One evening in February 2017, Sarah Dudley’s husband, Joseph, begins to feel ill.
He had a high fever, head and body aches, she said, and seemed dizzy. The Dudley family had a decision to make: Go to a hospital emergency room or an urgent care clinic near their home in Des Moines, Iowa.
“Emergency rooms take five, six or seven hours before a doctor sees you, depending on how many people are in there,” Sarah said. “I know I can go to an urgent care clinic and be seen in an hour.”
According to court filings, at the clinic, a physician’s assistant misdiagnosed Joseph with the flu. His condition worsened. A few days later he was hospitalized with bacterial meningitis, and was placed in a medically induced coma. He’s had several strokes, lost hearing in one ear, and now has trouble processing information. The Dudleys sued for wrongdoing and the jury awarded them $27 million, even though the defendants asked for a new trial.
Their story reflects a challenge in the American healthcare system: injured or sick people are asked, in a moment of stress, to decide wisely which medical setting is the best place to seek help. And they must make that choice amidst an ever-increasing 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 kind of services different settings provide or what level of care they need, and an unconscious choice is a “recipe for poor outcome.” Caitlin Donovansenior director at the National Patient Advocate Foundation, a nonprofit patient rights organization.
“We’ve created this labyrinthine healthcare system that works to maximize profits,” said Donovan. “It does this by creating an opaque system that is difficult to navigate, continually pushing more costs onto patients.”
But the revenue-driven, risk-averse site 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 is, a health economist at Rice University. “If you’re going to open one of these facilities—even a not-for-profit—you’re looking to generate revenue.”
The number of urgent care clinics in the United States grew about 8% each year from 2018 to 2021, according to the Urgent Care Association. But the services and level of care provided can vary greatly by clinic. in its current strategic planThe industry group says it is working to help a broader public understand what counts as urgent care.
Concentrawhich operates urgent care clinics in the eastern and central United States, advertises its ability to care for allergies, minor injuries, colds, and the flu. Care NowHe, another major player in urgent care, says his clinics can treat similar issues, but services may vary by location. According to the American Academy of Urgent Care MedicineSome clinics offer labs and x-rays. Others have “more advanced diagnostic equipment”.
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Ho said urgent care clinics can provide faster access to cheaper care. On the other hand, stand-alone emergency departments, They tend to charge much higher prices For similar services, she said.
Stand-alone emergency departments increasingly common, although data on their exact numbers is murky. Some are hospital owned, others are independent; Some are open 24/7, some are not. Although they are often staffed with physicians with emergency medicine training, Many do not provide trauma services or have operating rooms on siteAnd Even they Saddle patients with large bills.
Patients said they didn’t always have a lot of options Dr. Ativ MehrotraProfessor of Health Care Policy at Harvard Medical School. Despite all the options, he said, the health care industry tends to steer patients on the highest, most expensive level of care.
“What is something you probably hear when you call a primary care doc while waiting? If this is a life-threatening emergency, please call 911,” said Mehrotra. “Risk aversion constantly drives people to the emergency department.”
Federal law requires emergency departments at participating Medicare hospitals to care for anyone who attends. The Emergency Medical Treatment Act and Labor, too known as ImtalaIt was created in 1986 in part to prevent hospitals from transferring uninsured or Medicaid-covered patients to other facilities before they stabilize.
But doctors said the lack of clear enforcement guidelines sometimes prevents emergency department doctors from redirecting patients to more appropriate facilities. The law does not apply to urgent care clinics and applies inconsistently to stand-alone emergency departments.
He said the law makes emergency physicians in hospitals nervous Dr. Ryan Stanton, an emergency medicine physician in Lexington, Kentucky. Those who wish to direct patients to settings with lower levels of care, when appropriate, are concerned that they may be exposed to EMTALA.
“It’s about protecting the consumer,” Stanton said. “But it has a downstream effect: There are things I’d like to be able to tell you, but federal law says I can’t.”
EMTALA could be updated to allow hospital emergency room physicians to be more open with patients about the level of care they need and whether the ER is the best — and most affordable — place to get it, Stanton said.
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 seeking care do not always eliminate confusion.
Karolina Levesque, a nurse practitioner with MedExpress in Kingston, Pennsylvania, said she continues to see patients with serious health warning signs, such as chest pain, who need a referral to the emergency room. Even these patients feel frustrated when they are sent elsewhere.
“Some patients will say, ‘Okay, I want to resubscribe. “You didn’t do anything for me,” Levesque said.
Some patients, like Edith Eastman of Decatur, Georgia, said they appreciate when providers are aware of their limitations. When Eastman got a call last February that her daughter had hurt her arm at school, her first thought was to take Maya, 13, to an urgent care center.
A local clinic took care of Maya when she had previously broken her arm, and Eastman thought the providers there could help again. Instead, fearing the fracture was more complicated, they referred Maya to the emergency room and charged $35 for a visit.
“Urgent care said, ‘Look, that’s above our paycheck,’” Eastman said. “She didn’t just fix it up and bring it home.”
Advocates say all parts of the health care system should play a role in decongesting. Insurance companies can better educate policyholders. Stand-alone urgent care clinics and emergency rooms can be more transparent about the types of services they provide. Patients can better educate themselves to make more informed decisions.
Otherwise, solutions will be piecemeal – like the short-lived ad campaign he’s running Bye Care, which operates hospitals and urgent care centers around Tampa Bay. Launched in 2019, an effort to educate patients went viral.
“I have the flu: urgent care. I have the plague: emergency care,” one ad wrote.
Helping patients self-triage means BayCare can reserve its most affordable online resources for patients who really need them, said Ed Rafalski, the system’s chief marketing and strategy officer.
But he said other hospitals only see competition in other players entering their markets.
“If you have a stand-alone, open urgent care facility across the street from your emergency room, you will lose certain parts of your business once they are there,” he said.
This kind of mentality perpetuates confusion that ultimately harms patients, said Donovan, a patient advocate.
She said, “If you break your leg, it’s not reasonable to be like, ‘Did you Google if urgent care or an emergency room would be appropriate?'” “No, you just need to get care as quickly as possible.”
KHN Kaiser Health News is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and reconnaissance, KHN is one of the three major drivers in the KFF (Caesar Family Foundation). KFF is a non-profit organization that provides information on health issues to the nation.