One evening in February 2017, Sarah Dudley\u2019s husband, Joseph, started to feel sick.<\/p>\n
He had a high fever, his head and body ached, and he seemed disoriented, she said. The Dudleys had a decision to make: go to the hospital emergency room or to an urgent care clinic near their home in Des Moines, Iowa.<\/p>\n
\u201cERs take five, six, seven hours before you\u2019re seen by a doctor, depending on how many people are there,\u201d Sarah said. \u201cI know that I can go to an urgent care clinic and be seen within an hour.\u201d<\/p>\n
According to court filings, at the clinic, a physician assistant misdiagnosed Joseph with the flu. His condition worsened. A few days later he was hospitalized for bacterial meningitis, and he was placed into a medically induced coma. He had multiple strokes, lost hearing in one ear, and now has trouble processing information. The Dudleys sued over the error and a jury awarded them $27 million, though the defendants have asked for a new trial.<\/p>\n
Their story reflects a challenge in the American health care system: People who are injured or sick are asked, in a moment of stress, to prudently decide which medical setting is the best place to seek help. And they must make that choice amid a growing number of options.<\/p>\n
Landing in the wrong setting can lead to higher and unexpected medical bills and increased frustration. Patients often don\u2019t understand what kind of services different settings provide or the level of care they need, and an uninformed choice is \u201ca recipe for poor outcomes,\u201d said Caitlin Donovan<\/a>, senior director at the National Patient Advocate Foundation, a patients\u2019 rights nonprofit.<\/p>\n \u201cWe\u2019ve created this labyrinth health care system that is functioning to maximize profit,\u201d Donovan said. \u201cIt does that by creating an ambiguous system that\u2019s difficult to navigate, that\u2019s constantly shoving more costs on the patients.\u201d<\/p>\n But revenue-driven and risk-averse operators of sites that act as alternatives to hospital emergency rooms have little incentive to make the process easier for patients.<\/p>\n \u201cWe live in a fee-for-service world, so the more patients you see, the more money you make,\u201d said Vivian Ho<\/a>, a health economist at Rice University. \u201cIf you\u2019re going to be opening one of these facilities up \u2014 even if you\u2019re a not-for-profit \u2014 you\u2019re looking to bring in revenues.\u201d<\/p>\n The number of urgent care clinics in the U.S. has grown by about 8% each year from 2018 to 2021, according to the Urgent Care Association. But the services and level of care offered can vary widely by clinic. In its current strategic plan<\/a>, the industry group says it\u2019s working to help a wider audience understand what counts as urgent care.<\/p>\n Concentra<\/a>, which operates urgent care clinics in the eastern and central U.S., advertises its ability to care for allergies, minor injuries, and colds and flu. CareNow<\/a>, another major urgent care player, says its clinics can treat similar issues, but services may vary by location. According to the American Academy of Urgent Care Medicine<\/a>, some clinics offer labs and X-rays; others have \u201cmore advanced diagnostic equipment.\u201d<\/p>\n Ho said urgent care clinics can provide quicker access to cheaper care. Free-standing emergency departments, on the other hand, tend to charge considerably higher prices<\/a> for similar services, she said.<\/p>\n Free-standing emergency departments are increasingly common<\/a>, though data on their exact numbers is murky. Some are owned by hospitals, while others are independent; some are open 24\/7, others aren\u2019t. While they\u2019re often staffed by doctors with emergency medicine training, many don\u2019t offer trauma services or have operating rooms onsite<\/a>, even as they<\/a> saddle patients with large bills.<\/p>\n Patients didn\u2019t always have so many options, said Ateev Mehrotra<\/a>, a professor of health care policy at Harvard Medical School. Despite all the choices, he said, the health care industry tends to direct patients to the highest and most expensive level of care.<\/p>\n \u201cWhat is the thing that you probably hear when you call your primary care doc while you\u2019re waiting on hold? \u2018If this is a life-threatening emergency, please call 911,\u2019\u201d Mehrotra said. \u201cRisk aversion is constantly pushing people to the emergency department.\u201d<\/p>\n Federal law requires emergency departments at Medicare-participating hospitals to care for anyone who shows up. The Emergency Medical Treatment and Labor Act, also known as EMTALA<\/a>, was created in 1986 in part to prevent hospitals from transferring uninsured or Medicaid-covered patients to other facilities before stabilizing them.<\/p>\n But the lack of clear guidelines on enforcement of the law sometimes stops emergency department doctors from redirecting patients to more appropriate facilities, physicians said. The law doesn\u2019t apply to urgent care clinics and applies inconsistently to free-standing emergency departments.<\/p>\n The law makes hospital-based ER doctors nervous, said Ryan Stanton<\/a>, an emergency medicine physician in Lexington, Kentucky. Those who would like to direct patients to settings with lower levels of care, when appropriate, worry they may run afoul of EMTALA.<\/p>\n \u201cIt is meant to protect the consumer,\u201d Stanton said. \u201cBut it has the downstream effect of: There\u2019s things I would like to be able to tell you, but federal law says I can\u2019t.\u201d<\/p>\n Stanton said EMTALA could be updated to allow hospital emergency room doctors to be more open with patients about the level of care they need and whether the ER\u2019s the best \u2014 and most affordable \u2014 place to get it.<\/p>\n The Centers for Medicare & Medicaid Services, the federal agency that enforces the law, said it is willing to work with hospitals on how to communicate with patients but did not elaborate on specific initiatives.<\/p>\n Efforts to educate patients before they seek care don\u2019t always clear up confusion.<\/p>\n Take, for example, urgent care chain MedExpress<\/a>, which offers a list of conditions it treats and a guide for when to seek more intensive care<\/a>.<\/p>\n Karolina Levesque, a nurse practitioner for MedExpress in Kingston, Pennsylvania, just north of Wilkes-Barre said she still sees patients with serious health warning signs, such as chest pain, who require referral to an emergency room. Even those patients are frustrated when they\u2019re sent somewhere else.<\/p>\n \u201cSome of the patients will say, \u2018Well, I want my copay back. You didn\u2019t do anything for me,\u2019\u201d Levesque said.<\/p>\n Some patients, like Edith Eastman of Decatur, Georgia, said they appreciate when providers realize their limits. When Eastman got a call last February that her daughter had hurt her arm at school, her first thought was to take Maia, 13, to an urgent care center.<\/p>\n A local clinic had cared for Maia when she broke her arm previously, and Eastman figured providers there could help out a second time. Instead, worried the fracture was more complex, they referred Maia to the emergency room and charged $35 for the visit.<\/p>\n \u201cThe urgent care said, \u2018Look, this is above our pay grade.\u2019 It didn\u2019t just patch her up and send her home,\u201d Eastman said.<\/p>\n All parts of the health care system need to play a role in clearing up the confusion, advocates say. Insurance companies can better educate policyholders. Urgent care clinics and free-standing emergency rooms can be more transparent about the kinds of services they offer. Patients can better educate themselves to make more empowered decisions.<\/p>\n Otherwise, solutions will be piecemeal \u2014 like the short-lived ad campaign run by BayCare<\/a>, which operates hospitals and urgent care centers around Tampa, Florida. Launched in 2019, the effort to educate patients went viral.<\/a><\/p>\n \u201cI have the flu: urgent care. I have the plague: emergency care,\u201d one ad read.<\/p>\n Helping patients self-triage means BayCare can reserve its more expensive ER resources for patients who really need them, said Ed Rafalski, the system\u2019s chief strategy and marketing officer.<\/p>\n But other hospitals, he said, see only competition in other players entering their markets.<\/p>\n \u201cIf you have a free-standing urgent care facility open across the street from your ER, you\u2019re going to lose certain portions of your business just by the fact of them being there,\u201d he said.<\/p>\n Donovan, the patient advocate, said that kind of mindset perpetuates confusion that is ultimately harmful for patients.<\/p>\n \u201cIf you break your leg, it\u2019s not reasonable to be like: \u2018Did you Google whether urgent care or ER is appropriate?\u2019\u2019’ she said. \u201cNo, you just need to get care as quickly as possible.\u201d<\/p>\n