Jury still out on urgent care savings

Urgent care centers recently have gained increased attention as one possible part of a solution to an expected surge in patient demand once the main coverage expansions of the Affordable Care Act take effect. According to a study of six communities by the Center for Studying Health System Change, the facilities have been useful in filling access gaps for some patient populations, but their impact on health system costs remains unclear.

Nearly 9,000 urgent care centers are in operation nationwide. Such facilities offer walk-in care during typical business hours as well as evenings and weekends for nonemergent problems such as strep throat, minor injuries and the flu. Many started out as independently owned, although a shift has taken place in which larger facilities such as hospitals have been establishing urgent care centers to extend their service areas. Health plans also have eyed these facilities as a way to control rising health care costs by keeping more patients out of emergency departments, the study said.

Researchers examined urgent care centers in six communities that were selected for their high penetration of the market: Detroit; Jacksonville, Fla.; Minneapolis; Phoenix; Raleigh-Durham, N.C.; and San Francisco. Center executives and directors, as well as health plan network managers and hospital-based ED directors, were interviewed for the study. For the most part, the respondents said urgent care centers, by offering convenient hours of operation, did improve access for patients who lacked regular primary care physicians or couldn’t schedule timely appointments with their regular physicians.

Urgent care centers tend to be more prevalent in higher-income areas, and for the most part they treat patients with either commercial insurance or Medicare. Low payment rates reportedly have steered these centers away from accepting Medicaid. “Of the six communities studied, only Phoenix appeared to have significant contracting between Medicaid health plans” and urgent care centers, the study said.

Questions have arisen as to whether these centers could disrupt continuity and coordination of care. At least for such entities at store-based health clinics, the American Medical Association has called for the adoption of protocols for ensuring continuity of care with local practicing doctors.

Most of the respondents in the HSC study didn’t cite care disruption as an issue. This is because a majority of the patients treated at these facilities had fairly basic health care needs that could be dealt with in isolation from other needs and conditions.

In 2006, only 2.5% of urgent care visits involved psychiatric or chronic conditions, the study indicated. The health care professionals in these facilities apparently did not want to provide care that either required intense coordination for chronically ill patients or management of patients over a long-term period.

As one urgent care director in Jacksonville told HSC researchers, “If they need a physical or have an earache, we’ll see them.” Those who are hypertensive or diabetic need to be referred to primary care doctors, the director said.

Urgent care centers overall “probably don’t disrupt much with regard to care coordination, because anything with any acuity can’t be seen there,” said Jesse Pines, MD, director of the Office for Clinical Practice Innovation and professor of emergency medicine and health policy at George Washington University. However, some centers’ ability to conduct procedures such as abscess drainage and laceration repair make them broader in scope than other nonemergent care facilities, such as retail clinics, he said.

Difficulty of measuring cost benefits

Less clear is the impact of urgent care centers on health care costs. “Respondents across the board reported a lack of data to show whether the growth of [urgent care centers] has generally saved money by diverting patients away from EDs or increased costs by drawing patients from primary care practices,” the HSC study said.

There are several reasons why it’s been difficult to come up with a precise national cost savings number for urgent care centers, said Alan Ayers, a member of the Urgent Care Assn. of America’s board of directors. The global trade group represents 6,400 members in the urgent care field. “Unlike hospital emergency rooms, which are regulated, urgent care centers are generally considered as ‘doctor’s offices,’ and thus there is no national repository of urgent care visits,” Ayers said.

Urgent care also is not consistently available across the United States, he said. “Payer recognition/promotion of urgent care, reimbursement rates, availability of primary care, operating costs and other factors mean that urgent care is more readily available in some communities than in others,” he added.

Even where urgent care does exist, there is considerable variability in the operating model of these centers. All of these factors add up to why it’s hard to quantify the financial impact of these facilities.

Possibly the best evidence of cost savings in urgent care are the financial investments health insurance companies have made in urgent care centers, such as providing reduced or waived co-pays in health plan designs, “as well as efforts to educate members on the availability of urgent care services in their communities,” Ayers said.

Some studies have pointed to the cost saving potential. A 2010 Health Affairs report found that up to 27% of ED cases could be seen in urgent care, a shift that would generate up to $4.4 billion in annual cost savings. A more recent white paper from the urgent care association estimated that the cost savings of using urgent care centers versus emergency departments could amount to as high as about $18.5 billion per year.

In working fast-track shifts in the ED with medical students, Dr. Pines said he always has them count up the percentage of patients who could have been seen in other settings, such as a primary care physician’s office, a retail clinic or an urgent care center. With the exception of urgent care centers that treat minor trauma or lacerations, “the number is usually pretty small,” he said.

Urgent care centers probably have a larger effect on the amount of acute care seen by primary care physicians, he said. As the HSC study highlighted, many patients report that their physicians don’t offer extended office hours, “suggesting a niche for urgent care centers to fill.”

That trend is changing, said Jeffrey Cain, MD, president of the American Academy of Family Physicians. The market-driven competitiveness of urgent care centers has encouraged family physicians to become more available to patients: Almost three out of four family doctors now offer same-day appointments, and nearly half have extended their office or weekend hours, he said.

“We understand that patients should have a wide variety of options and that urgent care centers can be one part of an approach for after-hours cuts and bruises when patients don’t have access to a primary care medical home.” However, they should not be substituted for primary care, he said.