ED fast tracks flourish but reveal their limitations

Making clinics cost-effective is a challenge, and some hospitals may be misusing their services

On-site urgent care centers (UCCs) have turned out to be an effective solution to relieving ED overcrowding. Now physicians are trying to keep these so-called "quick-and-easy" fast-track programs in proper perspective.

"I'm a big believer in them," reports David J. Pillow, MD, director of emergency medicine at St. Paul Medical Center in Dallas, TX. "The system cuts waiting time and boosts patient satisfaction, which keeps the health plans happy. And it's basically a no-brainer," he adds.

The fast track at St. Paul has reduced waiting times for nonurgent patient cases to one hour from the usual 1.5-3.5 hours for the ED. On a busy day, the track funnels as many as 1500 patient visits through the hospital without resorting to a separate, dedicated department.

Fast tracks get used as dumping grounds

"We do it all internally, right through the emergency suite," says Pillow. "The triage nurse stamps the patient's chart with a red FT [for fast track], and places the patient in any one of our 14 rooms. The staff then know which patients they can get out the fastest," he adds.

But fast tracks aren't always being put to such sterling uses. Some hospitals have employed them as dumping grounds for undesirable Medicaid or indigent cases. Others have reserved them for patients at the other extreme, segregating the more lucrative self-pay patients from the heavily discounted or capitated managed care enrollees.

Emergency physicians tell of these practices but are reluctant to name specific hospitals. What they are willing to acknowledge is that the walk-in centers have become flexible enough for a hospital to put fast tracks to more than one objective.

All this raises the question of the economics of fast tracks. Are they financially a good idea for a hospital?

"If you're doing things right, they can pay for themselves. But that's about it," says Sharon Spreitzer, manager of emergency trauma services at Scottsdale (AZ) Healthcare-Osborne.

Fast tracks weren't intended to be cash cows, says Spreitzer, who oversees the program at Scottsdale, which is part of a two-hospital not-for-profit system near Phoenix. "You've got to keep a tight rein on expenses or things can get pretty out of hand," she says.

Fast track should be self-sustaining

Economically, the UCC should be self-sustaining and financially independent of the ED. But at the same time, it should be a place in which nonurgent patients can be safely redirected away from the more expensive emergency setting.

Managed care organizations (MCOs) have pushed hard for such options. And hospitals have genuinely attempted to find lower-cost alternatives to the main emergency setting, says Pillow, who also serves as president of Dallas-based Metroplex Emergency Physicians Associates, a 140-member group practice.

More importantly for Scottsdale, the fast track has been a way of ensuring that the facility will get paid for those nonurgent cases, which the hospital would otherwise lose to a physician office practice or community-based UCC. And, in that sense, the track has been financially feasible.

That alone should justify the UCC's existence, Spreitzer notes. Nevertheless, Scottsdale's personnel seem to fight a daily battle keeping a lid on costs. To continue to justify itself to the hospital, the UCC has to prove itself financially self-sufficient, Spreitzer adds.

The hospital would not release financial information, but according to Spreitzer, the fast track is paying for itself.

Surprisingly, the biggest cost center isn't labor. Most hospital-based emergency UCCs are staffed by less-expensive physician extenders or nurse practitioners, although they operate under a board-certified physician's supervision. It's the equipment and supplies that can quickly erode patient revenue, says Spreitzer.

The facility, which was retrofitted from a vacant patio area adjacent to the ED, operates like a household on a frugal budget. "We use ace wraps and crutches instead of knee immobilizers whenever we can. And we're constantly trying to keep our rates within the scope of our health maintenance organization (HMO) contracts," Spreitzer says.

Hospital has two-tiered charge system

The program charges a global case rate for two categories of services: one for simple sprains, colds, and procedures that do not require x-ray or lab workups. The rate for this category is $65. The more expensive procedures, which include suturing lacerations and more complex treatments that require film and ancillary testing, are charged at $110. Anything more serious is triaged to the ED.

Both case rates are calculated at a minimum to cover fixed and allocated costs, Spreitzer says. How well the program performs financially depends on patient volume, which the hospital is trying aggressively to build through word of mouth and direct advertising, she adds.

To avoid competing with primary care physicians in the community, the clinic is open only during the evenings from 5 p.m. to midnight and from 10 a.m. to 10 p.m. on weekends and holidays.

So far, the arrangement works well, except for the fact that the fast track virtually excludes Medicare patients. Strict Medicare regulations require that physicians personally attend to patients if the facility expects to be paid by a carrier.

For this reason, the fast track sees very few Medicare cases, and the ones that do get seen, which is usually when the ED is overcrowded, are treated by a staff physician, Spreitzer says. (For a breakdown of Scottsdale's payment mix, see the chart on p.17.)

But this doesn't happen often. Despite a large retired population in the Scottsdale area, the hospital gets few seniors going through the UCC. Most patients who come in complaining of minor cuts, head colds, or abrasions are young and usually covered by an insurance plan, Spreitzer says. The older patients are typically sicker and are seen in the ED.

Many physicians believe the very same patient-centered emphasis, which has been important to UCCs is also one of best arguments in favor of employing an emergency fast track.

System offers perception of speed

"The trend toward fast tracks reflects a recognition of not only what's important for the patient but also to the patient," says John Proctor, MD, director of emergency medicine at Southern Hills Medical Center in Nashville, TN.

"Implied in the UCC concept is that every patient is important, that we treat all comers," says Proctor. The implication has strong connections with patient satisfaction, which from an economic standpoint makes sense to MCOs.

According to Proctor, the hospital's patient satisfaction surveys consistently support the belief within management that speed of service tops the list of concerns for patients in the ED. Ranking second and third are: perceived efficiency and a proper sense of urgency shown by the medical staff, respectively. Fast tracks aptly address each of these concerns, Proctor states.

But patients need to play a role in this process too if it is to be effective, Proctor warns. "Fast tracks can't be all things to all people," he adds. They certainly can be revenue generators because of the wide variety of reimbursable non-urgent services they can perform at an extremely low variable cost to the hospital. But they cannot be a regular primary care substitute for all patients. "Patients need to understand the system of primary care if we can expect to make it work," Proctor concludes.