We talked to executives, clinical leaders, and clinician members of our Insights Council for a closer look at whether retail clinics are helping or hurting primary care, as well as what conditions specialty providers need to adopt alternative payment models.
Like a third of his fellow NEJM Catalyst Insights Council members, Stanley Szefler, MD, Director of the Pediatric Asthma Research Program and Research Medical Director for The Breathing Institute at Children’s Hospital Colorado’s in Aurora, believes retail clinics are bad for primary care.
“Retail clinics are good for cuts and bruises or broken bones, but for chronic conditions, you need a long-term trusting relationship [with your doctor],” Szefler says.
“The more severe your condition, the more you need continuity of care and a connection to medical records,” he adds. Otherwise, care will inevitably be fragmented, he says.
David A. Paul, MD, Chair of the Department of Pediatrics and Clinical Leader of Women and Children’s service line at Christiana Care Health System in Wilmington, Del., says he’s in the “don’t know” category regarding retail clinics’ impact on primary care, along with 42% of survey respondents. “There are potential benefits, including providing increased access to some families who can’t get to a private practice.” The downside, he says, is “inconsistent” quality.
But he is confident that over time, retail clinics will experience better integration with primary care and better quality. Christiana Care itself has started to invest in local urgent care clinics, Paul says, adding that the health system aims to integrate urgent care with primary care and to use those clinics to offload the burden on busy and expensive emergency departments.
Paul also weighed in on what conditions would be necessary for specialty providers to adopt alternative payments. Like 68% of survey respondents, he says better data on improved outcomes cost and quality is imperative. “Before people change their systems of care and systems of payment, it has to be evidence-based,” he says. “Show me how [the payment model] will reduce costs and improve outcomes.”
“We need data from the industry to say ‘look what other systems did’ and ‘here are the improvements and cost,’” Paul says. For instance, if health care organizations are going to accept bundled payments, they need to know how their care costs compare to industry benchmarks.
Better data also might address some physician wariness to take on risk. “You’re asking practices to put money upfront for care management when there is uncertainty whether it will reduce readmissions,” he says. “That’s why people are asking for data — they are scared to take that risk.”
Paul A. S. Fishkin, MD, physician at Illinois CancerCare, P.C., a cancer and blood disorder specialty practice that serves 13 counties with 11 service sites, says obtaining detailed data on his practice’s costs is a benefit of participating in the Centers for Medicare & Medicaid Services’ Oncology Care Model (OCM). “Expensive health care is a complex problem, and as a profession, we need to spend more time understanding what drives the total cost of care,” he says.
The OCM features payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.
Fishkin says health care organizations also need more experience with the requirements of implementing new required care models, including accounting. For instance, a patient was receiving chemotherapy for malignant melanoma and, within the 180 days of the care plan, fell and broke a hip. Although physicians weren’t sure the fall was a result of chemotherapy, Fishkin says, the cost of treating the hip had to be included in the patient’s total cost of care. He says such accountability will lead to a higher quality of care at a lower cost. “Everyone will understand the cost of care along the chain,” he says.
Within the pediatric asthma specialty, the budget impact of alternative payment models is a concern, Szefler says. “How does it change the budget in terms of total budget, and how do you distribute that budget?” For example, The Breathing Institute has taken ownership of asthma and is pioneering research, developing systems of care, and creating supporting materials. “How do you pay for innovators and system contributors? Some hospitals take more of a leadership role than others. It’s not straightforward,” he says.
In general, “the mindset for alternative payment models has to shift into innovating health care models and how that is reimbursed,” he says.