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
- Convenience
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.
Cervantes
Yes, obviously people can’t be expected to know whether their chest pain (or whatever) really is an emergency until they go and get it checked out. Campaigns to discourage unnecessary ED use risk killing people. However, I don’t see why you can’t triage at intake and have co-located urgent care available. Might save a few bucks anyway.
ChrisS
So last month, I started feeling a bit of a cold coming on, not much, just my sinuses felt … slightly inflamed. This was monday night. Tuesday AM, I had a slightly sore throat. Tuesday afternoon, it was very sore, had an earache, and it hurt to talk a lot ( no more zoom meetings). Tuesday night, I took nyquil at bed time. Wednesday AM, it was awful. I called my PCP and they wouldn’t let me come in (COVID risk). I had a telehealth visit. The PA recommended antibiotics as it was likely strep or similar. By wednesday night I couldn’t swallow the antibiotic and even water was difficult. Off to urgent care, where the Dr said he thought was an abcess and I would need the ER. Off to the ER. I was finally treated at midnight with IV steroids and ABs. A pile of tests, including COVID, and a CT scan later, they couldn’t ID anything and by Thursday AM, I was feeling better, discharged at noon, and by Friday I was pretty much fine – just no voice.
Alex
Something that’s helped our family avoid several ED visits is the 24-hour triage line our pediatrician’s office has, staffed through their affiliation with a major teaching medical system. Kids always wait to get sick after office hours. So far we’ve avoided visits for flu (back when flu was still circulating, got Tamiflu started promptly and avoided a likely inpatient stay), bumped head (is the vomiting related, or was the kid carsick?), and bronchiolitis. Still had to go in for food impaction in the toddler’s esophagus, but 3 out of 4 isn’t bad! We also used a similar hotline during my high-risk pregnancies. Sometimes you just need to be able to talk to a medical professional to even know if it’s a serious problem.
I don’t know what it costs to have nurses answering calls and on-call docs responding as necessary, but it seems like you could serve a lot of patients for pretty low additional cost to the medical system.
Rick
@Cervantes: There’s only one reason why hospitals can’t or won’t do exactly what you stated: MONEY. They want the ER rate for primary care visits, not the reverse.
And hospitals won’t do the right thing unless a payor makes them do it.
jonas
I was last in an ER about two years ago with my daughter after a minor fender bender accident to get her neck checked out for possible whiplash. It wasn’t too busy, and I could watch the walk-up check-in window from where I was sitting and the people coming in were complaining about little routine things — sore throat, fever, stomach ache. One lady thought she was having an asthma attack, so that was legit. But mostly just basic dr. office stuff. I was expecting that the nurse would be like “you really should call your pcp or go to the urgent care clinic down the road.” But they all got a little id bracelet and were told to sit and wait to be called, of course. No triage, no nothing.
Fraud Guy
I find it surreal talking about PCP taking a day or so. Our PCP appointments must usually booked weeks in advance, and requesting any visit in less than a week normally results in being referred to the Urgent Care associated with their practice group, and they will “get updated” by the UC information. I would say this has been the standard for our PCPs going back at least several years. It has gotten to the point that I don’t really have a PCP anymore, since most issues are dealt with with the UC visit and followup visits to the PCP are long after and redundant.
Ohio Mom
Yeah, when I was a new mom, sometimes all I needed was a quick phone consult with the pediatrician’s office. I called the 800 poison control people a couple of times too, when Ohio Son was a toddler and did things like sample hand cream.
But at this stage of incipient old-geezerhood, the once-every few years off-hours to our long-standing PCPs with questions about sudden, weird symptoms is often answered with, Go to the ER.
That’s partly because we can do our own triage at this point in life, and have a sense about what might be, as doctors put it, concerning. Luckily, most of the time, they’ve been false alarms for us.
I’ll add that it helps to live in the suburbs because the nearby emergency rooms have never been overcrowded when we’ve visited.
StringOnAStick
At around the same time as the ACA becoming law, there was a sudden building boom in the Denver area of UC centres that were also independently located ED’s. One that landed in our old neighbourhood was sold as a triage location where patients who truly needed a hospital would immediately be sent to the top level trauma hospital 3 miles away.
A few years ago a bad oyster likely gave me a virus and overnight I was sure my brain was going to explode, on a weekend of course. We went to the neighbourhood UC/ER. The drug they wanted to give me had to go through an IV they said, which immediately upcoded the visit from UC to ED, and to $6,000. A couple of years ago this whole “starts out as UC but upcodes to ER” practice had gotten so egregious that the state legislature got involved to rein it in. Looks to me like the combo UC/ED building boom happened because the hospitals saw a huge loophole to exploit and jumped in with both feet.
WhatsMyNym
If you build it, they shall come. There’s just a lack of health care in many parts of the country. PCPs are overbooked and EDs understaffed. Urgent care in its many forms is filling the void.
jl
Looking at risk prospectively, more use of urgent care would seem to just blend the function of ED and urgent care. Probably lower fixed costs to urgent care because they don’t need to have a bunch of very fancy equipment for situations where quick action is necessary to avoid a disaster. Maybe a person with vague stroke symptoms, that could be a stroke or maybe not, is an example.
It would seem ACA would understand the issue of a high fixed cost department where marginal and average cost pricing can diverge, so maybe they understand something I don’t, either on real cost accounting or rent seeking end.
How close are most urgent care facilities to an ED? Might be important for adding another layer of triage on who needs high cost intensive care in ED or hospital.
Obviously, a lot I don’t understand about this issue.
Suzanne
@jonas:
Legally, they cannot do that. If you present with an issue, they have to see you. And if they miss something in a brief triage and you happen to be sicker or more injured than you thought, they would be liable AF.
kmax
In my case urgent care gets me same day service and the alternative is usually at least a one to two week wait for my PCP or her NP. So it is a vital service regardless of cost.
CAM-WA
@StringOnAStick: Ha! And I thought, naïvely, that combining an ED and a UC in the same space was a way to keep costs DOWN, by allowing lower acuity patients to be sent to the UC after triage.
WhatsMyNym
Our county hospital has a walk-in clinic next to the ER. Currently only open until 7pm.
Barbara
@Rick: It’s even worse than that because hospitals try to use the fact that they maintain an emergency department to raise rates on every other kind of service. Even as they charge an arm and a leg to visit the ED for the same reason. Sort of like the “house always wins,” except for health care.
So as a consumer, do what’s most convenient for you and let Medicare and payers figure out how to optimize policy to deal with the resulting costs. My own MO, honed from long practice by my parents, is to wait and wait and when it doesn’t get better, to go to either the ED, urgent care, or the PCP, depending on the timing and perceived complexity of the need. My husband fell down our basement steps on a Saturday evening and when he was still in acute pain on Sunday morning we went to the ED, and I don’t think waiting another day for a referral from the PCP would have been wise. OTOH, when I kept having tightness in my chest on a Monday morning, I called the PCP and they made time for me right away.
But it’s well-known that many people wait until after work and then visit EDs, suggesting that convenience and/or lost pay is a big issue in determining choice of care. Having no PCP is also a big factor, which is really what urgent care centers are intended to address, though nobody says that out loud.
Suzanne
@CAM-WA: Legally, you cannot be turned away from an ED due to EMTALA. Once you walk in the door and before you are triaged, you have been considered to have “presented yourself” and they CANNOT then send you to a UC. Triage can’t tell what’s really wrong with you, either, it’s just to help them figure out in what order to see people. So the idea that they would triage a patient and then say, “Aw, you probably don’t need to be here.” is not because they’re trying to take your money.
Barbara
@Suzanne: Yes, that’s true, EMTALA influences site of but reimbursement does indeed influence a lot of issues around ED organization and policies.
Another Scott
Paywall. :-(
I wonder if they tried to control for things like hospitals closing. I could envision a situation where ED usage went down and UC went up a lot as a direct consequence of the local hospital or two closing. So the “national managed care” company would see UC costs shooting up while ED costs fell, but for reasons that shouldn’t impact the decision of whether UC is a good idea.
I think that national data, and controlling for things like access to hospitals and transportation and hours and UC visits that turned into ED visits and so forth, is needed before concluding that UC is somehow too expensive compared to ED. And that’s before one considers real opportunity costs (like your prospective 5 hour wait).
Thanks.
Cheers,
Scott.
L85NJGT
There are different levels of urgent care. The top level is the functional equivalent of a stand alone emergency department. High skill staffing, expensive equipment…. how that was supposed to come in at a meaningful lower cost per patient idk.
It would be interesting to see the relative daily and weekly patient demand and staffing needs. I’d hazard a guess ER demand runs closer to full capacity over a longer period of the day and week.
Martin
The nearest urgent care for my HMO is about 8 miles away. Not terrible. But thy built a shiny new hospital with ER a mile from my house. Very nice. During construction they opened part of the building (it’s basically 2 connected buildings, and they completed and opened the side with the less involved engineering first) and had an urgent care there as the ER was another year out from completion. It was great. I’m a big fan of urgent care as I feel compelled to visit one several times a year. But when they finished the other side of the building they removed the urgent care, which I thought was dumb since even I, who is unusually aware of the societal cost of things and seeks to avoid adding to existing problems, could feel the tug of an easy access ER over a less convenient urgent care.
We asked around a bit, and while we didn’t get an authoritative answer, what we got was essentially Suzanne’s explanation. It would be impossible for them to make the urgent care work with the ER there. At a minimum, the site is engineered to steer everything toward the ER, so a significant fraction of patients that were headed for urgent care would either stop at the ER for directions because it’s always the most prominent point of entry, or they would stop to ask ‘should I take this to urgent care’ and now the ER has to take them. Their conclusion is that the two need to be sufficiently inconvenient to each other to work. Not necessarily 7 miles inconvenient, but probably ‘up the block’ inconvenient.
It’d be nice if they could change the law to allow for a dual-track. You have to take the patient, but you can steer them to UC or ER. I’m skeptical that would work though given the patient dumping issue here in CA recently where Nevada hospitals were putting uninsured patients on buses and dropping them off outside CA hospitals. That’s going to have to wait until single payer.
Procopius
One of the things that infuriates me about our “health care” system was the way high deductibles and co-pays were sold as ways to use the “magic of the market” to reduce medical costs, as though all people had to do was make better choices. A wonderful explanation of what happened to bring us here (the mechanics, not so much the underlying evil) is a blog series called The Beer Game. It’s a five part series, but you’ll be able to get the general idea from the first part. There are organizational changes we have made over the decades to try to fix the health care system. You ever stop and wonder why we have to have highly paid coders processing the bills? The series explains how so many good intentions paved the road to where we are now.
Art
I suspect that the effect seen is a result of the fact that ERs generally suck as a patient/ care giver experience.
The ER experience is physically and emotionally draining with people waiting for often twelve hours or more in cramped, packed and poorly ventilated waiting rooms with people who are in pain and are miserable. Often puking or bleeding and/or cussing. ER visits are right up there with root canals and IRS audits for comfort and fun.
So it figures people would steer clear of an ER. Fact is most people would rather take a beating than go to most ERs. I’ve stitched my own lacerations to avoid the ER.
OTOH the urgent care center, based upon my experience are, spacious, well ventilated, uncrowded, and I’ve got in and out in less than two hours. So sure, I go to the UC more. The physical and emotional cost of getting treatment is lower.
The fact that the system can be manipulated to limit the number of people asking for care is not new. If they lopped off a finger every time you went to the ER few people would go. Free champagne and back massages are going to increase usage. The bigger question is: How sick or damaged do people have to be to get treatment?
ERs set that bar fairly high. UC centers set that bar significantly lower. The statistics and costs all flow from this difference.