Examining the ED's Value Proposition


Recent retail clinic comparison studies highlight the need for EDs to take a hard look at patient value and sub-par service. 

Recent retail clinic comparison studies highlight the need for EDs to take a hard look at patient value and sub-par service. 


I think that the performance of many, if not most, emergency departments in this country is embarrassing. Yes, embarrassing. We have a national reputation for making people wait. Ask anyone. We are the only business that I know that routinely asks its customers (who are sick and injured) to wait protracted periods of time for service that costs exorbitant amounts of money.

I know these assertions will annoy and anger most emergency physicians. But I’m not blaming you. Having been the director of a community hospital for 25 years, I know the system. For some reason, hospital administrators have been taught in hospital administrator school that it is acceptable to run EDs in this way. It is very clear to me that if they wanted to, most could quickly improve the level of service they provide.

It is also clear that many who work in the industry have become totally numb to our surroundings. We act like we are stuck, like there is nothing we can do about the ED waiting time or any other of the challenges of managing an ED and so therefore we must do the best with what we have.


The most obvious reflection that we’ve admitted defeat is this ridiculous movement towards having billboards posting ED waiting times, or hospitals subscribing to programs where patients can call in to the ED to make an appointment to be seen to avoid having to wait. Totally nutty! The solution is not to monitor the wait time, but rather to eliminate it!

The fundamental question is who is doing whom a favor. Are we doing the patients a favor (we sure act that way) or are they doing us one. The fact is that in most EDs, it is unequivocal that the patients are doing us a favor. They are bringing serious money for service that is often mediocre at best. Here’s just one compelling study that makes the point, which has profound implications for the future.

Using information from a large insurance company database, payments (including copays) for three nothing illnesses, UTIs, otitis media and pharyngitis, were compared for a large number of visits in four different venues – a retail clinic (a la Walmart where you’ll be seen by a nurse practitioner), a doctor’s office, an urgent care center and an emergency department. The payments were $100, $160, $160 and, hold your hat, $570 – all for the same minor problems. But surely the quality of care was better in the EDs. Not so. On a review of 14 quality measures for the three entities treated, the three non-EDs ranged between 61% and 64%. What score was achieved in the EDs? 55%.

If a single physician-staffed ED can see 2.5 patients per hour and all they saw were sore throats, UTIs and otitis media, the revenue generated would be $1,720 per hour. But the assumption is that all comers would pay for service rendered. This is where those of us in the ED start beating our chests righteously claiming that we take care of everybody despite their ability to pay. And that is certainly true. We do take care of a disproportionate number of MediCaid patients and “cash” patients, but the truth is, we really put it to the people who are able to pay and cost shift to them tremendously – otherwise known as the “Robin Hood” approach to healthcare funding.


So, it would appear that we should kiss the feet of an insured patient presenting for a minor problem. We should have a greeter at the door. Waiting? No way. They need to be ushered in immediately because they are about to pay 3.5 times more than they have to for a simple service, and this extra payment will more than offset the “losses” from the uninsured and underinsured occupying a large percentage of our ED beds.

Would anyone who understands the value of an insured patient not want to create an environment that would attract as many of their discretionary visits as possible. Of course, they would. We want them badly. They are the ones who pay the bills of the others who can’t or won’t pay. But, since we can’t provide differential service based on insurance, the conclusion is clear, we must create great patient experiences for everyone.

To help put this further into perspective, ask your administrator how much money the average patient who is discharged from the ED pays for their visit. I bet you a dollar they cannot give you an answer. They don’t know. This is the crux of the problem. If you don’t know what a patient is worth, you can’t value them and respond to them appropriately. The fact is, it is by no means unusual for hospitals to collect, on average, $300 to $600 per discharged ED patient (insured or not). Bottom line, most EDs can be (or are) hugely successful businesses, not even counting the revenue generated from hospital admissions.

There are two caveats. Some hospitals are, in fact, doing the patients a favor. Inner city, tax-payer-funded, hospitals treating largely indigent populations – all are exceptions to the above and generally their waiting rooms are full. The economics noted above simply do not apply. Second, some communities only have one hospital. There is no competition, and in this setting, the patients have no choice but to endure whatever the hospital dishes out. The ideal situation for EDs, patients and ED staff is for competition to exist, allowing patients the power of choice, selecting the facility providing them with the greatest benefit.

In conclusion, we could do a lot better if hospital administrators, nurse managers and physicians stepped back a little and challenged some of our longstanding beliefs about the operation of emergency departments. There is much low hanging fruit.

InQuickER’s Online Check-In System Bypasses ED Waiting Room …and Undercuts Triage Processes

Could crowded emergency department waiting rooms become a thing of the past? Nashville-based InQuickER would like to think so. They’ve rolled out a system that allows patients to make an ED appointment online, bypassing the waiting room, for a fee of about $15. The “appointment” is a commitment to be seen within 15 minutes of a promised time. If the patient is not seen on time, the fee is refunded. As volumes and acuity flux, an email is sent to the patient adjusting their “appointment”. Patients may receive multiple such emails prior to arriving at the ED. According to their web site, InQuickER is available in 25 facilities in nine states across the country.

And why not? It works for Disney. You show up at a ride and are given a ticket printed with a time slot during which you can return and bypass the line. Even restaurants are beginning to take down cell phone numbers and call patrons when their table is available.

The problem is that emergency medicine is critically different from other service industries. Traditional queuing does not take acuity into consideration. Restaurants don’t take the hungriest customers first and EMTALA doesn’t mandate a medical screening examination for those waiting for a table.

Systems like InQuickER trivialize the complexity of triage and intake processes in the ED. It also misleads to patient who don’t realize that sicker patients will still be seen first, regardless of the 15-minute rule. Because of EMTALA and the unpredictability of the ED environment, InQuickER can only offer an empty guarantee. Not to mention that InQuickER only guarantees that you will be seen by “a healthcare professional” within 15 minutes of your projected treatment time. There’s no promise of what kind of training that person will have.

Is InQuickER concerned about having to refund $15 fees if appointments aren’t kept? With the average 50,000-visit ED
paying a monthly fee between $4,800 and $6,000 for their service, my guess is no. Finally, in the name of decency, is it appropriate to charge for something the ED should already be providing? If we know how to fix operational inefficiency, we should fix it for everyone, not just those willing to pay extra for it.

-Kevin Klauer, DO, EJD   


Mehrotra, A., et al, Ann Intern Med 151(5):321, September 1, 2009

BACKGROUND: Retail clinics expand access to the provision of care for acute minor conditions, but several national organizations have expressed concern regarding the quality of care provided at these facilities.

METHODS: The authors, from RAND Health in Santa Monica, CA, and the University of Pittsburgh, examined information from the database of HealthPartners, a large Minnesota insurer, to compare aspects of care provided for matched episodes of otitis media, pharyngitis and urinary tract infection (UTI) initially presenting to a retail clinic (2100 total episodes), physicians’ offices (6211 episodes), urgent care centers (5880 episodes) or emergency departments (979 episodes).

RESULTS: Overall costs of care (health plan reimbursement plus copayment) were $110 for retail clinic episodes and about $160 for episodes presenting to physician offices or urgent care centers, but $570 for episodes presenting to EDs. Prescription costs per episode were $21-$22 in the former three locations but $26 in EDs. Aggregate patient costs over twelve months were about $1200-$1400 in the former three groups but $2157 in the ED group. Aggregate quality-of-care scores for performance of 14 quality indicators were about 61-64% in the former three groups but 55% in the ED group. Finally, the proportion of patients who received preventive care (preventive health examination, Pap smear, vaccination, mammography, cholesterol testing and/or colon cancer screening) within three months after initial presentation were about 14% in the former three groups but 10.7% in the ED group.

CONCLUSIONS: Patients presenting to retail clinics for one of the three study conditions received care of comparable quality and had lower costs of care than those presenting to the other settings, and were at least as likely to receive subsequent preventive care. 38 references (mehrotra@rand.org for reprints)
Copyright 2010 by Emergency Medical Abstracts – All Rights Reserved 2/10 – #16



  1. Wow ! Talk about loss of contact with reality ! It’s an EMERGENCY ROOM ! If you can make an appointment, it’s not an emergency ! The only hospital in town ? I work in several ER’s and see the SAME patients in different ER’s all the time ! You say nothing of the abusers trying to milk the ER’s for drugs. Many of our patients have a doctor across the street but are too lazy to make and keep an appointment, thus fragmenting their care ad tying up our limited resources.
    We are more like the fire department- we head straight to the worse problem. The kitten in the tree can wait.
    If hospitals value these people so much, why don’t they staff the ER better ? Every weekend and night, it’s the same thing- understaffed and overcrowded. Even department stores have the sense to hire extra people for the christmas shopping season- why can’t the hospital administrators do the same for the ER on weekends and holidays ?
    And given the massive amount of paperwork we have to do on every patient versus a clinic, heck yes, we’re slower.
    You should be praising us for doing what we do with what little we have rather than trying to belittle us !

  2. Rick,

    It would be interesting to see exactly how many hospitals fall into the “exceptions” you present.

    While it is economically desirable to attract commercially insured patients to the emergency department for all of their medical problems, as the payor mix changes to increasing numbers of indigent patients, hospitals actually lose money for each patient seen and evaluated. I suspect that there is a large percentage of hospitals that have reached this tipping point and therefore don’t believe that a “one size fits all” approach will work in many circumstances.

    Do you have a citation for your assertion that hospitals make an average of $300-$600 for every outpatient visit? Medicaid payments in many states are nowhere near that number. Level 3 visits in most states are paid in the $40-50 range by Medicaid. I have a spreadsheet from a few years ago showing that New York Medicaid pays $17 for any level emergency department visit. Oklahoma and Maryland Medicaid both pay $25 for a Level 3. The cost of paying for malpractice insurance alone is more than the money earned from a patient visit. I was unable to find more recent payment schedules by doing an internet search.

    In addition, the collection rate in our area from “cash” patients in the emergency department is less than 10%.

    Given that few hospital administrators read EP Monthly, when the emergency department is overcrowded with emergent patients, half the room is full of boarded patients, and the only emergency physician on duty has to perform a chest tube or lumbar puncture, what steps should [i]emergency physicians[/i] take to provide a great experience to patients who are sitting in the emergency department waiting room for discretionary visits? What longstanding beliefs do we need to change?

    The emergency medical paradigm may need to change, but appropriate staffing and increased patient throughput are the key factors to this change.

    What should emergency physicians do to reach that goal?

  3. Joshua Michael, MD, FACEP on

    While I applaude the goal of minimizing wait times and reducing costs (generally to third payers), it is not simply a matter of philosophy, mission and antiquated management that renders the differences between the emergency department and a WalMart clinic. While more expensive, you are entitled to an EM standard of care in an ED. The added value of this standard over an ANRP at WalMart may not be worth the money to a given patient (assuming they were paying out of pocket), but it remains value added nonetheless. In terms of the longer wait, Walmart is allowed to triage based on ability to pay: those who can are seen, those who can’t are not. Ever. No EMTALA, no ethical issues. In the ED, low acuity patients also compete for resources with high acuity patients who are given priority.

    Wait times and cost of care are very important issues, but we should not use for-profit clinics as any kind of model of efficiency given the fundamentally different constraints we face in EM.

  4. I’ve been a patient four times in the last ten years in EDs,for Atrial Fib,for a kidney stone,for a very bloody facial cut and for a broken bone in my hand.For the last two I waited for over 4 hours before being treated.The A.F. and kidney stone got me admitted right away although I was not given anything for the pain (kidney stone) for over 90 minutes.It was only when I vomited that the doctor prescribed IV meds.My vomiting interrupted the little birthday cake party the ED doctor and staff were having so I was treated as an annoyance and rather badly. I was fully insured for all four occasions.I will not go again to that ED but I don’t know if I would be treated any better elsewhere. EDs have pretty much got you by the short hairs.

  5. Tom Bronaugh, MD on

    Dr. Bukata, although I do value your years of experience in ED management and education, I take significant exception to much of what you opine in your article.

    First, you can never compare an ED to a free-standing clinic/urgent care. We are simply not the same, you know it as well as I. We have to be staffed for the highest potential volume and acuity, which is expensive. We have to see every patient, even if they have no resources or have no emergent condition,and the list goes on.

    Secondly, the vast majority of conditions I see are non-emergent. Many need no professional medical care at all, much less an ED visit – seriously. Even so, we are here 24/7 so they use (abuse?) the service, driving up wait times for all. And their wait time, in real hours, is about 10% of what they would spend waiting for an appointment with thier PCP (i.e. 1-2 hrs versus 2-3 days or more). Additionally, this does not even include the time spent waiting for thier outpatient lab/imaging which we order and get back promptly.

    Lastly, we do not, by-in-large, see the same population as a doctor’s office or FFS clinic. They are here usually due to few general reasons- (1) They are in acute pain or distress (real or imagined) and therefore often upset from the outset. (2) They are frustrated by the inability of thier PCP to figure out thier problem or see them in a timely manner. (3) They are unisured or have no PCP and have had minimal preventive care, compounding the complexity of thier health issues. (4) They are too busy or lazy to make an apointment with thier PCP.

    In regards to catering to paying minor care patients- most of these issues can be easily remedied by running a few rooms as a fast track, staffed with a mid-level provider. This works well, and patient satisfaction goes up as wait time goes down. Why on earth every hospital does not do this is beyond me, especially in larger volume departments.

    Just a few thouhts from a worker bee.

  6. Can clinics deliver the same quality of care as EDs? What is the cost differential for an ED physician for emergent vs primary care actions in terms of hospital revenue?

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