Thought Leadership Healthquake™: Access Wars in Healthcare

Fellow Health Partners CEO Michael N. Brown and Advisory Board Member Philip Schrank M.D. explore a new paradigm developing within the universe of the Patient/Provider experience, and how healthcare providers and organizations are responding to compete for market share.

Healthcare facilities, including both hospital-based and private practice entities, have traditionally been slow to embrace change. For decades, patients had no choice but to endure an archaic system in order to make appointments. They would make a phone call and often play a game of “phone tag” with the office before an appointment was secured, since a return call would usually occur between 9am and 5pm, when many patients were working. When they finally were able to make an appointment, the date would usually be 4 weeks in the future at a time that would inevitably conflict with their work schedule. If the patient said it was urgent, they would be referred to the Emergency Room. The ER would then say that there was nothing they could do – because it wasn’t really an emergency – and just refer them back to the doctor’s office.

The world has dramatically changed in the last 15 years and patient expectations have changed along with it. In a culture where you can order groceries, book a plane ticket and schedule an electrician to come to your house online in under 10 minutes, patients are no longer tolerant of the previous status quo. The new patient expectation is to be able to see a healthcare professional the same day, including evenings and weekends. Because healthcare dollars were so abundant in the past, healthcare providers were empowered to stand together and not respond to this demand. However, as payor reimbursements have not kept pace with inflation, and the number and type of health care providers has expanded, there are no longer enough patients to go around. As a result, healthcare providers are now actively competing with one another for patients, forcing them to improve patient access to care.

Many of these transitions in patient access have taken place concurrently. Consider these relatively recent changes to the healthcare industry landscape:

  1. Expanded Office Hours: Providers are offering office hours on nights and/or weekends. Practices will hire new providers specifically to work these off-hour shifts.
  2. 24/7 Care: Urgent Care Centers have popped up everywhere to combat long wait times at emergency rooms, and the lack of available appointments in physician offices.
  3. Pharmacy Health Care Clinics: CVS and Walgreens, among others, offer limited patient care services like administration of vaccines, and treatment of minor illnesses and injuries.
  4. Patient Portals and Apps: The almost-universal adoption of Electronic Medical Records (EMRs) allowed for the development of online portals and mobile applications, enabling patients to obtain medical appointments and records, and communicate with their healthcare providers using their phones and computers.

The above list is by no means comprehensive. Virtually every day, healthcare systems, insurance companies, and physician practices are battling each other to devise new and better ways to allow patients near-immediate access to care. Even Amazon is looking to capture a portion of the healthcare pie, acquiring One Medical in February 2023. This will undoubtedly disrupt the healthcare market anew. Let the new era of access wars begin!

As Dr. Schrank recalls, “While in medical school at Georgetown University, I was taught that the recipe for success in a physician practice was to follow the “3 As”: Availability, Affability, and Ability…in that order. How true that adage has proven to be! The access wars not only reflect it, but reinforce it. Most patients will state that availability is, by far, their number one concern. Over the years I have had many patients come to me for a second opinion after a failed orthopedic procedure. Part of my medical history protocol was to ask them who performed their surgery. Their response commonly included, “I tried to get to you, but the wait for an appointment was too long so I went to another doctor.” The implied statement was, “I know that you might have been the better doctor, but it was more important for me to see someone sooner.” For better or for worse, we now live in a world of instant gratification, and as healthcare providers we have no choice but to adapt, or perish.”

The challenge for healthcare providers of today is how to provide the highest level of care in the least amount of time while maximizing reimbursement, keeping costs as low as possible, and minimizing medicolegal risk. If you think that sounds difficult, that’s because it is. But if you change your perspective to focus on patient satisfaction as the top priority, then the roadmap becomes clear: Improving access to care is your number one job.

Well, one could imagine that getting patients in the door is easy. If Physicians and Patients were the only stakeholders in healthcare, perhaps that would be the case. But in today’s world, the major stakeholders in healthcare now include the government, hospital organizations, insurance companies, private equity companies, pharmaceutical companies, medical device companies, and a host of competing healthcare provider types such as nurse practitioners, physician assistants, physical therapists, and wellness providers – just to name a few. All these entities are either vying for share of the patient’s healthcare expenditures and directly marketing to patients to get them to walk into their door, or they are looking for ways to reduce patient access to care because it is in their financial favor to do so.

The motivation and behaviors of the different stakeholders are determined by where they sit at the table of healthcare.

In the access wars, insurance companies and the government sit at the two heads of the table – and want to limit your access to certain types of care.

If you are a health insurance carrier, your sole source of revenue is member insurance premiums. The name of the game is to attract the greatest amount of members while spending the least amount of money on reimbursements and administrative costs. Insurers will entice members by demonstrating access to a wide array of providers and ancillary services. However, once you pay your premiums, it is in their best financial interest to restrict your access to care because the fewer medical services you use, the more money they get to keep. Insurance carriers aggressively negotiate with physicians and hospitals to pay the least amount possible for any services that you may need. Additionally, they institute a cadre of barriers to prevent you from seeing clinicians or having tests performed. These barriers include the need for referrals, prior authorization requirements to perform tests and surgeries, and high deductible plans that may discourage patients from choosing care when it results in further out-of-pocket expenses.

If you are the government, you are focused on the overall population’s health, with a laser-focus on preventative healthcare. Encouraging people to engage in healthy behaviors like exercise, proper diet, lack of smoking and drug use would ideally reduce use of the healthcare system as a whole, thereby lowering overall cost to society. Of course the government, like everyone else, wants the biggest bang for their buck. They would rather spend $30,000 to vaccinate 3000 children for measles and mumps than perform one spine fusion on a 75-year-old man for the same $30,000. The government limits the more expensive items by making the documentation of medical necessity more and more difficult for these procedures. While some may argue that the government limits access to healthcare in detrimental ways, the one inarguable positive is that everyone in society has access to SOME healthcare.

The balance of stakeholders are seated in different positions around the table of healthcare, and for the most part, are looking to boost patient access.

If you are a hospital organization, patient volume drives everything because you get paid based on how much care you provide. Most services are “Fee for Service”- meaning the more services you provide, the more you get paid. The hospital is usually the most expensive place to provide healthcare services, so it makes the most sense to perform big-ticket items, such as spine surgeries and open-heart surgeries, in a hospital setting. Other services, such as total hip and total knee replacements, are usually paid as a “bundled payment.” That means that the hospital gets one lump sum payment for the surgery in addition to any associated care including hospital stay, physician services, and physical therapy. This is supposed to incentivize the hospital to spend less money on each case and make patient care more efficient. In reality, bundled payments unintentionally incentivize the hospital to do as many surgeries as possible on the healthiest patients. As a hospital, you are now put in a position to have less interest in caring for complicated sick patients because they cost more to care for. Additionally, the hospital wants patients to come directly to them so they can refer you to physicians and services that they themselves own – thereby controlling your healthcare dollars and increasing their organization’s revenue.

Physicians, nurse practitioners, and physician assistants will sometimes compete with one another for patients, but in general all three of these groups want patients to get as much access as possible to all types of care. Much like hospitals, these clinicians are generally reimbursed on a Fee-For-Service model. Even if they are salaried practitioners, their salary will ultimately be determined by how many patients they see and how much revenue they generate. It is also worth noting that they get paid more for new patient visits than they do for follow-up visits. So, these clinicians want to attract as many new patients as possible, solve their issues quickly, and make room for more new patients. From a clinician viewpoint, the more access to healthcare for patients the better. Keep them coming.

Pharmaceutical companies and medical device companies obviously have skin in the game as well. They aggressively market directly to patients to encourage them to ask their clinician to use their marketed products. They establish relationships with physicians as well to ensure they offer their products regularly. If a consumer were to call the drug and implant companies directly, the company can usually facilitate more rapid and convenient appointments, utilizing their physician relationships. But as one would imagine, this all puts pressure on the physician to recommend the use of their product. This demonstrates how valuable controlling patient access to care can be.

In some states, Physical Therapists can treat patients without a prescription for a certain number of visits. As a result, they too have entered the access wars. They generally provide excellent access to services because their hours of operation are usually more patient-friendly than physician offices, and they are motivated to exhaust non-medical treatment before referring a patient to medical clinicians. It is important to note that Physical Therapists will tend to refer patients to clinicians that likewise refer patients back to them, if and when further physical therapy services are needed – essentially an access trade.

Often used as an umbrella term, Wellness Providers come in many forms, both licensed and unlicensed. These providers include chiropractors, acupuncturists, massage therapists, personal trainers, and nutritionists – the list goes on. Together and separately they can provide a wide array of both preventative and interventional treatments, and have attained a valuable status on the modern-day healthcare spectrum. In a combined fashion they provide a massive amount of healthcare access for patients, almost all of which are paid on a Fee-for-Service basis either through insurance or out-of-pocket expense. Their motivation is all-access, all the time.

The key component conspicuously missing in this discussion of patient access is quality of care. All patients should be asking themselves, “Is it worth it to have immediate access over quality access?” As Dr. Schrank recalls in his years as a practicing orthopedic subspecialist, “I had to address missteps in care from urgent care centers, emergency rooms, physical therapists, nurse practitioners, physician assistants, primary care physicians, and other non-specialized orthopedic surgeons. From a patient standpoint, they had to go through unnecessary or unsuccessful tests and treatments which in most cases has delayed their healing. While I would certainly agree that most conditions do not need subspecialty care, it is often difficult to determine which ones do even from a physician perspective. These unsuccessful treatments ultimately lead to higher cost of healthcare for an episode of care. This will lead to higher insurance premiums and further rationing of care. Sometimes saving money on a more rapid lower level of care on the front end can end up costing way more on the back end”.

While competition for patients is currently driven almost exclusively by economics, it is undeniable that which door patients choose will ultimately determine their course of treatment, their clinical outcomes, and cost.

Now that we have reviewed the patient access landscape, it is time to delve into solutions. From the patient perspective, the ideal situation is near-immediate access to subspecialty care any day of the year. This scenario is actually starting to materialize, in a few different ways:

  1. One-Stop Shopping: Large healthcare systems are acquiring great numbers of clinicians and combining them with wellness providers under one umbrella. The allows patients to easily be transferred through complicated systems no matter which access point they enter from. They offer walk-in hours at physical therapy and physician offices, urgent care centers, and emergency rooms – all of which serve as access points for the patient to utilize the system’s greater services. These systems are in many cases still working out their integration kinks, but potentially offer patients comprehensive access to all specialties.
  2. Mid-Level Providers: More frequent use of Physician Assistants (PAs) and Nurse Practitioners (NPs) broaden the access footprint. With proper training, these providers can handle a great deal of both primary care and subspecialty issues with a high degree of quality. The key element for success in this scenario is a) Understanding how to bill properly for PAs and NPs, and b) Proper experience and training, including close corroboration with partner physicians. This allows all clinicians to practice at the highest level of their training, in tandem.
  3. Telehealth: Naturally, the COVID-19 pandemic greatly increased utilization of telehealth encounters. Close attention and adherence to government and insurance payors’ telehealth policies will be essential to make this a financially viable option for quality patient care going forward.
  4. Concierge Services: Business-minded providers are now offering membership-based primary care that allows convenient, 24/7 premium access using a direct-pay model. While it cuts out the administrative burden of dealing with insurance companies, patients receive this care at a hefty out-of-pocket price tag.

Looking forward, it seems inevitable that Artificial Intelligence (AI) will be the lynchpin to revolutionize the future of patient care. AI has the potential to assist with diagnosis and treatment, patient monitoring, administrative tasks, and more. While controversial, the potential benefits of this technology to the healthcare industry appear almost limitless.

I think by now it is clear – the patient access wars are raging. Access for the sake of access – while ignoring quality – may have significant consequences for patients, and the healthcare system as a whole. Understanding the motivation of all these different entities is vital to navigate the healthcare battlefield, whether you are a patient or clinician. The wars are on. Stay alert, and stay tuned for more.