DOC-IN-THE-BOX

NEED STITCHES? Got a sprain? Drive in, day or night, for ambulatory care.

Traditional medicine recently passed away at our house after a long weekend of fever, coughs and bleeding. That was the weekend we fired our 9-to-5, Monday-through-Friday family physicians and transferred our allegiance to a more convenient form of health care: ambulatory care centers (ACCs), minor-emergency and routine-care facilities known collectively-both in praise and scorn-as Docs-in-the-Box.

Their bright billboards and signs beckon like Hippocrates with a neon nose. ACCs (many still call themselves minor emergency clinics) usually open early and close late, even on Saturdays and Sundays. And they require no appointments. Their names include a multitude of variations, all on a theme of fix-you-up-quick: MedStop, MedHelp, MedFirst, Medic 24, Doctors Care, Emergicenter.

Docs-in-the-Box have been popping up lately like medicinal mushrooms in small shopping centers, in malls and even sandwiched between popular hamburger restaurants on busy thoroughfares. If you’re sick or injured but still ambulatory-able to come in and pay-you can have it your way: sutures to go, a bandage or a sling, a quick shot of an antibiotic-one insurance physical, please, and cut the hassle.

Proponents of the decade-old concept say that extended-hours ACCs and similar independent or corporate-owned facilities for minor medical problems are forcing overdue changes in the way doctors and hospitals do business. Routine medical care, they say, is being made more accessible and more affordable.

Detractors claim that ACCs, known until recently as “freestanding emergency centers,” do “wallet biopsies” of potential patients and turn away those who don’t have the money to pay up front. Critics also claim that ACCs mislead the sick or injured into believing that they can handle almost any kind of medical problem that needs immediate attention.

Critics of drive-in medicine worry that one night, a person may have a heart attack or suffer a gunshot wound and hurry off in search of a Doc-in-the-Box when he should be seeking life-saving treatment in a hospital emergency room.



THE CONTROVERSY “is one of those mom-and-apple-pie deals,” says Dr. Ronald Hellstern, president-elect of the Dallas-based National Association for Ambulatory Care (NAFAC) and medical director of Primacare, which operates eight ambulatory care centers in the Dallas/Fort Worth area. “It’s almost impossible to argue against the guy who says that if you use the word ’emergency’ in your name, you might potentially mislead one unwary consumer out of a million. That potential always exists,” Hellstern says. “But I would venture to say there are umpteen family physicians’ offices around town where every day somebody walks in with a heart attack, and the doctor is totally unprepared. He doesn’t have a heart monitor, a defibrillator, cardiac medications- all the stuff we maintain. Yet nobody jumps up and says, ’My god, he’s treating emergencies!’

Hellstern, who was director of emergency services for Methodist Hospitals before opening his first Primacare in Dallas in 1979, argues that the clash over ambulatory care centers and minor emergency clinics is “a matter of semantics. To a busy executive with a sore throat on Sunday night, and who has a marketing presentation on Monday morning, that’s an emergency. And in my view, most hospital emergency departments are primary- care facilities much of the time. Even in the most trauma-oriented emergency department, the volume consists of, at best, 25 percent true emergencies and 75 percent ambulatory, urgent-type or convenient-care patients.”

THE AGGRAVATIONS that recently transformed my family into bleeding, hacking, feverish consumers in search of convenient care began, predictably enough, on a Friday afternoon. In one shaking hand, I held a thermometer, its mercury elevated ominously to 102.2 degrees. In the other I held the telephone, while I listened for vital signs that my family physician’s receptionist was impressed with my symptoms. She was not. “The doctor can see you in two weeks,” she announced firmly, as she flipped through the pages of her appointment book. “That’s the earliest opening.”

“Two weeks? By then, I could be dead from this stuff,” I pleaded.

“There’s a lot of it going arou-,” she was intoning as I hung up.

Minutes later, as I lay quaking from anger as well as ague, the telephone rang. Aha, I thought, a last-second cancellation. The doctor can see me now.

It was urgent news from the day-care center. “Sammy has gotten a cut above his eye. 1 think he needs stitches,” the director told me.

I sank back to my pillow and weighed my fading options. Connie was 20 miles away at work, embroiled in a must-finish project. Shelly was still in school but would need to be picked up in a hour and a half. And the last time I had taken 7-year-old Sammy to an appointment with a pediatrician, I had sat for more than two hours in a huge waiting room packed with squirming, whining, coughing children and their anxious, dispirited mothers.

Sammy, I figured, could go to a hospital emergency room instead. While he got sewed up, one of the other young doctors on duty could shine a flashlight down my throat and scribble a prescription. But the cost of it all would likely bleed every cent from the family checkbook. And how would I be able to pick up Shelly on time if this visit turned out like the last time I used an emergency department?

I had staggered into a modest-size hospital hunched over and groaning. A big muscle in my back had contracted in a spasm and locked into a knot. Unfortunately, I reached the emergency room just as three ambulances arrived and unloaded six victims of a horrible traffic accident. The besieged emergency staff did its job well, and saved some of the smashed-up people. My problem, though immobilizing, was far from life-threatening. So I was left to hurt and watch for more than an hour until working space, time and an extra physician-a gynecologist-could be found to unknot my back.

Now, trying to figure out what to do with the Friday flu and one bleeding child, I remembered an advertising flyer that had come in the mail. It had announced the opening of a new minor emergency clinic 2 miles from our house. Immediate care, it promised. No appointment necessary. I had scoffed and tossed it in the trash. A family needed the personalized care of family doctors, I had always believed. But suddenly the family doctors were inaccessible, and going to the hospital emergency room seemed too dramatic, too expensive and too time-consuming a way to solve our problems. We needed “minor” emergency care.

The advertising claims turned out to be true-aside from the necessary irritation of having to to fill out two lengthy medical history forms before treatment could begin. Sammy was stitched up, and I was examined and given a prescription-all in 30 minutes in a small but clean, well-equipped and adequately staffed facility. Afterward, we even had time for the soothing balm of McDonald’s ice cream cones before picking up Sammy’s 8-year-old sister.

The next morning, we suddenly needed Doc-in-the-Box medicine again. Now, Shelly was the injured party, her leg gashed by a rusty bolt on her swingset. Forty minutes, four stitches, $68 and one more McDonald’s ice cream cone later, she was home in time for lunch.

Connie’s turn came in the middle of Sunday afternoon. A sudden, allergic coughing spell refused to stop, and soon her breathing difficulties demanded quick medical attention. Once again, we received affordable help when we needed it, and the clinic’s doctors and nurses now greeted us as old friends and valued customers. They even chuckled when I asked about volume discounts.

“The realities of medical care are that people get sick or hurt 24 hours a day,” says Hellstern. And ambulatory-care centers, he explains, “attempt to match the atmosphere and friendliness of a physician’s office with the convenience of extended hours and no appointments that an emergency room presents, yet at a reasonable cost. Certain segments of our society are very convenience-oriented, and they are going to gravitate toward (medical) facilities that are trying to respond to that demand for convenience. There also are people who want an ongoing, single doctor-single patient relationship, and who value that relationship above convenience.”

A physician who works in a more traditional setting agrees that ambulatory care centers are finding a niche. “It would be nice if they would take the word ’emergency’ out of their names; they can’t handle major emergencies. But I do think there is a place for the minor emergency centers,” says Dr. Lynn Kirk, medical director of outpatient clinics at Parkland Hospital, which operates its own extended-hours ambulatory care facility. “In cost, they [the ACCs] end up somewhere between a visit to an emergency room and a visit to a traditional doctor’s office.”

Recent NAFAC estimates, in fact, peg the typical price of a visit to an ambulatory care center at $48, compared with $185 for a trip to a hospital emergency room, and $35 to $50 for care in a physician’s office.

More people are trying and embracing extended-hours ambulatory care. Corporations, partnerships and individual physicians have opened more than 2,000 ambulatory care facilities across the United States since the concept of free-standing minor emergency centers was created on the East Coast. The Dallas/Fort Worth area, according to a recent count, had more than 25 of the ACCs.

These centers and clinics are opening at such a rapid pace that hundreds more are expected to be in business by the end of 1985. Their growth is fueled in part by the traditional market forces of demand and supply, but a recent study by the American Medical Association also shows that a glut of physicians are competing for patients. This over-supply of doctors, combined with the high cost of setting up solo practices and recent changes in Medicare rules, has been fueling the creation of more and bigger group practices, including ambulatory care centers.

“Eventually, the consumer will benefit from the increased competition among physicians,” Kirk says. And ACCs may help take some of the logjams out of visits to regular physicians’ offices that are created when patients suddenly show up needing emergency care and must be taken ahead of those with appointments.

The hot field of ambulatory care, however, frequently is being seen as a way to get rich quick and as an easy path into the medical business, Hellstern says. “Most of us who started early are concerned about the ease-of-entry issue. Any doctor can throw up a shingle and say he’s an emergency center. At some point, that will have a negative impact.”

But well-equipped ambulatory care centers cost at least $250,000 to open, and their profit margins are frequently low, according to a report in Modern Healthcare magazine. Many ACCs, in fact, do not sew up any profits for at least four years. So the less profitable facilities are likely to fold in the near future, some health-care industry observers predict.

Still, the convenience and the competitive prices offered by ambulatory care centers are attracting more and more health-care consumers, says James Roberts, NAFAC’s executive director. “We are a more mobile society, and people who are mobile are less likely to have a family physician. We’re smarter, and we do more self-diagnosis,” Roberts says. “Also, more and more medical services can be provided on an outpatient basis. For example, more than 80 percent of hospital emergency-room visits could be medically served elsewhere.”

Although no exact statistics are available, ambulatory care centers are apparently beginning to have an impact on the profits of both family practitioners and some hospital emergency departments, Roberts says. “We know that a lot of physicians are expanding their hours and services. And we think that the ACCs have the potential to pull out 40 to 60 percent of the visits to hospital emergency rooms.”

The decision to go to an ambulatory care center rather than a hospital emergency room was an easy one for Scott Blackwell, a 22-year-old student at the University of Texas at Arlington. He awoke on a Sunday morning ill with a stomach virus, and found that UTA’s student health center was closed. Instead of traveling across town to a hospital, he decided to try an immediate care facility that had opened not far from his house. “I didn’t know what to expect from it,” Black-well says. “But I was very impressed with how quickly they helped me.” Although six patients were waiting ahead of him when he arrived, he was seen by a doctor in 15 minutes, he says.

But choosing a good ambulatory care center or minor emergency clinic is not simply a matter of going to the nearest one the next time you need help. “As in any free-enterprise sort of activity, there clearly is a difference between one facility and another,” says Hellstern. “And there are no yardsticks at the present time other than word-of-mouth and reputation. Ask your friends and neighbors if they have been to one and if they got good care.”

A national accreditation program for minor emergency facilities has been introduced by the NAFAC and the Accreditation Association for Ambulatory Health Care in Skokie, Illinois. Some states have also enacted tough regulations affecting the operations of minor emergency centers. But writers for consumer magazines, as well as NAFAC officials and many doctors, say that the best approach to finding a good ACC is to drop in for a visit before you need help. Go to several, talk to the staff, and check out the capabilities, prices and payment methods. Also, find out what hospitals they can admit you to if an illness or injury turns out to be more serious than they can handle.

Beckie Warren of Oak Cliff, who trains checkers at a Dallas Tom Thumb store, says she has seen “both the bad and the good” of minor emergency centers. During a weekend outing last summer, she stumbled in the dark, fell on her arm, and heard and felt a painful pop. She went first to a minor emergency center in a nearby suburban town. “The doctor X-rayed it from only one direction, and told me it was just badly bruised,” Warren says. “Two days later, my arm was swollen and turning yellow and purple, and I was screaming in pain.” Friends and relatives convinced her to go to another minor emergency center, one near her home in Oak Cliff. “The doctor there X-rayed my arm from several different directions and found that I had broken it in three places.” Her mixed experiences with Doc-in-the-Box medicine have left her hesitant to try other ACCs, she concedes. “But I still go to one if my personal doctor is too busy to see me.”

ACCs should be viewed as a convenient alternative, not as a total substitute for traditional physicians, specialists and emergency rooms, medical experts say. But consumers’ demands are fueling changes even in the relatively new business of retail ambulatory care, Hellstern and Roberts say. More and more ACCs are becoming primary-care centers as well as minor emergency clinics. “They are marketing themselves to be your family medical center,” Roberts says, adding that they are beginning to offer a greater range of medical options, including long-term doctor-patient relationships, health maintenance plans and easier access to a variety of physician specialists.

Company executives are also discovering that ACCs can save them money and lost productivity. Employees with minor injuries or ailments can often be treated at nearby ambulatory care centers and returned to their jobs in an hour or two. Today, about one-fourth of the patients at a successful ambulatory care center have been sent by their employers, and the ratio is expected to grow, Roberts says.

Ambulatory care centers, Hellstern says, are here to stay, despite continuing regulatory pressures from state legislators and the American Medical Association and criticisms from traditional physicians. “There is room in the world for all of us-ambulatory care centers, emergency departments, and traditional physicians’ offices,” he says. The consumer no longer has to settle for a 9-to-5, please-get-sick-at-my-convenience health care.”