Primary Care Access, the ED, and 1972

Stimulated by an entry over at Medical Humanities, what started as a comment took up too much space, so it goes here, instead:

There are many who believe with total sincerity that more primary care offices will alleviate the burden on ED’s; this is hamstrung by the horrid pay primary care docs get, so that currently they have to operate like airlines, and overbook. Too many empty seats/open appointments = financial disaster. There isn’t a lot more money coming to primary care in the near future. So, ED = safety valve.

That’s one of the big reasons why a lot of my patients in the ED have insurance and a primary doctor, but they (not unreasonably) believe their pneumonia symptoms shouldn’t have to wait 2 weeks for the next appointment. They come to the ED, they wait, but if willing to wait they’ll get seen. (If minor care clinics would bill insurance, a LOT of those people would flee to them, but the minor care owners have seen what bargaining with the crocodile has done for hospitals and conventional primary care, and want nothing to do with them).

To me, one of the biggest reasons ED volume continues to grow is that office medicine is still practiced like it’s 1972: wait a week or three for your appointment, take this chit to the lab, they’ll draw your blood, come back in a week and we’ll review your tests, then order some more studies if we need them. (And it’s that way for doctors, too: I had a stress test done about 6 months ago (I’m just fine, thanks) but I had to call six times over 10 days to get the result, and that was after waiting the four days they said it’d take to have it read, which was utterly ridiculous). Compare that to the ER: tests drawn and resulted in about 2 hours, decisions made on the tests; subsequent emergency tests readily available, usually around the clock. Americans (and not just Americans) are voting with their feet and choosing the ED, and not because it’s the shiniest place with smiling people, they come because we’re ready to see them around the clock, and we’re capable.

As for the PCP’s: there are about three who get bent out of shape when their patients go to the ED without telling them, and they are very good, old-school docs. They come in and see their patients in the ED, and admit themselves if needed. The rest are resigned to the current system that penalizes the office doc for admitting their patient but pays the hospitalist to admit the same patient they don’t know from Adam.

And, despite how screwed up the system is (and it is), a lot of terrific people work tirelessly to keep it moving, to keep helping patients. Frankly, it’s a wonder it still works at all. But it’s time we had a look at patient expectations about waits (most of which are reasonable concerns) and start moving the system to accommodate those concerns outside the ED. Without breaking the bank.


  1. I’m wondering if primary care groups (eg. all the groups in a single medical office building) could get together and share physicians, support staff, and diagnostic equipment in order to have a cooperative urgent care set up where the patients from all the clinics could come for a quick visit, and it was reimbursed by insurance as if the patient was going to his or her regular clinic. Profits from the urgent care could be distributed to all groups based on % of patients seen from that group or whatever.

    Not sure how that would work or if it would be profitable, but I know that I’d never sign up with a primary care group that also didn’t offer a realistic chance of a same-day appointments or an after-hours urgent care clinic.

  2. Goatwhacker says:

    I’m a solo FP and always keep back appts for same-day. Frankly those appts are money makers and I can’t see why any office would do differently. I can take care of those problems in a relatively short time as opposed to the multi-system disease medicare patients. You are right primary care has to survive on volume but the easiest way to generate volume is to see acute stuff.

  3. mchughdo says:

    What is the financial impact on you when a patient comes to the ED but is seen by their PCP? Are you paid less? After all — they are in your department and using your resources.

    As a military EP stationed overseas (i.e. moonlighting options not available) I am ignorant re reimbursement in civilian ED’s.

    Great blog. I read it every day. And thanks for your service…

  4. Trenchdoc says:

    PCP’s may be the gatekeepers, but damn if we aren’t the doorhops.

  5. Well, in our ED, we have a department policy that everyone who comes to the ED gets seen by an EP, whether their PCP is coming in or not.

    So, the reimbursement doesn’t change for us.

    And, frankly, I often ‘no-bill’ the physician charge for those patients, they don’t need two bills. You see enough patients you don’t need that charge.

  6. As a whole, I don’t think it does any good for various specialties to be finger-pointing at each other. That is not where the problems lie. It’s with the patients themselves.

    Everyone wants concierge medicine at no extra charge. So many believe that their particular problem demands immediate attention. They want to wait until 10pm on a Friday night, and then be seen. NOW. Scheduling doctor appointments is a hassle, so they wait until some routine complaint seems more acute, then want to be seen. NOW.

    I’ve gotten to the point that I don’t generally accept office referrals from EDs. Why? Because these are the most likely people not to show, especially for things like headache. So I tell the ED doc, “Have them see their primary MD first, then he will refer to me as needed.” Don’t have a primary MD? “Then they need to get one first.” Both I and the ED doc know that this person is unlikely to follow this advice, but it doesn’t end up wasting a slot on my office schedule.

    Whatever changes come about in the system, it needs to be designed to teach people how to be sensible patients, and if they don’t want to be sensible, they pay through the nose for it.

    Probably if FP offices were allowed to charge the exhorbitant rates an ED can, they would be more than willing to see some of these patients. But their fees are controlled, they are limited on what tests they are allowed to administer (what if FPs were allowed to have a CT scanner in their offices? They could contract with radiologists for the readings and make the profit instead of the hospitals, who have contrived a very restrictive environment, all in the name of “quality.”)

    Perhaps we need a outpatient version of hospitalists. Contract with FPs for coverage of a place to shunt nonemergent patients adjacent to the hospital. If you come in at 11pm with the sniffles, you get shunted — you may have to sit and wait until 8am when someone is there, but you will get care and not clog up the ED.

  7. This is a complicated issue, no doubt. I vote for using IT to transform PCP practices into a more efficient and convenient place to go – so that people with non-acute issues do not clog up the EDs.

    If we could create an automated (and secure) system where lab results are uploaded into a patient’s online PHR [so Allen doesn’t have to call for his stress test result 10 times], scheduling is available via Internet, email pings are triggered by new schedule availability (let’s say someone’s a no-show or cancels), physicians are reimbursed for email triage and patients can call a hotline for information (but not diagnosis or treatment)… and docs can follow chronic disease management goals as their patients participate with online programs… Wouldn’t that offload the EDs and also make the PCPs lives so much easier? Wouldn’t that also improve patient care?

    Call me crazy, but I believe that this is do-able. It may take a few years, but we’ve got to aim at something that will make a substantial improvement for EDs and PCPs and patients alike. I really do think that technology is a large part of the answer here.

  8. happyman says:

    I agree that electronic records in a commonly accessible database would help SOME problems, although they have pitfalls (ie. templates that get re-written with every note for “documentation” purposes, but that really make it tedious to figure out what the hell is going on with the patient).

    However, this model will NEVER take off until either insurance companies give PCPs a huge incentive to invest in the technology in terms of reimbursement, or recognize the potential savings & buy the technology for their credentialled doctors’ offices.

    Since insurance companies are run by MBAs and not practicing doctors, and they are quicker to reimburse a $500 ambulance ride to the ER for sniffles in a 20-yr-old than a $150 housecall to a 90-yr-old with a CHF exacerbation, I don’t think this’ll happen for a decade or more.

    (sorry for the run-on sentences)

  9. jrobatc says:

    We live in a McDonald’s society. People want fast food service in healthcare and the ER is the most convenient place to get it including the “Happy meal” (box lunch with work excuse and pain medication Rx toy suprises). NurseK is onto a possible solution where primary care could evolve into urgent care centers where patients can get rapid results and fast scheduling, and hopefully continuity would be maintained. The technology we use today was limited in 1972 and it now drives medicine as many tests have become a standard of care (sadly, as bedside clinical skills and decision making have taken a distant backseat to flowsheet medicine, protocols, and tests) thus making the ER a refuge for patients as well as a referal center, or in some cases dumping ground, for PCP’s.

    Patients do need to be educated that wait times are up as a result. If I go to a popular restaurant on Friday night I expect a long wait. It’s worse in the ER when one factors in waiting times, beds taken up by holds, increasingly lengthy work-ups, drunks (we get several a day courtesy of the police, who are no longer takig them to jail, and we are forced to hold them until sober which takes up a room for 8 to 20 hours). Patients also will create unecessary workups by voicing various complaints such as “chest pain” to get seen faster or multiple dramatic complaints to make us think they are really sick and more deserving of that pain med, admission, or work excuse. Homeless patients who are simply looking for a warm bed and a meal routinely come to my ER and claim they are having chest pain (many with multiple risk factors) or want to kill themself which also ties up beds for hours. It would be cheaper on the community to build a cushy shelter open year round 24/7 with TV’s and a buffet than to pay for all the unecessary medical work ups and lost bed availability.

  10. You know, around here (Willamette Valley Oregon) there is a system that buffers between the regular clinic setting and the ED – its called “Urgent Care” and is considered and is billed as a regular office visit. When I was between full time employment and grad school coverage the urgent care was where I went to get care for my out of control allergies, a few months ago when my 2 year old was obviously (to me) dealing with a very painful ear infection I took him to pediatric urgent care. No, its not open 24-7, but it has very good hours (often open until 9-10pm) and often on the weekend. If you are really ill they are usually located near the city hospital.

    I think urgent care is an appropriate answer and offers the kind of care that is needed for urgent issues. I am surprised that other parts of the country don’t have this, or is it that its sponsored by hospitals and clinic? (PeaceHealth, Good Samaritan and the Corvallis Clinic).

  11. Urgent Care is a nationwide phenomenon, they are just titled differently regionally. On the east coast, most people call them walk-in clinics, or express care. On the west coast, urgent care is more common. I was surprised to read someone’s comment that urgent cares do not serve as a solution to ER overcrowding because they refuse to accept insurance. You would be surprised how many major Urgent Care chains, and even privately owned facilities actually do accept major insurances.

    I also read somewhere above that it would be nice for hospitals to open outpatient centers next to the ED. This is also already happening.

    I also thought Nurse K had a great idea, I would be interested to see if it doesn’t start happening.

    Healthcare is definitely taking a consumer-driven shift, I reccommend “Market Driven Health Care” by Regina Herzlinger. She pretty much hits the nail on the head. It is to be expected with a convenience oriented society.


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