Use of Urgent Care Growing in Southern California

LOS ANGELES — Having matured from their early 1970s image of “Docs in a Box,” urgent care centers are growing in popularity with patients who would rather not wait to see a doctor — whether in an office or in the emergency department.

Urgent care’s growth is partly attributable to immediate and projected shortages of primary care physicians. California barely meets the nationally recognized standard for the number of primary care physicians. According to a July 2010 California HealthCare Foundation report, only the Orange, Sacramento, and Bay Area regions meet the recommended supply. Los Angeles falls just below.

Long waits in hospital EDs also are a factor in urgent care’s growth. The Hospital Association of Southern California reports that the average wait time for non-emergency care at a Los Angeles County hospital without a fast-track triage system is seven hours.

Only 29% of primary care doctors have after-hours coverage, according to the American Academy of Urgent Care Medicine. Most urgent care centers are open from 8 a.m. to 8 p.m. and see patients usually within 30 minutes, according to industry literature.

AAUCM reports that approximately 8,700 walk-in, stand-alone urgent care centers exist in the U.S. compared with about 4,600 hospital EDs. AAUCM and the Urgent Care Association of America, a trade group, estimate that 400 to 800 new urgent care clinics open each year across the country.

Most urgent care centers accept insurance and all accept cash, according to Lou Ellen Horwitz, executive director of the trade group. The treatment cost is usually comparable to a primary care visit, and less expensive than the ED, according to urgent care organizations. Charges vary according to insurance coverage, and patients are urged to learn about payment options before visiting.

‘A Market in Great Need of Access to Care’

With conditions in Southern California ripe for improved access, urgent care providers have taken notice. Centers in Los Angeles and Orange counties operate under several business models, ranging from independent to hospital-affiliated. Charges range from $80 to $130 for a “basic” visit; additional diagnostics can cost more, and some centers offer enhanced “tiers” of service.

Doctor’s Express, which bills itself as the nation’s first urgent care medical franchise, plans to open a clinic soon in Santa Clarita in Los Angeles County.

“It’s a market in great need of access to care,” according to Scott Burger, Doctor’s Express co-founder and chief medical officer.

“Southern California is no stranger to urgent care, with many successful clinics,” said Doctor’s Express franchise owner Paul Arvanitis.

Concentra, the nation’s largest urgent care provider, continues to see an increase at all of its centers, including those in Southern California. It operates four centers in Los Angeles.

CEO Jim Greenwood said the company aims to deliver “an accessible and welcoming health care experience that meets the needs of busy patients, without sacrificing personal service and quality of care.”

U.S. Healthworks Medical Group, based in Valencia, reports that urgent care business in 13 states is good and that expansion continues. The company has five urgent care centers in Orange County and 16 in Los Angeles.

Although urgent care, also known as episodic care, can help patients with some ailments, it should not replace regular care for chronic conditions, according to U.S. Healthworks Regional Medical Director Alicia Wagner. “Health care professionals in episodic care may not realize that you’ve gained 10 pounds. We encourage patients to work with a physician for continuing care,” Wagner said.

Urgent Care Largely Ignored in Health Care Reform

“When you’re ill, you want to be seen now. We’re a McDonald’s society,” said Franz Ritucci, president of the American Academy of Urgent Care Medicine.

As the leading academic society for physicians, physician assistants and nurse practitioners practicing urgent care medicine, AAUCM has 8,000 members — including about 1,500 in California — and is the only urgent care organization admitted to the American Medical Association.

Federal health care reform largely ignores urgent care centers.

“We’re too small to be on the radar of government,” said Horwitz, whose trade group UCAOA has 3,200 members.

A 2009 RAND study reported 14% to 27% of ED visits could be handled by urgent care centers or retail clinics, saving up to $4.4 billion annually in health care costs. “We’re not here to replace the ER,” Horwitz said. “The cut-off is that we won’t treat life- or limb-threatening situations. There is very little we take care of that can’t wait until the next day.” She said that if an emergency patient shows up, clinic staff will call 911.

According to Horwitz, primary care physicians might perceive urgent care centers as a threat, thinking: “If people go to urgent care, they’ll see how convenient it is, and they’ll leave me forever.”

“That is not our intent, nor our role. We’re not set up to be ongoing care,” Horwitz said. Centers do in fact communicate with physicians by sharing records. If a patient has no primary care physician, most urgent care centers will suggest he or she find one.

ED or Urgent Care?

The average patient doesn’t know the difference between urgent and non-urgent care, according to Ramon Johnson, board chair of the American College of Emergency Physicians, and ED associate director at Mission Hospital’s Regional Medical Center in Mission Viejo.

“Not every condition is so clear cut,” Johnson said, “and a patient not so in tune with himself could have something relatively serious that merits an ER visit while he’s at urgent care.”

The top reasons for ED visits are stomach and abdominal pain, chest pain and fever. Roughly 10% to 20% of ED visits are non-urgent, according to Johnson.

“ACEP has said for 40 years that when you go to an ER, you expect a certain quality of physician will be taking care of you or have oversight, even if you’re seen by a nurse practitioner or physician’s assistant,” Johnson said.

Under the 1986 Emergency Medical Treatment and Active Labor Act, hospitals receiving federal funding must treat any and all patients with emergency medical needs.

At the other end of the spectrum, “an urgent care center has the right to turn anyone away,” Johnson said. That could be because a patient was unable to pay, although an urgent care center, like a physician, may choose to provide care at no cost. More likely, as echoed by Horwitz, it’s because the patient belongs in the ED.

“We’re not set up to deliver babies or emergency medical treatment,” Horwitz said. “If a patient makes an incorrect choice — and that almost never happens — under the Good Samaritan Act, we’d try to stabilize the patient, but wouldn’t treat them.”

Although urgent care board certification is offered by the American Board of Urgent Care Medicine, no residency is yet offered in the genre. Johnson, who once worked in urgent care, said he witnessed different levels of physicians moonlighting there: dermatologists, anesthesiologists and more.

“The health care industry in general is really trying to provide quality and efficiency to patients,” Johnson said. “It’s not that urgent care physicians are practicing poorly.” Most work without the benefit of a physician colleague on hand. “Sometimes there’s a feeling, though, they would like a second opinion.”

Even given the higher costs of ED visits, Johnson said most patients, if asked, would say they valued the “transaction” that occurred. “We [emergency physicians] interface with one out of three Americans, and have the greatest effect on any part of the health care arena. In the long term, we are a bargain.”

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