The City of Fort Worth had experienced healthcare cost increases of eight percent for six straight years of when City of Fort Worth Human Resources and Civil Service Director Brian Dickerson took on the position. During that time, the cost of the health plan had increased 50 percent. “I had the realization that the city could not continue like this,” he said.
The city has a fixed yearly budget, so increased spending on healthcare meant fewer potholes, police officers, or city parks. But fixing the problem was about as complex as a problem gets in America.
Dickerson made it his mission to get control of the healthcare spending in North Texas, which was the most expensive market in the nation at the time. The city made the move to create health centers for their employees, but to use outside providers staff the employee clinic.
“Hospital systems are seen as the evil empire, and facility costs are seen as driving healthcare expenses,” Dickerson says. “So we tried to keep people from going to hospital system.”
In Fort Worth, Dickerson says there is a 90 percent chance an ambulance will take a patient to a Texas Health Resources Hospital, so it made sense to speak with the organization about the deal. After some unsuccessful negotiations, THR eventually made Fort Worth an offer “that we could not refuse,” Dickerson says.
The deal included three dedicated employee health centers staffed by THR staff, with satellite facilities and discounts on inpatient and outpatient services at THR hospitals. While Dickerson couldn’t mention the discount figures, he said they were substantial. If all employees consistently saw the health centers, received a physical, and sought care at the facilities, they predicted significant savings healthcare spending preventing more expensive procedures.
In 2018, there was a $5 million surplus in healthcare spending, and they are projecting an $11 million surplus in 2019 without an increase in premiums. The city is also predicting no premium increase in 2020 and possibly not for 2021 either. The days of the eight percent increases are over.
The health centers are free for employees, and include primary care and virtual visits. The city also added 40 common drugs that when purchased through the health center are free. Emergency room visits went down, adding to the savings. They found that one fourth of visits to the emergency room did not need to be at the ER, and so they changed the benefit plan to include a $350-$500 copay for the ER if it wasn’t an emergency.
ER utilization between 2017 and 2018 went down 16.5 percent and the amount paid per visit by 16.2 percent. Unnecessary emergency room visits from one in four to one in seven. Many of those visits shifted to urgent care, but even the total number of urgent care visits decreased by 9.7 percent.
Through UnitedHealthcare, the city employees had access to a Doc on Demand for virtual visits after hours, further avoiding costly ER and hospital visits. Between 2017 and 2018, virtual visit utilization went up 358.4 percent
“Our people have been very judicious,” Dickerson says. “The healthcare system for the most part has been demonized, but this partnership has been fantastic.”
The adoption of the health centers has been growing as word has spread. The centers are seeing 115 new patients each month in addition to the 12,000 patients that showed up to a health center or one of the satellites last year.
Part of the attractiveness has been the focus on efficiency of the THR-run clinics. They hope to get patients in and out in 30 or 35 minutes. “People love that you can call today and get in today or tomorrow,” Dickerson says.
The THR discounts on procedures and having a regular provider who understands their patients and keeps them out of emergency rooms for things like diabetes has added to the savings, Dickerson says. On the city’s health risk assessment scores, the scores went from 14 percent in 2017 to just 2.6 percent in 2018.
Moving forward, the Fort Worth wants to continue to leverage the satellite centers to provide care for employees, and they will look to pull in a rotation of specialists a couple days a week to treat patients. They want to focus on musculoskeletal conditions by following a conservative care pathway, which will use physical therapy and stem cell treatment to avoid costly surgery.
Further changes will reduce the ER copay, expand health centers to provide dermatology services, diabetes education, and reduced costs for physical therapy.
Dickerson says the low turnover for city employees makes it easier to make the investment to pay for the health centers and the free treatment. State law says that municipalities have to offer the same health plan to employees after they retire, so they have even more incentive to keep elderly patients out of the hospital unless absolutely necessary.
In order to create the savings, Dickerson and the City of Fort Worth had to make significant changes, but the results speak for themselves. “We have got to change how healthcare is delivered; it is just not working.”