Posts Tagged outpatient

Freestanding ER — the microhospital

microhospital

What is a freestanding emergency center?  And, is it something good for patients or not?  Michael Booth reported on the spread of this concept in Colorado in his article in the Denver Post “The parent of metro Denver’s Exempla to open four micro-hospitals” (4/14/13).   The feature that separates a simple urgent care clinic and a microhospital is the presence of a few patient rooms intended for short term “observation”.

These microhospitals exist to make money.  They are not charity operations or an improvement on hospital care or low cost options.  Patients with a high deductible insurance plans do think of the cost.   And such facilities may be less expensive than a hospital emergency room but more expensive than an urgent care center and much more expensive than a primary care office.

Urgent care clinics are much less expensive than a hospital sponsored emergency room because they are not allowed to charge the “facility fee” — the fee allowed by Medicare and insurance companies to compensate hospitals for special equipment and staff  for very sick patients.  Any facility that must own expensive diagnostic equipment does shift the cost to all that visit even if they don’t use the equipment.  Also, there is the tendency to over-utilize high tech equipment (because it makes money for the clinic).

What about those observation rooms?  They are very expensive and usually billed by the hour ($50-$100 per hour) plus a cost for medications that may be astronomical.  An observation room is helpful to provide time (at the patients expense) to wait for test results or to see if treatment is working (like for nausea).    Generally, if a patient does not have a condition that warrants full hospitalization they should be able to manage at home.  There are some social situations that prevent a patient from going home in which case outpatient observation may have a place — but not one that insurance will always cover.

Insurance companies vary in what they will pay for outpatient observation — often they exclude medication costs.     If  a patient has to take an ambulance ride it is best not to go to a freestanding ER because a second ambulance ride to an actual hospital may be needed.  Ambulance transport usually costs between $600 and $2000 — not something to be duplicated.

The notion that microhospitals have providers present 24/7 is of course true.  But those providers are ER doctors who have work to do in the emergency area, they work in shifts, and ER doctors are not accustomed to hospital type care — they are not hospitalists or surgeons or specialists as might be found at a true hospital.

People need to have primary care providers.  A primary care doctor may see someone with acute illness fairly soon (like the same day).   Often that is soon enough and certainly at much lower cost than any outside microhospital.  But, if the provider is busy or not available urgent care or microhospital care are substitutes.

Are microhospitals good or bad for patients?  They probably have little place in outpatient care.  If a patient has a condition that medically requires intravenous medications or oxygen then hospital care is probably better and safer.  A lower cost option for some people  is care at an urgent care center that does not have all the overhead cost of a hospital facility.

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Rate Your Health Care Provider

The following rating system is intended for adult primary care office visits, but could also apply to some specialty visits.  There are no extra points for famous doctors, university clinics or the only provider in town.  Add up the points to see how your provider’s office is doing.

Performance Points
When I call the office, who answers?
 A real person 2
 A computer answering system that connects to a real person 1
I know the office will provide appointments:
New patient appointments within 3 weeks or
Follow-up appointment for new problem in 3 days
2
Urgent problem (during office hours) on same day 3
 The office designates time for walk-in visits  2
 The office has some evening and weekend hours  2
Moving through the office (assuming you were on time)
 Checked-in within 5 minutes 2
 Checked-in within 5 to 10 minutes 1
 Face to face with the provider
within 5 minutes of appointment time or
within 30 minutes for a walk-in visit
3
 Face to face with the provider
within 10 minutes of appointment time or
within 45 minutes for a walk-in visit
2
Checked-out within 5 minutes of leaving provider 2
Checked-out within 5 to 10 minutes of leaving provider 1
 Provider visit
 I do not have to take off clothes before seeing provider 2
 I can sit in a chair at eye level with the provider 2
 Provider seems to care about me 5
 I am not interrupted while I say the reasons for the visit 4
 The part of my body with problems is examined 3
 The paper chart or the computer is just used
by the provider to find information to help me
2
 The diagnosis of my problem is made clear 4
 I am directed to handouts or Internet sites about my problems 1
 Before I leave, the provider asks if I have any other questions 3
 It is clear when I need to return for recheck 3
 Medication Management:
 The reasons I need to take all medications are explained 3
 My provider sends prescriptions by computer 2
 Possible side effects of medications are discussed 1
 At each visit I receive a list of my active medications 3
 Tests (x-rays, blood tests, EKG, biopsies etc.)
If I need tests I am told why 2
 The office always lets me know test results within a week 2
 I always get copies of test results 2
 Practice environment
 My provider has associates who substitute when needed 2
 Hospital care is done by hospitalists 2
 My provider is part of a system including specialists 2
 Physician assistants or nurse practitioners work at the office 2

 TOTAL POINTS  =  

Score Rating
 60 and over  5 star
 50 to 59  4 star
 40 to 49  3 star
 30 to 39  2 star
 below 30  1 star

Hotels have struggled to get the coveted 5 star rating for decades.  It is not just whether the hotel chef can make a souffle but whether the whole experience of staying in the hotel is superior.   The items in the above score are considered elements of quality for health care delivery.  It’s not easy to get 5 stars.

Medical and surgical care has focused on diagnosis and treatment for hundreds of years.  To that end individual providers spend years, if not decades, honing diagnosis and treatment (some say, to a fault).   The vast majority of problems in primary care are fairly easy to diagnose (like diaper rash, acne and diabetes).  Treatment is harder because it spans time, is a process and requires patient engagement.  So, as it turns out, the wrapper may be as important as the package.  Providers are well trained and licensed but the wrapper of delivering care is where quality, safety, cost-effectiveness and satisfaction reside.

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