Deciding where to seek care is complicated due to the many options
One afternoon in February 2017, Sarah Dudley’s husband, Joseph, began to feel ill.
He had a high fever, his head and body ached and he seemed disoriented, he said. The Dudleys had a choice to make: go to the hospital emergency room or to an urgent care clinic near his home in Des Moines, Iowa.
“Emergency rooms take five, six, seven hours before you see a doctor, depending on how many people there are,” Sarah said. “I know I can go to an urgent care clinic and be seen within the hour.”
According to court documents, at the clinic, a medical assistant misdiagnosed Joseph with the flu. His condition worsened. A few days later he was hospitalized for bacterial meningitis and was placed in a medically induced coma. He had multiple strokes, lost hearing in one ear, and now has trouble processing information. The Dudleys sued over the error and were awarded $27 million by a jury, though the defendants asked for a new trial.
Her story reflects a challenge in the American health care system: people who are injured or ill are asked, in a time of stress, to make wise decisions about the best medical setting to seek help. And they must make that choice amid a growing number of options.
Landing in the wrong configuration can lead to unexpectedly higher medical bills and increased frustration. Patients often don’t understand what kinds of services different settings provide or the level of care they need, and an uninformed choice is “a recipe for poor outcomes,” he said. Caitlin Donovansenior director of the National Patient Advocate Foundation, a nonprofit organization dedicated to patients’ rights.
“We’ve created this labyrinthine health care system that works to maximize profit,” Donovan said. “It does this by creating an ambiguous system that is difficult to navigate, which constantly leads to more costs for patients.”
But operators of revenue-averse, risk-averse alternatives to hospital ERs 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. viviana ho, a health economist at Rice University. “If you’re going to open one of these facilities, even if it’s a nonprofit, you’re looking to generate revenue.”
The number of urgent care clinics in the US has grown by approximately 8% each year from 2018 to 2021, according to the Urgent Care Association. But the services and level of care offered can vary greatly depending on the clinic. In your current strategic planthe industry group says it’s working to help a broader audience understand what counts as urgent care.
concentratedwhich operates urgent care clinics in the eastern and central US, advertises its ability to treat allergies, minor injuries, colds and flu. CareNowanother major urgent care player, says its clinics can treat similar problems, but services can vary by location. According to the American Academy of Urgent Care MedicineSome clinics offer labs and x-rays; others have “more advanced diagnostic equipment.”
Ho said urgent care clinics can provide quicker access to cheaper care. Independent emergency departments, on the other hand, tend to charge considerably higher prices for similar services, he said.
Independent emergency departments are becoming more common, although the data on their exact numbers are unclear. Some are owned by hospitals, while others are independent; some are open 24/7, some are not. Although they often have physicians trained in emergency medicine, many do not offer trauma services or do not have operating rooms on site, even like them saddle up patients with large bills.
Patients didn’t always have as many options, he said. Ateev Mehrotra, professor of health care policy at Harvard Medical School. Despite all the options, he said, the health care industry tends to direct patients to the highest and most expensive level of care.
“What are you probably hearing when you call your primary care doctor while you’re waiting on hold? ‘If it’s a life-threatening emergency, call 911,’” Mehrotra said. “Risk aversion is constantly pushing people to the emergency department.”
Federal law requires emergency departments at hospitals that participate in Medicare to treat anyone who shows up. The Labor and Emergency Medical Treatment Act, also known as EMTALAit was created in 1986 in part to prevent hospitals from transferring uninsured or Medicaid-covered patients to other facilities before stabilizing them.
But the lack of clear guidelines on compliance with the law sometimes prevents emergency department doctors from redirecting patients to more appropriate facilities, the doctors said. The law does not apply to urgent care clinics and is applied inconsistently to freestanding emergency departments.
The law makes hospital ER doctors nervous, he said ryan stanton, an emergency physician in Lexington, Kentucky. Those who wish to direct patients to settings with lower levels of care, where appropriate, fear that they could run afoul of EMTALA.
“It’s meant to protect the consumer,” Stanton said. “But it has the downstream effect of: There are things I wish I could tell you, but federal law says I can’t.”
Stanton said EMTALA could be updated to allow hospital ER doctors 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.
The Centers for Medicare & Medicaid Services, the federal law enforcement agency, 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 don’t always clear up the confusion.
Take, for example, the urgent care chain MedExpresswhich offers a list of conditions it treats and a guide to when to seek more intensive care.
Karolina Levesque, a nurse practitioner at MedExpress in Kingston, Pa., just north of Wilkes-Barre, said she still sees patients with serious health warning signs, such as chest pain, that require referral to an emergency room. Even those patients are frustrated when they are sent elsewhere.
“Some of the patients will say, ‘Well, I want my copay back. You didn’t do anything for me,’” Levesque said.
Some patients, like Edith Eastman of Decatur, Ga., said they appreciate it when providers realize their limits. When Eastman received a call 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 treated Maia when she broke her arm earlier, and Eastman thought the providers there could help her a second time. Instead, concerned that the fracture was more complex, they referred Maia to the ER, charging $35 for her visit.
“Urgent care said, ‘Look, this is above our salary level.’ He didn’t just fix her and send her home,” Eastman said.
All parts of the health care system must play a role in clearing up the confusion, advocates say. Insurance companies can better educate policyholders. Urgent care clinics and freestanding emergency rooms can be more transparent about the types of services they offer. Patients can better educate themselves to make more empowered decisions.
Otherwise, the solutions will be piecemeal, like the short-lived ad campaign. administered by BayCare, which operates hospitals and urgent care centers in Tampa, Florida. Launched in 2019, the effort to educate patients went viral.
“I have the flu: urgent attention. I have the plague: emergency care,” one ad read.
Helping patients self-assess means BayCare can reserve its most expensive emergency resources for the patients who really need them, said Ed Rafalski, the system’s director of strategy and marketing.
But other hospitals, he said, only see competition from other players entering their markets.
“If you have a free-standing urgent care center open across the street from your ER, you will lose certain parts of your business just because they are there,” he said.
Donovan, the patient advocate, said that kind of mindset perpetuates confusion that is ultimately harmful to patients.
“If you break your leg, it’s unreasonable to say, ‘Did you Google if urgent care or the ER is appropriate?’” he said. “No, you just need to get care as quickly as possible.”
Kaiser Health News is a national newsroom that produces journalism on health issues.