Urgent care centers help EDs provide cost-effective care
Working in conjunction with the ED, UCCs improve continuity of care, efficiency and patient satisfaction
With their focus on fast, efficient treatment of low-acuity complaints, urgent care/ambulatory care centers are an acknowledged key component of any comprehensive health system. Now, some experts are touting the use of urgent care centers (UCCs) in conjunction with EDs, as the wave of the future in creating seamless delivery of unscheduled care.
"The idea is to have input points in the health care system where patients can be directed toward the most appropriate venue for their problem," says Robert A. Rosen, MD, FACEP, president of Rosewood Medical Management in Tinton Falls, NJ, and medical director of the Doctor’s Office, an ambulatory care center in Matawan, NJ.
Freestanding UCCs help the health care system serve a broader population more effectively, which improves patient care, says Rosen. "In some regions where the ED serves a central population but also an outlying population, a UCC allows hospitals to provide [better] care to outlying areas."
When appropriate, patients can be directed to UCCs if an ED is overcrowded. "There is some evidence that when hospitals or groups have sent a subset of patients to UCCs for further care after the medical screening exam in the ED required by law, it can do a lot to help unload an overcrowded ED," he continues.
Urgent care may also be compatible with emergency medicine in other ways.
UCCs are providing career-extending opportunities for emergency physicians, contends William H. Wenmark, president of the National Association for Ambulatory Care in Minneapolis, MN. "This is something to consider when you’re tired of working in trauma rooms," he suggests. "You can apply your skills from the ED and develop a practice of medicine complementary to your skills."
Patient satisfaction rises with UCCs
The placement of a stand-alone UCC next door to the ED at Baylor University Medical Center in Dallas, has been instrumental in helping that department improve its patient satisfaction numbers, say staff members.
"As a rule, waiting times for patients with minor problems are much shorter in UCCs than in EDs. "Patients don’t get mixed up with severely sick or injured patients," explains Dighton Packard, MD, FACEP, medical director of the ED at Baylor. "If you can get your throughput times under an hour, that increases your satisfaction considerably. It’s good to be able to take care of people with minor illnesses in an efficient, cost effective environment."
Waiting times are extremely important to UCC patients. "Mothers have an internal clock that allocates a certain amount of time for the staff to deal with her child’s ear infection," says Wenmark. "She’ll give them about 35 minutes, and if you exceed that, you’ll have an unsatisfied customer."
Having an UCC can also be good for community image. "Many larger EDs have a reputation that if you have a minor problem, you’re overlooked, so having an UCC where that doesn’t happen certainly improves your image," Packard explains.
The number of patients who leave the ED without being seen will decrease, he adds. "Your patients are also much more satisfied. Those are two improvements you can objectively measure."
UCCs can service the need for unscheduled episodic care more cost-effectively than the ED, says Wenmark. "A sore throat shouldn’t go to the ED, which is one of the costliest of all places in the health care delivery system," he insists.
Others suggest the cost difference isn’t as great as it appears. "The cost per increment for the next patient is much lower than people would believe. However, it’s still not as cost-effective as an UCC," says Packard.
UCCs also provide a needed focus on patients who are otherwise healthy. "MCOs are focused on 20% of the public which are driving 80% of the costs," argues Wenmark. "The rest of the public is healthy, but we need episodic contact with these people, when they need to see a physician right away for sore throats, lacerations, bumps and bruises. As it stands now, they’re off the radar screen of managed care."
Although UCCs are not big money-makers, the hospital will avoid losing market share to local UCCs. "It’s very, very difficult to make money from an UCC, but hospitals want to protect the customers within their geographical area," notes Wenmark.
Others suggest that the financial gain from capturing that patient population isn’t the main advantage of having a UCC. "It will help, but if you get your price structure down significantly, it’s not going to make or break an ED," says Packard. "It’s a patient service, not a business venture to run an UCC across the street out of business."
Build lean and mean’ UCCs
To be truly cost-effective, UCCs need to be run differently from the ED. "The problem with many UCCs is that they are costed out with same type of overhead and expense as the ED, and if you do that, your cost benefit won’t be as much as it should be," explains Packard.
Many hospitals overbuild their UCCs, argues Wenmark. "That’s where a lot of hospitals make a mistake," he adds. "They tend to build UCCs as they build their hospital, so they run into problems with cost."
Benchmarks indicate UCCs need to be built at a cost of $45 per square foot, whereas hospitals may cost $175 to $200 per square foot, Wenmark says. "A huge facility with marble and mahogany and fancy pictures is not ambulatory care medicine, which needs to be lean, mean and efficient," he notes.
A cost-effective structure is needed. "You have to be very good at information systems and human resources management, because your margins are very thin," says Wenmark. "If you go in with the mentality of building an ultra-sophisticated facility, you’ll find it’s not what the public is looking for, and the cost structure won’t support it."
The staffing mix of a UCC is also crucial, he stresses. "Seventy-five to 80 % of your cost structure is human resources, and those numbers have to watched very closely," says Wenmark. "If there is an inappropriate staffing error with just one or two people, it can cause you to exceed your cost structure and revenues."
ED managers should work with administrators to ensure the hospital’s UCC is price-competitive with other community facilities, says Packard. "The simplest way to convince someone is to benchmark your prices with UCCs in your area," he suggests. "It’s acceptable for a UCC connected to an ED to be 10% more than UCC located out in the suburbs, but it can’t be a lot more than that."
One-stop shopping
UCC patients welcome a "one-stop shopping" care site, but to be cost-effective, a UCC shouldn’t mirror the extensive diagnostic equipment found in the ED. "You need a radiology department to do X-rays when necessary, and a lab to do basic tests to confirm a diagnosis, but nothing sophisticated," recommends Wenmark. "UCCs also do a great deal of worker’s comp, carpal tunnel or back strains, so physical therapy management onsite has become important." (For more information about occupational health clinics, see the related story on page XX.)
UCCs can also function as a pharmacy, offering prepackaged medications to patients. "You mix up liquid 250 mg. of liquid amoxicillin and Mom doesn’t have to make another stop at the drug store," says Wenmark.
Generally, UCCs are open from 8 a.m. to 9 p.m., says Wenmark. "That’s pretty consistent across the U.S. because medical problems that occur before 8 are typically male and cardiovascular, which are emergencies and should go to the ED," he explains. "Nine p.m. is also a critical time. Anything after that is usually associated with highway accidents, alcohol or drugs, gunshot wounds, domestic violence, or gang-related injuries."
UCCs allow patients to access medical care before the problem gets bad enough for a trip to the ED, he says. "UCCs are identifying medical problems early on that would otherwise go undetected until such time as the morbidity caused severe dysfunction," says Wenmark. "The costs are also are much higher to manage someone at that point, vs. intercepting them early."
When a UCC physician was doing a routine head and neck exam on a young woman with strep throat, he noticed thickened thyroid around her throat, which turned out to be hyperthyroidism, Wenmark recalls. "We’ve picked up a number of very malignant lung tumors which often don’t get treated until it’s too late."
A Blue Cross/Blue Shield study showed that in 1995, there were 871,000 ED visits in the state of Minnesota. "They estimate that 30-50% of those, approximately 60,000 visits, were inappropriate, at an excess cost of $175 per case," reports Wenmark. UCCs represent a potential savings of millions of dollars each year to MCOs, he argues.
Others argue that the appropriateness of ED visits can’t be assessed after the fact. "I’m not sure there is an inappropriate visit to the ED until after I’ve seen the patient and ascertained what’s wrong," says Packard. "There are some, but far less than 30-50%."
Some EDs have attempted to provide the same service by separating low-acuity patients and sending them through a separate "fast track" in the ED.
UCCs are more cost-effective care sites than fast tracks, argues Wenmark. "Fast tracks are mostly bait and switch, a ploy by the hospital to keep the ED doing what it did before, but disguising it as a fast-track makeover," he argues. "They have such burdensome administrative policies that when patients come in to get a laceration repaired, they get billed for a facility charge for the ED."
Should UCCs be in the ED?
Some experts say UCCs should be completely separate from the ED, with the ED downsizing to become a lean and mean emergency and trauma center. Others insist that UCCs should be considered an added service line for the ED.
If a UCC is separate from the ED, the ED will lose revenues, but stand to lose much more if MCOs pull out their patients completely. "You need to allocate resources appropriately, because you don’t want patients who are having a stroke with a lobby full of sore throats and sneezing," argues Packard.
The overhead of the ED is not cost-effective for low-acuity visits, he says. "If you look at the cost per revenue with a $250,000 physician, $30,000-$70,000 nurses, plus the support staff, how many sore throats at $57 reimbursement, or even lacerations at $100, would you have to see to cover your overhead?" asks Packard. "You can’t see enough in a day to justify infrastructure costs."
Ideally, the UCC should be next to, but physically separate from, the ED, he says. "If you triage somebody over to the UCC, it needs to be as close as possible for the convenience of the patient, not down the block and to the left," says Packard. "But, it’s better to have a separate entrance, because the atmosphere should be more relaxed than the ED."
The ideal location for the UCC also depends on the community’s needs. "If the need is to unload a busy ED and the served population is local, then a center right near the ED works," says Rosen. "On the other hand, if you want to properly serve a more geographically isolated population, having it in the outlying areas is better."
If the ED is overcrowded, and patients with minor illnesses or injuries are sent to a nearby UCC, COBRA regulations must be adhered to. "If the ED sends a patient anywhere else, it must be after the medical screening exam," stresses Rosen.
Some experts think the UCC should be next to the ED, so patients can be triaged to the ED if necessary. Others say the vast majority of patients know when they should go to the ED. "It’s disingenuous to say people will go to the UCC when they really should be in the ED," Wenmark insists. "The numbers just don’t support that. Granted, some people might assume chest pain is indigestion, but most educated people know to get straight to the ED."
Still, there is concern that some patients will go to UCCs inappropriately. "Studies have shown that 15-20% of patients who visit an ED have a condition worse than what they thought it was when they entered the ED, so certainly some of these people might triage themselves to a UCC," says Packard. "Patients have come to the ED after being referred from the UCC." In those cases, it’s better for patient care to have the UCC in close proximity to the ED.
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