‘Have it your way’ medicine

Seekers of acute care have a plethora of choices – primary care offices, retail clinics, free clinics, and even emergency departments. For the sake of convenience, many choose the emergency department over all other options.

As someone who indulges in the occasional fast food run, I’ll never forget a rhetorical question my speech teacher once asked: “Is fast food actually good?” I thought to myself, “Yes!”  After a pause, he answered, “No!  Think about it.  It doesn’t actually taste as good as a comparable meal from a more high-end restaurant.  Anyone who buys fast food is doing it for the convenience.  It’s FAST.”

My whole world was changed forevermore.  To this day when I still occasionally indulge on fast food, or when I read the recent study by Hwang and others looking into what effect free clinics have on visits to local emergency departments, I am reminded of the fact that convenience really does rule supreme.  And another question is asked: what if the higher-end meal was free?

In this study, uninsured patients who used local free clinics were compared to uninsured patients who did not use free clinics, looking at how often both groups of patients  subsequently used the local emergency departments (EDs) over the following one to three years and how sick these patients were when they actually did visit the ED.

For this study, patients who presented to the ED were graded on the complexity of their visit by two methods.  One was to use the Current Procedural Terminology (CPT) code for that visit, which takes into account the presenting complaint, how many resources were predicted to be necessary for that patient on arrival, and the patient’s vital signs (blood pressure, heart rate, etc.) on arrival.  The second method was an algorithm created by researchers at NYU to grade the ‘appropriateness’ of the visit to the ED, giving it a score which reflected if the visit was truly emergent or could have been avoidable and therefore taken care of in the primary care setting.

Overall there were almost 100,000 visits by uninsured patients to the EDs included in this study.  Just over 9,000 of these visits were made by almost 8,000 patients who also visited a free clinic during this time.  The remaining almost 90,000 visits were made by just over 44,000 patients who did not visit a free clinic during this time.

The data revealed that uninsured patients who go to free clinics were inherently a different group of people than those uninsured patients who do not go to free clinics.

For example, those patients who used free clinics had a higher chance of being older, white, female, and sicker.   Maybe more importantly, though, even when adjusting for all these differences, the people who used the free clinics were less likely to use the emergency department for a low complexity visit as measured by CPT codes compared to non-users of free clinics (69 percent versus 73 percent).  The uninsured patients who tended to use free clinics were more likely to actually require overnight hospitalization as well (10 percent versus 6 percent).  Interestingly, the two groups of uninsured patients were equally likely to visit the ED for an ‘avoidable’ visit as measured by the NYU algorithm.

Commentary

Although this study cannot really determine if the presence of the free clinic itself causes patients to use the ED less frequently for non-emergent injuries or illness, it seems that people who tend to use free clinics also tend to avoid the emergency room for things for which it was not meant.  This conclusion holds a big impact as EDs become more crowded.  Potentially, building more free clinics would relieve some of the pressure placed on EDs to provide this care.

Alternatively, though, many patients in this study still DO use the ED for the care they want.  Another interesting question is WHY?  The clinic in their area is FREE.  This is what brings me back to the fast food analogy.  Not that I enjoy being compared to Arby’s or Burger King as an ED physician myself, but convenience is the only reason I can come up with that would give the EDs an edge in drawing patients for any non-emergent visit.  That and maybe the fact that because the EDs are not familiar with these patients from previous visits as a clinic would be, EDs are forced into giving the ‘Deluxe Value Meal’ of testing each time. This could be perceived as better quality by patients receiving the tests.

These conclusions imply then that better support should be given to the free clinics to be more convenient.  These amazingly useful clinics might be sought out more often if they were open 24 hours every day.  If they were open on the weekends.  If they offered additional services (psychiatry, dentistry, social work, etc.) for one-stop shopping.  These investments may be more useful to innovative states looking for delivery system improvements instead of penalizing patients for going to the ED for ‘avoidable’ visits or paying the physicians less when they arrive in the emergency department.