I was at dinner with friends recently when I noticed that my right thumb was red, swollen and painful.  One of my friends is a biochemist and instructed me to immediately soak the finger in hot water.  I continued our social evening dipping my right thumb in and out of a cup of boiling water.

Early the next morning (Sunday) I called my primary care practice, looking for the on-call physician. Luckily, my doctor of 40 years was on call. He immediately requested that I send him a photo of the thumb and he prescribed a strong oral antibiotic. I had a staph infection.  He informed me that I should continue the soaks, apply a topical antibiotic and send photos to him via email every couple of hours.  If the infection started to spread. I would have to go into the hospital for intravenous antibiotic treatment. Over the next two days the doctor continued to monitor the finger with photos sent via email. The oral prescription worked and I avoided a hospital/ER visit which saved me, and the healthcare system, time and money.

Not everyone is fortunate enough to have a primary care physician reachable on nights and weekends. So what do you do when you have a sick baby who wakes up with fever and cough in the middle of the night?  When your elderly parent falls and twists an ankle on the weekend?  When your athletic son is injured at the Saturday morning soccer game? When you burn yourself cooking in the off hours? What do you do for countless less-than emergency situations, but situations, nevertheless, that require medical attention.  Your choices are to find medical assistance at a retail clinic, an urgent care clinic, or an online website. Your other choice is to go to the Emergency Room.

Access to a primary care physician is going to get more difficult in 2016 and beyond. According to the Department of Health and Human Services, nearly 67 million people in the United States live in a primary care shortage area. For Americans who have a regular physician, only 57% report having access to same or next-day appointments; 63% have difficulty getting access to care on nights, weekends or holidays without going to the emergency room. Over 20% of adults reported waiting six days or more to see a doctor when they were sick.

The Association of American Medical Colleges predicts that the shortfall of doctors who are graduating from medical schools and who will go into general/family practice could be as high as 90,000 doctors by 2020. With total physician demand projected to grow by up to 17 percent as baby boomers age and the Affordable Care Act universal coverage mandates are implemented, primary care doctors, in particular, are in short supply. The report estimates that between 12,500 and 31,000 primary care doctors that do not exist will be needed. As a result, patients must look to alternative options for basic sudden semi-emergency and routine medical care services.

Retail Clinics

Currently, according to a study conducted by the United Hospital Fund and the New York State Health Foundation, there are over 1,800 retail clinics, receiving more than 6 million visits annually. Most (70 percent) are owned by pharmacies or big-box retailers. These clinics rely on lower-cost providers, nurse practitioners and physician assistants, who offer services for specific minor acute conditions. Many are now expanding their scope to include management of chronic illness. The client base of these walk-in centers is primarily young adults (ages 18-44) and people without a basic healthcare provider.

Several trends are driving the expansion of health care retail clinics.  Most people are able to just walk right in and find help.  Appointments called in are guaranteed. When the patient arrives at a retail clinic, they sit down at a kiosk and choose their problem from the clinic’s menu of common complaints: bronchitis, ear infections, strep throat, etc. Many clinics also offer services such as childhood and adult vaccinations, pregnancy tests, and seasonal items such as flu shots and school and camp physical exams. There are set prices for all of these services, displayed at the clinic’s entrance. Most consultations take less than 15 minutes.

Retail clinics also offer a level of continuity and coordination of care.  When you visit a retail clinic, the provider will create an electronic record of the visit that includes a basic health history that you supply. After your treatment, you receive a printout of the results of your physical exam, your vital signs such as blood pressure, any in-clinic treatment you received, and any medications prescribed. The clinics will always send a record of the visit to your primary care physician and your insurance company, at your request.  Most clinics accept your health insurance. For the uninsured, the clinics offer basic preventive and acute care at prices lower than those incurred in the ER or in urgent care clinics. Retail clinics also keep their costs down by limiting their services and their space. Exam rooms are about the size of a walk-in closet in most places. They do not offer large diagnostic machines such as X-ray ultrasound, MRIs or CAT scans.

Urgent Care Centers

Urgent care centers generally treat patients with more acute conditions, with an emphasis on episodic illness and minor trauma. Nearly all urgent care clinics provide simple lab tests. Most offer basic x-ray services. Nationally, an estimated 9,000 urgent care centers receive some 160 million visits annually.
Ownership of urgent care clinics is divided among physicians/physician groups (35 percent), corporations (30 percent), hospitals (25 percent), and non-physician individuals or franchisers (7 percent). Nearly all centers have at least one physician on staff, (three-quarters of them board-certified), most often in family medicine. Patients generally have expressed satisfaction with the convenience of urgent care centers because an appointment is not required and a visit usually takes less than an hour.

At both urgent care centers and retail clinics. nurse practitioners and physician assistants serve as the basic health care providers. Wait times are short and your health plan generally will pay for the visit, and with a lower co-payment than you would pay in your doctor’s office or in the ER. Some health plans now list the fees on members’ insurance cards to highlight the difference.

Online Websites

There are many iterations of websites that offer users online, 24/7 access to board certified doctors who consult with you via a mobile device, tablet or computer.   The average cost is $50. Many of the online sites require a membership either through an employer or an insurer, others are direct to consumer.  As always the caution, particularly online, is to understand the quality of the care you are receiving.

Teladoc is one such online website that has 2,650 Board certified physicians and behavioral specialists and is available to members who come through the Teladoc network of employers and insurers.  They have been in business for 13 years and in 2015 handled over 550,000 consults via video, audio and with online images

Ask a doctor is a website where you can pose a question to a panel of doctors and receive an answer within minutes.   Basic quick questions are free of charge and more complicated questions are $29 per answer.

American Well is another 24/7 online website that provides services through employers and insurers and direct to consumer, for a number of one-off care issues like colds, and infections, or longer term chronic conditions such as diabetes or depression. A patient choosing Amwell can be connected to a board-certified doctor of their choosing in just minutes for a visit carried out over smartphone, tablet, kiosk, phone, or desktop.

The increasing numbers of senior citizens with multiple health issues; the scarcity of primary care physicians; the increasing cost of health services with higher percentages borne by the patient; the pressures of time and convenience are pushing patients to embrace alternative options. This is reinforced by payers including Medicare and Medicaid, who used to refuse to cover anything that was not a part of a traditional healthcare visit with a doctor.

Going into 2016, it is a brave new world in healthcare where technology plays a major role, making it easier for patients to engage and access many variations of care that resolve their health issues as quickly and inexpensively as possible.

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