Deciding where to seek medical care is complicated by many options

Sarah SmithJanuary 11, 2023

One evening in February 2017, Sarah Dudley’s husband, Joseph, felt unwell.

According to her, he had a high fever, his head and body ached, and he seemed disoriented. Dudley had a solution: go to a hospital emergency room or emergency clinic near their home in Des Moines, Iowa.

“The ambulance takes five, six, seven hours before the doctor sees you, depending on how many people are there,” Sarah said. “I know I can go to the emergency room and be seen within the hour.”

At the clinic, a physician’s assistant misdiagnosed Joseph with the flu, according to court documents. His condition worsened. A few days later he was hospitalized with bacterial meningitis and put into a medically induced coma. He’s had several strokes, lost his hearing in one ear, and now has trouble processing information. The Dudleys were sued due to the error and the jury awarded them $27 million, although the defendants requested a new trial.

Their story reflects a problem in the American healthcare system: the injured or sick are being asked, in a moment of stress, to wisely decide which medical facility is the best place to seek help. And they must make that choice among a growing number of options.

Landing in the wrong place can lead to higher and unexpected medical bills and increased frustration. Patients often don’t understand what services are available at different facilities or what level of care they need, and uninformed choices are a “recipe for bad outcomes,” said Caitlin Donovan, senior director of the National Patient Protection Fund. non-commercial rights.

“We have created this health system maze that works to maximize profits,” Donovan said. “He does this by creating an ambiguous, difficult-to-navigate system that continually increases patient costs.”

But the profit-driven, risk-averse station operators that act as alternatives to hospital emergency departments 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,” said Vivian Ho, a health economist at Rice University. “If you’re going to start one of these businesses – even if you’re a non-profit organization – you want to generate income.”

The number of U.S. emergency clinics has grown by about 8% annually from 2018 to 2021, according to the Association for Emergency Care. But the services offered and the level of care offered can vary greatly from clinic to clinic. In its current strategic plan, the industry group says it is working to help a wider audience understand what counts as emergency care.

Concentra, which operates emergency clinics in the eastern and central US, touts its ability to treat allergies, minor injuries, colds and flu. CareNow, another major player in the emergency care industry, says its clinics can treat similar problems, but services may vary by location. According to the American Academy of Emergency Medicine, some clinics offer lab tests and x-rays; others have “more advanced diagnostic equipment”.

Ho said emergency clinics could provide faster access to cheaper care. On the other hand, individual emergency departments tend to charge significantly higher prices for similar services, she said.

Separate emergency departments are becoming more common, although the exact number is unclear. Some are owned by hospitals while others are independent; some of them are open 24/7, others are not. Although they are often staffed by doctors trained in emergency medicine, many of them do not offer trauma services or have operating rooms on site, even if they burden patients with large bills.

Patients didn’t always have so many options, says Dr. Ateev Mehrotra, professor of health policy at Harvard Medical School. Despite all the choices, the healthcare industry tends to refer patients to the highest and most expensive level of care, he said.

“What are you likely to hear when you call your PCP while you are waiting for a response? “If this is a life-threatening emergency, call 911,” Mehrotra said. “Risk aversion pushes people to the emergency room all the time.”

Federal law requires emergency departments at Medicare participating hospitals to treat anyone who shows up. The Emergency Medical Services and Labor Act, also known as EMTALA, was passed in 1986 in part to prevent uninsured or Medicaid-covered patients from being transferred to other facilities before they were stabilized.

But the lack of clear guidelines to enforce the law sometimes prevents emergency room doctors from referring patients to more appropriate facilities, they say. The law does not cover acute care clinics and is inconsistently applied to individual emergency departments.

The law is making hospital emergency doctors nervous, said Dr. Ryan Stanton, an emergency physician in Lexington, Kentucky. Those who would like to refer patients to lower level care facilities when appropriate fear that they may be exposed to EMTALA.

“This is intended to protect the consumer,” Stanton said. “But it has the following effect: there are things I wish I could tell you, but federal law says I can’t.”

Stanton said EMTALA could be updated so hospital emergency room doctors can be more open with patients about the level of care they need and whether the emergency room is the best and most accessible place to get it.

The Centers for Medicare and Medicaid Services, the federal agency that enforces the law, said it was 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 medical care do not always resolve confusion.

Take, for example, the MedExpress emergency care network, which offers a list of the conditions it treats and guidance on when to seek more intensive care.

Carolina Levesque, a MedExpress nurse practitioner in Kingston, Pennsylvania, said she is still seeing patients with severe warning health symptoms, such as chest pain, who require a referral to the emergency room. Even these patients get upset when they are sent somewhere else.

“Some patients will say, ‘Well, I want my co-pay back. You didn’t do anything for me,” Levesque said.

Some patients, such as Edith Eastman of Decatur, Georgia, say they appreciate it when health workers recognize their limits. When Eastman received the call last February that her daughter had injured her hand at school, her first thought was to take 13-year-old Maya to an emergency center.

A local clinic treated Maya when she had previously broken her arm, and Eastman believed medical professionals could help a second time. Instead, fearing that the fracture was more complicated, they referred Maya to the emergency room and charged $35 for the visit.

“The emergency room said, ‘Look, this is above our paycheck.’ It didn’t just heal her and send her home,” Eastman said.

Proponents say all parts of the healthcare system have a role to play in clearing up the confusion. Insurance companies can better educate policyholders. Emergency clinics and stand-alone emergency departments can be more transparent about the types of services they offer. Patients may be better trained to make more authoritative decisions.

Otherwise, the solutions will be disjointed, like the short-lived ad campaign for BayCare, which operates hospitals and emergency centers in Tampa, Florida. Launched in 2019, the patient education campaign went viral.

“I have the flu: an emergency. I have the plague: an emergency,” one ad said.

Helping patients self-triage means BayCare can reserve its more expensive ambulance resources for patients who really need them, said Ed Rafalsky, the system’s chief strategy and marketing officer.

But other hospitals, he said, see only competition in the entry of other players into their markets.

“If you have a stand-alone emergency room open across the street from your ER, you will lose some of your business just because they are there,” he said.

Donovan, a patient advocate, said this kind of thinking perpetuates confusion that is ultimately harmful to patients.

“If you break your leg, it’s unreasonable to say, ‘Have you Googled if ER or ER is right?'” she said. “No, you just need to get help as soon as possible.”

KHN (Kaiser Health News) is a national news service that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is a charitable non-profit organization providing health information to the nation.