BHCG Monitor: Focus on Health Care Benefits - April 2012

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BHCG Monitor: Focus on Health Care Benefits - April 2012


As published in EH Connect, winter 2012 edition

Engage Worksite Health Services

Bruce Sherman, MD, Medical Director, Employers Health Coalition, Canton, Ohio

Until recently, employers have been focused on managing health care costs largely by addressing the demand side of the health care supply/demand equation. Cost containment strategies, including cost-shifting and benefits restrictions, have been most common. Some employers have adopted more progressive approaches, including high-deductible health plans, value-based benefit design, and reference-based pricing to promote individual accountability for health care costs. Despite these interventions, health care cost trend has continued to significantly exceed the general inflation rate, eroding company profits, and causing employers to evaluate other approaches to health benefits.

Many employers have begun to look more critically at the health care delivery system, which is widely recognized as being volume-driven, and often lacking in efficiency and quality. [The Employers Health data warehouse has provided convincing evidence of this, with considerable variation in health care quality and compliance with evidence-based treatment guidelines, shown in Figure 1.] Use of Centers of Excellence is a representative example of a commonly used employer supply-side strategy. Some employers have contracted directly with health care entities for services (including Lowes with the Cleveland Clinic, facilitated by Health Design Plus, a Hudson, OH-based organization). Still other employers have looked beyond high-cost treatments and focused on improving access to primary and preventive care as another supply-side intervention strategy, in the form of worksite health and wellness services.

Figure 1. Compliance with evidence-based care for diabetes for a representative employer in the Employers Health data warehouse. Note the low compliance with recommended care.




Claimants with Condition


Instances Where Rule Applied


Compliance Rate


Patient(s) that had at least 2 HbA1c tests in last 12 reported months.








Patient(s) that had an annual screening test for diabetic nephropathy.








Patient(s) that had an annual screening test for diabetic retinopathy.








Patient(s) with evidence of self-monitoring blood glucose testing.








Adult(s) that had a serum creatinine in last 12 reported months.








Adult(s) with a lipid profile in last 12 reported months.








Patient(s) that had an office visit for diabetes care in last 6 reported months.







Why provide these services in the workplace? When it comes to health care, individuals value access and convenience. What better example than flu shots, which are now more commonly provided in the workplace than in clinician offices. The intent here is to engage employees in more regular and timely use of preventive care services, as well as provide support for chronic condition management. More effective and timely treatment can result in fewer disease-related complications and earlier diagnosis and less costly treatment of conditions found during preventive screening.

A number of Employers Health members offer worksite health services, among them Smuckers, Wayne County Commissioners, and Seaman Corp., to name a few. Still others have provided on-site biometric screening and/or health coaching services as another means of improving access to health care for employees. These employers appreciate the potential impact of access to care on health care utilization and overall health care costs. At a high level, it is fair to represent the employer objective as what has been characterized as the "Triple Aim" – improved patient satisfaction, improved outcomes, and lower health care costs. And a proactive approach to identified population health issues incorporating worksite health care services has the potential to achieve exactly that.

Employers must appreciate that only about 6 percent of health care costs are spent on primary care. This is in significant contrast to many foreign health care systems, where primary care represents more than 25 percent of health care costs. Imagine if primary care was better utilized, then the number of hospitalizations, emergency department visits and specialist consultations would decline considerably. This is precisely what's been shown with the patient-centered medical home (PCMH). Figure 2 shows what could potentially result from improved use of primary care. Note the reduction in the size of the overall "pie" and the redistribution of health care costs. It's important to appreciate that primary care costs actually increase, despite an overall lowering of health care costs.

Figure 2. Current and potential allocation of health care costs in a system with more comprehensive primary care services. The chart on the left represents current costs; the chart on the right portrays the potential results of a more comprehensive primary care (patient-centered medical home) model.

And while interest and implementation of PCMH is accelerating in the U.S., many employers are frustrated with the relative slowness of health care systems and health plans to implement PCMH in their region. For some employers, worksite health care services represent a more immediate solution to rising costs.

And while not workplace services, the growing use of retail clinics in the U.S. reflects individual interest in easier access to health care. Employees who have to be at work and don't want to take time off to leave for a clinician visit will find the after-hours services of these convenience clinics appealing. Even more accessible, worksite services provide the opportunity for individuals to receive care without having to even drive anywhere, resulting in less time away from work.

What's now emerging as an important attribute in worksite health care is the fact that treatment compliance is better. As a result, individuals are more likely to be adherent with their medications, and may be more likely to reach evidence-based treatment goals. In contrast, and as the Employers Health data warehouse has shown, health care use is variable, and even when individuals see their clinician for chronic conditions, they may or may not receive the recommended care.

Another critical attribute of worksite services stems from the nature of the contracting. Employers typically direct contract with those providing the worksite services, and can incorporate performance guarantees to ensure minimum thresholds of utilization, appropriate clinical outcomes, population health improvements, and even demonstrated health care cost savings. This is in distinct contrast to the current health care system where employers have little, if any control over health plan service delivery.

As with other benefits, strategic planning, the decision to incorporate worksite health care services – whether wellness or primary care – should be driven by data. If employers are considering on-site wellness programming or primary care, aggregate health risk assessment and health care claims data can help to identify those companies that are likely to benefit from a worksite approach to health care delivery. Many factors warrant consideration, including organization size, workplace culture, employee interest, as well as available physical space for clinical and wellness services.

For many employers, wellness services may be easier to rationalize, due to lower start-up and operational costs, as well as the lack of availability of these services in the current health care delivery system. Worksite primary care should require more serious deliberation, and should include consideration of employee interest, access to spouses and dependents, as well as the quality of existing primary care. Additionally, the geographic dispersion of employee residences should be a consideration because of access concerns – individuals may not want to travel to the workplace for health care if available community resources are just a short distance away. Importantly, if employees and family members have well-established relationships with community primary care practitioners, they may not appreciate the value in using worksite health care services.

The arrival of accountable care organizations and the escalating growth of patient centered medical homes, now provide employers with a new set of options to help control health care costs and improve the workforce health. Nonetheless, with current health care inflation, employers may not have the luxury of time to wait for widespread implementation of these in health care delivery and associated payment reform innovations. Worksite health care offerings – primary care and wellness – may well provide a means for employers to have more direct and immediate control of the health care delivery system.

Care to discuss? Employers Health can help. Contact Bruce Sherman at

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BHCG Monitor: Focus on Health Care Benefits - April 2012