The Evolution of Urgent Care Centers

How they began and the factors that shaped them

Hospital emergency room entrance
Blend Images/ERproductions Ltd/Getty Images

Urgent care centers used to be in the same neighborhood as the doctor's office. If you saw an urgent care center (also commonly called an urgent care clinic) in the 1970s, it was probably in the same office complex where the doctors and the dentists were. And most of those were by the hospital.

An urgent care center in those days provided care that wasn't urgent because of the severity of the patient's medical condition.

They provided care urgent-ly (meaning without an appointment) for the convenience of the patient.

Those clinics or care centers were pretty uncommon. The whole concept was new. It wasn't until after the turn of the millennium that urgent care centers started expanding their services to include the ability to treat some relatively serious medical conditions.

The Old Days

At first, the idea was simply that patients wouldn't have to make an appointment to see the doc. They could simply walk in. Patients at the time only had two options: make an appointment with their private physician or go to the ER. Insurance companies were frustrated at patients because they didn't make appointments. They just went to the ER. At least that's what the insurers thought—and they still think that.

Data for emergency department visits earlier than 2000 are extremely hard to find. One thing is certain: insurers didn't like paying the increased cost of emergency department visits in the 1970s and they don't like it any more today.

Visiting the ER could cost as much as 10 times the bill for a visit to a doctor's office. Urgent care centers are somewhere in the middle.

Nobody Plans to Get Sick

Patients have never been really good at making appointments. Injuries and illnesses have a habit of coming on suddenly and requiring immediate treatment despite the fact that it's after 10 on a Saturday night.

Emergency departments didn't want to see the patients unless they were on death's door and doctor's offices would happily answer the phone on Monday morning to schedule an appointment for Thursday afternoon.

The earliest urgent care centers came from two places: either the private physicians were trying to be flexible for their patients by extending hours into evenings and weekends, or ER docs were trying to figure out ways to provide care to increasingly non-acute patients who were turning up at the emergency department. These two places created two very different systems.

The Role of Insurance

As private, usually employer-provided, medical insurance became more common, ER visits increased among those with full coverage because the cost of going to the doctor (after waiting for an appointment) was nearly the same as walking into the ER and being seen immediately. Uninsured patients went to the emergency department out of necessity. The ER was the only place where a patient could be seen for his or her life-threatening (or perceived life-threatening) emergency regardless of the ability to pay. Hospitals were required to evaluate patients and provide emergency care if necessary.

This was the beginning of inequality in the billing department.

Those with insurance were often coughing up the entire bill because the insurance, rather than the patient, was picking up the tab. Uninsured patients, on the other hand, often couldn't afford to pay. The ER was still going to treat them, but they made up the free care on the backs of the commercial insurance carriers.

Healthcare costs began to rise steeply. Hospitals had to pay to keep doctors and nurses in the hospital around the clock, even as a portion of the patient population was getting free or nearly free care. Prior to this, the cost of medical care was basically the same for everyone, but now those who could pay were subsidizing those who could not.

Insurers felt the sting. They developed financial incentives to drive patients away from the emergency department unless they really needed emergency care.

The Carrot, the Stick, and the Crystal Ball

The insured patients didn't like to wait and they didn't always have the ability to make appointments. To push patients to plan better, insurers introduced sliding scale reimbursement. Patients paid a lower deductible when an ER visit resulted in admission to the hospital. It was assumed that the visit must have been justified if the doctor kept the patient overnight.

Patients, however, were forced to know their diagnosis before they went to the emergency department. If they didn't really have an emergency, they were going to pay much more out of pocket. There was a reason to go to the doctor's office instead of the hospital unless the patient was really sure he or she was going to die.

But patients still didn't plan very well. They wanted the convenience of walk-in service. Private physicians responded with office hours in the evenings and on Saturdays. They moved out of the medical office parks and into the malls. Soon, parents could take Junior to see Santa and get his sore throat checked in the same trip. These new immediate service clinics had all sorts of names, but "urgent care" stuck. It had a ring to it that patients liked.

All Care Is Not Created Equal

The differences between emergency departments and urgent care centers were both financial and in the services provided. Urgent care centers often didn't have anything more to offer than a doctor's office did. Emergency departments, on the other hand, were the gateway to lifesaving healthcare. The ER could handle anything.

Now that the insured patients were going to the urgent care centers in bigger numbers, a greater percentage of uninsured patients were left to be treated at the emergency department. Healthcare costs continued to rise as the hospitals tried to keep up with an increasingly uninsured patient base. Insurers balked and everyone blamed the uninsured patients. They were easy targets, often coming back to the ER multiple times for the same care. To make matters worse, uninsured patients often have medical problems that are not socially acceptable, such as mental health issues or addiction.

More Insurance—Will That Work?

The push to get more folks insured was seen as a panacea. If these uninsured patients could have better access to healthcare—or so the thought went—they would seek care with a private physician instead of visiting the ER.

Alas, it was not to be. An early indicator came in Oregon. A Medicaid expansion in 2008 made the perfect opportunity to see if more insurance would lead to patients going to the doctor rather than the ER. Instead, patients went to the emergency department even more. Once the Affordable Care Act went into full swing, a similar trend happened in other states.

Even More Options

Urgent care centers expanded along with medical insurance coverage, but so did emergency care centers. Freestanding emergency rooms are now available in as many as 35 states. These are a cross between an urgent care center and an ER. They have the services of the emergency department, but, like an urgent care center, are not always attached or affiliated with a hospital and need to use an ambulance to get patients to definitive care.

The best version of an urgent care center (in my opinion) came from within the emergency department. The patient walks in the door and sees a nurse, who evaluates the complaint and ushers the patient to one of two pathways: the ER or the clinic.

Freestanding emergency centers and urgent care centers are likely here to stay. Unless healthcare regulation forces us in a different direction, a shortage of general practice physicians and the financial realities of healthcare dictate a model other than emergency department or doctor's office. Healthcare is changing rapidly. It's hard to guess where we're going, other than increasingly, not to the ER.

Sources:

(2017). Cdc.gov.  https://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf

O'Malley JP, O'Keeffe-Rosetti M, Lowe RA, Angier H, Gold R, Marino M, Hatch B, Hoopes M, Bailey SR, Heintzman J, Gallia C, DeVoe JE. Health Care Utilization Rates After Oregon's 2008 Medicaid Expansion: Within-Group and Between-Group Differences Over Time Among New, Returning, and Continuously Insured Enrollees. Med Care. 2016 Nov;54(11):984-991.

You thought it was an urgent care center, until you got the bill. (2017). NBC News. https://www.nbcnews.com/health/health-care/you-thought-it-was-urgent-care-center-until-you-got-n750906

Continue Reading