When Cheryl Samilio Meyer suffered an allergic reaction to wasp stings this summer, she steered clear of crowded emergency rooms and instead headed straight for an urgent care center.
The Amherst resident chose an Immediate Care center in Buffalo, with its comfortable hotel-like ambience and short wait.
“It was convenient. I came on a Saturday, and you’re not going to get your doctor on a Saturday,” said Samilio Meyer, who had been there before.
In less than a decade, urgent care here has mushroomed from a handful of pioneers.
Facilities dot the landscape, especially in the more-affluent suburbs. They range from physician practices with extended hours to chain-operated centers offering advanced services like X-ray and laboratory testing.
Among the thousands insured by BlueCross BlueShield of Western New York, urgent care visits increased 135 percent from 2010 to 2012.
Nationally, the number of new centers opening doubled in each of the past two years from about 300 to 600. That brings the total to about 9,000 in business last year, according to the Urgent Care Association of America.
Twenty-one centers operate in Erie County, and more are likely to open as health reform extends insurance to millions of Americans.
The facilities fill a gap, particularly at night and on weekends, offering walk-in attention to patients like Samilio Meyer for cuts, sprains and respiratory infections.
But as the demand grows, so do concerns and conflicts:
• Insurers and others had hoped urgent care centers would control costs by preventing patients with minor problems from using expensive hospital emergency departments. Instead, it remains unclear whether this has happened, and insurers are battling with centers over payment rates.
• The centers appear to be attracting patients with conditions that primary care physicians could treat at a lower cost.
• The urgent care business is largely a suburban phenomenon, with little development so far in the city or rural areas.
• And urgent care is mostly an unregulated industry in New York, with no requirements to meet certain standards for accreditation and not even an agreed-upon definition of what constitutes an urgent care center.
“Urgent care entrepreneurs have identified a consumer need and are filling it,” said Alwyn Cassil, spokeswoman at the Center for Studying Health System Change. “The real question is why patients don’t find it convenient to go to their primary physician.”
The center recently published one of the first studies of urgent care. The conclusion: A lack of data makes it hard to know if the growth of urgent care centers saves money by diverting patients away from emergency departments or increases costs by drawing patients from primary care practices.
Urgent care centers in the study were not seen as a major disruption yet of doctor-patient relationships. But their rise suggests big changes under way in how Americans get care.
Conditions in Buffalo remain just as murky.
“The centers have not yet been successful at controlling health costs, and they have pulled volume away from primary care doctors. But what’s happened is not all on urgent care centers and the insurers,” said Dr. Raghu Ram, vice president and chief medical officer at BlueCross BlueShield of Western New York.
He and others say Buffalo, like the rest of the nation, suffers from a shortage of primary care doctors for adults, such as family physicians and internal medicine specialists. That shortage coincides with increasing patient demand for convenience.
Ram said that unless physicians change their practices, such as expanding use of nurse practitioners, it will be difficult to consistently offer the same-day appointments and extended hours of urgent care.
“The health care system is broken. There is a shortage of primary care physicians because they are underpaid compared to specialists,” said Dr. Richard Dudrak, medical director of Urgent Care at Lifetime Heath. “Urgent care is the Band-Aid on the system, and it is a needed Band-Aid.”
To influence where patients go for care, insurance companies set urgent care co-payments lower than those for emergency departments but higher than fees for doctor visits.
Unlike hospitals, which are subject to government regulations, most urgent care centers are considered physicians’ offices, so there is little data reported about them. Information obtained from Buffalo-area insurers and hospitals offers a mixed picture.
Emergency department statistics since 2009 from the four Kaleida Health hospitals and five Catholic Health facilities show little change through June 2013 in activity.
The large increase in urgent care visits by BlueCross BlueShield customers in the region didn’t result in lower use of emergency rooms. Instead, the company reported that emergency department visits increased 18 percent from 2010 through 2012.
Dr. Thomas Foels, chief medical officer at Independent Health, said the insurer is seeing urgent care draw patients who can’t be seen immediately by physicians, as well as patients who might not have sought medical attention for minor problems.
“Urgent care is creating its own demand – visits that otherwise would not have occurred,” he said.
But at Independent Health, he said, patients appear to be using urgent care only occasionally and for certain issues, and not as a substitute for regular doctors.
At Univera Healthcare, the Buffalo-area arm of Excellus Blue Cross Blue Shield in Rochester, emergency room visits declined 3 percent, physician office visits increased 3.7 percent and urgent care visits rose 27.3 percent over one year, ending in March.
“Urgent care centers tell patients to follow up with their doctor, so the increase in our physician visits could be that. But you have now created two office visits,” said Dr. Richard Vienne, chief medical officer at Univera.
Filling a niche
Three urgent care organizations dominate the local market: MASH, with seven centers; Immediate Care, with five; and Lifetime Health, with three.
The centers operate largely in higher-income suburbs, with their larger proportion of insured individuals and proximity to retail centers.
Expanded insurance coverage under health reform will make the city more attractive, officials say.
Rural areas, with their small, scattered populations, pose a different challenge. But those in the industry said rural development is possible if facilities can lower operating costs to make it financially viable.
Immediate Care and MASH started small in the early 2000s. Now, they’re part of much larger companies.
Immediate Care is operated by the Amherst-based Exigence Group, which was purchased last year by TeamHealth Holdings Inc., a national physician staffing company in Knoxville, Tenn., that sought expertise to expand into urgent care.
MASH is operated by MedFirst Urgent Care, now a subsidiary of Buffalo-based Snyder Corp.’s Innovative Health Services of America. Ownership is split between the physicians and Snyder. Snyder also owns We Care Transportation, whose vehicles were renamed MASH to create a common brand.
The services are similar, and both groups employ physicians certified in advanced life support. Immediate Care is accredited by the Joint Commission, a nonprofit organization that sets medical standards; MASH is seeking accreditation.
Immediate Care treated 151,000 patients in 2012, most of them in Western New York. The group also operates centers in Rochester and Austin, Texas.
“We don’t supplant primary care doctors. We supplement them,” said Salvatore C. Durante, manager of urgent care operations. “We know our niche, and we do it well.”
Like other urgent care centers, Immediate Care sends patient records to their doctors. He also said surveys of Immediate Care patients indicate that they would have otherwise gone to an emergency room.
MASH saw 50,000 patients in 2012, but opened three new locations this year. By late summer 2013, visits totaled about 70,000.
Urgent care initially pulled patients away from doctors, but the landscape is changing as physician groups and insurers align with certain centers, according to Dr. Mark Pundt, MASH’s chief executive officer.
MASH has approached physicians, looking to establish arrangements that make the urgent care center an extension of the doctors’ practices.
“We want them to know that we’re not in the business of taking away all of their sore throats,” he said.
Lifetime Health operates differently because of its link to the insurer Univera. It began after-hours visits for patients years ago at its medical centers and in 2010 changed the name at three facilities to Urgent Care by Lifetime Health.
Shake up in urgent care
A shake up in the urgent care business is in the works.
Earlier this year, Univera announced it would no longer provide coverage for Immediate Care after the two organizations failed to come to terms on reimbursement rates.
The Catholic Health hospital system, BlueCross BlueShield and Independent Health recently partnered with MASH on programs with groups of physicians to establish guidelines for urgent care use, patient referrals, and communication back and forth.
BlueCross BlueShield on Nov. 6 announced that it would no longer consider Immediate Care a participating provider after the urgent care company rejected its rates. Immediate Care has contended the insurer wants to significantly lower reimbursement to the level of “less qualified” providers.
Disagreements with urgent care centers go beyond payment, according to the Blues’ Ram.
“An urgent care infrastructure – with X-ray, CT scans and labs – has been built to treat higher-level conditions – things like lacerations and minor fractures. Yet centers tend to treat a lot of low-intensity medical problems that should go to doctors. That has to change if we’re going to get value out of the centers,” he said.
An emerging model
Buffalo Medical Group may be the model for where things are headed.
Over the past year, the large physician practice has worked with MASH on a common electronic medical record.
That means doctors at MASH should know immediately the medical history of medical group patients, and the medical group’s doctors should know what happened at MASH.
Emergency room use by patients in the group’s primary care division is about 35 percent below the community average as a result of the arrangement and other measures, said Dr. John Notaro, associate medical director.
Meanwhile, the state is considering regulation.
A Health Department advisory panel in October released options that include defining the scope of services for urgent care. The Public Health and Health Planning Council has yet to act, but officials voiced skepticism about injecting new rules into a business being transformed by players in the marketplace.