Should more people be using urgent care?

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Is increased consumption of urgent care services a bad thing?

A few papers have been coming out recently which have a similar general theme: by lowering the barriers to entry for people to get healthcare via telemedicine and in-person urgent care, we’re actually increasing healthcare spending.

• Direct-To-Consumer Telemedicine Visits For Acute Respiratory Infections Linked To More Downstream Visits - 
  

“Comparing downstream care utilization data from a large, commercial payer for the period 2016–19, we found that patients with initial visits for acute respiratory infection were more likely to obtain follow-up care within seven days after direct-to-consumer telemedicine visits (10.3 percent) than after in-person visits (5.9 percent). In both settings approximately 90 percent of patients did not obtain additional care. The telemedicine cohort had fewer (0.5 percent versus 0.6 percent) emergency department visits—a small but statistically significant difference—but more subsequent office, urgent care, and telemedicine visits. Our findings suggest that potential savings from shifting initial care to a direct-to-consumer telemedicine setting should be balanced against the potential for higher spending on downstream care.”

• Do Urgent Care Centers Reduce Medicare Spending?
  

“We explore mechanisms by looking at categories of spending and by examining utilization. Increases in inpatient visits are the largest contributor to the overall increase in spending, rising by 6.65 percent within six years after Urgent Care Center (UCC) entry. The number of emergency room visits that result in a hospital admission also increases by 3.7 percent. In contrast, there is no change in the number of ER visits that do not result in admission to hospital, in visits to physicians outside a UCC, or in imaging and tests. Overall, these results provide little evidence that UCCs replace costly ER visits or that they crowd out visits to patients' regular doctors. Instead, the evidence is consistent with the possibility that UCCs—which are increasingly owned by or contract with hospital systems—induce greater spending on hospital care”

• Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending
  

“Using 2008–19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. 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.”

This has led quite a few people to comment on Twitter and in various op-eds that urgent care is not good, actually. Everyone cheers, the applause is deafening.

There are some valid points here, but I always have a few issues with this strain of commentary and thought:

• I find it weird to frame this issue as “making urgent care easier to access yields higher downstream care” and not “ the current financial incentives in fee-for-service billing are so messed up that this is viewed as bad”. Across these papers, the theme seems more tied to the idea that large hospitals which are much more expensive have started acquiring patients at the top of the funnel who are consuming more healthcare services and referring them to expensive hospital services they own. This is a hospital pricing and business model problem for me. 

• Almost all of these studies rely on claims data, which only further exacerbates point #1 since basically all of those are going to be from fee-for-service visits. This also reflects the issue that most of these studies only follow patients that get follow-up care because it gets reflected in claims, but what about the people that avoided the ER in the first place because they went to urgent care? I wonder how this compares to companies in value-based care arrangements like capitation.

• As far as I can tell, these studies haven’t examined if NET NEW patients are consuming urgent care services. If someone that hasn’t seen a physician in 3 years is now accessing primary care services through urgent care or telemedicine, is that not a good thing?
• I also don’t think the real benefits of this increased urgent care use are about the immediate increased downstream consumption of additional healthcare services, but should look at whether spend for a given patient increases in general over a longer period of time. If increased urgent care ended up avoiding way more expensive diseases that might develop 10+ years from now, wouldn’t that be worth it?
• In many of these studies it looks like patients are going to telemedicine or urgent care first to assess an issue, which actually seems like a good thing to me. It means triaging severity is working. If people are going to the urgent care center more often than the ED, that’s a good thing IMO.

• In the urgent care telemedicine studies the issue is usually around redundant care where a patient starts a telemedicine flow but has something that can’t be done over telemedicine, and then goes somewhere in-person and does the whole thing from the start. This is definitely an issue but is more about how the online-offline handoff needs to be a more continuous episode of care for telemedicine companies (which is slowly happening).
  

I’m actually in the camp that we should want to increase consumption of primary care services as much as possible, and for a lot of people, urgent care represents their first point of contact with the healthcare system. 

I think the fact that patients are coming to urgent care for a specific need + purpose represents a great way to convert patients into more long term primary care services that serve a less immediate need for the patient. Ideally, the patient is introduced to a team (physicians + NPs + nurses + social workers, etc.) for the longer term issues that might require proactive outreach from the team vs. being patient-initiated. This study suggests that more than 1/3rd of people that go to urgent care services have no primary care physician relationship, which seems like an opportunity. This also generally seems to be the bet that Teladoc-Livongo are making. 

Urgent care is not without its own issues, especially the high level of variance around quality of care between places (e.g. unnecessary antibiotic prescriptions in some cases) and that it can contribute to more care fragmentation issues. 

But I think we have to incentivize more consumption of urgent care services in tandem with the following:

• Monitoring and penalizing the excessive use of unnecessary prescriptions and low-value tests which are likely to lead to downstream unnecessary care.
• Creating more value-based care contracts where urgent care teams benefit financially from coordinating downstream care like Direct Contracting. This might incentivize them to actually hand patients off to a primary care team for longer episode issues.
• General interoperability stuff so that data from urgent care episodes easily travels with your record as you see other physicians. It won’t fix the care fragmentation issue but it might fix the data fragmentation part.
  

It’s possible that this still ends up increasing costs due to simply finding more health problems in people that see physicians more regularly, which maybe yields downstream care that wouldn’t have happened otherwise. But I would bet that it would still be net worthwhile from a cost perspective and from increasing touchpoints with patients that need primary care services broadly. In an ideal world urgent care can be used to create a longer patient relationship with longer-term goals.

On a personal level, urgent care has been a Godsend for me. Trying to see my PCP takes 1 week or more, and in many cases, I just need a test, labs, or asking “am I going to die”. Urgent care has been very helpful here. 

Curious to hear others’ thoughts on these studies or the increased consumption of urgent care services broadly.

Thinkboi out,

Nikhil aka. "CityMD frequent flier"

Twitter: @nikillinit
IG: @outofpockethealth

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