Latest Medical Convenience ER Appointments

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Scott knew he needed medical attention and had to visit the emergency room on a recent Sunday after his foot became so painful that he couldn’t walk. The one thing that made him pause was the thought of waiting several hours in a room with a bunch of people.

But his wife, Jeannette, remembered she’d seen television commercials featuring a woman sitting in a hospital waiting room and then cutting to the same woman sitting in her living room as words came up on the screen: “Wait for the ER from home.”

“I’ve been in emergency rooms before, so I thought I’d see if this worked out,” she said, and went online to book an appointment for her husband at Dignity’s St. Mary’s Medical Center in San Francisco.

“They actually had an appointment that was within the hour. It was fast, it was convenient and there was also immediate confirmation of the appointment,” she said.

Dignity Health, which runs a large network of hospitals out of its San Francisco headquarters, also offers online ER booking at Saint Francis Memorial Hospital in San Francisco and Sequoia Hospital in Redwood City as a way to overcome the frequently grueling emergency room wait times.

Dignity isn’t the only network employing the strategy. In an era of increased competition driven by the nation’s Affordable Care Act, hospital executives around the country are hoping online appointments will attract patients eager to avoid long waits in a crowded and often chaotic environment.

“It makes for a happier camper,” said Susan Dubuque, a national expert in hospital marketing. “When it comes to health care, consumers want more control over everything.”

Not For Everyone

Emergency room appointments are not intended for patients with serious emergencies — those with life-threatening, debilitating or urgent medical conditions.

Patients with chest pain, persistent bleeding or trouble breathing, for instance, are instructed to call 911 or go directly to an emergency room. Those with an ankle sprain or a fever, for instance, might be able to make an appointment.

At UCSF Medical Center, patients must explain in an online form the reason for their visit and check a box indicating they can wait for treatment until their scheduled appointment. Even then, they may be bumped by more seriously ill patients, but in most cases they will be seen soon after arrival.

The approach makes business sense for hospitals because it lets medical staff know who may be coming through the emergency room door and helps reduce crowding and decrease wait times. The service also helps build a loyal clientele among patients.

Patients want to access health care the same way they do services in other industries, such as retail or travel, said Chris Song, a spokesman for InQuicker, a Nashville company that offers the online scheduling in California and 25 other states.

“When is the last time someone bought plane tickets at the gate?” he said.
UCSF Medical Center started using InQuicker in its emergency department in 2012 and expanded it a year later to its acute care clinic, where less-critical cases are handled on a same-day, walk-in basis. Now the system is also being used to book primary care appointments.

Under the former way of doing things, Eva Turner, assistant director of ambulatory services for UCSF’s primary care department, said patients were often frustrated because they had no way of knowing in advance if same-day acute-care appointments were still available. “Before InQuicker, patients would park their car, pay the garage fee only to find out we can’t see them,” she said.

Critics Weigh Costs

Some critics say the online check-in system may be convenient but is not necessarily cost-effective. It could encourage patients to seek care in the costliest of settings, emergency rooms, when they should be going to less-expensive urgent care centers or medical offices, they say.

If the country wants to decrease health care costs, patients need to be treated at the right place at the right time, said Del Morris, president of the California Academy of Family Physicians. Patients who can make appointments should do so at their doctors’ offices, he said.

“This sounds like it is the most expensive place,” said Morris, medical director of the Stanislaus County Health Services Agency. “Emergency rooms are there to take care of people who have emergencies.”

San Ramon Regional Medical Center began using InQuicker in 2012 and sees about 33 patients a month through the service. Most are people who have sore throats, ear aches and stomach pains, said Sue Micheletti, the hospital’s chief operating officer.

On the Web page where patients can select their time slot, they are given the option of looking for somewhere else for care: “Not an Emergency? Locate an Urgent Care Center near you.”

Patients appreciate the convenience of knowing approximately when they will be seen – and avoiding the emergency room crunch times, she said. “That is worth a lot to them,” she said. “When it rains, it pours. Our emergency room sometimes gets slammed.”

Loma Linda University Medical Center in San Bernardino County, however, stopped using InQuicker after too many patients who hadn’t made the appointments complained that others were walking in the door and being seen ahead of them.

The emergency room physicians liked it, but the nurses got tired of dealing with frustrated patients, said Kathleen Clem, chairwoman of the emergency medicine department.

Dignity Health, is also offering the online reservations at urgent care centers and doctors’ offices.

12,000 Visits

The hospital network, which operates 39 medical centers in three states, began offering online reservations with InQuicker about a year ago. Since then, roughly 12,000 patients have scheduled visits for emergency rooms at hospitals in California, Arizona and Nevada, according to the company.

Bridget Duffy, chief medical officer at Vocera Communications in San Jose and an expert in the patient experience, said streamlining the emergency room experience for patients is necessary, but hospitals need do more.

They also need to assess patients quickly, improve communication with them and better manage their pain. Only then, she said, will hospitals be able to truly improve the patient experience.

For Scott, the San Francisco patient, the emergency-room visit led to an appointment with a podiatrist a couple of days later, where he was fitted with a boot for a stress fracture. His only complaint is that everything happened so quickly he didn’t get a chance to watch the U.S. play Portugal in that afternoon’s World Cup game in the waiting room.

His wife had no such qualms: “We went to the emergency room and they said, ‘We were expecting you.’ ”

Unlock A Social Security Windfall

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Creative use of Social Security timing strategies can be key to securing comfort throughout a long retirement. This seldom discussed strategy can possibly ensure longevity protection by delaying benefits and accessing a chunk of cash when needs become a reality.

The Social Security Lump Sum Strategy

Much of the accumulation phase of retirement income planning is a guessing game as a person may attempt to invest in products structured to meet their needs during retirement, but have no way of definitively know what those needs will be ahead of time. The Social Security lump sum strategy can give people access to the extra funds needed to purchase products that more accurately reflect reality at a time when they may not be ready to sell off current investments and are not yet required to take minimum distributions from traditional retirement accounts.

To be eligible for the lump sum payment, a person must first delay claiming Social Security retirement benefits for at least six months past the normal retirement age — currently 66 — but this figure will increase over time. Once the person ages past full retirement age, he or she is eligible to claim both retirement benefits and a lump sum payment.

The lump sum payment represents up to six months’ worth of retroactive benefits that were not paid between full retirement age and the date the person actually began claiming benefits. Note that retroactive benefits are only paid for time that elapses after full retirement age up until benefits are actually claimed — so that if the person claims benefits at age 66 and four months, he or she is only eligible for four months’ worth of retroactive benefits.

A simplified example can illustrate. Assume a person is eligible for a $2,400 monthly benefit if he or she begins claiming benefits at age 67 and six months, but waits until age 68 to actually begin claiming (when the monthly benefit has increased to $2,500). At this point, he or she can elect to take a lump sum payment equal to $14,400 — or what the person would have been entitled to receive had he or she claimed benefits six months prior to the date of the actual claim.

The person can then take these funds and roll them over into a product that can meet his or her needs as they exist at the time — such as a deferred annuity that begins payouts when the person reaches age 80 or a product with a long-term care rider to fund care after an accident.

Potential Pitfalls

In the example, it is important to note that the lump sum payment is based on the person’s monthly benefit level as it existed at age 67 and six months — not the level of entitlement at age 68. This is because the retroactive benefit claim is designed to put the person in the same position as he or she would have been in had the claim been made six months earlier.

This means that, going forward, the person in the example will be treated as though the initial claim was made at age 67 and six months, so that the permanent monthly benefit is reduced from $2,500 to $2,400. As a result, the strategy is often recommended for people who are in need of emergency funds or anticipate a shortened lifespan.

Further, the entire lump sum payment is taxable in the year it is received. The percentage of benefits that are taxed depends on the person’s total income for the year, so for people who have other income sources — including amounts drawn from traditional retirement accounts — in the year that the lump sum is received may wish to consider pushing that income into a subsequent tax year, if possible.


The Social Security lump sum strategy can give older people access to the funds they need to plan for contingencies arising late in life. Despite this, it is important to examine the potential pitfalls in order to evaluate the strategy’s effectiveness for each particular individual.

Medicare Could End Observation Penalties

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Medicare officials have allowed patients at dozens of hospitals participating in pilot projects across the country to be exempted from the controversial requirement that limits nursing home coverage to seniors admitted to a hospital for at least three days.

The idea behind these experiments is to find out whether new payment arrangements with the hospitals and other health care providers that drop the three-day rule can reduce costs or keep them the same while improving the quality of care. They are conducted under a provision of the Affordable Care Act that created the Center for Medicare and Medicaid Innovations to develop ways of improving Medicare.

“We’re testing whether it leads to better care and lower costs,” said Medicare’s Deputy Administrator Sean Cavanaugh. “And if those are successful, the secretary [of Health and Human Services] has the authority to expand those tests.” The health law allows the government to extend successful pilot projects nationwide.

If the experiment saves Medicare money and improves care, “we should be able to make an argument to Medicare that there is a way to do it for all our patients,” said Dr. Eric Weil, clinical affairs associate chief for the general internal medicine division at Massachusetts General Hospital in Boston. The hospital is one of five in the Partners Health System that began offering the waiver in April, after testing a limited version.

“It gets patients to the care they need much quicker and prevents them from clinically declining at home,” said Weil. If patients can spend less time in the hospital, he said that frees up valuable resources for sicker patients. And it saves money for Medicare because nursing home care or home health care is cheaper than a hospital stay.

Medicare’s three-day hospital admission rule has frustrated seniors who don’t qualify for nursing home coverage because they were in the hospital under observation care rather than being admitted. The number of observation patients ineligible for Medicare-covered nursing home care has shot up by 88 percent in just six years, to 1.8 million in 2012.

Officials in the past have argued that only Congress can change the rule.
Diane Paulson, senior attorney at Greater Boston Legal Services, who is handling observation care appeals for several seniors, said Medicare should get rid of the requirement without waiting for the experiments’ results. “Nursing home care and other benefits are supposed to be covered if medically necessary, and are not based on alleged cost savings,” she said.

One of the payment experiments involves about 600,000 seniors at more than 170 hospitals participating in what Medicare calls Pioneer Accountable Care Organizations, which are new models of providing and paying for care. Under this pilot, which includes the five Partners Health hospitals, patients who spend little or no time in the hospital can still qualify for Medicare’s nursing home benefit. Medicare makes a set payment for a patient, which is shared by the patient’s health care providers, including the nursing home.

This waiver of the three-day rule applies even to patients kept for observation, which is considered an outpatient service. (This rule is separate from Medicare’s so-called “two-midnight rule” which is designed to guide doctors and hospitals about when patients should be admitted.) No matter how long these patients stay, observation care normally doesn’t count toward meeting Medicare’s requirement for short-term nursing home coverage.

Medicare assigns patients to an ACO program and does not accept volunteers.
Another experiment involves a “bundled payment care initiative” that also moves hospitals away from Medicare’s traditional fee-for-service model and instead pays a set fee for any of 48 specific procedures chosen by the hospital, such as hip or knee replacements. In this program, patients admitted to about 70 participating hospitals may be eligible for the waiver to get nursing home coverage even though they haven’t spent three days in the hospital. Hospitals, doctors, nursing homes and other providers share Medicare’s discounted reimbursement for a patient receiving one of the eligible procedures. Medicare patients can check with their hospitals ahead of time to see if they are participating in the initiative.

Even if patients are here 24 hours, they would still qualify for a skilled nursing facility and are not penalized for getting well sooner,” said Joe Harrington, president of Lodi Memorial Hospital in Lodi, Calif., which provides the waiver to knee and hip replacement patients.

Medicare officials already allow private Medicare Advantage plans, an alternative to traditional Medicare, to drop the three-day requirement. This year, 95 percent of the plans waived the rule for their 12 million members, according to an analysis for Kaiser Health News by Avalere Health, a health research firm.

Hospital officials participating in the pilot programs say the waiver should be used conservatively, to ensure that patients don’t leave the hospital prematurely, are not kept longer than necessary and enter a nursing home only if they have the potential for short-term rehabilitation.

It’s been a long standing Medicare policy so if you want to change it, it’s important to make sure it’s safe to change it,” said Dr. Mark Froimson, an orthopedic surgeon who is president of the Cleveland Clinic system’s Euclid Hospital, in a Cleveland suburb. The hospital is in the bundled payment pilot project and offers the waiver to seniors who need nursing home care after undergoing a knee or hip replacement. The Cleveland Clinic has asked Medicare for permission to expand the waiver to more procedures and additional hospitals.

“This is one example where Medicare to their credit is saying we are willing to waive our rules and evaluate whether it is better care,” he said.