Like it or not, urgent care centers are here to stay

The New York Times had a front-page story about the growth of urgent care clinics nationwide.

These are the places that are often referred to as “minor emergency rooms,” or “doc-in-a-box” outfits. Their value proposition is simple: You don’t need an appointment. The costs are “reasonable,” and much more transparent than usual medical care at a doctor’s office, emergency room, or hospital. Best of all: They can treat a majority of acute conditions and have you in and out in under an hour. No ER can make that claim. Heck, not many doctors’ offices can make that claim.

As the article makes clear, urgent care centers have one tremendous advantage over emergency departments: They can cherry pick patients. ERs are required by a federal law called EMTALA to see and stabilize every patient, regardless of their ability to pay. Urgent cares have no such obligation. And they don’t take Medicaid. To be seen, you must have either private insurance or pay cash.

Seeing a money-making opportunity, big money (Wall Street, health insurers, hospital chains) are investing big in urgent care centers.

Naturally, skimming the straightforward acute cases out of the medical morass makes some unhappy. The article quotes one physician:

“The relationship I have with my patients and the comprehensiveness of care I provide to them is important,” said Dr. Robert L. Wergin, a family physician in Milford, Neb., and the president-elect of the American Academy of Family Physicians. “While there is a role for these centers, if I were sick I’d rather see my regular doctor, and I hope my patients feel that way.”

As a doctor, I very much see Dr. Wergin’s point of view. I believe in the importance of a relationship with a doctor (or, heck, a medical home) over the long term. But as a patient and “consumer,” I can certainly see the value in a place that can handle acute stuff on a walk-in, cash basis. My own patients who try to see me for minor maladies are often disappointed to find I’m not available for same day appointments much of the time.

I think the article gets it right. Urgent care is a trend likely to grow at least until the market is saturated. What will keep them afloat is the value they provide, until doctors’ offices (or medical homes) can offer truly expanded hours and availability, and come up with more transparent pricing and same day efficiencies.

Doctors and traditionalists will continue to wring their hands over this upstart economic/delivery model, but as the industry moves from cottage to corporate, this is just one more stream in a raging river.

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • querywoman

    Unless doctors want to maintain the mythical, ideal 24/7 availability, they should be glad to have urgent care centers.
    I’d like at 24/7 doctor available by phone, but I also want any doctor who treats me to get adequate rest.

    • buzzkillerjsmith

      UCs skim the cream. They take $ and the easy cases that help us keep the lights on.

      Large medical groups can make $ with UCs but it’s too hard for small groups. Another reason to join CorpMed and become clinically depressed in a year or two. Would you like that job?

      The bad driving out the good is a common thing. So is short-termism. So are corps smelling blood in the water like sharks.

      Better to go into radiology.

      • querywoman

        I read you, but are you on call 24/7?

        • buzzkillerjsmith

          No, but I’m pretty sure deceased MD was. That’s why he’s deceased.

  • Steven Reznick

    It depends on who is running the center. Our local ER staff run several facilities with the hospital and the evaluations and care are superb. Others give out antibiotics and pain meds like Pez out of a dispenser.

    • Thomas D Guastavino

      Cant beat ‘em, join ‘em?

      • Patient Kit

        This is the breakdown of urgent care center ownership as of 2012, according to a study done by the Urgent Care Association of America (UCAOA):

        - 35.4 percent of centers owned by physicians or physician groups, down from 50 percent in 2010
        -30.5 percent owned by a corporation, up from 13.5 percent in 2010
        -25.2 percent owned by a hospital
        -4.4 percent owned by a non-physician individual
        -2.2 percent owned by a franchise

        Halfway through 2014, I’m sure these numbers are constantly changing since urgent care centers seems to be growing like weeds.

  • LeoHolmMD

    Unfortunately, you are right. Until Primary Care can step up and deal with acute and chronic care for the right price at the same time, we will be doomed to fragmented care. Acute Care centers refuse to run at a loss. Could that be their secret?

  • DeceasedMD

    Urgent care centers as well as expensive buildings seem here to stay. I was reading NYTimes about fancy designs of Princeton Hospital like a hotel. The comments were all positive praising. No concerns voiced on HC waste or concerns about the HC itself. Kind of makes you wonder….

  • Thomas D Guastavino

    The only thing surprising about this is that anyone is surprised by this. Urgent Care Centers, Direct Pay, Super Sub-Specialization etc. are reflections of the same phenomenon and there is no end in sight.

    • Patient Kit

      In a nutshell, what are the things that make a patient high-risk to doctors?

      • buzzkillerjsmith

        Head injury except very minor, penetrating eye injuring, acute visual acuity abnormality, fever and neck stiffness, acute neck injury, inability to swallow with neck or throat pain, chest pain, shortness of breath, anaphylaxis, severe abdominal pain–upper or lower, severe pelvic pain in a female, pregnancy with anything else at all. diarrhea with significant fluid loss, diabetic ketoacidosis, diabetic coma, possible severe fracture and/or dislocation. Big lacerations that will take too much time. The big kahuna is acute low blood pressure. Those ones can die pretty fast. The list goes on and on.

        Other high-risk: Poor insurance or no insurance without cash. Figuring the pt will take more than 15 minutes for just about anything. Demanding or otherwise irritating patients.

        • Patient Kit

          Interesting, thanks. And who would be the unrisky desirable patients that both urgent care centers and private practice docs actually want to treat?

      • Thomas D Guastavino

        Several weeks I wrote a piece on Kevinmd titled “Medicine is like BlackJack, Physicians need to count cards” I invite you to read it.

        • Patient Kit

          Ah, yes, thanks. I remember reading your “Counting Cards” OP in July. I just went back and read it again.

          • Thomas D Guastavino

            Your Welcome.

        • lurking for answers

          I am still wondering what your solution would be for those “bad cards.” If you won’t see them, and urgent care won’t see them, but the illness is not acute enough for the ER, where should they go? Wait until their condition becomes bad enough to go to the ER or just wander away into the foggy background and not bother you? Cue the hooded black robes, skeletal hand and scythe….

          • Thomas D Guastavino

            My purpose in writing the piece was not to offer solutions, but to point out the unintended consequences of what seems to be a head long, not very well thought out, rush to overhaul the health care system. If you wish to discuss solutions, thats for another post.

          • lurking for answers

            I would very much like to see that discussion among doctors in a post.
            Dr. Rob Lamberts wrote a “Letter to Patients with Chronic Disease” that set off a firestorm of shares and comments. It gave seven “tips” to patients on dealing with doctors, but unfortunately no advice on finding a doctor that would take you in the first place.
            If a doctor is willing to “roll the dice” on a complicated patient, how do we, the patient, find that doctor?
            Should Chronic/Complicated care be a specialty or subset of primary care?
            What should the patient/doctor expectations be for that “relationship?”
            Paying for complicated or chronic disease care is also another messy conversation for a completely different post.

          • Thomas D Guastavino

            These days, in general, the more complicated the problem, the more specialists you will see and the more sub-specialized they will be. You are also more likely to be seen in a larger, likely teaching, institution.

          • Patient Kit

            That has worked out fine for me here in NYC, where we have numerous good teaching hospitals and major academic medical centers. But what are complicated and/or chronic patients supposed to do in rural America, where there are no academic medical centers or subspecialists nearby?

          • Thomas D Guastavino

            Travel farther.

          • Patient Kit

            Need clarification, please. Are you telling me to travel further so that I can better understand life outside of NYC? — or — Are you saying that peeps who live on a ranch in Idaho have to travel further to be treated at an academic medical center? Or both. ;-)

          • Thomas D Guastavino

            Peeps will have to travel further.

          • Patient Kit

            Bummer for rural peeps, especially if they are seriously ill. :-((((

  • Chiked

    I am surprised that physicians sick of corporate medicine and government regulations don’t jump on the bandwagon and open up their own practices.

    • Thomas D Guastavino

      Frying pan, fire.

    • Patient Kit

      I am under the impression that a large amount of urgent care centers are owned and operated by doctors. Others are owned by hospitals or corporations. But aren’t doctors themselves fairly big players in this growing urgent care trend?

  • Patient Kit

    When urgent care centers started opening in NYC (fairly recently), I did not understand their appeal. But now, I definitely see the appeal of being able to see a primary care doctor on weekends and in the evenings. For people working for an hourly wage, like I am now for the first time in decades, it costs much-needed money to take time off from work. And you can’t count on only needing to take two hours off to see a doctor. If you have a good salaried job like I used to with a PTO benefit, you can afford to take time off to see a doctor but it can be hard to schedule a good time for it, depending on what you do.

    That convenience of evening and weekend hours becomes an even bigger draw unless you already have a great relationship with a primary care doc, which you’d miss if you went elsewhere. The problem is that many people don’t have that great primary care right now. Many people have never had great primary care. And it’s hard to miss what you never had. So those convenient hours trump the hassles and costs of having to take time off from work to see a doctor.

    • fatherhash

      better yet, drop the paperwork aspect by dropping insurance…and have more time to spend with patients

      • Patient Kit

        Do most DPC docs have evening and weekend hours for patient visits?

        • fatherhash

          not sure how many DPC docs offer actual evening or weekend hours, but it seems like they are much more accessible than traditional insurance-based docs. if the DPC doc is not spending as much time charting and coding, i would assume that doctor has more time to spend with patients.

          the DPC doc doesn’t need to make patients come in for things that may not require an in-person visit, whereas the insurance-based doc does for billing purposes.

          • Patient Kit

            I understand what advantages DPC enthusiasts claim. One of them is easier access to the doctor, such as same day appointments and being able to reach the DPC doctor after office hours, some even say 24/7.

            What I’m asking, since the subject of this particular OP is the appeal of urgent care centers is this: Do most DPC docs have weekend and/or evening office hours so that patients who work days 9-5 can make appointments in the evenings or on weekends and, therefore, not have to take time off from work to see the doctor? I’m not talking about being able to reach the doctor by phone 24/7 or consult with a nurse 24/7. I’m asking whether patients can make appointments with DPC doctors outside of 9-5 days. Because that is one of the big appeals of getting primary care from urgent care centers for a lot of people.

    • SarahJ89

      Actually, Kit, most country doctors in my area had evening hours until maybe 25-30 years ago. House calls were still going on when I was in high school and college.

  • buzzkillerjsmith

    And my specialty continues to spin down the toilet…

    • Suzi Q 38

      Why do you say that?

  • querywoman

    The other side of the coin, as in a real witch of a boss I had once, is some employers would ask why you don’t to an urgent care center when you are off when you’d really prefer to go to your cheaper GP. I just hate the term PCP!

    • Patient Kit

      I’m resistant to the term GP because it sounds very old-fashioned and makes me thinks of a doctor who has the least amount of residency training possible. Re PCPs, I do want to know who are the docs, who are the NPs and who are the PAs. And I always refer to any doctor as a doctor, a title that they worked hard to earn and deserve to be called. But I have fallen into using PCP more when discussing healthcare policy and systems because, like it or not, there are a variety of primary care providers providing primary care. I can’t get used to GP though. I don’t think I’ve every used GP for any doctor I’ve ever seen.

      • querywoman

        Each to their own! Even though I mostly see specialists, and have some terrific ones, I have always found knowledge to be dangerous in doctors.
        I like a non-board certified GP who has true general medical instincts.

  • BK Berryman

    I am a family medicine and emergency medicine physician who has morphed over to urgent care. Urgent Care works because patients have an acute illness or injury and cannot get into their primary provider. The majority of our business is sore throats, UTIs, lacerations, and sprains. We have minimal lab and X-ray. We do take Medicaid and our visits are up because more people have health insurance; conversely, we get lots of Medicaid visits that may be inappropriate because there is no co-pay. Most Medicaid patients do not have a PCP so we become the de facto provider.

    • Patient Kit

      The first urgent care center that accepts Medicaid just opened in NYC this month in Queens. It’s a branch of CityMD, which already has 30 locations in NYC. I think most CityMD urgent care centers started popping up around the city only a few years ago and have been mushrooming ever since. I’m pretty sure that urgent care became a phenomena in other parts of the US way before they ever hit NYC. Often it’s the reverse. Think fashion and cupcakes. CityMD accepts almost all commercial insurance, Medicare and cash but not Medicaid. They are calling this new division that does treat Medicaid patients, HEAL, an acronym for Health, Education, Access and Love (we’ll have to see whether they deliver on that promise).

      I’ve only been to one urgent care center once myself (one connected to a hospital system) when I was transitioning between insurances and didn’t have a new PCP yet, but it’s hard not to notice them growing in leaps and bounds all over the city — and get curious about them. As I said elsewhere in this thread, I can see the appeal of the weekend and evening hours for working people who cannot afford, either timewise or moneywise, to take time off from work during the day to see a private practice do with traditional 9-5 hours only. Those traditional 9-5 hours may be one of the ways that private practice docs need to consider changing.

      • BK Berryman

        Urgent Care is for acute care only. Urgent Care will not treat chronic problems, perform preventative exams or testing, etc. urgent care fills a gap between emergent care (loss of life or limb) and primary providers who have no space available. Some providers that I know do offer open-access afternoons with walk-in, no appointment, one problem only visits. I have done primary care and got tired of longer days, more weekends, and less family / spouse time. Expanding hours is only a band-aid in the face of rising costs and decreasing reimbursements.

        • Patient Kit

          In theory, ERs are only for acute care too. (Is a sore throat really something that needs to go to the ER or urgent care? What’s the treatment for a sore throat?) Yet, despite the above-mentioned theory of how ERs should be used only for acute problems, many Medicaid patients use the ER for all or most of the medical care they need — primary, acute, chronic. I’d prefer that we all have primary care docs and specialists who know us well. But many people in the US simply do not have that.

      • SherryH

        I have a PCP who I really like. Yet, if I cut my hand and need stitches and it is evening hours or a weekend, I would go to the UC. Life doesn’t stop after 5:00, and accidents happen. In many ways, UC’s are a fill-gap. Would I go there for a cold? No way. But since they are sprouting up everywhere I am not surprised that others do. They are fulfilling a need, or they wouldn’t have so much business. There is a new one down the street from me that charges $25 for an appointment, that’s cheaper than my co-pay to my PCP. But would I replace my PCP with this kind of service, no (it means something to me to have a regular doctor who knows me). Still, if I needed them after hours or because my doc couldn’t fit me in, yes I would go there. Do I use the emergency room in such a fashion? Absolutely not, never have, never will. I tell all my friends to never, ever take me to the ER, I better be bleeding from the eyes or missing a limb!

        • Patient Kit

          I agree that they must be fulfilling a big need or they wouldn’t be growing so rapidly. I agree that it’s better to have a PCP who knows you and who you have a long-term relationship with. But, facing reality, many Americans don’t have that. I’m as ER resistant as you are. I didn’t go to the ER with a femur fracture. Instead, I hopped around in extreme pain all weekend until I could see my orthopedist on Monday morning. Of course, I didn’t realize that my femur was fractured. In that case, it would have been better to go to the ER. I wouldn’t go to an urgent care center or my primary care doc with a cold. I self-treat colds. What can a doc do for a cold?

          • SherryH

            Agree. I self treat for a cold too, everyone should.

  • Patient Kit

    Agreed. If you go to the ER with a non-emergency, you (and/or your insurance) is going to pay more for ER care and you are going to be triaged to the end of the line and wait a long time to be seen after the true emergencies (and rightfully so). And you might be forced to have expensive tests in the ER. So urgent care definitely seems better than ER for cases that are not true emergencies but can’t wait until you can see your regular PCP.
    However, since many (most?) urgent care centers apparently accept almost every kind of payment but Medicaid (many accept most commercial insurance, union insurance, Medicare, cash, credit but not Medicaid and I don’t know about the exchange plans but would love to find out about that since I may have to buy a plan soon on the exchange), many Medicaid patients who don’t have or can’t get to a PCP, will continue going to the ER for primary care.

  • Patient Kit

    Of course, they do. I never said they don’t. I’m just pointing out that one of the big appeals of urgent care centers is the hours. Why not have office hours maybe two days a week be noon until 8 or 9pm instead of rigidly 9am to 5pm every day? I’m not suggesting 12-hour days. Or have no office hours on Monday but have Saturday morning hours, maybe 9 to 1. Doctors keep saying that they work much longer than the 9 to 5 hours that they see patients anyway. I’m just suggesting moving some of those hours that they see patients to times that are more convenient for many people who work 9 to 5. And do some of the things that you usually do when you stay late (after 5) in the office, earlier in the day in a block of time during which you don’t schedule patients. Just suggesting a little flexibility and thinking outside the box.

  • SarahJ89

    My husband *only* gets to see his doctor at his annual physical. The rest of the time he sees an RNNP. There’s not much difference between the RNNP in the urgent care center and the one at the doctor’s office. But getting in to the latter is much more of a hassle so why on earth not go to urgent care?

  • fatherhash

    Seems that the unfair advantage is in that the hospitals MUST care for anyone, whereas the urgent cares don’t. Hmmm, I wonder how to level that playing field….I see only 2 logical ways, but others may see more. Either don’t force the hospitals OR also force the urgent cares.