• Practicing Workplace Medicine at the Point of Care

    Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the sixth post in an occasional series of blogs that will look at the different roles family physicians can play.

    Traditionally, a family doctor would set up shop, and patients would come in to the office for most of their care, with the physician stepping out for hospital visits and house calls as needed. For better or worse, that paradigm slowly shifted over time to clinic-based care, and now a large proportion of family physicians practice exclusively in outpatient clinics.

    As a medical student, I dreamed of returning to my rural home, opening a solo practice and doing it all, like "Marcus Welby, M.D.," or "Doc Hollywood." From delivering babies to holding the hands of elderly patients breathing their last, I wanted to be the quintessential Family Doctor, capital “F,” capital “D." The modern health care system -- with long waits for patients and mounting paperwork hassles for physicians -- didn’t (and still doesn’t) appeal to me.

    Here I am talking with a patient at my on-site primary care clinic, which provides care for local government employees and their family members.

    I tried initially to circumvent those problems by opening a direct primary care (DPC) practice. My father and I had moderate success, but the area where we chose to practice couldn’t really support two physicians.

    Thus, I jumped at a chance to work as the family doctor for local government employees and their families. I took a job with a corporate primary care group serving Kenton County and the city of Covington in northern Kentucky, initially caring for about 1,500 individuals. My patient panel has since expanded to include the employees and families of a neighboring city and a large manufacturer in the area. In conjunction with another clinic, we provide broad-spectrum primary care, with a focus on employee health and wellness.

    As discussion abounds about DPC, defining the framework for this approach to family medicine practice requires some outside-the-box thinking. Many of the old ideas about taking care of patients “where they are” inform the new models of practice, with some physicians opting to hold traditional office hours, and offer full-spectrum care with house calls and hospital care for a set fee. Others choose to see patients in some fixed setting other than an office, which is often more convenient to the patient.

    My current practice falls into the latter category. I am an employee of a company that provides corporate primary care -- sometimes called on-site primary care -- for corporations and businesses across the country. In essence, I provide DPC at the jobsite.

    Several different models of corporate primary care exist, although most consist of some combination of basic insurance and an on-site clinic staffed by family physicians to provide primary care for employees and their dependents. Our model includes a lab and an in-house dispensary, with prepackaged medications prepared at a central pharmacy. The employer pays a per-patient, per-year fee to offset visit copays, as well as the medications in the dispensary, meaning no money is handled in our clinic. Some other clinics use a traditional copay model, but often with discounts.

    From an occupational medicine perspective, I spend a lot of time talking with the human resources staff of the employers I serve, helping to coordinate their plans for wellness, organizing events such as influenza vaccination days and looking for new resources we can provide or large-scale issues we can address. We also handle things like Department of Transportation physicals and workers’ compensation issues.

    Patients often comment on the convenience of our clinic, both in location and the limited time spent waiting. We use open scheduling with a Web-based component, allowing patients to schedule up-to-the-minute appointments, each covering a 20-minute block. The intake process, given the lack of copay and the prearranged interface with insurance, consists of obtaining vitals and eliciting the chief complaint, leaving much of the 20-minute appointment block for the face-to-face visit between patient and physician. Many of the annoyances of the traditional doctor visit, such as copying insurance cards or collecting payment, have been eliminated.

    I like the structure of this style of practice because it puts the focus of the visit back on the patient, gives more time for adequate history-taking and allows me to discuss the treatment plan in depth. I don’t walk into the room of a patient who waited for two hours to see me for just eight minutes and feels cheated out of even that meager amount of time by the hassles of registration and waiting. The scheduling system and the dispensary reduce many barriers to care, and the focus on preventive medicine encourages employees to take control of their health.

    Many of the 20- to 30-year-old patients who come through the clinic for acute visits have not had a health assessment since their last visit to a pediatrician’s office, but once they realize the clinic is on-site and there’s no copay, they are eager to go over their history and health behaviors.

    I spend a lot of time talking about the preventive care aspects of medicine that we all learned about as medical students but rarely have the time to emphasize in private practice. I discuss appropriate nutrition and exercise. I get to do in-person smoking-cessation counseling, and the clinic even has a smoking-cessation counselor on staff. I spend time going over medication lists, immunizations and medical histories, and patients have time to tell their stories. It’s also satisfying to know that the patients with multiple chronic diseases are leaving the clinic with medications in hand and don't have to worry about how they are going to pay to have a prescription filled.

    I do miss providing hospital care for my patients, and I’m still an employed physician, but my employer practices good communication and works to ensure autonomy for clinical decision-making and patient care. I do my own prior authorizations and call-backs, and I still have to use ICD-9 (eventually ICD-10) codes.

    But I get to take care of patients, coordinate their care and make sure they get plugged in to the resources they need. I’m free to take care of people, instead of worrying about the financial bottom line. It’s even freed me up to pursue other projects, like a rural outreach free clinic.

    On the flip side, the employer gets guaranteed, accessible, coordinated care for employees and their families, often resulting in fewer lost hours and healthier employees. The companies using corporate primary care also end up saving money on insurance premiums, even with the DPC fees. It’s a win-win situation.

    If you have questions about corporate primary care or want to debate the merits of cash-pay systems, drop me a line on Twitter or respond using the comments feature below.

    Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.


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