As the first private commuter shuttles return to Silicon Valley, a lesser-known perk at companies like Google, Apple and Facebook is poised to emerge from the coronavirus crisis in a new form: the corporate health clinic.

For years, employer medical providers like Stanford Health Care, Crossover Health and One Medical have been building out custom clinics to offer not only urgent care and routine doctor's appointments, but also dental work, musculoskeletal assessments, acupuncture and therapy — both physical and mental. The idea is to rein in health care costs while providing another attractive recruiting benefit.

Now, in Silicon Valley's rarefied version of the company town, the question is how premium health insurance plans and contracted doctors might be used to administer COVID-19 diagnostic tests, virtually screen employees for risk factors or issue some form of "immunity passports" based on so-far-unproven antibody tests. In the process, tech executives and HR departments must grapple with unprecedented questions about worker privacy, corporate liability and the role of employers in a health care system on the brink.

"They are now becoming public health officials," said Scott Shreeve, an emergency medicine physician-turned-CEO of employer medical provider Crossover Health, which works with Apple, Facebook, LinkedIn and others. "They didn't realize they had these little cities."

Public health departments and hospitals are wary of a second wave of COVID-19 cases, especially with police brutality protests roiling cities, so any efforts by employers to stave off virus hospitalizations are likely to be welcomed. And even though offices in the Bay Area are permitted to reopen beginning June 15, big companies including Facebook and Salesforce have said their nonessential employees will not be forced to come back in 2020, reducing the number of people circulating in the area.

But as with previous social flash points driven by the tech boom, like policy fights over the commuter shuttles and affordable housing, a retrenchment to isolation to set up blue-chip employee health services could add fuel to the "techlash" that has defined recent years in Silicon Valley.

"Companies that define their role narrowly in these crises do so at their own peril," said Mark Muro, a senior fellow and policy director of the Brookings Institution's Metropolitan Policy Program. "We've been seeing a drift toward a broader definition of the company's responsibility in the United States."

It could be read as "grotesquely tone deaf" for tech employers to wall themselves off, he said, when companies like drugmaker Eli Lilly in Indianapolis have "turned themselves inside-out" to offer free testing to medical workers. Some tech executives have made large donations to groups working on vaccines or to social programs in recent months, but more hands-on relief efforts like a tech task force convened by Apple, Google, Amazon and Microsoft have largely "failed to materialize," The Wall Street Journal reported.

The details of tech companies' in-house plans are still in flux for COVID-19 testing, antibody testing and the process of helping infected employees navigate the treatment process while retaining their privacy. Given the virus' lethality among less-protected workers, though, the stakes are high.

"The disparities in impact of COVID could be paralleled by the disparities in safety in returning to work," said Robert Harrison, a clinical professor of medicine who specializes in occupational health and safety at the University of California San Francisco.

'Totally uncharted'

Where should employees get tested for COVID-19? How often should they get tested? What happens if it turns out there's a "super-spreader" in the office? These are the kinds of questions that Harrison and others well-versed in the world of employer medical care are getting.

Ultimately, the responsibility for public health during a pandemic "rests primarily with the local county health departments," Harrison said. So he's urging employers to report all positive coronavirus test results to health officials and ensure that any on-site symptom screening is integrated with isolation procedures and HR privacy protections.

"A company like Google or Tesla, I mean, they should be doing that also," Harrison said. "But they can probably act like their own local, mini health department on site."

At One Medical, which operates clinics that serve employees of Airbnb, Instacart and Google, Chief Quality Officer Raj Behal and his team are working with tech employers considering a wide range of screening measures. Some lean toward lower-cost, less-invasive temperature checks and apps that ask employees to self-certify that they are symptom-free.

One Medical is among a growing number of vendors that have devised a new platform to dole out employee "boarding passes" to go back to work after they've been screened for risk factors like travel and preexisting conditions. Class 1 workers are lowest-risk and have tested negative for the virus, Class 2 haven't had symptoms, exposure or testing, and Class 3 have symptoms or have tested positive.

Some employers concerned about privacy have told One Medical, "We don't want any of that information. Just tell us which risk class they're in," Behal said. "But there are a handful that would like the detailed data. They want to know if somebody tested positive and what their antibody status would be."

One Medical, however, cannot share that information unless employees sign an explicit waiver. Experts like Harrison say companies should create a new "firewall" between any on-staff or hired medical providers and HR to protect confidential medical data.

"This is totally uncharted," Behal said. "There's legal rights on both sides, and pandemic exceptions kind of loosen things up."

All of these issues are magnified for employers who choose to set up hands-on virus or antibody testing programs. On-site clinics, outdoor tents or drive-throughs are all options, but Shreeve favors at-home diagnostic tests — that is, assuming companies can get access to enough of them.

"You can imagine an employer, you have 5,000 workers, you're going to send 5,000 tests to everyone's home," Shreeve said. "Employers have never had to do anything like this, and then the science is like, well, I don't even know if this is the right thing to do, but it's something to do."

The murkiest area — and the most intriguing, in Shreeve's opinion — is antibody testing, done through serologic tests already on the market. They carry the caveat, at least so far, that they should not be interpreted as a guarantee of immunity. But there's already interest in Silicon Valley in adopting that approach as antibody tests 2.0 emerge.

"Immunity status is going to be a really big deal," he said. "No one's going to want you back on campus unless you have immunity."

The 21st-century company doctor

The concept of companies offering employees subsidized medical service at work is not new. It started with railroad companies in the 1930s and expanded to manufacturers and other industrial bosses looking to reduce workplace injuries that drove up employer costs in emergency rooms and through worker's compensation claims.

But in the last decade, amid the erosion of U.S. primary care and skyrocketing health costs, health clinics have been absorbed into Silicon Valley's perks economy, with a range of services geared toward desk-dwellers rather than the factory workers for whom occupational medicine was created to serve.

"Technology, for lack of a better word, is very loosely goosey," said Katelyn Johnson, integrated health manager for Cisco's four global employee health clinics. "There are no drug screens. There's no preemployment physical. There's no occupational health center you go to, and that's because our work is sedentary."

Johnson, a long-distance runner and veteran of the fitness and hospital industries, was hired by Cisco in 2007 to create the company's first clinic at its San Jose headquarters. The company wanted to rein in health care costs that were steadily increasing thanks to chronic conditions like obesity and heart disease by offering primary care visits with high-quality doctors hired through a contract with Stanford Medical Center, instead of the nurse practitioners and other "midlevels" increasingly staffing ordinary doctor's offices.

The 25-person San Jose clinic that opened in 2009 was designed to better integrate employee health care and encourage usage by tacking on popular wellness services like physical therapy and acupuncture. Though such clinics can cost millions of dollars to build out, the resulting decrease in health care costs has proven so valuable that Cisco's operation has since grown to 40 full-time staffers and three additional clinics in North Carolina, Bangalore and Mexico City.

"Every time somebody uses the health center versus a community center, Cisco saves money," Johnson said. And if employees are referred out to specialists, she said, the clinic helps ensure that they're encouraged to go to "value-based providers."

The financial advantages have pushed the field beyond tech. Goldman Sachs advertises access to specialists like dermatologists. One 2018 survey found that one-third of U.S. companies with more than 5,000 employees offered "general medical clinics" at work, up nearly 10% from a similar survey in 2012.

But most companies aren't trying to get into the health care business themselves. While Amazon and Apple have posted job listings for medical personnel to staff employee clinics, almost three-quarters of the companies surveyed in 2018 outsourced the work of running on-site clinics.

That demand has bolstered growth for companies like Crossover and One Medical, which position themselves somewhere between mass-market medicine and white-glove "concierge" services

For employers still nervous about the up-front investment in a clinic, there are also shared "near-site" clinics located between several employers who split the costs, said Larry Boress, executive director of the National Association of Worksite Health Centers. He expects the pandemic to boost demand for such services.

"Employers, even though it's not their core business, will find that it's going to be a necessity," Boress said, "just as many of them offer child care and other kinds of support."

A third way?

At Dropbox, which does not have an employee health clinic, Chief Legal Officer Bart Volkmer said he and the rest of the company's crisis response team are now evaluating whether — and how — to bring medical personnel to its Silicon Valley campus.

"I don't know on the on-site health clinics if we're going to go down that road," Volkmer said. But he added, "We don't want to say, 'Hey, just go deal with the health care system.'"

From a policy perspective, employer-provided health care is at a complicated crossroads. Gig companies like Uber, under fire for providing no health insurance, are seeking to align themselves with left-leaning workers rights groups in calling for state or national action on "portable benefits" that decouple insurance from individual jobs. Meanwhile, employers including Amazon and Apple are pushing further toward creating their own insurance pools and severing traditional fee-for-service health care models.

Lisa Yee of the Silicon Valley Employers Forum, a tech membership group that works on issues related to employment benefits, is among those who wonder if COVID-19 will unleash political changes that could leave even tech companies on the vanguard of generous benefit packages scrambling to react.

"Given that so many people are unemployed now, the question of the viability of self-insured employer plans is sort of in question," said Yee, who is the group's executive director. "It raises the question of, is there going to be a move toward a one-payer system for this country?"

In the meantime, Boress of the National Association of Worksite Health Centers said the value of a centralized employer medical system that can refer workers out to any number of providers is magnified in a high-stakes situation like COVID-19. "In a perfect setting, you have an on-site center, and most have electronic records," Boress said. "They can be the hub of the wheel."

At Crossover Health, Shreeve sees another path forward — that third-party membership medical programs like his or One Medical's will expand beyond the realm of Silicon Valley to be the norm. Like a gym membership, but for health care, and borrowing heavily from the Medicare Advantage model in which patients are also offered related services like meal programs or prescription deliveries.

"What is the same concept for the modern employer?" he said. "I don't think it exists today."