David Boles, DO, owns a family medicine clinic with four physicians in Clarksville, Tenn. In recent years, he has seen an upsurge in competition from retail clinics, urgent care centers and a freestanding emergency clinic.
Those alternative care sites have hit his bottom line hard by taking away the lion’s share of the minor acute-care visits that used to be his practice’s bread and butter. That has left him and his colleagues to deal with the harder cases that they get paid less for in relation to the amount of time they take.
“If I see 25 patients in a day, it will be 25 complicated patients,” he says. In the past, he recalls, his practice saw a lot of patients with the flu during flu season and did most of the patients’ immunizations. But now the alternative care settings—including four new urgent care clinics and the freestanding ER—are taking all the easy cases. As a result, he often finds it difficult to keep his midlevel practitioners busy.
Boles’ situation is not unique. Russell Kohl, MD, a board member of the American Academy of Family Physicians (AAFP), says he’s heard similar complaints from some AAFP members. Jillian Schneider, manager of the department of medical practice for the American College of Physicians (ACP), acknowledges that alternative care settings are also a challenge for internists. And Scott Cullen, MD, a consultant with ECG Management Consultants, says that fast-growing alternative care settings pose significant competition for some primary care physicians.
Along with physical care sites, telehealth services are part of the provider mix that is meeting some of the demand for minor acute care. FAIR Health, a research organization, says that telemedicine utilization leaped by 1200 percent from 2012 to 2017. The bulk of that growth appears to represent consumers’ use of telehealth services.
Although a growing number of practices—especially larger groups--are doing telehealth visits with their own patients, a recent ACP survey found that just 18 percent of internal medicine practices had the technology needed to do secure video visits, and a third had online consult capabilities.
Meanwhile, the number of alternative care settings is soaring. At latest count, there were about 2,200 retail clinics, of which more than half were operated by CVS or Walgreens. The number of urgent care clinics jumped from 6,946 in 2016 to 8,774 in November 2018, according to the Urgent Care Association.
Convenience and access
People use alternative care settings for low-acuity conditions because they offer convenience and access. Sick patients don’t want to wait to see a primary care doctor in a conventional office. Often, they can’t leave work to visit a physician practice during office hours. They may not be sure whether they need to see a doctor, or they may just need a prescription.
Price can be a differentiator. Urgent care centers are more cost effective than standalone ERs, which charge close to what hospital emergency departments do, but they charge more than physician practices do, on average. And, among physical sites, retail clinics charge the least for primary care.
FAIR Health’s analysis of a large national claims database, for example, found that median charges for a CPT 99202 visit ranged from $160 in an urgent center to $138 in an office to $104 in a retail clinic. Median allowed amounts for CPT 99202 were $93 for urgent care centers, $66 for offices, and $73 for retail clinics. CPT 99203 median charges were $213, $207 and $129, respectively. Urgent care centers were allowed $114, offices, $92, and retail clinics, $85, for CPT 99203. According to other reports, a telehealth visit may cost $50 to $80.
Considering that primary care offices must also see patients with chronic conditions and cope with an ever-increasing, complex blizzard of rules and regulations, the lower or similar payments to primary care offices place them at a disadvantage, Boles notes.
“The expectations on primary care are so overwhelming,” he says. “Then you throw on top of that a walk-in clinic right down the street that doesn’t deal with any of those things and sees this person for a minor problem and gets paid similar to what we do for an office visit. They get the icing, and the real meat of the issue is left to us.”
Seeing mainly complex patients is a losing proposition for an independent family physician, explains Richard Young, MD, who works for a safety-net hospital in Fort Worth, Tex., and who researches the local market for an affiliated family practice residency. “If I take care of four problems in a visit—say a patient has high blood pressure, diabetes, back pain and a rash—I’ve given away half my services, because the CPT coding system quits paying me after I’ve seen two things.”
What can primary care practices do to meet this competition? Schneider urges them, first of all, to investigate the possibility of collaborating with alternative care sites. Retail and urgent care clinics can refer patients who need more extensive diagnosis and treatment to primary care offices, she says, and primary care providers can advise patients to go to certain walk-in clinics when their offices are closed. Of course, the alternative care sites must agree to send documentation of each encounter to the patient’s primary care physician.
Practices should also extend their hours, Schneider says, even if it’s only on certain days of the week and/or selected weekends each month. Practices should plan their extended hours to meet the particular needs of their patient population, Cullen advises. On different days, for example, Jeff Pearson, DO, a family doctor in Carlsbad, Calif., has early morning and evening hours designed for patients who are on various schedules, he says.
Kohl agrees extended hours are important, but notes that they can create staff scheduling challenges. When he was in private practice, he recalls, he and his nurse practitioner were on staggered schedules: he handled the early hours and she covered the evenings, and the staff schedules were staggered to match.
The vast majority of FPs offer some version of same-day scheduling, another technique that increases access. Not too many doctors open up their entire schedules to whomever happens to walk in or call in. But a generous number of open slots can help patients get in when they need to be seen. In his former practice, Kohl kept all of his afternoon appointments open, and they all filled up.
Similarly, Robert S. Kaufmann, MD, a general internist in Atlanta, says that his five-doctor group has regular walk-in slots for patients with low-acuity problems.
Schneider also suggests that practices post the prices for their most common services, just as the alternative care settings do. Even though a provider’s charges may not equate to what the patient will pay out of pocket, she says, “People want to know what’s going to hit their pocketbooks.” If practices want to give patients a better idea of out of pocket costs, she adds, they can ask their major payers what their allowed charges are on the most common services.
Pearson says he’s been posting his prices ever since he started out in practice. Today, all of his charges are on his website.
Build a digital platform
In today’s world, Cullen says, it’s essential for a primary care practice to have a digital platform. Primary care physicians must be able to interact with patients online, not only to give advice, but to set up appointments, deliver test results, and provide educational materials.
These online activities, as well as secure video visits, depend on patient portals. Not many patients, however, take advantage of these sites, according to a 2018 Government Accountability Office’s study that shows only 30% of Medicare patients used them. Cullen says the more value patient portals deliver, the more they’ll be used. Schneider urges practices to promote their portal to patients, talking about it at every visit and providing handouts on how to use it. In a clinic she used to manage, she says, staff would show patients how to log onto the portal on a computer in the waiting room.
It’s also essential to use social media, Schneider says. This is particularly true if practices hope to reach the millennials who are among the biggest customers of retail and urgent care clinics. Practices can employ Facebook, Twitter and Instagram to get out the word about their services and hours of operation, she notes.
E-consults and video visits represent another promising avenue to connect with younger patients. One Tulsa practice that recently started offering e-visits for 10 minor acute conditions has seen quite a bit of patient uptake, Schneider says.
According to ACP’s telehealth survey, the majority of practices that have the technology aren’t using it. Now that reimbursement for telehealth is widely available, Schneider says, the main barrier is lack of training. EHR vendors who license video visit modules are not training providers on how to use them, and physicians also have to teach their patients how to use the technology.
Kaufmann’s telemedicine vendor provided the hands-on training that the physicians and staff needed to feel comfortable with virtual care. When the group’s doctors are busy, they do audio-video consults on minor acute problems so that patients don’t have to come into the office. “We can provide service without making them wait,” Kaufmann says. At the same time, telemedicine has added a new profit center for the practice, he adds.
Primary care’s advantages
Kohl says the AAFP is less concerned about the competition from alternative care settings than about the fragmentation of care that can result. At least in one respect, that problem is diminishing, he says: Recently, he has seen more retail and urgent care clinics send information about patients’ visits to their regular family physicians.
Still, he says, alternative care settings “represent a misunderstanding of the value of comprehensive, continuous care.” Patients at walk-in clinics don’t receive the same type of attention to all of their risk factors and current conditions.
Pearson recently restarted a cash-only solo practice after several years working for a large group, and this has turned out to be an effective way to compete with alternative care sites, since he can provide more personalized care.
“I don’t have a seven-minute window,” he points out. “They get better service. Also, when they go to urgent care, they’re being seen by a PA a lot of the time. When they come to me, they’re seeing a seasoned doctor with 35 years’ experience.”