Checks on Urgent-Care Centers Prescribed

They’ve popped up everywhere. With signs proclaiming “physician on duty,” they open early and close late, promising to quickly treat cuts, broken bones, coughs and other ailments that don’t respect traditional doctors’ office hours.

Because they’re there for life’s little emergencies--the earache at 9 p.m. or the stomach flu on Saturday morning--some call themselves “emergicenters” or “emergiclinics.”

But the medical establishment has taken exception to their monikers, charging that these free-standing doctors’ offices are ill-qualified to handle the emergencies their names and advertising call out for.

Known by their detractors as “doc-in-the-boxes” and by their defenders as inexpensive medical care providers, the convenience-oriented doctors’ offices are the target of two state bills that would restrict them from using the word “emergency” or any derivation of it unless they meet a list of standards.

That word misleads the public and might attract patients with heart attacks, internal injuries or other medical crises who need the services and expertise of a full-fledged emergency room, say spokesmen for the California Medical Assn. and the state chapter of the American College of Emergency Physicians.

But spokesmen for the centers say the legislation is a salvo in a “turf war.” Hospital emergency room physicians are striking back politically because they are losing patients to the burgeoning industry of urgent-care centers, say emergency center spokesmen.

According to their national association, there are about 2,800 “ambulatory care centers” nationwide, which will deliver $6 billion worth of medical care to 55 million patients this year. They have grown from an estimated 500 at the close of 1982 and are expected to number 4,000 by the end of 1990.

The Orange County Yellow Pages have 46 listings under “emergency medical and surgical services,” about half of which are hospitals with emergency rooms. In the White Pages, there are 20 listings for Emergi-Care, Emergiclinic or Emergicenter.

“Our concern is that the public is likely to be misled when they walk into a clinic that is not truly equipped to handle emergencies, even though it advertises itself for emergencies,” said Bill Cleveland, a spokesman for the California Medical Assn.

“Patients don’t know the difference if they see the word ‘emergency’ or ‘urgent,’ ” said Dr. Michael Jay Bresler, president of the California chapter of the American College of Emergency Physicians. Many of these centers are run by family-practice physicians who are not trained in emergency medicine, he said.

Critics of the bills contend that the legislation is unnecessary, a violation of free speech and a political maneuver by hospitals and emergency physicians to restrict competition.

“This legislation did not come out of public complaint. It’s from people whose ox is being gored,” said Dr. Stanley Gold, medical director of a Fullerton hospital emergency room. Gold, immediate past president of the National Assn. for Ambulatory Centers, once operated several centers.

“The industry has moved away from the word ‘emergency,’ ” said James Roberts, executive director of the association--once called the National Assn. of Free-standing Emergency Centers before the debate over “emergency” kept cropping up. The centers don’t solicit and don’t want cases of life- or limb-threatening injuries, he said. Those that continue to use the word emergency are “a very minor minority,” Roberts said.

First Regulation

If either bill succeeds, it would be the first regulation of California’s estimated 150 to 200 walk-in centers. Currently, all centers in the state are regarded, legally, as private doctors’ offices. Neither bill would require licenses or certificates, which are mandated for clinics (medical offices operated primarily by nonprofit agencies) and hospitals in the state.

Georgia tried to license “free-standing emergency centers” but a federal district court threw out the regulations in February for being too broad.

In Ohio, any office that accepts ambulance deliveries, uses the word emergency or holds itself out to treat life-threatening injuries must have state “certificates of need,” like hospitals. There have been no applications in the two years since the regulation was adopted, said Louis Pomerantz, spokesman for Ohio’s health department.

Most centers “are a little bit more than a doctor’s office but a heck of a lot less than an emergency room,” Pomerantz said. “If you just cut off your leg with a lawn mower, you want to get yourself to an emergency room, not a glorified doctor’s office.”

The centers’ spokesman, Roberts, has a more flattering description for them.

“What they really are are 19th-Century physicians’ offices using 20th-Century technology,” Roberts said. “A physician is always available, nearly any condition can be treated, they’re convenient and accessible, they have all the latest medical equipment in them . . . and they use strong business formulas to succeed.”

Not Emergencies

The vast majority of cases in the average hospital emergency room are not in fact emergencies, and these centers are easily capable of handling them, he said.

Their numbers have mushroomed, Roberts said, because they fill a need. No appointments are necessary. Patients, who might wait an hour or more in an emergency room while the real emergencies are tended to first, usually are seen immediately. The bills average $45 to $55, compared to $100 to $160 for an emergency room visit.

But unlike hospitals, the centers are not legally required to treat patients who walk in with emergencies but no money. In the process, they have irritated many of the doctors of hospital emergency departments, which count on a steady flow of runny noses and upset stomachs to make up for their nonpaying patients.

Whether people are truly being confused by the centers’ use of the word “emergency” is hard to prove. Bresler said he has heard stories about patients with chest pain driving to urgent-care centers in the middle of the night--when most are closed--and being found dead in their cars the next morning when employees arrive. He and other emergency physicians, while saying many of the centers are well run, can cite instances of botched diagnoses or improper treatment by urgent-care doctors that have landed the patients in hospital emergency rooms.

Tragedy in Orange

A tragedy did arrive on the doorstep of an ambulatory care center in Orange last year. Even Gold, who operated the center that received the case, admits it was “a horror story.”

A woman had accidentally backed her car over her daughter in front of her house, Gold recalled. Frantic, she did not call the paramedics but rushed the tiny girl to the walk-in center, where a doctor in turn summoned paramedics, who rushed the child to the closest trauma center, a hospital emergency department specially trained and equipped to handle life-threatening injuries. The child died.

Gold estimates there was a 30-minute delay because the mother took the child to the wrong place, but he said all authorities agreed afterward that the child’s internal injuries were so massive that nothing could have saved her.

Apparently the only study in the state on the issue was done in 1983 by Dr. Robert H. Bade, edical director of Orange County emergency medical services.

Bade and the county Paramedic Advisory Committee determined that paramedics were called to “free-standing emergency centers” 34 times between Aug. 1 and Oct. 31, 1983.

Paramedics felt they were being used as a transport system for many of these patients and were particularly irritated when some of the calls occurred at the centers’ closing times, according to the report. “By far the most serious complaint was on one of the cardiac arrests, which was found by the paramedics in a side room of the FEC (free-standing emergency center), slumped in a wheelchair, unmonitored and unattended,” the report said.

Cases Tracked

The cases were tracked from 25 medical offices that advertised in the telephone book under “emergency care” and used words like acute or urgent in their titles or ads.

“We were concerned about the potential (for confusion) because we had seen some of the advertising that some of the irresponsible places were using. They were clearly going out of their way to convey the notion that they were just as good as an emergency room,” Bade said. One, he recalled, had color a brochure with photographs of the medical staff holding defibrillators, electrical devices used to shock the heart into beating.

“We were concerned that people thought that’s the place to go when you have chest pains, or you can’t breathe or you’re shot in the abdomen,” Bade said. “This is not a global problem; many of them are responsibly run and don’t pretend to be emergency rooms.”

The same year of Bade’s study, the California Emergency Nurses Assn. issued a position paper calling for the establishment of standards for free-standing centers that seek out emergencies.

Intent Is to Set Standards

Two bills now seek to do that.

The intent of his legislation “is to set standards, so that a patient expecting a level of (emergency) care would get that. At a (free-standing) clinic, it’s doubtful” that all the necessary equipment and staffing will be provided, said state Sen. Henry Mello (D-Monterey), who is carrying the bill backed by the California Medical Assn.

His bill, as well as the emergency physician-backed bill carried by state Sen. Ken Maddy (R-Fresno), would require centers that use the word “emergency” or any derivation of it to be open 24 hours a day, seven days a week, have equipment, medication, staffing, radiology and laboratory facilities available for emergencies, have at least one physician trained in emergency medical care and meet additional standards for bookkeeping, referrals and chain of command.

Abuse of the word “emergency” by ambulatory care centers is “not widespread,” Maddy said. The concern is “mostly on the part of emergency physicians trying to ensure that we don’t have any bad cases.” Maddy’s bill has a much broader purpose as well. The bill would tack $1 onto traffic ticket fines to establish a fund to reimburse hospital emergency rooms and trauma centers which go into debt by treating the poor. A separate section of the bill addresses the emergi-center issue.

While the proposed legislation would be the first regulation of the centers, some say the review process could go further.

“I think if you’re going to hold yourself out as experienced or take in people off the street, then you should submit yourself to a review,” said Gregory Super, director of emergency medicine at Hoag Memorial Hospital Presbyterian. “There’s a big difference between that and practicing pulmonary medicine or internal medicine because there is special training involved. But doctors who are going to set up clinics and say they can take care of a range of illnesses . . . and urgent problems, they should hold themselves out to reviews.”

Called Group Practices

Kenneth Wagstaff, executive director of the state Board of Medical Quality Assurance, said the centers are essentially group practices that advertise and have extended hours. Still, he said, it’s possible that their heavy emphasis on marketing and their entrepreneurial mission is putting them in a “gray area” between autonomous private doctors’ offices and regulated medical clinics.

Wagstaff’s license fraud investigators last month arrested a man who allegedly posed as a physician, performing minor surgeries, setting fractures and carrying out medical examinations for 1 1/2 years at Emergi-Care Family Center in Fountain Valley and Westminster. The medical director thought he was hiring Dr. Alvin J. Stewart, but in fact the man is Enrique Herrera, 36, of Santa Ana, according to authorities. Stewart is a retired physician in Oxnard, authorities said.

“I think it’s too early to conclude that it’s because it was an urgent care center that this happened . . . I’m not prepared to say they (free-standing centers) represent a breakdown,” Wagstaff said.

But the structure of traditional private doctors’ offices may lend itself to more review and quality control among colleagues, he said. Physicians in a group practice often are all affiliated with the same hospital, and hospitals conduct case reviews and perform credential checks on their doctors, Wagstaff said.

Economically Stung

Just how much money hospital emergency rooms have lost to ambulatory care centers can’t be measured, said Larry Selwitz, a health care analyst for Bateman Eichler, Hill Richards Inc. Selwitz, who managed ambulatory care centers for six years, said many of the cases funneled away from the emergency rooms had no business going there in the first place because they were minor ailments.

Further, he said, in response to the growth of walk-in doctor’ offices, many hospitals have developed new pricing schedules so that a minor emergency is charged less than a major crisis. Or hospitals have set up separate areas for “quick care,” in hospital versions of the ambulatory care centers, and steer patients out of the emergency room and into their special area for minor ailments.

Some hospitals have struck back by opening their own free-standing urgent-care offices out in the community, just like the doc-in-the-boxes, other health care observers pointed out. Some open up in their own neighborhoods, while others have ventured out into competing hospitals’ communities to set up shop--and then refer patients to the sponsoring hospital when emergencies or chronic illnesses are diagnosed.

Complain as they may, emergency physicians and hospitals have to admit that the medical care offered at the free-standing centers is what patients want, Roberts, the spokesman for the centers, said.

“People have confidence in these centers or they would not be growing,” Roberts said. “The public votes with dollars, and the landslide is on to more convenient, accessible, affordable health care.”

If either of the bills by Mello and Maddy passes, it is unknown how many free-standers calling themselves “emergi-centers” or “emergi-care” will be affected, backers of both pieces of legislation said.

Repeat Visits

But one that could be is Emergicenter Family Care Medical Group on busy Beach Boulevard in Huntington Beach. Located at the end of a small commercial development, the center has enjoyed a healthy practice, with most patients returning for repeat visits, officials said.

Medical director Dr. R. J. Maurer sees no need for the legislation. Emergicenter does not seek out life- or limb-threatening injuries, he said. “In all of our literature, that is pretty well stated. It (the emergency issue) is a moot point.” The last time anyone was transferred to a hospital from the center was probably more than three months ago, he said.

Even the industrial businesses which have contracts with free-standing centers for treatment of on-the-job accidents and illnesses know real emergencies go to the hospital, said Joe Garramone, a health care consultant to Emergicenter and other facilities.

“We are, in essence, an extended hours office practice,” Maurer said. Then why the objection to changing the name and the red-and-white Emergicenter sign. Because the center is known throughout the community by its name and it has a following, Maurer said.

Besides, when a child comes down with a painful ear infection at 9 p.m., “in the eye of the mother,” Maurer said, “that’s an emergency.”