No hospital, just an emergency ‘department’. They’re popping up all over | Hacker News Reader

No hospital, just an emergency ‘department’. They’re popping up all over

tampabay.com

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>But critics say that having too many emergency departments in one community reduces the quality of care because it shrinks the amount of practice that local trauma-trained physicians get when treating complicated injuries. A similar argument was made when Northside Hospital tried to open a trauma center earlier this year, but withdrew after two other area hospitals with trauma centers contested the expansion.

A spin on the Roemer Effect it seems. Florida apparently has a Certificate of Need policy.

I would guess the major motivation for this is that the ED is one of the most profitable parts of the hospital? The article kind of hints at it, but doesn't really go out and say that.

In my experience it is often a "loss leader". ERs have to treat everyone, including the large number of people who are never going to pay a cent. However, by getting people in the door, you then control (for all intents and purposes) where they go if they need to be admitted.

ERs lose money for real hospitals.

Standalone ERs are borderline insurance fraud and make lots of money.

Just look at the financial reports for hospitals using the standalone ed's. They are very profitable.

On the contrary, ER is expensive and a loss leader.

That's one reason why increasingly popular ASCs (Ambulatory Surgery Centers) charge significantly less than full hospitals for the same procedure: they don't have the overhead of maintain emergency capabilities.

Stand-alone emergency departments are definitely a good thing. At least, the kind we have in Redmond is.

The "main" hospital is about 5 miles away from the stand-alone ER, both run by the same company. They have the full compliment of equipment and physicians you'd expect, and can handle most serious scenarios there. And most importantly, there is never a significant wait, while the hospital is usually very busy. If you need to be admitted, they ambulance you to the main campus at no charge.

There really is no downside. You get the part of the hospital that matters, in more places. The only problem seems to be that people don't realize that they're available, so the ER at the primary campus is still overcrowded.

Are these ERs or Urgent Care depts?

In essence they're urgent care clinics that follow the regulations of an emergency department, and therefore are able to bill as one.

The core components that I'm aware of:

- An urgent care clinic can be staffed with just a nurse practitioner on duty. An ER requires a full doctor on duty at all times.

- An urgent care clinic can close. An ER has to be open 24 hours a day.

- An urgent care clinic can decline to see patients. An ER is legally obligated to accept all patients in need of critical care, regardless of ability to pay.

- In some states, a freestanding ER has to have the word 'Emergency' in it. Although that's not a requirement in every state.

- In some states, a freestanding ER has to be affiliated with a fully fledged hospital. Although that's not a requirement in every state. And being affiliated with a hospital doesn't actually mean you're owned by said hospital.

"Upgrading" an urgent care clinic to a freestanding ER is effectively just a logistics concern. Adjust your staffing schedule to have a doctor on duty 24 hours a day, train your front desk on a new intake process that ensures you don't accidentally turn down indigent patients you're legally obligated to see, and you're good to go. In a few states, add on the additional steps of incorporating the word Emergency into your name and possibly pay a nominal licensing fee to borrow a hospital's name for affiliation purposes.

Then, it's as simple as implicitly exploiting the consumer confusion that ensues for a decade or so, until the regulatory and insurance environment (hopefully) catches up with the practice.

FTA "... but residents should know that they can't stay there overnight for care. Such facilities operate in a space between urgent care clinics and regular emergency rooms, the latter where patients can be quickly admitted into hospitals..."

So somewhere in between I guess?

I find it quite ridiculous to expect people to keep track of these nuances. Especially considering this is people who are severely ill, or maybe panicking about being ill.

The advertisements for these sites is unusual. Actual examples of appropriate use according to one of the operators:

- Stomach pain

- Wounds that won't heal

- Shortness of breath

- Bleeding that doesn't stop (minor bleeding illustrated by the cartoon)

> maybe panicking about being ill

This, except for the shortness of breath.

EDIT: copyedit

Where I live there are both. The word on the street (thankfully no firsthand experience) is to pay attention to the name if you go there for a sprained ankle. If it says "emergency" in the name, you're going to pay a LOT more.

Why would you go to an emergency room for a sprained ankle anyway? Doesn't seem like an emergency.

In general, why would a _patient_ be expected to know what's an emergency and what isn't? Isn't that health care professionals' job to determine?

Some things might be obvious (although what seems obvious isn't to everyone equally), but in general, there are lots of times I have no idea if something is an emergency or not. That's what I want a doctor to tell me!

If you make people (sick/injured people at that) choose themselves, guarantee they are going to choose wrong sometimes in both directions -- including something that really _was_ an emergency, and they avoided the emergency room through lack of medical knowledge or fear of being billed for it, and suffer harm by lack of timely proper care.

Do people get a lot of education on what constitutes an emergency vs what can be treated at an urgent care? I certainly don't remember getting taught much.

In my experience, an Urgent Care feels more like a screening room to real medicine than a place where treatments can occur. If you think you're sick, you might just go to the ER because they have everything there.

An urgent care is largely for things where you would see your primary care physician, but they are closed, on vacation, or don't have appointments available (urgent cares usually can do more treatment and diagnosis on site than your PCP, but your PCP would screen and refer) without excessive delay.

An ER is largely for “I might imminently die if this issue isn't addressed”. Not necessarily an imminently life threatening condition, but symptoms that suggest that might reasonably be the case.

For doubtful cases, if your primary care physician (usually, their medical group) has a 24-hour nurse advice line, it's good to call them (both for direction, and often because they need to authorize urgent care, so calling them first avoids delays.)

Many people lack the knowledge about what an ER is for. If they don’t learn in their own, the bill and the experience teaches them quickly.

ER is for critical issues. If you have time to think about where you should go, it’s probably not the ER.

ER is like 40% serious stuff and 60% bullshit. My brother is a fireman — there are even people who use it as a cheap, high latency way to get a free cab voucher.

Urgent care is a place to deal with lesser acute issues that cannot wait for you to go to a primary care doctor.

In my view, there should be no need for such a distinction, unless it's to conduct some sort of financial chicanery.

I once went to the ER for something. When I walked in, I went to a desk, where a person asked me some questions and directed me down a corridor to an urgent care facility on the same premises.

  When I walked in

If you were ambulatory and not bleeding or in other visible distress, that's basic triage.

What we now call Urgent Care used to be called "Ambulatory Emergency" by Kaiser in the 1970s.

Indeed, and I think the ability to triage incoming patients can be part of the model for how an emergency facility works.

> I once went to the ER for something. When I walked in, I went to a desk, where a person asked me some questions and directed me down a corridor to an urgent care facility on the same premises.

I've had that happen as a Kaiser patient at a Kaiser hospital, but not seen it otherwise. As I understand, it's rare because:

(1) colocated ER and UC are rare, (2) even when they are present, they may be distinct businesses such that one cannot rely on the other, (3) ER mandates create liability if a person needs medical stabilization and is turned away without seeing a doctor on-duty in the ER.

Where they occur, I think it is because the urgent care is actually legally conjoined to the ER, such that the cross-referral from triage is still within the ER from a regulatory standpoint.

Actually, a lot of people go to "emergency rooms" for rudimentary care.

I'd bet that most people don't know the difference between "Urgent Care" and "Emergency Rooms".

Because there's a standalone emergency room located in the shopping center by your house, and you don't realize it isn't just an urgent care center.

Which in turn is probably because only a few years ago, emergency rooms were essentially only located in hospitals, and you don't realize anything has changed.

Because you might not be an expert in technical medical lingo, so you go to the nearest place with doctors.

Urgent care is just a doctors office and are unable to do many things. If you mention that you may have a serious ailment before registering as a patient, they will often ask you to leave the office and call 911.

> Patients in states like Texas and Colorado have reported receiving bills for thousands of dollars from emergency departments

If you’re paying more than several hundred dollars for non-admitted treatment you’re being swindled. Outside a few treatments such as dialysis and chemotherapy anything that expensive warrants admission.

> swindled

Do people generally have a choice what ER they go to? I’ve definitely seen people complain on the internet because they were passed out on the sidewalk and someone called an ambulance on them which stuck them with a large bill.

This always raises an interesting question about the concept of charging someone for a service that they did not have an opportunity to ask for or consent to until after the fact.

On one hand, you have doctors wanting to save or improve someone's life. On the other hand, especially when death is the result despite attempts to safe the patient's life, the person/estate has now incurred a cost that was potentially undesired.

We (EMS) operate under "implied consent" in those cases. If someone is incapable of consenting to treatment, we assume that they would want to treated (because that's a better failure mode than not treating someone who does want it).

The issue here is that we as a society recognize different standards of consent. In the framework of Medical Consent, if someone is unconscious, then they are implicitly consenting to medical treatment[1][2]. I don't have any background in contract law besides occasionally reading /r/legaladvice, but it seems unlikely that that matches our common-law concept of consent to a contract. So where does that obligation to pay for the ambulance come from? It doesn't exist in the UK, but did it before 1948? Are there statutes in US states which create that obligation?

[1] First aid training my MIT's Office of Emergency Management

[2] First Aid training my St. Johns Ambulance in London.

Yes, you can ask to be taken wherever.

I grew up in a rural area and it was a big deal, because the volunteers were EMTs only and meeting the county paramedic could cost $500, and sometimes they would ask for air transport, which was either free (provided by state police) or $5,000+, depending on the day. Insurance pays $0 if you are not admitted.

> Do people generally have a choice what ER they go to?

Yes, people often take themselves to an ER and have more than one within reasonable range.

> I’ve definitely seen people complain on the internet because they were passed out on the sidewalk and someone called an ambulance on them which stuck them with a large bill

The majority of ER visits are not people who had an ambulance summoned when they were unconscious, but, yes, in that case people generally don't have a choice about whether they go to an ER or which one.

There's plenty of scans that cost more than that on their own. I got dramatically run over as a pedestrian and while I turned out fine (for heavily bruised values of fine), I was certainly happy for them to verify that with a CAT scan and some xrays of the more scraped up limbs instead of have them say that it was probably just shock and since I couldn't remember if I had hit my head we could assume it was ok.

Heck I went to the er for chest pains and what felt like an irregular heartbeat when I was 24. Had and ekg and everything. Was still around $300 (after jnsurance) even tho I was fine and it turned out to just be anxiety and dehydration.

There is no way I should be convinced by some fucking insurance company that something like this would be better seen in urgent care. What about the 0.1% of people where it actually is serious?

What if that allergy to peanuts your kid has is actually life threatening? You want the most comprehensive care available at the time available ASAP.

I saw these fake emergency rooms all over Texas in strip-malls. They shouldn't be allowed because they don't have the staff or resources to provide adequate care and delay life-saving interventional medicine.

Yeah, I'm going to disagree. I visited one just today while traveling, and it was a (figurative) life saver.

I deal with cyclic vomiting syndrome, and when an episode hits, about only thing that stops it is a promethazine injection. Last night's episode had me retching every 5 minutes, starting from around 8pm. I figured since the nearby urgent care centers were closed, I'd suck it up and puke til 8am. By around 3am I gave up and was looking into where the nearest ER was. It turned out to be an ED as described in the article.

Within 10 minutes of arriving, I was already through triage, and talking to a doctor. Within 20 minutes, I'd been poked, and another 20 until I was out the door. To top it off, I was expecting the $200 co-pay that comes from a normal ER visit, but was instead met with only a $75 co-pay.

I'm gonna say this is a huge win over the alternatives.

In the UK a private prescription for this costs £1. It's IM so anyone can administer.

And FWIW, get yourself a pack of the suppository version of this. Sounds like it'll save you a lot of inconvenience and money.

This is simply not true, at least for the ones I've been to. They typically contain beds, a lab, and their own OR suite. They actually have extra overhead since they are self contained and do not have other departments to lean on. They are located in areas far from their main hospital, essentially extending fast emergency service to those regions. If patients need additional services they are transferred to the main hospital.

This may be the case at the ones you've been to but the ones referred to by the article are all within 5 miles of existing, thriving major hospitals.

This is exactly right. I live in a large TX metro area and we're inundated with these "ER in a Box" facilities. We also have at least three major full service hospitals in that 5 mile radius. The majority of these places are just a re-branding, with higher fees, of the older "Doc in box" model. Over and over again we hear stories of people visiting these places for fairly minor things, like stitches or back pain that are slapped with $2000 bills because they are "out of network" or coded as ER visits. If you have a real emergency, they call 911 and have you transported.

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