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Sunday, August 11, 2013

Planning for acute unscheduled care

In the Annals of Internal Medicine, Kocher, et al published a piece titled: "What is our plan for acute unscheduled care" (Acute Unscheduled Care). This piece really resonated with me because we are in the midst of grappling with this very issue. Our management is encouraging us to use a model pioneered by the Cleveland Clinic where patients are spontaneously offered same day appointments. Their acute care model is built into their system. How they actually pull this off is another story. Perhaps it has to do with the fact they are based in a rust belt city where the demands for care are somewhat more modest.

For the rest of the world the reality of acute unscheduled care is Emergency Rooms, urgent care centers, Minute Clinics, and begging to get into your primary care provider's office. The burden is substantial since the authors of the article cite studies showing unscheduled care makes up about 30% of the 1.2 billion outpatient visits in the US annually. This data comes from the National Center for Health Statistics. The Rand Corporation published a fact sheet on this three years ago and I think their comments are spot on (Rand):
The results indicate that a relatively small proportion of doctors — emergency department (ER) physicians, who comprise only 4 percent of doctors — handle more than one-fourth of all acute care encounters and nearly all after-hours and weekend care. ER physicians also provide more acute care to the uninsured than all other doctors combined.
The main barriers to getting acute care in primary care settings are timeliness and complexity. Because the schedules of many primary care physicians are packed with 15-minute office visits, they have little or no time to see unscheduled patients, particularly those who have complicated problems. And primary care physicians have few incentives to offer extended hours of practice (only 40 percent do) or see patients on weekends.
I run a specialty practice which is essentially all outpatient based. We make our margins by consistently having appointment utilization at greater than 95%. The practitioners in our practice have also been impacted by the deployment of the electronic medical record. We have no place to put unscheduled acute care other than in places which guarantee that they will create waits and delays.  

It used to be said, better, faster, cheaper; which two do you want? I am afraid the choice is which one do you want, that is unless we change the payment and licensing systems to allow for real innovation in health care delivery.

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