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15-minute policy results in few refunds
Payouts are for waits of 20 minutes or so
Representatives at Emerus Emergency Hospitals, a licensed emergency specialty hospital company based in The Woodlands, TX, have been telling patients at several of its "24-hour EDs" for months now that if they are not seen by a physician within 15 minutes, the hospital will pay for their $1,000 visit. So far, the new policy is working quite well, say Emerus representatives.
"In the first six weeks at two facilities we saw 1,500 patients, and only four left without a bill," says Randy Park, MD, director of the facility in Aubrey, TX. "All of those patients were seen in less than 20 minutes, but it was still more than 15 minutes."
If anything, such "failures" serve to strengthen patient satisfaction, says Hemant Vankawala, MD, FACEP, who is a partner and medical director of the Emerus facility in McKinney, TX. "If you wait only 17 minutes and the visit is free not only are you not upset, but you're impressed that we did what we said we would do," Vankawala says.
Park says, "We were looking for ways to let the public know about the changes we have made in our practice of emergency medicine and how it might benefit them. In looking at our performance, it appeared we could make this claim with minimal risk to ourselves because we were already meeting it."
When a patient comes into the ED, front office staff registers them. "If they look like they're in distress, they will page back to the nurse, and they will immediately go to the back," Park says. "If they're relatively stable, they will formally register in the waiting room and wait to be called to the back, but even a complete registration process is only a few minutes."
The offer is made to all patients, regardless of insurance status. When the registration process is complete, the patient is given a stopwatch to time how long it takes to see a physician, he says.
There are several aspects of the Emerus approach that make it easier to deliver on the 15-minute promise. For example, Park notes, Emerus employs a significant amount cross-training. "Our work environment is good, and people will do other chores, which eliminate a lot of time losers," he says.
In a traditional ED, the doctor sees a patient, orders labs and EKGs, and a different person performs each of those tasks, Park points out. As a result, you have to wait for one person to finish a test before the next one can be conducted. "We cross-trained our nurses so that one nurse does all those things, and there's no waiting between the order and the steps," he says. "Those handoffs and waiting for ancillary persons to arrive are critical in a lot of EDs."
In a large traditional hospital, each department such as the lab is separate from the ED, notes Vankawala. The focus of those departments is to run inpatient services, he says. The radiology tech is accountable to the department of radiology, and the nurse is accountable to the nursing department, he says.
"In our facilities everyone is immediately accountable to the corporate vision, which is to provide high-quality ED care," Vankawala says. "Everyone reports up through the ED."
Park adds, "Our radiology tech is right in the department with us." Park and Vankawala are experienced, board-certified ED physicians who have worked in a variety of clinical settings, from busy trauma centers to tents in New Orleans for Hurricane Katrina.
From a practice standpoint, says Vankawala, he actually had to re-set his "internal clock" in the new environment. "In a traditional setting, if you saw someone in abdominal pain, you'd order labs and CAT scans, and that would take four to six hours," he notes. In that time, most patients would get better or stay worse and be admitted, Vankawala says. "In our ED, I get them back every 45 minutes," he says. "That's a good problem to have."
Because of that system, "the average dwelling time in our department is less than 50 minutes," Park says. In addition, he acknowledges, the Emerus facilities do not have to cope with poor bed availability on the inpatient side. (The compensation program for physicians allows for a lighter patient load, notes Park. See the story below.)
Charging holds is key to staffing
The reimbursement policy used by Emerus Emergency Hospitals, a licensed emergency specialty hospital company in Texas, impacts its staffing policy and is one reason it's able to guarantee patients will be seen by a physician within 15 minutes, says Randy Park, MD, director of the facility in Aubrey, TX.
"In most hospital-based EDs, the charging is done in two areas: the facility side charge and the physician charge," Park says. "The hospital bills for the facility side charges include ancillary services, while the doctor only bills for what he does."
Such a policy means that out of the $1,000 the average patient pays for a visit, the physician receives less than $200, he says. This system, in turn, puts pressure on the doctors to see about four patients per hour to achieve the compensation they require. "If you imagine I am able take care of four patients per hour, when 12 patients come in, the other eight have to wait," says Park, pointing to that issue as one of the causes of ED crowding.
By involving physicians in the ownership of the EDs, "we've been able redistribute those funds," he says. "We recognize the traditional approach as a misuse of funds, and we want to give those funds to the people who actually do the work."
Accordingly, he adds, "we do not staff down to keep doctors busy all the time." Thus, when an abnormal number of patients present, the ED has enough reserve capacity to see them.
Hemant Vankawala, MD, FACEP, who is at the facility in McKinney, TX, says, "We actually operate under our capacity most of the time. In most traditional hospitals, they operate at or near their capacity continually, so when they do get a surge they are overrun. When we get a surge, it is well within our reach."
In most EDs, they aim for 10 acute care beds or so, Park says. "In ours, the most beds we have in one facility is eight, and we generally use four as primary and the other four are extra," he says.
For more information on seeing ED patients quickly, contact: