Theory #2: nextHospitals must provide primary care–*on site*

Conventional wisdom breaks the healthcare system into two big silos.

There’s acute-care hospitals, which tend the acutely ill, and there’s primary care providers, which handle the sniffles,  hives, chronic disease management and anything else that isn’t likely to kill a patient within a few hours.  In between, there’s a big black hole where patients pretty much sit around feeling like hell and wondering just how much worse things are going to get.

This bifurcation is absolutely insane and has got to end.  It makes an assumption which is absolutely counterintuitive–in fact, which is simply crazy–which is that hospitals have no business treating anyone who isn’t at death’s door.  The nextHospital has to completely shatter this assumption by providing appropriate care, from throat cultures to the crash cart, for anyone who shows up at its door.  

Not only is the only sane, humane and appropriate way to treat the human beings who enter your doors, it’s the cheapest way to treat those who don’t need intensive services; after all, an all-night walk in clinic is almost 50 percent cheaper than ED care! Kinda sounds like a good idea, doesn’t it?

What makes hospitals’ failure to offer step down care even more foolsh is that all they’d have to do is invite Walgreens or CVS to bring in one of their TakeCare or MinuteClinics, which I’m pretty darned sure they’d be happy to do. No fuss, no muss, virtually no overhead. Everyone wins. Explain to me why this isn’t a good idea?

The current system assumes that if the healthcare system is falling apart, it’s all the fault  of nughty patients who come to an emergency department and somehow don’t know that they aren’t that sick after all.  Remember, the learned papers that castigate patients who show up in the ED and somehow fail to need lifesaving treatment aren’t any kinder to those who simply overestimated their acuity than those who use the ED as a primary care center.

Now, I’m not suggesting that primary care physicians shouldn’t exist, and that hospitals should take over their place in the community. But I am suggesting that hospitals accept their role as caring for people, not emergencies, and govern themselves accordingly.  It’s more efficient, it’s more effective, and it’s more appropriate.  Anything else just wastes time and money, while scaring away patients who need your help.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.


  • I could not agree more! People need one point of reference. Separating out emergencies as “favorite children” has created a very expensive system. People need answers. Yes, many medical items seem like an emergency to a family. And it is better to err on the side of caution but what can the medical system do to make this more accessible and more cost effective.

    There are probably a myriad of ways to put in place accessible care, one method I would encourage is higher exposure for the nurse practitioner.

    Nurse practitioners know when to refer to a physician – I don’t wish to learn. I want the professional to handle that decision for me.

    Same day surgeries are wonderful and great step in the right direction so far but we need to be careful not to eliminate the “care” for the individual.

    I try to follow a 4 hour rule – if my pain is severe where I am not functional for 4 hours, I make a phone call to an expert. Unfortunately, it is nurse / doctor friends not a designated person with my primary care physician. I really need a place to call easily, easily stop in before I in frustration declare the pain a full emergency.

    Great discussion – thank you for initiating!

    Kelly Kline Engaldo

  • For years hospitals have provided those 24 hour/7 day/week clinic approaches that we called “urgent care” – that is not a viable hospital model. As for having a CVS come in…well, I wonder how ready they would be to do that because their biggest boon to having a minute clinic on site is the pharmacy purchase. Are they willing to give that up? Would they set up shop with not fee to a hospital? Who would Joint Commission say was liable for the care? Who would the state say was liable for the care? Who monitors the quality?

    Sounds like a great and simple idea – yet…the complications are so overwhelming. Would love to hear thoughts from others.

  • I do not agree. You describe a health system from US as if it was the only health system. It is quite different all over the world – primary from a cultural POV and secondly from a political view – what do politicans think are “patients” minimal needs. Do “patients” need highly qualified health care providers 24/7 or can some “patients” wait untill the qualified doctor/nurse/dentist and so on happens to be available. In other words: visitation. A top trained visitator can be the bifurcation that solves the problem: who needs care from whom when.

  • I think hospitals do take other people in, but there is channel for that which goes throuhg primary care, and then may be to specialist and then to hospitals. Looking into the model of hospitals, they can be more taken as a place where you go when you need equiments and a place. If you do not need to be admitted, you pretty much end up at the clinic of the specialists.

    Most of the doctors do not work for the hospitals, they have their own clinics and work parttime for several facilities.

    I have not yet figured it our why ERs are so expensive. Afterall, where you go for a scheduled visit or not, you have a person dealing with you. You have the same equipments, etc. So where does the big cost differentiator comes from?

    Nice topic…good discussion


  • In a way, this is already happening. A lot of hospitals these days are buying up urgent care centers and physician practices (to increase patient throughput). Though it may not be in the hospital, it is still part of the hospital. I don’t think a hospital needs to provide 24/7 care in a hospital, they can do it in other out patient clinics such as the urgent care center. Unfortunately for the patient, the hospital may not advertise that because they get increased payments for treating them at the ER.

  • One problem with the premise is that you are talking about “hospitals”. Primary care has always been the venue of the GP or Family Practice doctors (except where they have failed to serve a community and were replaced with public clinics or neighborhood health clinics. Hospitals have had to carefull craft their relationships with their primary care physicians. They and the specialists affiliated with the hospital depend upon the private practice primary care docs for referals. Some hospitals have invested in buying or setting up primary care docs in practice to build this service in the community. Some of these moves have alienated other “non-alighed” primary care docs and resulted in significant medical staff battles.
    I even know some pediatric hospitals whichhave refrained from offering “daytime” urgent care to avoid the conflict with urgent care opening in the evenings and night and not encouraging continued use.

    Why aren’t the primary care docs cutting off more of the flow from inappropriate use of the ED ? Money. In maany places, reimburseemnt for primary care patients on medicaid or SCHIP or even Medicare is considered too low and the doctors have refused those patients in their practice above a certain level, leaving the patient no where else to go.

  • How are those retail clinics working out for the folks investing the money?
    [Not well according to my reading]

    Primary Care is more than colds and coughs…that’s urgent care

    Comprehensive Mangement and solutions are the domain of Primary Care and hospitals do what they do and have never managed to do Physicans well much less primary care well

  • I miss the days of urgent care clinics. They filled a much needed void in healthcare, but as you said, they were not a viable hospital model. The idea of leasing out hospital space to a Walgreen’s Take Care Clinic is brilliant and is really based on the successful department store model — Macy’s is thriving, in part, because all of their cosmetics counters (and even some other departments) are leased out and run by specialists. In the case of hospitals, Walgreen’s has a toehold because they run pharmacy operations in lots of hospitals already. It makes sense that liability falls to the “lease-holder” and service-provider — Walgreen’s already assumes that with their current clinics and it would be no different. Accountability for quality is also inherent in their system: Walgreen’s is a bigger brand to protect than the brand of a local hospital. And remember, too, we are talking about care for the sniffles and ear infections and flu shots — simple care for the kinds of things that help keep people on the job and in schools. If quick, easy access to care is available, fewer will find themselves going through hospital doors for ER visits. Seems like a simple win-win to me –love it!

  • The problem with the Walgreens or CVS approach to primary care is that is ignores one of the most criitical tenents – continuity. This really encourages people to not establish a relationship with a medical home, just to buy medical attention “retail” without structure for follow-up. It is almost like “avoiding” the medical relationsihp to get quick “cheap” attention. Okay for colds, but not for chronic or life-threatening life-style problems – high blood pressure, diabetes, obesity, etc.
    And currently, providers are avoiding the health management approach because reimbursement is still focused on paying and encouraging episodic care. Until the incentives are changed and providers (doctor and hospitals) are ready to commit resources and organization to continuity and health maangement, the episodic retail model is leading in the wrong direction and encourageing/enabling misuse by the consumer.

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