After-hours care doesn’t have to drain practice’s finances

It is possible for primary care physicians to provide patients access to care 24 hours a day, seven days a week without superhuman powers of endurance and a huge budget. In a report published in June, researchers with the Center for Studying Health System Change advised physicians on how to make after-hours care a part of their strategy to better coordinate care and improve access for patients.

The study, posted online on the website of the Journal of General Internal Medicine, interviewed 28 practices and categorized strategies into five models: offer round-the-clock access to the patients’ physician, rotate call among partner physicians, share call with a network of local physicians, contract with an affiliated urgent-care center, and own an urgent care center.

Researchers approached the issue of after-hours care with the limitations of the current health care system in mind, said co-author Ann O’Malley, MD, MPH, a senior health researcher with the Center for Studying Health System Change.

“The payment for after-hours care is not always sufficient for the overhead required on the part of the practice, and the additional hours people might have to work,” she said. “There isn’t a lot of financial support for after-hours care.”

But on the other hand, as the fee-for-service system falls out of favor and is replaced by global payments or pay-for-performance, physicians who don’t have a plan to provide after-hours care risk leaving payments on the table, researchers said.

Marci Nielsen, PhD, MPH, is executive director of the Patient-Centered Primary Care Collaborative, a group of employers, insurers, health systems and medical associations that offers support to practices that are working toward or maintaining certification as patient-centered medical homes.

To qualify as a patient-centered medical home, Dr. Nielsen said, physicians have to establish “superb access to care.”

“It’s broader than just having an answering service pick up the phone,” she said.

But Dr. Nielsen said after-hours care also shouldn’t mean having the physician on call or in the office around the clock.

“When we ask the doctor to be doing everything, in many ways it’s a recipe for disaster,” she said. “They’re already so stressed.”

Delegating after-hours call to nurses has worked well for primary care physicians at the Houston-based Kelsey-Seybold Clinic. Twenty years ago, when it was much smaller, primary care physicians took turns taking call on weeknights and weekends.

Patrick Carter, MD, did not remember those days fondly. He is chair of department of family medicine and medical director for care coordination and quality improvement for the clinic. In the early years, the physician on call could count on being up all night, he said. It wasn’t working well for physicians or patients.

“Frankly, when a doc is being paged constantly at 2 o’clock in the morning, we’re not on our best behavior.”

In 1997, Kelsey-Seybold started using some of its nurses to staff an after-hours help line and, more recently, the clinic has begun offering online access to patients who want to make appointments or even have an electronic visit with a physician.

Dr. Carter said he realized that for smaller practices, it could be too costly to establish and staff a nurse call-in line, but he suggested pooling resources could make that more manageable.

Drs. Nielsen and O’Malley said that making after-hours access part of a strategy of overall improved availability along with the other elements of a medical home can end up saving money and actually decrease the demand for care outside of office hours.

Part of the plan for after-hours care should be about working as a team with emergency department physicians, said Ryan Stanton, MD, an emergency physician, spokesman for the American College of Emergency Physicians and medical director at the University of Kentucky’s Good Samaritan Hospital in Lexington. Better access to primary care can cut down on the emergency department visits that aren’t true emergencies, he said.

“The better access people have to primary care, the better communication we have with primary care, the better the care is going to be overall,” he said.