5 Essential Outpatient Venues for Accountable Care

Accountable care breathes new life into ambulatory care, an essential component of a comprehensive, low-cost service offering. Fueled by the promise of volume-based revenue, freestanding venues have proliferated in the last decade. In building accountable care networks, the strategic role of non-hospital sites should be articulated, since it makes sense to shift volume to low cost settings. While it may seem counterintuitive to drive business away from existing hospital and physician assets, a distributed ambulatory model that includes strategic partnerships can be an important part of a broad network to expand access and manage population health.

Outpatient care offers value for patients seeking convenience, speed and simplicity. Suburban residents are less willing to travel to urban centers for basic levels of care, especially on nights and weekends when the only viable options are overcrowded emergency rooms. A recent Commonwealth Fund survey revealed that 85 percent of respondents cited as "important/very important" the ability to have a clearly defined, convenient place to seek after hours care. This takes on greater importance in accountable care, where every patient encounter is potentially a sentinel event.  Information gained in a quick care visit may have ramifications for managing total patient health, which is the ultimate objective of the medical home. The ACO strives to educate patients to ensure they find the best way to deal with disease or injury, whether to self-treat, make an appointment or access urgent/emergent services. A distributed care model offers an array of options to help mitigate inappropriate utilization. Rather than viewing freestanding centers as competition that siphons off business, distributed care models can increase value and reduce costs.

Here are five outpatient venues and their potential role in accountable care:

1.  Retail clinics. Walk-in clinics at the local CVS or Wal-Mart are not the enemy.  This is a tough sell to primary care physicians who view these clinics as direct threats that siphon off profitable work that might otherwise flow through the practice. It is tough to deny the trend that patients are voting with their feet as they opt for quick, easy alternatives to hospital centers or limited-hours practices.

One solution is to partner. OhioHealth and Cleveland Clinic now provide medical directorships for CVS MinuteClinics. This builds an immediate network of distribution points and creates a streamlined process of data interface and specialty referral.

Retail clinics can become front-line access points for the patient-centered medical home. Remember, accountable is not about episodic encounters; it’s about panel participation and patient engagement. As an extension of the patient-centered medical home, retail clinics can occupy a primary care niche while expanding access and keeping the patient in network.

2. Urgent care centers. One level up in the "unscheduled" system of care is the urgent care center, a model that has yet to realize its potential as a convenient, low-cost alternative to overcrowded EDs. By limiting services to low-level care and rule-out testing, the UCC can be an effective venue for offering patients a place to quickly address semi-emergent concerns. Companies such as MedExpress have realized success building referral networks with hospital systems, providing a pre-emergent alternative that increases distribution points.  Anthem Blue Cross now provides a Google map app to locate clinics and UCCs in an effort to steer care from hospital-based EDs. Consider the UCC in any ACO plans, if for no reason than to ease the ED burden.

3. Freestanding EDs. Following the greenlighting of unattached, full-service EDs in states such as Washington and Texas, the freestanding ED has become a popular alternative for augmenting emergency services in areas where transport is a challenge. In addition to the obvious convenience factor of bringing full emergency services to communities, freestanding centers may be less likely to resort to hospital admissions as an outlet to drive throughput. The admission decision in the freestanding ED is more measured and deliberate, while offering equivalent quality and level of care to the hospital.

4. Ambulatory surgery centers. It may seem that the underlying premises of ASCs and ACOs are in conflict.  The incentive for ASCs is to emphasize volume and higher rates, while ACOs are designed to limit utilization. Looking closely, a shared purpose derives from ASCs' lower cost profile compared to hospitals with the added bonus of the potential to avoid inpatient expense. Accountable care may be a tough sell for ASCs, but there is a value proposition: ACOs with sufficiently large panels may be able to direct a steady stream of contracted business to the ASC at guaranteed rates and actuarially-determined volumes.  This offers predictability.

There may be an unintended consequence to partnering with ASCs. During a recent webinar, a question was raised about the impact of delaying elective procedures to the out years. Certainly the possibility exists that aggressive ACO utilization management may result in delaying elective procedures and not really driving out cost. To prevent this, ASC physicians should be engaged in a program of appropriate checks and balances.

5. Home. The best place for any patient to receive care has nothing to do with the health system. Home is rapidly becoming the preferred venue for monitoring, testing and follow-up to catch problems before the need arises to access the care system. Technology has played a major role in enabling the collection of real-time data through telehealth and web-based programs to track the trending of patient status and improve post-discharge compliance. A successful ACO grew its home visit volume by 20 percent without direct reimbursement, a cost easily recaptured in shared savings.

In pursuing an ACO, think outside the lines of what currently exists.  Look to partner with existing organizations to expand the care continuum and create a distributed model.

Related Articles by Bob Edmondson:
Post-Acute Care Networks: The Key to Success in Accountable Care
6 Ways ACOs Differ From HMOs

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