Increasing hospital revenues through urgent care referrals

Not long ago, Tracy Hume, a freelance writer who lives in Greeley, Colorado, sent me an email posing this question: “Do ER-affiliated urgent care providers ever try to escalate patients to the ER when it is not medically necessary?”

It seems that over the July 4th weekend, Tracy’s teenage son was complaining of a headache, nausea and abdominal pain, and was vomiting. He doesn’t complain much, she said, so thinking that maybe he was seriously sick, she took him to an urgent care center that was part of her insurance plan’s network.

A clerk asked about his symptoms, but instead of letting him see a doctor at the center, she quickly referred him to the emergency room, across the street, that just happened to be part of the same hospital system as the urgent care center. The clerk told Hume that since her son was experiencing abdominal pain, he needed a CT scan. The urgent care center did not have the capability to do one.

Hume thought twice. The urgent care center co-pay was $75; at the ER it was $250. Plus, no one at the urgent care center had bothered to examine her son to see if he even needed a CT scan, an overused procedure, especially in the nation’s emergency rooms. In today’s ERs, patients are getting scans at rates five times higher than in the mid-1990s. Dr. Rita Redberg, a cardiologist at the University of California San Francisco Medical Center, has pointed out, “CT scans, once rare, are now routine. One in ten Americans undergoes a CT scan every year, and many get more than one.”

Never mind the wasted health care dollars! Think of all the unnecessary radiation that patients who don’t need CT scans are getting. Redberg says, “The rate of medical imaging using high doses of radiation, particularly CT scans, has increased more than sixfold between the 1980s and 2006.”

What’s causing this overdose of CT scanning? Doctors’ fears of malpractice claims are one factor, for sure, but there is also pressure on facilities to use them. Once hospitals have invested in CT scanners and other imaging equipment, they need to utilize them to recoup their costs and generate revenue.

Was this urgent care center sending some patients to its related hospital ER, clearly a place of high-priced care, to gin up revenue for the system’s bottom line? Hume told me that the two hospital systems in Greeley, a city of about 100,000 people, are aggressively competing for business, and each one has built “fancy, fully-equipped new emergency rooms” located on the affluent side of town within two miles of each other.

If cross-marketing of services works in banking and other industries, why wouldn’t it work in hospitals? Worried moms just might bite and take their kids across the street for a CT scan, especially if the required co-pay or co-insurance were not a drain on the pocketbook.

In a 2011 report for Kaiser Health News, Phil Galewitz wrote that hospitals are using “aggressive marketing of ERs to increase admissions and profits.” That’s also what’s behind all those new digital billboards — the ones advertising short ER wait times.

Hume’s experience with her son’s illness suggests that referring patients from urgent care centers might be a logical source of additional revenue for emergency rooms. She wrote, “I sometimes wonder if the hospital is using the urgent care center as a front just to shuttle people over to the ER and increase their ER utilization numbers. Which seems ridiculous, as overuse of ERs is purported to be one reason health care costs are escalating.” One reason for health reform was to help people access insurance so they would go to a doctor’s office instead of flocking to expensive emergency rooms.

Do marketing and the prospect of profits trump a much-touted principle of the Affordable Care Act? What’s a patient to do? Maybe this is one time shopping around for health care might really mean something.

Since this wasn’t an acute emergency, Hume had time to take her son to another urgent care center not affiliated with either hospital system. That center accepted her $75 co-pay, a physician’s assistant examined her son, asked him about his symptoms, felt his abdomen, diagnosed gastroenteritis and prescribed anti-nausea medication. He was fine in a couple of days. No CT scan, no unnecessary radiation, no expensive co-pay.

Trudy Lieberman is a journalist and an adjunct associate professor of public health, Hunter College, New York, NY. She blogs on the Prepared Patient blog.

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  • Hexanchus

    Where in the OP did it say that it was an “acute onset” situation?

    To the contrary, it said the symptoms developed over the weekend (sounds like over time?), and specifically stated “Since this wasn’t an acute emergency, Hume had time to take her son to another urgent care center not affiliated with either hospital system.”

    And since when are clerical personnel qualified to judge the seriousness or nature of a patient’s symptoms and recommend specific tests (because he had abdominal pain he needed a CT scan)?

    The sad fact of the matter is that our health care system is not run by medical personnel, but by bean counters – who are guess what….profit driven. The medical industry is a huge multi-trillion dollar business and is very focused on maximizing revenue. While patients may trust their physicians, they have every reason to be very wary of the business side of medicine.

    I do agree with the comments about CYA driven testing, and the desperate need for serious tort reform.

    • James Pookay

      Semantics I suppose, but I’m using acute-onset as a synonym for recent/new problem, not for level of intensity. Starting within the last few days is “acute” in my world.

      The acuity (seriousness) of my average walk-in patients is obviously my much lower than an ER doc. But as a GP, I still constantly see undifferentiated strangers whom present to me, where my first order of business is usually “How long/Has this been worked up before/Why now?”

      The main issue with most systems, especially single-payer like Canada, is long waits as the MDs time/attention is always the bottleneck. Of course you want the MD to tell you if you are in the right place, but a bare minimum face-to-face assessment is required to give an answer and you may wait a long time to get it. It’s chicken and egg.

      I’m always amazed by two thing
      1) How good my MOA is at triaging/scheduling without any clinical training. I just assess the next person on my list, she is the one whom makes the order and it’s pretty bang on
      2) When oblivious patients give my MOA a hard time. Don’t they understand that she is effectively my boss and gatekeeper? She decides whom I see, how many and when. Best to stay in her good books if you want to keep timely access to me.

  • Lisa

    If the mother had taken her son to her primary care doctor, assuming she had one, would the primary doctor have automatically sent the him for to the ER or ordered a CT scan? I strongly suspect a primary care doctor would have examined him to determine if any additional testing was necessary.

    Given the information provided by the OP, of two competing hospitals with new emergency rooms competing for patients/revenue, I can believe the referral was not based solely on medical need.

    One more thing, I think those signs that advertise waiting times at ERs should be banned. Seriously, if you have an actute problem you aren’t going to wait until the wait time is less. You are going to head to the ER, and pray you are seen as soon as possible.

    • JR DNR

      Unfortunately, I was actually sent to the ER for a CT scan by a primary care physician for abdominal pain that had passed. The resident told me I didn’t need one, and I said “great can you let my doc know” – he rolled his eyes, left, and they gave me the CT scan anyways. They injected me with some chemical – still no clue what it was, what the risk of that were. I thought I was getting an MRI, so I had no clue I was getting a dose of radiation either.

      I only went because the doctor told me “it could be that your appendix burst and you are dying before my eyes!” but my current doctor reviewed the notes and agrees the CT was completely unnecessary (I didn’t have a fever or any other signs of infection. Ultimately I was diagnosed with celiac disease, but I got severely ill before getting that diagnosed.)

      • Lisa


        Although the on flip side, my son has ulcerative colitis and a CT scan (he went to the ER with abdominal pain) is what led to his getting diagnosed. Long story but his doctor thought he had IBS and didn’t order a colonoscopy until my son had the CT scan.

        • JR DNR

          I guess for me this situation was a case of a doctor just not listening to me or believing me, she ran tests on me without my consent, etc. I was young and she told me I had not right to refuse any tests, and I didn’t know any better. She didn’t even tell me what she was doing. I only know I was given a pregnancy test because it was in the medical bill. I just wish she’d listened to me and discussed what tests she wanted to do.

          • rbthe4th2

            There is your trust factor … or shall I say the lack thereof?

  • logicaldoc

    Basic mistake from the start: Front non-Medical, non-Triage Staff should not be making medical decisions and recommendations. Period.

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