County Progress asked the director of the Webb County Risk Management Department, Pedro F. Alfaro, M.D., to explain how the county’s new employee clinic grew from an idea to a reality. We would like to thank Dr. Alfaro for taking the time to visit with us.
What prompted Webb County to open a county clinic?
Webb County is a self-funded entity for employee health insurance. In 2017, health care costs were spiraling with rising employee premiums and yearly budget deficits with an approved budget of $17,666,240. Webb County health insurance had a 60/40 insurance coverage base plan and a fixed rigid pharmacy plan. Employment enrollment dwindled down with approximately 850-plus enrolled employees out of 1,500 employees; in addition, the county’s preventive health services program was very limited. Commissioners Court issued an edict of financial accountability and fiscal responsibility with a focus on utilizing existing resources. County Judge Tano Tijerina and the Commissioners Court directed a complete, in-depth review and analysis of the existing health insurance plan available to employees.
What was the process?
Health insurance plans are complex with multiple variables to be considered when analyzing a return of investment on services provided. The multiple factors of deductibles, premiums, discounts within networks, multiple tier pharmaceutical plans, and utilization of services, be it in network or out of network, and medical providers will all have an impact on cost within the health plan. An in-depth analysis, i.e. a multi-variate analysis, will quickly identify the various permutations/options of what is the best combination for your specific insured population. A county can then structure its health plan based on its specific population with a maximum return on utilization.
Our Risk Management Benefits Section was tasked with a total review of the County Health Plan on the premise that every employer population has unique pathophysiology as determined by culture, demographics, and genetics.
Webb County has three main pathophysiology diagnoses in its population: diabetes, hypertension, and hyperlipidemias. No wellness programs were in place, and preventive screenings such as pap smears, mammograms, colonoscopies, and diabetes checks were non-existent and not promoted. The use of out-of-network urgent care centers and stand-alone emergency rooms for ear aches, sore throats, and upper respiratory tract infections were routinely utilized, and these uses added to the spiraling health care costs incurred to Webb County’s self-funded insurance plan. There was no cohesive structure to the health plan and no integration of services with pharmacy benefits or any other health benefit be it dental and/or vision. In summary, we had a failed county health insurance fund with rampant expenses and no return of investment for its employees.
Commissioners Court initiated a review of possible options, and Risk Management was tasked with revamping the Health Insurance Plan via a request for proposals with all best and final offers considered and reviewed. Having the information provided by the initial filing of proposals, a Wellness Fund was allocated by the various insurance carriers applying. Discussion centered on how the Wellness Program could be structured in lowering claims and engaging the employee population to participate and contribute to keeping health care costs down.
AETNA Insurance Company strategized and incorporated into its proposal a twofold approach to wellness and established a Wellness Fund as well as a Clinical Operations Support Program for preventive services. The Clinical Operations Support Program became an integral part of the Wellness Program so as to enhance screenings and prevention programs dealing with the three dominant pathologies in our employee/patient population. AETNA also opted to fund a Wellness Program manager to develop and promote engagement of all Webb County employees seeking and participating in preventive health screenings and/or health monitoring programs.
Securing funding and identifying the weaknesses of the County Health Plan led to the concept of a multi-faceted approach to decrease costs. The first step was to select a site for an employee clinic/wellness center. The second step was to construct a center utilizing existing available resources followed by developing a protocol addressing liabilities and a return of investment methodology so as to establish the infrastructure of a treatment/wellness center. An abandoned work site/mobile trailer located at Road and Bridge was identified. Clinic and emergency centers were reviewed to structure patient flow and access. Printers, computers, furniture, fiber optic cables, electrical conduits, and HVAC systems were refurbished with employees donating desks, office supplies, wheel chairs, and examination tables. Surplus lumber identified from other county projects was found to build patient ramps. All construction, restructuring, plumbing, electrical connections, HVAC system installation, and information technology systems were provided by Webb County employees and thus done in house. The total amount of expenditures for supplies drawn from the Risk Management Department totaled $2,000.
Commissioners Court has a strict policy of accountability and fiscal management; with a unanimous vote, the Commissioners Court supported the proposal to authorize a Webb County Employee Medical Clinic.
The project was authorized as a pilot project by Commissioners Court wholly funded by the Wellness Program Account to provide medical treatment to employees by outsourcing for medical professionals. The Commissioners Court contracted Nuestra Salud Urgent Care Clinic to provide nurse practitioners and medical office assistants. The outsourcing process secured that all medical treatment done by Nuestra Salud staff under the direction of the medical director insulated the county, as they provided their own liability/malpractice insurance and relieved the county from investing in an electronic medical record repository as mandated by HIPPA regulations.
Risk Management then proceeded to train and provide clerical medical office assistants to integrate not only the medical services to be provided, but also to provide direction and information on all health benefits available under the health plan. The staff also confirmed the in-network providers, be they medical specialists and/or laboratory or radiology services. This combination of hybrid staffing has led to the development of a comprehensive Wellness Program with a focus on addressing the specific needs of our patient/employee population, i.e. diabetes, hypertension, and hyperlipidemias.
The model programs currently being developed and refined allow the utilization of the specialty referrals of our insured population to the specific AETNA insurance in-network providers, and allow the staff to provide specific direction. Glucometers, lancets, and test strips are being provided to all employees engaged in our programs at no cost. All are provided with a notebook to annotate glucose readings and will be scheduled every three months for a hemoglobin AlC blood test to monitor the progress of treatment. Diabetes and hypertensive patients are also being directed to meet and consult with a registered dietitian. Hypertensive patients are also being provided with a portable wrist blood pressure monitor. All glucometers and test strips as well as the blood pressure monitors are provided at no cost to the patient/employee. All services are also available to all dependents enrolled under the Webb County employee insurance plan. Medical treatment, referrals, test strips, glucometers, dietary consults, and if available injectable antibiotic treatment are being provided at no cost to the employee/patient.
For a full list of clinic services, see the related article, page 47 of our April issue.
What are the benefits to Webb County?
The Webb County Employee Medical and Wellness Center is still in its infancy and is still developing and expanding services. The Center does not yet have a full year of data collected so as to provide solid data for analysis. However, we can safely state that in one year we will have averted a minimum of $250,000 impact on our health plan, as no claims are being filed. Having ownership of the clinic and a sense of participating in your personal health provides not only a monetary incentive, but also peace of mind that every employee enrolled in the health plan and their enrolled dependents have access to medical health care. The clinic accepts all walk-ins, and there is absolutely no cost to the employee/patient and dependents.
The projected and sought benefit is that not only will the clinic provide employee health by engagement and ownership, but it will avert a financial impact on the Health Fund as maintained by the taxpayer. Webb County is utilizing every available existing resource and self-funding the clinic through Wellness Funding provided by AETNA. This process is innovative and basic yet effective in averting claims, engaging employees so as to participate in maintaining good health, cutting down on lost productivity of sick days taken, and fostering a family environment.
The very existence of having this clinic will decrease the use of free-standing emergency rooms and urgent care clinics that result in out-of-network costs to the insurance plan and the employee.
How would you advise a county interested in launching its own wellness clinic?
This is not a simple question, as various specialties are involved:
- a physician who has had a clinical practice to analyze the multi-variate factors so as to evaluate the utilization of the existing health plan;
- an individual cognizant of reporting utilization parameters with an in-depth knowledge of medical providers be they in-network and/or out of-network;
- an insurance specialist who understands the processing of claim fees, CPT Codes, ICD Codes, and their modifiers;
- a pharmacist to analyze the utilization of prescribed medication and the various formularies so as to enhance and control RX costs thus maximizing formulary rebates from the manufacturers; and
- a risk management specialist with knowledgeable staff in health and life with licenses by the Texas Department of Insurance.
The optimal ingredient is having a project manager who has the management skills to integrate the entire process and put it together matching the specific needs of its insured population and their dependents. The project manager must be able to monitor and derive the various permutations given the rolling, sometimes less-than-optimal conditions of the employee community given the pandemic. The individual must earn the respect of all participants and be willing to think outside the box, as there is no specific blueprint, and each county is separate and distinct.
Last but not least, the project must have the full support of the County Judges and the County Commissioner. Nothing is possible without their leadership and support!