www.jucm.com | The Official Publication of the Urgent Care Association of America IN THIS ISSUE A BRAVEHEART PUBLICATION THE JOURNAL OF URGENT CARE MEDICINE ® APRIL 2011 VOLUME 5, NUMBER 7 FEATURES 9 Giant Cell Arteritis: A Clini- cal Review for Urgent Care Providers 29 Competitive Analysis to Stand Above the Crowd DEPARTMENTS 19 Abstracts in Urgent Care 22 Pearls in Practice 25 Insights in Images: Clinical Challenge 33 Health Law 34 Occupational Medicine 36 Coding Q&A 40 Developing Data ™
Transcript
www.jucm.com | The Official Publication of the Urgent Care Association of America I N T H I S I S S U E
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THE JOURNAL OF URGENT CARE MEDICINE®
APRIL 2011VOLUME 5, NUMBER 7
F E A T U R E S9 Giant Cell Arteritis: A Clini-
cal Review for Urgent CareProviders
29 Competitive Analysis toStand Above the Crowd
D E P A R T M E N T S19 Abstracts in Urgent Care22 Pearls in Practice25 Insights in Images:
Clinical Challenge33 Health Law34 Occupational Medicine36 Coding Q&A40 Developing Data
™
www. jucm.com JUCM The Journa l o f Urgent Care Medic ine | Apr i l 201 1 3
A p r i l 2 0 1 1VOLUME 5 , NUMBER 7
The Official Publication of the Urgent Care Association of America
™
9 Giant Cell Arteritis: A Clinical Review for Urgent Care ProvidersWhether you know it as temporal arteritis, the “great masquerader,” or theabbreviation GCA, giant cell arteritis is an under-recognized, easily missed vasculitisof older adults. Are you familiar with its signs and symptoms?
By Ryan C. Jacobsen, MD, EMT-P
7 From the UCAOA Executive Director
D E P A R T M E N T19 Abstracts in Urgent Care22 Pearls in Practice25 Insights in Images:
Clincal Challenge33 Health Law34 Occupational Medicine36 Coding Q&A40 Developing Data
C L A S S I F I E D S38 Career Opportunities
CLINICAL
29 Competitive Analysis to StandAbove the CrowdYou might offer the best care intown, but if your competitor’s careis “good enough” and they offerservices that you don’t, you may belosing business to them. The firststep is to find out what “the otherguy” is up to.
By Alan A. Ayers, MBA, MAcc
PRACTICE MANAGEMENT
“How are you feeling?” may seem like a straight-forward question in the context of physician–patient encounters. Sometimes, though, under-standing a patient’s feelings can be the differencebetween optimal and sub-optimal outcomes.Available exclusively at www.jucm.com.
By Bob Stuart, MD and Bob Bichler, RN
Technically, a “burn” is defined as a traumatic, thermal injury to the skin
and deeper structures. Hence, it can result not only from heat, but also
cold, chemicals, electricity, or radiation. And the majority of them are
managed in an outpatient setting.
IN THE NEXT ISSUE OF JUCM
W E B E X C L U S I V E
4 JUCM The Journa l o f Urgent Care Medic ine | Apr i l 201 1 www. jucm.com
Mission StatementJUCM The Journal of Urgent Care Medicine supports theevolution of urgent care medicine by creating contentthat addresses both the clinical practice of urgent caremedicine and the practice management challenges ofkeeping pace with an ever-changing healthcare market-place. As the Official Publication of the Urgent CareAssociation of America, JUCM seeks to provide a forumfor the exchange of ideas and to expand on the corecompetencies of urgent care medicine as they apply tophysicians, physician assistants, and nurse practitioners.JUCM The Journal of Urgent Care Medicine (JUCM) makes everyeffort to select authors who are knowledgeable in their fields.However, JUCM does not warrant the expertise of any author ina particular field, nor is it responsible for any statements by suchauthors. The opinions expressed in the articles and columns arethose of the authors, do not imply endorsement of advertisedproducts, and do not necessarily reflect the opinions or recom-mendations of Braveheart Publishing or the editors and staff ofJUCM. Any procedures, medications, or other courses of diagno-sis or treatment discussed or suggested by authors should notbe used by clinicians without evaluation of their patients’ con-ditions and possible contraindications or dangers in use, reviewof any applicable manufacturer’s product information, andcomparison with the recommendations of other authorities.
JUCM (ISSN 1938-002X) printed edition is published monthlyexcept for August for $50.00 by Braveheart Group LLC, 65 NorthFranklin Turnpike, Second Floor, Ramsey, NJ 07446. JUCM ispending periodical status at Mahwah Postal Annex, 46 IndustrialDrive, Mahwah, NJ 07430 and additional mailing offices. POSTMASTER: Send address changes to Braveheart Group LLC,65 North Franklin Turnpike, Second Floor, Ramsey NJ 07446.
JUCM The Journal of Urgent Care Medicine (www.jucm.com) is published through a partnershipbetween Braveheart Publishing (www.braveheart-group.com) and the Urgent Care Association ofAmerica (www.ucaoa.org).
J U C M EDITORIAL BOARD
Jeffrey P. Collins, MD, MAHarvard Medical School;Massachusetts General Hospital
Tanise Edwards, MD, FAAEMAuthor/editor (Urgent Care Medicine)
William Gluckman, DO, MBA, FACEP, CPE, CPCSt. Joseph's Regional Medical CenterPaterson, NJNew Jersey Medical School
Nahum Kovalski, BSc, MDCMTerem Emergency Medical Centers
Peter Lamelas, MD, MBA, FACEP, FAAEPMD Now Urgent Care Medical Centers, Inc.
Melvin Lee, MDUrgent Cares of America;Raleigh Urgent Care Networks
Genevieve M. Messick, MDImmediate Health Associates
Marc R. Salzberg, MD, FACEPStat Health Immediate Medical Care, PC
John Shufeldt, MD, JD, MBA, FACEPShufeldt Consulting
Joseph Toscano, MDSan Ramon (CA) Regional Medical CenterUrgent Care Center, Palo Alto (CA) MedicalFoundation
Mark D. Wright, MDThe University of Arizona
J U C M ADVISORY BOARDMichelle H. Biros, MD, MSUniversity of MinnesotaKenneth V. Iserson, MD, MBA, FACEP,FAAEMThe University of ArizonaGary M. Klein, MD, MPH, MBA, CHS-V,FAADMmEDhealth advisors; Military Health Systems,Department of DefenseBenson S. Munger, PhDThe University of ArizonaEmory Petrack, MD, FAAPPetrack Consulting, Inc.;Fairview HospitalHillcrest HospitalCleveland, OHPeter Rosen, MDHarvard Medical SchoolDavid Rosenberg, MD, MPHUniversity Hospitals Medical PracticesCase Western Reserve University School of MedicineMartin A. Samuels, MD, DSc (hon), FAAN,MACPHarvard Medical SchoolKurt C. Stange, MD, PhDCase Western Reserve UniversityRobin M. Weinick, PhDRAND
J U C M EDITOR- IN- CHIEFLee A. Resnick, MDCase Western Reserve UniversityDepartment of Family MedicineInstitute of Urgent Care Medicine
To paraphrase Shakespeare, albeit less eloquently, GCA by anyother name would be as potentially damaging. And, in fact, gi-ant cell arteritis (GCA) is also known as temporal arteritis or
more colloquially as the “great masquerader” due to its appar-ent—but not actual—similarities with other diagnoses.
Call it what you will, that very characteristic is what makes itdifficult to identify. With the prospect of consequences like visionloss looming for patients who are not treated in time, it is incum-bent upon the urgent care clinician to understand and be vigi-lant for its signs and symptoms based on presenting complaintand patient characteristics.
Giant Cell Arteritis: A Clinical Review for UrgentCare Providers (page 9), by Ryan C. Jacobsen, MD,EMT-P seeks to prepare you by reviewing its epi-demiology, differential diagnoses, relevant diag-nostic tools, and management options.
Dr. Jacobsen is assistant professor of emergency medicine atthe University of Missouri-Kansas City School of Medicine, as wellas a practitioner in the Department of Emergency Medicine atTruman Medical Center and the Division of Emergency MedicalServices at Children’s Mercy Hospital in Kansas City, MO. He isalso the associate EMS medical director for Kansas City, MO EMS.
Along the same concept of “what you don’t know can hurtyou,” are you aware of what your competitors are doing? If not,you’d better find out because they’re trying to make sure poten-tial patients find their services superior to yours.
In Competitive Analysis to Stand Above the Crowd (page 29), AlanA. Ayers, MBA, MAccoffers some keen insights into methods forgathering intelligence on the urgent care center down the block.
Mr. Ayers is content advisor to the Urgent Care Association ofAmerica and vice president of Strategy & Execution with Dallas-based Concentra Urgent Care.
And, in an article you can find only atwww.jucm.com, Bob Stuart, MD and Bob Bichler, RNoffer perspectives on understanding the link betweena patient’s emotions and optimal patient care.
Dr. Stuart is a medical director with responsibili-ty for multiple urgent care centers in the Aurora Med-ical Group system in Milwaukee, WI. Mr. Bichler isalso with Aurora; in addition to his nursing training,
he is a graduate of the Froedtert Hospital Pastoral Care Volun-teer Program, which he credits with introducing him to “listen-ing to emotions.”
Also in this issue:Nahum Kovalski, BSc, MDCM identifies new abstracts relevantto the urgent care clinicians, including several concerning careof younger patients (e.g., cephalexin versus clindamycin for un-complicated skin infections in children), among other topics.
John Shufeldt, MD, JD, MBA, FACEP describes the profes-sional and legal dangers of posting too much information (the
J U C M C O N T R I B U T O R S
JUCM The Journal of Urgent Care Medicine | Apr i l 201 1 5
new possibilities.new possibilities.w possibilities.
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All too often, urgent careentrepreneurs operate in avacuum. They feel that if
they offer a well-appointedfacility with good signage,convenient hours, and in-surance participation, pa-tients will come. And ifthose patients receive friend-ly service and quality care,they will return and tellfriends and family to dolikewise.
But such an operations fo-cus ignores that others arecourting the same patientbase—everything you dowell, a competitor might bedoing better. Thus, it’s crit-ical for urgent care operatorsto understand the strengths and weaknesses of their com-petition and to respond with strategies to make their cen-ters stand above the crowd.
Physicians’ Dilemma ofCompetitionPhysicians are no strangersto competition. Throughouttheir lives they compete forgood grades, admission tomedical school, acceptanceto residency, and even forpatients and referrals byproviding higher qualityservices than their peers.
But when it comes to the“business” of medicine,some physicians are un-comfortable with the con-cept of competition. Thismay be due to a history ofcollaboration through pro-fessional associations, theneed for solidarity in the
face of uncertain payor and regulatory environments, orpersonal ethics that simply dictate “hands off” anoth-er provider’s patients.
Economics teaches that the presence of competition
Practice Management
Competitive Analysis to StandAbove the CrowdUrgent message: Providing high-quality care and good service is notnecessarily enough to attract and keep patients, especially if thosepatients can take their pick from among several urgent care centers.More and more, urgent care operators need to be aware of how theircompetitors operate.Alan A. Ayers, MBA, MAcc
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C O M P E T I T I V E A N A L Y S I S T O S T A N D A B O V E T H E C R O W D
Table 1: Sample Urgent Care Competitor Evaluation GridMy UCC Competitor A Competitor B
Number of LocationsPhysical FacilityStreet addressType of facility (e.g., freestanding, medical building)Size of facilityTraffic countSize and visibility of exterior signageEase of turning into/exiting the centerCurb appeal of facilityInterior condition/aesthetics of facilityAdjacent tenants (driving traffic/visibility)Operating HoursMonday–FridaySaturdaySundayHolidaysOperating ModelOwnership (e.g., hospital, physician, corporate, etc.)Owner name(s)Investor name(s)AffiliationsCertifications (e.g., UCAOA certification)Accreditations (e.g., JCAHO urgent care accreditation)Scope of ServicesUrgent care
Target consumer segmentsImaging services (digital/analog x-ray, ultrasound, etc.)Lab services (certifications, complex vs. waived)Procedures/minor surgery
Staffing ModelProvider staffing (physicians, mid-levels)Physician leadersPhysician employment (employed vs. contractor)Physician background, board certification, reputationPhysician tenure and turnover (provider vacancies)Physician pay and benefitsManagement/operations leadersManagement/operations background and reputationManagement and staff turnover (position vacancies)Reimbursement and CollectionsCredentialing/billing/collections model (in-house/outsourced)Insurance plans acceptedUninsured pricing/cash discountsMarketing TacticsPaid advertisingGrassrootsInternet/social mediaMarketing staff or agencyReferral relationships (primary care, ED, etc.)
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C O M P E T I T I V E A N A L Y S I S T O S T A N D A B O V E T H E C R O W D
spurs innovation, reduces prices, increases transparency,and improves the quality of products and services. Ur-gent care—a solution for basic medical access that savestime and money—is proof that a competitive healthcaremarketplace can benefit patients, providers, payors, andother stakeholders.
But unlike other types of medical practice that rely onprofessional relationships or hospital affiliations for re-ferrals, urgent care is essentially a “retail” model that ap-peals directly to a consumer decision-maker. This meansurgent care operators must identify, evaluate, and re-spond to competitors—direct competitors in the form ofother walk-in, retail and occupational health centers andindirect competitors in the form of hospital emergencyrooms and primary care offices.
Identify and Evaluate CompetitorsPut yourself in a prospective patient’s shoes and askyourself, “What is every alternative available to treat myminor illness or injury?” Make a list of all the optionsthat come to mind—including doctors’ offices, emer-gency rooms, “non-providers” such as the Internet, andeven “self-treatment” using over-the-counter medica-tion. Every option on your list is a competitor—and theideal outcome of competitive research is to assure yourcenter offers consumers something greater than thoseother options.
For local, “brick-and-mortar” competitors, become fa-miliar with their service offerings, operating model,and marketing tactics by visiting their physical loca-tions, checking out their websites, and gathering theiradvertising collateral to assess:
� What is the scope of their services? What overlapswith what I’m doing? Are they adding anythingnew?
� What types of marketing or promotions tactics arethey using? What is the public’s awareness of theirfacility and perceptions of their brand? Have adver-tising levels increased or decreased?
� What is the positioning of their physical facility?Do they have visible signage, easy entrance/exitfrom the street, and is there plenty of well-lit park-ing? How does their location, facility, and signagecompare to mine?
� What are their operating hours, and how long aretheir typical wait times?
� How many cars are parked outside their facility atvarious times of day?
� When you call on the phone, are you greeted by afriendly voice—or put on indefinite hold by an
overburdened front desk staff?� Who are the owners, what is their source of fund-
ing, and what are their expansion plans?� What has been reported in the local news about
them? � What are the background and qualifications of
their medical staff?� From where do they recruit providers, and do they
currently have any staff openings posted? What istheir reputation among their current and former em-ployees and referral providers in the community?
� If it’s a multi-site operation, what geographic areasare they expanding into, and what areas mightthey expand to next? Have they grown organi-cally or through acquisition?
� How are they doing financially?� How many visits per day are they averaging? Are
their volumes increasing or decreasing?(Table 1 provides a chart that can be used to evalu-
ate each competitor’s strengths and weaknesses relativeto your own operation.)
Some urgent care operators have also been known toenlist friends or family members to physically visit thecompetitor’s facility for services and provide feedback ontheir experiences afterwards.
Regardless of the source, information gatheringshould be without falsification or misrepresentationand through observations and information sources gen-erally available to an inquiring public.
Strategic Response to Competitive InsightsIdentifying and evaluating competitors will illuminatethe strengths that should differentiate your center. Asyou research competitors, ask what each is doing welland what could be improved upon.
What makes them successful or unsuccessful?How loyal is their patient base?How convenient or affordable is their product?And, ultimately: What opportunities can you seize?With this information, you can develop operations
and marketing plans to better position your center to at-tract patients. For example, if you observe cars parkedoutside a competitor at 7:55 in the morning and youdon’t open until 9 a.m., could you start opening at7:30 to better serve patients needing services beforework?
Or, if you learn your competitor is advertising $12high school sports physicals and you realize you won’tbe competitive at $35, could you find a creative way to
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Thus, for services billed to Medicare, the physician mustbe physically on site.
For services billed to other third-party payors, your practicemay instead opt to follow CPT guidelines, as long as this is allowedby your contract with the payor. If a provider is in the office, listthe rendering provider as the provider who was in the office suiteat the time services were rendered. n
Note: CPT codes, descriptions, and other data only are copyright 2011,American Medical Association. All Rights Reserved (or such other dateof publication of CPT). CPT is a trademark of the American MedicalAssociation (AMA).Disclaimer: JUCM and the author provide this information for edu-cational purposes only. The reader should not make any applicationof this information without consulting with the particular payors inquestion and/or obtaining appropriate legal advice.
C O D I N G Q & A
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get into the schools to promote free physicals as agrassroots tactic and loss leader for athletic injury cases?
Likewise, say you want to build your workers compen-sation business but notice two or three occupationalmedicine competitors en route to the industrial busi-nesses where injuries occur. Could your efforts be betterinvested in services that appeal directly to consumers?
Competition and Site SelectionIgnoring competition can lead to critical mistakes whendeveloping a business plan—including whether to openthe center in the first place. Before committing to a newlocation, it’s important to understand:
� What competition is present and how is it posi-tioned relative to consumer traffic and residentialgrowth patterns?
� Can the area’s population and demographics sup-port one or multiple urgent care centers?
� Is there sufficient new business to support your cen-ter, or will you rely on capturing market sharefrom an existing, weaker competitor?
Don’t be deterred, however…The presence of urgent care competition should not nec-essarily deter a prospective center. In fact, the more ur-gent care competition, the more marketing activity andthe greater consumer awareness of how and when to uti-lize urgent care—benefiting all centers in the market. Inmost cases, a concentration of urgent care centers ismerely reflective of high population density—in largemarkets, there are simply more people, and more urgentcare centers are able to thrive.
Because many urgent care entrepreneurs open centerswhere they want to live and work—and not based onoptimal demand or market potential—they frequentlyenter into highly competitive situations and then strug-gle to build their practices.
For example, major cities in Arizona, Florida, andTexas have a high density of urgent care centers, while
nationally there are many other metropolitan areaswith more than 50,000 people that could support atleast one center but currently have none. Not only arethese outlying communities ripe for an independent op-erator, but there is likely little to no competition exceptfor the local hospital ED, meaning consumers shouldembrace urgent care as a long-awaited and much-needed community resource.
Where there are too many urgent care providers chas-ing too little business, eventually one or a few will “fallout.” For example, a recent news story in Lancaster, PA(population 55,351) describes how urgent care centersare “taking off” with local hospitals, out-of-state oper-ators, and physician entrepreneurs opening a total of 12walk-in centers by 2011 (five of which are within a 1.5-mile radius).1 Another story out of Charlotte, NC reportsthat three urgent care centers have opened on one cityblock, each operating 12 hours per day, seven days aweek.2 It’s likely after several years of these competitors“duking it out,” markets like Lancaster and Charlottewill be a prime example of “survival of the fittest.”
In such markets, it’s even more critical to understandthe strengths and weaknesses of competition and to po-sition your business accordingly.
ConclusionWhether an urgent care center survives or thrives is de-pendent upon how well it differentiates itself from com-petitors. Unlike other medical practices, urgent care de-pends on consumers to decide when, how, and where theyseek care. Competitive research that takes the con-sumer’s perspective in evaluating the strengths and weak-nesses of various healthcare options can yield insights thathelp the urgent care operator better position his or hercenter to increase visits and capture market share. n
References1. “A dozen clinics will be operating her next year,” Lancaster, PA: Intelligencer Journal, December 12, 2010. http://articles.lancasteronline.com/local/4/323584.2. “1 Block in Charlotte; 3 Urgent Care Facilities, A Lot of Head Scratching,” Charlotte, NC:Mecklenburg Times, February 15, 2011.
