Case Study: When Urgent Care Isn’t Enough
Value-based models design for the whole cycle of care
A middle-aged woman presented to the walk-in clinic for a cough and shortness of breath starting a few months ago. Prior to the current visit, she had been diagnosed with a viral illness and given prednisone (steroid medicine for lung inflammation) because of her history of asthma. The chest x-ray at that time was initially read by the clinician as normal, but later the radiologist read the chest x-ray as being consistent with pneumonia and therefore antibiotics were also prescribed.
The patient revealed to me she had been confused about which treatment she should proceed with – the antibiotics or the steroid or both at the same time? She had only been able to afford one of the medications. She decided to buy the antibiotic. Months later she was still coughing, so she decided to fill the prescription for the steroid (which she could now afford). She was already most of the way through the treatment but still had no improvement. A repeat chest x-ray no longer showed pneumonia, leading me to believe her uncontrolled asthma and smoking were the culprit. I recommended a treatment plan for asthma, nicotine replacement products to help her quit, and arranged follow-up with her PCP.
How could value-based care potentially have improved this patient’s journey? Recall the value equation: change in health outcome over the costs to achieve it.
Acute care from your PCP is about more than just someone who knows you. Value-based care models prioritize relationships and continuity within primary care. This patient fortunately had a PCP, but in neither instance did she receive care from the PCP. It had been a few years since she had seen the PCP, and the relationship was clearly weak as she did not even think to call for an appointment. An ongoing PCP-relationship might have been more likely to address her need for smoking cessation earlier on with medication and/or behavioral support. Few urgent cares clinicians routinely address or prescribe medicine for smoking cessation beyond a cursory, “You need to quit smoking.” Although the FFS model does allow one to bill for smoking cessation, it can be cumbersome. In VBC, “extras” which are truly essential, like behavioral support for smoking cessation, can be baked into the care model.
When you are paid to help the patient get better, not just to deliver a service, you will design for the whole cycle of care. I have no doubt the original treating clinician did their best to design a treatment plan to help the patient improve at the first visit. However, the service ended there. In value-based care models, proactive follow-up until you reach the desired outcome is incentivized. In the case, follow-up a few days after the visit would have helped the care team to recognize 1) the gap in ability to acquire medication 2) the patient’s confusion about how to take the medication 3) the lack of improvement with the initial treatment plan.
Follow-up costs, but not as much as failure. Early follow-up (from either the PCP or the walk-in clinic) would have potentially saved the patient the need for an additional visit at the walk-in clinic, time away from work, an additional chest x-ray, and not to mention months of suffering. The cost of these interventions would have been less than the total cost of a follow-up phone call by a nurse or pharmacist and the cost of the steroid medicine in the first place. If you add smoking cessation counseling and the cost of nicotine replacement, the total cost still would have been less than the cost of the cigarettes she had been smoking. Value-based care considers the costs over the whole cycle of care and gives the team flexibility to make those investments early in the care journey (e.g. paying for her medicines if needed) to save the later costs. Thankfully this woman didn’t end up in an ER or hospital, which would have magnified the cost differential.
Urgent cares and walk-in clinics sprang out of a lack of sufficient primary care access. It’s a stop-gap and does a fair job at handling simple, non-emergent conditions less expensively than the ER. Like the ER setting, urgent care is challenging because by (current) design you do not see the patient through to when they are well. You make the best assessment and treatment plan for the urgent need and then try to hand the patient back to their PCP (if they have one) for follow-up. However, in these acute, fee-for-service settings fewer resources are assigned to wrap around the patient. Sometimes the connection to primary care or follow-up never happens. The convenience and ready access are seen by some as a sufficient substitute for primary care…until it isn’t. Value-based care models change the status quo of care from one that is siloed and episodic to one that demands integration and continuity to achieve more consistently positive outcomes.
