The Urgent Care Sector of Healthcare & Its Impact on Healthcare Reform

Cost, access and quality are all major subjects, as governments (local, state and federal alike) focus on new ways to affect “healthcare reform”.  What Congress has approved has absolutely nothing to do with healthcare reform. In order to have any meaningful reform of healthcare, the delivery process must be affected.  Expanding coverage to those that are uninsured is healthcare expansion…not reform. Merriam-Webster defines reform in two primary ways:

• to put or change into an improved form or condition
• to amend or improve by change of form or removal of faults or abuses.

Expanding coverage without addressing the infrastructure of our ineffective delivery system will not improve or correct the deficiencies, faults and abuses of the current system.

No doubt, hospitals will enjoy short term benefit from what Congress passed but the system that chews up dollars like they are breath mints has just latched onto a warehouse full of them.  Ironically, the same government that verbally abused the insurance payors for their failures in controlling healthcare costs just got a huge shot in the arm with this legislation.  Expanding coverage expands revenue opportunities for the payors and will clearly facilitate higher utilization that will make the hospitals happy…attendance in the winner’s circle, however, stops there.

The prevailing thought on Capitol Hill holds fast to some outdated and idealistic beliefs that hamper the correction of the real problems in healthcare and that are driving costs upward:

1. The passé belief in the concept of the “Medical Home”:  The phrase was introduced by the American Academy of Pediatrics in 1967 and in 2002 expanded and further refined the definition.  In 2002, seven U.S. national family medicine organizations created the Future of Family Medicine project to "transform and renew the specialty of family medicine." Among the recommendations of the project was that every American should have a "personal medical home" through which to receive his or her acute, chronic, and preventive services. The services should be "accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians." By 2005, the American College of Physicians had developed an "advanced medical home" model. The model involved the use of evidence-based medicine, clinical decision support tools, the Chronic Care Model, medical care plans, "enhanced and convenient" access to care, quantitative indicators of quality, health information technology, and feedback on performance. Payment reform was recognized as important to implement the model. In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association — the leading primary care physician organizations in the United States — released the "Joint Principles of the Patient-Centered Medical Home." In spite of all the emphasis on this concept, however, a survey of 3,535 U.S. adults released in 2007 found that 27% of the respondents reported having "four indicators of a medical home."

The principal, however, fails to take into consideration that approximately 16% of the U.S. population has a “significant” relocation each year.  Given this, the U.S. Population is statistically the most mobile of any on the face of the earth.  It is truly difficult to define a “medical home” given such a mobile society.  Additionally, the clogging of the “so-called” medical homes with patients with chronic conditions leaves the acute care customer with limited alternatives.

1. Failure to facilitate more cost effective access:  While holding fast to the idealistic view of the “Medical Home”, access is being compromised and patients are left to scamper about aimlessly to find a portal for acute care.  Emergency departments are overcrowded and costs are escalating, primary care physicians are stuck with an inappropriate mix of patients that clogs their offices and compromises access.  Insurance payors and the government have both struggled with payment rationales that direct patients to the most appropriate service line and create a fair and consistent delivery program that gets patients what they need when they need it.
2. Privacy at all costs:  Burdened by special interests, red ink, red tape and conflicting objectives, the Federal government has failed to establish a “blue print” that puts key players on the same page.  While other countries have established standards in electronic medical records that facilitate adaptation by providers and interconnectivity for better transparency and reporting, the U.S. took a different route.  We created the Health Insurance Portability and Accountability Act (HIPAA).  This legislation took a negative turn from its original beginnings when it was intended to facilitate that insurance coverage would remain portable as employees move from one company to another.  What we ended up with was an expensive and cumbersome process designed to protect patient privacy.  Privacy wasn’t a major concern until portability became a big topic.  This legislation stalled if not stopped providers from collaboration and created a mountain of expense that has resulted in sending the U.S. to the rear of the bus relative to medical information management.

The government’s role in healthcare reform is not to be the manager but to set policy by which managers operate.  Their failure to set policy that would drive the system in the right direction is monumental.  The government must refocus the country on the two things that are at the core of our problems: ACCESS and COST.

Patients have proven to be much more savvy and discriminating in finding solutions that meet their needs and physicians that have taken notice are following their lead.  The solution that both have concluded improves quality/access and cost for day to day medical needs/problems is urgent care medicine.

I have conducted research on over 300,000 urgent care encounters and have identified the top 100 diagnoses treated therein.  I compared this information to the “average U.S. hospital emergency department as identified by HCUP and found that 51 of the top 100 diagnoses treated in the average U.S. hospital E.D. were also represented in the data set from the urgent care population.  This study revealed that, for the majority of cases that are treated in the emergency department, treatment could be sought in the urgent care setting.  Additionally, the average cost for the hospital emergency department for those diagnoses was $576 compared to $162 for the very same diagnoses.  Of the 118 million patients treated in hospital emergency departments annually, 35 million are in this diagnoses range.  This means that if those cases were diverted to the urgent care setting instead of the hospital emergency department, the savings would be in excess of $14.5 billion per year.  Further, patient satisfaction with urgent care is clearly among the best in the industry at 96%.  This is largely due to the vastly lower wait times in urgent care than the hospital emergency department and the convenient treatment environment.

Hospitals are increasingly under pressure for volumes and their emergency departments are the “front door”.  Nearly 70% of the average hospital’s admissions come from their emergency department.  Hospitals actively monitor admission rates of patients to the hospital and have cultivated sophisticated data systems to facilitate higher admission rates from the E.R.  The expanded testing regiments that are used to facilitate this increase are expensive and time consuming.  Primary care physicians rarely manage their patients today with the development of “hospitalists” who assume management for inpatient care and then refer the patient back to the attending.  At no point in this process are there any financial incentives to manage the patient outside of the hospital or in a cost effective manner; on the contrary, they are financial incented to move patients into the hospital and to then quickly treat and discharge them.

Despite the growth of the urgent care sector, the development of organizations entirely focused on urgent care (the Urgent Care Association of America and the American Academy of Urgent Care Medicine), payors and government entities have failed to coordinate and better define the place of urgent care in the U.S. healthcare mix.  In states like Illinois, the term urgent care is specifically prohibited from use because of confusion as to the scope of services and capability. Providers in that state and all others like get around this by using alternative terms like “immediate care”, “express care”, etc.  This further confuses the market and compromises development.

While the politicians push to eliminate exclusions for pre-existing coverage, press for individual responsibility, the creation of accountable health networks and providing coverage for all….bright, qualified physicians are creating real success stories in the public arena that are not even being recognized.  Physicians bold enough to escape from the hospital emergency departments and strike out on their own to create a haven for the patients that want improved access, lower cost and better quality are being rewarded with success but rarely acknowledged as a fitting part of the puzzle that has become known as “healthcare reform”.
A recent PriceWaterhouseCoopers survey found that companies with slowed profit growth are more likely to offer "high deductible insurance plans" that provide no coverage for the first several thousand dollars of treatment. Another is a Kaiser Family Foundation study which showed that 36% of people nationally are skipping or delaying needed medical treatments because of cost.  Providing expanded access to urgent care center delivery improves the access and manageability of both these scenarios.

It is unlikely that our consensus-minded government will favor a look at urgent care outside of the broader discussion of healthcare, but it will most certainly be a force that will drive reform if it is not discussed at all because patients like it and it alters the delivery of acute care in this country in a thoughtful and cost effective way. The most important reason that it will be a factor is even simpler, however….the cost of doing it is being borne by physicians with the desire to be successful and different.  There is no substitute for American ingenuity in times of crisis and these well educated physician escapees from the hospital emergency departments are leading the way.

Smart hospital leaders are already embracing alternative delivery that places urgent care where it is most accessible and in conjunction with physician leaders that see its future clearly but others view urgent care as a competitor.

Coordination between hospitals and urgent care centers generally results in better options for patients and should always be encouraged but the provision of urgent care access will thrive even if hospitals fight any such cooperation…because patients like it.

The Federal Government must create a formal identity for urgent care in the delivery system and payors must work to direct patients that can be more efficiently and cost effectively treated in urgent care out of the hospital emergency departments and to the urgent care centers.  Qualifying standards for urgent care must be adopted by all states and coordinated by the federal government.

Banning the use of the term “Urgent Care” is clearly ducking the responsibility that government has to define the term that the consuming public so easily relates to.

Governmental expansion of insurance coverage is premature given the lacking coordination in the delivery system.  The frantic rush for consumers to consume as much as possible and providers to get what they can before the spending stops, will result in a catastrophe that we will be measuring in continued growth of healthcare costs as percentage of the GDP.

There are many things that must be addressed to reform healthcare but without addressing the inefficiencies of the delivery system we are just printing an old headline.  Some espouse that the U.S. healthcare system is the best and they may be correct but it is also the most expensive and growing faster than any other in the world.  For more information, please visit http://www.urgentcareamerica.net for more information.

About The Author

Mr. Barber is the founder and CEO of Urgent Care America, which provides management services to urgent care centers across the United States.  Prior to that he served as the Senior Vice President for Health Management Associates, Inc., (NYSE: HMA).  HMA is a leader in hospital management and operates 55 hospitals in 16 states. Mr. Barber has served as a hospital CEO in four different hospitals and has experience in both academic and proprietary ownership structures.  Mr. Barber has been a featured speaker for several organizations and has a vast amount of experience in physician practice management, urgent care management and hospital management.  Mr. Barber is well connected to physicians in many markets around the United States.   Other experience includes, the creation of a Risk Retention Group, development of a corporate-wide medical staff credentials program and the creation of a comprehensive CME and physician relations program designed to better connect hospitals with staff physicians and building physician networks.