Urgent care centers have sprouted like weeds over the past two decades. These centers can be almost anywhere. The one that my family used for years was in a strip mall between a Panera and an Ann Taylor’s Loft. The center typically had one or two physician assistants or certified nurse practicioners on duty plus a few nurses and a med tech. It was convenient for low to mid-acuity things such as needing a prescription for antibiotics for one hell of a nasty sinus infection but it was limited for things with moderate to high acuity such as a 4 year old’s asthma attack that was not responsive to the first drowning of albuterol.
There is a big question in the economics literature — do these urgent cares save money? Do they prevent expensive services — either hospitalizations or Emergency Department (ED) visits that don’t result in admissions — or do they offer value by convenience but does not divert enough/any hospital based care?
Janet Currie et al ask and answer this question in the current issue of the Journal of Health Economics:
When residents of a zip code are first served by a UCC, total Medicare spending rises while mortality remains flat. In the sixth year after entry, 4.2% of the Medicare beneficiaries in a zip code that is served use a UCC, and the average per-capita annual Medicare spending in the zip code increases by $268, implying an incremental spending increase of $6,335 for each new UCC user. UCC entry is also associated with a significant increase in hospital stays and increased hospital spending accounts for half of the total increase in annual spending. These results raise the possibility that, on balance, UCCs increase costs by steering patients to hospitals.
There can be a solid argument that urgent cares create value for patient acting as a consumer for preference based purposes. But these are unlikely to be cost-saving.
Walker
I always thought they were a form of self triage to minimize ER crowding. Why wait four hours to get stitches after you cut yourself with a knife (because you are in line behind all the cardiac events), when you can get it done in minutes.
sab
We stupidly took my cardiac event to an urgent care because we didn’t know it was a cardiac event and we didn’t want to sit for hours in the ER. They knew exactly what was wrong with me, called an ambulance which treated me in the parking lot, and then took me to the ER with two ekg tapes documenting my cardiac event so I got immediate attention from cardiologists. In my case I don’t think things could have gone any better with a direct trip to the ER. But I had to survive the side trip to urgent care.
lee
@Walker:
I always thought this as well.
A new twist in this in my area some hospital chains have opened Urgent care locations.
Central Planning
Is the assumption that UCCs are supposed to save money, or they are supposed to provide convenience for people? If I know I can walk into a UCC and be seen vs. wait in the ED for hours or try to get an appointment with my GP (seems like days), the UCC convenience will win every time.
If there was no UCC, I think some people would not bother going to the ED or their GP at all.
bbleh
Mortality is obviously an important endpoint, but I wonder what a QOL survey — obviously more difficult and expensive — would show.
In my limited experience, the threshold for going to a UCC is materially lower than for an ER. If true generally, it would mean they get a significant number of “worried well” — or almost well — who would otherwise stay home. That would lead to an increase in costs, but perhaps also to an increase in QOL, by treating minor things that people otherwise would treat at home and generally by assuring patients (and parents) that things weren’t serious
ETA: and yes, the “convenience” factor is significant: walk-ins at our local ERs can wait a LONG time — sometimes even hours — which is pretty much never the case at the UCCs.
Eolirin
Is this data based solely on the Medicare population? That’s not exactly a representative group if we want to talk about the economics of urgent care for the whole population.
Especially when it comes to hospitalization rates which are making up a significant part of the increase in costs. That mortality rates are flat while spending is up is a bit of a red flag, suggesting there’s maybe a little too much funneling into hospitals unnecessarily, but increased utilization isn’t necessarily an issue if that utilization is necessary.
Improvements to quality of life or quicker recovery from illness might not be cost saving to health insurance, but it’s cost saving to society. We shouldn’t be trying to save money at the cost of effective care, and I’m not sure that study is properly answering that question.
Additionally the UCC utilizing population is small enough here, relative to the total population, that it’s entirely possible the results are partially driven by statistical noise and self selection issues.
We need more studies here to be able to say anything definitively.
Brachiator
In Southern California I get the impression that urgent care is often used by people who have health insurance for their children, but not for themselves (not unusual for some undocumented adults) or for people who have health insurance, but who do not have a regular primary care physician.
Also, even for people with primary care doctors, they can often more reliably get same day service at urgent care or even an emergency room than they can get in to see their primary care doctor, where an appointment often is necessary. Waiting until after work to go to urgent care is still better than having to wait a couple of days to see your doctor, especially if you have to take off from work.
Even with all this, urgent care may relieve pressure on emergency rooms.
gvg
I don’t trust and don’t go to the mushroom type urgent cares but my local big state teaching hospital has opened a bunch around town and they are like just local branches, same staff, sometimes rotated, same records system. Since my main doc GP is part of their system and I work for the state and my insurance says all care through them is covered etc plus they have a good rep, I have used them. Infected foot after hours on a weekend, tetnus etc.
The big hospital is a huge complex that has been building up since at least the 50’s across the street for a huge VA hospital almost as long. I am not sure where they could expand too. Emergency room does have a wait. They have bought 2 nearby hotels and an apartment complex, torn down and built expansions. They bought part of the local mall to expand into. I actually like their neighborhood/area urgent care. Don’t trust the chains that are urgent only at all. The hospital (Shands) centers have doctors, xrays, and other significant equipment without being full centers. I also notice Shands gets ambulances in from at least 4 other counties. Gainesville is surrounded by some fairly rural areas who don’t even have population centers.
gvg
@gvg: Anyway, my point is, some of the choice isn’t really a choice. Emergency rooms of hospitals are not usually able to be infinitely expanded. They needed to have out offices. Too many of them are of low quality which is a different issue, but they were going to happen, and probably at a cost increase too.
The using instead of going to a doctor for routine care is a different problem related to the lack of healthcare which Obama care helped a lot but it’s still being fought. A prolonged labor shortage may actually help this too because that got us improved work insurance in the past.
Brachiator
I have also noted some urgent care operations near industrial parks, close to workers who may have accidents. The closest hospitals are miles away.
PJ
Last fall, I went into a local urgent care center near me (CityMD) that was in-network for a Covid PCR test and a flu shot. I wondered why they had a doctor give me the flu shot, and found out when they billed me $550 for the services. Both items were supposed to be covered under my insurance, but the doctor was supposedly out-of-network, though the facility was definitely in-network (my insurer even advertises them on every bill and EoB.) My insurer (BCBS) was still supposed to cover this as a surprise bill, and in the end, I didn’t pay anything, but I still had to spend hours on the phone with CityMD and my insurer protesting it, and it was a huge headache. So that was the last time I will use CityMD.
PJ
Another thing, at least in NYC, tied to the explosion of the numbers of these for-profit urgent care centers is that several large hospitals have closed in the last two decades (to be replaced by luxury condos), which puts a greater burden on the remaining hospitals, which means emergency room waits are often many hours. Coupled with a typical months-long wait for an appointment to see in-network doctors, if you need non-critical care and can’t afford to spend half a day waiting (or months), the urgent care centers are the only alternative.
Roger Moore
@Walker:
I think that makes some sense for a UCC that’s part of a larger hospital. As an example, the Kaiser hospitals I’ve gone to have both an ER and a UCC. That lets them provide a separate queue for patients who just need to see a doctor today but aren’t in immediate danger. But it doesn’t make a lot of sense for a stand-alone UCC.
I had assumed stand-alone UCCs were a response to EMTALA, which requires an emergency room to provide treatment to anyone in a genuine emergency without checking on their ability to pay. ERs have a reputation for losing their hospitals money. That’s both because emergency treatments can be expensive and because they attract patients without insurance who go there even for non-emergency care. Stand-alone UCCs are designed to siphon off the non-emergency care for patients who can pay, exacerbating the situation for ERs.
MattF
There’s an ‘immediate care’ storefront that recently opened up in my neighborhood, run by George Washington University Hospital. It’s pretty clear that they are looking for regular primary care patients rather than walk-ins— when I walked in, the receptionist asked if I had an appointment, and then said I’d have to wait to see if anyone was available to deal with my request (to take out some stitches). They did the job, and I saved some time, so I’m not complaining.
Ohio Mom
@Walker: That’s what I thought last month when I needed stitches in my hand. Nope, the Urgent Care NP took one look and said, “That’s too deep for me, I can see your bone. Go to the ER.”
At the ER, I was assigned to the Express department. Which is ironically named. The other ER department, where they take care of trauma, heart attacks and the like, no doubt is staffed by speedy practitioners.
The Express department staff was in slow motion. A NP listened to my story, took a look at my hand, ambled off and disappeared for a while, ambled back with what she needed to stitch me up, laid it all out, disappeared again, ambled back, gave me shot to numb my hand and finally got down to stitching me up.
Inbetween there was a tetanus shot and afterwards, a wait for a doctor to amble by and approve the final product (in retrospect, maybe having the doctor come by before I was stitched up would have made more sense but IANAD). I was given vague aftercare instructions, an antibiotic prescription, and told to see my PCP in ten days to have the stitches removed.
I’m not really complaining, my hand is pretty much healed, I don’t seem to be worse for the wear, and that’s what is most important.
My time in each of the waiting rooms was only about ten minutes, which I think is perfectly acceptable.
Obviously I could have skipped Urgent Care and now that I know the hospital I went to has an “Express Department,” Ohio Family will go there instead of an Urgent Care Center if any us ever needs urgent care again. It will also be reassuring to know that if we miscalculate and actually need to be seen by the real ER and not just the Express department, we’ll already be there.
What was the question, Did Urgent Care save money for Medicare in this instance? No.
Cec65
My two biggest Urgent Care Events. I have gone for sprains, muscle pulls, fevers in the past. But two visits stand out positively, The first was the last Saturday night in March 2014. Woke up suddenly and was experiencing a ongoing Back Spasm. Went to Urgent Care in the middle of the night. Was seen right away and told to go to the ER. It was not a back spasm, it was a seizure due to a brain tumor. That Wednesday I had brain surgery. That Urgent Care Nurse Practitioner was able to realize that was not just a spasmed back. The second just happened Saturday. I had traveled out of town to visit Family and then go to a Comic Con. in my birth metropolis. I started feeling sick on Friday, it was Covid, there an Urgent Care Center within walking distance of the convention center/hotel, went there, got a prescription for Paxlovid, quarantined until today, and am I leaving back after several day late. Urgent Care saved my life more than once
KayInMD (formerly Kay (not the front-pager))
That’s how I’ve always used them for myself.; UTI on the weekend, something in the eye that I can’t get out myself, a cut that needs a stitch or two.
My younger son has worked swing shift – 1 to 9 – for years, and with commute time his hours never allowed him to get to a regular doctor appointment. Most 24-hour Urgent Care Centers in our area staff at least one doctor at all hours, so when he needed to see a doc he just stopped on his way home. He’s not working ATM, trying to get his own business off the ground, so I guess he’s just hoping not to get sick at all… (he did get insurance through the exchange).
Eunicecycle
I have always had good experiences at my local UCC affiliated with my hospital. I used them on weekends or at night when my doctor’s office wasn’t open. But I probably wouldn’t have gone to an ER for the problems, just would have waited if the UCC wasn’t available, so not a cost saving just convenient.
Anonymous At Work
@bbleh: I agree. Mortality at 6 years wasn’t listed in blurb and I’m curious about that. I am also curious about QOL adjustments because how many people were going to hospitals that would have otherwise “toughed it out” and how do you normalize increased bed stays for the severity of a bed stay (i.e. being treated medically and observed for 4 days vs. emergency surgery and 3 days recovery is technically 4 bed-days vs. 3 bed-days but vastly different severity).
Maxim
@Central Planning:
This is what I wondered. Do the increased costs of UCCs (sometimes) sending people to the hospital actually save money in the long run, by preventing more serious, expensive outcomes (if things that should be seen to aren’t)?
Lymie
@Eolirin:
I agree with you. These studies always draw the boundaries of where they are looking for cost/benefit too narrowly, ignoring QoL, or long term value and only focussing on cost. It is a pervasive problem in trying to evaluate care – the benefits don’t accrue to the entity that pays (NB preventive care).
djwid
Pre-ACA my wife and I used UC heavily. The locations were often much more convenient for us as we were car free. BTW staff act odd when you are there because you are really sick but biked to the location.
We still use UC frequently since getting to our doctors is such a pain in the ass. The UC in the PNW are not as leanly staffed or light on doctors as this study indicates either.
JustRuss
I have about zero-chance of seeing my primary without an appointment. Urgent care has been incredibly useful for the can’t-wait-but-not-life-threatening issues I’ve experienced. Much quicker than an ER visit, and I’m not taking up critical resources.
OverTwistWillie
They do contracted pre-employment physicals and vaccinations, DOT exams, etc.
Job sites will have a list of insurance approved local UCs for minor injuries.
I think that’s part of the business model.
wonkie
I almost lost my eye because of an urgent care doctor. I got stabbed by a rose bush–the thorn went right through my pupil into my eye. Suddenly no sight in that eye. I went to the urgent care where the doctor told I had a scratch that would get better in a little while. I went home. The next day when I had no vision in that eye I went back and insisted on a referral to an eye specialist. The specialist told me that I would have a series of surgeries and that he might not be able to save my eye. Two hours later I had the first surgery to close up the rip in my cornea. Subsequently I had a cataract surgery , a cornea transplant Lasek, and surgery to get my retina to stick to the back of my eye. I also have been on a daily period for twenty years to prevent my eye from rejecting the cornea transplant.
StringOnAStick
The local UCC got the X-rays done and a temporary cast when my husband broke his wrist last fall, a non-displaced fracture so not a “surgery ASAP” situation. Getting in to see an orthopaedic surgeon took 10 days because we are short on providers here, pretty annoying in a full cast with very little mobility. That was better than waiting 10 days just to be seen at an orthopaedic practice.
My UCC experience was with the new UCC plus ER in our old neighborhood, sold to us as a “stabilize and transport” facility owned by the big New hospital 3 miles away; I thought it was odd given how close their level 1 trauma center was. Then I needed help with a raw oyster induced viral infection that gave me a head about to explode headache, and the pain med they wanted to give me required an IV, which upcodes it to an ER visit. The cost went from $600 to $6,000. Then I understood their whole “stabilize and transport” sales job to get the locals to accept the facility, because being able to push some visits up to ER prices without sending the person to the hospital has got to be more profitable.
ProfDamatu
I’m not surprised that urgent cares don’t save Medicare money, and I agree with others that QOL is a better metric to use to suss out how good of a value they are. Having said that, I think there’s real value in having the “convenience” of being able to quickly see a provider without going to the (very expensive!) ED.
Full disclosure – I’m extremely biased here, because it was an urgent care PA who set the wheels in motion for my lymphoma diagnosis almost ten years ago – he recognized the presentation as probably more than just “swollen glands, random infection” and sent me for imaging when a week’s worth of antibiotics had no effect. If I’d had to get in with a primary care doc (at the time, I was using my long-time GYN in another state as primary – up til then, I was very healthy!), it might well have been MONTHS before I could be seen…at which point, the cancer would almost certainly have progressed well beyond the Stage I at which I was diagnosed. Yeah, I recognize that I’m a corner case, and that on societal level, maybe we say it’s more cost effective to sacrifice dumbasses like me who don’t immediately establish with a primary care doc when they move…but I’ll still lean in the other direction
Edit – Here’s another one. Couple years ago, I was bitten by an insect, and the resulting lesion kindasorta looked like the bulls-eye rash that indicates Lyme. I called my primary (I may be a dumbass, but I am capable of learning), and was told it would be a week before I could be seen. So off to urgent care I went, because the rash might well have been gone by then, and what’s the doc going to do if all I can say is – well, it kinda looked like it, but now it’s different….. (Turned out to be garden variety cellulitis, cleared up quickly with meds.)
JaneE
Kaiser health plans need to use Kaiser facilities. Most of the care is delivered by appointment, but there are regional hospitals with ER facilities. Way back when, “urgent” same or next day appointments were available, but the phone system wasn’t up to handling the volume, so getting one was next to impossible. The alternative was to show up at the hospital – triage in the lobby or ER. If it was really serious, you would get treatment then, if not quite that bad you might get a clinic appointment for the next day, or more likely, you would be told to make an urgent appointment on your own. Catch-22 most of the time.
More recently they have started offering urgent care at normal office locations – extended hours, available 7 days, more or less triaged when you register. There is a sign in the waiting area – the old building lobby – saying how long it averages for treatment. Most of the time it seems stuck on 2 hours. It does depend on what your problem is. During Covid-19, they were not doing in person appointments, and the line for urgent care was wrapped throughout the building. Now even on weekends there are rarely a handful of people waiting for care.
Most of the people who go to urgent care need help now, not two weeks from now, but they are not serious enough to rate a 50 mile drive to the Kaiser ER. How much it costs doesn’t concern them, as the co-pay is a standard rate based on their coverage. The patients are much happier, and get better care when they need it as a result. We all want more hospitals and wider distribution of specialists into outlying areas, but that is slow coming.
I have used urgent care to get stitches for a bleeding gash I couldn’t stop – before the UC opened I had to go to the ER for something similar. Much better to drive 5 miles than 20 or 50.
JMS
My family has used urgent care twice, both arthropod related. In case 1 I went for a rash and flu symptoms that I thought might be Lyme disease. The doc didn’t think so but gave me a prescription for an antibiotic that doesn’t do anything for Lyme disease. She told me to go to the ER if I didn’t get better. I didn’t so I did. I was admitted, but didn’t get diagnosed with Lyme disease until 24 hours later. I took the same doxycycline I could have gotten from an outpatient pharmacy and immediately got better. I had also started a new job where the insurance hadn’t started so I scrambled to get onto Cobra from my old job. I was visited by the hospital’s financial counselor because I was “uninsured”. I should have pushed harder for a Lyme diagnosis at urgent care…
A few years later my husband was stung in the ankle by several angry yellow jackets while he was doing yard work. I told him to go to urgent care since he actually saw his adversaries and was unlikely to be misdiagnosed. He got a pack of prednisone and went on his merry way.
ProfDamatu
Exactly what I was getting at, more succinctly! I think there is a subset of medical issues that are not true emergencies, but which nonetheless require attention more quickly than most people can get in to see their regular doctor. Urgent cares seem to be a reasonable solution, especially in underserved areas.
Your last example – yeah, me too. That was another UC visit; a cut on my chin from falling on the trails that wouldn’t stop bleeding. I would have felt ridiculous going to the ER for that, but at the same time, I wanted it professionally seen to, in case stitches were required (call me vain, but I wanted to minimize the chances of another facial scar).
Central Planning
@gvg: I know you’re not in Rochester, NY, but holy shit, that sounds just like what the University of Rochester Medical Center is doing around here. I wonder if they are using the same playbook.
gvg
@wonkie: For anyones info: My eye doctor told me that if I had any vision problems of a certain type I had to go to a certain big hospital EM because that was the only one in several counties that had 24 hour eye surgeons. I have a slight chance of someday having a detached retina, and my father has a higher chance. He indicated Eye problems needed eye experts not general doctors and that I was to say so when I came in if it ever happened. So anyone else that ever has an eye problem, try to already know where you should go. You regular eye doctor or any eye doctor can probably tell you. They often take turns being the oncall physician for that specialty.
gvg
@Central Planning: Probably. They do pay attention to what works.
I will add that I like that the UC has my full records if I use it and anything they do is known to my real doc right away.
Unrelated to UC, decades before they also built some small clinics in the very poorest areas such as the black side of town and some rural areas with no doctors. Part of their system, their employees, and I don’t think those were profitable, but they did serve people, even though they aren’t saints. I sort of think that may have started them on the road to setting up these satellite units though.
My UC happens to be about 3 blocks from me.
wonkie
@wonkie: I meant steroid, not period!