Insurers turn to retail, urgent care clinics to keep members out of emergency rooms

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Insurers turn to retail, urgent care clinics to keep members out of emergency rooms

By Jim Frederick - 01/28/2013

Shifting patients away from hospital emergency rooms and into retail-based and urgent care walk-in clinics can significantly lower healthcare costs, improve access to care and reduce the impact of such chronic diseases as diabetes and hyperlipidemia, two health benefits experts asserted in a recent online presentation.

In a webinar titled “How Retail and Urgent Care Clinics Can Be a Win-Win for Health Plans and Their Members,” the two experts — Susan Menendez, director of strategic provider relationships for Blue Cross and Blue Shield of North Carolina, and Tom Charland, CEO of health consulting firm Merchant Medicine — laid out a strong case for walk-in clinics as a powerful tool to reduce expensive visits by health plan members to emergency rooms and provide an accessible professional care alternative for millions of Americans living in areas facing a shortage of primary care physicians. Such clinics also can extend a local health system’s reach within a community as part of an accountable care organization, provide a medical home for some patients and make patients more responsible for their own health, they said.

Retail and urgent care clinics, Charland said, are “expanding the scope of services” they offer walk-in patients, providing “an alternative to primary care.” And health plan payers, he said, are taking notice. Increasingly, they’re looking to clinics to play a role in improving patient access to health services, lowering costs for routine and preventive care and serving as ad hoc medical homes for patients “where there’s an extreme shortage of primary care physicians,” he noted.

Given “the hours, the locations, the consistency of service,” Charland said, “I personally believe that walk-in medicine has done more for patient-centric behavior and patient satisfaction — and the focus on patients as customers — than anything since doctors made house calls.” Charland attributed the rise in retail and urgent care clinics to “medical providers acting like merchants, and acting like they want patients to come back and have a positive experience.

“It’s no longer built around the provider, or providers’ hours or locations,” he added. “It’s built around the patient.”

To this point, however, retail and urgent care clinics have followed different growth tracks. Although urgent care has seen steady gains over the past decade, the retail clinic market experienced “a leveling off in 2008 and 2009, when people were trying to figure out what was going on, and it’s only just recently that Minute Clinic, under CVS’ guidance, has decided to start opening new clinics,” Charland said.

Nationally, the use of retail clinics saw healthy gains from 2006 to 2009, according to a study from Rand Corp., from 1.48 million total patient visits to roughly 6 million. “But those figures still pale in comparison to ER and regular physician visits,” noted Atlantic Information Services in a report. “An estimated 117 million ER visits and 577 million visits to doctors’ offices are made each year.”

Nevertheless, said Charland, “These clinics are here to stay” as health plans, payers and patients incorporate them into the nexus of care. He also predicted “a lot more cooperation” from doctors as “the changing economic model is starting to change their behavior from being able to do as many procedures as you can, to getting that procedure in the spot where it can be done with the highest quality at the lowest cost. And if that does take over, I think we’ll see walk-in clinics start to be integrated into more of these ACOs and clinically integrated networks.”

Although most retail clinics “have yet to break even,” Charland added, the profit picture is improving as operators have learned to “smooth out some of the seasonality” of their business by broadening their menu of services and as patient traffic has picked up. “Now that these clinics are at break-even, we’re going to start to see some of the operators open more clinics,” he predicted.

Investing in urgent care solutions

The need among health plan payers to curb the rising costs of emergency room care for non-emergency health problems has become increasingly urgent, Menendez said. “We have seen our costs for ER services continue to increase over the last several years,” said the Blue Cross Blue Shield strategist. “We know that thousands of patients visit crowded emergency rooms for non-life-threatening conditions that we believe can be treated very cost-effectively and efficiently in urgent care centers. And we know that a visit to an ER can cost up to 10 times more than visiting an urgent care center…[at] nearly $1,500,” she said.

In response, BCBS purchased a stake last year in FastMed Urgent Care, the largest urgent care clinic provider in North Carolina. “In those pockets of the state where we have primary-care shortages, this type of model is very attractive to us,” said Menendez. “We know that primary care shortages in North Carolina will only worsen in 2014 and beyond. So we’re looking now at solutions around primary care, as well as having options other than the local hospital for these members.”

Menendez said the Blues launched a project in 2010 “to look at these ER costs and services, and really try to understand what is driving members going to ERs. What are the behaviors and the most common diagnoses that members go to ERs for?”

ER-use rates are higher in rural areas of the state, she said, at rates of “around 200 per 1,000 members, and that’s incredibly high,” versus about 140 visits per 1,000 members living in urban areas. In addition, BCBS knows that “women of childbearing years and young males have the highest ER rates. We’re trying to drill down into that and understand why.”

The Blues tracks a list of 15 to 20 diagnoses that drive the most nonemergency ER visits, including headaches, back pain, sore throats, urinary tract infections and upper respiratory infections.

One big reason for the high ER utilization rates: the shortage of primary care physicians, coupled with the fact that many residents in North Carolina don’t have a regular doctor to visit for treatment and counseling, even for common conditions. And again, BSBC members in rural areas — including “some pockets of the state where the only option for receiving nonemergent care is the local hospital,” Menendez said — are the least likely to have a primary care physician. “That’s very concerning to us, given some of the health crisis issues we have today.”

Thus, the executive said, BCBS is targeting some distinct population groups to lower their rate of ER visits and steer them into retail clinics, urgent care centers and other alternative, lower-cost healthcare sites. Among the target groups are:

  • Members in poor access areas;

  • Those with no primary care doctor;

  • Members with a moderate health situation that has not occurred previously; and

  • Those with persistent health conditions.

In a bid to shift its members away from high-ticket visits to the emergency room for nonemergency health issues, the company also adopted a tiered approach to out-of-pocket patient costs. To that end, BCBS began raising its patient co-payments for routine care at the ER.

The boost in co-payments — $100 in 2001 to $150