Urgent care? ER? Many choices confuse patients


by Sam Whitehead

Kaiser Health News

One night in February 2017, Sarah Dudley’s husband, Joseph, became ill.

He had a high fever, his head and body ached, and he seemed confused, she said. The Dudleys had a decision to make: go to a hospital emergency room or an urgent care clinic near their home in Des Moines, Iowa.

“ERs take five, six, seven hours, depending on how many people are there, before you get seen by a doctor,” Sarah said. “I know I can go to an urgent care clinic and be seen within an hour.”

According to court filings, at the clinic, a physician assistant diagnosed Joseph with the flu. The situation worsened. A few days later, he was hospitalized with bacterial meningitis, and was put into a medically induced coma. He’s had multiple strokes, lost hearing in one ear, and now has trouble processing information. The Dudleys filed a wrongful-death lawsuit and a jury awarded them $27 million, although the defendants asked for a new trial.

Their stories reflect a challenge in the American health care system: injured or ill people are asked to carefully decide which medical facility is best to seek help in times of stress. And they have to make that choice among a growing number of options.

Landing in the wrong place can lead to high and unexpected medical bills and increased frustration. Patients often don’t understand what services they are getting or what level of care they need, and an uninformed choice is a “recipe for poor outcomes.” Caitlin DonovanSenior Director of the National Patient Advocacy Foundation, a patients’ rights nonprofit.

“We created this laboratory-based health care system that maximizes profits,” Donovan said. “It does this by creating a confusing system that is difficult to navigate and is constantly costing patients more.”

But the revenue-driven and risk-averse operators of sites that serve as alternatives to hospital emergency rooms have little incentive to make the process easier for patients.

“We live in a fee-for-service world, so the more patients you see, the more money you make,” he said. Vivian Ho“If you’re going to open one of these facilities — even if it’s a nonprofit — you’re looking to bring in revenue,” said the Rice University health economist.

More common and growing rapidly

The number of urgent care clinics in the US will increase by about 8 percent from 2018 to 2021, according to the Urgent Care Association. However, the services provided and the level of care can vary widely from clinic to clinic. In the current strategic planthe industry group said, is working to make a broader audience understand what urgent care is.

ConcentrationIt operates urgent care clinics in the eastern and central US and promotes its ability to treat allergies, minor injuries and colds and flu. CareNowAnother urgent care player said the clinics may treat similar cases, but services may vary by location. According to the American Academy of Emergency MedicineSome clinics offer lab and x-ray; Others have “advanced diagnostic tools.”

Urgent care clinics can provide faster access to cheaper care, Ho said. Freestanding emergency rooms, on the other hand, Tend to ask very high prices For the same services, she said.

Free-standing emergency room They are very commonAlthough the information on their exact number is very dark. Some are owned by hospitals, others are independent; Some are open 24/7, others are not. They are often staffed by doctors with emergency medicine training. Many do not offer trauma services or have operating rooms on site, Even like them Saddle patients with large bills.

Patients haven’t always had many options, he said Dr. Ateev MehrotraProfessor of Health Care Policy at Harvard Medical School. Despite all the choices, the health care industry tends to direct patients to the highest and most expensive level of treatment.

“What do you hear when you call your primary care doctor while you’re waiting? ‘If this is a life-threatening emergency, please call 911,’ Mehrotra said. “Risk aversion is driving people to the emergency room.”

Federal law requires Medicare-participating hospitals to provide care to anyone who comes to emergency departments. Emergency medicine and labor law, as well It is known as EMTALAIt was created in part in 1986 to prevent hospitals from transferring uninsured or Medicaid-covered patients to other facilities before stabilizing them.

But the lack of clear guidance on law enforcement sometimes prevents emergency room doctors from transferring patients to appropriate facilities, physicians said. The law does not apply to urgent care clinics and applies consistently to free-standing emergency rooms.

‘Beyond our paycheck’

He said the law would worry hospital-based ER doctors. Dr. Ryan StantonAn emergency medicine physician in Lexington, Kentucky. They worry that patients who want to be directed to settings with a lower standard of care, when necessary, may go along with EMTALA.

“It’s about protecting the consumer,” Stanton said. But it has a downstream effect: There are things I want to tell you, but federal law says I can’t.

Stanton said EMTALA could be updated to allow hospital emergency room doctors to be more open to patients about the level of care they need and whether the ER is the best — and most affordable — place.

The Centers for Medicare and Medicaid Services, the federal agency that enforces the law, said it is willing to work with hospitals on how to communicate with patients, but did not elaborate on specific initiatives.

Efforts to educate patients before they seek care do not always clear up confusion.

Take the urgent care chain for example MedExpressIt provides a list of conditions it treats and Guidance on when to seek more careful care.

Carolina Levesque, MD, a nurse practitioner at MedExpress in Kingston, Pennsylvania, says she still sees patients with serious health warning symptoms, such as chest pain, who need to be referred to the emergency room. Even those patients resent being sent elsewhere.

“Some of the patients said, ‘Well, I’d like to get my personal payment back. You didn’t do anything for me,’ said Levesque.

Some patients, like Edith Eastman of Decatur, Georgia, say they appreciate it when providers recognize their limitations. When Eastman called last February that her daughter had hurt her arm at school, her first thought was to take 13-year-old Maia to an urgent care center.

A local clinic had previously cared for Mia when she broke her arm, and Eastman figured providers there could help a second time. Instead, worried that the fracture was more complicated, they referred Maia to the emergency room and charged $35 for the visit.

“Acute care said, ‘Look, this is beyond our paycheck.’ He didn’t just send her home missing,” Eastman said.

Advocates say all health care providers must play a role to avoid confusion. Insurance companies can better educate policyholders. Urgent care clinics and freestanding emergency rooms may be more specific. About the types of services you offer. Patients can better educate themselves to make more empowered decisions.

Otherwise, the solutions will be piecemeal – like a short-lived advertising campaign Managed by Baycarewhich operates hospitals and urgent care centers around Tampa, Florida. In the year Started in 2019, the effort to educate patients A virus has entered.

“I have the flu: urgent care. I have an outbreak: emergency care,” one ad read.

Helping patients self-identify means BayCare can reserve its most valuable AR resources for patients who really need them, said Ed Rafalski, the system’s chief strategy and marketing officer.

But he said other hospitals only see competition from players entering their market.

“If a freestanding urgent care facility opens across the street from your airport, you’re going to lose some of your business just because they’re there,” he said.

Patient advocate Donovan said such thinking ultimately creates confusion that is harmful to patients.

“If you break your leg, it’s not reasonable to be like, ‘Have you Googled whether urgent care or ER is appropriate?'” she said. “No, you need to get taken care of as soon as possible.”

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