In previous posts we’ve focused on issues relevant to hospital based Emergency Departments: how they operate, how they are regulated, the different services available, and the types of patients they care for. Considering the title of this series, ER 101, this makes sense. But Emergency Departments are not the only venues offering urgent or emergent care on a walk-in, no-appointment-needed basis. Other types of practices exist to compete in this market, and a discussion of what they are and what they do, or don’t do, will help put emergency care into better perspective.
It’s fair to say pretty much everyone is familiar with the term “urgent care center”, and many of you have probably visited one at some point. It was close, convenient, quick, and less expensive than a trip to the ER. A win-win by any definition. Why, you ask, aren’t there more of them? In fact, there are more of them than you may realize, and many more on the way.
Urgent care centers, (UCC’s), function like a private doctor’s office with a few important differences. The first, and most obvious, is the extended hours of operation. Unlike the doctor’s office, which is typically open from nine to five, with an hour or two reserved for “lunch” generally starting at noon, an urgent care center will be open anywhere from twelve to twenty-four hours a day, with no down time for meals.
The second obvious difference is the walk-in nature of the practice. No appointments made or needed. If you’ve been sick for a couple of days and decide it’s time to get it checked out, you don’t have to wait until a week from this Tuesday for the next available appointment with your primary care physician. Nor do you have to go to the hospital and risk being exposed to God-knows-what while you wait your turn to be seen in the ER.
Urgent care centers generally have more equipment than your doctor’s office. There will be x-ray and ultrasound machines, a lab, and supplies necessary for repairing a laceration or splinting a broken bone. Patients of all ages are welcome. So why doesn’t everyone just go to an urgent care center for their episodic care? Why bother with your doctor’s office at all?
A couple reasons come to mind. The first is lack of familiarity. If you have a primary care doctor, chances are you have a certain attachment to this person. He or she knows all your most intimate health secrets. You’ve developed a level of trust in his or her judgment impossible to achieve with someone you are meeting for the first time, whose credentials you’ve not had an opportunity to inspect.
Or you might be concerned about the lack of continuity of care. Wouldn’t it be better to see the person who knows your history, who can put your current problem in better perspective? Maybe. But if you problem is a cut finger, sprained ankle, or sore throat the fact that you have chronic asthma probably doesn’t matter all that much. You can get the immediate care you need at the Doc-in-the-Box and follow up with your primary care person a week from this Tuesday.
The more significant consideration is financial. Because the urgent care center operates like an extended private office it is not obligated to take all comers regardless of their ability to pay. (As we’ve explored in previous installments, ER’s are obligated to do so.) Many urgent care centers won’t even accept your insurance, regardless of how good it is. You will be asked to pay cash and will possibly be given some help submitting your claim to the insurance company for reimbursement. So though the urgent care charges considerably less than the ER, it actually expects to be paid what it charges.
Another similarity to your doctor’s office is the lack of Federal regulations governing its operation. No EMTALA, no Joint Commission surveys, so in theory there could be a wide variation in the capabilities of various UCC’s and the people staffing them. Though at one time this was undoubtedly the case things are changing. A new urgent care model is emerging, one that is owned and staffed by board certified emergency medicine specialists. The same sorts of people who staff hospital based ER’s.
This is happening in response to changes in the way health care is being reimbursed. The expansion of the Medicaid program under the ACA has been good for the millions of people who previously had no insurance coverage at all. They have some access to care without exposure to large medical bills. Unfortunately, because reimbursements under Medicaid are so low, their access is limited. Emergency rooms are seeing increasing numbers of patients covered by Medicaid managed care plans because they cannot get an appointment to see their assigned doctor in a timely manner and because emergency care for them is free. They also have learned to go to the ER for lab tests and imaging studies they won’t have to wait weeks to get pending approval from the health plan.
The new UCC’s, staffed by real ER doctors, offer high quality urgent and emergent care for a price. Those who can afford it can avoid the chaotic ER except in cases of life- or limb-threatening emergencies. The physicians working in them can make more money on a per-patient basis without the stress of ER crowds, severely ill patients, and onerous government regulations.
There is a third option for walk-in care available in some states. So-called freestanding emergency rooms sit apart from any hospital, but offer the same level of service a hospital based ER does. They may be owned by a hospital and used to expand the hospital’s catchment area. Or, they may be owned by physicians or private investment groups. Whatever the arrangement they must abide by the same rules that apply to hospital based ER’s. They must see all patients seeking care and cannot turn someone away for financial reasons. They are accredited by the Joint Commission and must meet certain standards of performance and staffing. If a patient presents with a problem requiring hospitalization, transfer agreements must be in place with near-by hospitals to ensure safe and timely transfers.
Freestanding ER’s are popular in Texas, a state that has not as yet adopted an expansion of its Medicaid program to accommodate the ACA. There they offer a convenient and comfortable alternative to hospital based ER care in communities with a significant percentage of well-insured, or well-healed, individuals. Because the number of Medicaid and uninsured patients is relatively low, they can afford to keep their doors open to everyone and still maintain profitability. Freestanding ER’s are illegal in California, and would likely not be financially viable if they were, except in the most affluent areas.
The landscape of healthcare delivery and reimbursement is undergoing enormous changes. Though it is unclear how this will eventually settle, it is certain that physicians and others in the industry will continue to find new ways to adapt to these changes. This is the future, and this installment is the first hint of what we can expect.