By Sam Whitehead
Kaiser Health News
One evening in February 2017, Sarah Dudley’s husband, Joseph, started to feel sick.
He had a high fever, his head and body ached, and he seemed disoriented, she said. The Dudleys had a decision to make: go to the hospital emergency room or to an urgent care clinic near their home in Des Moines, Iowa.
“ERs take five, six, seven hours before you’re seen by a doctor, depending on how many people are there,” Sarah said. “I know that I can go to an urgent care clinic and be seen within an hour.”
According to court filings, at the clinic, a physician assistant misdiagnosed Joseph with the flu. His condition worsened. A few days later he was hospitalized for bacterial meningitis, and he was placed into 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 a jury awarded them $27 million, though the defendants have asked for a new trial.
Their story reflects a challenge in the American health care system: People who are injured or sick are asked, in a moment of stress, to prudently decide which medical setting is the best place to seek help. And they must make that choice amid a growing number of options.
Landing in the wrong setting can lead to higher and unexpected medical bills and increased frustration. Patients often don’t understand what kind of services different settings provide or the level of care they need, and an uninformed choice is “a recipe for poor outcomes,” said Caitlin Donovan, senior director at the National Patient Advocate Foundation, a patients’ rights nonprofit.
“We’ve created this labyrinth health care system that is functioning to maximize profit,” Donovan said. “It does that by creating an ambiguous system that’s difficult to navigate, that’s constantly shoving more costs on the patients.”
But revenue-driven and risk-averse operators of sites that act 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,” said Vivian Ho, a health economist at Rice University. “If you’re going to be opening one of these facilities up — even if you’re a not-for-profit — you’re looking to bring in revenues.”
More common and growing fast
The number of urgent care clinics in the US has grown by about 8 percent each year from 2018 to 2021, according to the Urgent Care Association. But the services and level of care offered can vary widely by clinic. In its current strategic plan, the industry group says it’s working to help a wider audience understand what counts as urgent care.
Concentra, which operates urgent care clinics in the eastern and central US, advertises its ability to care for allergies, minor injuries, and colds and flu. CareNow, another major urgent care player, says its clinics can treat similar issues, but services may vary by location. According to the American Academy of Urgent Care Medicine, some clinics offer labs and X-rays; others have “more advanced diagnostic equipment.”
Ho said urgent care clinics can provide quicker access to cheaper care. Free-standing emergency departments, on the other hand, tend to charge considerably higher prices for similar services, she said.
Free-standing emergency departments are increasingly common, though data on their exact numbers is murky. Some are owned by hospitals, while others are independent; some are open 24/7, others aren’t. While they’re often staffed by doctors with emergency medicine training, many don’t offer trauma services or have operating rooms onsite, even as they saddle patients with large bills.
Patients didn’t always have so many options, said Dr. Ateev Mehrotra, a professor of health care policy at Harvard Medical School. Despite all the choices, he said, the health care industry tends to direct patients to the highest and most expensive level of care.
“What is the thing that you probably hear when you call your primary care doc while you’re waiting on hold? ‘If this is a life-threatening emergency, please call 911,’” Mehrotra said. “Risk aversion is constantly pushing people to the emergency department.”
Federal law requires emergency departments at Medicare-participating hospitals to care for anyone who shows up. The Emergency Medical Treatment and Labor Act, also known as EMTALA, 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 enforcement of the law sometimes stops emergency department doctors from redirecting patients to more appropriate facilities, physicians said. The law doesn’t apply to urgent care clinics and applies inconsistently to free-standing emergency departments.
‘Above our pay grade’
The law makes hospital-based ER doctors nervous, said Dr. Ryan Stanton, an emergency medicine physician in Lexington, Kentucky. Those who would like to direct patients to settings with lower levels of care, when appropriate, worry they may run afoul of EMTALA.
“It is meant to protect the consumer,” Stanton said. “But it has the downstream effect of: There’s things I would like to be able to tell you, but federal law says I can’t.”
Stanton said EMTALA could be updated to allow hospital emergency room doctors to be more open with patients about the level of care they need and whether the ER’s the best — and most affordable — place to get it.
The Centers for Medicare & 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 they seek care don’t always clear up confusion.
Take, for example, urgent care chain MedExpress, which offers a list of conditions it treats and a guide for when to seek more intensive care.
Karolina Levesque, a nurse practitioner for MedExpress in Kingston, Pennsylvania, said she still sees patients with serious health warning signs, such as chest pain, who require referral to an emergency room. Even those patients are frustrated when they’re sent somewhere else.
“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, Georgia, said they appreciate when providers realize their limits. When Eastman got a call last February that her daughter had hurt her arm at school, her first thought was to take Maia, 13, to an urgent care center.
A local clinic had cared for Maia when she broke her arm previously, and Eastman figured providers there could help out a second time. Instead, worried the fracture was more complex, they referred Maia to the emergency room and charged $35 for the visit.
“The urgent care said, ‘Look, this is above our pay grade.’ It didn’t just patch her up and send her home,” Eastman said.
All parts of the health care system need to play a role in clearing up the confusion, advocates say. Insurance companies can better educate policyholders. Urgent care clinics and free-standing emergency rooms can be more transparent about the kinds of services they offer. Patients can better educate themselves to make more empowered decisions.
Otherwise, solutions will be piecemeal — like the short-lived ad campaign run by BayCare, which operates hospitals and urgent care centers around Tampa, Florida. Launched in 2019, the effort to educate patients went viral.
“I have the flu: urgent care. I have the plague: emergency care,” one ad read.
Helping patients self-triage means BayCare can reserve its more expensive ER resources for patients who really need them, said Ed Rafalski, the system’s chief strategy and marketing officer.
But other hospitals, he said, see only competition in other players entering their markets.
“If you have a free-standing urgent care facility open across the street from your ER, you’re going to lose certain portions of your business just by the fact of them being there,” he said.
Donovan, the patient advocate, said that kind of mindset perpetuates confusion that is ultimately harmful for patients.
“If you break your leg, it’s not reasonable to be like: ‘Did you Google whether urgent care or ER is appropriate?”’ she said. “No, you just need to get care as quickly as possible.”