Today I came across a blog post (http://www.kevinmd.com/blog/2013/03/working-urgent-care-center-assault-soul.html) by Richard Young, MD. He is an attending physician for a resident who wrote an email to him for some “mentoring advice.” The resident physician had been moonlighting in an urgent care center and complained that he had been taken aside and spoken to about not prescribing enough antibiotics and not doing enough testing.
The attending responded with a diatribe, based on his misperceptions about urgent care. I may respond to the antibiotic issue in another post, but for today I will list several of his misperceptions and respond to each:
“…unethical urgent care facilities. They’ve sprouted up like mushrooms all over the country in high income zip codes.” It is true that Medicaid rates generally can not support full-service communities, so communities with a majority of the population without insurance or on Medicaid can not support urgent care. However, most communities in America can financially support and benefit from urgent care services, and recent years have seen a tremendous growth in urgent care centers in lower-income rural communities. For example, Rapid Care in TN has opened nine centers (in modest-income, rural communities) in the past four years.
“They skim the easy work – they sew up the laceration in an inebriated person, but take no responsibility for the alcoholism, depression, and high blood pressure – and overcharge for the easy work to boot.” This is an interesting condemnation. Most family practice docs no longer perform laceration repairs and generally refer out laceration repairs. Those family docs who will repair lacerations are generally not available to provide services on evenings and weekends, when the lion’s share of these lacerations occur. Without a local urgent care center, the only option for care is the local hospital emergency department. The hospital ED will almost never address the other medical problems. Physicians in both locations are likely to refer the patient for care of other medical problems. Many urgent care centers, also, have primary care services and may even follow up the medical problems in the same clinic. The hospital ED will, also, suture the laceration, but the charges will be about three times the rate of an urgent care center. Doesn’t sound like “skimming” or “overcharging” to me.
“[Urgent care doctors] over-prescribe antibiotics…. This contributes to antibiotic resistance across the country.” Now, granted, many urgent care docs do over-prescribe antibiotics, but I can not tell you how many patients have told me over the years that their own primary care doctor “always gives me [name the antibiotic] for this minor viral or non-infectious issue. Patients with “scratchy throats” and “headaches” for several hours were convinced that they had early strep or sinus infections (most were really migraines). Why were they so sure? Because their doctor always gave them an antibiotic, and they were always better within a few days. Of course, they would have been better within a few days anyways, but the doctor (and the antibiotic) got the credit. Thus, antibiotic overuse is a real problem. Many studies show it to be very common in primary care offices, and I am unaware of any study that shows this problem to be more common in the urgent care setting.
“…Medicaid will pay $150 to one of these facilities, but only $70 to a family medicine center….” Our billers bill for urgent care centers in 34 states. I do not know of a single Medicaid carrier in the USA that will pay anywhere near this much for a typical urgent care visit. If they did pay this much, you can be sure that urgent care centers would sprout up in the poorest inner-city neighborhoods, and the crowding of inner-city hospital emergency departments would be alleviated.
Dr. Young’s final point is very well taken, and should be a lesson for all physicians in urgent care.
“Physicians should be supported when they do the right thing, even if it means they won’t get a “5” on their patient satisfaction scorecard. Denying requests for antibiotics for colds, MRIs for acute low back pain, and hydrocodone for minor injuries are some of the difficult conversations that ethical physicians should have with their patients. A dissatisfied patient who had demanded antibiotics for a cold is the best outcome.”
Well said! In urgent care, and in every other practice, doctors should do the right thing. Now, learning how to do this in a way that educates rather than alienates is an art that requires tremendous skill and practice–but that is a topic for another blog.