Emergency Care by Appointment: An Oxymoron?

By Dr. Alan Pitt

emergency room hallway with bed and nursesIn a WSJ article entitled“Why ER Visits for Non-Emergencies Aren’t Going Away,” Dr. Paul Auerbach, a teaching professor of Emergency Medicine at Stanford’s School of Medicine, summarizes some of the critical factors contributing to and causing over utilization within emergency departments. As outlined by Dr. Auerbach, emergency departments are currently a necessary part of American healthcare. However, active marketing of hospital emergency departments as “America’s clinic”—seems ill conceived. To understand why, let’s look at the emergency room experience from all sides: that of the patient, the provider, and the hospital.

The Patient’s Perspective

Although policy makers and insurers would like to believe otherwise, when you’re sick, injured or in pain, you’re not in a frame of mind to make rational decisions about the lowest cost, highest quality provider. Patients want answers and reassurance as quickly as possible. Unfortunately, access to prompt care has become a real issue. Often people prefer to pay a convenience charge (or they don’t pay) to be seen immediately rather than wait weeks (or even months). Emergency physicians often provide such instant gratification, but they are not equipped to deliver long-term solutions.

The Provider’s Perspective

Overworked and overbooked providers often use the emergency department as a backstop for their practice. One way they do this is through the nearly universal after-hours use of the recording, “If this is an emergency, hang up and dial 911,” which pushes the patient to the emergency department. Alternatively, some primary care physicians actively send patients to the emergency room simply to expedite specialty care. Here at my center it is not uncommon for a patient to come to the ED with back pain because the neurosurgeon’s next available appointment was eight weeks out.

The Hospital’s Perspective

Emergency departments can be a profit center. Charges for the same low acuity conditions treated in primary care clinics increase two to three fold in an urgent care setting, and then another five to ten times in an emergency department. Also, to some degree, and based on federal legislation, hospitals are forced to treat (or at least triage) all patients coming to their emergency department.

In short, Americans’ addiction to emergency departments represents a perfect storm of circumstances: Patients want rapid answers; primary care providers have a pop off valve for after-hours or specialty care; and hospitals get revenue. As a result, many hospitals have begun actively promoting ED care. If you call my hospital and many of our competitors, a pleasant recorded voice says, “We heard you. You didn’t like waiting in our emergency department. So why not sign up, stay at home and we’ll call you when it’s your turn.”

But wait? Stay at home until you’re called? Doesn’t this—almost by definition—make the situation not an emergency? Seeking help for an emergency health issue after hours shouldn’t be like taking a number to be served at the deli counter.

What are some possible solutions? For starters, rather than compete for the most compassionate marketing slogans, perhaps resources could be devoted to “right spacing” and “right placing” patients. Imagine being worried about a headache, back pain, fever, or a myriad of other typically non-life threatening conditions. You get yourself to an emergency room, where a healthcare professional meets you and determines your condition is non-life threatening. You are offered to be shuttled to the primary care clinic a block away, or alternatively, you can walk over to a kiosk ten feet away—just like the ones at many local drug stores. In either case, you could be offered follow up treatment as part of the solution.

Yes, there are obstacles to overcome. Most notably, providers would have to be paid for this type of care. Emergency physicians rightfully object to triaging patients (with the associated liability that comes with such work) without some form of reimbursement. Ultimately however, the patients we’re responsible for are better served at a lower cost in less emergent settings. As healthcare professionals, doctors, and administrators, we’re in the business of dispensing diagnoses and treatments. But, shouldn’t we be something more, a guide helping our patients make good choices in terms of where and how they are treated during their journey through the healthcare system?

Dr. Alan Pitt is Chief Medical Officer at Avizia, as well as an attending physician and professor of neuroradiology at the Barrow Neurological Institute.

Avizia was acquired by American Well in July of 2018. Information on this page refers to activities that occurred prior to the acquisition and are presented for historical context. Together we provide a comprehensive acute care offering—a full end-to-end telemedicine solution for health systems and their providers.