One of the most common pitches any risk based health finance and insurance propositions will make is that there is some special sauce that reduces emergency department utilization. ED visits are expensive and retrospectively many visits can be categorized as non-emergencies. This idea has been used to sell the ACA with the story that that more routine primary care will reduce visits and save money. It has not. This idea has been used to sell extremely high cost sharing. This idea has been behind the idea of insurers not paying for certain diagnosis codes that are only known retrospectively and not prospectively. This is part of the business case for urgent care centers. Cutting ED usage is hard short of a massive once in a century pandemic.
Wang, Mehrota and Friedman have a new article in Health Affairs that tries to establish the substitution ratio between urgent care visits and emergency room visits. Each urgent care visit is significantly cheaper than an ED visit, but urgent care is more likely to be used for non-emergency services like x-raying a referee’s ankle after they turned it real hard while trying to cut right to avoid a scrum of players or seeing what the hell is going on with that rash. So this is an empirical question — if the number is really big, than urgent care is less likely to be a cost-effective means of reducing ED visits. If the number is pretty small, then our belief that urgent care is an effective means of reducing ED visits should be slightly strengthened.
What do they find?
We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.
Urgent care has many use cases.
- Some ED diversion
- Some temporal substitution as urgent cares usually have longer hours than a PCP office
- Some PCP substitution for routine care
- Some intermediate care that diverts from specialists
Paying for convenience and access is not a bad thing. I know that when my son had the flu in January 2020, being able to take him to the urgent care forty five minutes after he woke up and had his orange juice was quite valuable to our peace of mind than taking him in the next day to the pediatrician’s office. I know that when I wrecked my ankle in 2014, getting an X-ray 20 minutes after the end of the game to get confirmation that nothing big broke was better for me than either waiting at an ER for 5 hours or not knowing while I waited a week for an orthopedist appointment to open up. There is a lot of value in what an urgent care does.
However, we cannot expect urgent cares to cost-effectively reduce ED utilization on a general case. There are plenty of needs and use cases where prospectively, a constellation of symptoms have a plausible chance of being an actual emergency but retrospectively the visit is low acuity. The ED is good at that type of identification and triage. A care delivery strategy that relies on urgent cares to reduce total spend by massively reducing low acuity emergency room visits has a massive hill of evidence to climb.