Presentation on theme: "convenient care models"— Presentation transcript:
1convenient care models 3/25/2014Amer Kaissi, Ph.D.
2Other convenient care models Future OutlineConvenient careRetail clinicsOther convenient care modelsFuture
3Then there is Jurassic Park." "There's a place where ancient animals are roaming around near extinction. They are completely clueless about their future fate.Then there is Jurassic Park."I am going to start with this picture of an ancient physician’s office. A while ago, I was attending a presentation and one of the speakers commented and said….What did he mean? He meant that many healthcare organizations especially hospitals and physician offices, have not kept up with the times.Think of the last time you tried to schedule an appointment with a doctor. You picked up the phone- how long did it take for you to talk to a real person? How long were you on hold? What options were you given to you in terms of appointment times? In most office, the options are Monday-Thursday, from 8-5. of course, on Friday they are closed because the doctor is playing golf. How many weeks did you have to wait? And then once you go there, how many forms did you fill up? How long did you wait in the waiting room? And then in the examination room? How long did you wait for your prescription to get refilled?The point is we have designed our HC system around the preferences of the providers, no the patients or the consumers.
461%of primary care physician offices do not have an arrangement where patients could be seen after hoursWhat that leads to is that for many people, the only option for after hours care is the emergency room!Schoen et al. (2009)
568%of emergency room visits are neither “immediate” nor “emergent” in natureEmergency room visits are classified into five categories, depending on the level of immediacy (in minutes) assigned upon arrival by the triage staff: (1) Immediate (patient needs to be seen immediately); (2) emergent (needs to be seen within 15 minutes upon arrival); (3) urgent (between minutes); (4) semi-urgent (1-2 hours) and non-urgent (2-24 hours) (Niska, Bhuiya & Xu, 2010). In 2008, 4% of emergency room visits were for patients that needed to be seen immediately; 12% were emergent; 39% were urgent; 21% were semi-urgent, and 8% were non-urgent (Cunningham, 2011). These numbers indicate that about 68% of emergency room visits can, theoretically, be taken care of in other lower-acuity settings such as urgent care centers, primary care physician offices, retail clinics and others.Cunnigham (2011)
6Time Required to See Provider Type of visitTime Required to See ProviderActualWait timeImmediate0 min28 minEmergent15 min37 minUrgent15-60 min50 minSemi-urgentmin68 minNon-urgent> 120 min76 minThis has lead to overcrowding of ERs and long wait times.Emergency room visits are classified into five categories, depending on the level of immediacy (in minutes) assigned upon arrival by the triage staff: (1) Immediate (patient needs to be seen immediately); (2) emergent (needs to be seen within 15 minutes upon arrival); (3) urgent (between minutes); (4) semi-urgent (1-2 hours) and non-urgent (2-24 hours)Government Accountability Office (2009)
7expected primary care physician shortage by 2025 46,000expected primary care physician shortage by 2025Another contributing factor is the well know PCP shortage that is reducing accessBodenheimer (2012)
8Convenient CareCare that is cheap, effective, and delivered in more convenient settings than traditional physician officesIn the face of all of this, convenient care options have started to appear in the last 10 years or so.
9Disruptive Innovations Same as ATMs, mobile phonesA powerful change in which a larger population of less-skilled providers can provide care in more convenient, less expensive setting that historically was only provided by expensive specialists in centralized, inconvenient locations
10Other convenient care models Future Outline10Convenient careRetail clinicsOther convenient care modelsFuture
11Up-front menu-style pricing Retail ClinicsWalk-in clinics located in grocery stores, drugstores and general merchandise retailersCare is usually delivered by a Nurse Practitioner or Physician AssistantUp-front menu-style pricing
12RC started in 2000 in Minneapolis at a Kruger Store. Rick Krieger is the founder of QuickMedx (which became Minute Clinic later) and so is credited for being the father of retail clinics. In 1999, Krieger’s son had a sore throat. Realizing that he needed to test him for strep, he drove him to an urgent care center in Minneapolis. After waiting for two hours, the physician performed a strep test that turned out to be negative. Krieger recalls: “We started talking about why there was not a way to just get a simple question answered or a simple test, like strep throat, done. Why was there not a way to just slip in and be seen quickly? Wasn’t there some way to get care in a timely manner for a relatively simple illness? A quick, convenient way to diagnose without waiting in the ER or clinic for two hours? We are not talking about diabetes, cancer, or heart disease! We are talking about colds and throat and ear infections” (Bohmer & Groberg, 2002). Along with two business partners, Krieger set up pilot clinics in the Cub Foods grocery store chain.
13Conditions treated: 90% of the conditions treated fall within 10 diagnoses Upper respiratory infectionsUrinary tract infectionsSinusitis/Bronchitis/PharyngitisEar infectionsConjunctivitisImmunizationsScreening laboratory tests/blood pressure checks
15Clinics are mostly located in densely populated states and major metropolitan areas Current number is 1,574 clinics
16774 388 109 91 57 Major Players # of clinics These constitute 89% of all clinics- market is very consolidated
17$570 Cost per visit $103 $106 Emergency room Urgent care Physician officeRetail clinicl$103$106$66Mehrotra et al. (2012)
18Quality scores Mehrotra et al. (2009) Arguably, the most influential study on retail clinic quality is the one conducted by the Rand corporation and published in 2009 (Mehrotra, Liu, Adam, et al., 2009). The researchers examined episodes of care (initial and follow-up visits, pharmaceutical and ancillary tests) for three conditions treated: otitis media (ear infection); pharyngitis and urinary tract infections. They constructed 14 quality indicators based on guidelines published by the American Academy of Pediatrics, the American Academy of Family Physicians, and the Infectious Diseases Society of America, and created an aggregate quality score for all conditions. They also measured whether patients received specific preventative services in the three months following their visits. They compared care provided for the three conditions in retail clinics, physician offices, urgent care centers and hospital emergency rooms. Overall, aggregate quality scores were similar at retail clinics (63.6%), physician offices (61.0%) and urgent care centers (62.6%), but were lower for emergency rooms (55.1%). Individual quality scores on the specific measures showed that retail clinics were better or as good as other settingsMehrotra et al. (2009)
20Company NPS Apple Hardware 71% Trader’s Joe 73% Amazon.com 76% Retail Clinics80%USAA Banking83%Customers respond on a 0-to-10 point rating scale and are categorized as follows:Promoters (score 9-10) are loyal enthusiasts who will keep buying and refer others, fueling growth.Passives (score 7-8) are satisfied but unenthusiastic customers who are vulnerable to competitive offerings.Detractors (score 0-6) are unhappy customers who can damage your brand and impede growth through negative word-of-mouth.To calculate your company's Net Promoter Score (NPS), take the percentage of customers who are Promoters and subtract the percentage who are Detractors.Si if you like your I-phone, you will like retail clinics
212013 Consumer Survey-RC Reason for use % I didn’t need to make an appointment57%It accepted my insurance46%Its location was more convenient45%It was less expensive41%I didn’t have to wait too long35%It was open when the Dr’s office wasn’t34%I don’t have a regular Dr.18%
22“What would you have done today if the retail clinic was not an available option?” AnswerPercentage“Just wait and see”30%“Go to ER”26%“Go to urgent care center”18%“Go to any clinic that would see me”Wang et al. (2012)22
2361%of patients that visit a retail clinic indicate that they don’t have a primary care physicianMehrotra et al. (2012)
24Other convenient care models Future Outline2424Convenient careRetail clinicsOther convenient care modelsFuture
25Other convenient care models Future Outline2525Convenient careRetail clinicsOther convenient care modelsFuture
26Urgent Care Centers Usually free-standing At least one MD is present at the clinic all the timeCare is typically delivered by MD+ NP or PACan treat serious conditions such as sprains, strains, lacerations, contusions, fracturesWhile most retail clinics are located inside retail/grocery stores, UCCs are usually free-standing in less crowded settings such as strip-malls. Moreover, UCCs have at least one physician that is present at the clinic all the time, even though care is typically delivered by a physician assistant, nurse practitioner or nurse. This is due to the fact that UCCs can treat, in addition to minor conditions, more serious conditions such as sprains, strains, lacerations, contusions, back pain, fractures and even minor surgeries.
27There are approximately 8,700 walk-in, stand-alone UCCs, and they continue to grow with new clinics opening every yearThe top 17 operators own less than 10% of the clinics
292013 Consumer Survey- UCC Reason for use % It was open when the Dr’s office wasn’t54%I didn’t need to make an appointment44%It accepted my insurance35%Its location was more convenient32%It was less expensive22%I didn’t have to wait too long27%I don’t have a regular Dr.16%
30Online Health Services 24/7 access to providerMinor medical conditionsAnswer questions based on algorithm/protocol/text/video communicationLow feeallows patients unlimited online access to a nurse practitioner for the treatment of 40 common medical conditions. Patients describe their medical conditions by answering online questions based on medical protocols. Shortly after, a nurse practitioner reviews the answers, designs a treatment plan, and then contacts the patient by or text message. The treatment plan includes a diagnosis and prescriptions that are sent directly to the patient’s designated pharmacy. The service is currently offered at a fee of $40 or less
31“VirtuWell,” a service provided by HealthPartners in Minnesota allows patients unlimited online access to a nurse practitioner for the treatment of 40 common medical conditions. Patients describe their medical conditions by answering online questions based on medical protocols. Shortly after, a nurse practitioner reviews the answers, designs a treatment plan, and then contacts the patient by or text message. The treatment plan includes a diagnosis and prescriptions that are sent directly to the patient’s designated pharmacy. The service is currently offered at a fee of $40 or less, depending on insurance status
33Provider visits home/work on evenings and weekends House Call ServicesProvider visits home/work on evenings and weekendsContracts with employers/ insurance companiesAnnual membership + low visit feeWhite Glove” offers patients a yearly membership in return for unlimited access to care. Patients pay a monthly fee to become members and when they need medical attention, they can request an appointment via phone or web. Within hours, a nurse practitioner visits the patient at work or at home. During the visit, the nurse practitioners diagnoses and treats the patient and provides him/her with most of the generic medications that are prescribed on the visit. Patients also have secure online access to their information including their medical history, lab results, visit history, etc. The scope of care is more or less similar to that of a retail clinic and each visit costs $35 out of pocket.48 It is important to note that White Glove is an alternative for people who already have insurance. Many large employers are offering it as part of their benefits, and therefore individuals don’t have to pay the annual fee, only the visit fee. Therefore, it is unlikely that people from a lower socioeconomic status will seek this service
43Predictions A two-tiered health care system: 434343A two-tiered health care system:Basic primary care delivered by NP/PA in convenient locations/waysComplex primary care & specialty care delivered by MDs in more traditional locations
44‘Flipping’ Health Care: Retail Clinics and Other Convenient Care ModelsAmer Kaissi44