Where to Go When You Need Urgent Care

The growth of walk-in clinics and urgent care facilities provide additional options.

For many people, even those with patently non-emergent concerns, the path of least resistance is usually to head to the nearest hospital emergency department. However, that path is often the most costly and can lead to the longest wait times. But there are more avenues to care than simply taking your chances at the ED. (It should go without saying that if you have an emergency, you should call 9-1-1 or proceed directly to the nearest emergency department).
Emergency Department Care in Context
At the Miriam Hospital ED in Providence, medical director Dr. Gary Bubly estimates that around 90 percent of the cases that come through the doors should be treated in that setting. He cautions against a completely retrospective context for looking at these numbers. A patient could present with chest pains that turn out to be gastric rather than cardiac in nature, for example, but that doesn’t mean that it wasn’t prudent to seek the resources available at the ED. “You can’t be retrospective. You have to look at it based on the patients’ presenting complaint,” Bubly says.

“Clearly, there are very important, time-sensitive issues…particularly with heart attack, stroke and trauma,” he adds, as well as episodes of altered mental status, fainting episodes, psychiatric emergencies and the like that belong in the ED.

Since the ED must be prepared for a broad range of diagnostics and interventions, Bubly says, the costs are proportionally higher for the ER visit — you (and your insurance company, if applicable) are paying for the care from the physician as well as from the facility, which must provide the necessary resources. And since EDs are required to treat patients regardless of their ability to pay, the bottom line continues to grow as the hospitals must absorb those costs.

No matter how you slice it, EDs end up treating many patients with chronic conditions (pain, diabetes, etc.); Bubly says that, in a perfect world, these conditions would be managed by a PCP who knows the patient and his history. But our world is far from perfect. “I never blame patients for [not having access to PCPs],” says Bubly.

Steven Juchnik, a registered nurse who is director of emergency services and emergency preparedness for South County Hospital, says that the problem is one of supply and demand: There are not nearly enough PCPs to go around. A 2013 study out of Lifespan found that as much as 75 percent of patients identified lack of PCPs as their biggest healthcare obstacle. “Access is a huge problem. [PCPs] are sometimes booking up to four to six weeks out for appointments,” he says. “That’s part of the bigger global healthcare system failure.”

Juchnik says it costs about $1 million to educate a physician, and young doctors coming out of medical school with substantial student loans find it more difficult to repay those loans as PCPs, than in more lucrative specialties.

Widening the Net: Urgent Care
With these issues in mind, providers like South County Hospital, which has a walk-in clinic in East Greenwich with another slated to open in 2016 in Westerly, have had to think of ways to close the gap. “[Walk-in clinics] fill a void for the community and that’s the most important thing. It is an alternative access point to healthcare for patients,” says Juchnik.
In Rhode Island, many urgent care clinics are affiliated with PCPs. Dr. John Martin is a managing partner for Ocean State Urgent Care and Primary Care Centers of RI, one such group of practices. Not all of its urgent cares are affiliated with the PCP offices in the community, but the channels of communication and relationships are in place nevertheless. “We find the model of having primary care and urgent care next to one another is really helpful,” Martin says. “The urgent cares that we have are sort of stewards of communities where they reside.”

Martin says that urgent cares are equipped to handle lacerations, broken bones, infections, non-life-threatening aches and pains, flu, upper respiratory infections, administration of certain intravenous fluids and the like. Many of these can be treated by PCPs, but time constraints make it such that they are unable to perform even basic procedures, like sutures, for example. Urgent care centers have flexible hours and provider availability that extends beyond what PCPs can most likely offer, but at a fraction of the cost of the ED, Martin says. “The average cost of an ED visit is over $1,000. If I walk into the urgent care, it’s generally about a tenth of that,” he says.

Healthcare Goes Retail: CVS MinuteClinic  
In 2006, CVS Health purchased what is now CVS MinuteClinic. Currently, there are more than 1,000 locations nationwide, and the company opened its first Rhode Island site about a year ago. It now has expanded to seven clinics statewide, with a handful in nearby North Attleboro, Swansea and Seekonk, Massachusetts.

MinuteClinics are walk-in medical clinics located inside CVS storefronts and staffed by nurse practitioners and physician assistants (exact staffing may vary, according to company reps, but there is always an NP or PA in the clinic). They provide services including treatment for minor illnesses and injuries, health screenings and monitoring, vaccinations, some labs and even wellness visits and physical exams (such as for college, camp or sports). An appointment is never necessary, and weekend and evening hours are available.
Angela Patterson is the company’s chief nurse practitioner officer. A trained family nurse practitioner, she provides leadership and oversight for the company across the country. “On the continuum of care that exists in the community in addition to the PCP, we call ourselves a safety net for the PCP, or a patient-centered medical home,” she says.

MinuteClinic, like its urgent care counterparts, is careful to clarify whom they should not serve — its website warns patients who have complaints such as severe chest pain, suspected poisoning, children/adults with temperatures of more than 104/103 degrees and other emergent conditions to proceed to a more clinically appropriate setting. But Patterson says that for those who have a “condition [or symptom] that can be cared for with safety and quality in a convenient, lower-cost setting,” MinuteClinic is a great option.

Both insured and out-of-pocket patients are welcome. Patterson says that MinuteClinic’s use of the electronic medical record system EPIC guarantees easy communication with existing providers, and there’s an emphasis on continuity of care and preventative practices, where possible. All situations are unique, of course, but fairly transparent pricing is available at minuteclinic.com. “And the national average wait time is about twenty minutes,” according to Patterson.