My pediatrician made house calls. I always knew when I heard the pan of water being placed on the stove that a needle was being sterilized and an injection was coming. He knew that I was a gymnast and that my brother was on the swim team, and frequently asked how we were doing in competition.
What I just described was commonplace in the 1950s and 1960s. To me, those were the "good old days" when the doctor actually knew me. And he was my doctor in the hospital, outside the hospital and even in the emergency room! He called the surgeon, orthopedist or urologist and facilitated the specialized care I needed.
Times Have Changed
Fast forward to today … we have too many patients in the emergency department (ED), too few inpatient hospital beds, too few primary care providers and too many people who are uninsured or underinsured. For primary care physicians, the income is in the office, not the hospital. And given their workload, very few have the time to make house calls.
This struggle is playing out across our country, with more consolidation of services, creation of medical homes and efforts to expand coverage (though the depth of these new insurance products is questionable). It all boils down to diminished capacity to provide care.
So, how do we ensure that patients get the quality care that they need in a timely manner while navigating the new age of medical practice?
The ambulatory & urgent care models may hold a solution.
Urgent care centers (UCCs) are currently enjoying a surge in popularity, and new ones are springing up across the country. Many are run by private companies; with hospitals, health systems and payers also getting into the urgent care game — either by running their own centers or forming strategic partnerships with existing ones.
So why all this interest? And what does it mean for patients? Let's consider how the ambulatory and urgent care practice fits into the new healthcare landscape.
Population Health Management: Healthcare's New Deal
Perhaps one of the most profound shifts to come out of the Affordable Care Act (ACA) has been the shift from fee-for-service medicine toward value-based reimbursement — and especially toward population health management (PHM).
Simply put, PHM is a strategy for improving health outcomes of a given population by ensuring that members of that population are receiving the healthcare they need (generally via an integrated delivery network). Through proactive management of defined patient groups, PHM strives to contain costs while improving health outcomes and engaging patients in their care.
An example of PHM at work is the Medicare Advantage program. Under these plans, CMS contracts with private HMOs and PPOs on a capitated (per-patient) basis. This creates an incentive to maximize health (and reduce healthcare spending) for each covered patient. Organizations can take any number of approaches, depending on the needs of the covered population.
For high-risk sub-groups within the population:
- Case management for patients with chronic conditions
- Monitoring and in-home services for "frail elderly"
- Care transition management for patients recently discharged from the hospital
For all patients:
- Wellness promotion
- Health assessments
- Triage hotlines (to help patients reach the appropriate level of care)
- The success of PHM depends greatly on the reduction of costly hospital admissions and the expansion of outpatient services. Unfortunately, access to primary care providers is strained in many parts of the country and not expected to improve any time soon.
This is one reason that hospitals, health systems and physician groups are striving to develop stronger ambulatory/urgent care networks.
The Age of Urgent Care?
Like primary care physicians and retail clinics, urgent care centers (UCCs) provide ambulatory care — acute care services on an outpatient basis.
Urgent care centers serve as a bridge between the physician's office and the ED. Many have ancillary services like labs and imaging on site. And most UCCs provide advanced services like suturing, casting and administration of IV fluids that would otherwise require an ED.
Providers can gain many competitive advantages by incorporating urgent care into their networks:
- Patient convenience and preference. Urgent care centers generally offer patient-friendly hours. Walk-ins are welcome, and waits are often shorter than at an ED. Some populations (e.g., those under 30) are actually more likely to visit an ambulatory care center than a primary care physician.
- Cost savings for patients. Urgent care centers are far less expensive than EDs, and in some cases they're even cheaper than office visits. This can make them an attractive option for patients with high-deductible insurance plans.
- Cost savings for payers. Insurance companies are working to educate patients about lower-cost care options and steer them away from expensive emergency rooms when appropriate. Some have set up hotlines for just this purpose.
- Relieve ED crowding. A 2010 study published in Health Affairs estimated that 15–27 percent of ED visits could be appropriately handled in the ambulatory care setting at a savings of $4.4 billion a year.
- Take advantage of new reimbursement models. A strong ambulatory services network can be a competitive advantage for hospitals, physician groups and health systems seeking to partner with payers under a population health management model.
- Improved payer mix. Because they're not bound by EMTALA, UCCs can require upfront payment from all patients.
Ambulatory/urgent care can play many useful roles in a PHM strategy. In areas where access to primary care is limited, ambulatory networks can help to fill the gaps by delivering preventative services and assisting patients with chronic disease management.
UCCs can also work with EDs to transition patients to a higher level of care when needed and provide follow-up care for discharged patients.
As our industry shifts toward value-based reimbursement, experts predict that UCCs will grow in prominence — and could even become our default acute care providers. "Ambulatory networks will eventually supplant hospitals as the hubs of successful healthcare organizations," Mark Coughlin, senior vice president of advisory services at Hammes Company, told Becker's Hospital Review last year.
The ascendance of UCCs was underscored by HealthLeaders 2013 intelligence report, which surveyed leaders at 315 health systems, hospitals and physician groups nationwide. Fifty-three percent of respondents reported that they were establishing their own clinics or walk-in centers in preparation for PHM, and an additional 40 percent were working to partner with existing ambulatory facilities in the community.
But there are potential down sides to this shift — perhaps most notably the loss of the traditional doctor-patient relationship. While most primary care physicians don't make house calls like my pediatrician did, they do feel personally invested in their patients. They know their histories. And ideally, there's a certain level of trust.
"The relationship I have with my patients and the comprehensiveness of care I provide to them is important," Dr. Robert L. Wergin, president-elect of the American Academy of Family Physicians, recently told the New York Times. "While there is a role for these centers, if I were sick I'd rather see my regular doctor, and I hope my patients feel that way."
I think he has a point. We're facing a scenario where access, cost and convenience could trump the once-sacred patient-physician relationship.
Under PHM, our physicians will have access to a wealth of data about us (which they'll ideally use to guide care). But that's not the same as knowing us. And I can't help feeling that despite the benefits, something important will be lost.