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.
NEWS & VIEWS
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
COMPARING COSTS AND QUALITY OF CARE AT RETAIL CLINICS WITH THAT OF OTHER MEDICAL SETTINGS FOR 3 COMMON ILLNESSES
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.
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