When a heavy metal door swung over her 14-year-old son's foot, ripping the nail almost completely off his big toe, Tina Mobley didn't want to take her chances in a crowded hospital emergency room or wait for an appointment at the pediatrician's office the next day. Instead, she drove to an urgent-care clinic inside a Wal-Mart in Yulee, Fla., near her rural home. Within minutes, the doctor on duty numbed the pain with an injection, removed the nail, and cleaned and bandaged the injury.Patients who need immediate care for injuries and illness, be it a nail-gun puncture or a severe stomach bug, are increasingly turning to walk-in urgent-care clinics. These facilities aim to fill the gap between the growing shortage of primary-care doctors and a shrinking number of already-crowded hospital emergency departments, with no appointment necessary and extended evening and weekend hours. Urgent-care clinics are staffed by physicians, offer wait times as little as a few minutes and charge $60 to $200 depending on the procedure -- a fraction of the typical $1,000-plus emergency department visit. Some offer discounts and payment plans for the uninsured; for those with coverage, co-payments vary by insurance plan but may be less than half the amount of an ER visit, which can range from $50 to $200.
While the Yulee clinic that treated Ms. Mobley's son is one of three operated inside Wal-Mart stores by Jacksonville, Fla.-based Solantic, urgent-care centers aren't to be confused with the new crop of retail health clinics popping up in drugstores, which are run by nurse practitioners who prescribe medicine for minor illnesses and provide vaccinations. Urgent-care-center physicians and other medical staffers can put casts on broken bones, sew up lacerations, provide intravenous fluids for dehydrated patients, and deploy advanced life-support equipment for both adults and children. They often have equipment not available in physicians' offices, such as X-rays.
There are currently more than 8,000 urgent-care centers around the country, including about 1,200 affiliated with hospitals, and that number is expected to expand. By contrast, between 1995 and 2005, the number of emergency departments decreased to 3,795 from 4,176, while the annual number of visits to ERs rose by 20% to 115.3 million, according to the most recent data from the Centers for Disease Control and Prevention.
Voluntary Accreditation
But as the number of urgent-care clinics has grown, so have concerns about their quality and safety, as well questions about the risks of patients substituting urgent-care centers for an ongoing relationship with a primary-care doctor who coordinates care and follows them over time. While physicians who work at clinics must be licensed like any other doctor, clinics aren't typically licensed or regulated by states and can vary widely in the services, hours, staffing and equipment they offer. Some have undergone voluntary accreditation programs to evaluate quality and safety, but no national standards exist to determine the range of services an urgent-care clinic should offer or the steps they should take to ensure safe, high-quality care.
Recently, the Urgent Care Association of America, a trade group representing 3,141 urgent-care professionals, struck an agreement with the Joint Commission, the non-profit group that accredits hospitals and other health-care organizations, to take over accreditation and publish national quality standards by 2010. Lou Ellen Horwitz, executive director of the association, says the aim is both to avoid future regulation and to establish guidelines that can help patients and health plans evaluate urgent-care centers. She also stresses that patients should always have a relationship with a primary-care doctor and use urgent-care clinics when they can't get an appointment during office hours.
Some urgent-care clinics say they don't see the need to pay the thousands of dollars the accreditation process can cost. But a standard accreditation program developed by the Joint Commission could make it easier for urgent-care clinics to strike better deals with insurance companies and health plans. Though insurers are increasingly including clinics in their networks because of the cost savings, they tend to reimburse the clinics at lower rates than urgent-care clinics say they need to cover costs of longer hours, larger staffs and expensive equipment.
"We'd look far more favorably at an urgent-care clinic that was accredited than one that wasn't," says Troy Brennan, chief medical officer at insurer Aetna. By undergoing the rigors of an evaluation, "it means an organization is taking a hard look at a variety of safety issues that should be involved in caring for someone who is acutely ill," he notes. While Aetna says patients shouldn't seek treatment in an urgent-care facility if their condition requires emergency services, and encourages them to call their doctor first, "if it is a good high-quality urgent-care center that can keep someone out of the emergency department who doesn't need to be there, that is a good thing."
Efforts are now under way by members of the urgent-care trade association to develop urgent care as a recognized subspecialty of family practice or emergency medicine. Several teaching hospitals are now offering post-graduate fellowships in urgent care to medical interns, and two medical journals are dedicated to urgent-care issues. The Orlando-based American Board of Urgent Care offers to certify physicians in urgent care for a fee, but it isn't formally recognized by the American Board of Medical Specialties.
Avoiding the Wait
Urgent-care centers first appeared about 20 years ago, but didn't catch on widely among consumers, who preferred to see their own doctor or seek care in a hospital ER. But the industry began resurging in the mid-1990s, and demand has increased in recent years as more consumers experience long waits in the emergency room, or wait weeks to get an appointment with their own doctor, says Robin Weinick, a researcher at Massachusetts General Hospital's Institute for Health Policy.
Urgent-care centers have most frequently chosen busy intersections or strip malls, but they are also opening in rural areas with few other medical providers. In addition to chains such as Solantic and Mesa, Ariz.-based NextCare Inc. clinics are being opened by physicians and hospitals looking to expand their business or ease crowding in their own ERs. Of the 115.3 million emergency-room visits in 2005, according to the CDC, only 5.5% needed to be seen immediately, with 9.8% triaged as needing to be seen within 14 minutes, 33% within 15 minutes to an hour, and 21% as "semi-urgent," needing to be seen one to two hours. About 14% were evaluated as "non-urgent," meaning they could be treated in anywhere from two to 24 hours.
But Linda Lawrence, president of the American College of Emergency Physicians, says the majority of patients who show up in the ER belong there until their conditions can be evaluated. Overcrowding, she says, is due to hospitals' practice of "boarding" patients for hours or days in the ER when they should be admitted to the hospital -- a problem urgent-care clinics won't solve. "One of our concerns that people can't recognize when they have an emergency or don't," says Dr. Lawrence. "A patient who says they are having indigestion and goes to an urgent-care clinic may really be having a heart attack."
"We don't encourage patients with chest pain to go to urgent-care centers, but the reality is that we need to be prepared for anything that walks through our doors," says Lee Resnick, president of the urgent-care association and director of University Hospitals Urgent Care, a five-clinic urgent-care group in suburban Cleveland. The clinics are affiliated with University Hospitals Case Medical Center. In many cases, Dr. Resnick says, urgent-care clinics diagnose more serious illnesses like cancer for patients who come in for a seemingly lesser complaint, and recognize heart attacks or strokes in time to get patients by ambulance to an ER, where they can be fast-tracked through the admission process.
Transfer to Hospital
Recently, for example, 24-year-old Carly Solomon arrived at one of Dr. Resnick's clinics with a pounding headache, dizziness, nausea and blurred vision. Julie Keller, the physician on duty, determined her condition was more serious than a bad migraine; though the clinic had the equipment to do a brain scan, she summoned an ambulance. By the time it arrived, Ms. Solomon had begun having seizures, the beginning of a blood clot in the cavity at the base of her brain that resulted in a nine-day hospitalization. Ms. Solomon says she was impressed by how quickly she was seen and transferred to the hospital, and with Dr. Keller, who later went to check on her in the intensive-care unit.
Stephen Kovacs, the medical director and co-owner of Urgent Care of Green County, with several clinics in Owasso, Claremore and Bixby, Okla., urges patients to "research a facility first to be sure they are going to be seen by a physician and that the facility will be able to provide all of the necessary services that might be required," such as X-rays, scans, intravenous fluids for dehydrated patients and advanced life-support equipment. His clinics also work closely with patients' primary-care physicians, sending records from urgent-care visits and coordinating care with specialists in the area.
Some patients use the urgent care centers often enough to strike up a long-term relationship. Shelly Rogers says Dr. Kovacs has treated her kids for accidental burns and broken bones, and diagnosed her husband Doug's sore throat as a benign cyst on his thyroid. After he cared for her during several episodes related to her own complicated medical history, Ms. Rogers has started to think of him as her personal physician. At times when both spouses were out of work or had trouble getting insurance to cover treatment, Dr. Kovacs didn't charge them for care, or helped them set up a payment plan. "They really get to know you, and they pay attention," she says.
By: Laura Landro
Wall Street Journal; August 6, 2008
