The American Healthcare System

This chapter provides an overview of the American healthcare system in terms of cost, quality, access, and convenience. Problems that have resulted in an unsustainable, inefficient, oversized, fragmented, and provider-centric system are discussed. While cost of care per capita and as a percentage of the Gross Domestic Product is much higher than in other countries, quality of care measured in terms of life expectancy at birth, infant mortality rates, and preventable mortality rates is questionable. The U.S. is the only developed country that does not provide coverage to 99.9% of its citizens. A large number of uninsured patients are expected to receive coverage under various provisions of the Patient Protection and Affordable Care (PPACA), but many others will remain uninsured or underinsured. Moreover, problems in hospital emergency rooms such as overcrowding, long wait times, ambulance diversions, patient boarding, and patients leaving without being seen by a provider are addressed. The author predicts that these problems will only be exacerbated by the expected shortage of physicians and other primary care providers.

Primary Care and Physician Shortages

In this chapter, the author provides an overview of the primary care system. Primary care is the backbone of healthcare systems and is defined as “the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Donaldson, 1996, p. 1). The primary care system in the United States is stricken with chronic systematic problems related to access, cost, and provider shortages. The chapter explicates the impact of recent legislation, including the Patient Protection and Affordable Care Act (PPACA) on these issues. It also highlights some solutions to increase access such as Community Health Centers (CHCs), the restructuring of care models to foster teamwork, the use of information technology, the provision of after-hours care, as well as the use of non-physician providers such as nurse practitioners and physician assistants.

Worksite Clinics

In this chapter, the evolution and growth of worksite clinics is discussed. Worksite clinics are not a new phenomenon. Prior to the 1980s, many large employers operated onsite company clinics to treat work-related injuries. However, many of these clinics closed in the 1980s and 1990s because of the decline in heavy industry and manufacturing sectors and the reduction in workplace hazards. Recently, there has been a significant resurgence of worksite clinics. The new generation of clinics is markedly different in that their main focus is on primary care, health promotion, and wellness rather than occupational injuries. The authors discuss in-depth the operations, stakeholders, and outcomes of care in worksite clinics. They predict that worksite clinics seem to be well positioned to thrive in a post-reform healthcare environment.

Non-Physician Providers

In this chapter, the role played by non-physician providers such as Nurse Practitioners (NPs) and Physician Assistants (PAs) is discussed in depth. These providers have delivered services in a variety of healthcare settings for a long time, but there is a recent urgency about the importance of the role that they can play in the healthcare system. The authors expound on research related to cost, quality, and satisfaction of patients receiving care from non-physician providers, and address barriers such as restrictive scope of practice and unjust payment policies. The use of other providers such as pharmacists and grand-aides is also addressed.

The Future

In this chapter, the author evaluates the convenient care models on convenience, costs, access, and quality. The models studied receive high scores on convenience, costs, and quality when compared to hospital emergency rooms and primary care physician offices, despite issues related to possible fragmentation of care. However, improving access to care, especially among uninsured and underserved populations, does not seem to be an advantage offered by convenient care. The author posits that the American healthcare system appears to be at a tipping point, with rising consumerism, demands for price and quality transparency, and regulatory forces that are forcing providers to focus on value over quantity. He envisages that the race between hospital systems under legislative pressures and giant retailers spotting strategic opportunities will accelerate innovations and enable convenient care models to move from the margins to become the mainstream way of providing preventative services, treating minor conditions, and managing some chronic conditions.

Hospital Systems and Healthcare Reform

In this chapter, the author addresses the degree of involvement of large hospital systems in convenient care models. These systems are not known for being nimble and innovative, as many are inhibited by fixed budgets and low tolerance for risk. However, they have recently joined the trends and developed their own retail clinics, urgent care centers, and online clinics. In fact, several hospital systems now have a “convenient care strategy” to reduce demand on their overwhelmed emergency rooms and better serve their patients. These strategies also help the systems better position themselves to deal with recent regulatory provisions. Implications of the Patient Protection and Affordable Care Act (PPACA), such as value-based purchasing and bundled payments are discussed in depth. The authors propose that hospital-based convenient care models that are appropriately aligned and integrated with the new arrangements will embody excellent opportunities for hospital systems to provide easy-access entry-points for new patients, to substitute expensive traditional care settings with less costly alternatives, and to deliver high quality and expedient care that will keep patients in their network.

Retail Clinics

This chapter addresses the poster-child of convenient care models, namely retail clinics. Retail clinics are walk-in clinics located in grocery stores, drugstores, and general merchandise retailers such as Wal-Mart, Target, CVS, Walgreens, etc. They offer a limited scope of diagnostic and treatment services for common medical conditions, as well as preventative and wellness services. Most retail clinic visits are for simple conditions and services such as upper respiratory infections, urinary tract infections, immunizations, and tests. Care is delivered by a nurse practitioner or physician assistant, and many clinics have up-front menu-style pricing, a feature that is unparalleled in the American healthcare system. The clinics operate on a walk-in basis with no appointments needed and very short wait times, and are open on evenings and weekends when most physician offices are closed. The chapter discusses the evolution, operations, and stakeholders of retail clinics, and highlights the research related to their outcomes, such as cost, quality, continuity of care, and patient satisfaction. The author describes how some operators are expanding the scope of services to include management and treatment of chronic conditions and conclude that the future of retail clinics in terms of numbers and usage rates looks very bright.

Convenient Care Trends

In this chapter, the author introduces several alternatives to traditional care provided in the physician office during regular business hours. While the settings where the care is delivered are different, the common characteristics among these alternatives are to have non-physician providers deliver care that is more convenient and less costly than that delivered in regular physician offices. Convenient care alternatives such as urgent care centers, retail clinics, worksite clinics, house call services, and virtual/online services are highlighted. These services are described as “disruptive innovations,” or powerful changes in which a larger population of less-skilled providers can provide care in more convenient, less expensive settings that historically was only provided by expensive specialists in centralized, inconvenient locations. Given the myriad of problems faced by the American healthcare systems, the authors argue that these innovations are well positioned to change the way healthcare is delivered for generations to come.

Urgent Care Centers

This chapter focuses on urgent care centers as a unique innovation that has been in the making for the last 30 years. Urgent care centers provide unscheduled or walk-in care, are open for extended hours on weeknights and weekends, and provide services that go beyond what primary care physicians provide, such as occupational medicine, laboratory tests, and fracture care such as splinting and casting, with some providing intravenous fluids, routine immunizations, and primary care services. This chapter describes in-depth the history and growth, operations, and stakeholders of urgent care centers, and overviews the research that relates to quality of care, costs, and patient satisfaction in these centers. Given the expanding industry, strong growth in company numbers, greater employment opportunities, and rising per-capita usage of urgent care centers, the author argues that the urgent care industry is in the growth phase of its life cycle.

Online, House Call, and Other Services

This chapter focuses on new healthcare services provided online, in the patient home, and elsewhere. Under the umbrella of telehealth, there are three key modes of delivery. First, real time (synchronous) delivery requires a live telecommunication connection and uses phones, video conferencing, and chat sessions. Second, “store & forward” (asynchronous) delivery captures digital media and transmits to it to providers via images, video, audio, x-rays, etc. Third, remote monitoring (synchronous or not) is a combination of real-time and store and forward and it uses connected devices. The author highlights the example of several online care companies such as Hello Health, virtuwell, Zipnosis, and American Well. House call services by nurse practitioners are on the rise again. The author focuses on the example of WhiteGlove, a service that offers access to nurse practitioner care at home or at the office seven days a week. They conclude that many patient visits to the hospital emergency rooms and to primary care physician offices are unnecessary and can be taken care of in a much cheaper and more convenient way through online interactions and house visits.