As Americans seek out coronavirus tests more than ever, urgent care is quickly becoming the go-to health care destination for a growing share of the population. Ateev Mehrotra, MD, MPH (Medicine, BIDMC) argues that if the medical system was to be redrawn, he’d want primary care doctors spending time on the sicker population.

Vox – November 19, 2020

Covid-19 is turning urgent care centers into America’s favorite clinics

Demand for urgent care is spiking as the country continually breaks daily records for new Covid-19 cases. This makes sense: Americans are seeking out coronavirus tests more than ever and urgent care centers are one of few places people can walk up and get one without an appointment. In fact, urgent care is quickly becoming the go-to health care destination for a growing share of the population.

As the third wave of the pandemic began across the United States, visits to urgent care jumped nearly 10 percent in October compared to September according to the industry group Urgent Care Association — and urgent care centers had already been busier than ever after starting to offer Covid-19 tests in earnest back in May. Fifty percent more people are going to urgent care currently than is typical for this time of year, according to data from Solv, an app that handles online and in-person booking for urgent care centers. Searches for urgent care on Google are at an all-time high, as are searches for Covid-19 testing.

A big reason for this growth is the unique role that urgent care centers have played in the American health care system. Urgent care centers are standalone medical practices where patients can drop in for immediate medical care for anything from fractures to the flu, no appointment necessary. Their hours tend to be longer — some are 24 hours, 7 days a week — than primary care doctors, though their copays are usually higher. While state testing sites, pharmacies, community clinics, and primary care doctors all offer Covid-19 tests, urgent care centers do so on demand.

In addition to the record number of Covid-19 cases, urgent care centers are seeing a rise in the number of people seeking testing because it’s the start of the season for colds and flu, which have similar symptoms to Covid-19. Many people are also getting tested as a way of trying to safely visit family for the holidays.

It’s not clear exactly what share of the 172 million coronavirus tests conducted so far in the US have been done through urgent care centers, but it’s certainly sizable and growing. Urgent Care Association CEO Lou Ellen Horwitz said urgent care centers are conducting a “tremendous” number of Covid-19 tests, which accounts for the “vast majority of visits.”

Urgent care centers were doing about 725,000 tests per week in late October, which roughly amounted to 10 percent of the total tests per week in the US at that time. Since the number of tests urgent care centers conduct per week has grown so quickly — as has the total number of tests conducted in the US — we don’t have precise current numbers for urgent care’s contribution. The urgent care market has grown rapidly and is estimated to be $28 billion in the US this year, and coronavirus care is likely to add to its growth.

That said, all this new business might not be that great for the financial viability of urgent care in the short term, since Covid-19 tests and precautions are so expensive. Insurance companies commonly pay urgent cares a flat fee per visit, regardless of what services are provided. The cost for Covid-19 tests and the added personal protective equipment needed is high — high enough that the reimbursement from insurance companies does not always cover the total cost of conducting these tests, according to Horwitz. There is a provision in the federal CARES Act that should help cover these added costs, but Horwitz says that has been a “struggle in reality,” though she’s hopeful that insurance companies and urgent care will sort out fair payment.

Regardless, Covid-19 tests are continuing to be a large portion of urgent care’s new business. And the extent to which these clinics remain popular after the pandemic could have lasting effects on how health care is delivered in the United States.

The rise of urgent care and the decline of primary care businesses

The first urgent care clinics launched in the early 1980s, and the concept grew slowly through the early aughts. They began to grow more rapidly thanks to shortages — both real and perceived — of primary care doctors and a growing effort to avoid expensive emergency room visits. Then, about a decade ago, investors started pouring money into the industry, whose retail model seemed to fit American consumerism, and health systems started opening their own urgent care centers.

There are currently more than 10,000 urgent care centers in the US, up 44 percent from five years ago, according to the Urgent Care Association.

Urgent care had been gaining in popularity long before the pandemic due to a unique space it filled between primary care doctors and emergency room visits. Research published in JAMA Internal Medicine found that Americans had increasingly been going to urgent care for “low-acuity conditions” — complaints like respiratory infections, muscle strains, and rashes. From 2008 to 2015, urgent care centers saw a 120 percent increase in those types of visits.

These places are also equipped to treat more severe injuries like fractures or wounds that need stitches. Indeed, Americans have been utilizing urgent care to avoid expensive emergency room bills. Young people especially have been drawn to the convenience of urgent care, where longer hours and walk-in appointments seem to outweigh the cost of bigger copays.

At the same time, the number of Americans getting health care from primary care doctors has been declining, which could be detrimental to people’s health, according to a report in the Annals of Internal Medicine. Estimates from the Urgent Care Association indicate that urgent care represented more than 23 percent of all primary care visits in the US before the pandemic, and that number is undeniably higher now.

“Primary care is super important because it’s associated with better outcomes and lower health care costs,” said one of the report’s authors, Ishani Ganguli, an assistant professor of medicine at Harvard Medical School and a primary care physician at Brigham and Women’s Hospital. She added that primary care is also important for coordinating all of a person’s medical care and for finding underlying problems that could be missed in one-off visits to urgent care.

While urgent care has certainly been taking some of that traffic, there are other reasons for that decline, according to Ganguli’s research. The internet, accessible from the comfort and privacy of our homes, is the first stop for many Americans looking for answers about their health. And sometimes those answers — what to do about pink eye, for example — obviate the need for medical care. The rising cost of health care, meanwhile, means that some people cannot afford to see a doctor.

Other reasons for the decline in visits to primary care doctors have to do with how their practices have changed. Patients are getting more done in fewer visits and are supplementing those visits with calls and emails to their primary care doctors. These are positive developments for patients, but they can have a negative effect on the bottom lines of medical practices. Doctors are often paid by the visit, which doesn’t always take into consideration this increased care.

Doctors are increasingly adding online portals for communication and telehealth visits, reducing the need for in-person visits, and online health care grew rapidly due to the necessities of the coronavirus pandemic. The share of Americans who tried telemedicine had already doubled this spring. Online visits, however, are not being covered by insurance companies or Medicare at the same rates as in-person appointments. That coupled with people putting off routine care during the pandemic has forced some primary care businesses across the country to close.

There’s been a lot of interest from policymakers, insurers, and doctors in moving from a per-service payment model to a per-person system, and the pandemic is making it more likely. But by the time that happens, many of the primary care businesses operating in the US will have already gone under.

What this means for medical care

The increased use of urgent care doesn’t have to be a bad thing for primary care. It can be a complement to it. While urgent care can be used to treat one-off issues like the flu or stitching a wound, primary care physicians can focus on managing more long-term and major health care needs.

“If I were to redraw the medical system to decide where do I want primary care doctors spending time, it would be on the sicker population,” Ateev Mehrotra, an associate professor at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center, said, referring to those with more severe health conditions. “If that means that other providers are taking care of flu and sinusitis, so be it.”

As far as the pandemic is concerned, urgent care centers have become a critical part of a patchwork of health care providers who can meet the high demand for testing in lieu of a national strategy. Their on-demand appointments, relatively straightforward test offerings, and ubiquity have made urgent care centers ideal places for the public to find Covid-19 tests, in addition to other medical care.

“It makes good sense to me to get certain services at urgent care. Covid testing is a good example of that,” said Ganguli, who thinks urgent care and primary doctors can collaborate to create more informed, holistic treatment. “The ideal future state is that retail clinics and urgent care are an extension of what primary care is already doing, helping us do that job better.”

The fear, however, is that people will use urgent care centers in place of seeing a regular primary care physician. When you go to urgent care, you see a different nurse or doctor each time, whereas at primary care you’d see your regular doctor, who could follow your health over time and across different providers.

“By skipping primary care, you risk delayed or missed diagnoses of major yet treatable conditions like high blood pressure, heart disease, cervical cancer, and depression, as well as higher medical bills,” Ganguli said.

The consequences of going to urgent care rather than seeing a regular doctor also depend on the patient and their particular situation.

“If we’re talking about younger, healthier folks, it’s fine to have a more convenient care option,” Mehrotra said. “My concern goes up if people using it have a lot of medical conditions or are on lots of medications.”

While urgent care centers serve all sorts of demographics, millennials and people with young children tend to be top customers, according to Horwitz, the head of the Urgent Care Association. It’s less popular among elderly people, who are more familiar with the primary care model and who see a wider range of doctors whose care needs to be coordinated. Horwitz added that there has been a low rate of urgent care patients who have needed to be transferred to the emergency room. This suggests that people aren’t mistakenly using urgent care for more serious issues.

How urgent care could be at the center of Covid-19 care

Urgent care was a bridge between primary care and the emergency room in normal times, and now, it’s filling a variety of needs around the coronavirus. That includes not only testing but advising people on treating the illness, quarantining properly, and, if necessary, when to go to the emergency room.

In order to stop the spread of the virus, it’s essential that people know whether they have it in the first place. Some 193 million tests per month are necessary to safely operate schools and nursing homes, according to a report released in September by the Rockefeller Foundation. Currently, the US is doing less than a quarter of that. To reach that level of testing, all Covid-19 test providers, including urgent cares, will have to accommodate more customers.

For many, Covid-19 testing will be their first experience using urgent care. Horwitz says urgent cares “fully intend to participate” in distributing coronavirus vaccines, so those visits likely won’t be their last.

One of the major challenges with the coronavirus vaccines, once they are ultimately approved for use, will be distributing them to the population. That task will largely fall to the states, which will in turn work with local medical providers like urgent care centers to make sure that those who need it can get it, beginning with priority populations like health care workers and the elderly.

Horwitz expects urgent care’s popularity, buoyed by coronavirus testing and — someday —vaccines, to increase the use of urgent care for other reasons after the pandemic.

“Coronavirus gives urgent care the opportunity to show their communities as well as government entities what urgent care is capable of,” Horwitz said.