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Urgency vs. Emergency

Kim Bullock’s daughter Sasha, 13, returned home from ballet class one evening complaining of leg pain. When the Dallas mom took a closer look, she noticed an enlarged vein. “My dad has a history of deep vein thrombosis, so I didn’t want to wait until the next morning to take Sasha to our pediatrician,” Bullock recalls. She remembered seeing a new stand-alone emergency room nearby and went online to check out their information. “I figured if I took Sasha there, we wouldn’t have to wait to be seen as opposed to taking her to the hospital,” shares Bullock.
Her assumption proved correct. She and Sasha were taken immediately into an exam room, and the doctor came in within five minutes. There was a slight delay for a precautionary ultrasound. But, while they waited, the physician remained with them and even gave Bullock a referral to a physical therapist to address Sasha’s unrelated knee pain. “The doctor was fabulous, the diagnosis was accurate and everyone treated us so well,” Bullock says. She didn’t even have to pay before being seen; she just presented her insurance information and ID upon check-in and was told they’d submit the bills for her.
When your child becomes ill or injured and your pediatrician’s office isn’t an option, where’s the best place to go for care? Do you head to the nearest hospital, find a convenient urgent care clinic or visit one of the many new freestanding emergency rooms popping up around town? Your choice can make a difference in the level of care you receive, how long you wait to be seen and the amount you pay for services.
Urgent Care = Convenient, Routine Services

When your pediatrician’s office is closed and your child is too sick to wait until it’s open, it’s nice to know you have options beyond the sliding glass doors of your local hospital emergency room.
Justin Smith, M.D., a Cook Children’s pediatrician in Lewisville, urges parents to call their pediatrician first if it’s not a true emergency. “Even if the office is not open, our parents can get advice from our pediatric nurses who take calls overnight,” he says. “Or they can check out one of our Urgent Care Centers in the area.” Cook Children’s Health Care System operates four pediatric urgent care centers in Fort Worth, Mansfield, Southlake and Northeast Hospital to treat children with nonemergency medical concerns, theoretically easing the patient load in Cook Children’s emergency room.
Urgent care centers offer extended hours — evenings and weekends — and provide a convenient option for nonemergency medical care. Great for working parents or those times when you can’t reach your family physician, your neighborhood urgent care center is equipped to handle routine medical conditions and concerns, as well as vaccinations, sports physicals and strep tests. They also do a good job of keeping the local hospital emergency rooms from filling up with minor cases of fevers, vomiting, sore throats and ear infections, and most allow you to check in via an online portal. Physicians at urgent care centers are not required to have emergency medicine experience and are often board-certified in family medicine.
Halim Hennes, M.D., medical director of emergency services at Children’s Health, says their hospital has a good working relationship with local urgent care centers. “We see quite a few patients who have been to an urgent care center and receive very good advice and yet come to our emergency room [unnecessarily] for a second opinion,” says Hennes. “[Urgent care physicians] will also call us for advice and send us patients when necessary.”
Freestanding ER = Less Wait, Highly Trained Docs

Freestanding emergency centers offer a higher level of care than urgent care centers, and patients are attended to by physicians and nurses with hospital emergency room experience. The centers must also be licensed by the state, remain open 24/7, provide an ambulance entrance and have transfer agreements with local hospitals in case patients need admission. A red and/or white sign with EMERGENCY in all caps will be easily visible from the street. The physician must hold a current certification in advanced cardiac life support, pediatric advanced life support and advanced trauma life support.
If it’s determined that you need care beyond what’s available at a freestanding ER, you may request to be transferred to the hospital of your choosing or use one of the hospitals the facility has a transfer agreement with. Josh L.V. Prickett, M.D., medical director of E-Care in North Richland Hills, says their center has transfer agreements with four area hospitals, as well as a trauma center and Cook Children’s Medical Center. “We have a direct phone line with Cook Children’s, so we can immediately access someone to coordinate a transfer for our pediatric patients, if needed,” he says. All local E-Care’s have similar arrangements with their nearby pediatric hospitals.
Medical City Children’s Hospital, which operates six pediatric urgent care facilities across North Texas and freestanding ERs, shuttles their ER physicians between the hospital and freestanding centers for a very good reason. “At the hospital, we see the sickest of the sick, so we’re always prepared,” says Mini DeLashaw, M.D., Ph.D., medical director of emergency medicine at Medical City Dallas Hospital and Medical City Children's Hospital. “But freestanding ERs tend to experience a lighter patient load than hospital emergency rooms.” If a patient needs to be intubated at either facility, she expects their teams to be ready. “It’s important for doctors to keep up their skills,” she adds.
Pediatric Hospital ER = Severe Trauma, Specialists on Hand

It’s reassuring to know our area is home to several pediatric hospitals should a need arise. These hospital emergency departments are well-equipped to care for the most fragile patients — from newborns to teens. If your child has a medical emergency that could possibly require hospitalization or has received a traumatic injury, call 911 or take him to the nearest hospital ER. If you’re able to get him to a pediatric hospital ER, even better, but getting him seen quickly so he can be stabilized is the goal. Transfers can always be considered later if deemed necessary by the physician.
Children’s Health is the only Level I Pediatric Trauma Center in North Texas and therefore is capable of providing total care for every aspect of injury from prevention through rehabilitation. “We can provide pediatric surgical and subspecialty services 24/7,” Hennes says. “If a child comes into the ER with a fracture, we have orthopedics. If a child has complex lacerations, we have plastic surgeons. If a child has seizures, we have neurologists.”
Unfortunately, hospital ERs are notorious for long waits. “When you’re in the waiting room, what you don’t see is what’s happening in the emergency department,” Hennes says. “We might be getting one trauma after another and those take priority.” Patients who come to Children’s Health Emergency Department are sorted out (triaged) by a nurse based on the severity of their illness or complaint to either the emergency department (patients with serious complaints or illness) or the Fast Track area (minor illness). Patients are seen in order of arrival, their triage level and availability of exam rooms.
“Our current ER was built for 45,000 visits a year,” says Corwin Wormink, M.D., Cook Children's medical director of emergency services. “We’re seeing 120,000 visits a year … in an area we’re actively trying to expand.” Cook Children’s has built a new Urgent Care Center on Rosedale Avenue, near the main campus in Fort Worth. Also a new Emergency Department is part of Cook Children’s South Tower expansion, scheduled for completion October 2016; it’s designed to lessen the wait times for patients and better accommodate the existing volume of patients visiting the emergency department.
Hennes says families are best served by establishing a medical home (e.g. a pediatric practice) where their children can be seen for minor illnesses and save trips to the ER for emergencies only.
The American Academy of Pediatrics agrees. Their studies show that children who received care in medical homes were less likely to have unmet medical and dental needs and were more likely to have annual preventive medical visits. Children should have not only a usual source of care and a personal physician or nurse, but also care that is family-centered and provides ready access to referrals and care coordination when needed. An urgent care center or your local ER does not meet the definition of a “medical home.”
The Cost of Care … Varies Drastically

Read any online reviews of freestanding ERs and you’ll likely see five-star services flanked by one-star complaints about fees. Bullock is among those patients. While she left her visit feeling confident in the level of care Sasha received, weeks later, when the bills began to arrive, Bullock questioned her choice.
“Just to walk through the door was $1900,” she says. In total, Sasha’s short visit cost over $3000 out of pocket due to the high deductible with their insurance policy. Bullock admits the bill was a shock and says next time she would inquire about fees before submitting to tests.
Corinth parents Kathy and Jon Schultz (whose names have been changed) suffered similar sticker shock. They took their son, Connor, 12, to a freestanding ER for severe stomach pains and later their daughter, Millie, 11, to the same center for a strep test. Jon called an urgent care center first for Millie, but there was a three-hour wait to be seen. Neither child ended up with a serious diagnosis and spent less than 30 minutes per visit. Likewise, their bills were around $1000 each. 
Jon Schultz, who is a surgical physician’s assistant, knew the true costs of the tests administered and disputed the expenses.
“I was able to get both of the clinic bills reduced to below half of what the initial charges were,” he says. He didn’t question the doctors’ fees since he felt they were fair. “The actual patient care part of the experience was quite good; the staff was friendly and knowledgeable.” He was informed during the bill negotiation about a cash discount at the time of services, but the clinic didn’t present this option upon check-in.
Urgent care centers also typically charge higher rates than your family doctor. You’re paying for the extended hours and the convenience, plus they offer X-rays and perform lab work onsite. Freestanding ERs have an even higher overhead due to costly imaging and diagnostics such as CT scanners, ultrasounds and EKGs. Plus they undergo state licensing expenses and must be staffed 24/7 just like a hospital ER. Therefore, you should expect to pay ER rates even if the care you need is nominal.
To avoid paying more than you’re prepared to, check out your options in advance. Consult with your insurance company to see what co-pays apply at your neighborhood centers. Many policies have one co-pay for general practice, a slightly higher one for specialists and a significantly higher fee for urgent and emergency care. You can also ask providers if discounts for paying cash out-of-pocket are offered if you have a high deductible.
“Before we took our daughter in, we called to see if the emergency center would do a strep test,” Kathy Schultz recalls. “And the receptionist said yes, but they were not an urgent care center.” Schultz didn’t know the difference between urgent care and emergency care and didn’t ask about fees.
“Later a friend told us the same test can even be done at our local pharmacy.” Area retailers such as MinuteClinics at CVS pharmacies, Walgreen’s Healthcare Clinics and Target Clinics do offer routine vaccinations, physicals and services (including strep tests) for patients 18 months and older; care is provided by a nurse practitioner or a physician’s assistant.
Realizing that the biggest complaint patients had was not the level of care provided but the cost associated with it, some centers have unveiled hybrid models, allowing them to treat both urgent and emergency situations under one roof. Legacy ER & Urgent Care, with locations in Allen and Frisco, as well as E-Care Emergency Centers, which will soon open a fifth center, are examples of two in our area.
Prickett says his team at E-Care works diligently to communicate to patients when they’ve “crossed over” from urgent care to emergency. Before they developed their current approach to care, he says patients felt duped when they received a $1500 bill for a throat swab.
“It didn’t seem right to them or to us either,” Prickett admits. “Today, even if we move a patient to an ER room to administer urgent care — the lighting might be better for stitching a wound — we’ll still bill at the urgent care rate.” The only caveat: urgent care is limited to extended weekday hours from 8 a.m. to 8 p.m. on Saturday and 9 a.m. to 5 p.m. on Sunday. “If you come in during the night, you’re going to pay ER rates for care,” he explains.
Making the Right Choice

Medical concerns can arise at any time and accidents happen to even the most cautious of families, so it makes sense to plan ahead. Ask your pediatrician who she recommends you see for care when her office is closed. If your concern is urgent and not an emergency, calling her after-hours line might alleviate your fears and point you in the right direction for care.
Know your local options. If you drive by an urgent care center or a freestanding emergency room every day, go online and look at their services. See who the practice manager is and what his or her qualifications are. Determine if they accept your insurance and what your co-pay might be. Stop by and visit, especially if you have a child with a chronic condition, and see if they’re comfortable providing treatment. “You want to know who works there and that they’re competent and trustworthy,” Hennes advises. Reviews from patients are also prevalent online through Google and Yelp.
Whenever your child is seen by someone other than his pediatrician, make sure you get detailed information about what services were performed and what medication was administered so you can relay this information back to your child’s medical home. “We use a pretty robust electronic system that notifies the physician that we’ve seen the child and what tests were run,” says DeLashaw. “In turn, they can follow up with us to see the results of those tests.”

Published September 2015