Urgent message: As the population ages, the healthcare system will be faced with a growing number of cancer patients who have unique care needs. Since typical hospital EDs are rarely equipped to capably and cost-effectively service cancer patients who present with timely medical issues, there remains a growing need for additional cancer-focused urgent care resources—an opportunity that urgent care operators and health systems would do well to capitalize on.
Alan A. Ayers, MBA, MAcc is Vice President of Strategic Initiatives for Practice Velocity, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine.
The statistics are certainly eye-opening: According to the National Cancer Institute, 1.6 million new cases of all-cause cancer are diagnosed each year. And while the rate of cancer diagnoses has held steady over the last several years, the population as a whole is aging—and, naturally, cancer rates are increasing along with them.
As such, increasing numbers of cancer patients are turning to emergency departments when emergent symptoms or treatment-related complications occur outside of normal oncology provider business hours. Indeed, traditional cancer treatments such as chemotherapy can be extremely toxic, and carry with them a whole host of side effects and symptoms. Thus, cancer-related presentations to the ED can run the gamut, but most often include some combination of the following:
- Pain
- Fever
- Nausea/vomiting
- Severe diarrhea
- Dehydration
- Kidney/bowel obstruction
- Infection
- Edema
- Weakness
- Headache
A 2011 report by Mayer, et al, published in the Journal of Clinical Oncology revealed that over half the visits to emergency rooms by cancer patients in North Carolina occurred on weekends or evenings. While urgent care was outside the scope of that study, clearly it could have been a viable—and probably more convenient, less expensive—option for a good number of those patients. In addition, the ED is generally a suboptimal treatment venue for a cancer patient with an urgent medical issue, for a variety of reasons:
Infection risk. Cancer patients, especially those undergoing chemotherapy, generally have weakened and/or depressed immune systems. Thus, having to sit in a crowded ED waiting room full of sick patients puts them at increased risk of serious infection.
Dearth of cancer-experienced clinicians. Most ED clinicians lack oncology-specific medical training. Hence, a lack of confidence in their ability to treat cancer patients can lead to increased hospital admissions, many of which turn out to be unnecessary. Even if a cancer patient presents with a condition that wouldn’t necessarily be “high-worry” in an otherwise healthy individual—such as a high fever, for example—few ED clinicians can confidently discern whether the presentation is a minor issue, or the sign of a serious one.
Higher-cost care venue. Given the aforementioned lack of oncology-trained ED clinicians, roughly 80% of ED cancer patients are admitted to the hospital. So not only does the visit result in a ED bill that averages $1,600 – according to data put forth by the John Hopkins Kimmel Cancer Center – they’re also faced with a hefty hospital admission bill on top of it.
Cancer-Focused Urgent Care
With few standard EDs staffed with oncology-trained personnel, the result is excessive hospitalization, poor utilization of ED resources, and overall lowered quality of care. Yet, cancer patients are still showing up to the ED in droves, as evidenced by healthcare consulting firm Advisory Board asserting that a mere 20% of hospital cancer programs provide their patients nontraditional, after-hours support. With the value-based care era upon us, however, health organizations are becoming more accountable. Patient experience and reduced costs have moved to the forefront; hence, offering timely cancer care in the most appropriate setting has emerged as a top priority.
As a result, hospital systems and oncology practices, as part of a broader shift towards improved patient-centered oncology care, have begun offering dedicated, cancer-focused urgent care services. These dedicated units are often integrated into the larger ED, yet share a similar profile with traditional urgent care centers: Namely, same-day appointments and early-morning/ late-evening hours. Additionally, these urgent cancer centers feature:
- Separate waiting areas for immunocompromised patients
- Providers and clinicians familiar with cancer treatment symptoms and chemotherapy side effects, who therefore are clinically proficient at the proper diagnosis and treatment of emergent issues
- Coordination with the patient’s primary oncology caregiver, who can often be contacted in real-time for further instruction
Although most centers are ambulatory, cancer patients with emergent symptoms will first call a nurse hotline designed to help them over the phone. If this is unsuccessful, the patient is then directed to the dedicated center. In either case, these facilities are proving effective at helping cancer patients avoid the ED and unnecessary hospital admissions.
One notable example of a thriving cancer-focused emergency unit is the one operated by the Kimmel Cancer Center, part of the Johns Hopkins Hospital in Baltimore. Opened in 2014, the unit is open 12 hours a day, 6 days a week, and currently has 10 beds. With a knowledgeable medical staff prepared to treat cancer patients, utilization of this urgent care center has resulted in a 50% decrease in hospitalizations of Kimmel Center cancer patients.
Another example is the University of Texas Southwestern Medical Center, which created an urgent care unit for cancer patients in 2013. ED providers came to the realization that they lacked the resources and expertise to effectively treat chemotherapy patients, who were frequently presenting with maladies such as nausea, sores, fever, and dehydration. After implementation, the UTSMC has reported lower costs and improved patient experience metrics stemming from the initiative.
Benefits to Health Systems
Clearly, the concept of a cancer-focused urgent care center is a boon to cancer patients; they can receive on-demand care for their emergent issues even if their oncology caregiver is unavailable, and feel relieved that their care is in the hands of medical professionals who are experienced and prepared to treat them.
But it’s not just cancer patients that stand to benefit. Hospitals and health systems have economic incentive, as well. The reality is, cancer patients are a lucrative source of revenue for hospitals. The ubiquitous advertisements for cancer services attest to this. A dedicated urgent care component specifically for cancer patients also acts as another entry point into a health system, and encourages loyalty from its high revenue-generating customers.
Additionally, the industry as a whole is moving toward value-based, accountable care of patient populations. Cancer-focused urgent care widens access, improves outcomes, and contributes to a better patient experience. In fact, the Centers for Medicare & Medicaid Services are currently implementing new delivery and payment models to that very end. The takeaway? High-quality cancer care will be financially rewarded going forward. Conversely, beginning in 2020, hospitals may face financial penalties if their outpatient chemotherapy patients get admitted into the hospital or present to the ED. In short, the incentive to provide cancer-focused urgent care services is real and tangible, and poised to grow for the foreseeable future.
Conclusion
As an aging population confronts the hardships of cancer in greater numbers, the already overburdened healthcare system must brace for the coming influx of cancer patients and their specific care needs. Thus, urgent care again finds itself in the spotlight, given its efficacy and versatility in filling the gaps. The same-day, ambulatory, extended-hours model that launched urgent care is now being effectively employed in an important medical specialty: oncology.
The benefits extend to all stakeholders. Cancer patients receive on-demand specialty care, widened access, and lowered costs. Providers can offer better care delivery and improved outcomes while reaping financial reward. Payors save money as cancer patients are shifted to more appropriate and lower-cost treatment venues. And urgent care continues to demonstrate its enormous value across the changing, ever-evolving healthcare landscape.
(For more on the clinical side of supporting cancer patients, read An Urgent Care Approach to Malignancy Complications in the JUCM archive.)
