Near-site and onsite clinics are growing cottage industries within the health care world. Onsite clinics are increasingly popular among self-funded, primarily large employers. Small employers have also been inserting themselves into the market, sometimes sharing a near-site clinic with other small employers. As these clinics continue to operate and grow in popularity, the question becomes, are they performing according to client expectations?
Vendors specializing in setting up and managing clinics have developed business models to fit the needs of their clients. Because every clinic site is different, any meaningful analysis will be tailored to the needs of the client. The key to long-term success is to work with a qualified health care consultant or health care actuary. In the meantime, the following general guidelines and prompting questions are helpful when it comes to evaluating a clinic’s performance.
Establish a Baseline
What were the initial reasons for the clinic? Was it a response to limited provider access? Was the clinic initiated to bend the trend of growing healthcare costs? Was it intended to improve absenteeism in the workplace?
What expectations were set at the beginning? If an ROI estimate was provided, how was it developed? If assumptions were made to estimate ROI prospectively, how will those assumptions be evaluated going forward?
How do you view start-up costs for the clinic? Should they be factored into the analysis, or are they simply a sunk cost?
Analyze Available Data
What data is accessible to evaluate the clinic? Does the clinic track claims and services and to what level of detail? Is there a way to compare data with the traditional medical third-party administrator (TPA) and/or pharmacy benefit manager (PBM)?
Is the data from the clinic credible? Is the sample of claims sufficient to conduct a review for a given service offered by the clinic?
If the clinic is near-site and services are shared among multiple employers, is employer-specific utilization data available?
Determine Costs and Savings
Is the employer saving money on specific services performed at the clinic once capitated fees are included? Does the organization save money without making assumptions regarding cost avoidance or other behavior changes?
If cost avoidance assumptions are included when evaluating savings, what are reasonable assumptions? Do cost avoidance assumptions align with corresponding utilization reductions from claims administered by the traditional medical TPA and/or Rx PBM?
Evaluate Risk Going Forward
If multiple employers share a near-site clinic, how is the contract designed and what contingency plans are in place if an employer leaves the group?
Who assumes the risk of maintaining or increasing utilization? Are there services that are not cost advantageous at the clinic? Are there specific services that should be steered toward or away from the clinic?
If business needs change, is the business model and contract scalable? Is the clinic vendor/partner nimble enough to meet changing needs?
In general, onsite clinics and near-site clinics are unique, and there is no one size fits all way to evaluate a clinic’s performance. Given the investment employers are making in clinics, regular reevaluations and rejustifications are best practices. Working with a qualified health care consultant or actuary during the review process is an essential part of finding answers to these questions.
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