The news cycle in healthcare seems to be following the news cycle in politics. Twenty-four hours is now 24 minutes if not 24 seconds. With that in mind, let’s hit the rewind button to take a closer look at two recent studies on urgent care. They showed that even well-intended innovations have consequences.
The first study, by researchers from Brigham and Women’s Hospital in Boston and published in JAMA Internal Medicine, looked at changes in where patients go when they don’t feel well.
They studied 20.6 million visits by patients from 2008 through 2015 to emergency departments, urgent-care centers, retail clinics and telemedicine providers. All the patients had commercial health coverage through Aetna, and all were under the age of 65. They all suffered from “low-acuity” medical conditions like sore throats, earaches, muscle sprains and eye infections.
The finding that grabbed quick headlines was this: Fewer people used the ED for non-emergent care and more people used urgent care, retail clinic care and telemedicine for those problems. The rate of visits to EDs for low-acuity conditions dropped by 36 percent to 57 per 1,000 enrollees in 2015 from 89 per 1,000 enrollees in 2008. Over that same eight-year period:
- The rate of urgent care visits rose to 103 per 1,000 enrollees from 47, or 119 percent
- The rate of retail clinic visits rose to 22 per 1,000 enrollees from seven, or 214 percent
- The rate of telemedicine visits rose to six per 1,000 enrollees from zero
Now, you’d think costs would go down as more patients used these new, cheaper and more convenient settings for aches and pains for which they wanted immediate attention. Well, you’d be wrong. The cost per member for treating low-acuity conditions actually rose 14 percent to $80 per member from $70 per member over that period. The researchers defined cost as the total of what Aetna and the patient paid out of pocket for the visit.
Though the cost per visit to urgent care, retail clinic care and telemedicine was relatively unchanged, the cost per visit to the ED jumped 79 percent to $1,637 from $914.In other words, patients who continued to use the ED for aches and pains were charged so much more by the hospitals that those charges erased Aetna’s savings from the patients going to other settings.
That’s the story.
The researchers suggested a few reasons for the jump in costs for hospital emergency care for patients who weren’t having an emergency.
- The need to charge more to cover the costs of treating more acutely ill patients
- Growth in high-cost emergency care
- More aggressive coding of emergency care, or upcoding
- Increased market power to raise prices thanks to provider consolidation
- More unnecessary testing driven by clinical guidelines and protocols
The second study, by researchers from the Centers for Disease Control and Prevention and also published in JAMA Internal Medicine, looked at the inappropriate use of antibiotics by EDs, urgent-care centers, retail clinics and physician offices.
They studied more than 156 million visits to the four sites in 2014 by people under the age of 65 and who had employer-based health insurance.
The CDC researchers found that urgent-care centers overprescribed antibiotics more frequently than providers in the other three settings. For example, urgent-care centers prescribed antibiotics for about 42 percent of patients with viral upper respiratory tract infections who didn’t need antibiotics. That’s compared with 30 percent for physician offices, 19 percent for EDs and 11 percent for retail clinics.
Other researchers invited to comment on the findings suggested that the urgent-care business model might be to blame. They said patients may go to urgent care specifically because they want and expect antibiotics, knowing that the clinicians there are more likely to prescribe them.
“Clinicians may worry that patients will not return to urgent care in the future if their expectations are not met,” they said. “Innovations that may help reduce unnecessary prescription of antibiotics may conflict with the business model of urgent care and retail clinics.”
The boom in urgent care is a market-based response to patients who want immediate care for whatever ails them and to insurers who want patients to avoid expensive hospital emergency rooms for that care when their members don’t have a true emergency.
What the two studies show is that market-based responses to what patients and payers want must take a lot more into consideration if they truly want to succeed in improving access without raising costs and hurting quality.