Earlier this year, my wife was attempting to bring a towering stack of patio chair pads out the back door onto our beautiful (but precarious) natural stone patio. Her line of sight was blocked by the chair pads and as she crossed the threshold, she missed a step and down she went, seriously injuring her knee in the process. The fall was a bad one. Even worse, though, was the timing. It occurred at around 7 PM on a summer evening. The primary care docs in town had shuttered their offices and scurried away to their shore homes hours earlier. My immediate thoughts: 1) “I hope she’s okay,” 2) “There’s no way we’re getting into the doctor’s office any time soon,” and 3) “Oh jeez. What’s my copay on an ER visit?” Full disclosure, those thoughts may not have occurred in that exact order.
Anyhow, instead of heading over to the Robert Wood Johnson University Hospital Somerset Emergency Department, we opted for the newly minted RWJ-backed, urgent care facility just a couple of miles from our home. My wife left at around 8 o’clock and returned a little more than an hour later with a diagnosis – thankfully just a bone bruise – x-ray confirmation of said diagnosis and pain med prescription. Almost immediately after returning she launched into a monologue about how great this place was. The staff was courteous and thorough. The receptionist explained and confirmed coverage. She was seen by a physician after only a few minutes of waiting, and received imaging services onsite.
What kind of place was this? How did they operate so efficiently? Why were they so nice? Did they really have an x-ray machine onsite? They got the billing right, really? What’s the catch? Why have I heard so little of these facilities from my colleagues in the healthcare industry?
I had to know more about these urgent care centers. What follows is my first foray into the world of urgent care: a series of questions that popped into my head and brief answers to each. I hope to follow this up with more in depth pieces on the ways in which they are changing primary patient care.
What are urgent care centers and how many of them are there?
Urgent care centers (UCCs) are typically stand-alone locations where a person can see a medical professional for an unexpected acute condition or event. Such events might include respiratory conditions, nausea and vomiting, diarrhea, urinary tract infections, rashes, insect bites and headaches, minor sprains, strains, cuts, fractures and the like. Urgent care facilities differ from primary care offices in a number of ways: no appointment is necessary, operating hours are typically longer and include nights, weekends, and holidays, and expanded services are typically available (e.g., x-ray, lab services, casting).
UCCs are often staffed by primary care physicians and/or nurse practitioners trained in emergency medicine. If a UCC is affiliated with a hospital system, the doctor you see at a UCC may be the same one you would see in that hospital’s emergency department (ED). X-ray technicians, medical assistants and registered nurses may also be onsite.
According to the Urgent Care Association of America, there are more than 6,900 centers nationwide, though other sources put the number at upwards of 9,000. It’s hard to peg the number exactly because definitions vary and there is no federally-required registration/classification process. Regardless, this number is believed to be growing.
Who visits UCCs?
The short answer: privately insured, high income, suburbanites. Unlike hospital EDs, UCCs are not legally obligated to treat everyone; hence, they can cherry-pick their patient population. They readily accept private insurance from a wide variety of providers, but largely turn away Medicaid patients. As a result, UCCs target higher income areas with a working population. Members of such communities often have limited access to primary care physicians (due to high demand), limited availability for physician visits (due to work schedule), and limited access to hospitals (due to distance). UCCs are increasingly owned by corporations and hospitals, though a large proportion are run by physicians or physician groups.
What are the benefits for patients?
Patients gain access to medical care outside of their physician’s office hours, without an appointment, and at similar out-of-pocket cost. They also receive a level of care that may extend beyond what their primary care physician is able to provide. What they may not get, however, is continuity of care. Unless the UCC is a part of a larger integrated system, the patient’s visit may not be “logged” by their primary care provider.
What are the benefits for managed care organizations?
Managed care organizations (MCOs) get a lower cost (and more appropriate in most cases) alternative to the ED. Many patients who present at the hospital do not need the breadth of services that an ED can provide. Further, treatment in a hospital setting is more costly to payer organizations than treatment in a physician’s office or UCC. That being said, any insured patient who receives treatment at a UCC rather and an ED, reduces costs for the organization. For that reason, many MCOs contract with UCCs so that the cost of care is equivalent to that provided at a primary care physician’s office. That means similar copays for patients who visit their doctor’s office or a UCC; a higher copay for those who visit the ED. This tiered copay structure is intended to drive patients to UCCs as opposed to EDs.
What are the benefits for primary care physicians?
This is where things get sticky. Primary care physicians are likely divided on the topic of UCCs. They are beneficial in that they give their patients a place to go should they need medical assistance outside of office hours. They are detrimental in that patients without an established primary care provider may not designate one if they receive satisfactory treatment at a UCC. Further, any illness treated in a UCC that could have otherwise been treated at a physician’s office is money out of the physician’s pocket.
What are the benefits for healthcare systems?
Healthcare systems can benefit in a number of ways. Health systems that expand to include UCCs can reduce burden on hospital emergency departments. Vertically integrated systems can drive referrals and admissions to physicians and hospitals within the system, while maintaining continuity of care. Risk-bearing systems can ensure proper patient care if members have greater access to healthcare (i.e., nights, weekends, and holidays) and are correctly routed to specialists, hospitals and other branches within the system.
How will UCCs change the provider landscape as we know it?
You can read others’ opinions on the web – there are plenty out there – but I’ll give you mine here. Please keep in mind this is coming from someone with an emerging knowledge of UCCs. It seems primary care offices have really dropped the ball. Demand for their services is increasing but they are not flexing to accommodate that demand. Too few are offering increased appointment times, they are scaling back in-house services as opposed to increasing them, and they are not effectively leveraging the relationships they have with existing patients (particularly those who visit infrequently). They are on the defensive rather than the offensive. As a result, they have allowed UCCs to position themselves more as a primary care physician alternative than an ED alternative. Without dramatic change from our traditional primary care providers, the first step in every patient journey may be into a UCC, a CVS- or Walmart-based clinic or some type of other designated primary care center within an integrated health system at the intersection of standardized medicine and convenient care.
I would love to hear your thoughts on the topics above, particularly how these facilities may change the provider landscape. Go ahead and leave a comment and let’s keep the discussion going. Your input may serve as the impetus for the next installment.
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