Ambulatory Clinics May Help Save the Safety Net

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Editor: As dedicated emergency and ambulatory medicine physicians, we are writing to you out of great concern for the state of emergency care in the United States. We need to do everything we can to ensure that EDs will always be able to provide the emergency care that only they can deliver. Because of their hours of operation and ease of access, they will always be de facto our safety net for any medical problem. Yet, phrases like “serious ED overcrowding,” “unraveling safety net,” and “emergency medicine in crisis” have been appearing quite frequently in the medical literature, and the issue was discussed in at least three medical news publications just last month.1–3 These and other similar articles identify and catalog the supposed root causes: increased patient volume and acuity; decreased ED capacity due to ED closures; decreased hospital bed capacity due to nursing shortages; decreased reimbursement due to increasing numbers of uninsured patients and managed care influences; EMTALA requirements; and decreased access to timely appointments with primary care providers, to name a few. To some extent, all of these are true, but due to their complexity, none will change quickly if at all, and many are far beyond our control as physicians. Whatever the reasons, there has been a steadily increasing need for acute and emergency care services in this country. Though some might perceive the boon as “job security” for hospitals and emergency physicians, ED overcrowding is felt by ED directors themselves to have an increasingly negative impact on patient care.4 Moreover, some of the same forces causing the increased demand for care have resulted in a steadily decreasing capacity to comfortably meet the demand. Even if one were to purposefully buck the prevailing trends and build more EDs, this would take quite a long time and likely prove unprofitable for the same reasons that the previous EDs had closed in the first place. Even adding medical staff, which is more easily and quickly done, does not proportionally increase capacity because of ancillary service and infrastructure constraints. As we instead attack the root causes, we lobby and enlist the aid of legislators, nursing unions, and third party payors, because they have some control over the underlying issues. However, each of these groups rightfully has its own agenda and needs, and the strength of any outcome is accordingly diluted and delayed. It is, of course, extremely important that we as physicians work together with all of those involved in the process of providing medical care to patients. Given the complexity of the business and politics of modern medicine, this involves a lot of folks in many disciplines. Perhaps we would be better served by independently enhancing what we do best, namely caring for patients. If we as a body of physicians focus our resources on developing and fostering those practices that increase the capacity that we (both individually and as a system) have to care for patients, we might be able to meet the challenge of the “unraveling safety net.” For example, information technology provides some tools for improving our efficiency. Techniques for streamlining administrative duties, making chart work easier, and tracking how far along ED patients are in their work-ups all promise to leave more time for patient care. Helping to develop these products and make them economical and widely available would increase our capacity to meet the rising needs for acute and emergency care. Moreover, using some of these tools in an office practice also might provide more opportunity to see patients with urgent, same-day medical needs in this venue. Another technique that would likely increase the capacity of our health care system to handle more patients would be to redirect those who could be cared for in a more simple setting away from the ED. Though methods for determining the exact number are debatable, reasonable estimates of the number of ED patients who could be safely and adequately cared for in a clinic type facility range between 10 and 50 percent.2 Similar care in this type of a facility is usually more quickly provided than in the ED. The result is that a greater number of patients with needs at this level of acuity could be seen per unit of physician time. Though much has been said about the low marginal cost of “treating one more ED patient,”5–7 the price still remains high. A patient (or the payor) seeking care at an ED for a sprained ankle might receive hospital and physician's bills totaling several hundred dollars, even if radiography is conscientiously excluded by using the Ottawa Ankle Rules. The same type of care provided in a clinic setting would be priced hundreds of dollars less, allowing the savings to pay for more care for this patient or others. Because it is a more reasonable amount, an uninsured patient might even be able to pay the bill himself, rather than adding the stress of another uncollectable account to the system to be compensated for by increasing prices further. Lobbying Congress to pass laws to oblige payors to remit $600 to $700 for the care of a minor injury is one solution to the problem, but there might be a better return for our effort if we were to redirect it toward developing a safe, reliable system where patients can receive such care more efficiently and economically. Because of lower overhead, lack of facility charges, and lower professional fees, ambulatory care centers or urgent care centers present an opportunity to provide efficient, lower-priced care to 10 to 50 percent of patients who present to EDs. As well, new capacity of this type can be created more quickly and economically than new ED capacity. A full-service ambulatory care clinic can be capable of caring for 100 patients a day or more, and can be up and running in less than six months. Sometimes referred to as “Doc-in-the-boxes” and perhaps disregarded because of a perception of substandard care, these clinics are indeed being increasingly utilized by patients. In response to this trend a new specialty society has developed and is flourishing. Founded in 1997, the American Academy of Ambulatory Care (www.ambulatorymedicine.org) is an organization dedicated to the development and advancement of the practice of ambulatory care. Through continuing medical education activities and supervising board certification through the American Board of Ambulatory Medicine, the AAAC's goal is to ensure excellence among practitioners of ambulatory care. The Academy also is currently developing JCAHO-type standards to evaluate quality at urgent care and ambulatory care facilities, and is working with the American Medical Association and the American Board of Medical Specialties to have the new specialty recognized and to develop residency programs. Doubtless, there will always be a need for trained emergency physicians, but such training is not necessary for the practice of ambulatory care. In fact, some aspects of ambulatory medicine are outside the scope of emergency medicine practice. In addition to providing a way to develop this specific skill set, the AAAC feels that making the investment in training ambulatory medicine specialists will proportionally add more patient care capacity to our health care system. In closing, we hope you will consider the following when deciding what can be done about the stresses being placed on the emergency care system in the US: ▪ Investigate, develop, and make widely available technologies that streamline the administrative duties that physicians face to increase the time available for patient care. ▪ Study ambulatory and urgent care centers as a venue for caring for many of the patients overcrowding our EDs; evaluate quality, timeliness, and the price and cost of care; and, if appropriate, work to integrate such facilities into the system of health care provided for suitable patients with urgent medical needs. ▪ Work with the American Academy of Ambulatory Care to develop ambulatory medicine as a viable specialty to ensure quality care for these patients and to optimize the capacity of our health care system to meet the rising demands it is currently facing and will likely continue to face. Franz Ritucci, MD Director, American Academy of Ambulatory Care, Orlando, FL

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