The health care system continues to get more expensive without commensurate improvements in quality and access. Employers and other health care purchasers under constant pressure to rein in costs are seeking innovative ways to offer their plan members access to high quality and affordable care. As a result, urgent and retail care centers are seeing a resurgence, presenting new opportunities and challenges for purchasers and their members.

Urgent care facilities and retail clinics have existed since the late 20th century, commonly attached to hospitals to treat minor conditions. Privately owned clinics were briefly popular in the 1970s and 80s, but were met with aggressive marketing and acquisition by hospital systems, and derided by the medical community as a "doc in a box." By 2000, most urgent care and retail providers were gone, either merged into existing emergency departments (EDs) or closed.

Twenty years later, the tide has turned. Privately owned urgent care chains and retail clinics began to open and expand and have continued to rapidly grow. According to the Urgent Care Association of America, there were 8,774 clinics in the United States in 2018, up from 6,100 just five years earlier. The popularity of convenient care has pushed several major health systems across the country to open (or acquire) their own fleet of outpatient clinics. As of 2019, the convenient care market consists of a wide variety of clinics – some are owned and operated by established health systems, some are subsidiaries of retail pharmacies or big-box stores, and some are independent.

This growth has been driven by several factors including the implementation of the Affordable Care Act, which expanded the insured population without increasing the number of primary care providers. Urgent care and retail clinics may have helped fill this gap in access to primary care. Between 2008 and 2015, utilization of non–ED acute care venues like urgent care centers increased by 140 percent.

To maximize the potential benefits of these clinics, purchasers should familiarize themselves with the evidence surrounding the role that convenient care plays in today's health care system and its impact on the cost and quality of health care services.

What are convenient care clinics?

One of the major shifts in the primary care landscape has been the emergence of urgent care and retail health clinics across the country–in big cities, small towns, drugstores and strip malls. These "convenient care clinics" offer an alternative to a primary care doctor office visit or the emergency room and most treat both adults and children. Retail clinics are staffed with physician assistants and nurse practitioners, while urgent care facilities are more likely to have a physician on duty. Care provided at these clinics is largely preventive, such as immunizations and lab screenings.

Convenient care is also commonly used for minor illnesses (colds, flu, and bacterial infections) as well as injuries, such as fractures, lacerations and burns. Clinics attract busy professionals and parents with short waits, walk-in appointments, and evening or weekend hours. Urgent care clinics are often free standing, while retail clinics are often located inside drug stores and grocery stores, allowing patients to be treated during their regular errand schedules.

Who uses convenient care?

Millennials (ages 23-39 in 2019) have been a propelling force in the growth of convenient care in the past decade, as many entered the workforce, became financially responsible for their health needs and were first-time parents. Unlike older generations, millennials value efficiency and convenience over building a relationship with a primary care provider. Millennials are also more comfortable with integrated technology and app-based communication, which convenient care clinics frequently offer. A PNC Healthcare white paper indicated that 34 percent of millennials and 28 percent of gen-Xers (born between 1965 and 1980) visited a retail health care clinic in the 12 months preceding the survey, followed by 17 percent of baby boomers and 15 percent of older generations.

People who live near convenient care clinics are most likely to use them. Most convenient care patients are high-income, healthy and insured. In fact, clinics open locations in wealthier neighborhoods with high concentrations of healthy people. Patients in lower-income neighborhoods may not have the same access to walk-in care – even though lower-income individuals are more likely to work off-hours, lack health insurance, and lack a regular primary care provider.

Does convenient care cost less than traditional primary care?

Data suggest that retail clinics and urgent care clinics can offer lower prices than physician offices or the ED for the same services. A 2007 study in Minnesota found that average costs for treating three common illnesses (otitis media, pharyngitis, or urinary tract infection) during the 2005-2006 time period was $110 at a retail clinic, $156 at urgent care, and $160 at a physician's office, versus $570 in the ED.

Ten years later, a Texas-based study found that the average cost in 2015 of an urgent care visit was $168, while the average hospital ED visit was $1,842, though the study acknowledges that case mix is slightly different, as higher-severity ED cases that would not be treatable at an urgent care center were counted in this analysis. The costs of care at retail clinics and urgent care centers remained stable during this time period, while costs of treatment in the ED soared.

A 2018 study found that between 2008 and 2015, the average cost of a retail clinic visit rose only $1 (from $74 to $75) and the cost of an urgent care visit declined by $3 (from 165 to 162). By contrast, the cost of an ED visit rose from $914 to $1637 in the same time period.

Retail clinic users fall into one of two categories – those who would have gone to a physician's office or emergency room in the absence of the clinic, and those who would have gone without care. One study suggests that around 88 percent of patients would seek care at the ED or another more expensive location. Increased care utilization is generally considered to improve health outcomes, especially when minor conditions are treated before they become serious. However, costs increase when patients access more health care services. Instead of reducing spending, use of retail clinics has been shown to be associated with a 21 percent increase in spending on low-acuity conditions, because patients are seeking care they otherwise would have foregone.

How does convenient care quality compare to traditional care?

While retail clinics and urgent care facilities can provide care for lower costs than traditional facilities, the quality of care must be on par for convenient care clinics to provide a high-value alternative. Most literature suggests that care provided in a convenient care clinic is on par with care provided in a physician's office setting for most conditions, and superior to care provided in an ED. One paper evaluated retail clinics' rates of adherence to quality standards for pediatric pharyngitis and upper-respiratory infection.

Assessing care provided in clinics with Healthcare Effectiveness Data and Information Set (HEDIS) measures, it found that the clinics scored in the 90th percentile for the pharyngitis measure and between the 50th and 90th percentile for the upper-respiratory infection measure, suggesting that care is average to higher-than-average quality. In a comprehensive survey of college students, urgent care centers scored higher in quality and in perceived value than emergency rooms.

However, even if care is considered to be of equal quality, care continuity between the retail clinic and the patient's primary care provider is a concern. Research supports the fact that patients who used retail clinics had less continuity in their care than patients who did not.

How can employers take advantage of this changing landscape?

Increased use of convenient care as a substitute for ED visits will likely reduce costs and deliver care of the same or better quality. Employers, patients and the health care system in general will be better off when patients choose convenience care for appropriate instances. Employers and other health care purchasers can communicate to their plan members that convenient care is a covered service and widely available in many urban and suburban areas.

To ensure appropriate use, employers can direct employees to resources that explain which conditions are appropriate for a convenient care setting, versus a provider office visit or an ED visit. Finally, employers and purchasers can ensure that members are aware when their health plans incentivize use of these facilities over the ED through lower copayments or other cost sharing.

However, while increased use of retail/urgent care as a substitute for primary care visits may reduce costs, it may lead to issues with care continuity. Purchasers should emphasize to employees that records from these clinics can (and should) be sent back to their primary care physician, if they have one.

Additionally, purchasers can encourage primary care providers in traditional settings to add online scheduling, extended hours, and walk-in availability to their practices. Despite the trend away from the physician's office, some surveys indicate that millennials do still value care continuity and provider relationships, and may be convinced to switch back to traditional primary care if it offered the same conveniences. Creating a more modern primary care office will allow patients to fit continuous primary care into their busy lifestyles, achieving the dual aim of reducing inefficiency while increasing access to care.

Emma Wager is project and research assistant, and Suzanne Delbanco is executive director at Catalyst for Payment Reform.

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Cost, quality and access: Employers looking at urgent care and retail centers in a new light

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