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Where and how is Primary Care provided?

Single Specialty Practices

Single speciality practices are offices with one or more physicians (and possibly one or more nurse practitioners or physician’s assistants) of the same specialty. When there is more than one provider, they will often cover each other’s patients when one provider is unavailable. OBGYN practices are often single specialty, and in the course of a pregnancy, the expecting Mom will likely be introduced to most or all of the other doctors in the practice so whomever is on call when the baby decides to come, Mom knows in advance who she’ll be sharing the arrival experience with.

 

Multi-specialty Practices

Multi-specialty practices are physician’s offices with two or more physicians representing at least two specialties.   A typical multi-specialty practice would have several to many family practice, pediatrics, OBGYN, and internal medicine providers. Some might also have allergists, dermatologists, or other specialists.

Multi-specialty practices can be good choices when you or your family member has one or more chronic conditions, since referrals for specialty care within the practice are more likely to result in better care coordination. Multi-specialty practices are also attractive for families that would like to coordinate multiple patient visits (Mom, Dad, teenager and infant) on a single trip.

 

Direct Primary Care Practices

The American Association of Family Practitioners defines Direct Primary Care as ‘ … a model that gives family physicians a meaningful alternative to fee-for-service insurance billing, typically b charging patients a monthly, quarterly, or annual fee (ie a retainer) that covers all or most primary care services including cliinical, laboratory, and consultative services, and care coordination and comprehensive care management.  Because some services are not covered by a retainer, DPC practices often suggest that patients acquire a high-deductible wraparound policy to cover emergencies.  DPC benefits patients by providing substantial savings and a greater degree of access to, and time with, physicians.’  This means insurance is not used for most primary care – but is still required for hospital and other acute care.

While DPC is a relatively new practice model, it’s popularity with both patients and providers is causing it to grow rapidly.  Check out The Direct Primary Care Coalition or The DPC Journal to find a DPC practice in your area.

Direct Primary Care practices can be excellent choices when you or your family member has one or more chronic conditions, since referrals for specialty care within the practice are more likely to result in better care coordination.  And more importantly, whether specialists are within the practice or not, DPC physicians have both the time and inclination to dedicate to true care coordination.  For many individuals and families, when paired with a complimentary high deductible or catastrophic health insurance plan, DPC offers an opportunity for significant savings on out of pocket expenses.

 

Walk In Clinics

Walk in clinics are usually located within retail outlets such as pharmacies or WalMart, but they can also be offered by large group practices and hospitals. They differ from other primary care sites in that they don’t require an appointment in advance, are often open nights and weekends, and are often more geographically convenient than your PCP’s office.   The services offered by various Walk In Clinics vary significantly; some Walk In Clinics are staffed by nurse practioners or physician’s assistants, and their services (such as writing or renewing prescriptions) are limited to the scope of practice for those providers in that state. Some are defined by the equipment they have on hand. Some are staffed and equipped to a level equivalent to a physician’s office or Urgent Care clinic, and offer comparable services. Still others offer specific services such as chronic condition care or weight loss.

A typical Walk In Clinic offers care to address conditions such as:

Basic physicals and student athletic physicals

Coughs, Colds, and flu-like symptoms, or flu shots

Skin and dermatology conditions

Respiratory, Sinus, Ear and Urinary tract infections

Diarrhea

Vomiting

Allergies

Some prescriptions

When walk-in clinics are offered by large group practices or hospitals, they usually (but not always) accept insurance and are paid just like their parent organizations. Retail based walk in clinics generally have relatively low prices and the best pricing transparency of all providers, and will often post or advertise prices for common services such as student athletic physicals. Historically, retail based walk in clinics were cash only – you paid up front, and no insurance claim was filed by the clinic. Recently, more insurance plans have recognized the attraction of easy access, low cost, and reasonable quality and have begun accepting claims from retail clinics as in-network providers. Some insurance plans feel strongly enough about the value and convenience of walk in clinics that they have waived co-pays, and others, such as BCBS of Minnesota, have gone so far as to pay 100% for Walk In clinic visits.

The combination of easy access (no appointment necessary, open nights and weekends, low to no wait time, and geographic convenience), and both competitive and transparent pricing have made Walk In Clinics increasingly popular, especially with working parents. Easy access and relatively low cost may also encourage some to seek earlier care, thus preventing a later ER or Urgent Care visit. There have been questions raised regarding possible quality issues in Walk In Clinics, but there has been little evidence to support these claims, and they are usually raised by the same physicians and hospitals that are losing their patients (and thus their business) to this new competitor.

The one serious consideration is that Walk In clinics generally don’t offer very strong continuity of care, either within their organization or between the Walk In Clinic and your PCP. It would be rare to see the same provider twice within most Walk In Clinics. This downside can be mitigated somewhat by requesting visit notes or continuity of care/patient summary records from the Walk In Clinic and providing them back to your PCP. Continuity can also be substantially enhanced if the patient can provide validated history from their personal health record when visiting anyone other than their PCP.

Notable among the emerging retail Walk In Clinics is WalMart, who’s stated goal is ‘To be the number one healthcare provider in the industry’, specifically in rural settings where patients might otherwise have to travel a substantial distance to see a PCP.   They’re accepting Medicare and some Medicaid patients, but as of summer of 2015 they were not accepting commercial insurance. At $40/visit ($4 for employees), however, their price point and convenience may still attract significant volumes of patients.

Examples of Walk In clinics include:

CVS’s Minute Clinic is staffed by nurse practitioners and physician assistants (in selected states). Prices and insurance coverage information are available on-line. Approximately 660+ clinics nationwide as of Sept 2015. Services include:

Diagnose, treat and write prescriptions for common family illnesses such as strep throat, bladder infections, pink eye, and infections of the ears, nose and throat

Provide common vaccinations for flu, pneumonia, pertussis and hepatitis, among others

Treat minor wounds, abrasions, joint sprains, and skin conditions such as poison ivy, ringworm, lice and acne

Provide a wide range of wellness services including TB testing, sports and camp physicals, and lifestyle programs such as smoking cessation and a medically based weight loss program

Offer routine lab tests, instant results and education for those with diabetes, high cholesterol or high blood pressure

Provide care to adults and children 18 months and older for most services

Share records with primary care provider with patient permission

 

Walgreen’s Healthcare Clinics are open 7 days a week including weeknights, and are staffed by nurse practitioners. Locations, visit times, prices and insurance coverage are available on-line. Approximately 370+ clinics nationwide as of Sept 2015. Their services include:

Vaccines

Travel Immunizations

Physicals (Sports, school, camp, and administrative)

Health screening, testing, risk assessments and counseling for blood pressure, cholesterol, diabetes, PPD/tuberculosis.

Treatment for illness, aches, and pains including allergies, bladder and urinary tract infections (females age 6+), bronchitis, colds, coughs, diarrhea, nausea and vomiting, ear ache and infections, ear wax removal, fever, flu, headaches and migraines, joint pain, laryngitis, minor back pain, mononucleosis, pink eye and styes, sinus infections, sore throat and strep throat, STD evaluation and testing (in certain states), swimmer’s ear, and upper respiratory infections.

Treatment for minor injuries including burns (minor), corneal (eye) abrasions, minor cut and wound closure with skin adhesive, splinter removal, sprains and strains.

Treatment for skin conditions including acne, eczema, head lice, hives, impetigo, mouth and cold sores, poison ivy, poison oak, and poison sumac, rashes, ringworm, scabies, skin infections and irritations, skin tag removal, tick/insect bites and stings.

Monitoring and management of ongoing health conditions[1] including acid influx and acid indigestion, asthma, chronic bronchitis, diabetes, emphysema, high blood pressure, high cholesterol, minor depression, osteoarthritis, osteoporosis, and thyroid disorders.

Monitoring and management of medications and treatments, including breathing treatments with nebulizer, EpiPen refills, Xolair® and Prolia® injection services[2], medication renewals, and travel medications.

Concentra offers a broader range of services depending on location.   Location details, including hours for that location, and insurance coverage are available on-line.   Approximately 300+ clinics nationwide as of Sept 2015.   Their services include:

Urgent Care

Physical Therapy

Occupational Health

Vaccinations and Flu shots

Travel Health

Physicals

 

The Clinic at Walmart are open 7 days a week including weeknights, and are staffed by a variety of different independent companies.   Locations are available on line. Prices and insurance coverage (some stores are cash only) are available at each store.   Approximately 80+ clinics nationwide as of Sept 2015.   Services can vary site by site, but typical services include:

Allergy Care

Acne Care

Bladder infection treatment

Blood Pressure checks

Blood Sugar testing

Camp/School physicals

Cholesterol screening

Common vaccinations

Earache treatment

Flu treatment

Insect bite and sting treatment

Sinus infection treatment

Upper respiratory infection care

Wart removal

[1] Not available for children under the age of 18 and patients of all ages in the state of Missouri.

[2] In select locations only; please call Take Care Health Systems at 866-292-8465 for information on how to access injection services.

 

Urgent Care Clinics

Urgent Care Clinics are designed to be the last stop before heading to the Emergency Room. For non-life threatening problems, they’re almost always quicker to get to and have shorter wait times than Emergency Rooms, and are almost always far less expensive. To be a certified Urgent Care site, there must be a licensed provider (MD/DO for ‘category 1’ or MD/DO/NP/PA for ‘category 2) on site during all hours of operation. The site must be open 7 days a week (not including national holidays) for at least 4hrs per day, but most are open during extended hours. Walk-in patients of all ages must be accepted for a broad spectrum of illness, injury, and disease. If pediatric specialization is included in the name of the facility, the all ages requirement is waived.

The following capabilities, equipment and certified/licensed staff must be available:

X-Rays, Automated External Defibrillator, and EKG

Phlebotomy (collecting lab specimens – usually blood)

Ability to administer PO, IM and IV medications/fluids and oxygen

Perform minor procedures including sutures, cyst removal, incision and drainage, and splinting

More on Urgent Care clinics can be found here.

If you have kids and a swing set, go here now to find Urgent Care clinics near you so you don’t have to scramble when you really need one.

Note that if you use an internet search engine to find an Urgent Care Clinic, it will almost certainly also pull up Walk In and other non-Urgent Care clinics.  So if you specifically need one of the Urgent Care services above, call ahead and make sure they’re available at your clinic of choice.

 

Hospital Owned Outpatient Clinics

Hospital Owned outpatient clinics can be any combination of single or multi-specialty; walk in or urgent care clinic.   Being owned by a hospital means there is one key difference between these and other private or corporate primary care centers; the hospitals often consider them both significant sources of revenue, and, more importantly, ‘feeders’ into the hospital’s specialty, procedure, or inpatient service lines. This can result in a bias toward specialty referrals within the hospital network (as opposed to a specialist choice based on your personal circumstances and desires), as well as a tendency toward high utilization of diagnostic tests and procedures within the hospital network.  Also be aware that under some circumstances, hospital owned clinics can charge a higher rate under Medicare and Medicaid (compared to clinics not owned by hospitals) , and often carry that premium over to their commercial fee schedules.

 

Tele-medicine, email, or something other than a physical visit

Tele-medicine, email, or something other than a physical visit.   Telemedicine offers the opportunity for a ‘virtual visit’ for some care circumstances, usually using some form of secure video connection to a group of physicians. The main advantage of telemedicine is convenience; it can be as close as your nearest smartphone or computer, and available 24/7/365. No traveling to a medical office, no appointments, no waiting room – just near instant gratification.   Tele-medicine is normally reimbursed on a cash basis, so you will generally pay directly to the telemedicine practice via credit/debit card and will not file through your insurance company. Prices range from $40 up per virtual visit.

There is a growing number of employers and health insurance companies, however, that offer telemed options to their employees/customers at a discounted or no-charge rate since – under appropriate circumstances – since telemed visits are typically much less expensive than office visits. Surveys are indicating up to 48 percent of employers may be offering some form of telehealth services by 2015, with the potential of saving them up to $6b per year.

Conditions that often lend themselves to effective care via telemedicine include:

Coughs, Colds, and flu-like symptoms

Skin and dermatology conditions

Respiratory, Sinus, Ear and Urinary tract infections

Diarrhea

Vomiting

Allergies

Some prescriptions

Mental/Behavioral health conditions

Virtual practices that specialize in telemedicine have limits to what they’re willing and able to diagnose and treat. They generally don’t work with patients with chronic conditions, and problems requiring a physical examination may be referred back to your PCP.

Examples of telemed practices include:

The Cleveland Clinic offers MyCare Online 24/7 nationwide. They also offer a specific service (MyConsult Online) specifically for second opinions via telemedicine.

American Well enables provides telemedicine infrastructure to other providers, but also allows direct patient access for Urgent Care, Online Therapy (psychologists and counselors), and Diet and Nutrition counseling.  Prices are posted on line.

Doctor on Demand provides virtual visits for adult and pediatric general medical care, as well as Psychology and lactation consulting.

MDLive provides telemedicine services for general medicine and behavioral health (the later via Breakthrough). Partnered with Walgreens.

Lantern combines mobile and online tools with remote nudging from a professional to help users tackle troubles like anxiety, sleep problems and poor body image. The service links users with licensed therapists who check in with their clients, initially by telephone and then via secure electronic messaging.

Zipnosis offers online diagnosis and treatment for common conditions.

Teladoc provides phone and video consults for adult and pediatric general medical care.

HealthTap is a network of ~69,000 physicians who answer user questions for free, or provides telemed services via their Prime and Concierge services.

SkinVision allows users to take smartphone photos of skin conditions and send them in for diagnosis.

Analyte Health provides digital diagnostics that helps patients get convenient, faster, and cost effective lab testing.  Based on lab test results, next steps could include a self-care action plan, a virtual visit with an Analyte Doctor, picking up meds at a local pharmacy, or getting linked to a local doctor for follow-up care.

Normal PCP (and less often, some specialty practices) may offer telemed, email or text connections for existing patients to monitor conditions, provide prescription refills, or provide other limited services beyond those listed above.

 

The Emergency Room

The Emergency Room is the one place you do NOT want to go for primary care services.

Emergency rooms exist to treat emergencies like auto accidents and heart attacks. Showing up at the emergency room for what the triage nurse or doctor would define as primary care usually results in very long wait times and extremely expensive bills. Unfortunately, some patients – most often those without a primary care provider – don’t know where else to go besides the emergency room, or they wait so long that their primary care or chronic condition (poor management of diabetes and allergies are common examples) becomes emergent.   While any hospital that accepts Medicare patients is obligated to treat any patient who presents themselves in their ER, they will often co-locate (as in adjacent space) an Urgent Care or Primary Care clinic with their ER so they can refer patients there whenever possible.

 

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