Almost 25 years ago, I recall reading an article with the title “The Hospital: Is it a Place or a Thing?”.  The author argued that hospitals and health care in general had espoused the “place” option, concentrating in urban “pill hills” and focusing their investments on building facilities of eminence and technology.  This was fine, but it ignored opportunities to think of themselves more as “things” that could develop ways to deliver health care in far more ways and settings.

Since then, hospital places have persisted, though many have moved from urban centers to the suburbs, chasing affluent patients in hopes of competing with physician-owned specialty hospitals, ambulatory surgery and diagnostic imaging centers.  But most of the new places where health care is available have been developed by non-hospital organizations, even non-physician organizations in many cases.

Closest to hospitals in concept, free-standing emergency rooms have appeared, the one example of new places usually owned and operated by hospitals.  As traditional ERs have become overcrowded with poorly paying patients, hospitals have opened free-standing alternatives in shopping centers and similar convenient locations to both attract better-paying patients, and relieve the hospital-based ERs. [J. Appleby “More Emergency Rooms Open Away from Hospitals” USA Today, Apr 24, 2008]

Next in terms of similarity to ERs are physician-staffed “urgent care centers”, which have also been growing of late.  These were being developed as early as the 1970s, though many fell out of favor, but they have enjoyed a recent resurgence.  The “new consumerism” that is demanding greater convenience of care is finding waiting for appointments with traditional physician practices onerous, and has created a new wave of demand for these “walk-in clinics”.  M.J. Feldstein “Time-Strapped Patients Feeding Growth of Urgent Care Centers” STLToday.com, Jan 9, 2008]

Many of these centers are owned and operated by hospitals, such as St. Anthony’s Medical Center and St. Luke’s Hospital in St. Louis, cited in the above story.  But more often, they are developed by physicians or physician-owned (at least partially) companies.  Their resurgence came after roughly 15 years of decline following their initial emergence, and there are reportedly 12-20,000 such centers in operation according to a report by the California Health Care Foundation.

Competing with the physician-staffed urgent care model are nurse-practitioner-staffed “retail clinics”, typically small “kiosk” or minimal-space operations inside pharmacies and retail stores or superstores.  These also number in the thousands, though not yet as many as those reported for urgent care models.  They are growing faster, however, as major chains such as Minute Clinic and RediClinic link up with pharmacy and superstore chains throughout the US.  These are rarely linked to hospitals or physicians, except as sources of oversight and support, though many create working relationships with physicians their patients report using.

An old style place option is the worksite medical clinic.  Originally, and these go back many decades, they were simply places where workers who were otherwise far from medical care could get it without having to travel far, such as the medical facilities that Kaiser Permanente created for workers during WWII.  Most provided routine primary care, though many included immunizations and physical exams related to work.  But their resurgence has gone well beyond “occupational health and safety” to include proactive health management aimed at reducing risks plus preventing disease and injury, as well as treating people for them.

The most recent development moving away from traditional healthcare places is e-health, where online and phone communications with nurses and physicians take the place of visits in many cases, include advice on the type of care needed including self-care options, and may include health coaching as well.  What has made this development possible has been the growth of new methods by which healthcare providers can generate revenue thereby, including, but not limited to, consumers’ out-of-pocket payments.

Initially, physician practices charged patients a little extra, perhaps $25 per month or so, to cover any and all online communications, or phone for patients without Internet access.  Concierge physicians have routinely included such communications under their annual retainers, usually one or two thousand dollars.  But increasingly, third-party payers are catching on to the advantages for them in paying for such contacts, and covering selected types of “placeless” visits.

While payers are split on covering retail clinic services, many have realized they cost less than traditional sources, particularly ERs.  Payers are generally opposed to concierge practices that include placeless visits in their extra services, but generally support the idea of patients being able to avoid visits by accessing online consultations.  Many have begun paying a pre-determined fee for online visits, for example.

As the “medical home” idea catches on, one element common to the model amounts to turning patients’ homes and workplaces into places where people can get medical advice, plus screening and coaching, from physicians or health management suppliers.  People can already get home, worksite or hotel visits from physicians who specialize in such services on a fee-for service basis, or from their concierge physician, covered by the annual fee.  At least one physician, Jay Parkinson, MD in New York City, offers an entirely online plus home visit practice, where there is no physician practice location other than where patients live.

Physicians in traditional practices have been slow and remain somewhat reluctant to offer e-mail or phone consultations to their patients.  Hospitals have moved only a modest amount toward expanding the places where they offer care to patients.  But at least a few thousand physicians and many entrepreneurs have ensured that health care, though not usually hospitals, is definitely not a place but a thing