After-Hours Doctor Calls Save Holland Money

In the United States, the growing number of uninsured Americans means more people do not have a family doctor or primary care provider. When they suffer a worrisome accident or problem, they may end up in the nearest hospital emergency room.

In fact, costs to hospital ERs have been growing over the past decade and ERs nationwide have had to close their doors or limit their hours as a result of out of control, burdensome costs.

Estimates vary but health officials suggest that as many as half of all hospital ER visits are non-urgent, meaning those patients could be treated effectively in a doctor's office or health clinic. But often, people don't have that choice. They don't have a doctor, and there is no health clinic nearby.

In the Netherlands, all citizens have access to 24/7 primary healthcare. The system is organized much like a health maintenance organization, so patients are required to get approval from their primary care provider before they can see a specialist or go to the hospital.

The Group Nieuw-West (New West), a clinic in a low income neighborhood in Amsterdam, is a good example of this 24/7 availability. It opens at 6 p.m., when most doctors' offices close for the day, and provides care throughout the night until doctors offices open the next morning.

On a recent evening at 6 p.m., things at the clinic were already beginning to bustle. A couple of doctors were gulping down dinner, a paramedic checked his medical bag for supplies, and Lita Van den Burg was beginning to field phone calls. Van den Burg is a physician's assistant trained to figure out when patients can stay home and when they need to come in to the clinic. She offers a variety of advice, such as ointments for rashes, what to expect with an ankle strain or whether a fever is serious or not.

Sometimes she'll tell patients to come into the clinic. On this night, patients were treated by Dr. Nora Bartelsman, a family practitioner on duty about three times a month. "Who do I see?" Bartelsman says, "I see children with fevers, back aches, skin rashes, infected eyes, bladder infections, anything. With the more serious situations, we'll visit patients in their homes."

Just as Bartelsman is describing the process of house calls, the clinic gets a call from the son of an elderly, bedridden man who can't come in to the clinic. Bartelsman's colleague, Dr. Pascale Paques heads out the door with her partner, paramedic Gerard Kuil. "The son can't judge the situation," Paques tells us. "So we just have to go and have a look at what's going on."

They drive around in what looks like a half ambulance, half taxi. It's an Audi A4 painted bright yellow and blue, with a siren stashed inside that can be put on top of the car. They have some medical gear but not a lot. En route to the elderly man's home, a call about another patient comes in and Kuil writes down the address. Soon they arrive at their first stop.

Ushered in, Paques and Kuil head up a steep narrow staircase in a typically small Dutch home. At the top of the stairs, they find two tiny bedrooms with twin beds. A frail man lies in a sort of fetal position in one of the rooms. The son stands a few feet away, wringing his hands. He explains to the doctor that his father is 91 years old and unusually listless. He won't get out of bed, not even to help his elderly wife, whom he usually cares for.

As Paques begins the exam, she feels the man's forehead and his swollen legs, takes his blood pressure and gently taps on his abdomen. Although the man's calves and face are severely swollen, Paques decides this is not heart failure and gives him an injection to relieve the fluid build up. Then she hands the son a prescription for more diuretics, telling him to check in with the doctors in the morning.

The second patient lives with his wife in an assisted living facility. It's bright and clean, particularly compared with the first house. This patient is also elderly, but he's up and about. The man describes abdominal pain that has now subsided. Paques decides to do an exam anyway, and gives him a clean bill of health. Meanwhile, a third call has come in, and Paques and Kuil head to the home of a terminally ill man with prostate cancer who's vomiting and can't seem to stop. The vomiting is a symptom of chemotherapy. Paques gives the patient's a prescription for anti-nausea medication. There's not much more she can do.

Back at the New West Clinic, Paques enters her notes about each patient's treatment into their electronic medical records. Just like their family physicians, she has access to all the information about these three patients and can pass along what happened this evening. It's a seamless communication system.

Paques is about to settle in and maybe even have some dinner when she gets a call about another patient. An elderly diabetic woman is disoriented and dizzy. The patient's son is on the phone, and Paques knows this could be a serious situation. She nearly runs to the car, and arrives at the home within 10 minutes. The patient's son, Rudolph Heemeijer, is amazed at how quickly she got there "I was still hanging on the phone; there was a miscommunication with the operator," Heemeijer says "I was waiting for an answer on if the doctor was to come, and then the doctor was here and I was still hanging on the phone!"

This is longest visit of the evening so far. Paques examines the patient and talks with her as well as with her husband and two sons. After deciding the woman must go to the hospital, Paques calls an ambulance and leaves the son in charge.

Of the six patients she's seen tonight, this is the only one she admits to the hospital. "I do think house calls are very good to have, because several people are quite ill and unable to come with their own transport to the GP or hospital," Paques says. "I can still manage to keep them at home; it's a more comfortable situation for the patient than in the hospital. And it's a lot less costly for the health care system.

Because the Dutch after-hours system is relatively new, officials don't know yet whether it is saving money. But it's clear from medical systems around the world that, when health care is delivered by primary care providers, there is a cost savings. In the Netherlands, for example, primary care doctors make one-third less than specialists Dutch patients would see if they went for care to an emergency room. Also, an emergency room — with its high-tech medical equipment and surgical facilities — costs more to maintain than a primary care office with a car and some portable equipment.

"The cost of an ambulance is already very high and, once you're in a hospital, you have to do a certain amount of tests which we don't do," Paques says. "Very often you can keep people at home especially if they're very ill, terminally ill. It's much more patient friendly and better for your budget."

Meanwhile, back at the clinic, Bartelsman has seen about 30 patients. Clinic visits are still a lot cheaper than going to the hospital.

"Anxiousness is always a good reason to see someone," Bartelsman says. "If parents are worried about a sick child, we let them come. If they have symptoms that haven't been going away, we let them come. If they have things that we think need to be seen especially on Friday evening it's a long wait until their doctor's are back again on Monday, so we'd rather see them now than wait till Monday to see their own doctor when they could have been treated much earlier."

Across the Netherlands, there are about 120 after-hours clinics like New West. And more than 90 percent of the Dutch population has access to them.

Radio story produced by Sarah Spivack