Shifting Sources of Patient Access

Express clinics, mobile apps, online tools, video visits and even house calls are reshaping the way health care is delivered by some cutting-edge systems across the U.S.

Physicians used to scoff at drug store clinics. Telemedicine was considered exotic. Health care construction meant inpatient towers and medical office buildings. Those days are gone. Health care providers rapidly are reinventing themselves to succeed with new payment systems that reward value — outcomes divided by cost — and punish wasteful spending. “That is going to demand that we take care of a large number of lives under management and do it in a very high-value, cost-effective manner,” said David James, MD, JD, CPE, the chief executive officer of Memorial Hermann Medical Group. There always will be a need for medical clinics staffed by physicians, but that traditional access point for outpatient care is losing some of its luster as providers face the truth: The best care is that which helps people have good health, and that can happen in many ways other than an office visit. Consumers have been making this point for a while, choosing free-standing urgent care centers, retail clinics and other convenient options when they can. But traditional provider organizations have been slow to embrace new venues— until now.

In the fee-for-service pay system, provider organizations need to attract patients to earn payment for services rendered. Emerging payment models expected to supplant fee-for-service as the dominant payment system in the foreseeable future — will hold providers accountable for the cost and quality of care for a population of patients. That incentivizes providers to manage a patient’s health care, which means keeping it all in one organization so there is a complete record that guides good decision-making. And it means providers need long-term relationships with patients to justify the expense of proactive, preventive care.

The return on investment may not be seen for years, when a patient whose well-controlled diabetes avoids an amputation or smoking cessation prevents an individual from developing chronic obstructive pulmonary disease. “But if patient churn leads patients to go from our system to another one, someone else is benefiting from that investment that we made,” Jason O’Riordan, a vice president at Kaufman Hall’s financial planning practice, said.

Preventing that churn means offering access that makes it easy for consumers to choose the same system every time they want care. O’Riordan said retail industry terms such as “omni-channel strategy” are beginning to resonate with provider organizations. “It’s the idea that retailers need to be accessible wherever consumers want them,” he explained. “How do we have what some people call the best ‘first touch’ strategy? Just about every system we work with is trying to figure that out.”

MOVING CARE CLOSER TO HOME

Providence Health & Services, one of the biggest health systems in the western U.S., expects to add about 1 million primary care visit slots in the foreseeable future. The new access points will move care closer to patients’ homes and support Providence’s population health initiatives. “For population health, we need to know the needs of the people we are serving and we need to improve our outcomes,” said Mike Waters, senior vice president of physician services. “This is an opportunity for us to do just that.”

Waters oversees about 5,200 physicians — employed or affiliated — operating in 685 locations in five states. The primary care division, currently doing more than 3 million visits a year and adding 40,000 new patients a month, needs to be managed with new solutions as the primary care physician shortage looms large. The system is proactively moving to add new modalities, including express clinics, virtual visits, onsite employer-based clinics and even home visits. In addition to increasing access and convenience for patients, the new capacity will give traditional primary care providers more time to manage their patients. If it works as envisioned, that will be two wins — improved provider satisfaction and improved patient experience— that are key to population health management.

Providence’s plans show the system has embraced consumerism, going so far as to introduce the term “products” into the health care vernacular. Health care providers won’t evolve rapidly if they keep using the same words and concepts they have always used. “We’ve been trying to shift our thinking from these more traditional access points into having a menu of products that we offer consumers so they have choice,” Waters said. “A lot of people get hung up on ‘should we offer same-day access?’ Frankly, what we’re hearing from consumers is they want care when they want it, where they want it, how they want it. So we need to provide them options.”

Its boldest move is the launch of 50 eXpress Care clinics by mid-2017. Of those, 25 will be embedded in Walgreens stores but owned and operated by the health system, rather than the retail giant. The eXpress Care sites opening in the Portland and Seattle markets are the first phase of a relationship that Waters expects to grow significantly in the years ahead. “Eighty percent of the U.S. population lives within five miles of a Walgreens, so certainly this aligns with one of our key strategies of moving care closer to home,” he said. At first, the Providence eXpress Care at Walgreens (called Swedish eXpress Care at Walgreens in the Seattle market) will provide episodic services such as strep tests and care for minor burns or sprains.

“But in the future, it may become a better way for us to manage populations such as patients with diabetes that are already going to Walgreens 20 to 30 times per year,” he said. “This is a key component to our larger population health strategy in which we really want to create healthier communities.” Meanwhile, Providence will introduce free-standing eXpress Care clinics in all its markets in the next 18 months. Some will go to suburban locations to make choosing Providence easier for residents in those neighborhoods; some will be positioned near established Providence clinics to offer overflow capacity. Waters expects the first 50 eXpress clinics will add 500,000 primary care slots a year when they are fully operational, and another half-million slots will be created through other new modalities. Providence is exploring asynchronous e-visits, he said, and it introduced Health eXpress, on-demand visits via smartphone, tablet or computer in all its markets late last year. Staffed by nurse practitioners, the telehealth visits are offered 8 a.m. to midnight seven days a week for a $39 flat fee.

The system has also piloted a technology platform that supports home visits by advanced care practitioners. It is testing the concept in Los Angeles and Seattle to see what kind of customers it attracts. Working moms with sick kids at home? Consumers seeking a “concierge” level of service delivered at home? Patients whose medical condition makes traveling to appointments challenging?

“We’re trying to better understand our consumers and what their desires are, so that we can meet their needs,” Waters said. “It’s early on, so payers’ willingness to pay for certain types of care is evolving. Telehealth is a great example — it’s now actually paid for by most of our payers. We believe the same thing will happen for home visits, and we are working through that right now. “

VIRTUAL CARE GAINS MOMENTUM

Every time a patient chooses its online AnywhereCare service for low acuity, primary care services, the UPMC Health Plan, the insurer affiliated with the University of Pittsburgh Medical Center (UPMC) Health System, saves $86.60 in the cost of providing services. “What we know is that if patients utilize the online UPMC AnywhereCare platform, it’s absolutely a cost advantage to the system,” said Natasa Sokolovich, executive director of telehealth at UPMC. “We really are viewing telehealth and expansion of technology which enables televisits as a way to transform the delivery system and support the move from a volume-based to a value-based model.”

UPMC, which employs some 3,600 physicians, operates more than 20 hospitals and more than 500 physician offices and outpatient locations. The online primary care visits were introduced in November 2013, offering around-the-clock access for patients who want the convenience of not leaving their home or office. And UPMC is just getting started.

“We always had the vision that we would expand that platform to facilitate subspecialty services, as well as different ways to support population health management,” she said. The next step came last July when UPMC launched e-dermatology — direct-to-consumer online access to a board- certified dermatologist. The visits are asynchronous; patients fill out an online questionnaire, upload three images, submit payment and receive a diagnosis and treatment plan within three business days.

In Pennsylvania, AnywhereCare primary care visits are also asynchronous — patients provide information online via secure technology and providers respond, usually within 30 minutes — although patients can request a video visit. In Maryland, state regulations require a video visit. UPMC provided just under 5,000 AnywhereCare visits in 2015, but Sokolovich expects that to grow steadily as aware- ness of the service grows. A focus group of large-employer executives who negotiate benefit plans for their companies revealed that many of them have heard of telemedicine but do not understand what UPMC offers or how it improves access. Individual consumers are equally uninformed.

HOW CAN WE MAKE THE FRONT DOOR TO THE MEDICAL HOME MUCH, MUCH WIDER?

“There’s still a very, very significant untapped consumer group that really just doesn’t know what these visits are or how they can benefit from them,” she said. Meanwhile, UPMC aggressively is pursuing other types of virtual care. Building off a limited program for congestive heart failure (CHF) patients, the system is launching a remote monitoring program for patients with diabetes and chronic obstructive pulmonary disease, in addition to CHF, with plans to expand to palliative care. Monitoring technology will alert nurses and technicians when biometric readings are outside the normal range, prompting them to contact patients for immediate intervention.

“This will eliminate some of the frequent flyers to the ED who end up being unnecessarily admitted much more often than they should for a chronic condition that is not well-controlled,” Sokolovich said. UPMC also is using telemedicine to expand access to specialty care for patients in rural communities. Through four virtual, multispecialty clinics — three located on rural hospital campuses and one in an urgent care center — patients have access to telemedicine visits with various specialists, including endocrinologists, cardiologists, surgeons and more than 30 additional subspecialties, without traveling to UPMC’s home base in Pittsburgh.

In those clinics, a telepresenter — a nurse or other clinician — uses a Bluetooth stethoscope, high-definition camera or other peripheral device to facilitate the examination being conducted by a physician from a remote location. Patient satisfaction scores across the virtual multispecialty clinics average 4.8 on a five-point scale. In addition, 40 percent of patients responding to a survey share that, if the specialty telemedicine visit was not available, they would have foregone much-needed care entirely. “Considering the chronic disease burden, we think there’s a true opportunity to impact continuity of care and better manage overall patient care,” Sokolovich said.

PATIENT-CENTERED MEDICAL HOME, REIMAGINED

Although the health care industry was busy reorganizing itself around the patient-centered medical home, consumers were just looking for a place to get a flu shot on the way home from work. “What people really want is on-demand access — they just need to get things done,” James said. “Time has become a really big commodity.”

Time is particularly a priority for the “walking well,” those consumers who are proactively maintaining their good health or controlling their chronic conditions. Because of their low health costs, those consumers are particularly important in new payment models that hold providers accountable for the cost and outcomes for a population of patients.That’s why James likes to think of two versions of the patient-centered medical home: the traditional version for high-risk patients who need close medical supervision for chronic conditions and the “consumer-driven medical home without walls” for everyone else. “How can we make the front door to the medical home much, much wider than we ever used to think it needed to be?” he says. “As long as we have a common health record, we can offer to people many more channels by which to access the medical home.”

Memorial Hermann, with 5,500 affiliated physicians and 13 hospitals, is the largest not-for-profit health system in south- east Texas. The medical home team now includes the clinicians engaging with patients at a retail clinic, through a telehealth visit and at an urgent care site. That frees traditional primary care physicians to manage more patients without asking them to always come to a physician office for care. “The other thing is that these access channels allow us to serve the community of potential customers that are often non-discriminating, showing up at free-standing ERs, urgent cares, retail clinics, using phone apps to get care, etc,” James said. “If they can experience a Memorial Hermann version of that, and we create stickiness, it allows us to garner more potential lives under attribution to increase our primary care footprint.” He buckets Memorial Hermann’s access points into “clicks” and “bricks.” The virtual components start with a web portal that allows consumers to schedule appointments, refill prescriptions and interact with the physician’s office online. The system just introduced telemedicine visits; urgent care physicians staff those visits using an outside vendor’s platform.

In the “bricks” category, Memorial Hermann has affiliated with RediClinic, now owned by Walgreens, in 23 grocery stores in the Houston metro area. A patient who calls Memorial Hermann’s nurse triage line seeking advice about an earache on the weekend, for example, is likely to be referred to a RediClinic close to his or her home. The nurse practitioner staffing that walk-in clinic is a RediClinic employee, but he or she will interact with Memorial Hermann’s electronic medical record system. “Whatever happens at the retail clinic becomes part of the medical record, and it’s still monitored and managed by your primary care physician,” James said.

The health system has opened one urgent care center, with two more under construction. And the centerpiece of Memorial Hermann’s expanded access is a growing network of “convenient care centers” located at high-traffic retail cen- ters around the Houston area. Eight centers each include a 24-hour emergency department, “fast-track” walk-in primary care, imaging and lab services, physical therapy and some multispecialty care. Five more are in the works. Each conve- nient care center includes a primary care office with three to six physicians. “So when the patient is done being seen either at the ER or the fast-track area, the question comes ‘What about follow up?’ and the primary care site is right there in the convenient care center,” James said.

RIGHT VENUE FOR THE RIGHT PATIENT

Some patients need to go to the emergency department and others need to exchange an email with a provider, and both are essential for Novant Health’s access strategy.

“Our thought process is you’ve got to design venues of care and opportunities of care for folks that meet them wherever they are,” said Hank Capps, MD, chief operating officer for Novant Health Medical Group. The group — more than 2,000 providers in 420 locations in North Carolina, South Carolina, Georgia and Virginia — is part of the 13-hospital health system that serves more than 4 million patients.

Its vision is to create a web of access points that creates two dynamics. “We believe strongly in an authentic real relationship between the patient and the people caring for you, whether you’re sick or healthy,” Capps said. “The second thing is that all of your care providers have access to the same information so that you have both relationship continuity and information continuity throughout the whole spectrum of care.”

Outside the hospital setting, that spectrum looks like this:

• Emergency department.

• Urgent care center for immediate access to a physician.

• Primary care physician’s office, an important setting for both acute and chronic care.

• Express Care, a convenient, low-cost setting for services delivered by physician assistant or nurse practitioner.

• Video visits, online appointments conducted via mobile app or webcam-enabled computer. These are mostly used for chronic care management.

• E-visits, formal online questionnaire and online visits in the context of the patient’s medical home and integrated medical record.

Novant Health is creating new ways to engage patients. It recently launched Care Connection, which uses telephone calls, email and online chat to help patients navigate the health system. “It’s not easy for a patient to figure out where they need to go,” Capps said. “We’re trying to make it as easy as possible for people to reach out to us so we can help them find the right venue of care at the right time.” Care Connection staff also provide outbound population health activities, contacting high-risk patients to monitor their status, checking in on patients who have had a recent health event or intervening at the request of pharmacy, social work or some other discipline.

Novant’s access strategy has been evolving rapidly — video visits and e-visits were introduced two years ago; eight Express Care sites opened in the past year, with more in the works — and Capps expects that to continue. “Over the next five years, you’re going to see smaller locations for these new models of care, plus models we haven’t even thought of,” he said. “We will also see traditional primary care being delivered differently — with convenience being a priority — and also an uptick in the use of virtual technology as both patients and providers get more comfortable with that as a mechanism of seeking care.”

This article first appeared in the Physician Leadership Journal, July/August, 2016Lola Butcher is a freelance health care writer based in Missouri.lola@lolabutcher.com