Labs in ambulatory care centers: medicine's growth sector.
Where do ACCs, originally known as emergicenters or urgent care centers, fit into the overall health care system? In the past, most centers concentrated on treating acute illnesses and injuries that didn't necessarily require hospital emergency room attention but couldn't wait, on a weekend or at night, for the family physician's office to reopen. Hospitals regarded these facilities as a drain on ER billings, while family practitioners felt they threatened the office patient base.
Hospitals may be somewhat relieved, physicians more alarmed, to see that growth has brought diversification in the ACC field. Many ambulatory care center operators are downplaying or eliminating "emergency" from the brightly lit signs and polished advertising that make them so visible. They are turning to primary care, specialty medicine, and employee health screening.
These shifts promise an increase in ACC laboratory work. Minor urgent care doesn't demand much lab service, but the turn to ongoing patient care is prompting moderate expansion of in-house testing, MLO has found. The result could be more group-practice-type labs with some opportunities for medical technologists and technicians.
As test requirements increase, send-out work will, too. Reference and hospital laboratories may find ACCs a good source of business.
Labels such as "medical McDonald's" from some quarters haven't crushed community support for the convenience that ACCs offer. Open seven days a week from early morning to late evening, the centers welcome patients without appointments, and a doctor is usually available in less than 30 minutes. Fees are substantially less than emergency room charges, although most ACCs require payment at time of service.
The rate of ACC growth recently prompted the National Association for Ambulatory Care to boost its projections through 1990, according to James Roberts, executive director of the 900-member industry association. Figure I shows the new forecast, a leap in centers to 5,500 by the end of the decade.
At that time, ACCs may draw off 10 per cent of the money--estimated at more than $50 billion annually in recent years--that consumers spend on outpatient care (Figure II). Last year's ACC revenue totaled $1.6 billion. The projected 1990 figure: $6.7 billion. The largest chain operator in the field, Humana Inc. of Louisville, Ky., recorded $36 million in fiscal 1984 revenue from more than 80 MedFirst centers.
"When the industry started up," Roberts says, "we thought it could penetrate 40 per cent of the hospital emergency room market--half the 80 per cent of Er visits that are said to be medically better served elsewhere. ACCs did not do that--the penetration was closer to 10 to 15 per cent."
Nevertheless, ACCs are expected to tally 45 million visits this year, almost 10 times as many as in 1982. This level of activity has provoked a competitive response: Hospitals are opening ACCs, often close to freestanding centers, and some group practices are expanding treatment capability and hours of business.
In 1982, most ACCS were owned by one or more physicians. But that's changing: A 1984 study conducted for Roberts's association showed 42 per cent of the ACCs owned by nonphysician corporations, 41 per cent by physicians, 4 per cent by hospitals, and 13 per cent by private investors, foundations, and religious organizations. The hospital proportion has increased since then and may climb still higher.
"Competition helps insure quality and gives the public more choices," Roberts says. "Hospitals are developing two kinds of treatment--one for true trauma and a second for primary care. That means two or three price tiers, which expands access to services and helps cap costs."
If most patients still don't realize they have an alternative to the hospital emergency room, Roberts is optimistic that will change: "More people are beginning to understand ambulatory care centers. And more are using them and are satisfied with their experience."
But "physicians with a traditional outlook are very hesitant about ACCs," Roberts points out. "Many still refer patients only to the ER."
"We have had good relations with local practitioners," says Gary Meller, M.D., owner and medical director of the MedAccess chain of 10 centers in Ohio and Wisconsin. "We provide a lot of after-hours and weekend coverage for primary care physicians, and we make a lot of referrals to specialists. We also do some lab and x-ray work for physicians close to our centers."
The rapport exists with neighboring hospitals too, Meller claims. In part he credits his policy of recruiting local physicians to staff the centers. Despite all the effort and tact, he acknowledges that "there's always a fear somebody is going to take patients away from somebody else."
Fear may have been the initial reaction of physicians in the Middletown, N.J., area when the Emergency Medical Office opened its doors in 1984. Staff director Mary Paskow, RN, recalls: "The feelings we got from private practices were bad at first. We did a mailing to all local doctors before we opened, offering to put them on our referral list. The response was poor. But when we did a second mailing a few months later, we got a good response."
There is still resentment among the local hospital's emergency room medical and nursing staff toward the center, Paskow says. The hospital is opening its own from the Emergency Medical Office.
Shamus Holt, vice president of diagnostics for Centra Care Medical Centers in Altamonte Springs, Fla., isn't sure that making referrals to local practitioners always helps in his center.
"Some of our referrals go to a vocal minority of physicians who are bad-mouthing us to begin with," he explains. "We probably won't see the patients again because we are not well accepted by that segment of the medical community." As a result, Centra Care is considering refining its referral care system or building its own following of primary care patients.
Until last fall, NAFAC--the National Association for Ambulatory Care--was named the N ational Association of Freestanding Emergency Centers. The move to shed the one-track "emergency" label led the organization to soften its position on ACC staffing. Guidelines once called for a physician qualified in emergency medicine, but centers now need only someone with emergency medicine experience (such as a rotation through an ER or cardiac-care unit) on duty during all hours of operation.
ACCs discourage ambulance services from bringing in patients. If the patients are too ill to come in by any other means, they should be taken to a hospital ER. When an ambulatory patient's condition is assessed as an emergency beyond the center's capacility--a myocardial infarction, spinal fracture, or ectopic pregnancy, for example--the patient is stabilized and transferred by ambulance to an ER.
Ambultaory care centers that MLO canvassed still see mostly minor acute illnesses and emergencies, threatening neither life nor limb. All reported a crush of upper respiratory tract infection patients, especially children, during the winter flu season, for example. Pneumonia and ear infections were also common.
Peter Sawchuk, M.D., medical director of the Emergency Medical Office in Middletown, N.J., notes that trauma takes over in the summer. "We then see people who run and fall or who are hurt in sports activities--just what emergency rooms see." Figure III lists the most common ACC cases as indicated in a NAFAC survey.
Most ACCs have x-ray facilities for minor trauma. In many states this calls for a certified technician. At the offices of Health First in Philadelphia, routine x-ray work includes chest, abdominal, sinus, extremity, head, neck, and cervial spine films. "We do not do invasive work or barium studies, intravenous pyelograms, upper GI series, or mammography," says medical director Peter C. Toren, M.D.
Besides physicians, ACC staffing varies: part- and full-time RN s and LPNs (often with ER background), paramedics, occasional MTs and MLTs, medical assistants, and office help.
NAFAC guidelines set minimum lab capability at complete blood counts, glucose testing, urinalysis, and Gram staining--all available Stat. More than three-quarters of the ACCs in the association's 1982-83 survey reported that they had a blood cell counter, and between 80 and 90 per cent said they had a microscope, autoclave, centrifuge, and incubator. Only 32 per cent had a spectrophotometer; 25 per cent, a colorimeter. Centers generally set aside a small area for laboratory work, close to refrigerator, counter, and cabinet space.
ACC labs are seldom regulated by state agencies--except when they perform testing for outside clients or have extensive menus (such as Immediate Medical Care in Allentown, Pa., licensed by the state of Pennsylvania and highlighted in the accompanying box).
To bring some uniformity to ACC operations and ward off regulatory moves, NAFAC recently affiliated itself with the Accrediting Association for Ambulatory Health Care to develop guidelines for defining distinct functions for ambulatory care centers, urgent care centers, and emergicenters. (Three centers have been accredited in the young program.) The program offers some guidelines for ACC laboratory operation, but they are general rules for record keeping, quality control, and staffing that allow individual centers substantial latitude.
Where lab capability is small, nurses and x-ray technicians are cross-trained to perform tests. At Centra Care centers, a medical technologist gives x-ray technicians a two-week course on running tests. The MT checks out their laboratory performance every six months thereafter. Physicians do the microscopic urinalyses and review Gram stains and wet mounts.
In Greenbush, N.Y., Urgent Care Medical Associates draws on the services of a full-time technologist who is seeking ASCP certification. Technologist Vivian Gonzalez performs a variety of chemistry, hematology, and microbiology procedures, including cultures, differentials, sperm counts, and sedimentation rates.
"Except for the occasional chemistry profile, reference testing is rare here," managing partner Edgar Elum, M.D., says. About 25 per cent of the center's tests are sent out. Elum wants the in-house menu to include more cultures and therapeutic drug monitorin in the near future.
Laboratory services are uniform at all Humana MedFirst centers. Each location's menu includes hemoglobin, hematocrit, complete blood count, WBC differential, pregnancy and mononucleosis tests, blood glucose, urinalysis, KOH wet preps, and throat cultures for strep ID. Blood chemistries are referred to a reference lab or to a Humana hospital if one is near. Tests are performed only if diagnostically indicated. Each center's lab is staffed by an x-ray technician cross-trained for test work, an MLT (also trained to take x-ray films), or a medical assistant.
Human plans expansion from a current 114 ACCs to 200 by the end of fiscal 1985, according to marketing communications manager Susan Miller. Laboratory capability will not change. The corporation recently finalized its purchase of the Doctors Officenters chain of 21 ACCs in Chicago and New York.
"Humana is interested in referrals to its hospitals," Miller says, "but freestanding centers are also part of its philosophy of an integrated health care system." It views its centers as extended-hour, walk-in physicians' offices, providing ongoing primary care as well as episodic treatment.
NAFAC's Roberts emphasizes the importance of multiple roles: "Treating episodic injuries and ailments is a limited market. The industry is evolving and expanding its base. Primary care will be at the center of the industry."
Some ACCs are also expected to branch into specialties like sports medicine, orthopedics, gynecology, and allergy. But NAFAC guidelines still call for emergency capability, including a cardiac crash cart, oxygen, incubation equipment, defibrillator, I.V. lines and fluids.
To the public, however, "the term 'emergency' doesn't mean anything," Roberts says. "They're not clinicians. They don't know what an emergency really is. Any situation where they need prompt medical care becomes an emergency."
Such confusion might lead critically ill patients to head for an ACC when in fact they should go to a hospital ER. Thus, fear of wrongful death or injury claims on grounds of misrepresentation has also spurred ACCs to drop the word "emergency" from their names. To date, there hasn't been any litigation along those lines.
In 1983, the American Medical Association's Commission on Emergency Medical Services took the position that a center without specific emergency capabilities should not use the word.
Centers have emphasized in marketing materials that patients should seek hospital ER care for life-threatening emergencies. Working with the AAAHC, NAFAC in its accreditation guidelines discourages use of the word "emergency" unless a center is open 24 hours a day.
When ACC operators realized that patients couldn't clearly define the exact purpose of the centers, "some owners started focusing their messages and titles and going after the larger market (of continuing care)," Roberts says.
A number of ACCs aren't taking that tack, though. They flatly discouraged patients from becoming "attached." Patients who need care for chronic illnesses or who don't have a family physician are referred to a local practitioner. Patients are also given copies of their charts and sometimes receive written instructions for home care.
Not that the parting is unfriendly. Energency Medical Offices telephones patients the day after their visit to the Middletown center, Paskow notes. Patients also receive a questionnaire to rate services and mail in. Highest praise on the survey goes to the call-back policy. But medical director Sawchuk emphasizes that "we dissuade patients from coming here for chronic care. We see ourselves taking care of acute episodes. We tell patients to come back in seven days to be rechecked for something like pneumonia, but once they're well, we tell them to go home."
Other centers invite closer ties. Toren of Health First says "people have the option of becoming regular patients, but we still feel no appointment is necessary."
Centra Care's ACCs have been made outpatient arms of the hospital chain that purchased them, Holt explains. Some not near one of the hospitals were sold.
"We're being used to protect the hospitals' patient base," Holt Says. "That's the name of the game. Otherwise, if you rely on episodic ailments and injuries, you have to get patients under a PPO or HMO contract."
Centra Care is also contemplating taking "emergency" out of its literature, but recent AAAHC accreditation as an urgent care center means its facilities will maintain that capability.
Industry and business have become fruitful sources of patients for ACCs via word of mouth or marketing. Companies whose workers sustain on-the-job injuries often refer them to an ACC. Arrangements frequently rely on the strength of patient satisfaction rather than on signed contracts.
"We take no money up front--it's a verbal understanding," says E.V. McGinley, M.D., owner/director of Medemerge, an ACC profiled in the January 1983 issue of MLO. In 1982, the center saw a maximum of 60 patients a day. Last year, 26,000 patients--an average of more than 70 a day--came through its doors, thanks in part to the "800 businesses that use us as their prime source of industrially related acute care," according to McGinley.
Roberts says that a successful ACC may draw a quarter of its business from workers' compensation cases. "We have definitely become a friend of the employer because an ACC is less costly than an emergency room and reduces travel and treatment time in many cases."
Paskow of Emergency Medical Offices ticks off several reasons why businesses like ACC services: "One supermarket sends patients here because management knows the employee will finish at the center and be back on the job fairly quickly.
"If the injury is serious, the office promptly hears our physician's diagnosis over the phone, including how much work time stands to be lost. They appreciate that personal contact. We're also close. Most of all, employees give us favorable reviews. That encourages the employer to keep sending patients."
ACCs contract to provide pre-employment and annual physical exams. Emergency Medical Offices recently signed one with a home health aide firm. The company gave the center copies of a printed list of what it wants to know; when an employee comes in, the physician knows explicitly which tests and measurements to perform.
In heavily industrialized Allentown, Pa., Immediate Medical Care offers numerous employers similar services and also provides an "executive physical" for local companies. The physical includes a 20-parameter reference laboratory chemistry screen.
Owner and medical director Robert F. Brennen, M.D., says high volume allows the center to charge companies about 80 per cent of the fee total for the individual procedures in the exam. In general, he says, patients are billed for send-outs at cost. Only in-house testing offers the center a chance for profit.
ACCs seek payment from patients before they leave the center, but most will assist in completing insurance claims. Blue Shield and other insurance carriers accept ACC charges as they do office-based physicians' bills. The centers don't see too many Medicare patients now, but that may soon change.
Stanley Gold, M.D. NAFAC president and owner of Americare One Immediate Medicine centers in Orange County, Calif., comments: "Most centers have been reluctant to take payment by insurance. But wait one year and you'll find hardly a cash-only center left. Most will operate on a billing system. I doubt that there will be anyone who won't handle Medicare on an assignemnt basis.
"Centers don't see enough patients on any other basis. They turn people away at the door because they have insurance programs. And there are just too many of those people. Our centers opened on a cash-only basis, and one day we saw two patients and turned away six or seven who asked us if we accepted Medicare. By that afternoon, we were accepting every kind of insurance.
"The population is shifting from young to old, too. The medical needs of older persons arise more suddenly and are more pressing. A center that does not have the facilities to care for someone with Government health insurance isn't going to be around in five years."
ACC labs may start to resemble group practice labs (except for longer hours) as centers shift away from urgent treatment and toward primary care. Roberts believes test volume in general will grow as ACCs become more solidly grounded in their communities. Some of the jump will occur in-house. That's the case with Centra Care facilities.
"We have to change our lab," Holt explains. "We now have a Stat lab, with screening tests for chemistry and hematology. Our CBC instrument is a manual centrifugal unit that's primarily for acute ambulatory cases. Everything is manual--there's no automation.
"That's O.K. for the patients we see now, but as we go to continuing care, we will have to upgrade our hematology capability. We use manual chemistry methods, too, because you don't do many on episodic patients. We're going to be doing more glucoses and potassiums, for example. And we will have to add several tests to the five we can do now."
Holt expects that automation will lower the amount of expertise needed to perform tests and narrow the chances for operator error. Toren of Health First also thinks the trend will be for ACCs to expand lab capability--"especially in culturing" at his center.
Test ordering is on a rising curve, but that doesn't mean all ACCs are making room for new instruments. "Our reference lab service is fine," says Steve Fagin, administrator of the Doctors Officenter in Lynbrook, N.Y. "The equipment is too expensive for us to buy." As part of a chain, the center receives volume discounts on send-outs.
W. Allen Schaffer, M.D., president and medical director of Med-Help centers in Memphis and New Orleans, says, "We will continue to send tests like chemistry profiles out to the reference lab. The service is good--we get 24-hour turnaround." But he will gladly switch to more in-house testing, including chemistry assays, once technology produces smaller, less expensive equipment.
ACCs may be good candidates for rapid microbiology instruments and some streamlined therapeutic drug monitoring methods, according to Joseph Migliara, president of Migliara/Kaplan Associates of Towson, Md., whose affiliate, Medical Surveys & Audits, is analyzing purchasing trends in ambulatory care as it prepares a supplier data base.
"Centers are trying to do well-focused diagnostics, not broadscale screening or case finding," Migliara says. "Most ACC patients are symptomatic in some way, so doctors have a pretty good idea of what to look for. Small-scale systems are idenally focused. Once you cross the threshold of three or four tests, it's probably cheaper to buy a profile."
Roberts of NAFAC offers these final observations on ACCs: "Ambulatory care centers are nothing more than old-fashioned physicians' offices," he says, now that that the shine is off urgent care, "except that they're comprehensive and they meet the need for unscheduled visits. They use 20th century technology and take advantage of advertising to get their message across. We're likely to see a lot of small one- or two-unit operations at one end of the scale and big national chains at the other."
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|Publication:||Medical Laboratory Observer|
|Date:||May 1, 1985|
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