By Kate Woldhuis, Medcor

The landscape of health care is constantly evolving (too often it is “eroding” for many businesses). Employers are challenged with rising health care costs, ever-changing and more complex regulations, health care reform uncertainty and barriers to access.

Small- and medium-sized companies struggle to address health care issues in the best of circumstances. Even large companies with more resources find it difficult to keep up with the constantly increasing health care challenges of cost, access, and quality.

Remote worksites face even more complications as they struggle with these same challenges, plus the additional challenges of fewer medical providers to choose from, even higher costs, long response times for emergencies and long travel times away from work even for routine care. For businesses operating in remote locations, solving these health care problems doesn’t just affect productivity and the bottom line—it can determine whether or not they stay in business.

Most people think of health care in remote places in terms of responding to exposure from the elements, outdoor adventures gone wrong, and even encounters with wild animals. However, remote health care affects many business types, including: resort and lodge operators, restaurants, transport companies, outfitters, construction firms, and even government agencies that work in remote locations.

These businesses have to overcome health care challenges not just for their employees (especially in off-hours), but often for their customers, too. Furthermore, all the obstacles are magnified when the worksite is hours from the nearest clinic or hospital—everything becomes more expensive, more difficult to coordinate and takes longer.

Out of necessity, some remote businesses are finding ways to treat these problems, if not curing them completely. These solutions have to be unusually efficient and self-contained, since they cannot rely on outside resources.  It turns out that some of these solutions can work for other businesses, too, even when not operating in isolated environments.

One solution for remote businesses is to host a clinic located at the worksite (“on site” or “near site”) dedicated to the businesses’ employees, dependents and customers. This provides immediate, convenient access, customized services, and, if done properly, controls costs. The concept of providing health services for employees on site is not new, and is one that is gaining popularity.

In the past, the concept was thought to suit only large self-insured employers, but now many medium-sized firms are also finding benefits including savings on health care, lower injury rates and improved productivity from on-site models that cost less to operate by leveraging technology and other efficiencies. Employees utilizing these clinics receive the appropriate level of care at the onset of injury or illness, experience cost savings as the result of no or reduced copays, and improved access to a health care provider.

As an added benefit, on-site providers dedicated to the site and community become familiar with applicable resources, plans, community, etc., and have a greater knowledge of the employees’ duties, workers’ health histories, and in some cases, they have developed relationships with local off-site providers to coordinate continuity of care.

On-site providers still have limitations and challenges to overcome. Components of successful clinics require great effort and attention to detail—from selecting the right scope of care and staff, to ensuring the services replace more costly off-site services, rather than simply adding to them. Additionally, opening an on-site clinic can require a substantial amount of start-up capital and ongoing operating expenditures.

The return on investment depends heavily on utilization by employees, and how well the medical provider performs. Even in remote areas, employees may choose to continue seeing the provider they are used to rather than seeing a new provider at their workplace, so creating incentives to use the on-site clinic that fit the workplace culture and medical scope are key to ensuring utilization at startup and beyond. On-going coordination and cooperation with community providers is also key.

In urban areas, on-site clinics can rely on nearby medical infrastructure, such as specialists, hospitals, and labs. However, on-site employer-hosted clinics in remote locations don’t have those resources to lean on; consequently, they are forced to be more efficient and self-reliant. They develop specific protocols, training for staff, software (including electronic medical records), operating systems, referral guidelines and networks, incentives and QA processes. As a result, these remote clinics can operate very cost effectively, with less use of off-site resources and their associated costs. These lean operations are valuable for non-remote businesses, as well.

There is no silver bullet when it comes to reducing injuries and illnesses. It is inevitable that some patients will require off-site specialty care because it is Medcor's Ashley Polucci, sitting and Karen Drescher are two employees at the Lake Clinic at Yellowstone National Park. impractical and costly to provide specialists and advanced technology (e.g., MRI, CT Scans, surgery) in an on-site clinic. Developing good protocols to ensure appropriate referrals are made at the right time to the right place are key to ensuring good care and lower costs. Some on-site clinics are operated by off-site hospitals, clinics or pharmacy companies.

This offers opportunity for integrated data and services, but also builds in potential conflicts of interest, since the off-site owner can generate revenue from referrals and prescriptions from the on-site clinic. Other on-site operators specialize in on-site operations and avoid financial ties to off-site providers.

The best models combine benefits of both on-site and off-site resources that are used in coordination.

One remote location that has found success with on-site clinics is Yellowstone National Park. Responding to the changing landscape of health care, Yellowstone National Park conducted a competitive RFP to find a more efficient operating model for its on-site clinics, focused on controlling costs, and improving quality and service.

Yellowstone contracted with Medcor in 2003 to operate three clinics at the Park to provide primary care, urgent care, family medicine and occupational health care services for employees, their dependents and visitors to Yellowstone. Walking through the three clinics, it is evident that they provide the services and amenities found in any traditional clinic—exam and treatment facilities, pharmacy, lab, x-ray and EKGs.  What makes them different is how they operate in a remote environment.

One difference is a flexible scope of care customized for the environment. For example, parts of Yellowstone can be a three-hour drive or more from the nearest emergency department. Consequently, access to immediate care is critical.

“Our clinics are staffed and equipped to treat most emergencies— including life-threats—in addition to handling more routine cases,” stated Deborah Brown, director of operations for the Yellowstone clinics. “We have to be able to handle a wide range of ailments—from simple poison ivy and heat rash, to strokes, heart attacks and car accidents.”

Serious cases requiring surgery and other off-site specialty care still have to be stabilized and managed during transport. The clinics at Yellowstone also provide family medicine for year-round residents, and care for any of the millions of visitors to Yellowstone each year that get sick. Another difference is extended hours of operation to give patients access to clinics.

“We’re open to meet the needs of our patients, not for the convenience of our staff,” Brown explained.  “That means seven-day operations, 12 hours a day when the park is busy, with staff on call even when the clinic is closed.”

Urban businesses often find the only health care available during their second and third shifts is an expensive hospital emergency department or urgent care center.  On-site clinics can operate early to allow families to bring kids in before school, and late to allow employees to seek care without having to take time off work.

Clinic schedules also accommodate the park’s seasonality, adding staff and services each year during peak summer months. This kind of flexibility requires more recruiting and training, but controls costs in the off-season and maximizes service when it’s needed. Medcor utilizes a core staff that stays year-round, augmented by seasonal staff, many of whom return year after year.

The on-site clinics operating today are quite different from what they were a decade ago. Today’s model handles just as many patients, but with roughly half the staff and cost. Working with the National Park Service, Medcor made several updates, converting from an in-patient model to an out-patient operation.

Medcor updated clinic technology, converting x-rays to digital imaging and introducing telemedicine to gain immediate consultation from off-site physicians. They implemented an electronic medical record system, making the clinics near paperless. They converted from physician staffing at the seasonal clinics at Lake and Old Faithful to using physician assistants and nurse practitioners, overseen by board-certified physicians.

These clinics also serve multiple constituents: patients include employees of the National Park Service and more than a dozen other area employers numbering more than 5,000 people –and their dependents, residents of the surrounding communities, and visitors to the park. To be successful, the clinics must be able to meet the different needs of these groups. Employers and employees are concerned with return to work and regulatory compliance. Visitors want to get back to their vacations. Residents need their on-going health care, and everyone has an increased desire for wellness and preventative medicine.

Clinic providers and managers meet with employers regularly to review services and work through any issues that come up. Open communication is key to good coordination. When cases are referred to off-site facilities, it causes employees to lose hours (or in extreme cases, days) of work at a time. These costs can become larger than necessary for employers in remote locations since the ramifications of injuries may become magnified when employees are faced with long travel times to get the care they need.

“It equates to them in dollars and cents that their employees do not have to lose days of work,” Brown stated. “If the clinics were not there, it would require one or two days off work to be seen. It would require hours of travel for them to receive care and then possibly more days for follow-up care.”

Many area employers have large seasonal staff that are young or retired and have limited health insurance benefits. Working together with the park and employers, Medcor developed a program of discounted services for this population.

Serving visitors from all over the world has also been a challenge. Good on-site clinics are used to coordinating with the multiple health plans offered by large employers, but at Yellowstone, patients can present insurance plans and expectations from literally anywhere in the country or abroad. The clinics at Yellowstone accept a huge range of plans, and provide courtesy submissions to all other insurances and assist individuals in filing claims appeals as necessary.

“We assist our patients with guidance and medical records, and we accommodate hardship cases, too,” Brown said. “No one in need is turned away.  Additionally, our on-site clinics provide a service that is less expensive for patients, employers and insurers alike.”

Managing logistics for referrals, transfers and follow-ups requires constant attention as well. Yellowstone covers two million acres of wilderness (bigger than some states), and spans parts of three states: Wyoming, Montana and Idaho. The Medcor team must coordinate care with multiple hospitals, specialists and ambulance services in surrounding cities, most of which are hours away.

This presents many opportunities for miscommunication and problems. The providers at Yellowstone meet formally twice a year, once at the end of the summer season and once in the beginning. Meetings include the stakeholders of the clinics including Medcor and local medical directors and primary care physicians, operations directors, CEOs and legal counsel.

“Working on establishing personal relationships helps them understand our constraints; they become part of our team, and as a team, we provide better care to our patients,” said Dr. Luanne Freer, Medcor’s medical director at Yellowstone National Park.

Dr. Freer also explains that the on-site team is never short on obstacles when it comes to daily operations.

“In general, geography, extreme and unpredictable weather, moderate altitude, bison jams (when an animal that weighs a ton—and 200 of his closest family and friends—decide to camp out in the middle of the only road out of the park) can delay traffic for hours, so we’re always on our toes.”

Providing on-site care at a remote location such as Yellowstone is challenging, but in the eight years of operation, Medcor has been successful in meeting the Park’s objectives and the needs of all their constituents. Out of more than ten thousand patients treated at the clinics each year, approximately 250 are sent off-site for care, on average.

“What we’re doing at Yellowstone can serve as a successful template for other on-site clinics, even if they are in less remote and extreme conditions,” Medcor Chief Operating Officer, Ben Petersen said. “Employers can control costs and improve access and service levels while maintaining quality. To do that, their clinic provider must deliver the services they need when they need them, operate efficiently, accommodate their unique logistics and financial challenges, communicate openly and stay flexible.”