Integrated Physical Medicine at Employer-Sponsored Health Clinics Improves Quality of Care at Reduced Cost

Costs of Specialist Referrals From Employer-Sponsored Integrated Health Care Clinics Are Lower Than Those From Community Providers

BACKGROUND

There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers.

OBJECTIVE

Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers.

DESIGN

Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers.

PATIENTS

Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community.

INTERVENTION

Specialist referral management program implemented by Crossover Health employer-sponsored clinics.

MAIN MEASURES

Rates and costs of specialist referrals.

KEY RESULTS

The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001).

CONCLUSIONS

Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed.

Employer-Sponsored Health Centers Provide Access to Integrated Care via a Hybrid of Virtual and In-Person Visits

Background: Since the explosion of telemedicine resulting from the SARS-CoV2 pandemic, employers have been particularly interested in virtual primary care as a novel means of expanding primary care services. The purpose of this study is to describe a model of integrated care delivered both in-person and virtually at employer-sponsored health centers nationwide. The key outcomes of this analysis were the proportion of all care delivered in-person and virtually by clinical discipline, the types of care and member satisfaction for care delivered in-person and virtually, and a description of the use of multiple clinical disciplines by the employee population. Methods: Retrospective observational study comparing health services utilization of primary care, behavioral health, and physical medicine services both in-person and virtually in employer-sponsored clinics between January 1, 2020 and June 30, 2021. Results: Of the 331,967 visits with employer-sponsored health center staff, 63% were in-person and 37% were delivered virtually. Most visits were for primary care services (59.5%), with physical medicine visits and behavioral health visits accounting for 25.1% and 15.4%, respectively. Whereas the preponderance of behavioral health visits were virtual visits (72.5%), less than a quarter (18.2%) of physical medicine visits were delivered virtually. 19.6% of patients were seen by more than two clinical disciplines and 2.6% were seen by three different disciplines. Overall, patients were highly likely to recommend the health center across both modalities (Net Promoter Score 89.1 for in-person care and 88.4 for virtual care). Discussion: The future of employer-sponsored integrated team-based care may require a hybrid approach that can lean heavily on virtual visits but requires the infrastructure necessary for in-person care.

Rapid Deployment of Chiropractic Telehealth at 2 Worksite Health Centers in Response to the COVID-19 Pandemic: Observations from the Field

OBJECTIVE

The purpose of this paper is to describe the rapid deployment of telehealth, particularly real time video conference, for chiropractic services as a response to COVID-19.

METHODS

Two health centers at 2 campuses of a large California corporation have chiropractic care integrated into physical medicine services. Care was suspended beginning on March 17, 2020 to prevent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among patients and staff. On March 19, the Governor of California issued a stay at home order. With musculoskeletal problems being common in the employee patient population, telehealth services were quickly developed to continue chiropractic care for patients. Using existing infrastructure, several members of the health center team developed chiropractic telehealth operations within 2 days.

RESULTS

Musculoskeletal telehealth services included examinations, risk assessment, advice, and rehabilitative exercises. These telehealth visits facilitated care that would have otherwise been unavailable to employees. Patients reported that the appointments were helpful, addressed their concerns, and provided a safe method to see their doctor. Regular interprofessional teamwork and relations between the clinic operator and client company were key contributors to operationalizing this service in our integrated healthcare environment.

CONCLUSION

We were able to quickly implement real time video conferencing and other forms of telehealth for chiropractic services at 2 worksite health centers. This paper includes information and insights to providers about setting up similar telehealth systems so they may also provide this benefit for patients in their communities during pandemics or disasters.

Utilization and Cost of an Employer-Sponsored Comprehensive Primary Care Delivery Model

IMPORTANCE

Primary care is increasingly delivered at or near workplaces, yet utilization and cost of employer-sponsored primary care services remain unknown.

OBJECTIVE

To compare the health care utilization and cost of an employer-sponsored on-site, near-site, and virtual comprehensive primary care service delivery model with those of traditional community-based primary care.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study of 23 518 commercially insured employees and dependents of an engineering and manufacturing firm headquartered in southern California was performed from January 1, 2016, to July 1, 2019. A subset of the population with most (≥50%) primary care visits through employer-sponsored on-site, near-site, or virtual care clinics was matched to a subset not having most such visits through the employer-sponsored clinics using propensity score matching (n = 1983 each). In sensitivity analyses, employees were matched to dependents at neighboring firms that lacked access to the employer-sponsored primary care delivery model (additional n = 1680).

EXPOSURES

Integrated primary care, mental health, and physical therapy delivered through on-site, near-site, and virtual clinics.

MAIN OUTCOMES AND MEASURES

Utilization (inpatient, outpatient, emergency department, pharmaceutical, radiology, and laboratory visits per 1000 member-months) and spending (2019 costs per member per month in US dollars) by service type.

RESULTS

A total of 23 518 individuals (mean [SD] age, 27 [15] years; 14 604 [62.1%] male) were included in the full population sample and had been enrolled in the employer-sponsored health plan for a mean of 29 months (interquartile range, 14-48 months). Of eligible members, 5292 (22.5%) used the employer-sponsored services, with 2305 (9.8%) using them for most of their primary care. The mean (SD) cost of employer-sponsored service delivery was $87 ($32) per member month. Among the matched populations (mean [SD] age, 31 [11] years; 3349 [84.5%] male) of primary users vs control individuals, total spending was 45% lower per member per month (95% CI, 35%-55%; cost difference, -$167 per member per month; 95% CI, -$204 to -$130; P < .001) among users after adjustment. The lower spending was associated with lower spending on non-primary care services, such as emergency department (-33%; 95% CI, -44% to -22%) and hospital visits (-16%; 95% CI, -22% to -10%), despite higher spending on primary care (109%; 95% CI, 102%-116%) and mental health (20%; 95% CI, 13%-27%).

CONCLUSIONS AND RELEVANCE

The findings suggest that individuals who used the models' services for most of their primary care had lower total spending despite higher primary care spending, which may be associated with self-selection of lower-risk persons to the employer-sponsored services and/or with the use of comprehensive primary care.