Is the integration of urgent, emergent, inpatient and
care of patients with
acute medical conditions.
Ambulatory and urgent care centers
By Gary Li, MD, FACEP
In most of the prior blogs you have heard a lot about the inexorable forces of change in our healthcare system which are leading to consolidation of health care entities, integration of service lines, accountable care organizations, and so on. Fundamentally, these forces are the oft-state three mandates of improving quality, improving access, and decreasing costs. Keith Bontrager of mountain bike building fame used to say “strong, light, cheap—pick two out of three.” Well, perhaps carbon fiber has changed that paradigm for bikes. Going forward, in medicine, we are also expected to go three for three. Here I would like get into the weeds a bit and ponder resource utilization in clinical practice and the relationship with the Acute Care Continuum.
Analogous to fast food “supersize” meals, more medical care does not always mean better care. Gradually, many healthcare providers and members of the public are beginning to understand this. The “Choosing Wisely” initiative of the American Board of Internal Medicine Foundation is indicative of this recognition and concern. In this program, each medical specialty identifies five diagnostic or therapeutic interventions that may be of questionable value. Programs like this are encouraging medical providers to let go of tests and procedures that are not helpful, may be harmful, and are expensive.
By Ted Kloth, MD, FACEP
The time is coming when consolidation and transparency will reign supreme, and the effects are already being felt throughout the healthcare arena.
Looking at the healthcare landscape and how the major players are reacting to the effects of reform, it is obvious to me that the need to consolidate is becoming a reality for many physician groups and service providers. Health systems are merging with larger health systems and clinical outsourcing groups are entering into joint ventures with their long-time clients to provide care at a lower cost. The rationale behind this shift is the belief that integrated systems reduce costs and increase profits for all parties involved. And with fewer reimbursement dollars at play, it seems most are looking for ways to increase profit margins by doing more for less.
By Josh Sheridan, MD, MS
The hospital system I work for has an ED and two Urgent Care Centers (UCCs) in the same city. Between the two UCCs, we serve all payer populations so that everyone in the community can access urgent care services when needed. In this way, we try to be highly available for everyone who needs immediate care. At the same time, we have also made the decision to have limited testing facilities in the urgent cares and to focus them on particular patient populations. While our UCC set up is not the standard, the results have been beneficial for both patients and the hospital.
When I hear people talk about lack of access to healthcare in our society, I realize right away that they are not talking about where I work. At our Urgent Care Center (UCC), our mission is to help people feel better as soon as possible and to transition them quickly to the additional service they may need. Our Center is designed to increase access to medical care for low-income patients and for low-acuity patients who do not have a primary care physician.
The UCC concept of making access to healthcare more convenient appears to be resonating with the ‘fix it now’ mentality of our society. The number of UCCs in the country is growing fast. Of the 8,700 UCCs currently operating in the US, only about half of them have been in business for over five years.
By Wes Fields, MD, FACEP
One of the ironies of our intensely divisive political season is that Republican and Democratic candidates agree that universal access to health care already exists in the United States, and preceded the Affordable Care Act by 24 years.
The Emergency Treatment and Active Labor Act (EMTALA) will continue to define unscheduled ambulatory care and acute hospitalization for the entire US population, regardless of how the elections for the White House and Congress impact ACA, the Fiscal Cliff, and the precipice in Medicare for physicians known as the Sustainable Growth Rate.
Taken together, the patient protections of EMTALA structured as mandates on Medicare participating hospitals touch nearly half of all costs in the current US health care system. Inpatient hospital care accounts for more than one third of expenditures(pdf). And more than half of all admissions are direct results of ED visits for patients who are too unstable to be discharged home. Ambulatory ED visits account for nearly one third of all unscheduled visits. A far larger proportion of first contact conditions of higher risk and higher cost are performed in EDs. This high-acuity effect is compounded for those who are uninsured, or underinsured.
I read the recent CDC report on “Emergency Room Use Among Adults Aged 18-64: Early Release of Estimates From the National Health Interview Survey, January-June 2011”[PDF] and felt compelled to respond. As an emergency physician helping to lead a physician group which sees four million emergency patients per year, I had both an intellectual and emotional response to this article. My comments are about this specific article as well as the general issue – the widely held belief that there are too many ED visits. I hope my ED based perspectives will be viewed as helpful and not defensive.
I have doubts about the conclusions based on the data because of the retrospective design of the study and the small number of surveys used. Most of these studies were done retrospectively based on discharge diagnosis. One conclusion from the CDC study was that only 54.5% of visits required a hospital for their care, suggesting that only these patients had true ‘emergencies.’ The lay public are often very unaware as to what is a serious problem needing emergent or very urgent care versus a not so serious problem—especially prospectively.
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