A solution to ER overcrowding: Direct care

Emergency departments in U.S. hospitals see copious patients who aren’t terribly ill, but don’t have insurance and need somewhere to go. I see some of these patients when I moonlight on nights and weekends at a local county hospital. Sadly, these patients run through a gantlet of expensive tests — I’m required by protocol to administer them. The reality is that 80% of what I see in the ER is “family medicine after hours.” I could just as safely see these patients in my own direct care practice, saving them time and money.

It’s not that hospitals aren’t aware of how silly these tests are, and what a waste they are for less endangered patients. But there’s not much they can do about it. In desperation, some 50% of acute care hospitals have begun charging a fee in the $100-$150 range for a patient deemed safe to be seen in a less acute setting remains determined to stay in the ED. This can even include hospitals with urgent care centers on-site. And that’s on top of the care that’s provided.

Let’s break some numbers. According to the American Hospital Association, in 2012 hospitals had uncompensated care costs of $45.9 billion, spread across about 5,000 hospitals (including both charity care and bad debt). That equates to 6.1% of their total expenses, the AHA reports.

So who’s ready to cut some red tape? For $150 I’m more than happy to see an urgent patient and give them a 3-month subscription to my practice.

You know how that one urgent care trip usually turns into two because your doctor is so harried that he or she can’t make a proper diagnosis? Yeah, that doesn’t happen with direct care. Instead, I’ll call you or text you or direct message you on Twitter (your call) and make sure everything’s going okay. And if it’s not, instead of ignoring my outreach and hoping the problem goes away, because you don’t want to pay another $150 for ten minutes with us, you can get all the help you need for free.

Oh, and you can come in and see me anytime for three months (if you’re between 18 and 44 years old).

And are you really, really short on cash? Remember that we’re a business, and we’re here to negotiate. The power of direct care is that bureaucracy isn’t looking over our shoulder extorting us to administer needless procedures just so they’ll pay us, which forces us to try to racketeer our uninsured patients.

No, here, in direct care, we do what we want to do. That means serving patients and keeping the lights on, without someone else’s oversight.

Josh Umbehr is founder, Atlas.md.

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  • http://www.ronsmithmd.com/ Ron Smith

    Hi, Josh.

    Great post!

    “The reality is that 80% of what I see in the ER is “family medicine after hours.” I could just as safely see these patients in my own direct care practice, saving them time and money.”

    ER has changed from emergency room care to expedient, i.e., convenient care. Until triage can at the ER can and will tell patients they can’t be seen in the ER for non-emergent issues that need to be dealt with in the primary care physician’s office, this problem will not go away.

    We’ve trained patients that these are really just walk-in clinics. What could be easier than walking in where you have to be seen rather than play by the rules of any particular primary care office. The ball’s in your court and the patient is in control.

    The patient can no longer be in control, and ERs should be restricted to true emergencies and urgent cares to that which doesn’t rise to that emergent level but which truly can’t wait until office hours.

    I practice Pediatrics this way. For example, if I get a patient call or email that their child’s ear is hurting on Saturday night, I will check their medical records, fax in something for their ears and see them Monday.

    Maybe there should be only certain emergency diagnoses that would be paid on ER claims? I don’t know, but we have to move the base of primary care back to the primary care office and out of the ER.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Dr. Josh, AtlasMD

      Hi Ron, thanks and you’re absolutely right. Its convenient care for the doctors on call and the patients after hours. Unfortunately, most do not realize until they get their bill, just how outrageous the prices are.

      By being available for our smaller number of patients (600 per doc) 24/7, we’re able to help our patients when they need us and help save them money.

      The key part is that by not accepting insurance, we’re able to keep our overhead low (~22% for a 3 doc practice) and pass the price savings on to the patients, their employers and even their insurance.

      • alicia

        Plastic surgery doesn’t except insurance for the most part and it has stayed realistically low. I can foresee a credit card for health care if the out of pocket is to high, similar to plastic surgery modes of payment. A goal would be to have a secondary insurance to cover high expenses. Did the Obama Adm. make this difficult to purchase the enactment of the unaffordable care act?

        • Lisa

          Plastic surgeons are very happy to take insurance for breast reconstruction surgery. It seems to me that during the recent recession, when their incomes from other sources probably dropped, they really pushed reconstruction. Even got a national day dedicated to educating women of their ‘options.’

          By the way, I have talked to many people who are paying less money for insurance under the ACA. Unaffordable? I don’t think so.

    • azmd

      Patients are merely behaving rationally (some of them). The ED provides efficient, thorough care, which they can’t get at their PCP’s office, since their insurance company won’t pay their PCP to provide such care, which is expensive. Their insurance company WILL pay the ED to provide the kind of care that patients want, so that’s where they go.

      Personally, as a physician with private insurance, but a busy schedule, I sympathize. It has become incredibly time consuming to get care through normal channels here in the U.S. There are long wait times for appointments, long wait times once you get to the doctor, even longer wait times to get blood drawn somewhat once the doctor orders it, etc., etc. It once took me a total of probably 20 hours to have one of my children assessed (not that thoroughly) for a complaint of persistent fatigue, and his pediatrician still missed the diagnosis. Those were 20 hours that somehow had to come out of my workday, since no medical facilities or offices other than the ED are open outside of 8-6.

      • Lisa

        Some of the things you say in this post just aren’t universally true. I have conventional insurance & can get into see my doctor (or another doctor in the practice) on the same day basis if needed. Normally, my wait times at the office are not long. Wait times at the lab can be long, but not usually. It depends on the time of day. You can also schedule appointments at the labs. In my area, there are a fair number of urgent care clincs that are open outside of office hours, including holidays, although my doctor’s office is usually open on half days on holidays for follow up visits.

        I would never think of going to the emergency room for something that could be handled through an office visit. because of the waits and expense. $100 co-pay versus $20.

        The ER is used by people who have no insurance because they have to been seen there. People with insurance generally have a good reason to avoid the ER.

  • Ncmedic

    I want so badly to put an ad on the front page of the local newspaper entitled “When (and when not) to Call 911/Go to the ER.” Some of the calls I run as a paramedic simply amazes me. Why on earth would a reasonable human being call 911 and go to the ER for a hang nail? The sniffles? A boil? The answer is simple: because they can. They know the ER will see them any time , day or night, no matter how trivial the complaint. Most folks who use (abuse) the ER do not care one bit about the associated (unnecessary) costs as they have no intention of paying the bills or the government foots the bills. Not to mention the waste of resources and drain on the system. It truly defies logic.

    • Dr. Josh, AtlasMD

      sad but true. I once had a CC of “loss of appetite” that came to the ER at 2am by EMS….frustrating waste of resources.

      • medicontheedge

        Wow… We see these patients by the DOZENS every day.. Like I posted, hospitals/ED’s are directly marketing to this customer base. It’s not about patient care. It’s about market share. Even in a non-profit like the one I work for.

    • medicontheedge

      I have come to the realization that our ED’s are NOT ED’s any longer. They are 24 hour walk-in clinics that are capable of handling emergencies. The hospitals are actively marketing to this consumer demographic. I have come to embrace this. It makes t a lot easier to cope at work every shift. And as long as the insurance companies and state welfare administrators continue to pay these bills without any oversight, it will only get worse. Especially the medicaid crowd. THEY have zero skin in the game, by way of no co-pays. THAT alone would put a throttle on misuse of EMS and the ED.

      • guest

        Yep…I’ll look through patient histories in our EMR prior to surgery. If someone is under 30 and has more than 2 ER visits in 1 year, they’re always medicaid.

        • medicontheedge

          2 visits in a year!?!? Our ED sees a demographics that uses our ED for 20, 30, visits for them and their families. We also have a dozen or so “super users” who hit the 50/60 mark. And not a penny of co-pay or out of pocket for these visits. THAT is the problem.

          • guest

            Corrected my typo. I think we serve a similar demographic: Medicare, medicaid, and no pay.

  • lord acton

    Couldn’t agree more. i am in my fourth year of doing direct primary care and I know that I am saving the “system” boatloads of money. Funny how putting a huge fat layer between the doctor and the patient adds so much cost, huh?

    • Dr. Josh, AtlasMD

      thats great to hear!! congrats!

  • Lisa

    I think the opening sentence in this article is key: Emergency departments in U.S. hospitals see copious patients who aren’t terribly ill, but don’t have insurance and need somewhere to go. However, I don’t think direct care is not going to solve the problem as many of those who use emergency rooms as a clinic don’t have enough money to see a direct pay doctor. Try going to a urgent care clinic or a doctor’s office if you can’t write a check – in most cases, you won’t get far.

    Until emergency rooms can turn away people who don’t need to be seen in an emergency room and workable alternatives are provided, nothing will change.

    • Dr. Josh, AtlasMD

      Lisa, are you familiar with our pricing? The avg DPC clinic like ours charges $10-100/pt/mo based only on age. The membership provides for unlimited home/work/office/technology visits, no copays, all office procedures are free of charge*, wholesale medicines and labs for up to a 95% savings** and even insruance premiums that are 30-60% less. It may not fix everything, but it helps in a lot of places.

      *procedures: laceration repair, ekgs, holter, dexa, ultrasound, biopsies, joint injectinos, cryotherapy, lesion removal, medical lasers, minor surgical procedures, audiometry, urinalysis, strep throat testing….

      ** http://atlas.md/blog/2013/06/you-cant-beat-our-prices-at-atlsmd/

      hope that helps, thanks,

      • Lisa

        Unless I totally misunderstand the direct pay concept you still have to pay for office visits. I know very few families who could afford to pay an additional $1,000 a year/per person on top of charges for insurance premiums, as the direct pay concept does not do away with the need for insurance. The majority of people I know who can afford such models are off younger people and they may not think it is worth while because they rarely go to the doctor.

        • Dr. Josh, AtlasMD

          to clarify, the patients pay for the membership which provides unlimited visits for NO additional fee, no copays (ever) and any office procedure free of charge.

          The only additional fee is meds/labs which we offer wholesale for huge savings. Or imaging which we still get for about an 80% discount.

          The key to our success in the DPC space is taking the value described and helping families and employers lower ins premiums by up to 60% savings. In fact in march we helped lower premiums so much the employees got a raise!

          we base prices on age for a variety of reasons.

          • Lisa

            When I click on the link you provided above it takes me to a link for a web site that sells an EMR, not to a link for clinic.

            I’d like to see your clinics book, to evaluate for myself if it is actually a sucess. It is not at all clear to me whose insurance premiums you lowered.

          • Dr. Josh, AtlasMD

            yes, we post a lot of educational info on DPC clinics at our blog or podcast.

            the patient side / clinic site is http://www.atlas.md/wichita and you can see all of our prices, FAQs, etc.

            We’re an open book, what info would you like.

          • Lisa

            Thanks for the link.

            For many people, paying a subscription fee for direct care practice and for a high deductible insurance policy would still leave them exposed to the risk of medical bankruptcy. How does Johnson Garden Centers deal with that issue? I know the article mentioned the use of HSA accounts, but do the high deductilbe insurance plans Johnson Garden Centers really mesh with the limits of an HSA? Is Johnson Garden Centers contributing to their employees HSA accounts?

            I would like to know what percentage of your patients do not have employer provided insurance. It seems like you are marketing your services to businesses, not individuals.

          • Dr. Josh, AtlasMD

            Thats one of the benefits of this model; 1/3 of our patients have no insurance at all. But now they have unprecedented access to their doctor, no copays, free procedures and medicines that are cheaper they have ever been before.

            And after you include the savings on meds and labs, many people are making money by being a member in a DPC model.

            Yes, we custom design the plans for the high deductible to work with the HSA and the DPC model.

            We also often move employers to ERISA plans (happy to explain) but the take home message is that any money not spent on care is returned to the employer/ee for next years premiums, effectively lowering that expense.

            We market our services to everyone, but businesses a larger purchaser of health insurance.

          • Lisa

            I can see how a DPC plan works for businesses who provide insurance for their employees. However, I am still not sure if it works for their emplyees. If the business does not increase employees salary to cover the need for an HSA, it really is a way of shifting costs to the employee. That has been going on for a long time.

            If 1/3 of your patients have no insurance at all, how do they plan to deal with a major illness or a serious injury? How do they handle a cancer diagnosis? What do they do if they need surgery, say a joint replacement? Yes, they may not be going to an emergency room for routine care, but what happens when they do need emergency services?

          • Dr. Josh, AtlasMD

            Often, the employers who are able to decrease their premium cost, are willing to share the savings with the employees to incentivise them to embrace the cheaper the insurance. Also, did you see the part about the raise? :-)

            How do uninsured every plan for cancer? I can’t fix everything, but i try to fix what i can.

            ER services? see the article we’re talking about :)

          • Lisa

            It wasn’t clear from the article you linked to that the garden center raised their employees salaries.

            What I think is DPC will work for a certian segment of the population. It will be interesting to see if such practices become wide spread enough to make a difference in the demand for ER services.

            But what worries me is that 1/3 of your patients who don’t have any insurance. What happens to them if they have a serious illness? I guess they can always wait until the next open enrollement period and buy incurance via the ACA. At least that way their out of pocket costs are capped.

          • azmd

            It’s not his fault that they don’t have insurance. And his plan at least gives them good access to high-quality primary care. One could argue that they are at less risk for medical bankruptcy if they are getting decent primary and preventive care services.

            In any case, they are at no MORE risk for medical bankruptcy than they were before direct pay care came along, so it’s hard to understand why this keeps being mentioned.

          • Lisa

            Without medical insurance and access to specialist care, I would be unable to walk, would have limited visual accuity and might not have survived my cancer diagnosis. Many people I know have needed treament beyond what a pcp can provide; at some point in their lives, they have had serious injuries or illnesses. So the idea that DPC can replace insurance bothers me.

            The way I see it is DPC is a form of insurance, one that needs to be supplemented with other forms of insurance. There are still affordablity issues.

          • alicia

            I guess it will work for a segment of the population, the rest have the unaffordable care act. This is a great option for families who put aside cash for health care. A blanket fix has not helped our situation. Dr. Atlas is filling a necessary void.

          • Lisa

            I suspect when you pencil it out, the cost of DPC and a high deductible insurance works out to be much the same, given the need to maintain enough cash to cover the deductible.

          • Dr. Josh, AtlasMD
  • alicia

    personally I am traumitized by visiting ER. I ask myself and family, “Do you want to sit in ER with the coughers and masses or wait till we see our dr in morning?” It looks like a breeding ground for the flu or other nefarious diseases. I had a dr s office whent the kids were little that stayed open till 11. Much better than ER

    • Dr. Josh, AtlasMD

      we’re available 24/7 for our patients :)

      met some patients at the office this weekend in <30 minutes to save them an er visit.

  • Lisa

    It is not a ruse. While some people are payign more for insurance, I sispect in most cases they were people who had a high dedictible policy. the policy they got through the exchange has a lower deductible and a out of pocket max that is probably less than their old deductible.

    I couldn’t have bought insurance on the open market due to my health history. While I have insurance through work, I checked what I would pay if I bought insurance through the California exange. I would have paid around $55O/month without subsidies. Many of my friends who did not have insurance through work were able to buy insurance through the exchanges and received subsidies. They now have insurance, which they couldn’t afford before.

    In Calfornia, pre ACA, adults could not be covered by medical except in very limited circumstances. One of my best friends is very low income. She now has insurance for the first time in her life because she now qualifies for medical.

  • Lisa

    Low income people may have had the ability to buy insurance, but only if they could afford it.

  • fatherhash

    not knowing the details of your conditions, i am merely speculating here but…

    how much time did your PCP ever spend with you? many PCP’s are referring off merely because there is not enough time to deal with all the symptoms/complaints a patient may have. insurance essentially reimburses per visit and not for time….so the doctor that takes an hour to deal(completely) with all complaints on 1 visit will likely go out of business.

    the U.S. has a higher % of specialist vs % of PCPs compared to other industrialized countries. our system kinda needs it since PCPs are many times just case managers. IMO, i think PCPs could nail a lot of the diagnosis if they took/had the time to listen to and evaluate the patient….but alas, we live in an insurance system….[enter Dr.Josh]

    • Dr. Josh, AtlasMD

      well said!