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Urgent Care & Managed Care: A Popular Source of Low-Cost Care

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By Dave Muoio

Although the past few decades have seen a steady rise in popularity of walk-in clinics, the industry’s growth appears to be accelerating. 

Currently, there are nearly 7100 urgent care clinics verified by the Urgent Care Association of America (UCAOA) as capable of providing full-service, walk-in care, which includes x-ray, suturing, and episodic care. According to the organization, approximately 300 new urgent care centers opened per year from 2008 to 2011, and since 2012 appear to be growing at a rate of 600 centers annually. Meanwhile, the number of retail clinics—walk-in clinics often found in pharmacies, supermarkets, or other retail stores—operating in the United States rose 900% between 2006 and 2014 from 200 locations to 1800 locations, while the number of visits increased from approximately 1.5 million in 2006 to 10.5 million in 2012, according to a 2015 report from Manatt Health.

“There’s a market that’s not being tapped, except by these clinics,” Thomas Morrow, MD, chief medical officer of Next IT and member of the First Report Managed Care Editorial Advisory Board, said in an interview. “They’re meeting an unmet need in a transparent manner for a subset of common conditions. They’re profitable to the provider, and they’re convenient, affordable, and accessible to the patient.”

As more patients are choosing walk-in clinics over primary or emergency care for episodic illness and minor injury, Laurel Stoimenoff, PT, CHC, chair of the UCAOA Health and Public Policy Committee, noted that both providers and payers have come to appreciate the advantages offered by these facilities. 

“For the most part, managed care plans perceive the value of what urgent care can provide, and it historically has been a good relationship,” Ms Stoimenoff said in an interview. “Your standard commercial payer still is the biggest percentage of what is typically seen in an urgent care center… they are very important to the urgent care center, and I think the commercial payers tend to perceive the urgent care as being important to them as well.”

 

Reduced costs for comparable care

In a 2013 study published in the American Journal of Managed Care, Andrew Sussman, MD, executive vice president and associate chief medical officer at CVS Health, and colleagues compared the annual cost of care between CVS Caremark employees who visited the retail pharmacy’s MinuteClinic to those who sought treatment elsewhere. The researchers found that employees who visited the retail clinic lowered their total cost of care by an average $262 (95% CI, –$510 to –$31), primarily due to fewer expenses at physicians’ offices and hospitals’ inpatient departments. One year later, another study conducted by William H Shrank, MD, MSHS, chief medical officer for UPMC Health Plan, and colleagues comparing 20,153 episodes of care on at least one of 14 quality measures found that treatment in retail clinics was comparable and, for specific acute conditions, superior to that provided by ambulatory care facilities or emergency departments. 

“Within their capabilities, [walk-in clinics] do a pretty good job, and if I go to a physician to do the same exact thing that can be done in one of these walk-in clinics, it’s going to cost a lot more,” Dr Morrow said. “It’s a lower cost alternative, and it’s kind of like the difference of getting a brand-name can of beans versus a fake brand-name can of beans; for most people, it’s perceived to be an equivalent product.”

Alongside reduced cost, walk-in clinics also have another clear advantage over the primary and emergency setting: transparency. Vague price points and unexpected follow-up charges often drive those living paycheck-to-paycheck from seeking medical care, regardless of their current coverage, Dr Morrow explained. 

“I have no idea what it’s going to cost to walk into my doctor’s office—none whatsoever,” he said. “But if I went to Walgreens’ clinic, for example, I know it’s going to be $50, and if you want a strep test or whatever it’s going to be another $10. I know what my liability is regardless of what my insurance coverage is, or where I am in the calendar year.” 

Dr Morrow also noted that patients are not the only ones to benefit from retail and urgent care clinics. Assuming that the clinic is appropriately processing their services, payers have just as much to gain from cheap, quality care with no strings attached. 

“From a managed care perspective, these clinics are a godsend,” Dr Morrow said. “If I contract with them, I know what the cost is going to be to me, and the patients know what the max cost is, if it’s still out of their pocketbook because they haven’t met deductibles. Everybody wins in that situation—except maybe the doctors that may lose some of their lower-intensity care.”

 

Service limitations and other obstacles

Because retail clinics and urgent cares are primarily staffed by nurse practitioners and have limited equipment on-site, these facilities are occasionally forced to turn away those seeking care. Although Ms Stoimenoff noted that only one in 50 patients visiting an urgent care is redirected to the emergency department (ED), Dr Morrow argued that reduced capacity and expertise remain a “big limitation” for both settings. 

“[Retail clinics] are not going to take care of most lacerations unless you go to an urgent care center, and even there there’s a high variability of what they’ll actually take care of,” he said. “They’re a mid-level provider, so they’re not going to make complex diagnoses. They’ll send you back to your primary care or a specialist to get that.”

Cooperation between some walk-in clinics and physician practices can also be limited by poor communication, Dr Morrow continued, particularly when dealing with patient data transfers.

“If I’m a physician with Walgreens’ clinic right next door, I have no idea what’s going on there unless they somehow integrate with me, and that’s probably going to be a piece of paper they mail me,” he said. “They may have other programs in place that may integrate, but the reality is that they don’t have very good ones, in most cases.”

Some experts have also raised concerns over retail and walk-in clinics’ impact on patient access and expenses. In a 2013 article published in the Harvard Business Review, Jason Hwang, MD, MBA, chief medical officer at Icebreaker Health, and Ateev Mehrotra, MD, associate professor in the department of health care policy at Harvard Medical School, wrote that due to “antiquated payment models,” the convenience of retail clinics has passed over by poorer demographics “who paradoxically continue to rely on costlier sources of care such as EDs.” More recently, an analysis of insurance claims data published by Dr Mehrotra and colleagues earlier this year found that 58% of retail clinic patients with low-acuity conditions would not have sought care if not for the availability of convenient treatment, and by doing so increased their annual medical spending for such conditions by 21%.

“These findings suggest retail clinics do not trim medical spending, but instead may drive it up modestly because they encourage people to use more medical services,” Dr Mehrotra stated in a press release. “If the goal is to lower costs, then encouraging use of retail clinics may not be a successful strategy.”

 

A “satellite to the medical home”

Regardless of these concerns, both Dr Morrow and Ms Stoimenoff asserted that the walk-in clinic is uniquely situated to support more traditional primary care providers. Along with providing a cheaper alternative for geographically displaced patients or those in need of after-hours care, Ms Stoimenoff discussed the walk-in clinics’ role in engaging patients outside of the medical home.

“There are still a substantial number of patients that are using the much more expensive ED as their primary care provider,” Ms Stoimenoff said. “There’s that opportunity to be that link [and] assign those patients who really do need a primary care doctor to a primary care practice.”

As a “satellite to the medical home,” clinics are already in a position to support patients receiving regular care for chronic illnesses by treating their episodic illnesses, Ms Stoimenoff said, thereby allowing primary care to “treat the 10% of patients costing 80% of the dollars.” However, she also argued that many urgent cares have the resources and expertise to provide services focused on long-term care. 

“The urgent care is kind of pigeon holed into episodic illness and injury… and that’s the only thing [insurance or managed care] is going to pay for when someone comes in,” Ms Stoimenoff said. “Let’s compensate them to help with some of our wellness programs and that kind of thing. I think there are opportunities, because we are open typically evenings and weekends, to create better accessibility for wellness programs that are oftentimes [left out] of what we are perceived as being able to deliver.”

Preventative and wellness services such as these are already being investigated in the retail space. During a presentation given at Patient-Centered Diabetes Care 2016 meeting, Eileen Myers, MPH, RDN, and Cathleen McKnight, DNP, both of The Little Clinic, discussed how dietitians stationed in their retail clinics could identify undiagnosed cases of diabetes, and link those patients to regular medical care while supplying diabetes-specific nutritional support. 

But if more walk-in clinics are to expand their capacity to include satellite care for diabetes or other chronic conditions, Ms Stoimenoff said it will be crucial for payers to consider urgent cares and other clinics for the provision of select wellness and screening services, and to maintain open lines of bidirectional communication with interested centers.  

“We can be such a good part of the solution in terms of managing patients, because access to same-day care really can be a beautiful thing,” she said. “There are innovations that could be used if we could just have more time to sit down at the table and speak with the managed care organizations. [These innovations] would help them, the patient, and the urgent care sector.” 

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