As part of an ongoing series about the “revolution” in primary care, the Kaiser
Family Foundation (KFF) published an article on the rise in smaller employers offering
work-site primary care. 1 According to the people interviewed, on-site care allowed people
to access primary care without having to take a day off, and, as one CEO put it:
“Why did we do this? So my employees would not drop dead on the floor. We had
such an unhealthy workforce, and drastic times call for drastic measures.”
According to KFF, there are about a dozen companies in the business of providing
worksite clinics. The website of the company mentioned in the article, Marathon Health, 2
“We empower your employees to improve or maintain their health. We focus on
enabling higher engagement, better experiences, and ultimately healthier individuals.
Our job isn’t to treat the symptoms like most healthcare providers do. We build
trusting relationships with our patients so we can uncover the underlying conditions
and heal the whole person. Our care team spends over 30 minutes on average with
each patient at each visit, because the best medicine is more than a prescription.
leveraged its work-site clinic into a chain of urgent care clinics sited using the same model
they use to locate gas stations. 3 But the article questions if the urgent care model works.
“But urgent care and retail clinics may not be a panacea for rising health care
costs. A study co-authored by Harvard Medical School health policy professor Ateev
Mehrotra shows urgent care clinics reduce less serious visits to the emergency room,
yet 37 urgent care visits are needed to prevent a single trip to the ER, increasing total
health care spending with all those trips.
And ongoing research by Vanderbilt University assistant professor Kevin
Griffith suggests that newly constructed urgent care or retail clinics can decrease wait
times at nearby private and public sector health centers initially. Eventually, however,
the increased access provided by the new clinics increases demand as well, he is
finding, and wait times creep back up.
1 Galewitz, P. KFF Health News—Care: Their Own Clinics. 27 October 2023.
3 Sable-Smith, B. KFF Health News—Funyuns and Flu Shots? Gas Station Company Ventures Into Urgent Care.
16 August 2023. https://kffhealthnews.org/news/article/funyuns-flu-shots-gas-station-chain-urgent-care-
“It’s kind of like the ‘build it and they will come’ of health care,” said Griffith,
adding that even though the clinics may not decrease wait times long-term or reduce
costs, they are getting patients seen. “There is a huge problem with unmet care in the
United States. And so ostensibly, these clinics are making a dent into that problem as
As with much else about the state of healthcare, there seems to be a series of
overlapping goals which don’t mesh well. For the health economist, primary care in the
office is cheaper than primary care in the ER. For the payer, keeping costs down is primary,
but they depend on the contracting provider organizations, who have different strategies.
Some attempt to replicate the feel of the Marcus Welby model, albeit with a group of
providers, while others promise to save money by education and activation. Others are
simply after efficient production of fee-for-service care for acute minor illnesses.
What of primary care physicians? I haven’t done any recent polling, but the original
notion of primary care as provision of all routine services from sprains and colds, to pre-
natal and chronic disease management has all but evaporated. Most primary physicians I
know are overwhelmed by the volume of chronic disease management patients wanting to
see them. And every year more guidelines recommend more care with financial penalties to
providers if steps are not followed. Going to the hospital? Forget it. That has become a new
branch of medicine all its own.
I want to share two anecdotes. Many years ago, my group opened an after-hours
urgent care center, but we had trouble recruiting physicians. One Sunday evening there
was a three hour slot not covered, so, as medical director, I took it. I saw 12 patients, and
could not figure out why six of them were there. Two needed work excuses for Monday,
two had worsening of chronic symptoms, one had an acute injury and one an acute illness. I
guess the others were what we used to call “worried well.” It seems demand is unlimited
unless there are financial barriers.
During the managed care era, my group was approached by a local manufacturer
who wanted to try something different. We agreed to a capitation payment and let
employees seek care as before without strings, but reserved “case management” for those
who seemed to be high users of care. We also sent a nurse to the plant to do simple
screenings, such as BP checks, and encouraged follow up as appropriate. The experiment
was a success with the group and the employees, but terminated when the manufacturer
consolidated operations elsewhere.
How much outpatient volume is driven by systemic factors like how or if paid sick
leave is available and how it is handled? Why is a doctor’s note essential? Of course,
extended service hour clinics are part of the answer, but are they connected with the larger
resources in the community? (I note parenthetically that these are usually located in the
wealthiest part of town.) Is there any evidence for a program being able to “activate” more
patients to care about their health, or is this just vaporware? Lastly, what do we mean by
primary care? And if we think it is important, how do we invest in it so physicians will be
willing to do it? The articles note the difficulty of creating disruption in the healthcare
industry. Maybe the real problem is we don’t know which questions are more important.
9 November 2023
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