If you’re not the lead dog, the view never changes.

—Gale Adcock’s motto

Gale Adcock is a big advocate of the nurse practitioner (NP) role in corporate health. Although not every NP can find a situation as ideal as the one she enjoys at SAS, they can flourish in this growing niche.

THE EMPLOYER

SAS is a global corporation that has become the largest privately-held software company in the world. Founded by four college professors in 1976, SAS provides a wonderfully entrepreneurial environment. Gale commented that the corporate leadership has never lost the ability to think like a small company. “SAS was named Fortune magazine’s #1 company to work for in 2010 and again in 2011,” Gale said proudly, “and it has been among the top 100 companies since the list was begun.” She knows that the onsite health care offered to its employees is a big part of SAS’s success.

The primary SAS location resembles a small city, laid out over 300 acres in Cary, North Carolina. This city of about 143,000 people has been recognized by Money Magazine and other publications as one of the best places to live in America. True to its founders’ roots, SAS’s Cary location resembles a college campus, with separate buildings for different purposes. “It’s wonderful to work for a company that doesn’t worry about being like other companies,” Gale noted. SAS has several dozen US regional offices and a second, smaller Health Care Center (HCC) at its Austin, Texas regional office.

THE BACKGROUND

Gale’s first experience with SAS was as an independent contractor at its small onsite Cary HCC in 1989. She then joined the company on a full-time basis almost 20 years ago. The healthcare program was originally quite small and was focused on health screenings, early risk identification, referral to community providers for chronic disease management, and care for acute illnesses and injuries. After Gale had been with SAS not quite 2-1/2 years, the NP who had pioneered the healthcare program retired. Gale was tapped to become the director of Corporate Health Services, a position she has now held for 17 years. During that period, the staff has more than tripled from the original 17, and the practice has morphed from urgent care to primary care, with everything that entails.

“We have renovated two buildings and have moved twice,” she said. “We are currently in a 35,000 sq. ft. built-to-spec building that we designed. It is drop-dead gorgeous!” Gale described the circumstances that led to their new building. “SAS wanted to build a five-star hotel on campus. Since our old building sat right on the site needed for valet parking, the company tore it down after building us a new $8 million building with plenty of space for future growth and beautiful surroundings. We’re located near the Recreation & Fitness Center and the Work/Life Center in a lovely part of the campus.”

CORPORATE HEALTH SERVICES TODAY

As the director of Corporate Health Services, Gale currently oversees 55 employees in two states and controls an annual budget of $4.6 million. She commented that it is an NP-dominant practice, with 10 NPs, four family physicians, a nutritionist, 3 physical therapists, a psychologist, and 10 nurses. Gale spends one week every year with the NP at the Austin regional office HCC. Corporate Health Services provides primary care to SAS’s 4500 employees and their family members— about 11,000 people—free of charge. “Almost threefourths (73%) of our employees have chosen the HCC as their primary ealthcare provider, or ‘medical home’—the latest terminology used by the federal government and others,” Gale said. The health care we provide is true to the NP model, with health promotion and disease prevention being key. What we do isn’t just medicine, it is advanced-practice nursing.”

SAS Corporate Health Services offers the same breadth of options as other primary-care practices. In addition to managing chronic illnesses or conditions (eg, asthma, diabetes,hypertension, obesity, etc.), Gale’s department offers periodic health maintenance exams; physical exams for camp, school,and sports; adult and childhood immunizations; health education; and nutrition services (eg, general health; food allergies and intolerances; endocrine, gastrointestinal, heart, pediatric, and women’s health; sports nutrition; and weight management). Pediatric primary-care visits begin during the first week following a baby’s birth and are scheduled according to the American Academy of Pediatrics recommendations. Like adult physicals, well-child visits are scheduled with the same provider for continuity of care. Pediatric primary-care visits include immunizations, developmental assessments, and anticipatory guidance. Parents are informed about their child’s growth and development, nutritional needs, age-appropriatesafety needs, and recommended immunizations.

Annual blood drives

Breastfeeding education, consultation, and support

Counseling

Diabetes Self Management Program (that can actually begin at the diagnosis of insulin resistance/metabolic syndrome or prediabetes)

“Healthy Living Events” on a variety of topics (eg, neck pain, grocery shopping tips for diabetics, food allergy/intolerance, etc.)

Health checks prior to use of the onsite Recreation & Fitness Center

A full-service lab

Lending library of books, audio tapes, and video tapes/DVDs

Physical therapy

Tobacco cessation program 

Travel immunizations and related health advice 

Healthcare services offered free of charge to SAS employees and their dependents at the Austin location include the diagnosis and treatment of acute illnesses, triage, treatment or referral of injuries, physical exams, health education, allergy shots, immunizations, and lab work. Blood is also drawn for lab tests for SAS employees and dependents that are ordered by community providers.

Patients see clinicians by appointment. “Patients complete online ‘satisfaction’ surveys to tell us how we’re doing,” Gale said. She and her staff are always trying to improve not just their care but also their programs and responsiveness to the employee population. Gale explained that there is a high degree of accountability because the very patient an NP cares for in the morning may serve her lunch in one of the three onsite cafes later in the day. “Because 69% of visits are made by employees—who tend to share their HCC experiences personally and on the SAS intranet—we not so jokingly comment that we are only as good as the last diagnosis we made.” Gale emphasized that the real core of a primary-care practice is risk identification, early intervention, and disease prevention or management. “The promotion of health is the real cornerstone of what we do,” she said. “And in doing so, we save the company a great deal of money every year.”

Because SAS leaders know a lot about software but are not healthcare experts, Gale is not subject to micromanagement. As a general rule, when she describes to her boss or others in upper-level management positions what she plans to do, they agree. She commented that over the years she has been given all the resources that she has really needed. For example, the HCC was allowed to take over all of the building in which it was previously housed after she explained the need for additional space in order to enroll more primary-care patients. Other SAS services were moved out of the building, which was then renovated to meet their needs. Occasionally, she will be asked about using a formulary as a cost-saving measure. Gale’s reply is always along these lines… “When you’re sitting in the exam room with your NP, who do you want making the decision about which drug or treatment you are going to get? Do you want it to be you and your NP or some pencil-pusher in Philadelphia? Who knows more about you and what you need than your clinician/prescriber?” And so the formulary idea is quickly dropped. Gale acknowledges that her approach would not work everywhere; in some companies, the prevailing opinion is that the almighty dollar is the most important thing, leaving healthcare providers with limited power.

THE THORNS AMONG THE ROSES

A number of states still do not allow NPs completely independent practice. “North Carolina is one of the Draconian 23 states that still require physician supervision,” Gale commented. NPs are required to have a collaborative practice agreement with a physician who is listed as the “primary supervising physician” on their application for approval to practice as an NP. They must meet with this designated physician at least every 6 months to discuss a relevant clinical topic (and maintain documentation of these meetings) and consult with him/her as needed. The collaborative practice agreement contains a drug-and-device agreement in which the NP and primary supervising physician decide which drugs and devices the NP will prescribe. In Gale’s practice at SAS, the agreement basically states that anything approved by the FDA may be prescribed, with restrictions on controlled drugs consistent with state regulations. NPs can prescribe Schedules II–V CS, but they cannot write refills for Schedule II drugs. Gale noted that in April North Carolina implemented a rule change that lifted the refill restriction on Schedule III drugs. “My job is a little schizophrenic in that the physicians on staff are my employees and report to me,” she explained, “but when I see patients every Thursday morning, one of the physicians is required by state law and regulations to supervise the ‘medical acts’ that I perform.”

SPREADING THE WORD

Because the HCC at SAS illustrates how well this employee benefit impacts an employer’s bottom line and lowers employee turnover, Gale is often asked to describe her model. She favors a healthcare model with NPs and physicians as equally powerful partners, not the more typical AMA-espoused model with the “physician as captain of the ship.” For example, representatives from Chesapeake Energy in Oklahoma City spent half a day with her in 2010 to see how to take their small contracted healthcare center to the next level and do what is being done at SAS. “Basically,” she said with a laugh, “we just sat around a table for a few hours and I told them how to do it. After all, it’s not rocket science.”

Gale traveled to San Diego in July 2010 to present at a World Research Group conference called Maximizing ROI of Onsite Health Clinics (ROI is return on investment). As one of several speakers, she talked to dozens of people about what she has learned at SAS. Gale explained that they had to decide on the best model for their company based on many individual aspects such as corporate culture, what is known about employees and dependents (if included in coverage), and demographics, among others. “You build a corporate healthcare system to spec,” she noted. “It isn’t an off-the-rack solution.” When people tell Gale that they want to offer onsite health care, she asks them why. What is the ultimate goal? Is it to save money? Is it to have a healthier population? What are they trying to achieve? If they do not know their goals, how will they know when they have reached them? If the CFO says they need to cut healthcare expenses by 25%, she first asks how long they are being given to accomplish that goal. If they must show a return on investment in 6 months, she tells them that onsite health care is not for them. After all, who would put money in the stock market and expect to see a big return in 6 months? In order to be successful, companies offering onsite healthcare must be in it for the long term. She advises them to set some realistic milestones and to start small—not using a ponderous model with so many moving parts that one of them is certain to go wrong. “You grow this kind of model the way you treat hypertension. Start low and go slow. As you experience success, you communicate the message. ‘See how well we’ve done thus far; now we’re going to do this.’ Sometimes the timeline is very slow,” Gale noted, “while at other times it could be fast. Nothing succeeds like success.  When you get a little success under your belt, you have traction to do other neat things.”

Gale unapologetically puts her bias on the table up front—she believes in using NPs as the majority clinicians in a corporate onsite practice. She feels that a typical physician-based onsite healthcare model is too costly and does not hit the mark. “The type of primary care offered at an onsite healthcare facility must be heavy on education, health promotion, and partnering with patients,” Gale explained. “In addition to being more expensive, many physicians aren’t attracted to this work because it isn’t sexy enough and requires them to work as a true team member. To be most successful, this model needs physicians who practice like NPs.”

REACHING BEYOND THE HEALTHCARE ARENA

Gale’s clinical background, leadership experience, political savvy, and business and professional contacts make her a valuable asset to SAS beyond HCC operations. She serves as a voting member of the company’s Benefits Committee, which makes decisions about health plan design, preauthorization (or not) for certain treatments, and pharmaceutical benefits. She is the designated expert for pandemic flu planning within the comprehensive SAS Continuity of Business Plan. In her role as the company’s spokesperson for health care, Gale has been interviewed for stories about SAS by 60 Minutes, Fortune Magazine, The New York Times, The Economist, National Public Radio, and Korean television, among others. She is regularly interviewed by reporters from local print and broadcast media who view SAS as the benchmark for employee benefits in general and onsite employee health care in particular. Gale represents SAS on the World Economic Forum Global Wellness Alliance and in 2009 was appointed by North Carolina Governor Beverly Perdue to represent the business community on a Blue Ribbon Task Force on the State Health Plan; Gale was the only nurse member. Gale’s willingness to share her interpersonal skills and take on additional responsibilities exemplifies the tremendous value nurses and NPs can have beyond the important goal of providing excellent health care.

CLOSING THOUGHTS…

“We’ve been very fortunate and we know it,” Gale said in closing. “We work hard, but we also get a lot of satisfaction from what we do, and we are held in high esteem by SAS leadership. Our patients tell us all the time that we are the best benefit SAS has to offer. We’re like a big family. I did three physicals yesterday. I had been seeing one of the women for at least 20 years, starting back in my contract days. It’s not just a handshake situation—the woman hugged me hello and good-bye. It’s part of the SAS culture.”