20 May 2009

In which I shall agree with Scalpel

I'll pause a moment for you to wipe the coffee off your monitors.

Yesterday, Scalpel and ERP tackled an interesting question: What is an ER?
[whether] it is our duty as emergency physicians to see every patient that presents for care whether they have the inclination or ability to pay us or not, and if we do not treat all comers then we are not practicing Emergency Medicine.
and Scalpel lauded the concept of the boutique freestanding ER, which accepts cash and private insurance but not government insurance, thereby evading the obligation to provide EMTALA-mandated services to all comers.  ERP was concerned about the implications of this sort of practice with specific reference to whether this violates a core principle of emergency medicine -- the mission to care for all patients first and worry about money later.

Strangely, I don't have a moral problem with the boutique practices.  You'd think, being such a bleeding heart lefty that I'd be reflexively bitching about the poor and vulnerable who are denied care at these boutique practices.  I'll admit that it's a troubling thought, but the local community, county and academic ERs are already the dumping grounds for the clinics, urgent cares, nursing homes, and anybody else that wants to get unburdened by troublesome patients.  So the boutiques don't change that one iota, and could even improve access by decompressing those existing ERs.

Moreover, I don't buy the notion that a defining characteristic of being an ER doc is an abandonment of financial interest in your work.  Just because you have the letters FACEP after your name doesn't mean that you have entered holy orders or taken a vow of charity and poverty.  I take a very entreprenurial approach to running our practice and I have nothing but admiration for those ER docs who have thought creatively and taken a risk in setting out on a new course.

But (and you just knew there had to be a "but," right?) there are some serious drawbacks of these boutique ERs, from a systems perspective.

My biggest concern regarding their existence, were they to become more common, is that they skim the profitable business off of traditional ERs and thereby weaken their parent institutions.  The same argument, by the way, applies to outpatient surgical centers and other outlets which remove profit centers from hospitals.   While such projects make great financial sense for their owners and for their physicians (often one and the same), the overall effect is quite destructive on the system.  Hospitals are required to provide many many services at a loss -- inpatient medicinal services prominently among them.  They have no choice in that.  They also have to provide care to the uncompensated and the under-compensated.  The entire economic basis for a hospital is frantic cost-shifting from profit centers to loss centers in a hopes of eking out a 3% margin at the end of the year.  The grim fact of hospital closures and the national shortage of inpatient beds is due to this incredibly tenuous business model hospitals exist within.  (The lack of inpatient beds, BTW, is largely reponsible for the ER boarding and crowding crisis.)

To the degree that boutique ERs could make the hospitals' fiscal problems worse, I'm glad that they are unlikely to become widespread.  In fact, I predict that they will either completely cease to exist or will be only a very small niche within healthcare.  

One big obstacle to boutique ERs is the requirement that the docs opt out of Medicare.  This is a huge and scary step for most docs and will ensure that only the most committed few take the plunge.  Remember, you can't reapply to medicare for two full years once you opt out, so if the venture fails, you're unemployable as an ER doc for two years.  That risk, I think, will cause many ER docs to shy away from a boutique practice.  (The alternative, BTW, is for docs to remain in the medicare program and just turn all seniors away from the door of their boutique ER.  Good luck with that business model!)

State regulations pose real obstacles to these practices as well.  In California and other states where balance billing is not permitted, this sort of practice is essentially impossible, since you can't bill a patient for anything above what an insurer is willing to pay (which includes medicare).  As balance billing legislation becomes more widespread (and it will), this will progressively narrow the playing field on which boutique practices can even compete.   The willingness of insurers to pay ER billing codes for non-EMTALA-compliant ERs will also vary greatly by state, and by the degree of clout that insurers have in each state.  If these practices became more common, the insurers would logically respond by creating edits in their software that would transform ED site of service codes into ambulatory codes.

Another obstacle which is not insignificant is that the capital requirements for a fully functional ER is not insignificant.  A "real" ER is going to need, at a minimum, a CT scanner, a radiology suite, an ultrasound tech, and a stat lab in addition to the physical plant and ancillary staff.  That money is tough to raise unless you have the backing of an institution.  It's possible to make an ER on the cheap, but I would contend that as you scale down the ancillary services offered, the difference between an ER and urgent care center becomes fuzzier and fuzzer.  To the degree that there will exist a market for emergency services and funded patients to utilize them, it's more likely that hospitals will create EMTALA-participating free-standing ERs to fill that niche.

So ultimately I have a hard time getting too exercised about the boutique ER practices.  They pose a theoretical threat to the fabric of the safety net, but there are just too many barriers and pitfalls for them to become widespread players in the acute care field, even assuming that they don't get legislated out of existence by reactional lawmakers or regulators.


  1. That is surprising, I must say. A couple of points:

    1) Nobody opts out of Medicare. Most docs employed at these places keep their "main" jobs in the hospital ERs to keep their options open and their skills sharp. Seniors must swipe a credit card or use private insurance and sign a waiver promising not to forward any part of their bill to Medicare, or they will be kindly directed to a facility that takes Medicare.

    2) You don't need an ultrasound tech, just a bedside ultrasound machine (and honestly you could get by without even that, but you'd have to send more patients elsewhere). You don't need a lab tech either, really just one doc, one nurse, one X-ray/CT tech all of whom are cross-trained to do the labs.

    Your other concerns are spot on.

  2. "Most docs employed at these places keep their "main" jobs in the hospital ERs ... Seniors must swipe a credit card or use private insurance and sign a waiver promising not to forward any part of their bill"

    Wooooh! They'd better hope that they don't get caught doing that! That's a violation of the medicare participation agreement! They are liable for reparations, punitive fines & getting kicked out of the program.

    Consider, if you will, the case of a PCP who participates in medicare. That PCP cannot charge one medicare patient at the standard medicare rate and make another agree to pay cash. This is the same thing -- the fact that it's two sites makes not a bit of difference to CMS.

  3. Hm, so if I'm the only nurse and you get a "real" patient (someone bleeding out, septic, whatever), I have to stabilize the patient, get labs, and run them all at the same time?

    Sounds kinda fun and a good way to lose your license all at the same time.

  4. SF- I said "seniors" not "Medicare recipients." We are unable to see Medicare recipients, but as the baby boomers retire and many of them realize the relative worthlessness of their Medicare benefits, we expect some of them will choose to self-insure.

    Obviously seniors are not a market we are targeting with these enterprises (and we can be successful without them), but if they want to be seen at our facility, they want to pay cash, and they tell us they don't have Medicare, then we'll be happy to see them.

    K- we won't be getting much if any EMS traffic, and we aren't in the hood, so no shootings or stabbings. We'll be making our money on the 11 month olds with a fever, the $1000 sprained ankles, the $500 UTIs, and the occasional chest and belly-painers. If 0.5-1 relatively stable pts/hr is too stressful for you, you don't have to work there.

  5. Well, I agree there is a place for "boutique ER's" or what I would call "advanced urgicare centres" - and personally, if I worked there, I would not want to see senior/medicare patients anyway since they have too high a chance of having something really bad happen to them. They need to be admitted so much of the time and are on drugs like coumadin which increases their risk of everything, etc. This would slow you down and prevent you from seeing the fast track type patients which I imagine would be 90% of the volume anyway. That said, I think working at a place like this would be mind-numbingly BOORING. Granted if you worked full time at a knife and gun club, a little respite would be nice but I don't see how an ER doc could just work at a place like this and still call himself or herself an ER doc.
    We will see how the lawsuit in CA plays out as to what the definition of "practising Emergency Medicine" is.

  6. Which would you say would be more satisfying...helping a little girl with her broken wrist then reassuring a worried mother when her firstborn child has a fever and maybe diagnosing an acute appendicitis before taking a 4 hour paid nap until your next patient arrives, or juggling a double handful of drunks, sicklers, dialysis patients, and septic nursing home residents all night without a break for about the same income?


  7. Your second scenario is EXACTLY why I went into Emergency Medicine and not Family Practise, Internal Medicine, or Pediatrics. To do the former scenario, you certainly do not need to do an ER residency.

  8. How to buy prescription drugs...? My doctor prescribed vicodin for a while back, my back hurts, I think it is a great help, but in my country it is difficult to find, it is paramount to have my information on it and found information about findrxonline the medicine, because it provided me.

  9. ERP, sounds like YOU are the one who should have done an Internal Medicine residency. Then you would be able to manage your favorite types of patients even more expertly.

  10. Ah, but you see Scaplel, my "favourite" patients are the ones who are really sick and deserving an EM physiciain. I make them better (at least while they are in my shop) and then let the internists struggle with trying to get them to be compliant and stay healthy. Personally, I am not a big fan of most "fast track" - type patients (except eye cases for some weird reason).

  11. Scalpel's "ER" sounds like urgent care run by an ER doc. We already have those where I live. And for all of you bashing internists, come do a shift with me as I roam the hospital filled with "drunks, sicklers, dialysis patients and septic nursing home residents." No wonder hospitalists and ED MDs don't have respect for each other!

  12. These are:
    1. a tiny market at most.
    2. Will always have a hard time overcoming a reputation bias that they are "all about money".
    3.Going to find that the can't compete vs. a system where both the facility fee and the professional fee are paid.
    4. Are glorified urgent care facilities and if they have a real issue will have to send the patient to the ED thereby doubling much work (classic tragedy of the commons play).

    The Key to solving the ED dilemma is that they should be merged and there should not be (if at all possible) and ED under 30,000- obviously this will not be reasonable for the majority of rural America, but while these represent the largest % of hospitals and EDs, they only represent about a 1/3 of care in America.

    Get the other 2/3 of ED's up above 30,000 and really it is better if the ED is 65+ thousand for further economies of scales which are always true the larger the ED gets.

    This just needs balancing vs. drive times + waits for the people using the EDs.

  13. Don't put any money in them imho.

    Nurses in a box is a much better idea/investment for society.

    Speaking of which, Shadowfax, what % of your staffing is MLPs and what is your volume and admission rate?


  14. "These are:
    1. a tiny market at most.
    - true, not all locales will support this business model.

    2. Will always have a hard time overcoming a reputation bias that they are "all about money".
    - Only among those who can't afford it. Sort of like the reputations of Lexus, Mercedes, and BMW.

    3.Going to find that the can't compete vs. a system where both the facility fee and the professional fee are paid.
    - Both fees are currently paid by many insurers and cash payers in selected markets. Besides, it's easy to compete against a system where frequently neither fees are paid (by the uninsured), or both fees are paid below market value (by Medicare) or even below cost (Medicaid).

    4. Are glorified urgent care facilities and if they have a real issue will have to send the patient to the ED thereby doubling much work (classic tragedy of the commons play).
    - You could make the same argument about "Fast Tracks" in the ER, but they still charge ER fees. Most freestanding ER patients can be directly admitted to any hospital without sending patients to another ER for duplicate workups. Some others can be identified prior to the initiation of a workup and directed to a hospital ER without the paperwork/regulatory delays mandated by EMTALA.

  15. Scalpel,

    "Most freestanding ER patients can be directly admitted to any hospital without sending patients to another ER for duplicate workups."

    This may be true, but good luck finding a physician who is willing to admit a patient to the hospital sight unseen from an urgicare center (or whatever you want to call it). Most of my specialists won't accept transfers from anywhere--outside EDs, ICUs, whatever--without a stop in the ER first.


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