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Viewpoint: Have-It-Your-Way Medicine

Maurer, Lisa MD

doi: 10.1097/01.EEM.0000443925.69100.52

Dr. Maureris with Emergency Medicine Specialists in Milwaukee, WI, where she is the legislative liaison. She serves on the ACEP State Legislative and Regulatory Committee, and is a contributor to Policy Prescriptions, where this article first appeared. Policy Prescriptions was created byCedric Dark, MD, MPH, the site's executive editor, and it advocates for evidence-based health policy., @PolicyRx, and “Have it your way” is a trademark of the Burger King Corp.



As someone who indulges in an occasional fast-food run, I'll never forget a rhetorical question my speech teacher once asked: “Is fast food actually good?” I thought to myself, “Yes!” After a pause, he answered, “No! Think about it. It doesn't actually taste as good as a comparable meal from a high-end restaurant. Anyone who buys fast food is doing it for the convenience.”

My world was changed. I was reminded that convenience really does rule supreme when I read the recent study by Hwang et al looking at the effect free clinics have on visits to local emergency departments. But what if the higher-end “meal” were free?

Uninsured patients who used local free clinics were compared in this study with uninsured patients who did not use free clinics, and it looked at how often both groups subsequently used the local emergency departments over the following one to three years and how sick they were when they actually did visit the ED. (J Health Care Poor Underserved 2012;23[3]:1189.)

Patients who presented to the ED were graded on the complexity of their visit by Current Procedural Terminology (CPT), which takes into account the presenting complaint, how many resources were predicted as necessary for that patient on arrival, and the patient's vital signs on arrival. They were also classified by an algorithm created by researchers at New York University to rank the “appropriateness” of the visit to the ED, giving it a score that reflected if the visit were truly emergent or could have been avoided and taken care of by primary care.

Uninsured patients made almost 100,000 visits to the EDs in this study. Just more than 9,000 of these visits were made by almost 8,000 patients who also visited a free clinic during this time. The remaining 90,000 visits were made by just more than 44,000 patients who did not visit a free clinic during this time. The data revealed that uninsured patients who go to free clinics were a different group of people from those uninsured patients who do not go to free clinics.

Those patients who used free clinics had a higher chance of being older, white, female, and sicker, for example. Maybe more importantly, though, even when adjusting for all these differences, the people who used the free clinics were less likely to use the emergency department for a low complexity visit as measured by CPT codes compared with non-users of free clinics (69% vs. 73%). The uninsured patients who tended to use free clinics were more likely to require overnight hospitalization as well (10% vs. 6%). Interestingly, the two groups of uninsured patients were equally likely to visit the ED for an “avoidable” visit as measured by the NYU algorithm.

This study cannot really determine if the presence of the free clinic itself causes patients to use the ED less frequently for non-emergent injuries or illness, but it seems that people who tend to use free clinics also tend to avoid the ED for things for which it was not meant. This conclusion holds a big impact as EDs become more crowded. Potentially, building more free clinics would relieve some of the pressure placed on EDs to provide this care.

Alternatively, though, many patients in this study do still use the ED for the care they want. Why? The clinic in their area is free. This brings me back to the fast-food analogy. Not that I enjoy being compared with Arby's or Burger King as an emergency physician, but convenience is the only reason I can come up with that would give the EDs an edge in drawing patients for any non-emergent visit. And maybe the fact that because the EDs are not familiar with these patients from previous visits as a clinic would be, EDs are forced into giving them the Deluxe Value Meal of testing each time. This could be perceived as better quality by patients receiving the tests.

These conclusions imply that better support should be given to the free clinics to be more convenient. These amazingly useful clinics might be sought out more often if they were open 24 hours every day or if they offered additional services (psychiatry, dentistry, social work) for one-stop shopping. These investments may be more useful to innovative states looking for delivery system improvements instead of penalizing patients for going to the ED for “avoidable” visits or paying the physicians less when they arrive in the emergency department.

© 2014 by Lippincott Williams & Wilkins