Urgent Cares, EDs, Reliability, Reputation, and the Rise of New Paradigms

A guest blog from my colleague and friend, Dr. Donald Kamens.  Enjoy!

Several weeks ago I happened to be walking down a street in Brooklyn, NY, when a downed sign tripped my step.  Likely it was my clumsiness, or my age, that were the big contributors to that fall, the result of which was a cut lip and profuse bleeding.  Getting back to my room with applied pressure, it was clear some stiches were needed.  The wound was not terrible, though somewhat complex it did not cross the vermillion border, so repair by a competent ED physician, or an experienced PA working under one, seemed the best bet. No plastic surgeon needed (as yet).  I decided on going to an UC, to save time, effort, and avoid the crazy waiting rooms of larger NYC hospital EDs.

It was a Sunday, around 1pm, and Google showed four or five urgent care centers, all open for a few more hours, within several miles.  That became my plan to get this minor boo-boo fixed. If I’d have had two-hands, an assistant, and some equipment, I’d have done it myself. But no. So here I go, to the other side of the doctor-patient virtual fence, becoming a patient, an ED doc in an environment familiar but unnatural to him.

Of the UCs in the area, two were owned by a doc I’d known for decades; I kept looking.  The other three advertised “a full staff of 13 (or in another case 15) board-certified emergency physicians on staff and one always on duty,” “we can handle anything,” etc., etc.   Bingo.  So I picked one that seemed closest, just over the Brooklyn Bridge, called to be sure, and got the message “we are open ‘til 6pm on Sundays, and waiting to help you,” got a cab, and headed there.

The sign on the door said “closed today.”  What?  Really?! Okay, will deal with it. So far I’d used nearly a full tissue box compressing the wound. Got another cab, asked the driver to head back over the bridge, and called UC#2. After describing the small, relatively simple, facial wound to the female on the other end of the phone, she said “let me check with the provider on duty.” Note: no mention of “the provider on the premises.” Several minutes later she returned and said: “I’m sorry, we cannot handle face injuries here, you will have to go to an emergency room.”  Seriously!?  I wanted to say “Can I use a few ccs of xylocaine, a needle-holder, and some suture? But they did not know me from Adam, and not to be fully beaten down from the UC concept that I have supported for decades, I tried the third on my list, telling the driver I’d give him a target address as soon as I knew it.  “Sorry,” the UC desk person said, “We have no one here that can handle a laceration.”  Where am I? Sub-Saharan Africa? No, I’m in Brooklyn – NYC. So I bit the bullet and went to a not-too-distant large metropolitan hospital, whose director I’d known for years. The waiting room was not overwhelming, I was cared for in minutes, and out in under an hour, of which maybe 20 were taken up with wound repair itself.  On the cab-ride back, and the in the hours and days afterward, this experience left me scratching my head, and thinking.  

Reputation and Reliability:

Urgent Care centers have skyrocketed into the US healthcare scene, and not without reason.  They promise things that EDs cannot fully guarantee:  short waits, quick face-to-face with a provider, and decreased cost and complexity.  What became clear to me, as a proponent of this development, is that the UC, as a site of care-delivery, has not yet matured.  Hmmmm.  Now, what would such maturation look like?

 

For one thing, there would be recognition that reputation for being reliable (at least for the key components of immediate care) is an essential piece for success of the whole concept. Independent UC have a need to promote a reliability reputation not only for their own success and survival, but also for all others. That is, if, for example, a person goes into an ED in Newark, NJ, and has a downright terrible experience, then when later in, say, Los Angeles, needing ED-type care, that previous terrible experience, a full continent width away, will inform the real-time choices that person makes. In the same way, experience in an UC on Long Island will inform the consciousness, and care-choices of a patient who may need care later in Georgia or Florida. Thus, UCs are not independent of one another with respect to reputation. This is especially so in these early years of the UC paradigm.

Fortunately an organization like UCAOA has an opportunity to impact the entirety of the emerging specialty by developing criteria that best-practice UCs work to meet.  No, these won’t always reach full compliance. But operators of UCs should be aware that what they do on an individual basis makes a difference to all UCs. What happens in a UC does not stay in that UC.

And, while UCs have a spectrum of capabilities, from “free-standing” EDs to PA-only, the reputation of the entire UC endeavor pivots on reliable, honest, and dependable advertising.

New Paradigm

No matter how one views emergence of UCs, its paradigm is new-kid-on-the-block in the US healthcare landscape.  Welcome, for now, but needing some “getting-used-to.”

UCs arose because of need, as do most elements of the healthcare system, from penicillin to fiberoptic intubation. In UCs case it was the complexity and difficulty of encountering an ED; the seeming failure of ED “fast-tracks” to actually be “fast” as their rooms were taken over by critical-side overflow; and the overlying gray-cloud of cost that EDs seem unable to escape.

At this point in the infancy of the UC paradigm, those who operate them should be keenly aware of the importance of building reputation. And, as noted before, the communal reputation each UC generates for all others.

For me, at this moment, if (when) I get crushing sub -sternal chest pain, I know where I will go, and it will not be an UC.  If I fall and cut myself again, or if I develop bronchitis/pneumonia, it will be a head-scratcher (unless my hand is bleeding badly). While, minor injuries, wounds, lacerations, and upper-respiratory and GI infections form the bread-and-butter of UC operations, not all people understand these distinctions.  What they do understand is that UCs generally promise quick in-out, dependability, but with a more limited door-open time than EDs. I think that UCs would want me as a paying, insured, patient, who generally causes no trouble. Maybe I am wrong. But I am hoping, for my sake, and for the sake of my family, that those I love are able to rely in the future on those places that are opening up all over the map.  If real-estate uses the three Ls, UCs should be thinking the three Rs (reputation, reputation, reputation).

Why the Consumer “Loves” the Emergency Department

The article US Emergency-room Visits Keep Climbing posted in the Wall Street Journal reports the not unexpected rise in Emergency department visits.  This was an easily predictable event.  Despite the official pronouncements that the Affordable Care Act would limit such events, there are multiple reasons for the rise:

1. Lack of access.  With the addition of multiple new Medicaid patients, without the adequate primary care infrastructure, these patients are voting with their feet.
2. High deductible health insurance plans that are de facto catastrophic self-pay policies.  The consumer cannot afford both the premiums and the deductible on their salaries.  They make the choice of care, which the Emergency department provides without mandatory upfront payments.
3. The Emergency departments, in general with all their technology, access to specialists, convenience, and board certified/experienced physicians, make an attractive package.
4. Private practice phone trees start out with call 911 and then, go to the Emergency department.
5. The Emergency department has the capacity to do an extensive medical evaluation that might take 4-6 weeks with multiple appointments in under 4-6 hours.
6. Immediate gratification of the consumer.
7. Emergency departments advertise wait times- patients will be seen in under 30 minutes and special Fast-track aka Urgent care areas for low acuity patients.
8. Call ahead or online appointments in the Emergency department.
9. Primary physicians' use of the expertise and technology of the Emergency department as an extension of their practices.
10. Emergency department 24/7 hours of operation.

 

The problem is the cost associated with the ED visit.  The consumer is paying for the 24/7 infrastructure, which is massive.  These include the staff, physicians, Nurse practitioners, Physician assistants, techs of various types, on-call consultants, etc.  The prices are a reflection of the disconnect between charges and costs that are rampant in hospitals and insurance company contracts.  With an appropriate cost and charging scheme, the Emergency department could be quite cost-effective because everything and everybody is already there.

Hospitals and EDs compete for business because they are the main driver of hospital admissions where the money is.  The Fast-Track low acuity patients help pay the freight to generate more admissions. 

One of my prior blogs offers the suggestion that the Emergency department become the center of health care with primary care, specialists and urgent care as the spokes of a wheel.  This would provide constant direct interaction directing the consumer to the best logical point of care.  This is controversial, but reality is when the family member is ill, the first impulse is to go to the Emergency department.

A Blast from the Past!

In December of 2012, we posted the Changing Paradigm for Outpatient Care blog.  Reading through Emergency Medicine News latest February 2015 magazine this afternoon, I found a blast from the past!  The Special Report: ED as Hub of Healthcare discusses why folks go to the emergency department for health-care.  Read both the article and the blog post below for some insight.  Enjoy!


December 3, 2012: The Changing Paradigm for Outpatient Care
The present model has the primary care physician as the provider and gatekeeper of patient care. They evaluate the patient, obtain consultation, admit to the hospital (the hospitalists have taken over this role), and are the general coordinators of care. However, this model in theory works well; it has proven to be ineffective. This is no criticism of the concept but the complexity of modern medicine has made this very difficult for the average family practice unit.

Current Model

The family physician is supposed be the “gatekeeper” of resources and keep people out of other venues like Emergency Departments and urgent cares.

The problem is that the general public has voted “with their feet” that they prefer the family doctor when they are well, but the Emergency Department when they perceive themselves to be quite ill and the urgent care for quick, convenient care.  Call any doctor’s office and the first non-human response is: “If this is an EMERGENCY call 911 or go to the nearest Emergency Department.”

At the present time Emergency Department Services comprise approximately 2% of the nation’s annual healthcare expenditures.

Almost every ED has the built-in infrastructure to accommodate large number of patients which could be expanded. These are centrally located in most communities and already are the de facto safety net of the United States.

Make the ED the central piece of an organized system of emergency department, urgent care, family physicians with an integrated use of consultants.

New Model

Advantages are:

• Lack of duplication of hard assets
• Patients already prefer the ED
• Coordination of care

Urgent Care vs. Emergency Department

How does should a consumer decide if they should go to an ED or an urgent care facility?

 

This on the surface looks obvious but as usual the “Devil is in the Details.”

 

Chief complaints, severity of pain, ease of access, time of day or night, insurance mandates, technological needs (cat scan etc.) and the ability of the consumer through the internet to predict complexity of work-up are all factors to consider when deciding.

 

Emergency Department:

Consider these factors when deciding if an ED visit is necessary:

•  If there is high complexity of care needed
• If immediate treatment is needed, what facility will be able to do so
•  If extensive testing is needed, what facility will be able to do so
•  Possible admission to hospital
• Emergent need of specialists

The follow chief complaints are better served initially at an ED:

• Chest Pain
• Shortness of Breath
• Severe Abdominal/Pelvic Pain
• Pregnancy issues
• Severe Headaches
•  Severe back pain with numbness
•  Tingling
•  Urinating problems
• Multiple injuries
• Head injury with loss of consciousness
•  Deep lacerations
•  Fractures with deformity
•  Children< 3 months old
•  Elderly patients with multiple medical issues
• Psychiatry issues

Urgent Care:

Research capability of the urgent care of your choice:

• Hours
• X-ray
• Relationships with local institutions and specialists

Most other complaints can be seen by the urgent care and then referred to a specialist or a hospital for further care.  The urgent care can treat most illnesses that do not need extensive evaluation. The smart consumer will develop a relationship with their local urgent care and call for advice.

A few more things to keep in mind for the consumer: 

• A significant number of cases are seen first in an UC, and later in an ED. These fall into two categories: a) those that are transferred or referred to the ED for more complete evaluation, and b) those that do not recover or progress as expected and need a more intense workup.
• Many EDs have, in effect, UCs within their ED environment.  These are usually called, when so embedded, “Fast Track” units.  But sometimes the term UC may be used.  The problem here is that because many EDs are quite full, embedded FT or UC units may receive overflow from the main ED. This impedes the ability of the FT to flow as fast as the off-campus UC, in which hospital limitations are not present. 
• It is of value to inquire of your personal physician regarding his experience with any local ED or UC, since he may be called if you happen to appear in either site.  At times, he/she may be able to recommend the best approach for various circumstances that may arise for you or your family.

Take Me to the Emergency Department? Urgent Care? Free-Standing ED? Hybrid UC?

The average consumer has a lot of confusion on what venue of emergency medical care is available or appropriate for their immediate needs.

An emergency department (ED), also known as accident & emergency (A&E), emergency room (ER), or casualty department is a medical treatment facility specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance.  These are 24 hour venues with full services that are usually attached to a hospital and function under the EMTALA law.  In 1986, Congress enacted the Emergency Medical treatment & Labor Act to ensure public access to emergency services regardless of ability to pay. 

Free-Standing Emergency Department functions as full facility that is not attached to a hospital.  They are also subject to the EMTALA law.  Patients who need hospitalization are transferred to a hospital.

Urgent care is a walk-in clinic focused on the delivery of ambulatory care in a dedicated medical facility outside of a traditional emergency room.  Urgent care centers primarily treat injuries or illnesses requiring immediate care, but not serious enough to require a ER visit or hospitalization.
Urgent care centers are distinguished from similar ambulatory healthcare centers such as emergency departments and convenient care clinics by their scope of conditions and treatment available on-site.  While urgent care centers are not typically open 24-hours a day, 70% open by 8:00am and 95% close after 7:00pm.  They do not fall under the EMTALA law.

Hybrid Urgent Cares are designed to evaluate all levels of patients.  They usually perform ultrasound, cat scan, or x-ray and complex lab tests on-site.  Most are open from 8am to 10pm.  Patients who need hospitalization are transferred.  There is no emergency department facility fee, so the process are lower.  They too are not subject to EMTALA law.


When an individual is ill, where should they go and get the most "bang for the buck"?  This is not an easy decision under stress.  The best method is working with your primary care physician and figuring out, in advance, what level of care and convenience you desire or need.  Insurance companies play a huge role in this as they drive patients toward less expensive platforms of care.

Do your homework!

1. Pick a hospital system you trust where your primary care physicians operate.
2. Ask your neighbors/relatives.  They might not recognize quality care, but are aware of attitude, efficiency and caring.
3. Analyze the capacities of local and hybrid urgent cares -

Good questions are...

• Level of testing
• Transfer policies
• Procedures performed
• Insurance issues
• How do they relate to your primary care physician

What to do when you are ill?

If you have time "Google your symptoms" and try to figure how complex a problem is.

1. High risk illnesses: need a higher level of care.  This list is not inclusive. - chest pain, severe abdominal pain, severe shortness of breath, severe bleeding, syncope (passing out), possible stroke, pregnancy related vaginal bleeding, potential labor, sever infections, acute exacerbations of a chronic illness that leads to hospitalization routinely, pediatric patients under 3 months of age elderly patients with multiple complex illnesses and medications, sever trauma, head injuries, severe fractures that need surgery, and severe lacerations.
2. Moderate illnesses can probably go to a quality urgent care.  A quick phone call to you primary doctor's office can direct you to the "right place".  The primary care provider can to handle most of these problems, if they can see you immediately.

Bottom line- when in doubt GO TO THE EMERGENCY DEPARTMENT!  If there is time to sort things out, make an informed decision (medical and financial).  A little pre-planning can go a long way.

Why I Always Choose the ED

We are fortunate to have a guest blog by Dr. Donald Kamens, MD, FACEP,  FAAEM.  Hope you enjoy!

Suppose you had a broken car and had two fundamental choices to fix it.

1. You could take it to the repair shop down the street.  You've known the mechanic for a long time; and you like him.  He's generally thought to do good work, too, though sometimes his office staff doesn't get things done in time.  The problem you have with choice 1 is finding out what is wrong with the car may take some time.  He'll likely add some oil or give you some other remedy, and tell you to drive it and see how it runs.  But then, if things still aren't working out, he may even look under the hood.  Depending on what he sees there, he may either run a few tests or tell you everything looks good, and you should give it a few more weeks.  After a few weeks or a few tests that are marginal, he will then tell you to see his friend, the engine specialist, to see what he has to say.  It takes three more weeks to get an opening in the specialist's schedule, and that one charges you $700 for parts and labor.  The total cost was about $1,400 between all the parts, materials, and labor.  To say nothing of the time costs when you were not working.

Then we have choice 2- This is the modern garage.  Not only is the place full with every high-tech instrument known, but the mechanic and his crew listen to Car Talk.  You know that if you go in there, it will cost you more than your visit to your choice 1 mechanic.  But you also know your car will get a thorough work over.  Before you leave, you may have 10 fuel tests, 2 auto scans, and an electro-car-o-gram.  However, in a few hours, you will know what's up.  Really, you don't have the time to run all over the place, when you can get it all done with a one shop stop.  So you choose option 2.  They find what's wrong in a hour.  You are done.  The bill is...$1,400.  Wait...wasn't that the same amount you spent chasing the mechanic in plan 1??  No one ever said that comparing a single visit to option 2 was the same as comparing the many visits option 1 would require.

And this folks, is why the ED ought to be the center of the US health care system.  It is already in place.  It knows how to function.  It is effective.  A few tweaks...and it would be the envy of the world.

Go tell Washington.  BUT...you might have to walk!!

“Resistance is Futile”

Since the Luddite ‘s anti-technology movement in the 19^th century in response to the industrial revolution, modern technology has been not always welcomed with open arms.

Fear of change and the inability to cope with new processes make the  end-user feel like nobody is listening to them.

The Electronic Health Record is a good example of forcing a one- size-fit-all solution to complex processes that are not all linear, obvious, or easy to categorize.

It throws another obstacle at the end-user already who is already burdened with endless multitasking, interruptions (some important and critical), time concerns, and living up to quotas.

There are solutions:

1.     “Best of Breed” computer programs for various departments that integrate with the monolith ENTEPRISE SYSTEM.  IT people all want one program to make it easier for them. They are not the customer.

2.     Use of various platforms that individual providers can use to accomplish the same goals.

3.     Listen to the END-USER. The owners of the institutions and the practice will be rewarded with increased productivity, safety, and net revenues.  Job satisfaction will be increased and burnout will be delayed.

4.     The Russian space writing utensil (the pencil) may be the best solution instead an exotic, complex solution.

For the Luddites in the audience---embrace technology but with the caveat that common sense, simple solutions are the best.

In the end, technology should exist help - not create “work-arounds” to fit square pegs in round holes.