If asked to name models for ambulatory care, most healthcare experts will rattle off a short list:
- Traditional private practice
- Federally-qualified Health Centers (FQHCs)
- Free and charitable clinics.
True, these three models are critical for providing healthcare services. But there are also many others that can do much to offer care—particularly to underserved segments of the population. By getting a little creative about how we think about healthcare models, we can start to fill in some of the health services gaps and help the most marginalized communities receive healthcare.
Here are several ambulatory care models, including out-of-the-box options. As we’ll explain, each option has its pros and cons:
Traditional private practice
When most people think about going to the doctor, this is what they imagine: visiting a privately practicing provider (or a group of providers) in an office or complex. There are, in fact, three common private practice models:
- Solo practice: a private practice where one provider and a small staff serve all patients.
- Group practice: multiple providers working together out of the same office. Group practices may be single-specialty or multi-specialty.
- Employed provider practice: A clinic is owned and operated by a hospital or another major care provider. From patients’ perspective, an employed provider practice looks a lot like the other two models, but providers at this type of practice are typically salaried employees (rather than partners or owners of the practice).
The major advantage of traditional private practice is that providers and administrators enjoy a great deal of autonomy in determining the goals and methods of the practice.
However, private practice is oftentimes inaccessible to lower-income patients. Private practice clinicians (especially employed provider practices) often must place limits on Medicaid or self-pay patients because the reimbursement is too low. Traditional private practice also tends to have high overhead thanks to the costs of computer systems, office space, etc.
Some clinics receive federal funding, or are otherwise designated with a special status under the Public Health Services Act (PHS). Within that umbrella, there are three main types of health centers that receive federal funding:
- FQHCs: These health centers qualify for federal funding under Section 330 of PHS. They serve underserved areas or populations, and receive enhanced Medicaid/Medicare reimbursements. There are also grants to cover self-pay patients. In order to retain federal funding, FQHCs must continually demonstrate that they are meeting federal regulations. While FQHCs are able to serve many low-income patients, the burden of meeting federal requirements (and demonstrating compliance) can oftentimes be onerous. They are also eligible for federal medical malpractice liability insurance or Federal Tort Claims Act (FTCA) deeming-a major perk for health centers.
- Look-alikes: Some health centers may meet the standards laid out in Section 330, but do not receive federal grant funding. They may be eligible for special Medicare and Medicaid reimbursement rates. These health centers face a similar regulatory burden as FQHCs but are not eligible for FTCA deeming.
- Sub-recipients: A sub-recipient is a healthcare provider that does not directly receive federal funding, but is contracted with a FQHC to provide certain services. They receive many FQHC benefits, including access to federal malpractice insurance (FTCA), enhanced Medicare/Medicaid rates, and grants to cover self-payment. Since they’re oftentimes partnered with larger organizations, responsibilities can be shared. But sub-recipients are also subject to federal oversight and compliance requirements.
Direct primary care
Direct primary care (DPC) is an emerging healthcare model in which patients and providers make direct arrangements for payment and billing, without the involvement (or even limited involvement) of insurance companies. There are a few commonly used DPC models in the U.S.:
- Robin Hood model: A provider or group of providers starts a low-overhead private practice. The provider recruits a small group of patients who are able and willing to pay out-of-pocket for healthcare services superior to what they would otherwise receive. These patients pay an annual fee for all services. With these patients’ fees as an income stream, providers can then provide care to uninsured patients at a low cost or no cost. This model can be financially sustainable, and offers care to uninsured people without red tape. But it remains to be seen whether the model can be scaled.
- Good Samaritan model: This model operates similarly to the Robin Hood model. However, paying patients decide to donate their unused service fees to patients who are unable to pay. So if a patient pays $1000 in annual fees but only uses $500 in services, the remaining $500 would go towards services for low-income patients. While this model can provide care to many people who couldn’t otherwise pay, the Good Samaritan model isn’t always self-sustainable without philanthropic assistance.
With a concierge care or “boutique care” model, providers in private practice greatly reduce the number of patients they serve. All patients must pay an annual retainer fee. In return, patients receive more flexibility in terms of appointments, faster processing of lab results, and longer appointments. This can be particularly beneficial for patients who must see a provider more frequently. For patients who receive concierge care, it can be highly convenient and customizable. But concierge care is also costly and inefficient, putting it out of reach for many patients. This model may sound very similar to the Direct Primary Care model but differs in that administrators running Concierge clinics will often bill insurance companies. If the clinic does bill Medicare, they are then subject to all of the government regulations that come with that (Meaningful Use, etc.).
Free and charitable clinics
Free and charitable clinics provide health services to needy patients for free, or else utilize a sliding scale for fees. Eligibility for services is restricted to those who cannot pay, or who cannot otherwise access healthcare services. Free and charitable clinics qualify as 501(c)(3) tax-exempt organizations. Many are affiliated with religious organizations. Clinical staff may be volunteers or full-time employees.
In addition to offering affordable healthcare services to marginalized populations, free and charitable clinics offer meaningful volunteer opportunities for clinicians. They are also a great way for faith communities and community donors to give back. Even so, free and charitable clinics may be able to provide only a limited number of services or hours of operation if they do not have significant philanthropic involvement.
Telemedicine services involve an appointment between a patient and a provider, conducted through real-time video conferencing. This is a cost-effective way for patients to receive medical care, at greater convenience. (No more waiting around in the office!) Telemedicine also enables better service for people who live far away from an accessible provider.
On the negative side, telemedicine isn’t ideal for some types of healthcare services. It also requires the patient to have access to technology, and continuity of care is limited.
Mobile care—often provided through vans or other vehicles—brings healthcare directly to patients. It’s a great model for reaching people who might otherwise have a hard time blocking off several hours for a doctor’s appointment.
There isn’t much continuity of care with mobile care, and often services can be limited. Mobile care may be a service of several different models but is typically seen in the Free and Charitable Clinic and FQHC models.
Retail health clinics are making healthcare more convenient by offering limited healthcare services at pharmacies and grocery stores. Some common names may include “The Little Clinic”, “RediClinics”, or “Minute Clinics” and have the advantage of convenience and efficiency. For services such as vaccinations or offering care for common medical problems, retail clinics can be highly effective and convenient.
But retail clinics can be costly, and typically there is limited continuity of care. The model isn’t effective for dealing with complex, long-term medical problems that would be best cared for in a patient-centered medical home.
Patients with a medical complaint can go to an urgent care as an alternative to the emergency room. Typically, these clinics have extended hours and accept walk-in patients. The advantages of urgent care are that it’s convenient, provides fairly extensive healthcare services, and is less expensive than emergency room services. However, urgent care is more expensive than primary care, and patients don’t usually receive much in the way of continuity of care for chronic issues.
Freestanding emergency departments
A freestanding emergency department (FSED) is basically what it sounds like: a healthcare clinic that provides all of the standard services of an emergency room (ER), but are not attached to a hospital. Oftentimes, FSEDs are owned and operated by for-profit entities not associated with hospitals.
For patients, FSEDs have the advantage of convenience and offering a wide range of services. At the same time, however, services from FSEDs can be very costly as compared to alternatives. There isn’t much continuity and care and, like traditional ERs, care tends to be more oriented towards treating an immediate complaint than preventing long-term health problems.
At a workplace clinic, an employer offers healthcare services directly to employees. Sometimes, these services are provided at locations close to the workplace, and clinics may be shared between different employees. Such services are typically part of health benefits options that employers offer.
Workplace clinics offer easy access for employees. Some employees may not be able to receive healthcare if not for these services. But if an employee does receive services from another provider, care can become fragmented. Services offered through work-based clinics are limited, and provision of such care is inefficient because only a limited number of patients are served. Because access to workplace clinics is contingent on employment, they remain inaccessible for many.
Specialty care clinics
Many patients have needs that are too complex to be handled by a primary care provider alone. At the same time, they don’t require hospitalization. They can go to the ER—but that’s expensive, inefficient, and contributes to ER overcrowding.
The solution is a specialty care clinic. Patients can go to a “hub” that includes a diverse selection of specialists. For example, Kaiser Permanente operates several such specialty care clinics in California.
Specialty care clinics offer highly specialized care, meeting needs that might otherwise go unmet in communities. They typically provide superior care as compared with the ER (where many patients might otherwise end up). But on the downside, specialty care can be quite expensive. Care received at these clinics isn’t always well-coordinated with primary care.
With the community paramedicine model, a trained first responder is posted somewhere in the community with high needs (such as a homeless shelter). The clinician (often an RN or advanced practice nurse) provides a range of primary and preventative care services, with the aim of reducing hospitalizations. This model, which has been used in both urban and rural medicine, has successfully reduced ER visits and emergency calls.
Community paramedicine allows communities to make emergency medical services more efficient while offering care to underserved patients. The biggest problem is that it’s sometimes difficult to receive reimbursement and funding for these services. Additionally, many emergency service providers are reluctant to partner with community paramedicine providers since its funding is not often secured and it is drastically different from the long-standing EMS model.
So, there is no magic bullet that will give everyone access to healthcare. But there are many potential models that can improve healthcare for a whole lot of people. By thinking more creatively, healthcare decision-makers can do much to eliminate the inequalities that still plague the field. (No pun intended!)
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