Explore This Issue
January 2013When Peter Batra, MD, sees patients at his office at the University of Texas Southwestern Medical Center in Dallas, some of them have already tried to get medical treatment at urgent care facilities but didn’t find relief.
“A lot of patients are sent to me with chronic sinonasal issues, and many of them have sought care at urgent care facilities,” said Dr. Batra, the co-director of Southwestern’s Comprehensive Skull Base Program. “Patients with complex sinus issues may end up undertreated or treated inappropriately because the treating physician may not have the right diagnosis.”
He typically urges his patients to avoid seeking medical care at such facilities and notes that while urgent care centers can offer basic care for routine ear, nose and throat issues, otolaryngologists can better manage a complicated diagnosis. “For a more significant problem, we can do endoscopy,” he said. “It allows us to better guide their care. We also have the ability to get imaging, if needed, so we can get a diagnosis with a CT scan if necessary.”
But urgent care facilities, which feature walk-in medical care with extended hours, have their place and, quite frankly, are here to stay. In fact, their numbers are growing. According to the Urgent Care Association of America, there are more than 8,700 urgent care centers in the United States—up from about 8,000 in 2008. Designed to handle one-time illnesses or injuries, they are an alternative for patients who might otherwise head to a hospital’s emergency room for treatment or wait for an opening at a primary care physician’s office. For patients with routine otolaryngology issues such as ear infections, sinus problems, coughs, allergies or asthma, the convenience of a facility that’s open later than most doctor’s offices, that will see patients soon after they walk in the door and that are committed to shorter wait times than patients would find in a typical emergency room experience can’t be beat.
What’s also appealing is their potential to help curb health care spending. “It’s a cost-effective way to deliver care appropriately,” said Laurel Stoimenoff, the interim executive director and a member of the board of directors of the Urgent Care Association of America in Naperville, Ill. According to a 2009 Medical Expenditure Panel Survey by the Agency for Healthcare Research and Quality, the median cost of an emergency room visit was $615 and the mean cost was $1,318. The average cost of a visit at an urgent care center was $118 to $120, depending on regional nuances and other factors, said Stoimenoff.
Maximizing the Quality of Patient Care
For some patients, urgent care facilities are a great resource. “The benefit of urgent care is that it lends itself to ear, nose and throat problems such as ear infections or sinus problems,” said Subinoy Das, MD, director of the Ohio Statue University Sinus and Allergy Center in Columbus. “The more rapidly you see someone, the less likely it is that aggressive care will be needed.”
As with any service model, quality can range based on the provider. “Some urgent care physicians, or physician’s assistants, are fairly accurate with their diagnoses, and some are not; it depends on how well trained they are,” said G. Paul Doxey, MD, an otolaryngologist in private practice based in St. George, Utah. “It’s not all negative. Some are trained fairly well.”
The majority of urgent care centers, nearly 64 percent, are staffed with a mix of health care professionals: primary care physicians, nurse practitioners and physician assistants, according to the Urgent Care Association of America. In 65 percent of these facilities, at least one physician works on site the entire time the office is open.
Yet, some otolaryngologists worry about a lack of continuity when patients consistently choose an urgent care facility over a primary care physician or specialist. “I think [urgent care centers] contributed to ongoing fragmentation of care,” said Dr. Batra. “I think that’s true for any practice setting. I would be concerned if a doctor isn’t seeing a patient on a continued basis, because they might not know all the issues” involved with a patient’s background and history.
At many urgent care facilities, a nurse practitioner or a physician’s assistant is the front line of care, said Dr. Das. “They have to take care of so much of the body, and when caring [for] every kind of complaint, they might not catch the warning signs of a more severe problem.”
Most sinus problems are viral and resolve on their own, but approximately 10 to 15 percent are associated with a bacterial infection that can be accompanied by subtle signs that include facial swelling around the eye, forehead or cheek, or an intermittent fever. “If those signs are missed, that bacterial infection can become a life-threatening blood or brain infection,” he said.
Communication Is Key
Urgent care centers typically refer more complicated cases to specialists in the community, said Stoimenoff. “I think urgent care centers have been established to provide episodic care,” she said. “We need to remember that urgent care centers provide a great service to referring to specialists in the community, particularly with things like chronic allergies. It’s just like how a primary care physician would do it.”
Such referrals are important, particularly when there’s communication between the urgent care provider and a specialist. “Urgent care centers are not going to go away; we just have to work with them,” said Dr. Doxey, who worked in such a facility for about a year between his residency and internship in 1981 and 1982, and again for a three-year stint before opening his practice 28 years ago.
“We need to communicate with [the referring urgent care health care provider], particularly if they made a wrong diagnosis, and follow up,” he said. “Someone who refers patients to a specialist should always get a letter. Sometimes, I’ll even phone because of the seriousness of the situation. They are interested in follow-up because that’s how they get better—by learning what the accurate diagnosis is.”
Antibiotic Usage
There is concern over the potential for antibiotic overuse at urgent care facilities. “One of my concerns about physicians who work in an ambulatory setting that is controlled by a hospital setting is that the M.O. is volume, not quality,” said Gary H. Lambert, MD, an emergency medicine doctor employed by Utah Emergency Physicians in Salt Lake City. “The simple fix is an antibiotic prescription, and patients are on their way. But most of sinusitis is allergic or viral in origin, and antibiotics don’t address this.”
But at least one study found that antibiotic use isn’t excessive at urgent care centers, said Stoimenoff. In “Health Care on Aisle 7: The Growing Phenomenon of Retail Clinics,” a 2009 study published by the RAND Corporation, researchers found that the number of antibiotic prescriptions given for people with otitis media were relatively close at urgent care centers, doctor’s offices, emergency departments and retail clinics, which are facilities that provide care similar to freestanding urgent care centers but operate out of established businesses such as pharmacies, grocery stores and “big box” stores like Target. Antibiotic prescriptions for sore throats were also consistent across facilities (see “Antibiotic Usage by Health Care Setting, below).
The Changing Health Care Landscape
How might urgent care centers fare in the future? The Patient Protection and Affordable Care Act is expected to be fully implemented by 2014. “It’s going to be interesting,” said Dr. Das. “The big change of the Affordable Care Act is the development of a value-based purchasing of care. In that system, it is theoretically possible that care is more efficiently allocated utilizing urgent care centers. However, I’m concerned that urgent care centers might be used as a gateway to deny access to specialists.”
Dr. Das cited the early days of health maintenance organizations, when it was harder for patients to access care to specialist physicians without prior approval by a primary care physician. “If there are huge cost controls for urgent care, it might be that urgent care and primary care physicians receive a financial incentive not to refer to specialists,” he said, which could delay needed care. “The financial penalties of referring patients to specialists might cloud the judgment of primary care physicians, nurse practitioners and physician assistants. It’s tough to see if it will be a good thing or a bad thing.”
However, something needs to be done about spiraling medical bills, added Dr. Das. “We desperately need to reduce health care costs. We need efficient ways of delivering health care. If urgent care can do that, then it will be beneficial. If they act as a way to ration health care, there will be a bigger problem.”
Urgent care facilities will likely see an influx of cases once the Affordable Care Act is enacted. “Fewer patients will have care with a primary care physician and, with the influx of Medicaid patients into the health care environment, there will be an inadequate number of primary care physicians,” said Dr. Lambert.
Such clinics can help relieve the burden of noncritical patients flocking to hospital emergency departments, too. Dr. Doxey has already seen this happen. He is the founder and a board member of The Doctor’s Volunteer Clinic of St. George, Utah, a clinic for uninsured patients that is funded entirely by grants and donations and staffed almost entirely by up to 40 volunteer health care professionals. Founded in 1999, the clinic provides dental, mental health and general medical care, similar to many urgent care clinics, and had 12,000 patient visits in 2011.
“When we opened our doors, the numbers of visits to the emergency room went down, particularly [from] those who shouldn’t have been there in the first place,” said Dr. Doxey, who said the facility doubled in size a year ago, and patients continue to seek care, filling the space. Like Dr. Lambert, he thinks his and similar urgent care centers will be busy after the Affordable Care Act kicks in. “Personally, I think Obamacare will not cover every person, and there’s always someone who will fall through the cracks,” he said. “But who knows exactly how Obamacare will play out? We just don’t know.”