When is an ER not an ER? When it's not an emergency.

[Michael]

http://www.nytimes.com/2008/11/11/nyregion/11clinic.html

November 11, 2008

When You Need a Flu Shot at 3 A.M.

By ANEMONA HARTOCOLLIS

In New York City, it is possible to get a manicure at 10 p.m., watch movies at midnight, order blintzes in a restaurant at 3 a.m. and catch a crowded subway home as the sun is rising.

Now, add to the list of only-in-New York after-hours activities getting a flu shot — or a full-blown physical. In the city that never sleeps, a Manhattan hospital has opened New York’s first round-the-clock health clinic, hoping to capitalize on its many night owls, workaholics and insomniacs.

Some other cities with late-night cultures, like Las Vegas, have 24-hour clinics meant to be quicker and cheaper alternatives to hospital emergency rooms for urgent matters like stitching up cuts or treating heat stroke. In Temecula, Calif., a casino town near San Diego, a former Navy medic opened an all-night operation 14 months ago with physician’s assistants and nurse practitioners handling fever, earaches, migraines and eye infections.

New York’s new clinic, run by Beth Israel Medical Center and situated in Chelsea, a neighborhood with a vibrant nightlife, takes the concept a step further by providing 24-hour access to the routine services of a general practitioner, like cholesterol tests, allergy treatment, breast exams or diabetes maintenance. The idea is to catch people who have struggled to fit their lifestyles into the narrow hours offered by many doctors, thus increasing the likelihood of preventive care (emergencies are still sent by ambulance to the emergency room).

Jurron Bradley, a 35-year-old technology and marketing analyst, wandered into the clinic at 11 p.m. on a recent Thursday, on his way home from the gym. An admitted workaholic, Mr. Bradley had not yet eaten dinner. He stopped by in the hope of making an appointment for a physical — and, to his delight, discovered he could get one that very night.

“It’s tough making appointments during regular business hours,” said Mr. Bradley, who lives nearby. “You have to change meetings, change travel plans. It’s nice that I don’t have to break up my day.”

Ann O’Malley, a senior researcher at the Center for Studying Health System Change in Washington, said “the fact that they’ve got M.D.’s is pretty unique” for an overnight clinic, citing a 2007 study by the Commonwealth Fund showing that after-hours primary care is less available in the United States than in other developed countries, such as Germany, the Netherlands and New Zealand.

Situated steps from the No. 1 subway stop at 23rd Street and Seventh Avenue, Beth Israel’s new clinic grows out of a decade-old practice whose hours were 8 a.m. to 7 or 8 p.m. on weekdays and 9 a.m. to 2 or 3 p.m. on weekends. Since Oct. 13, it has been open all the time, going from five to eight doctors and adding a security guard and more support staff, at an extra cost of $750,000 over its $3 million operating budget.

The extended hours have yielded an average of 100 additional patients each week, with the highest traffic from 7 to 8 a.m. and 8 to 9 p.m. But there have also been a smattering of cases with all manner of mundane complaints in the wee hours.

Dr. David J. Shulkin, Beth Israel’s chief executive, said the all-night clinic was an antidote to the health care industry’s disdain for the convenience of its patients, in an era when their satisfaction is among the criteria that determine whether hospitals get reimbursed for Medicaid and Medicare cases.

He denied that the expanded hours were a counterattack on the proliferation of retail clinics in drugstores and Wal-Marts, noting that these clinics were generally not staffed by doctors.

People get sick at all hours, Dr. Shulkin noted, yet are left to the intensity of the emergency room or the uncertainty of waiting for advice over the phone from a doctor or nurse on call. The clinic promises more personalized, attentive late-night care than understaffed hospitals, and the continuity of primary-care physicians rather than a rotating cast of residents.

“I really believe that part of the quality of care is being able to get health care when you need it, when you want it,” Dr. Shulkin said. “People say, ‘I started having this pain, but I put it off for the last month because I couldn’t find time to go to the doctor.’ By then it’s really a shame they waited that long.”

The clinic takes private health insurance and Medicare for the elderly, but not Medicaid for the poor. Uninsured people pay $125 fee for the first visit and $65 for subsequent visits, with discounts available depending on income.

It offers general medical services for adults, but has no pediatrician or specialists on staff. If it attracts enough people, Beth Israel’s parent company, Continuum Health Partners, is considering replicating the model in working-class areas of Morningside Heights and Harlem, which have few primary-care physicians, said Adam Henick, a senior vice president for enterprise. The demand for all-night services can be seen in the steady rise in emergency room admissions, Mr. Henick said, noting that an estimated 60 percent of emergency room patients could be treated in a doctor’s office.

The marketing concept is irresistible: “In the city that never sleeps, we don’t either,” read ads plastered on the outer walls. Inside, the receptionist sits behind a sign warning, “The staff does not have access to cash or narcotics.”

One recent night, the clinic was staffed by Dr. Steven Strauss, edgy and white-haired, who said that his bosses had proposed the new title of “walkinist,” to go with his old one, internist.

Dr. Strauss said his past had helped prepare him for the rigors of nighttime work: He had dabbled in est and Scientology, and, in his early 20s, worked at a Safeway in Washington. He said his boss at Safeway used to berate him for being slower than the middle-aged checker working next to him; he quit, went to medical school, and hung his Safeway checker’s diploma in his bathroom to remind him of what might have been.

So far, Dr. Strauss said, there has been a run of urinary tract infections, chest pain, abdominal pain, internal bleeding and genital herpes. “That’s pretty challenging, to tell someone at 2 in the morning for the first time that they’ve got genital herpes,” Dr. Strauss confessed.

He has also treated a fair amount of insomnia. “I actually talk to them a lot,” he said. “I try to keep them off sleeping pills as much as I can.”

Despite the warning on the reception desk, few people have so far come in trying to get drugs. Except for one patient who, Dr. Strauss said, announced right upfront, “I lost my prescription for Percocet.”

“I never heard anybody tell me, ‘I lost my blood pressure medication,’ ” he said.

Even relatively routine things have a way of seeming stranger at night. One patient came in complaining of a mysterious skin rash. Dr. Strauss pulled out a dermatology textbook, which fell open to a page discussing lichen planus, a skin disease with no known cure that disappears by itself over months but sometimes recurs. It was the correct diagnosis, a trick he ascribed to some kind of late-night karma.

Michael McCarthy, vice president of operations at one of three all-night clinics in Las Vegas, said 2.75 to 3 patients per hour was his break-even point. But on this night, Dr. Strauss saw just four souls between 10 p.m. and 6 a.m.

The early bird was Robert Martin, a heavyset 60-year-old who said he was an agent with Immigration and Customs Enforcement and came in around 10:30 complaining of gastrointestinal problems. It was his second visit in two weeks in which he took advantage of the late hours when there was no wait. “I hope they don’t get too busy,” he said.

At 11:03, Mr. Bradley got his physical and a flu shot.

At midnight, Samuel Calloway, w a 42-year-old school crossing guard, came in with a headache and back pain. He spent half an hour closeted with Dr. Strauss, and he left satisfied but uninterested in discussing the diagnosis or treatment.

At 3 a.m., a man walked in with hives, worried that he would look bad at his friend’s wedding over the weekend. Dr. Strauss traced the rash to an antibiotic the man had been given by his dentist, told him to stop taking it, and prescribed an antihistamine.

Dr. Strauss passed the next three hours eating crackers and reading medical journals online. At 8 a.m., as the streets filled with suits and schoolchildren across the city took their seats, he headed home.

Copyright 2008 The New York Times Company

[Richard B the EMT]

OK, instead of an independent "Doc in a box" operation, this one is operated by a hospital. By that status, I think it is unique.

[firedoc5]

Maybe it will relieve actual ER's from those who use it as a free clinic all the time. That's something that has always been one of my pet peeves.

I've seen some who say they'd been sick for two days. When asked why they didn't go to a clinic or their doc's office they just say that going to the ER their "medical card/ insurance" will cover an ER visit while the others may require a co-pay.

I like the idea.

[sirduke]

The local hospitals have gone to a MSO, (Medical Screen Out) in which patient are seen by the triage nurse, then the doc. If the doc decides they have no emergency, then they are required to put up $100 or what ever their co-pay is if they have insurance, before being treated. This has slowed the rate some, and caused a lot of bitching and threats from some.

Don't you wish you could do the same on an ambulance?

Oh yes, I know, I'm about to be flamed for that, "How do you know they don't have an emergency you pompous Intermediate slug."