JACKSONVILLE, Fla. — Facing an ultracompetitive market in one of the nation’s fastest-growing cities, UF Health is trying a new way to attract patients: a combination emergency room and urgent care center.

In the past year and a half, UF Health and a private equity-backed company, Intuitive Health, have opened three centers that offer both types of care 24/7 so patients don’t have to decide which facility they need.

Instead, doctors there decide whether it’s urgent or emergency care —the health system bills accordingly — and inform the patient of their decision at the time of the service.

“Most of the time you do not realize where you should go — to an urgent care or an ER — and that triage decision you make can have dramatic economic repercussions,” said Steven Wylie, associate vice president for planning and business development at UF Health Jacksonville. About 70% of patients at its facilities are billed at urgent care rates, Wylie said.

Emergency care is almost always more expensive than urgent care. For patients who might otherwise show up at the ER with an urgent care-level problem — a small cut that requires stitches or an infection treatable with antibiotics — the savings could be hundreds or thousands of dollars.

While no research has been conducted on this new hybrid model, consumer advocates worry hospitals are more likely to route patients to costlier ER-level care whenever possible.

For instance, some services that trigger higher-priced, ER-level care at UF Health’s facilities — such as blood work and ultrasounds — can be obtained at some urgent care centers.

“That sounds crazy, that a blood test can trigger an ER fee, which can cost thousands of dollars,” said Cynthia Fisher, founder and chair of PatientRightsAdvocate.org, a patient advocacy organization.

For UF Health, the hybrid centers can increase profits because they help attract patients. Those patient visits can lead to more revenue through diagnostic testing and referrals for specialists or inpatient care.

Offering less expensive urgent care around-the-clock, the hybrid facilities stand out in an industry known for its aggressive billing practices.

On a recent visit to one of UF Health’s facilities about 15 miles southeast of downtown, several patients said in interviews that they sought a short wait for care. None had sat in the waiting room more than five minutes.

“Sometimes urgent care sends you to the ER, so here you can get everything,” said Andrea Cruz, 24, who was pregnant and came in for shortness of breath. Cruz said she was being treated as an ER patient because she needed blood tests and monitoring.

“It’s good to have a place like this that can treat you no matter what,” said Penny Wilding, 91, who said she has no regular physician and was being evaluated for a likely urinary tract infection.

UF Health is one of about a dozen health systems in 10 states partnering with Intuitive Health to set up and run hybrid ER-urgent care facilities. More are in the works; VHC Health, a large hospital in Arlington, Virginia, plans to start building one this year.

Intuitive Health was established in 2008 by three emergency physicians. For several years the company ran independent combination ER-urgent care centers in Texas.

Then Altamont Capital Partners, a multibillion-dollar private equity firm based in Palo Alto, California, bought a majority stake in Intuitive in 2014.

Soon after, the company began partnering with hospitals to open facilities in states including Arizona, Indiana, Kentucky, and Delaware. Under their agreements, the hospitals handle medical staff and billing while Intuitive manages administrative functions — including initial efforts to collect payment, including checking insurance and taking copays — and nonclinical staff, said Thom Herrmann, CEO of Intuitive Health.

Herrmann said hospitals have become more interested in the concept as Medicare and other insurers pay for value instead of just a fee for each service. That means hospitals have an incentive to find ways to treat patients for less.

And Intuitive has a strong incentive to partner with hospitals, said Christine Monahan, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University: Facilities licensed as freestanding emergency rooms — as Intuitive’s are — must be affiliated with hospitals to be covered by Medicare.

At the combo facilities, emergency room specialists determine whether to bill for higher-priced ER or lower-priced urgent care after patients undergo a medical screening. They compare the care needed against a list of criteria that trigger emergency-level care and bills, such as the patient requiring IV fluids or cardiac monitoring.

Inside its combo facilities, UF posts a sign listing some of the urgent care services it offers, including treatment for ear infections, sprains, and minor wounds. When its doctors determine ER-level care is necessary, UF requires patients to sign a form acknowledging they will be billed for an ER visit.

Patients who opt out of ER care at that time are charged a triage fee. UF would not disclose the amount of the fee, saying it varies.

UF officials say patients pay only for the level of care they need. Its centers accept most insurance plans, including Medicare, which covers people older than 65 and those with disabilities, and Medicaid, the program for low-income people.

But there are important caveats, said Fisher, the patient advocate.

Patients who pay cash for urgent care at UF’s hybrid centers are charged an “all-inclusive” $250 fee, whether they need an X-ray or a rapid strep test, to name two such services, or both.

But if they use insurance, patients may have higher cost sharing if their health plan is charged more than it would pay for stand-alone urgent care, she said.

Also, federal surprise billing protections that shield patients in an ER don’t extend to urgent care centers, Fisher said.

Herrmann said Intuitive’s facilities charge commercial insurers for urgent care the same as if they provided only urgent care. But Medicare may pay more.

While urgent care has long been intended for minor injuries and illnesses and ERs are supposed to be for life- or health-threatening conditions, the two models have melded in recent years. Urgent care clinics have increased the scope of injuries and conditions they can treat, while hospitals have taken to advertising ER wait times on highway billboards to attract patients.

Intuitive is credited with pioneering hybrid ER-urgent care, though its facilities are not the only ones with both “emergency” and “urgent care” on their signs. Such branding can sometimes confuse patients.

While Intuitive’s hybrid facilities offer some price transparency, providers have the upper hand on cost, said Vivian Ho, a health economist at Rice University in Texas. “Patients are at the mercy of what the hospital tells them,” she said.

But Daniel Marthey, an assistant professor of health policy and management at Texas A&M University, said the facilities can help patients find a lower-cost option for care by avoiding steep ER bills when they need only urgent-level care. “This is a potentially good thing for patients,” he said.

Marthey said hospitals may be investing in hybrid facilities to make up for lost revenue after federal surprise medical billing protections took effect in 2022 and restricted what hospitals could charge patients treated by out-of-network providers, particularly in emergencies.

“Basically, they are just competing for market share,” Marthey said.

UF Health has placed its new facilities in suburban areas near freestanding ERs owned by competitors HCA Healthcare and Ascension rather than near its downtown hospital in Jacksonville. It is also building a fourth facility, near The Villages, a large retirement community more than 100 miles south.

“This has been more of an offensive move to expand our market reach and go into suburban markets,” Wylie said.

Though the three centers are not state-approved to care for trauma patients, doctors there said they can handle almost any emergency, including heart attacks and strokes. Patients needing hospitalization are taken by ambulance to the UF hospital about 20 minutes away. If they need to follow up with a specialist, they’re referred to a UF physician.

“If you fall and sprain your leg and need an X-ray and crutches, you can come here and get charged urgent care,” said Justin Nippert, medical director of two of UF’s combo centers. “But if you break your ankle and need it put back in place it can get treated here, too. It’s a one-stop shop.”

Author: Phil Galewitz: pgalewitz@kff.org, @philgalewitz

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People-centred care represents an essential evolution from patient-centred care, which “restores a functional life”, to person-centred care, which “promotes a meaningful life.”[1] As the authors explain, “People-centred care expands the scale and scope of person-centred care to the level of health systems and populations. People-centred care requires a whole-of-government approach that engages patients, carers, families, and communities in shared decision-making to ensure health services are provided ‘at the right time, in the right place, in the right way’.”[2]

The Commission seeks to fill crucial gaps by defining how people-centred care can be “operationally defined, rigorously measured, and effectively implemented across various settings and income levels.”[2] Achieving this will require determining the current state of people-centeredness in different contexts, developing optimal measurement approaches, and identifying best practices for the co-production of health systems and services through “shared partnership and leadership alongside people with lived experience.”[2]

Notably, the Commission is grounded in participatory principles, using “community-engaged methods and shared governance models”[2], starting with an open call for commissioner nominations. The authors emphasise, “Such a shift toward transparency and shared decision-making is crucially needed in publications with such global influence as the Lancet, which can intentionally contribute to dismantling unequal power structures in global health.”[2]

The open call aims to recruit a “diverse, independent group of multidisciplinary experts on people-centred care including people with lived experience, academic researchers, policymakers, health-care providers, private sector actors, and civil society.”[3] Commissioners will be selected rigorously based on their experience, impact, commitment to equity, networks, and availability.[3] Selection will ensure an appropriate mix of skills and diversity across gender, geography, income-level and inclusion of marginalised groups.[3]

Over 2.5 years, the Commissioners will formulate research questions, synthesise evidence, and conduct new research to inform policy and practice recommendations for operationalising people-centred care in diverse settings.[3] Working groups will use participatory, community-engaged methods aligned with people-centred principles.[3]

Through this innovative and inclusive approach, the Commission aims to “forge a new way of knowing and practicing health care in the post-Sustainable Development Goal era, using people-centred care as our guide to achieving Universal Health Coverage”[2]. If successful, this could help reorient health systems worldwide to be for and with the people they serve truly.

References:

1. Håkansson Eklund J, Holmström IK, Kumlin T, et al. “Same same or different?” A review of reviews of person-centered and patient-centred care. Patient Educ Couns 2019; 102: 3–11.

2. Duong DB, Holt B, Munoz C, Pollack TM. For and with people: announcing the Lancet Global Health Commission on people-centred care for universal health coverage and a call for commissioner nominations. Lancet Glob Health 2024; published online May 29.

3. Supplementary Appendix to Duong et al. Lancet Glob Health 2024.

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Barrier After Barrier

“How do I get a vaccine?” It’s the singular question on the mind of the nation. 

The process has proven challenging for many. A recent study found that 4 in 10 adults found the vaccine process difficult, and another 4 in 10 adults reported needing assistance to schedule their vaccination (KFF COVID-19 Vaccine Monitor Dashboard). Now, imagine the vaccination process with even more barriers. Maybe you know where to go to get a vaccine but you don’t have reliable transportation. Maybe you’re told to find vaccine information online, but you don’t have internet access.

Access to the internet is a privilege that many take for granted. The US Census reported that more than a million people in Texas alone do not have access to internet at home (“Presence and Types of Internet Subscriptions at Home”). For those returning to society after years away, like the formerly incarcerated, the internet is a mystery of science fiction. Many states released inmates early to decrease prison population density during the pandemic, but for those who have been away for a decade or more, the new world is inaccessible.

“People would say things like they were so simple.” said Hudson, 57. “‘Listen, go to your browser and open this up.’ I’m like, ‘Who is the browser?’”

-“Former prisoners struggle to re-enter society. What happens when society moves online?” by Alexandra Marquez

Even if you’re lucky enough to have reliable transportation and internet access, be digitally literate, and be able to flex your schedule to suit whatever appointment you can get, there’s still one more condition to meet. English. For the limited English proficient, Deaf, and hard of hearing, vaccine information can be almost impossible to obtain.

Lost in Interpretation

In California, native Mixteco speakers don’t know the details of their own care because there are no available interpreters. Cultural incompetent systems pair Mixteco speakers with Hispanic interpreters who speak a different dialect. This apples-to-oranges solution leaves patients scared and alone, unable to advocate for themselves.

“I feel a lot of sadness in my heart, because I don’t know what’s going to happen to my husband, and I don’t know what his condition is,” she said through an interpreter on Feb. 19, as her husband lay in a hospital bed. “He’s suffering a lot in that place … He tells me people come and give him injections, he wants to know what they are, but he doesn’t understand.”

– “Hospitalized For COVID-19 Without Information: What Californians Who Speak an Indigenous Language Often Face” by Claudia Boyd-Barrett

Linguistic barriers aren’t reserved for unique cases of rare dialects. California’s large Spanish-speaking population faces the same struggle. “Rosa Lazarovits, a Ventura-based marriage and family therapist who works mainly with Latinx seniors, said many of her patients have expressed panic over not knowing how to get vaccinated. The county does have an online portal with vaccine information in Spanish. But many seniors don’t know how to navigate the internet, she said” (Boyd-Barrett, Claudia).

A Virginia hotline sought to make vaccine information more accessible by providing a phone number in addition to online services. The problem? Interpreters weren’t available in enough languages. “Only two languages were offered when callers dialed in — ‘press 1 for English’ or ’press 2 for Spanish.’ But Virginia is home to speakers of many other languages — Chinese, Korean, Vietnamese, Arabic, Mongolian, Amharic and dozens more — who would need the help of [interpreters] to get their place in line for a vaccine” (Pradhan, Rachana).

In addition to facing language barriers, many minority populations distrust the healthcare system. This leads to even lower vaccination rates in those who are able to access vaccination information. Connecticut is seeing that impact in their community. “New data released from DPH showed that of the nearly 12,000 Black residents who were 75 and older and eligible to receive the vaccine, only 2,248 had received the first dosage. For the Hispanic population, of the nearly 8,000 eligible to receive the vaccine, only 2,780 receive their first dosage” (Moody, Dominique).

The reality is that equitable vaccine distribution is not a local issue. It’s a global one. WHO published a vaccine equity declaration in January, stating that “I“In the majority of low- and middle-income countries, vaccination has not even started which is a catastrophe as hospitals fill up,”,” (World Health Organization).

Putting Accessibility at the Forefront

We’re making strides to correct low vaccination numbers in minority populations, but since we already knew that COVID-19 disproportionately impacts these groups, it’s fair to ask: Why weren’t these measures implemented in the first place?

“You need to proactively plan,” said Christensen Lundin. “You’re not going to do a great job serving people if what you’re doing is reacting three minutes (after) someone told you they had a language need and you’re scrambling to figure it out.”

– “Hospitalized For COVID-19 Without Information: What Californians Who Speak an Indigenous Language Often Face” by Claudia Boyd-Barrett

Accessibility cannot be an afterthought. The failure to provide care accommodations costs lives. To that end, we have not only failed our minority communities. We have failed as a community, as a nation, and as a people.

How do we correct such an egregious failure? We have to look to the people already dedicated to overcoming healthcare disparities, and let them lead larger initiatives with leadership buy-in. Supervisor of Interpreter Services for CentraCare Health in Minnesota, Laura Cranston, knew that misinformation, work schedules, and community trepidation were huge stumbling blocks for her community. Cranston set up COVID testing facilities in the parking lots of local businesses that employed minority workers. She also worked with community leaders to disperse accurate vaccine information. “I encourage everyone to use all available communication channels,” she said. “You have to reach your communities where they are instead of trying to make them come to you.”

Resources

Boyd-Barrett, Claudia. “Hospitalized For COVID-19 Without Information: What Californians Who Speak an Indigenous Language Often Face.” California Health Report, 18 Feb. 2021, https://www.calhealthreport.org/2021/02/18/hospitalized-for-covid-19-and-no-information-what-californians-who-speak-an-indigenous-language-often-face/.

“KFF COVID-19 Vaccine Monitor Dashboard.” KFF, 30 Mar. 2021, www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard. 

Marquez, Alexandra. “Former Prisoners Struggle to Re-Enter Society. What Happens When Society Moves Online?” NBC News, 29 Mar. 2021, www.nbcnews.com/tech/tech-news/former-prisoners-struggle-re-enter-society-happens-society-moves-onlin-rcna518.

Moody, Dominique. “Federal, Local, and Health Leaders Push for Vaccine Equity.” NBC Connecticut, 16 Feb. 2021, www.nbcconnecticut.com/news/local/federal-local-and-health-leaders-push-for-vaccine-equity/2423924.

Pradhan, Rachana. “‘Press 1 for English’: Vaccination Sign-Ups Prove Daunting for Speakers of Other Languages.” Kaiser Health News, 22 Mar. 2021, www.usnews.com/news/health-news/articles/2021-03-22/vaccination-sign-ups-prove-daunting-for-speakers-of-other-languages?fbclid=IwAR3wQYigSCCan2tzra98Ldg7dfsVVjMIRCmrRQng-eCJmixSx3_joU89SVw.

“PRESENCE AND TYPES OF INTERNET SUBSCRIPTIONS IN HOUSEHOLD.” United States Census Bureau, www.data.census.gov/cedsci/table?q=B28002&g=0100000US.04000.001&tid=ACSDT1Y2018.B28002. Accessed 8 Apr. 2021.

World Health Organization. “Vaccine Equity Declaration.” World Health Organization, www.who.int/campaigns/annual-theme/year-of-health-and-care-workers-2021/vaccine-equity-declaration. Accessed 8 Apr. 2021.

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Medicine is pioneering new technologies that can identify patients at risk for cardiac events through the wireless connection in their hospital beds, alert physicians to possible drug prescribing errors, and enable consumers to use wearables to check their heart rate and rhythm. Yet, our health is too often determined by information technology most people long slated for their town’s dump heap or recycling center — the facsimile machine. Best known as “the fax.”

Would a student at any academic medical center today even know how to operate this tech dinosaur without training? Did they have one in their dorm or library when they first arrived at college? Would one of their peers have ever asked for the day’s class notes with the words: “fax it over?” Ridiculous. Yet, much of a person’s medical information — the stuff that influences life and longevity — is forwarded from provider to provider by way of outdated technology. How can we ever overcome the challenges of “interoperability” and information blocking when we continue to rely on fax to transmit timely patient information? How can patients gain timely access to their own data?

To implement the Cures Act rule and improve access to care, antiquated policies must be revised. Lack of consumer trust in data security inhibits the adoption of ideas that reduce costs, speed medical decision-making and help secure needed treatments. However, medicine’s unrequited love for the faxes is not love at all. 

It is legal anxiety related to staying safely inside the swim lanes of the Health Insurance Portability and Accountability Act (HIPAA). The Department of Health and Human Services (HHS) created HIPAA to set privacy standards for health information; providers recognized the fax and phone as preferred ways to share patient data between providers and among labs, hospitals, specialists, and payers. But, more and more, this system of data transfer limits patient access to the very information their lives depend on.

The Cures Act is designed to help give patients greater ownership and voice over their own medical intellectual property. Yet, the HHS website still lists fax as a preferred path to share medical records, test results, instructions, and treatments.

The Privacy Rule requires that covered health care providers apply reasonable safeguards when making these communications to protect the information from inappropriate use or disclosure. These safeguards may vary depending on the mode of communication used. For example, when faxing protected health information to a telephone number that is not regularly used, a reasonable safeguard may involve a provider first confirming the fax number with the intended recipient. Similarly, a covered entity may pre-program frequently used numbers directly into the fax machine to avoid misdirecting the information. When discussing patient health information orally with another provider in proximity of others, a doctor may be able to reasonably safeguard the information by lowering his or her voice.

Four years ago, faxing remained the “best” HIPAA–compliant way of sending and receiving sensitive patient information. Why? According to the experts: it “can be a more efficient form of written communication because of the trouble and accuracy issues involved with gathering multiple email addresses.” Convenience for patients? Physicians? Regulators? Who?

We need new ways — secure and fast — to share information. Interoperability embraces a world where a consumer’s health history is accessible whether they are at world-class medical centers or community care centers. At a time when we are handwringing about medical costs, diagnostics and blood tests are repeated multiple times because physicians need data that is not readily accessible, despite its existence elsewhere. Information saves lives and keeps costs down. Pioneer companies around the globe are creating Electronic Medical Record Systems (EMR) and cloud-based AI platforms that support interoperability. It’s possible — albeit unlikely — that these companies — some challengers to the behemoths — will be at the forefront of this sorely needed evolution. However, the system has built-in “security” obstacles that will continue to tie health professionals’ hands behind their backs. It is certainly frustrating for physicians. More so, to the people, they seek to heal.

Is HIPAA Advancing Patient Access to Information?

Years ago, when my mother lay dying of cancer, I learned that the OB/GYN at a major New York-metro medical academic center had discovered a new 14 cm tumor one week before her death. That physician told me that she was waiting for the department to “type up the clinical notes,” so that they could be “faxed” to my mother’s oncologist — working in the same hospital system. The oncologist, unaware of the deadly threat posed by the growing tumor, continued to treat as if it didn’t exist. As my mother transitioned from this world to the next, I asked both of these distinguished physicians — OB/GYN and Oncologist — what they had learned. Their answer speaks to the heart of this information challenge. In unison, they replied: “We should have communicated with each other immediately.” Lesson learned! Retire the fax.

HIPAA was created for an important purpose — to maintain people’s medical-record confidentiality. However, this system, created before encrypted email and password-protect communications, is now placing people’s lives at risk. The confirmed examples of HIPAA-snafus goes on and on…

Recently, my almost 90-year old mother-in-law struggled to schedule an appointment with her physician she had not seen for more than a year. At a time when even elderly people who are vaccinated are frightened to venture outside the security of their homes, the visit required her to fill in a multi-page medical update. The problem? The physician’s office insisted that she receive and return their document by fax! Who has a fax in their home today? The unwieldy solution was to send the document by mail and have a home-health aid return the forms prior to the in-office visit. How does that advance someone’s urgent care?

While the fax may be the safest way to keep physicians HIPAA compliant, it creates a behavior inconsistent with their chosen mission — to save lives. Data safety is a priority! No question! However, this outmoded technology is in direct conflict with the physicians’ Hippocratic oath: “Do no harm!” Playing it safe may be harming people. We can invent breakthrough vaccines and therapies that arrest viruses rare diseases and cancers. Somehow, we have yet to find an agreed policy pathway to share information with confidence and speed. This is not our finest moment in medicine.

CMS Administrators have called for an end to physician fax machines. Will our medical system be ready to finally enter the 21st century of medical information sharing? Not really!

While we live in an age of wonder at technological advancements such as fitness apps and precision medicine tailored to an individual’s genetic code, health information technology remains far behind all of the major industries. Healthcare remains in a 1990s-time warp.

Now is the time to use the Cures Act and recognize that information blocking — however it’s done — is no longer acceptable.

What would Dr. Leonard “Bones” McCoy, the famed Star Trek Enterprise’s chief medical officer, say about how we share data from doctor to doctor? Likely, a similar cry from his visit to a state-of-the-art 20th-century hospital: “What is this? The Dark Ages?” Health and Human Services did not deliver on its pledge to retire the fax by 2020. Our lives should not be dependent on the policies or antiquated technologies of the previous century.

Did you get my fax yet?

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