Guest Editorial: The Outpatient Conundrum

    In most healthcare systems, the number of outpatient hospital visits continues to increase.

At the University of Virginia Health System, we see nearly 600,000 outpatients each year in more than 100 clinic sites. Despite the fact that HMOs that utilize a PCP gatekeeper failed to penetrate this market and many others, the shift toward the outpatient arena predicted years ago has been realized. Unfortunately, this shift toward outpatient care has not resulted in patients being less sick. Quite the contrary, the care delivered in outpatient settings is often intensive as well as multidisciplinary. It is not uncommon for a patient to see several physicians in one visit to the outpatient areas or to be seen by any number of support staff — including nutritionists, psychologists, occupational therapists — in the same location. This creates a number of challenges for healthcare providers.

    One consideration is that many payors have difficulty recognizing the myriad of services provided to the patient in a single visit and seem to incentivize the system to schedule multiple visits rather than just one. However, facilities often are not equipped to accommodate large groups of multidisciplinary providers, including residents and fellows, in a single exam room along with the patient and his/her extended family. Plus, as reimbursement levels continue to fail to keep pace with inflation, providers are encouraged to see as many patients as possible in a clinic session — but multidisciplinary visits with chronically ill patients take more time.

    The hurdle for clinicians, particularly in the outpatient arena, is providing quality healthcare in a safe and effective manner that meets the needs of an increasingly well-educated patient population. A number of strategies are being implemented across the healthcare continuum. For example, nurse practitioners are now seeing patients either before their initial visit with the physician or after surgery for their post-op visit. Some physician extenders even manage their own patient loads with oversight by their physician colleagues. This model is particularly useful in clinics where patient education is central, such as for patients needing coumadin or diabetes education.

    In addition, technology now allows patients to retrieve their lab results by phone, view parts of their medical record online, or schedule their own follow-up appointments. Although they may increase the productivity of healthcare providers, such advancements underscore the need for a system of checks and balances to ensure that we do not over-rely on technology to the detriment of face-to-face interaction and dialogue.

    In 2003, Medicare covered 41 million people, including 35 million Americans age 65 years and older and 6 million people with disabilities or end-stage renal disease below age 65 years. Spending totaled $280.8 billion or 2.6% of the gross domestic product. As baby boomers continue to age and Medicare benefits are enhanced, these numbers will continue to rise.

    Finding innovative ways to treat patients in the outpatient setting is essential. However, we must be certain that the care we provide is medically appropriate and safe and protects the relationship carefully crafted between patient and caregiver.