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Financial stress spurs doctors toward new ways to practice

By Ira Zunin

LAST UPDATED: 2:26 p.m. HST, Aug 5, 2011

Not many years ago, patients could expect their primary care doctor to care for them at the doctor's office and, when necessary, admit them to the hospital.

Economic problems including high overhead, wage pressures and difficulties with insurance reimbursement have fostered a new niche in health care, the "hospitalist."

Hospitalists are medical doctors, usually internists, who work only in the hospital on a shift basis. Patients seen in the emergency department, who require admission, are transferred to hospitalists who care for them until they can be discharged to follow up with their primary care providers. Hospitalists are truly off when they are off, and have no clinic overhead.

With hospitalists on the scene, primary care providers are freed to work full time at their offices. This has become the new standard of care.

Still, there are times when a patient is too sick to wait for the next available appointment at the doctor's office but not sick enough to visit the emergency room. The new division between doctor's offices that offer continuity care and hospitalist services has left a gap which is filled by "urgent care," another niche market.

Historically, urgent care clinics were staffed by moonlighting residents, physicians without board certification and sometimes those between jobs. In fact, still earlier this could have been said about emergency medicine. Today, emergency departments are staffed primarily by residency-trained physicians, board-certified in emergency medicine.

Increasingly, urgent care is also moving in that direction.

According to the Urgent Care Association of America, to qualify, such facilities must have a medical doctor on at all times, be open for extended hours and weekends, have laboratory and X-ray capability and accept patients of all ages. There are about 8,700 urgent care centers in the United States. Sixty-five percent have a doctor on duty at all times, and 67 percent use electronic medical records.

Kahala Urgent Care is a stellar example. Started by Dr. Robert Ruggieri, a board-certified emergency physician, and located just across the street from Kahala Mall, this facility is staffed primarily by ER docs. Many of our patients who have sudden onset of flu or food poisoning, on a Sunday afternoon, for example, have gone there and raved about the care they received.

Dr. James Barahal started a premier facility back in the 1980s called Doctors on Call (DOC) located in Waikiki and now owned by Hawaii Pacific Health. It offers urgent care services for locals, injured workers and visitors and truly emphasizes convenience, customer service and quality. With full-time Japanese translators, the facility is well known in Japan for its success in catering to the needs of Japanese visitors to Hawaii. For those who have existing health issues or who are fearful of health problems but wish to travel, the facility makes Hawaii a particularly attractive destination for the Japanese.

HMSA and other payers are still plagued by the high cost of emergency visits, many of which could be prevented with continuity care offered by a primary care doctor or avoided by the use of an urgent care or after-hours facility. Avoiding emergency rooms is an HMSA priority.

People can get into trouble when using urgent care facilities exclusively for their health care needs in the long run.

While the ability to walk in any time without an appointment is convenient and the location might be handy, you might not see the same doctor at each visit, and preventive screening is not usually on the menu.

For this reason it still makes sense to have a good primary care doctor who knows you, one to whom you will return after an urgent care visit, emergency department encounter or hospital admission. According to Dr. Ruggieri, "Urgent care clinics offer access to care, but we recommend that all patients have a primary physician."

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to

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