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Insurers turn to retail, urgent care clinics to keep members out of emergency rooms

BY Jim Frederick

Shifting patients away from hospital emergency rooms and into retail-based and urgent care walk-in clinics can significantly lower healthcare costs, improve access to care and reduce the impact of such chronic diseases as diabetes and hyperlipidemia, two health benefits experts asserted in a recent online presentation.

In a webinar titled “How Retail and Urgent Care Clinics Can Be a Win-Win for Health Plans and Their Members,” the two experts — Susan Menendez, director of strategic provider relationships for Blue Cross and Blue Shield of North Carolina, and Tom Charland, CEO of health consulting firm Merchant Medicine — laid out a strong case for walk-in clinics as a powerful tool to reduce expensive visits by health plan members to emergency rooms and provide an accessible professional care alternative for millions of Americans living in areas facing a shortage of primary care physicians. Such clinics also can extend a local health system’s reach within a community as part of an accountable care organization, provide a medical home for some patients and make patients more responsible for their own health, they said.

Retail and urgent care clinics, Charland said, are “expanding the scope of services” they offer walk-in patients, providing “an alternative to primary care.” And health plan payers, he said, are taking notice. Increasingly, they’re looking to clinics to play a role in improving patient access to health services, lowering costs for routine and preventive care and serving as ad hoc medical homes for patients “where there’s an extreme shortage of primary care physicians,” he noted.

Given “the hours, the locations, the consistency of service,” Charland said, “I personally believe that walk-in medicine has done more for patient-centric behavior and patient satisfaction — and the focus on patients as customers — than anything since doctors made house calls.” Charland attributed the rise in retail and urgent care clinics to “medical providers acting like merchants, and acting like they want patients to come back and have a positive experience.

“It’s no longer built around the provider, or providers’ hours or locations,” he added. “It’s built around the patient.”

To this point, however, retail and urgent care clinics have followed different growth tracks. Although urgent care has seen steady gains over the past decade, the retail clinic market experienced “a leveling off in 2008 and 2009, when people were trying to figure out what was going on, and it’s only just recently that Minute Clinic, under CVS’ guidance, has decided to start opening new clinics,” Charland said.

Nationally, the use of retail clinics saw healthy gains from 2006 to 2009, according to a study from Rand Corp., from 1.48 million total patient visits to roughly 6 million. “But those figures still pale in comparison to ER and regular physician visits,” noted Atlantic Information Services in a report. “An estimated 117 million ER visits and 577 million visits to doctors’ offices are made each year.”
Nevertheless, said Charland, “These clinics are here to stay” as health plans, payers and patients incorporate them into the nexus of care. He also predicted “a lot more cooperation” from doctors as “the changing economic model is starting to change their behavior from being able to do as many procedures as you can, to getting that procedure in the spot where it can be done with the highest quality at the lowest cost. And if that does take over, I think we’ll see walk-in clinics start to be integrated into more of these ACOs and clinically integrated networks.”

Although most retail clinics “have yet to break even,” Charland added, the profit picture is improving as operators have learned to “smooth out some of the seasonality” of their business by broadening their menu of services and as patient traffic has picked up. “Now that these clinics are at break-even, we’re going to start to see some of the operators open more clinics,” he predicted.

Investing in urgent care solutions
The need among health plan payers to curb the rising costs of emergency room care for non-emergency health problems has become increasingly urgent, Menendez said. “We have seen our costs for ER services continue to increase over the last several years,” said the Blue Cross Blue Shield strategist. “We know that thousands of patients visit crowded emergency rooms for non-life-threatening conditions that we believe can be treated very cost-effectively and efficiently in urgent care centers. And we know that a visit to an ER can cost up to 10 times more than visiting an urgent care center…[at] nearly $1,500,” she said.

In response, BCBS purchased a stake last year in FastMed Urgent Care, the largest urgent care clinic provider in North Carolina. “In those pockets of the state where we have primary-care shortages, this type of model is very attractive to us,” said Menendez. “We know that primary care shortages in North Carolina will only worsen in 2014 and beyond. So we’re looking now at solutions around primary care, as well as having options other than the local hospital for these members.”

Menendez said the Blues launched a project in 2010 “to look at these ER costs and services, and really try to understand what is driving members going to ERs. What are the behaviors and the most common diagnoses that members go to ERs for?”

ER-use rates are higher in rural areas of the state, she said, at rates of “around 200 per 1,000 members, and that’s incredibly high,” versus about 140 visits per 1,000 members living in urban areas. In addition, BCBS knows that “women of childbearing years and young males have the highest ER rates. We’re trying to drill down into that and understand why.”

The Blues tracks a list of 15 to 20 diagnoses that drive the most nonemergency ER visits, including headaches, back pain, sore throats, urinary tract infections and upper respiratory infections.

One big reason for the high ER utilization rates: the shortage of primary care physicians, coupled with the fact that many residents in North Carolina don’t have a regular doctor to visit for treatment and counseling, even for common conditions. And again, BSBC members in rural areas — including “some pockets of the state where the only option for receiving nonemergent care is the local hospital,” Menendez said — are the least likely to have a primary care physician. “That’s very concerning to us, given some of the health crisis issues we have today.”

Thus, the executive said, BCBS is targeting some distinct population groups to lower their rate of ER visits and steer them into retail clinics, urgent care centers and other alternative, lower-cost healthcare sites. Among the target groups are:

  • Members in poor access areas;

  • Those with no primary care doctor;

  • Members with a moderate health situation that has not occurred previously; and

  • Those with persistent health conditions.

In a bid to shift its members away from high-ticket visits to the emergency room for nonemergency health issues, the company also adopted a tiered approach to out-of-pocket patient costs. To that end, BCBS began raising its patient co-payments for routine care at the ER.

The boost in co-payments — $100 in 2001 to $150 beginning in 2004 — did result in reductions in ER utilization among members, but what’s needed is a broader, more comprehensive approach to providing health services that encourages patients to make better use of other care options like retail clinics and urgent care centers. To that end, BCBS also invested in FastMed, a network of 26 urgent care centers across North Carolina. The insurer also began a pilot project with several employer groups to help educate their workers on alternative care sites like clinics.

“We believe that providing access to additional clinics in North Carolina can help us achieve that reduction in ER visits,” Menendez said.

Indeed, shifting patients away from the ER and into retail or urgent care clinics in the state would yield significant cost savings. “An overall 5% shift in ER to urgent care utilization would result in about a 74 cent-per-member-per-month savings, and that translates into almost $8 million annually,” she said.

BCBS of North Carolina and FastMed now co-sponsor community events like health fairs, wellness and prevention events, and blood-pressure checks. “We did a huge voucher mailing in mid-November to members who live close to a FastMed location, waiving co-payments for those members. And we continue to work together to identify short- and long-term strategies around strategically placing new clinics across the state where we have high ER costs and inappropriate utilization.

“We know that if we can get these members who don’t have primary care physicians into that [clinic-based] primary care space, and get them linked into preventive and wellness programs, we can do incredible things to head off such chronic diseases as diabetes, hypertension and cardiovascular problems — all the things that we are so struggling with here in North Carolina due to environmental factors,” Menendez added.

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Addressing drug-related nutritional deficiencies

BY Michael Johnsen

As more Americans are prescribed medicines to alleviate their chronic metabolic conditions, more Americans are exposed to common drug-induced nutrient depletions, noted pharmacist and supplement expert James LaValle, CEO of Integrative Health Resources.

Drugs can inhibit the absorption of a nutrient, LaValle noted. “It can change its metabolism, its synthesis, the way it’s transported, the way it’s excreted,” he said. Another compounding factor is that each patient is unique, he added. “The problem is issues [with prescribed medicines] don’t pop up in a linear fashion because people are complex.”

Another problem contributing to nutrient depletion is the adoption of new drug therapies as patients age because they never adequately addressed the underlying cause of their chronic condition through better health choices, meaning diet and exercise. Lavalle uses the example of “Patient Joe” to illustrate the impact the layering on of additional drug therapies can have on the patient’s total health over the course of adulthood. “Patient Joe” might start out on a statin, a proton-pump inhibitor and ace inhibitor at age 35, but if he doesn’t lose weight, quit smoking and exercise more, then he may pick up prescriptions for metformin for diabetes and/or an NSAID for osteoarthritis in five to 10 years, or a calcium channel blocker for blood pressure and/or a beta blocker for arrhythmia in another five years beyond that.

So given the complexity of the patient, the objective at any health consultation touchpoint is to evaluate what medicines a particular person is taking and the nutrients that are depleted by them. “The reality is this — people are put on medications every day,” LaValle said, and unless they present with something like a physically-evident allergic reaction “we assume that when somebody goes on a medication that it’s OK. That they’re doing fine on that medication. No big adverse event happened,” he said.

It’s important to know which medicines deplete which nutrients.
“A statin depletes Co Q-10, but it also depletes [vitamin] C, selenium and omega-3 fatty acids,” he said. “Proton-pump inhibitors we know deplete vitamin D and calcium; it’s a warning [on the drug facts label],” LaValle said. PPIs cause bone loss. “Two-in-10 cases of osteoporosis are now men. Now we’re putting men in their 30s on drugs like PPIs, and we’re keeping them on them for decades,” he noted. “Are we screening our men at 45 years when they’ve been on PPI therapy for 10 years?”

Many prescription medicines include information regarding increased risk for other disease states, such as diabetes or cardiovascular disease, LaValle said. “What they don’t tell you is ‘why?’ A lot of it is nutrient-related.”

Nutrient depletion can exacerbate underlying conditions. For example, men on statins are two times more likely to have low testosterone, LaValle noted. “Low testosterone is now a big risk factor for men as it relates to their cardiovascular risk,” he said. “So if I take their cholesterol down, but I take their testosterone [down too], that’s a big problem.”

To make testosterone, men need magnesium and zinc. To help control high blood pressure — another factor that can lead to increased cardiovascular risk — physicians may prescribe a thiazide, which depletes magnesium and zinc. So prescriptions for a statin and thiazide can lead to increased cardiovascular risk due to underlying nutrient depletions, LaValle noted.

Patients on these nutrient-depleted therapies may need to supplement with the depleted nutrients — it may not be good enough to improve diet and increase exercise, LaValle suggested. “The issue is we’re not realizing that all of the trace minerals and nutrients that people aren’t getting in their diet are what are regulating our genomic expression,” he said. “It’s not just eating right and exercise. It’s about understanding these complications when people are on medications, understanding that they’re individuals and they need individual evaluation,” LaValle noted.

“I’m passionate about the patients [with whom] I come in contact,” LaValle added. “I want to make a difference in their life and I’m going to do anything I can to convince them … into feeling a little bit better,” he said. “If you have patients who are in a polypharmacy event with multiple nutrients that have been depleted over a long period of time” then take care of them, LaValle said.

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CDC reports strong flu season

BY Michael Johnsen

The Centers for Disease Control and Prevention in early January reported a slight drop in influenza-like illnesses across the country, but even so the season was still going strong. The proportion of outpatient visits for influenza-like illness for the week ended Jan. 19 was 4.3%, above the national baseline of 2.2%.

“About halfway through [the flu season], it’s shaping up to be a worse than average season, and a bad season particularly for the elderly,” noted Tom Frieden, director of the Centers for Disease Control and Prevention during a Jan. 18 press conference. “Seasonal influenza always takes the heaviest toll on seniors when it comes to deaths, particularly during seasons when H3N2 is the predominant strain — as it is this year,” he said. “In general, we estimate that about 90% of flu-related deaths are in people 65 years and older.”

The predominant strains this year do not appear resistant to antiviral treatments. “For high-risk patients antiviral treatment really can mean the difference between a milder illness and a stay in the hospital or in the intensive care unit, or even death,” Frieden said. “The drugs clearly work much better if they’re started soon after onset of illness in the first 48 hours.”

“I also want to assure patients that Tamiflu (oseltamivir) 30-mg and 40-mg capsules remain available, and pediatric patients 1 year of age and older can be dosed correctly using the 30-mg and 40-mg capsules,” noted Food and Drug Administration commissioner Margaret Hamburg, addressing reports of shortages of pediatric antiviral medicines. “Tamiflu 75-mg capsules are currently available, but supplies may run low if many pharmacies have to use the capsules to prepare an oral suspension for pediatric patients or to fill large numbers of prescriptions for adult patients. So to help avoid a shortage, the FDA is now allowing Genentech to distribute 2 million units of Tamiflu at the 75-mg capsule level that have an older version of the package insert. … It’s important to note that this medicine is fully approved. It is not outdated.”

The high incidence of flu has prompted a run on available immunizations. According to Frieden, flu shot manufacturers had allotted for distribution of up to 145 million doses this season. As of Jan. 18, 129 million of those doses had been distributed, meaning some 14 million vaccinations had yet to be ordered.

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