Urgent Care Clinics Arrive With Mixed Reviews in San Diego

SAN DIEGO ― Grabbing medical care on the fly is about to get easier for San Diegans. In early November, former health care executive and San Diegan Paul Arvanitis opened the state’s first outpost of the Doctors Express urgent care center in Santee. The Doctors Express franchise, based in Towson, Md., has created a business model for urgent care that many compare with businesses such as McDonald’s or Postal Annex.  

The demand for urgent care has grown in recent years, shifting the way many Americans think about accessing the health care system. A shortage of primary care physicians and the loss of insurance coverage for millions — coinciding with a high rate of unemployment — has propelled more people to seek care at retail walk-in clinics and urgent care centers, rather than face long waits for a primary care appointment or receive treatment in a hospital emergency department.

“When you look at the average wait times in the emergency rooms in Southern California, it is about 4.5 hours,” said Kari Knowles, a practicing chiropractor and franchise owner of the Oceanside Doctors Express, scheduled to open in January 2011. The Oceanside location will be California’s second Doctors Express facility.

Doctors Express, the first — and so far only — national urgent care franchise, has to date sold 80 franchises, 15 of which are currently open and operating. Ten of the 80 franchises will be based in California.

Over the past decade, urgent care clinics have expanded dramatically. Across the country, there are currently 8,700 centers, with approximately 300 new centers opening each year, according to Lou Ellen Horwitz, executive director of Urgent Care Association of America.

Saving Time and Money

A recent study conducted by the RAND Corporation, which was published in the September edition of Health Affairs, found that across the United States, approximately 17% of all visits to hospital EDs involved conditions could be treated at retail clinics, such as those found in Walmart or CVS, or urgent care centers. Such a move, the study found, could save $4.4 billion annually in health care costs.

Covering the middle ground between the physician office and the ED, urgent care centers treat a variety of health concerns that do not rise to the level of an emergency, but may also be more serious than conditions typically treated in a primary care physician’s office. Minor infections, strains, fractures and lacerations are some examples.

“The way we describe it when we talk about ailments treated in urgent care is things that are not life or limb threatening,” said Horwitz.

In addition, urgent care offers extended office hours — generally from 8 a.m. until 8 p.m. Monday through Friday and 8 a.m. to 5 p.m. on weekends, when most physician offices are closed for business.

While the extended hours are helpful, they may not be enough to make a dent in ED visits, according to Theodore Mazer, communications director for the San Diego County Medical Society.

“It certainly extends hours beyond most doctors’ offices, but it doesn’t take the load off the emergency rooms that are still seeing these patients because most of those are coming in after 8 p.m. anyway,” he said. 

There’s little argument, however, about the ability of urgent care centers to reduce costs in cases where the ED can be avoided. According to Doctors Express corporate headquarters, the average ED visit costs $575 compared with an average of $125 to $140 at an urgent care center.

Supporting San Diego’s Medical Community

As in most cities around the country, San Diego residents struggle in some areas to gain access to adequate medical care. The eastern portion of San Diego County, where the Santee center is located, is one such area.

“There is a shortage of primary care physicians in general and that leads to people having to either wait or end up the emergency rooms or other urgent care centers,” said Mazer.

Doctors Express sees itself as the ideal complement, rather than a replacement for, the existing system.

“We meet with local specialists and doctors in the community and [let them know] we are here to support you if you’re not available or aren’t on-call after hours. We’re not here to take your patients,” Knowles says. 

But according to Mazer, his organization has not yet been contacted by either of the San Diego-based franchise owners to discuss their entry into the community.

“I would have hoped they would have worked with the medical society,” Mazer said, adding, “It would be nice if they contacted us and said we’re moving in and how can we work with you?”

Both Arvanitis and Knowles said they have extensive plans to reach out to local physicians, hospitals and medical societies in an effort to work closely with them.

One-Stop Shopping

Doctors Express urgent care centers are staffed by physicians.

“These are doctors who are actually licensed physicians working in the clinics and that’s a good thing for quality of care,” said Mazer.

And the centers are set up to handle a wide array of ailments.

“It’s a one-stop shop,” Arvanitis said. “We offer X-ray, lab and dispensary services, where we carry the most common pre-packaged pharmaceuticals.”

In addition, Knowles said, the centers will all be equipped with electronic health records. This will enable staff to communicate with a patient’s primary care physician within 24 hours of a visit about the treatment delivered so he or she can follow up.

The Issue of Insurance

Doctors Express says it accepts most types of insurance. But San Diego is a unique market in that there is still significant HMO penetration, which would likely require HMO patients visiting urgent care centers to pay out of pocket.

Santee and Oceanside also have large numbers of people enrolled in Medi-Cal, California’s Medicaid program, who often have difficulty finding care providers. 

“We have lots of community clinics that serve [the Santee] area and that take on the Medicaid population and some of the uninsured, but they still have difficulty accessing care,” Mazer said. Another urgent care center in the area that accepts patients enrolled in Medi-Cal would be of help to the community, Mazer said.

Although Arvanitis claims to still be considering whether to accept Medi-Cal patients, Knowles will not do so when she opens her center in Oceanside.

The decision as to whether a site will treat Medicaid patients, according the Doctors Express corporate office, is up to each individual center owner. Of the 15 Doctors Express centers currently open, only one, based in Colorado, accepts Medicaid.

“Do I think urgent care will answer all the needs?” Mazer asks. “Maybe for the uninsured and PPO patient by giving another point of contact. But unless they open up to the Medicaid population, it won’t help.”

In addition to concerns about serving the community is uncertainty about how these centers will affect primary care physicians’ business.

“That could have a significant hit on those primary care offices in the region out in Santee and then again when they open up in Oceanside, because there is a cost shift here,” Mazer said. “That means the primary care office now has less to offset their losses on Medi-Cal. That could have a negative impact. Plus, if these offices are not going to accept Medi-Cal that’s really cherry picking, and it’s not meeting the needs of that community,” Mazer said.

Health Reform’s Impact

Barring any dramatic changes to the health reform law following midterm elections, the country is on course to provide health insurance to an additional 35 million Americans over the coming years. The expectation is that the growing need for services can only bode well for urgent care centers such as Doctors Express.

“I think it will take pressure from the emergency rooms and patients will not have to sit for long hours. It should be a benefit to us,” according to Knowles.

Arvanitis agrees, saying that an additional 35 million Americans with insurance will only exacerbate the situation of more people trying to access care via the ED.

Mazer agrees that the expansion of primary care access through urgent care should help offset some of the increased numbers of people seeking care. But the vast majority of newly insured are going to be in the Medicaid program, Mazer said.

Mazer added, “Unless these urgent care centers are going to accept those patients it only exacerbates the low-pay to reasonable-pay ratios for places like emergency rooms already floundering.”

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