How ED Alternatives Are Killing More Than Wait Times

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Retail clinics, telemedicine providers and house call apps swoop in to pick up the low hanging fruit of high-profit ambulatory patients. What’s your hospital going to do about it?

On a recent road trip here in Southern California I saw three billboards advertising ways to find out the wait time at local EDs. I have never seen any billboards advertising how to determine the wait time at the local bank, grocery store, McDonalds, movie theatre or, frankly, any other business.

EDs have had such a bad reputation for making people wait for care (and most of their customers are sick or injured – hardly people in a mood to wait) that there are all manner of workarounds dealing with the problem.

Some EDs have subscribed to companies that provide ED preregistration and online self-scheduling (except the small print says they’re not for life-threatening, urgent or emergent medical conditions). Other hospitals use software apps to advise of estimated waiting times while others provide guarantees regarding how little time patients will wait.

And still others actually have tried to decrease the wait times. But this has been a tough task given the surge in ED visits being reported by most EDs. And this will only likely increase with the perfect storm of an aging of the population, more patients with insurance, more patients on Medicaid (where there are no costs to go to the ED) and a growing problem with access to primary care.

Door-to-provider times are now being recognized as a marker of service quality and many EDs are shooting for 30 minutes or less. But just because you’ve been “seen” by a provider doesn’t necessarily mean that you’ll be getting out of the ED much faster.

So now there are a number of programs coming to the rescue – all designed to remove those pesky patients with fairly minor problems who have insurance or the money to pay – usually at the time of service. And remember, about 80% of ED patients go home and it has been estimated that between 13-27% of ED patients could be seen in a retail clinic or urgent care center (most of the stats for this column are from two recent articles in the July 23rd issue of the NEJM – see pages 382 and 301).

The world of “convenience care medicine” is rapidly expanding (the opposite type of care, the care provided in ED must be, by definition, “inconvenient care”). Although “convenience care” is usually thought of as care provided at urgent care centers and retail clinics, there are some other options that are becoming increasingly popular. But more on them later.

According to the NEJM papers there are about 6,400 urgent care centers in the United States with the number increasing by about 300-600 per year. Most are owned by hospitals, physicians or other investors. According to an Urgent Care Association of America report released in February of 2012, the average net revenue per patient ranged from $105 to $135. But remember, all of the patients seen at an urgent care center pay – not the case in a hospital ED – and urgent care centers don’t have to accept Medicaid.

Retail clinics are a sleeping giant. Although CVS Health is the largest player (with about 980 locations and plans to get to 1500 by 2017), there are three other companies that are providing these services – Walgreens, Kroger and Target (the Target clinics were recently bought by CVS). Together these companies account for 85% of the estimated 1,900 retail clinics. To put the growth potential in this market in perspective, these companies have clinics in only 8% of their 20,000 stores.

Recently Walmart has gotten into the game with 17 “Walmart Care Clinics.” These clinics go beyond the traditional services of retail clinics and provide care for such chronic conditions as high blood pressure and high cholesterol. With approximately 4,500 stores, and pharmacies in virtually all of them, the potential is only limited by the number of clinicians available to staff them (usually NPs or PAs) and the success of the program.

And let’s not forget telemedicine. According to a story in the New York Times (Jennifer Jolly, May 5, 2015), Google and “Dr Phil” McGraw have partnered to form Doctor on Demand. A software app provides access to over 1,400 board-certified physicians. The app, which has been downloaded a few million times since its inception in late 2013, allows patients to consult with a physician via video for $40. They even provide psychological counseling at $50 for 25 minutes and lactation consulting for $40-$70.

The New York Times article noted that the typical client is a working mother with children. An example is given of a pediatrician giving some follow-up advice concerning a child seen in an ED for a broken nose. The mother noted that all of her questions were answered and a revisit to the ED was avoided. A Doctor on Demand spokesperson said their consultations diagnose and treat 95% of the patients who call with the other 5% being referred to specialists.

Other telemedicine services offering direct access to the public include Teladoc, MDLive, American Well and HealthTap. Specialized services include Spruce, which provides dermatologic consults, and Maven, which focuses on women’s health. The American Telemedicine Association estimates that nearly 1 million people will see a physician via a webcam in 2015 and recently UnitedHealthcare announced plans to cover video doctor consults.

The ultimate in convenience care are the services recently launched where the doctor comes to you. Heal is a smartphone app that summons a family doctor or pediatrician. It started in Los Angeles and is now also in the San Francisco area and is set to role out in another 15 cities. A doctor and an assistant arrive in 20-60 minutes for a flat fee of $99. Equipped with the latest in high-tech health gadgets (including the ability to record high definition video of an ear drum), the service is available from 8am to 8pm. Not only can they stitch up a cut, they can even pick up a prescription for an extra $19. Pager is a service similar to Heal in New York City. It was co-founded by Oscar Salazar, a part of the team that created Uber, and charges $50 for the first visit and $200 for subsequent visits.

But all is not rosy for some of these alternatives to traditional care. There has been opposition by some prominent medical groups to the idea of telemedicine and there are all manor of regulatory issues involved with telemedicine and retail clinics. Clearly, these alternatives have not relieved the pressure on primary care physicians or EDs – but they all have the potential to grow quickly and relieve EDs of the large number of low-acuity, bread and butter, paying patients, leaving the EDs with increasing numbers of uninsured, Medicaid and sicker patients.

Finally, just a brief note about freestanding emergency departments. Seems the idea has taken off big-time in Texas with over 145 such centers. Some are owned by hospitals and they bill under the hospital’s ID number with the usual hefty facility fee and some are owned by physicians or other investors – and they also have hefty facility fees. In areas far from hospitals, seems a freestanding ED could meet a genuine need but when they are competing with nearby hospitals and taking primarily insured patients, that may be another matter all together.

And, of course, there is the predictable confusion between urgent care clinics and freestanding EDs. An investigative report aired on NBC channel 5 on April 27, 2015 (Dallas-Fort Worth) detailed a physician bill of $73.11 and a facility fee of $980 for a URI-type illness. Whether in a hospital-based ED or a freestanding ED, a fee of over $1,000 for a cold is outrageous. A report in AMA Medical News dated April 29, 2013, on the backlash being created by freestanding ED facility fees noted they can average a charge of about $1,500 per patient.

So retail clinics, telemedicine and doctor house calls all are going after the low hanging fruit of minor illnesses or injuries that can be treated with a credit card. And despite their need to make money, it seems that many hospital administrators are unwilling to protect themselves from the competition of other care settings for high-profit ambulatory cases. But as long as hospitals choose not to provide the ED with resources to give rapid, fairly priced care for the large percentage of patients who are discharged, this will all be fair game.

ABOUT THE AUTHOR

EXECUTIVE EDITOR
Dr. Bukata is the Editor of Emergency Medical Abstracts.

4 Comments

  1. 100% – all this has been a long time coming.

    Selfish over-utilizers with the financial means deserve the a la cart medicine the market will deliver them: unnecessary tests and radiation wrapped around expedited care and a smile. Btw, I work at one of these places on the other end of the billboards…the times are fabricated.

    You’d have to be a fool to believe that the status quo was going to last forever: high billings for urgent care low hanging fruit to make up for the uninsured but critically ill. Now just yank Medicare and the house of cards can collapse.

    No need to get out yet…given the pace of medicine, we can continue to abuse our paying customers until most us out of residency retire. We’re like NYC taxi drivers and our AMA/ACEP mafia will protect us…but it’s only a matter of time until the right balance of technology, management and policy shifts play out and someone more deserving eats our lunch.

    I doesn’t actually matter why you thought this was your calling and how well you THINK you should be compensated. “Emergency” medicine will ultimately be funded by the grace of tax payers as market efficiencies remove our abilities to shift costs between patients to make the bottom line. Get use to it.

  2. “But as long as hospitals choose not to provide the ED with resources to give rapid, fairly priced care for the large percentage of patients who are discharged, this will all be fair game.” And why would they be bothered to change anything, if they (hospitals) also own the freestanding and can somehow charge their own overhead to users of the freestanding?
    I guess the EPs should all go out and form their own freestandings to encourage their hospitals to shape up. But by then, if EP’s are charging the same facility fees they will not readily give up the cash cow. Let’s see, it being Tx, hospital lobbyists can get legislation enacted that all EP’s must have full admitting privileges at all nearby hospitals so as to be able to take care of any complications their patients might experience. And charge astronomical fees to physicians for the privileges. I don’t know where this is going, but tend to agree with Myra that it is a somewhat predictable downward spiral. Question is, to where?

  3. Tony Cirillo, MD on

    Emergency Departments and hospitals cannot survive by continuing to operate like banks did in the 1970’s…forcing people to stand in long lines in order to spend a few minutes for services that could be provided in more convenient locations and manners. The banking industry has adapted using technology that allows us to do most transactions from the convenience of our home, office, car, boat or anywhere else in the world. Cash (for when it is still needed) is available from ATMs that are everywhere. From a patient-centric perspective, the ED is not a great option in many places, especially for minor illness and injury. Either we will adapt as a specialty and create quick, clean, convenient, and financially reasonable places for people to get care, or someone else will. My concern is that by holding onto an outdated care delivery system, providers who are not trained in identifying who really is sick will assume our rightful places in the “acute care” world.

  4. While some barriers still lie in the way of greater adoption of telemedicine, positive findings continue to move us forward. I think that the main merit of telehealth (even at the current level implementation) is that fact that patients are able to more effectively self-manage aspects of their long-term care, saving own money and physicians time

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