They are ignored, scorned, and blamed. They represent 30 percent of the 1.2 billion outpatient visits logged in the United States each year. They are adults with urinary tract and respiratory infections. They are children with painful earaches heralded by piercing shrieks and fever. When they call their usual sources of primary care — the doctor's office or the clinic — the next available appointment is two or three weeks away. When they go to the emergency department, they are scorned as not needing emergent care and blamed for being the source of crowding and rising health care costs.
Talk about being stuck between a rock and a hard place. Keith E. Kocher, MD, MPH, and Brent Asplin, MD, MPH, agreed, noting that it's high time that medicine definitively answers the question, What is our plan for acute unscheduled care?
“The burden of acute unscheduled care is substantial. It consists of about 30 percent of the 1.2 billion outpatient visits in the U.S. health care system, far outpacing the capacity of our nation's EDs and rivaling the total number of primary care visits. No single care venue can manage this burden alone,” wrote Dr. Kocher, an assistant professor of emergency medicine at the University of Michigan School of Medicine, and Dr. Brent Asplin, the president of Fairview Medical Group and the chief clinical officer of the nonprofit health care system based in Minneapolis, in a recent opinion piece. (Ann Intern Med 2013;158:907)
“The health system has neither a comprehensive plan to efficiently address the unique requirements of acute unscheduled care nor a system to help patients determine where to turn when in need,” they said. Current discussions center on the patient-centered medical home, which provides primary care access to avoid the ED, or accessibility to the emergency department and its vital services.
“This is an overwhelming problem,” Dr. Kocher said. “Finding a workable solution to efficiently and effectively manage all those visits is hard.” And he noted, getting people to think about solutions requires work. No one sector in the health care system has the capacity to take care of all patients, he said, though the emergency department is probably the most effective setting because it's really designed to take care of any acute care need and it's designed to triage people well. “But we would be completely inundated if we decided as a system to shunt all those patients to the ED,” Dr. Kocher said.
Another problem is that no efficient or uniform way can triage these patients in the outpatient setting,” he said. “Whether they are at home or at work and develop what they perceive as an acute health care need, they have nowhere to turn to figure out where to go with this problem.” Family, friends, and the primary care office, where the quality of care depends on who answers the phone, can all help a person decide, but it is not a uniform answer.
Dr. Kocher said medicine doesn't always think about this problem at the patient level. “What do patients feel they need when confronted with an acute problem? What patient-centered characteristics do we want to address? Most patients are looking for timely care. There is some reason to think that if it's accompanied by some consistency or continuity with their providers, that's great. But many patients, if that's impossible, would prefer to be seen quickly somewhere. We don't have a good mechanism to make that happen.”
Dr. Asplin, an emergency physician who is now leading an outpatient system, said three major providers care for patients with acute unscheduled needs — primary care, retail clinics, and emergency departments. “Urgent care could fit in with the retail clinics or primary care,” he said. “Each of these systems has limitations. Primary care does not have the capacity to meet the demand for acute unscheduled care, which is significant. Retail clinics have limited capabilities. They are not as connected to the primary care system.”
Emergency physicians appear to be recognizing that the economics of emergency care is driven by inefficiencies of the hospital business model in which they work, Dr. Asplin said. “It's real. We cannot pretend that facilities charges for the work we do for the simplest condition make us competitive with either of the other settings” when the facility charges are what make such visits noncompetitive. “The professional fees are comparable.”
Patients want access and affordability; they want their information connected to their primary care provider, and those should be the goals, Dr. Asplin said. The current drive in the health care system is to create value for populations.
One solution might be virtual care, and Dr. Asplin's system is using a service called Zipnosis that allows Fairview patients to answer questions about their illness and get a response from a clinician in less than an hour. The service decides whether to send patients to an urgent care clinic or the emergency department, though it is available only for limited conditions for limited hours during the day.
Outside some safety net hospitals, most institutions make money on the care provided in their emergency departments, Dr. Asplin said. “The reality is that there are more efficient places to get some components of acute unscheduled care. The question is, would you set up that capacity elsewhere and think about changing the business model? The only way to [do that] is to change the incentives. We have an opportunity to think about that from a system perspective. We need to continue the moment, creating better systems to deliver value, better outcomes at lower costs. This conversation will be part of that. How do we change the incentives?”
Systems like Fairview are considering the change because it has accepted the risk for the costs of providing care to populations as one of 32 pioneering accountable care organizations under the Affordable Care Act. Change will come slowly. “We will continue to see a lot of people in the emergency departments,” Dr. Asplin said. “I don't think we are suddenly going to see a significant drop in people coming to the emergency department.
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