claims costs were higher for casual users of the HCC than for the other 2 comparison groups. Employee and dependent HCC major users had significantly lower claims costs than the other groups for outpatient claims, including those related to preventive care services. Dependent HCC major users had significantly fewer hospital admissions than nonusers—a finding not replicated in employees. Additional research is needed to assess the extent and cost of the medical home’s utilization that may substitute for costs incurred by the health plan. We also concur with a recent review of the worksite medical home literature that further research should explore the extent to which the employees’ greater utilization of preventive and acute care services at an on-site primary care medical home affects employee health outcomes in the short and long term.21

Author Affiliations: Center for Health Policy and Inequities Research (CC), Duke University, Durham, NC; Department of Community and Family Medicine (RNB, TØ), Duke University, Durham, NC; SAS Institute Inc (GA, DO, JS), Cary, NC.

Source of Funding: SAS Institute Inc.

Author Disclosures: Drs Conover and Østbye and Ms Namenek Brouwer were contracted by SAS to evaluate on-site health center and have received/pending grants. Dr Olaleye, Ms Adcock, and Mr Shipway are employees of SAS Institute.

Authorship Information: Concept and design (RNB, CC, TØ, JS, GA); acquisition of data (JS); analysis and interpretation of data (RNB, CC, TØ, DO, JS); drafting of the manuscript (RNB, CC, TØ, DO, GA); critical revision of the manuscript for important intellectual content (RNB, CC, DO, GA); statistical analysis (TØ, DO, JS); provision of patients or study materials (GA); obtaining funding (CC, GA); and supervision (CC, TØ).

Address correspondence to: Rebecca Namenek Brouwer, MS, Associate Director of Research Operations, Duke University, DUMC Box 2713, Durham, NC 27710. E-mail: rebecca.brouwer@duke.edu.
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