Feeling ill, but not an emergency case? Increasingly, in big cities at least, there is likely to be an urgent care clinic that can provide rapid access to healthcare for patients who are very unwell, but who are not deemed medical emergencies.
Unlike the UK, quite a large proportion of the US population do not have a primary care physician or GP and use the ER as the front door to healthcare services
Dean Hatcher, President of MedExpress, which runs 250 urgent care centres in 19 US states, said such facilities must be located in neighbourhoods and communities so that healthcare is close to home and easily accessible between 8am and 8pm. “We offer walk-in treatment for everyday illness and injury, which includes more advanced offerings such as X-rays, labs, minor surgery, stitches and treatment for sprains and broken bones,” he said.
Hatcher explained that the need for urgent care centres has been driven by patients. “Our ability to offer a full medical team and convenient hours without an appointment speaks to our patients’ busy lifestyles,” he said. “Most MedExpress patients are in and out in less than an hour − making urgent care centres a great option for many people with unscheduled, time-sensitive needs.”
Across the Atlantic, HCA Healthcare UK (HCA) says common conditions seen at its urgent care facilities are broken bones, sports injuries, urinary and kidney infections, women’s health, and respiratory infections. Its facilities are also open for 12 hours a day, every day. Medical emergencies, on the other hand, such as heart attacks or road accidents, continue to head for 24-hour accident and emergency (A&E) or emergency departments (ED).
Patient access to care
HCA, which is responsible for about 50 per cent of all private medical treatment in London, has launched several urgent care clinics throughout the capital in recent years. The first urgent care centre, based at the Princess Grace Hospital, was piloted to fill what Andrew Coombs, Commercial Director at HCA, said was a healthcare gap in London. “We had quite a bit of consumer and corporate feedback that customers would like more rapid access into healthcare services – rather than either going to a GP who may then have to refer them onto a consultant, or going to A&E,” he said. “I think that people see us as a kind of alternative to going to an A&E because there, they might have a substantial waiting time and wonder whether they will be able to see a specialist quickly.”
The need to keep rising healthcare costs down across the US and Europe has influenced the move towards urgent care
The Princess Grace pilot was so successful that HCA opened more urgent care centres at the London Bridge Hospital, Lister Hospital, Wellington Hospital and a dedicated children’s urgent care clinic at the Portland Hospital within the last two years. “We’ve seen very strong growth in patient volumes,” he added.
Eighty per cent of those treated at HCA’s urgent care facilities are UK-based and 20 per cent are international patients – either travellers or second country nationals. Many access urgent care through private medical insurance provided by corporate schemes. “Increasingly, companies are including urgent care inside their policies,” said Coombs. “I certainly know that we’ve had very strong take-up from the City of London and a number of large corporate clients.”
Coombs extrapolated that international travellers or workers and expats find it extremely difficult to navigate the UK’s National Health System (NHS) and the GP gateway system. “We have discovered, from speaking to a number of Japanese or Chinese companies, they have found that having urgent care centres as the access point to the medical system a more understandable way of accessing healthcare in the UK,” he noted.
Coombs reckons that about 10 per cent of HCA’s total revenues come from customers on international private medical insurance policies. “Almost all of those international insurers have now asked for this to be included as standard within their policies,” he said. “We’ve had quite a lot of interest from international insurers when we have spoken to them about it. Those who offer it now actively market urgent care as a benefit to their policyholders who may be working in London, Europe or travelling through London.” The next step is to be included within UK domestic insurance policies added Coombs.
Insurers and assistance companies who use urgent care centres around the world say that, as well as faster turnaround times for their customers, urgent care centres work out cheaper. “Urgent care is much more cost-effective in comparison to ER. Urgent care costs on average 10 times lower than ER costs,” said Nicole Commander, Manager of Assist & Medical Management at US-based Seven Corners. “In addition,” she added, “Urgent care provides patients with a more diverse array of services than family doctors. Many facilities are equipped with in-house laboratory testing and diagnostic imaging equipment, such as CT scanners and X-ray machines.”
Interestingly, Commander sees urgent care as a burgeoning business worldwide, with the market leaders mainly based in the US. “However, we are beginning to see urgent care centres appear in other developed countries, specifically within Asia (Middle East & Pacific), Europe, and North America,” she detailed. While internationally, operations do vary to some extent, she sees some similarities: “We are seeing more commonly that global urgent care centres are modelling after the market leaders, as they recognise the benefits of urgent care.”
And those market leaders are jockeying for position in a very vibrant and changing industry. The Urgent Care Association (UCA) said that by the end of 2017, there were 8,154 clinics in the US – a growth from 6,003 in 2014.
HCA’s US parent has 160 urgent care centres across the country after finalising the purchase of 24 MedSpring urgent care centres from Fresenius Medical Care in July this year. The purchase is indicative of an industry that has mushroomed in recent years, with expanding players such as Tenet Healthcare and UnitedHealth Group’s Optum, which bought MedExpress walk-in centres in 2015.
Urgent care is a very much a tried and tested model in the US, although it works slightly differently there; substantial revenues come in from patients funded by Medicare and Medicaid. Unlike the UK, quite a large proportion of the US population do not have a primary care physician or GP and use the ER as the front door to healthcare services. There are also different models of provider in the US, from small so-called mom-and-pop organisations, to larger chains such as CareSpot or GoHealth.
In the US, 15 per cent of urgent care centres are hospital-owned; 14 per cent are owned by two or more physicians; 39 per cent by a corporate entity; and 10 per cent by a single physician. UCA says that the top staffing model is an urgent care centre run by a physician, a physician’s assistant, two medical assistants, a radiologic technician, plus support staff (receptionists for example); but others may be run with just a physician and a nurse practitioner and receptionist.
Keeping costs low
Urgent care centres market themselves primarily on the basis that there are as many as 18 million avoidable hospital emergency department visits a year. They present themselves as a cheaper alternative to emergency room treatment for the same conditions. On its website, MedExpress states that, according to the agency for Healthcare Research and Quality Medical Expenditure Panel Survey, 2013, the average cost of an ER visit is $1,423. Whereas the average cost of an urgent care visit is $155, according to the UCA benchmarking survey 2011. The difference in price is accounted for by the cost of more specialised staff, investigations and other emergency room costs. Indeed, the 10 most common primary care treatable conditions frequently treated at emergency departments are bronchitis, cough, dizziness, flu, headache, low back pain, nausea, sore throat, strep throat, and upper respiratory infection. These are the conditions urgent care centres seem to target.
Insurers and assistance companies who use urgent care centres around the world say that, as well as faster turnaround times for their customers, urgent care centres work out cheaper
For an insurer like Aetna, reimbursing the costs of urgent care is just one option from many, the likes of which range from wellness and health coaching right up to specialist quaternary hospitals. “Our responsibility as an insurer is getting the balance of providing healthcare in the right setting so that we spend our customer’s insurance dollars in an appropriate way,” said Dr Sneh Khemka, Head of Population Health. “What we don’t want to do is send someone with a sprained ankle to an expensive hospital where they will have an unnecessary and expensive scan, and give them medication they don’t need. Sometimes that means an emergency department, sometimes it means an urgent care clinic, and sometimes it means a primary health clinic.”
In other words, it’s important to triage a patient, and know what their need is and then send them to the right place. “As urgent care centres pop up that may often be the right place, but as an emerging stream, and we react to what the market offers,” Dr Khemka noted.
And the market is changing, with different kinds of primary care models emerging. Recently Aetna merged with CVS Health to transform its 10,000 drugstores into community-based healthcare hubs. These so-called ‘minute clinics’ enable patients to access blood tests or help manage a chronic disease like diabetes. These are not urgent care clinics, but they may be able to triage patients if they require urgent care or emergency help.
The need to keep rising healthcare costs down across the US and Europe has influenced the move towards urgent care. Take the UK, where publicly funded urgent care centres are a key part of the NHS. Today, many cases that would have gone to hospitals are being driven towards lower acuity settings staffed by fewer doctors and more experienced nurses. It’s a lower-cost model that’s since been adopted from France to Germany and Spain, Dr Khemka said. It’s also being copied by the private sector. “Now the private providers are also providing urgent care centres in the big cities where metropolitan urban-dwelling people are time poor and cash rich,” explained Dr Khemka.
Interestingly, Eastern Europe has always operated along these lines. “I think there is a lot we can learn from Poland and Slovakia, which have always operated a primary care and urgent care environment,” Dr Khemka said. “The general population tends to go to those places before they go to an emergency department.” And in those countries, there are both public and private providers.
But interestingly, Dr Khemka said Aetna has not experienced a noticeable spike in the numbers of urgent care providers offering services worldwide. “We have seen minor activity, but only spikes within certain countries and in certain metropolitan areas,” he said. “They haven’t made a dent in the market.”
In terms of what insurers look for in urgent care centres, Dr Khemka says that Aetna looks for several attributes. Firstly, it must be assured that facilities provide a quality service. “It’s not just about reputation but measurement – we look at processes, value and outcomes and to assess those, they need to supply us with data,” he said. So, for example, urgent care centres must share their outcomes, whether patients have had a good experience, as well as data on complications and things that went wrong.
Secondly, insurers look for evidence that customers are receiving appropriate healthcare; and thirdly, they prefer contracts with providers that have a number of different centres, a central governing body and geographical reach rather than standalone mom-and-pop centres.
Finally, healthcare services must be based on a fair price. “That’s not to say that we will say no to higher cost care. If expensive centres can prove they have better outcomes then we will reimburse,” Dr Khemka said.
It’s also becoming more widely recognised that urgent care centres play an integral role in the health care delivery system
Seven Corners’ Commander said that, at least in the US, preference is given to facilities accredited by organisations such as the Urgent Care Accreditation of America, Accreditation Association for Ambulatory Health Care or Joint Commission. It also looks for in-network facilities rather than those out-of-network. It assesses available services, including laboratory, diagnostic imaging, telemedicine, and occupational medicine too. Importantly, said Commander, it looks for hospital affiliation. “That provides continuity of care, a smoother transition for patient, and reduces duplication of costs,” she said.
Proximity to higher acuity care is crucial, agreed HCA’s Coombs. HCA’s urgent care centres are attached to its hospitals, so patients who need to be referred along a more serious medical pathway – which is about 15 per cent of cases – can do so easily. “We are not patching them up. They may need further treatment in our hospitals,” he added. “Patients find it reassuring. They are expecting rapid access to care, but they want the medical infrastructure behind it, if they need it,” he said.
The models for urgent care are legion, so are the players. It’s an evolving model, said MedExpress’s Hatcher. “It’s also becoming more widely recognised that urgent care centres play an integral role in the healthcare delivery system,” he concluded. ■