"Pulse Check": The Guide to Choosing a Healthcare Facility

A comprehensive guide to choosing the best, quickest, most cost-effective care: PCP, Urgent Care, Telehealth, ER, Freestanding ER and—my favorite—Home.

Hello readers and welcome back to “Pulse Check”, your bi-monthly (or more) guide through the labyrinth of health and healthcare. “Pulse Check” is inspired by the questions I field from friends and family – and now, you! This series aims to expand your healthspan, enhance health literacy and demystify the healthcare system. We’ll tackle your pressing questions. Whether it’s understanding the best way to prevent traveler’s diarrhea, how to make the most out of a 15 minute doctor’s visit, or what to do when you get a new cancer diagnosis, “Pulse Check” is here. Let’s unravel the complexities of healthcare so you can make better, cheaper and less infuriating healthcare choices. No question is too simple, too complex, or too odd. This series is fueled by your curiosity and concerns. So leave your questions in the comments section!

Where should I go when I’m sick or injured?

This article follows up on last week’s piece discussing how even leading news sources, such as the Wall Street Journal, provide misleading guidance about the most appropriate healthcare facilities for different illnesses. Understanding what services each type of healthcare facility offers is crucial for your health, time, and wallet. Here are our players:  The ER, Urgent Care, your primary care provider (PCP) (if you can get an appointment), the Freestanding ER, Telehealth, and one of my personal favorites for minor complaints: staying home!

PCP’s office: 

This is a great place to start when something is wrong, but you probably don’t have one. A  third of Americans don’t. Get one, though, because if you wait until you think you need one, the wait will probably be too long to be useful. Lots of people wait until they need one, though, which I understand.

Imaging:

PCPs can write referrals for imaging at radiology centers for urgent and standard studies like x-rays, ultrasounds, CT scans, and MRIs. Chronic back pain or chronic headaches? A PCP is the best place to get imaging orders.

Lab tests:

Blood work for screening and chronic conditions. Don’t expect STAT (urgent or same day) results. Blood work is usually sent out to a lab and results arrive in a week.

Time spent waiting:

Unless your office has urgent appointments, you’ll schedule your appointment ahead of time. New patient appointments can take months. Urgent appointments for established patients may mean you get squeezed in within a few days. Even if your doctor runs late (and they likely will be, because the corporate practice of medicine demands that docs see too many patients in one day) you’ll not have to wait like you typically must in an ER.

Cost:

Cheapest option with insurance, PCP co-pay is always lower than Urgent Care or ER.

What it’s best for:

Preventative care (especially if you’re 40+ and it’s time to start getting yearly mammograms, cancer screenings, or colonoscopies) and generalized health maintenance. Chronic conditions. Medication refills. An ER and urgent care won’t refill controlled meds like opiates or Xanax. If you’ve been experiencing symptoms for “a while,” see a PCP.

What it’s worst at:  

Severe, sudden onset symptoms: Crushing chest pain, chest pain on exertion, difficulty breathing, high fever with delirium or low blood pressure, severe abdominal pain, heavy bleeding from anywhere, abscesses or lacerations (many PCPs are not trained to perform these procedures in-office), or an obviously broken bone.

Urgent care:

An Urgent Care is between a PCP and Emergency room. It’s useful for a simple laceration repair, abscess, or a sore throat that might be strep—but your PCP doesn’t perform the procedure, and your symptoms aren’t so severe you’re afraid you’re going to need surgery or be admitted to the hospital. If you wonder: Is this going to potentially kill me? Go to the ER.

Urgent Cares are a quality grab-bag. Different urgent cares have different lab and imaging capabilities; they’ll also have healthcare providers with different training: ER docs, family medicine docs, PAs and NPs.

Imaging:

Depends on the Urgent Care. Many (but not all) will have X-Rays. Unless the Urgent Care is attached to an ER or PCP office in a larger hospital system, CT scans will be referrals to a radiology center. Most send you to the ER for a CT or ultrasound.

Lab test:

Variable. Some Urgent Cares perform same day “stat” labs that are sent out. Most can do COVID, Strep, flu, urinalysis, and pregnancy tests.

Time Spent waiting:

Seasonally dependent, but one of the quicker options. Plan on an hour and a half unless it’s empty, as there’s usually only one healthcare worker.

Cost:

Check your insurance care for your “urgent care copay” which is much more than a PCP and much less than an ER. Average is around $250, but co-insurance may increase the price. If you don’t have insurance, ask the Urgent Care for an itemized list of costs and their self-pay prices.

What it’s best for:

Mild to moderate illness or injury that needs minimal intervention. Lacerations that don’t go to the bone or deep into the hand. Evaluation of sore throats, urinary tract infections, sinus pain and fever that has been going on longer than 7-10 days, earaches, cough with fever but no respiratory distress. I worked at an urgent care in Williamsburg, Brooklyn that inadvertently specialized in antibiotics to clear up STIs.

What it’s worst at:

Very deep cuts that show bone or tendon, visibly broken bones, difficulty breathing that isn’t a minor asthma attack, significant chest pain, rapid heartbeat and palpitations, persistent vomiting, heavy bleeding from anywhere, head injuries.

A note about minute clinics:

If you want to go to an urgent care that can charge you urgent care prices and provide minimal care, choose a minute clinic. Most can’t perform laceration repairs, abscess drainage, or most of the aid that will keep you out of an ER. If all you want is a strep, flu or covid test, they’re fine, but they mostly exist to take your money and maybe give you unnecessary antibiotics or steroids to make you happy.

Urgent Care Telehealth:

Virtual urgent care telehealth providers such as Teladoc, K-health, or other is basically urgent care without an in-person exam or immediate labs to test for strep, flu or a UTI. If it’s covered by your insurance, it may be a good place to talk to an actual healthcare provider about your symptoms, and they can help figure out where you should be seen if you’re unsure. I spend about 20% of my time working telehealth just helping people understand their options. You can get antibiotics for a UTI, some medication refills, and non-controlled cough medications. Without an exam or tests, the diagnosis could be wrong, which can delay care and cause problems.

Imaging: Imaging is unavailable via most telehealth platforms.

Lab test: Most lab tests are unavailable, however, some basic orders like STD testing maybe available for you to take to a lab service in your area.

Time Spent waiting:

Usually brief and most platforms will place you in a queue and call you back when a healthcare provider is available. Most calls take under 15 minutes to complete

Cost:

Depends on insurance coverage. Average is between $0-$75/call.

What it’s best for:

Minor symptoms, mild UTI’s, one-time medication refills of non controlled prescriptions, consultation if you’re not sure how to best care for symptoms at home or what your next steps should be.

What it’s worst at:

Anything that would benefit from an in-person exam or testing. If your symptoms persist or worsen after a Telehealth visit, it’s important to be seen in-person for your next visit.

Emergency Room:

Go if you’re screaming in pain, unconscious, or asking yourself “Am I dying or potentially so sick I need to be admitted to the hospital?” The ER works on a triage principle, meaning the sickest people get seen first. The more minor a complaint, the longer the wait. The job of the ER is to make sure you’re not dying. If you’re well enough to go home, we’ll treat your problem the best we can, but you might not always get a definitive diagnosis.

You will be let down if you are looking for a diagnostic workup of a chronic, or non-acute condition. We’re a societal safety net, and we are always open, but treatment of EMERGENT conditions Is our goal. It’s hard and scary to wait, it’s terrible to be in pain, and it’s difficult to go through all the steps of an outpatient workup especially with how long it can take to get an appointment.

The ER can’t solve all the systems problems, including how long it takes to get an outpatient workup. We can’t get blood work and an MRI for Mom’s dementia workup, if her condition is stable, for example, because we need to focus on figuring out: admission or discharge, dying or stable. If you’re worried your condition is serious or life threatening, but it’s not? Great! We are here to help you figure that out. We love sending people home with good, or at least not terrible, news.

ERs are commonly said to lose money for hospitals. For that reason, nothing approaching the modern consumer approach to most market-based economic transaction has been seriously implemented in most ERs. This may be frustrating, but it’s also true, and incentive matter.   

Imaging:

X-ray, Ultrasound, CT scans.

What about an MRI? Getting an MRI in the ER is rare: If we really think you are having a stroke, but the CT doesn’t show it, you might get an MRI. If you have signs of acute spinal cord compression (like measurable weakness, incontinence, numbness in the perineal area) you’ll likely get an MRI. In many hospitals, you’ll have to be admitted overnight to get this.

Who won’t get an MRI? Patients with chronic lower back pain, or acute lower back pain without signs of spinal cord compression. Patients who need an MRI for the workup of headaches, dementia, or MS unless there is an acute neurologic deficit that might need immediate intervention. Your PCP should order this as an outpatient.

Lab tests:

ERs can perform many lab tests STAT (immediately), focusing on ones that help evaluate emergent conditions: Blood cell counts, metabolic tests, liver function tests, blood gasses, tests to look for heart failure and heart attack. We can also send tests that won’t come back right away, if they affect future treatment: STIs, tick-borne illnesses, and wound cultures, for example. Someone will call you with results, or they show up in your patient portal. Some tests, like cholesterol levels, PSA markersautoimmune workup and chronic monitoring of levels like your b12, vitamin D or thyroid are best ordered by outpatient specialists and your PCP

Time Spent waiting:

Depends on how sick you are! The ER is usually the most time-consuming place to go for healthcare. If you’re having a heart attack or stroke or look critically ill, the triage nurse will whisk you to the back quickly. You’d prefer not to be seen too quickly in the ER.  

Cost:

What if I can’t pay?

It doesn’t matter! “EMTALA” is a federal law that says anyone who comes to the ER must receive a medical screening exam. I don’t care who you are, where you came from, how much money you have, or what you’ve done: I’ll evaluate you. That doesn’t mean a bill will never show up, but we take care of everyone, and will have our social worker help set you up with state Medicaid if you qualify. People have been known to show up without ID, fake an address and  give their name as “John Smith.” I’m not saying you should, but I’ve seen it.

What it’s best for:

New and emergent symptoms, answering the question “Am I dying, where was I shot, what’s broken or do I need surgery or admission to the hospital?”

What it’s worst at:

Evaluating chronic conditions, medication refills, speeding up an outpatient workup, getting you home quickly.

Freestanding Emergency Rooms:

They’re ERs but also worse than regular ERs. If you don’t have good urgent cares in your area but have a freestanding ER, this may be a better choice than the “regular” ER in terms of wait time for more “urgent care” needs. You’ll pay ER prices, though.

What if you need an ER? Aren’t they the same? Yes and no. They’ll likely be staffed by an ER doctor, and they have a CT scanner, X-ray and labs. However, they’re not attached to a hospital. This matters because serious conditions like heart attacks or strokes are time sensitive, and how fast a hospital-attached ER can move you to the cath lab  or the interventional neurology suite, where a clot can be removed from your coronary artery or your brain, matters A LOT. A freestanding ER will have to call area hospitals to transfer you by ambulance. Many freestanding ERs can only perform basic labs, and other labs, including time-sensitive and important ones like those testing for heart attacks, have to be sent out by courier and may take hours to return.

Imaging:

X-rays, CTs, ultrasound. Ultrasound may require a tech to be called in, and may not be available in all locations.

Lab test:

 Some basic tests, but others have to be sent out. Varies depending on Freestanding.

Time Spent waiting:

Usually much faster than a regular ER, but it depends. They’re usually staffed by a single doctor, so one sick person needing a lot of attention means you can be waiting a very long time. Highly variable, though they’re more likely to post estimated wait-times somewhere online.

Cost:

ER prices.

What it’s best for:

When you need an ER but one attached to a hospital is too far away, or you need more help than the Urgent Care can give, but they think you can go home after being seen: for a complex laceration or an abscess drainage, for example, it’s probably going to be faster at a freestanding.

What it’s worst at:

Emergencies that require quick interventions by departments outside the ER. Heart attacks, strokes, gunshot wounds, anything that looks like it needs urgent surgery or a specialty consult. You can be transferred for these, it’ll just take time that may make your outcomes worse.

If you’re very ill, though, and there is a Freestanding ER 10 minutes away, and the hospital ER is an hour away, go to the freestanding ER.

Home

Staying home is an amazing option for many minor problems. People should probably stay home a lot more. Life is uncomfortable, and often, time is the cure. Sometimes life is not meant to be enjoyed; it’s meant to be gotten on with. For mild GI illnesses with nausea and vomiting (and no concerning abdominal pain) or mild migraines (not new or sudden onset), calling a mobile IV nurse to your home is a good way to get a liter of fluid, toradol and antiemetic for much cheaper than a trip to the ER.

Imaging:

Your eyes, or the eyes of those around you. I’m half kidding but I’m also serious. Papercuts, minor contusions and, most of all, colds that haven’t gone on longer than 7 days and don’t come with high fevers, difficulty breathing, difficulty swallowing, or pus-like discharge from the nose.

Lab tests: 

The drug store sells COVID tests, pregnancy tests, “Are you really the daddy?” DNA tests, and urine-dip tests that look for UTIs. You can find strep tests online, and they catch about 85% of cases. If your tests are positive, you may need to seek further treatment, but this is a good, cheap place to start.

Time Spent waiting:

However long it takes you to get to the pharmacy aisle at the

Cost:

Minimal. That Tylenol you just took for 25 cents? That’s gonna cost you a $55 in the ER.

What it’s best for:

Minor problems, hangovers, colds, papercuts, bumps and bruises and mild GI symptoms.

What it’s worst at:

Don’t be too much of a tough guy, okay? If you can’t fix it yourself, or if you’re getting worse not better, go to your PCP, Urgent Care or an ER.

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Stay healthy out there! Respiratory virus season (especially influenza A) is peaking, antibiotics won’t work for a virus, Tamiflu only reduces your symptoms by 12-24 hours and causes frequent severe nausea, but it turns out there are two drugs already on the market that may be able to decrease COVID viral load and reduce the risk of long COVID. We’ll talk about that next time!

Leave your questions in the comments section to be answered in future articles and let me know what you’d like to see more of.

Try not to visit me if you can:

And the numbers keep rising after all those New Year’s parties!

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