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Urgent Care: The new frontline of healthcare

Urgent Cares. They’re everywhere. But why?

Local experts have varying replies to that question – from “our healthcare system is broken” to “it’s about patient access” to “it’s a changing business model” – and there’s truth in all of them.

Matthew Bruckel, M.D., knows his views aren’t always popular and he quickly adds the disclaimer that he doesn’t speak for the greater medical community. He even goes so far as to label himself a “market agitator.”

But Bruckel, CEO and founder of Total Access Urgent Care [TAUC], is convinced our healthcare system is broken.

“We’re in a service industry,” Bruckel said. “But for the past 60 years, that service industry has meant – to too many people – that we’re here to serve the doctor.”

TAUC recently opened its 25th urgent care facility and has two more coming. All of that growth has taken place in just over a decade. And it isn’t the only healthcare provider who is expanding into the urgent care market.

Our Urgent Care has locations in St. Louis, St. Charles and Franklin Counties with medical centers located in the cities of Florissant, Maryland Heights, Richmond Heights, St. Charles, St. Peters, Washington and Wentzville.

In addition to private urgent cares, those operated by health systems are popping up all over town, which is consistent with the national trend.

According to a 2018 Forbes article, urgent care facilities across the U.S. now make up an $18 billion business that grew 5.8% in 2018.

A different kind of patient care

Bruckel attributes his company’s meteoric growth to patient care.

“I think patients want a different kind of experience,” Bruckel said. “I think patients want to be valued and appreciated.”

Bruckel contends that primary care doctors generally do a very good job of caring for patients with chronic health issues. Needs that can be scheduled and treated by appointment are best addressed by primary care physicians, he said. But acute care, according to Bruckel, is a different story and a task he says is too big for hospital emergency rooms to handle alone.

“The emergency department was never intended nor designed to be the catch-all for all unscheduled visits,” Bruckel said. “It’s just not built to be that way.”

Bruckel believes urgent care facilities can take care of the vast majority of acute care needs and non-life-threatening issues. John Relic, MPh, CEO of Our Urgent Care, agrees.

“I’m a pharmacologist by training and was a hospital executive,” Relic said. “I was in the hospital leadership role for about 22 years, and then I transitioned over to running very large regional medical groups. At one time, I had about 14,000 physicians that I managed. Then, I went into healthcare consulting for about 14 years. And, in the last 10 years, I’ve been doing interim CEO work for large healthcare organizations.

“So, I’ve witnessed first hand the history that created the urgent care market.”

Relic points to the acquisition of physician practices, “especially in areas like St. Louis where that’s very prominent,” and the diminution of family practitioners and primary care physicians as resulting in the need for alternative care centers. He also points to the Affordable Care Act.

“A big shift occurred with the ACA because basically the way those health plans worked was that the government was going to pay for emergency room services after the patient’s deductible was met. Emergency rooms became huge profit centers for healthcare systems,” Relic said. And they became increasingly busy – “creating a gap.”

“You couldn’t get into a primary care doctor because they were busy treating mostly chronic, long-term health-related issues such as heart conditions, diabetes, etc.,” Relic explained. But emergent care was busy with patients that didn’t need to be there. What some emergency room physicians saw was that there was a market for urgent cares.

“Today, there’s a plethora of urgent cares and they’re expanding like crazy because the market’s there and it makes sense,” Relic said.

A cautious view

Dr. Robert Poirier Jr. is a faculty member at Washington University in St. Louis School of Medicine and an ER physician at Barnes Jewish Hospital. He worries that urgent care facilities may be taking on more than they can chew.

“Many of the urgent cares advertise that they provide emergency services at urgent care prices,” Poirier said. “I don’t think that’s always true.”

His concern is that patients misunderstand what “emergency services” are and too often end up in an urgent care facility instead of a hospital emergency room. While those patients are eventually referred and transported to an ER, the extra stop means extra expense and the time lost could be life threatening.

“Twenty to 30% of the patients that come to my ER need specialized care. You’re not going to be able to provide that in an urgent care,” Poirier said. “[Urgent cares] can’t always provide the time critical and cutting-edge care we can provide at the emergency department.”

Poirier said every day his ER has at least four to five patients arrive from an urgent care facility that probably should have come directly to the hospital.

“We need to make sure our patient population out there knows when to use an urgent care over an emergency room,” Poirier said.

Bruckel contends his urgent care facilities aren’t trying to replace hospital emergency rooms but rather, fill the needed gaps left by overrun ERs. He sees the problems as emergency room care takes too long, costs too much and is too complicated. Relic and the federal government agree.

“The Department of Health and Human Services, which oversees Medicaid, Medicare and so forth, did a study, an analysis, when [Alex] Azar took office as Health Secretary,” Relic said. “He’s a very business-oriented guy so he looked and said, ‘What are we spending our money on? We’re the largest budget in the government, but are we spending our money smartly?’

“One of the things they looked at was emergency room care because it’s growing and it’s a big chunk of Medicare’s payment. The numbers were revealing. They spent close to $700 million in 2018 on ambulance services to take patients to emergency rooms, which are the highest cost healthcare delivery providers.”

According to Relic, Azar’s study prompted change.

“In January 2020, the Center for Medicare and Medicaid Innovation is launching the Emergency Triage, Treat, and Transport [ET3] Model, a pilot program that will set up a structure whereby ambulances will be able to deliver Medicare patients to urgent care centers for care when appropriate,” Relic said.

Officially, ET3 is described as a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address the emergency health care needs of Medicare beneficiaries following a 911 call. Under the ET3 model, the Centers for Medicare & Medicaid Services [CMS] will pay participating ambulance suppliers and providers to transport an individual to a hospital emergency department or other destination covered under the ET3 regulations; transport to an alternative destination, such as a primary care doctor’s office or an urgent care clinic; or provide treatment in place with a qualified health care practitioner, either on the scene or connected using telemedicine.

The catalyst for ET3 is cost and Relic said Medicare strongly recommends that ambulance districts also consider transporting Medicaid patients and insured or not insured patients to urgent care centers when it’s appropriate because those centers can provide “a much less expensive and more appropriate level of care.”

“It’s an appropriate business model,” Relic said. “For instance, in our centers we can provide CT scans, ultrasounds, X-rays. We can conduct about 97% of the relative emergent lab testing.”

A new type of medicine

Keith Dacus, vice president for business development and operations at Mercy Hospital, also see the appropriateness of alternative health care, including urgent care clinics and telemedicine.

“We’ve really started a market expansion and the focus within Mercy to be on a consumer-centric approach,” Dacus said.

Mercy Hospital has a long and storied tradition in St. Louis. Its forerunner, St. John’s Hospital, opened in 1871. It has been open at its current location in West County since 1963. But even with more than a century of institutional experience, no one can claim the leadership team at Mercy is stuck in old-school thinking.

In October 2015, Mercy opened the Virtual Care Center on South Outer Forty Road in Chesterfield. It was the first and only facility of its kind – a four-story, 125,000 square-foot building dedicated to developing and delivering telehealth. Likewise, Mercy has been in the urgent care business for many years.

Dacus said recent market research completed by his team has shown that consumers value being seen when and where they want to be seen.

“That really helped us bring a plan to fruition to expand the urgent cares that Mercy has,” Dacus said. He notes that Mercy had 13 urgent care facilities prior to the research and expansion. They’ve added 13 since then.

“It’s really just trying to help alleviate the crowded emergency rooms and reduce the costs,” Dacus said. “It’s about patient access.”

Dacus notes that Mercy’s expansive network of providers creates a “frictionless” experience for patients.

“We have all of those providers within Mercy … and then it’s one electronic medical record,” Dacus said. He contends this approach enhances the patient experience through continuity of care and lowers its cost.

Bruckel said TAUC also works with a large network of providers for needed referrals and follow ups. According to Bruckel, TAUC boasts an ER referral rate of 1.4%.

“We’re taking care of 98.6% of patients for 12% of the costs of the ER,” Bruckel said.

While the growth of urgent care facilities and services cannot be denied, ER physician Poirier worries that many patients are still being left behind. He points out that urgent care growth is mostly taking place in affluent communities and in areas where access to healthcare is not really dire. At the same time, some segments of the population are left without any choice but the hospital emergency room.

“We see the urgent cares popping up where there tends to be a better payer mix or where people are insured,” Poirier said. “Right now, we need more urgent cares in lower socioeconomic areas.”

If ET3 is successful and the urgent care explosion continues, Poirier just might get his way.

• • •

Kate Uptergrove contributed to this article.

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