Bonnie Arbittier / Rivard Report
When 2-year-old Braxton jumped off a bed last month while playing with his brother and sister and then couldn’t stand up, his parents Felecia and Nick DeBravo rushed him to an emergency clinic just a three-minute drive from their Northeast side home.
A doctor administered anti-nausea medicine, ordered an X-ray, found the toddler had a sprained ankle, and since then, Braxton has recovered fully.
With three young children, the DeBravos say Express ER has become their go-to for illnesses and injuries when they can't wait for an appointment with their pediatrician. “We went when Rylee broke her arm, Nick got food poisoning, and when Braxton was throwing up nonstop and diagnosed with stomach flu,” Felecia DeBravo said, adding that those experiences assured her they would receive good care for her son's latest injury and be covered by health insurance.
Such freestanding emergency centers (FECs) are popping up along busy byways in San Antonio and across the state. Open 24/7, FECs are staffed, equipped, and regulated more like a traditional hospital-based emergency room, and they charge higher rates to reflect that level of care.
Texas' Health and Human Services Commission (HHSC) has licensed a total of 19 FECs in Bexar County, and 215 in the state, up from only 19 statewide in 2010, the year after the Legislature allowed them to be licensed. In fact, Bexar County – population 1.9 million – has more licensed FECs than any other Texas county except Harris – population 4.5 million – which has 34, according to a report by David Kostroun, deputy executive commissioner of HHSC's Regulatory Services Division.
Also on the rise are what are known as urgent-care centers (UCCs). In San Antonio, there are currently 54 such centers, and more than 7,000 like them across the country.
Urgent-care centers often have extended hours and provide immediate care for non-life-threatening injuries and illnesses, with the top diagnostic codes being upper respiratory infections and acute sinusitis, as well as some occupational health services. Charges for care at UCCs are usually lower than at an emergency center.
In San Antonio, both freestanding emergency centers and urgent-care centers are concentrated in the city's northern half, where more people have private health insurance.
“It’s a geographic arms race, if you will,” said Edward Schumacher, a health care administration professor at Trinity University.
Research by Amer Kaissi, professor of health care administration at Trinity University, found that the Affordable Care Act, which introduced myriad cost and quality challenges for provider organizations, has “contributed to an unprecedented increase in demand for primary care and specialty services without a corresponding increase in the supply of providers.
"That has given rise in the last decade or more to new forms of healthcare delivery,” Kaissi wrote, “while older forms have reemerged to address care convenience.”
Urgency vs. Emergency
Feverish and coughing, Angela Garcia had been feeling sick for days, but when she awoke on a Monday no longer able to swallow and experiencing severe headaches, she drove to a medical facility nearest her Northwest side home, a freestanding emergency center known as Complete Care.
“I do have a primary doctor, but do not rely on visits to her office because scheduling is inconvenient,” Garcia said. “We typically visit emergency care clinics/urgent care clinics because of the convenience, and the cost is not such an issue for us.”
When Complete Care employees informed Garcia that because she had not met her $750 annual deductible yet, her visit would cost $200 up front and more if the doctor ordered any tests, she drove to Texas MedClinic, an urgent-care clinic. There, she was charged $50 to be seen by a physician and a nurse practitioner, diagnosed with a sinus infection, and sent home to rest.
Garcia’s recent experience helps illustrate not only the differences between these two health-delivery systems, but also some of the reasons there’s one on nearly every corner – at least in some parts of San Antonio – with more to come.
Dr. Bernard Swift founded Texas MedClinic, the first of San Antonio’s urgent-care centers, 35 years ago despite significant pushback, he said.
“It was a deviation from the standard way a physician would go into practice in those days, which was to open a practice in a medical office building and be low-key, and referrals would naturally come,” Swift said. “We were in a retail building, we had a neon sign, and that didn’t sit well with the medical community,” so much so that he was called before the Bexar County Medical Society's board of censors for an inquiry.
Fast-forward to a 2015 Fair Health survey that found 15 percent of the total population said they were most likely to visit an urgent-care center for a non-emergency situation, versus 55 percent who said they would go to a primary care doctor and 21 percent to an emergency room.
Urgent care is the future, Swift said. “Of that, there can be no doubt. The economics of urgent care are sound. Patients want the freedom to be able to go where and when they want to go. Urgent care provides that opportunity. It’s convenient, it’s relatively low cost compared to other venues, and the care is good.”
As the concept has caught on, Texas MedClinic hired many newly trained physicians who worked in the clinics for several years before opening their own private practices. “So many [doctors] know we’re not a threat to the primary care model and refer to us after hours when they are not available,” Swift said. “I know many of them, and they are friends, and we have a symbiotic relationship.”
Texas MedClinics mostly are situated in highly visible strip malls. Sites are chosen for their market demographics within a 1-, 3-, and 5-mile radius. Market data shows that the majority of patients live within a 10-mile radius of a clinic, most of which are on the Northside and central parts of town.
There are two Texas MedClinics on the Southside, but Swift himself couldn’t think of any other UCCs in that area, a part of town where more of the population is covered by Medicaid than by private insurance.
“That is a direct function of the very, very low Medicaid reimbursements allowed for providers,” Swift said. “I don’t care who you are, by seeing a substantial part of your practice as Medicaid patients, the economics just won’t work. You can’t meet your overhead and pay staff with Medicaid rates.”
Triage and Cost
For freestanding emergency centers, financial viability in choosing a location is also a concern. And, in fact, it’s against the law for them to accept Medicaid or Medicare. Dr. Derek Guillory, medical director of Complete Care emergency centers in LaVernia, said regulation blocks facilities like his from taking care of people the way he would like.
“What I’ve always wanted to do in our community is provide exceptional care every time, all the time, for the right price,” Guillory said.
“The law actually hamstrings us and doesn’t allow us to do that. If a patient comes in with an earache, you can’t charge them an earache fee, you have to charge them ER [prices]. It’s understandable – they want to try to prevent people from getting high bills for small problems. But people don’t know the difference between a sore throat they are dying from and a sore throat that’s just a cold.”
The Centers for Disease Control report that hospital emergency departments experienced nearly 142 million visits in 2014, with 11.2 million of those resulting in hospital admissions.
Trinity's Schumacher said studies show there are fewer hospital admissions among those who go to a FEC rather than a hospital-based ER, which reduces cost for all involved. And yet some hospital systems are jumping into the freestanding and urgent-care market through partnerships with other providers, to capture that business.
“The economics of hospitals is not going well lately, in part because baby boomers are entering into Medicare, which tends to be less lucrative than private insurance," Schumacher said. "The hospitals have been squeezed.
“If you look at the FECs, they are exclusively in areas that tend to be well-to-do. There are very few on the south and east sides of town largely because they go where the money is.”
One reason FECs are growing in numbers is that Texas is not a “certificate of needs” state, he explained, which allows hospitals and other providers such as Emerus to build healthcare facilities without proving a legitimate need, as other states require. “Texas lets the market do its thing,” Schumacher said.
Emerus is the largest operator of micro-hospitals and has partnered with the Baptist Hospital System here to establish a number of Baptist Emergency Centers. They are not considered freestanding emergency departments, however. According to spokesperson Richard Bonnin, they are “micro-hospitals,” or neighborhood hospitals, open 24/7 with small-scale inpatient facilities, an emergency department, pharmacy, lab, and imaging services.
Consumers still confuse freestanding emergency centers and micro-hospitals with urgent-care centers, which is a problem, Texas MedClinic’s Swift said. “Claiming to be full-boat ER and charging fees equivalent to hospital ER charges … the net effect is that their charges are 10 times what fees would be for urgent-care visits even though the types of problems they treat are virtually urgent-care problems,” he said.
“I can safely say, in my opinion, freestanding emergency departments are glorified urgent-care centers that charge more.”
At Complete Care in LaVernia and at the Pearl near downtown, patients can choose between side-by-side urgent care and emergency care clinics – separate offices as required by law. Most people make the right call, Guillory said, for whatever is ailing them. But he would prefer that the system be set up to allow medical staff to do that.
“We want people to be able, when they find themselves injured or ill, to present to some place close to their house and have the provider decide what is the appropriate level of treatment and do that at the right price,” Guillory said. “Right now, people have to triage themselves.”
In either setting, if there’s a true emergency – chest pain, for example – the staff is prepared to request airlift for patients to a major hospital. Even when transport time is factored in, time is not wasted, he said, because they can send the patient directly to a cardiac catheter lab, for instance, bypassing the crowded hospital ER.
“The hospitals are doing great work, taking care of a lot of people. Waiting rooms are full,” Guillory said. “But timing is key sometimes. If you have a bee sting and an allergic reaction, you can get treatment, and sometimes people’s lives are going to be saved.”