Treating the Walking Wounded

What do you do when you have a sudden medical problem that isn’t serious enough to warrant a trip to Emergency, but can’t wait until you can get in to see your general practitioner? The answer is ambulatory urgent care, according to Bill Wenmark.

“The development of urgent care and convenience medicine is an effort to get public health deeper and deeper into the communities where they really need it”

You have a pain in your shoulder, or a little trouble breathing, or you’re a bit dizzy. What do you do? Head to the overcrowded hospital emergency department? Wait a couple of weeks to get an appointment with your equally busy GP? Neither, says Bill Wenmark. His answer is ambulatory urgent care. “Some people have routine everyday little medical issues that come up that don’t need to be institutionalized or put on hold to make an appointment with your primary care doctor to see you in three or four weeks. We use the term “prudent layperson,” someone who is not a professional but in their own judgment has a level of identification of a certain medical issue that they happen to be affected by.

“And what they would normally be relegated to is trying to make an appointment to get in, or going to the emergency room, which is the inappropriate place. Urgent care and convenience medicine have both provided now opportunities for those people that have these minor issues and need to get them seen by a medical practitioner.”

Wenmark, who is President of the National Association for Ambulatory Urgent Care, explains that the notion of ambulatory urgent was originally invented in the early 1970s by doctors who noticed the disparity between these minor healthcare needs and the availability of a convenient option for treatment.

“There was a beginning effort back then by doctors who realized that the typical type of delivery system that we had, which was largely built around primary care physicians and specialty care physicians and hospitals and public health, while it served most people who had diseases that needed to be managed, did not address these routine little medical problems,” Wenmark points out.

“These doctors said, ‘I’m going to go ahead independently and make a difference in the public health delivery system.’ They decided to open up their offices and provide an opportunity for people to walk in and see a physician. They treated it as a consumer service, ust like you can walk in and buy groceries any time you would like or you can walk in and get your hair cut any time you like.

“This can also help reduce the costs of medical care, because we’re able to catch things that might otherwise have been postponed by that same prudent layperson and developed into much more serious problems. We’ve been able to pick up things like lung tumors and early strokes and intervene earlier because of urgent care being what it is. It is the ability for the consumer to access a public health delivery system without the complications either by time and sequence or by money, because it’s the most affordable place you can go. You can pay for this out of your pocket. You don’t need insurance to go to an urgent care center. If you have it, that’s great, but it’s designed to be something like you can afford. That access is what I call public health.”

Working as partners
Wenmark explains that there are three organizations in the United States that deal with the general concepts of urgent care and convenience medicine: NAFAC, the Urgent Care Association of America (UCAOA) and the American Academy of Urgent Care Medicine (AAUCM).

“UCAOA carries out more of the business-related activities – products, services, lab equipment, EMR record systems that they own and group purchasing options,” Wenmark says. “All of those things are very important if you’re going to be a business owner in any general sense. And then AAUCM is Franz Ritucci, who  has been working almost his entire life as a physician to try to get urgent care recognized in board certification and also develop a residency program to develop the skills necessary to work in an urgent care center.

“The doctors you see practicing in an urgent care center now will usually be board-certified family practitioners or a board-certified emergency room physicians. What Franz has been working on for years and is to try to develop that recognition of board certification for urgent care, and also develop a residency, university-based program for the specialty training of urgent care. His organization is looking at the clinical, educational, curriculum, academic kinds of urgent care-associated types of things.

“And he’s done a really good job. He got the American Medical Association to identify a UCM or Urgent Care Medicine as a self-designated practice specialty, which was very, very good. CMS, our Medicare organization in the government, still doesn’t recognize urgent care per se, but it does have a point of service code that does identify that the service would be given at an urgent care center.”

Community health
In Wenmark’s view, urgent care centers have allowed deeper penetration into communities with public health delivery systems where they’re less costly to build. He points out that it doesn’t cost as much to put a nurse practitioner in a retail grocery store, as it would to build an emergency room or to build a hospital.

“The development of urgent care and convenience medicine is an effort to get public health deeper and deeper into the communities where they really need it,” Wenmark continues. “This allows us to postpone the inappropriate use of the more costly structural medicine or healthcare that we have built into our system. Some people like to build these big buildings that they can worship, but that doesn’t do much for the public health of the person there in the community.

“Urgent care is available seven days a week, on average 13 hours a day, on average 365 days a year. You can walk in without an appointment. The physicians and the staff are waiting to see you. And then we exercise what’s called triage. In an urgent care center we don’t know how many people are going to be coming in, whereas with primary care, as an example, you already know who’s coming because you made that appointment. You’ve also had the chance to review that medical record of that person who made that appointment.

“In chronic care, you need to pay attention to medical management, disease management, the individual patient. You need to spend a little bit more time with them in the sense of managing that medical problem. Whereas that is not what urgent care does. We do not take care of hypertension, diabetes, cancer. We believe a primary care physician or a specialist should be doing the longitudinal care for that.”

The ‘urgent’ part of ambulatory urgent care means that anyone could turn up on the spur of the moment. How you deal with that? Wenmark explains that many urgent care physicians started their careers in hospital emergency departments, which means they have a background in a variety of cases as they come along. “You obviously also learn that by your training,” he says. “You make sure that your staff and your policies and your procedures are as efficient as possible. For instance, as an example, the first interface the patient might have when they walk into the clinic is the receptionist – who needs to be trained in her own or his own level of triage. If you see that the patient is bleeding, you don’t hand them a handful of paperwork to fill out. You say, ‘Come on in; we’ll take care of that.’

“You put them into the procedure room because you know that’s where it’s going to go. The nurse who’s dealing with that floor’s resources and people immediately diverts attention to that particular patient. Because each patient who arrives in the clinic has a perceived notion of how long it is going to take based on their ‘prudent lay’ understanding of what’s going on. For instance, if they’re coming in bleeding, or they’re coming in with chest pain, or they’re coming in with a broken bone, they don’t expect that to be treated in 10 minutes.

“They’re going to give you time, because they don’t want you to rush through their laceration or fracture or chest pain. So they give you an allocation of time. On the flip side of that, if Mom comes in with her little son who has 104 degree temperature and an earache, she’s been through that before. She knows that what she needs is liquid amoxicillin. She’s been there, done that before.

Customers first
For Wenmark, the most important thing in urgent care is the consumer interface: the ability to understand and communicate to someone who is interested in being a partner with the physician. He says that the physicians in urgent care who are successful are great communicators. They help people get through those difficult situations, and they’re very informative in terms of communication. He stresses again that urgent care is a retail and customer-oriented experience.

“You’re purchasing this. Well, when you’re a purchaser, you’re looking for value, and that’s what really you want to provide as a physician in charge of or in the delivery pathway of doing urgent care/convenience medicine – you want to deliver quality.

“When we look at in a higher goal, silo kind of way, that’s where medicine has gone wrong. You can talk to many people who are disillusioned by going into these huge, empirically designed organizations that are very impersonal, and very cold. People are trained to be more robots in terms of process instead of customer relations. Although, then, on the flip side of that, look at those facilities that have seen the importance of that consumer interface and that consumer satisfaction.

“When you have a government provided healthcare system, then that’s when you see it being indifferent. You get the impression the staff are thinking, “Oh, this is my job. I don’t really like my job.” And that impression comes off to the consumer. When you’re in the retail and competitive marketplace, then those other values come through, and that’s what’s happening now in the US.”

According to Wenmark, there are currently about 12,700 urgent care centers across the country, including ‘fast lanes,’ delivery systems next to emergency departments, occupational medicine facilities and fully fledged urgent care centers with radiology departments, laboratories, and doctors.

Certification
In order to help urgent care providers become even more knowledgeable about their work, NAFAC runs the National Urgent Care Practice Center certification program. “The certification is a process that I commissioned boy about 15 years ago,” Wenmark says.  “We looked at it from an absolute detailed letter by letter point of view of every possible thing that you could possibly have in an urgent care center. We identified each of those into different categories, and developed the matrix and the examination as a self-examination tool.

“We took a broad brush of a lot of people in the country and developed the NAFAC Certification Program. We also wanted to recognize the fact that we’re not certifying a hospital or a multi-million dollar facility. We’re certifying an urgent care center. By its nature, you want to help it keep costs affordable for the consumer to purchase this public health service. It’s not Cadillac service; it’s really just good fundamental medical care.

“We don’t send people out to your center to go and walk through like the Joint Commission does, or the Accreditation Association for Ambulatory Care. We don’t go out there and walk in and actually certify you. We decided that we would do a self-audit: when a center applies we send them out two documents: a center copy and an audit copy. They’re then required to go through and legally audit all of the basic elements of the certification. It takes about three people two weeks minimum to go through their entire center to do a certification.

“Once they’re done with that they have it legally notarized that they in fact did that – again, that’s their declaration, i.e. liability is specifically first person. You’re telling us that you did do all of these things. It comes back into our office, we review it, we look at it. We may call you on a few things just to be a double check to make sure that you actually did these things. And then we provide a certification for three years. Once that’s done, that’s recognized by United Healthcare Corporation as a credentialing for third party reimbursement by insurance companies.

Another important tool that NAFAC produces for the owners of urgent care centers is Bill’s Book, a 300-page compilation contaiing materials supplemental to Bill Wenmark’s annual NAFAC conference seminar for new owners who plan to open an urgent care center, as well as veterans who are looking for ways to improve their practice.

“We have all these people out there that may want to get into urgent care – why shouldn’t we give them a guidebook of how to do it, based on all the things we did wrong?” Wenmark says. “They shouldn’t have to go through it and repeat all the mistakes we made, which obviously increases the costs of creating urgent care. I thought, ‘How can I help people get started in urgent care? Bill’s Book is is a three-ring binder of what you would need to do to develop everything from the business model to internal paperwork to files, cabinets – everything. That’s what’s in Bill’s Book. We send that out to people as a helpful guide to say, ‘Here are the things that you’ve got to be thinking about,; that they may or may not have even thought about when they said, ‘I’d like to get into urgent care.’ Maybe it’s that emergency department doc who has been 20 years in their career and now they’re burned out.

“But they’ve got plenty of life left in their medicine, and plenty of life left in wanting to do things, and they want to open up an urgent care center. What do they know about business? Bill’s Book will help them a great deal of knowing about the business of urgent care, not just the medical practice of urgent care.”

Looking ahead
While Wenmark decries President Obama’s plans to bring the US healthcare system under more government control, he does admit they may indirectly prove an advantage to urgent care centers. “Unless urgent care is outlawed – and I wouldn’t put it past Obama to do that –I see tremendous opportunities for express care and for urgent care in the United States. 

“Right now, 20 percent of our people drive the majority of the cost of our healthcare system. They’re the people who have diabetes, hypertension, cardiac disease. The other 80 percent have routine medical needs that they want taken care of, and these people ar going be frustrated because the primary care doctors are now going to be government employees. Urgent care and convenience medicine will see a boom, because people are literally going to be looking for places where they see and talk to a doctor.”

William Wenmark is President of the National Association for Ambulatory Urgent Care (NAFAC).

National Association for Ambulatory Care

Founded in 1973, NAFAC is an organization helps its members open new clinics and thrive in the changing world of ambulatory healthcare. The association has more than 500 members from 46 states around the country, representing approximately 1700 clinics.

Members are predominantly physicians and clinic operators from a range of healthcare provider organizations, including large healthcare systems like Catholic Healthcare West in San Francisco, Deaconess Health System in Indiana or Carolinas Healthcare System in Charlotte; ambulatory surgery centers like Glasgow Medical Center in Newark, DE; multi-location urgent care practices like PrimaCare in Dallas; and single office urgent care and primary care practices all over the country.

The association publishes Bill’s Book: Developing Urgent Care Centers, and is scheduling regional one-day programs dealing with topics ranging from clinical standards and accreditation, to threats and opportunities facing member practices, to back-office procedures for streamlining administration. NAFAC also lobbies on behalf of members, most recently around a payment concept known as ‘problem-based coding.’