WHAT PROVIDER OPTION ACHIEVES QSA OPTIMIZATION?

Once you've considered the urgency of treatment need and the insurance and financial situation, it's time to examine which care setting, or settings, might offer you the right balance of high quality care, enjoyable patient experience, and affordability given your particular circumstances. The possibilities of your particular care need are limitless, so we're going to approach this by laying out provider types and discussing when each may be a good option. Hopefully this translates to most care needs, and if not, let us know by utilizing the Contact Us page, and we'll try to update the information as appropriate.

Emergency Rooms (ER)

As we discuss in multiple sections, an emergency room is the right and only option if you've sustained a very serious or life-threatening injury or you believe that you may be suffering from an illness or condition that requires immediate attention and the resources and breadth of expertise that a hospital can provide. In general, ER's should not be utilized for minor illnesses or injuries that could be handled by a primary care provider or urgent care center. Each individual's opinion of what constitutes an emergency or a "very serious" condition is probably different, so if you are unsure, we would suggest erring on the side of caution and utilizing the ER. Emergency rooms are generally the highest cost option for immediate care and are available to insured and uninsured individuals; however, insured individuals should know what hospitals are included in their plan's provider network, and uninsured and underinsured individuals should be aware of FQHC's and safety-net hospitals in their area. The patient service you'll experience in an ER can vary greatly depending on what condition you present with and how busy the ER happens to be at any given time. Maybe the biggest advantage of an ER is the quality of care that they are able to provide, including treatment of life-threatening emergencies, and the resources and broad treatment options that they and their associated hospitals can provide.

Primary Care Providers (PCP)

Primary care physicians and other providers that offer primary care services, such as nurse practitioners and physician assistants, serve a very important purpose in healthcare delivery. PCP's should be utilized as a first point of contact when you have a nonurgent and undiagnosed medical condition, and we strongly suggest selecting a PCP and utilizing him or her on an ongoing basis. Utilizing urgent care and retail centers for primary care services can be a good option in certain circumstances, but not having a PCP that contiuously follows your care can lead to disjointed care and make it difficult to track your health history. Most PCP's require an appointment for a visit. Insured patients can choose any PCP that is in their plan's provider network and is accepting new patients. For uninsured and underinsured individuals, FQHC's (please see below) offer primary care services at discounted rates. Primary care is normally the most affordable care option, and part of the Affordable Care Act requires that health insurance plans cover certain preventive services offered by PCP's at no extra cost to the patient. Most PCP's offer favorable patient service including timely access to appointments and a personal relationship with the provider. PCP quality can sometimes be hard to assess especially in small practices, but there are resources available to research a physician's education and board-certification status, and if you're not happy with your PCP, you can choose another one.

Urgent Care Centers

Urgent care centers accept walk-ins and offer primary care services for illnesses and injuries that require immediate attention but are generally not serious enough to require an emergency room visit, such as minor cuts that may require stitches or a suspected simple bone fracture. Urgent cares can also be utilized for primary care services and prescriptions if you do not have a PCP or visit the doctor rarely. Urgent care centers generally accept all major health insurance carriers and usually offer discounted self-pay rates for uninsured individuals. Urgent cares are significantly more affordable than emergency rooms, and we recommend utilizing them as opposed to an ER when appropriate. However, unlike ER's and FQHC's, urgent care centers are not required to treat you regardless of your ability to pay, so you should be prepared to present an insurance card or pay for services yourself. Service is generally favorable at urgent care centers as compared to emergency rooms, and urgent care accrediting bodies exist that you can use to assess quality.

Specialists

Even though many health insurers now allow patients to refer themselves to a specialist, the majority of patients who visit a specialist still arrive via a referral from their PCP or another provider. This is generally the appropriate process if you do not have a previously diagnosed condition. It irks some patients to be told that they should visit their PCP before a specialist, especially if they are certain they have a problem with their heart, lungs, skin, etc. Why schedule and incur the costs of two appointments when you can go directly to the specialist? This point is well taken; however, we believe that visiting your PCP first for undiagnosed conditions will actually save you money in the long run by allowing them to diagnose symptoms properly, refer appropriately, and spare you from unnecessary specialist visits. Now it's a different story if you have a condition that has been previously diagnosed and are in need of ongoing, or chronic, care by a specialist. In these cases, we absolutely agree that you shouldn't have to go to your PCP every time you need to see the specialist, and this is why most insurers allow self-referral these days. Specialty care is normally more expensive than primary care, and the costs usually go up the more specialized the care becomes. One significant point that we'd like to make regarding specialty care is that it is always good to shop around when you're in need of a specialist and the need is not urgent. Some specialists work in or for hospitals while others work in private and group practices. Many times the private and group practice specialists can offer the same services as their hospital counterparts at a more affordable price, with better service, and without sacrificing quality. High-risk testing, procedures, and surgeries should be performed in hospitals, but many specialty services can be performed in either setting. Always utilize the advice of a referring provider, but there's nothing wrong with doing some research of your own.

Hospitals

Most people arrive at hospitals either through the emergency room or through a referral from another provider. Hospitals serve an absolutely critical role in healthcare delivery and cannot be replaced by any other type of provider. The care provided by hospitals spans the entire spectrum of medical specialties, and in general, all high risk testing, procedures, and surgeries should be performed in a hospital. Hospitals are usually accredited by the Joint Commission and are held to high quality and safety standards, and there are resources available to compare hospitals on quality measures. It's hard to go wrong with care provided by a hospital; they have more resources and capabilities than any other provider, but they are expensive. To add to our discussion in the specialists section above, low risk procedures offered by hospitals can often be performed in outpatient, physician-owned practices at a much lower cost without sacrificing quality. We recommend utilizing the advice of your treating physicians regarding where to receive care, but it's usually helpful to ask about and research all of your options. Insured patients should always try to utilize a hospital in their plan's provider network, and uninsured and underinsured patients should be aware of FQHC's and safety-net hospitals in their area.

Federally Qualified Health Centers (FQHC)

Federally qualified health centers serve primarily low income (Medicaid), uninsured, and underinsured patient populations and will provide services to all patients regardless of ability pay. In some instances, they can be associated with a safety-net hospital. If you are uninsured, underinsured, or on Medicaid, these facilities are going to be your lowest cost option, and you can rest assured that they will not turn you away. FQHC's offer primary care services and are often a good option for uninsured patients looking for a PCP. FQHC's (and Healthcare Whiz!) encourage the populations they serve to utilize their services at the onset of symptoms as opposed to waiting until costly, and perhaps preventable, ER or hospital visits are necessary. The providers and staff are also a good resource to inform you about safety-net hospitals and other affordable care options in your area. To find an FQHC near you, please click here.

Ambulatory Surgery Centers (ASC)

Ambulatory surgery centers are outpatient facilities that offer same-day, low risk surgery procedures that do not require an overnight hospital stay. They can be a good option for patients in need of the services they provide because ASC's are significantly more affordable than hospital outpatient departments are for the same procedures. If you've been referred for a low risk surgical procedure, it's probably worth asking your provider what your options are and if an ASC may be appropriate. ASC's serve primarily insured patients and those willing to pay out-of-pocket, although there may be exceptions to this.

Home Health, Skilled Nursing Facilities (SNF), and Hospice

Home Health, Skilled Nursing Facilities, and Hospice are the most common medical options for patients that require assistance with activities of daily living and medical conditions, although each serves a different purpose. Home health brings healthcare providers into your home to assist you. SNF's, also known as nursing homes, provide a place of residence and care for their patients on site. Hospice is a little different as it's meant for patients whose illness has stopped responding to cure-oriented treatments and are looking to be as comfortable as possible in their final days. Cost, service, and quality can vary greatly depending on the facility, provider, and type of care necessary among other things. Home health is generally more affordable than an SNF, but may or may not be appropriate depending on the situation. We recommend consulting with your physicians to determine the best option for you.

Essential QSA Knowledge

If you've read through and considered your urgency of treatment need, insurance and financial situation, and the provider options here, it's time to make a decision! See the last heading on the Patient Choices main page for a couple final thoughts.

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