Urgent message: A new report from the California Health Care Foundation, excerpted here, examines how the growth of urgent care is influencing delivery of healthcare—and what the prospects for the future of the industry might be.
Prepared for the California HealthCare Foundation by Robin M. Weinick, PhD and Renée M. Betancourt, BA
The days of having a family doctor in town who cared for all of a patient’s health needs are long gone. In their place, an array of services and providers has developed to meet patients’ primary care needs, increasingly placing the burden on the consumer to make the appropriate choice.
This proliferation of choices includes primary care practices with one, several, or many physicians; community health centers; large multispecialty group practices that provide primary care; hospital emergency departments and, more recently, freestanding emergency departments; retail clinics; and urgent care centers. Among these, urgent care centers have emerged to fill a specific niche in the healthcare delivery system.
Urgent care centers first opened in the United States in the early 1980s. The industry declined, and then expanded in the mid-1990s. Since then, the industry has grown rapidly, to between 12,000 and 20,000 centers today.1 By one estimate, approximately two new urgent care centers open in the United States each week.2
Urgent Care Centers and the Healthcare Delivery System
Urgent care centers are uniquely positioned in the healthcare delivery system. Table 1 shows their relationship to other ambulatory care providers that offer overlapping types of service.
Urgent care centers generally emphasize convenient care and feature extended evening and weekend hours. While this is also true of retail clinics, neither typically comes close to the 24-hour-a day, seven-day-a-week availability of services in emergency departments. Urgent care centers, retail clinics, and emergency departments all emphasize unscheduled care to a far greater extent than most primary care practices do.
At the same time, urgent care centers often provide a wider and more complex array of services that are designed to address more urgent health needs than a primary care office does. Emergency departments—particularly those in large, Level 1 trauma centers— provide the broader scope of care.
All of these settings offer a broader scope and complexity of services than retail clinics, which are designed to address a limited number of health concerns.3 Emphasizing a view of patients as consumers who can choose where to get their healthcare is a hallmark of urgent care centers and retail clinics, both of which take a customer service approach to providing convenient care. This view is not as prevalent in doctors’ offices and emergency departments, which are designed to function around the physician’s availability, rather than the patients’.
Finally, primary care places considerable emphasis on continuity of care, ideally serving as a patient’s primary point of access to the healthcare system, following patients over time, providing management for chronic conditions, and coordinating specialist care.4
While emergency departments do serve as a usual source of care for a very small number of patients, and some patients are asked to return to the emergency department for a follow- up visit, continuity of care is generally very low. Retail clinics and urgent care centers primarily emphasize episodic care.
However, the addition of occupational medicine, which often involves more than one visit for a given health condition, moves urgent care centers slightly closer to primary care offices in terms of continuity.
How Urgent Care Centers Operate
The main emphasis at urgent care centers is on episodic care. Some urgent care centers have moved beyond simple point-of-care tests such as urinalysis, pregnancy tests, and hemoglobin testing to include more complex and more regulated testing, such as troponins for the diagnosis of chest pain—something typically done only in hospital emergency departments.5
The scope of services provided by urgent care centers can vary considerably. For example, Inland Empire Health Plan in Southern California uses explicit criteria to classify centers into two categories, based on the services they provide. Some can perform a wide variety of procedures, including laceration repair, fracture care, and response to cardiac events, while others function more like after-hours primary care services.
Occupational Medicine and Workers’ Compensation
One essential component of the services offered by many urgent care centers is occupational health, which has two main aspects: employer-paid services and workers’ compensation. Employer- paid services include employment- related physicals, drug screening tests, workplace evaluations, and other related services.
These services may be done under contractual arrangements with local employers. Many of the services, such as drug screening tests, can be carried out by a medical assistant without a physician’s involvement, generating income with low resource use.
Workers’ compensation is designed to pay for employees’ healthcare needs associated with on-the-job injuries. The nature of sudden, employment-related injuries means that appointments cannot be scheduled in advance, as would be necessary in many primary care offices, which makes urgent care centers a particularly attractive venue for workers’ compensation cases, especially when compared with the only other option for unscheduled care—the emergency department.6
From the urgent care center’s side, workers’ compensation cases are appealing because they typically result in multiple visits per injury, with a single billing process. This is a departure from the majority of their cases—patients who are seen once for each clinical episode, with a separate billing process each time.
Both employer-paid services and workers’ compensation cases complement the acute health side of the services provided in urgent care centers, generating business midday, a time that is often slow for many centers.
Point-of-Care Dispensing
Approximately one-third of respondents to the Urgent Care Association’s benchmarking survey reported providing prepackaged pharmacy services onsite, also known as point-of-care dispensing.7 Medications come in pre-filled, tamper-proof packages, and the contents are never handled by the urgent care center staff.
There are two main motivations for offering these services in an urgent care center. First, the profit per medication dispensed can be considerable for some centers. However, it is not clear how significant a revenue stream point-of-care dispensing represents for the industry.
The second draw is the benefit to the patient of one-stop shopping. The ability to remove an inconvenience— having to go to the pharmacy to fill a prescription when a patient is sick—is in keeping with the increased customer services focus at the heart of many urgent care centers.
Marketing Urgent Care Services to the Consumer
Marketing is crucial to the success of both new and established urgent care centers. Primary care providers benefit from the established relationships patients have with them, and emergency departments carry both the name recognition and the large physical presence of their hospitals.8 Urgent care centers benefit from neither of these, and the picture is complicated by the lack of clarity in the industry—and therefore among potential patients— about what exactly an urgent care center is and what it does.
The Advisory Board Company, which provides research services to hospitals, highlights the fact that hospital-based urgent care centers use newsprint and direct mail advertising to consumers.
These advertisements often feature an educational focus that may include introducing patients to the option of “self-triaging” as a way to help them understand what types of conditions can be treated at the urgent care center, with the hope that they will make clinically appropriate decisions about whether to seek urgent care or go to the emergency department.
In addition, the company notes that some hospital based urgent care centers market their services directly to physicians, with messages stressing the noncompeting, complementary nature of their services.8
Good signage is critical to the success of independent and chain-owned urgent care centers. It can help ensure that the center can be easily found and that drivers who are passing by will remember the center when they need care at a later time. In at least two states (Illinois and New Jersey), however, centers are prohibited from using the word “urgent” in their name and marketing materials because of concerns about public confusion with emergency deparments.2
Patient Satisfaction and Experiences with Care
A strong focus on customer service is a hallmark of the urgent care industry.
Press Ganey, an independent vendor of patient satisfaction surveys, has a survey tool designed specifically for use in urgent care centers.9 One analysis of its 2002 data on more than 64,000 patients in 107 urgent care centers showed that the overall satisfaction rating was fairly high, with an average score of 83 on a 100-point scale.10
This same study, however, showed that only 59% of patients indicated that their likelihood of recommending the center to others was “very good.” Recommendation scores could be improved by keeping patients well informed about delays when they are waiting to be seen. This may be crucial for enhancing patient satisfaction, as scores showed a substantial decline in satisfaction as wait times rose.
An online survey conducted by the National Headache Foundation found that many headache sufferers might benefit from treatment at an urgent care center. Patients were asked about the treatment they received for their headaches in emergency departments and urgent care centers. Urgent care center patients were more likely to report waiting less than one hour to see the doctor, having a medical provider who was polite and respectful, having a diagnosis clearly explained to them, having received effective treatment, and having been provided with clear instructions about what to do if the headache returned.11
Finally, one market research survey conducted by Scott & Company asked consumers about their preferences for having a sore throat treated when their regular doctor was not immediately available. The respondents’ first choice was to seek treatment in an urgent care center, while their second choice was to wait for their regular doctor. Their third choice was to seek care in the emergency department.12
Urgent Care Medicine as a Professional Field
As a newer area of clinical practice, urgent care medicine has only recently begun to move toward defining itself as a professional field.
The American Medical Association now has a code allowing physicians to self-designate their specialty as “urgent care medicine.”
The field also has a new fellowship offering postgraduate training in urgent care medicine through the Department of Family Medicine at Case Western Reserve University and University Hospitals Medical Practices in Cleveland, OH.
This program, developed in collaboration with the Urgent Care Association, started in 2006. It follows a curriculum designed around a set of defined core competencies and is modeled after the Accreditation Council for Graduate Medical Education’s training model.
A second program using the same curriculum will begin at Physicians Immediate Care in Rockford, IL, in collaboration with the Department of Family Medicine at the University of Illinois, Rockford, and themUrgent Care Association.13
Accreditation and Licensing of Urgent Care Centers
Accreditation of urgent care centers by a recognized body may be key to insurers’ willingness to pay a facility fee in addition to professional fees for physicians’ services. Before accreditation criteria can be uniquely tailored to the needs of urgent care centers, however, there needs to be a clearly accepted definition of what an urgent care center is.
Arizona is the only state to license and regulate urgent care centers. The licensing requirements there have been described as having unclear standards and a considerable paperwork burden, raising concerns within the urgent care community.14
REFERENCES
1. The Urgent Care Association (www.ucaoa.org/info/statistics.html) and Wikipedia (en.wikipedia.org/wiki/Urgent_Care_Association_of_America).
2. Stern D. Status of Urgent Care in the U.S.—2005, Business Briefing: Emergency MedicineReview. Available at: www.touchbriefings.com/pdf/1334/Stern.pdf.
3. Scott MK. Health Care in the Express Lane: The Emergence of Retail Clinics. California HealthCare Foundation, July 2006. Available at www.chcf.org/documents/poligy/HealthcareInTheExpressLaneRetailClinics.pdf.
4. Starfield B. Primary Care: Concept, Evaluation, and Policy. New York: Oxford University Press, 1992.
5. NextCare. Interview with John Shufeldt.
6. National Association of Occupational Health Professionals. Interview with Frank Leone.
7. “Developing Data: Urgent Care Services Rendered.” J Urg Care Med. 2006;1(1):40.
8. The Advisory Board Company. Marketing Urgent Care Centers in Suburban areas. Original Inquiry Brief. Aug. 10, 2004.
9. Press Ganey website, www.pressganey.com.
10. Miceli PH, Van Remortel D. Fostering Patient Loyalty in Urgent Care Setting. AAACN Viewpoint, November/December 2003. Also, Leddy KM. How Long Would You Wait for Your Doctor? The Satisfaction Monitor, March/April 2005. Available at: www.pressganey.com/files/satmon/issues/Mar_Apr%2005_3_30REV4.pdf.
11. National Headache Foundation. Emergency Room or Urgent Care Center: A Headache Sufferer’s Dilemma. June 2006. Available at: www.headaches.org/consuymer/press% 20releases/ 06.06.30%20-%20ER-UC%20Treatments.doc.
12. Scott & Company, Inc. www.marykatescott.com.
13. University Hospitals Urgent Care. Interview with Lee Resnick. Fellowship Programs in Urgent Care Medicine. Available at: www.ucaoa.org/fellowship.index.html.
14. Urgent Care Association. Interview with Lou Ellen Horwitz. Arizona: A Hostile State for Urgent Care Centers. Urgent Care News, November 2005. Available at: