The Healthcare Imperative Lowering Costs and Improving Outcomes: Workshop Series Summary (2010) / Chapter Skim
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13 Entrepreneurial Strategies
13 Entrepreneurial Strategies
Pages 433-452
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. Development of retail clinics and use of community health workers has expanded access to care (AHRQ, 2008; Ballester, 2005)
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Introduced in 2000 to deliver a limited set of simple clinical services in a convenient retail setting, retail clinics are typically staffed by mid-level providers with remote physician oversight. As the average cost per episode in a retail clinic is $55 less than in physician offices or urgent care clinics and $279 less than in emergency departments, Thygeson proposes that, if scaled to a national level, these clinics could yield savings as high as $7.5 billion.
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The trend toward outpatient care in ambulatory settings has existed for decades, but a more recent example is the rapid expansion of retail clinics staffed by nurse practitioners, at least in states that allow nurse practitioners to provide care without direct physician supervision. Advances in telehealth and home monitoring have further shifted care into patients' homes, and select patient groups, such as type 1 diabetics, have already assumed much of the routine, day-to-day management of their diseases.
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. Despite the lack of data regarding the financial impact of community health workers, it is reasonable to make some generalizations based on the cost trends that have resulted from similar decentralization of care in other areas, namely the shifting of care to nurse practitioners in the retail clinic model.
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Because of these added systemic effects, community health workers could indeed lead to an overall increase in healthcare spending. This would be consistent with recent analyses of the impact of retail clinics on healthcare costs (Thygeson et al., 2008)
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Impending formal training programs, state certifications, and the possibility of reimbursement will all increase the cost of community health worker programs and may exclude participation of some community health workers and patients, especially among undocumented aliens and non-English speaking individuals. A possible balanced solution would be to incorporate competencybased licensure, rather than credential-based licensure, of community health workers -- and perhaps all healthcare workers.1 Such a system would ensure patients that proficient, high-quality care is always being delivered, while divorcing health care from its more antiquated proxies for ability.
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One study found the quality of care in retail clinics for three common conditions was equal to or better than the quality in physician offices, urgent care centers, and emergency departments (Mehrotra et al., 2009)
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The average cost per episode for the top five retail clinic episodes is $55 less than in physician offices or urgent care settings, and $279 less than in emergency departments (Thygeson et al., 2008)
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Savings Estimates: Caveats However, several factors limit the potential cost savings of retail clinics. First, at least among the insured, patients using retail clinics appear to be switching from physician offices and urgent care centers but not from emergency departments.
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As patients shift to retail clinics, established providers can easily maintain revenue by increasing the number of visits per episode for the remaining patients, and over time by charging more for non-retail clinic-eligible services. Also, established providers are now competing directly with retail clinics for both patients and staff by adopting a convenience care model for the limited set of services provided by retail clinics (Merchant Medicine, 2008; Rudavsky et al., 2009)
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Finally, reforming malpractice laws to provide a higher level of evidentiary protection for guideline-compliant care would likely accelerate adoption of the retail clinic care approach. Potential Long-Term Impact For retail clinics to have a sustained beneficial impact on healthcare costs, they need to function like a true "disruptive innovation"5 and expand their services to treat more complex conditions, thereby forcing existing providers to adopt lower operational cost structures for a much broader set of services and patients (Christensen, 2003)
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A More Patient Centered Approach Routine outpatient clinic appointments remain the mainstay in managing chronic disease in the United States, but their effectiveness and costeffectiveness have not been substantiated by comparative effectiveness studies. Anecdotally, patients with chronic conditions such as chronic heart failure usually deteriorate at variable times before or after a routine clinic visit.
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In the late 1990s, a randomized-controlled study of chronic care patients (Johnston et al., 2000) by Kaiser Permanente using video home telehealth systems showed that in 102 patients versus 110 controls the technology was effective, well received by patients, maintained quality care, and had the potential for cost savings.
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Each care coordinator manages a patient panel of between 90 and 150 patients, depending on the complexity of their conditions, and the care is categorized as noninstitutional care, chronic care management, acute care management, or health promotion and disease prevention. Since January 2004, VHA's National CCHT Training Center has been certifying these staff using predominantly virtual modalities to provide these services.
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The annual cost of providing CCHT to these patients (whose overall healthcare costs were in excess of $27,000) was $1,600 per patient.
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bitmap with vector axis labels between 22 percent and 48 percent of healthcare costs for the populations of patients so managed (Figure 13-2)
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2005. Community health workers: Essential to improving health in Massachu setts.
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2002. Outcome effectiveness of community health workers: An integrative literature review.
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Why do patients seek care at retail clinics and what alternatives did they consider? American Journal of Managed Care.
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