If you're connected to the healthcare industry, you've likely been spending a lot of time this year thinking about what the future might look like, and probably imagining that it might look a bit different than what we've become accustomed to. As part of our efforts to address this issue, EUA recently hosted a virtual presentation and discussion with the Advisory Board. Our third in 2020, this installment was entitled, "Planning for Future Outpatient Shifts." Guiding our discussion was Miriam Sznycer-Taub, a Senior Consultant with Advisory Board's Health Care Industry Committee. Miriam discussed three major categories of shift opportunities and posed a question to the group at the end of each section.
Even pre-COVID-19, we have seen patient volumes shifting away from the hospital and into the outpatient setting. Forces driving this trend include appropriate use scrutiny, site of service payment leveling by public and private payers, payer steerage in the form of price transparency and incentives and the increase in procedure types allowed in ASCs (ambulatory surgery centers). In particular, the addition of PCI (percutaneous coronary intervention) to the allowable list for ASCs could be a game-changer for Cardiovascular services. Similarly, THA (total hip arthroplasty) may soon follow TKA (total knee arthroplasty) in being added to the CMS list of procedures approved for ASCs.
Of course, ASCs are attractive to consumers of elective procedures due to their typically lower cost, greater accessibility and shorter wait times when compared to hospitals. COVID-19 has likely increased this attraction by providing at least a perception of decreased risk of exposure and/or infection. In addition, drive-through options have been added by many providers for services such as warfarin clinics and simple blood tests. Longer term, the potential elimination of the IPO (Inpatient Only) list by CMS by 2024 could cement the notion that only the most acute, highest-risk patients should be seen in the hospital, while any patient who could be seen in an outpatient setting will be.
Discussion question #1: What will be the most significant impact of the continued outpatient shift for facility needs?
1. Acute care hospitals care for fewer patients but will see higher acuity
2. Outpatient facilities will need to accommodate patients with wider acuity levels
3. Demand for multi-specialty outpatient buildings with surgery facilities will grow
4. Something else?
All of these are happening and appear likely to continue; however, based on my recent experience as well as future outlook, my feeling is that #3 will have the biggest impact on the healthcare facility landscape.
Home Health Shift
Another shift that has been accelerated by the COVID-19 pandemic is care in the home. Patients feel safer at home during the pandemic, and in many cases have been ordered to remain there. They have experienced the convenience of receiving care at home, just as they have in many other aspects of their lives, and they have gotten more comfortable with telecommunication and remote monitoring technologies. However, a number of practical barriers remain.
Discussion question #2: Which barrier(s) do you think will pose the largest challenges to care shifting to home?
1. Clinical limitations such as the need for 24/7 support or access to high-licensure staff
2. Environmental constraints such as stairs or other obstacles in the home
3. Reimbursement barriers
4. Patient/family challenges such as limited health literacy or lack of a caregiver at home
Here again, my personal vote was for #3 since reimbursement seems like the most challenging problem to solve given the many stakeholders with competing interests.
Virtual Care Shift
Telehealth adoption has increased enormously this year. Real-time virtual interactions between patients and providers, remote physiological monitoring, and asynchronous messaging have all been used to implement and maintain treatment plans while minimizing in-person contact.
Discussion question #3: How do you think telehealth will impact the need for clinical space?
1. Providers will need more clinical space
2. Providers will need less clinical space
3. The amount of space won’t change, but providers might need to restructure what they have
I went for a perfect three for three on answer #3. Although there are good arguments for the first two possibilities, we know that financial pressures will likely make increasing space a challenge. Also, history has shown that even with increased efficiency driving toward smaller footprints, countervailing forces such as accommodations for bariatric patients have made this a risky bet.
As we have seen, site-of-care shifts are well under way and will likely continue. It is important to recognize, however, that capitalizing on this trend will require more than simply reacting to patient preferences. Physician comfort level, clinical feasibility and risk management, payment structures and regulations will also play an important role. If we can understand these forces, we can optimize our approach for our organizations.
I’d love to hear from you, what are your thoughts on site-of-care shifts in the near and medium term? Do you agree with my predictions?