When a patient is feeling pain in their chest, they’re likely unsure about where to go: do they call 911, go to the emergency department, go to an urgent care center, or make an appointment with a primary care physician?
It’s not an easy decision and it’s not easy to explain.
Urgency or Emergency?
Some conditions are considered absolute emergencies: heart attacks, strokes, sepsis, anaphylaxis, and gunshot wounds are just some of the medical conditions that are universally considered emergencies. They must be evaluated and treated in the emergency department. If a patient goes to an urgent care center with a true medical emergency, the urgent care staff should send them to the emergency department anyway, often by ambulance and often at a substantial cost.
That’s just a small sample of what constitutes an emergency. The list is a lot longer and it always includes a diagnosis. In other words, one almost has to know they’re having a heart attack in order for it to be a real emergency.
Isn’t it the responsibility of the emergency department to tell patients if the symptoms they’re experiencing are signs of an emergency? I’d say it is and the American College of Emergency Physicians agrees with me, but not all medical insurances do. More on that below.
Urgent Care Centers
So, when should patients go to the urgent care center? That’s not an easy question to answer.
One might hear the term “urgent care center” and assume that “urgent” means this is a place where serious medical conditions can be treated in a similar, if not identical, manner as in an emergency department. The truth is: every state is different. Some states consider urgent care centers nothing more than glorified physician offices. Other states treat them like stand-alone emergency departments (a third option that we’ll cover below) regardless if stand-alone emergency centers are even an option in that state.
Urgent care centers might be staffed with physicians or they might be staffed with nurse practitioners or physician’s assistants, depending on the state. As individual state legislatures address the needs of their populations, the rules change quickly.
With such irregular regulation, going to an urgent care center for a true medical emergency is a gamble unless the patient is very clear in advance what a particular urgent care center can handle. In most cases, people should treat the urgent care center the same as the doctor’s office. It just has more flexible hours.
Would you visit the doctor for a sore throat? Sure, and that is a decent option for an urgent care center. A spider bite or skin infection? Perfect for the urgent care doc, too.
Who Pays the Tab?
The whole concept of urgent care centers was born out of runaway healthcare costs. Folks regularly go to the ER when they could’ve gone to their private doctor for substantially less cost. Compare the bills for an emergency department and an urgent care center side by side, and you’ll see that urgent care centers are almost always substantially less expensive when the medical condition is something they can treat.
That doesn’t mean it’s always cheaper for the patient to go to an urgent care center. Even taking away the possibility of a serious medical emergency—one that requires ambulance transport from the urgent care center to the ER—comparing cost is really not apples to apples.
Insurance companies (also known as payors) usually contract with facilities and physicians (and sometimes ambulance companies) to get the best prices. There are networks of facilities and physicians that might be cheaper options for payors. The patient’s portion of the bill (co-payments, deductibles, or co-insurance) varies greatly depending on their insurance company, their coverage plan, and whether the facility or the doctor is in the network or not. It’s one of the most complicated financial processes that many consumers will ever face.
If urgent care is not in the network, but the emergency department is, it could end up costing the patient less to visit the more expensive option.
Let’s break it down: If both the emergency department and the urgent care center are in (or out) of the network, payors night not want to pay for the ER if it isn’t an emergency. Payors often feel it’s an unnecessary expense to pay for an emergency physician to examine and diagnose a complaint unless it turns out that the complaint is truly worthy of the emergency department.
How do patients know if their medical condition is a worthy emergency? The payor determines whether the patient’s judgment is correct using the doctor’s diagnosis, something they don’t know until they get there.
Some emergency departments have urgent care areas built-in, and the patient is easily moved from one area to the other based on a medical condition. These are my favorite. The patient (or the insurance) is charged based on which path the patient needed to take. That way, patients who get a lower deductible for visiting the ER only if the diagnosis is a real emergency won’t get charged the extra cash if they’re wrong. They’ll only be charged the more expensive emergency department bill when it’s appropriate, and when the insurance will pick up a larger chunk of the tab.
Many times, payors will use hospital admission as a litmus test to determine if the patient was truly sick enough to go to the ER. If the patient is admitted to the hospital, the payor might reduce or waive any co-pays or deductibles. On the other hand, if the patient is not admitted, they’re on the hook for the entire deductible or co-pay. It’s the benefit of hindsight and it only helps the insurers.
Payors do the sliding-scale deductibles as a disincentive for choosing the emergency department as first-line medical care. Most patients, however, don’t have a choice. Physician visits might not be available same-day. Patients don’t plan to get sick, and ERs are usually open 24 hours a day. Urgent care centers were meant to close that gap. It’s a doctor’s office that caters to last-minute appointments and walk-ins. Unfortunately, not all things that look like clinics are the same.
Freestanding Emergency Rooms
A freestanding or stand-alone ER is a relatively new invention cropping up all over the country. A 2017 NBC News story reported that 35 states allowed freestanding emergency centers. These aren’t emergency departments necessarily, because they aren’t always associated with actual hospitals. In many states, these emergency centers are allowed to be owned by physicians.
Stand-alone emergency centers might look very similar to an urgent care center. They often open in the same places: malls and retail districts. They won’t be adjacent to a hospital—at least not in the same building—and they may or may not have an ambulance entrance.
Most of these facilities advertise a full range of services, but the reality is that any patient who needs admission to the hospital will probably have to be taken there by ambulance. Show up with a stroke or a heart attack and true definitive treatment might have to wait until the ambulance responds and transports to the actual emergency department.
The Bottom Line
The ER, also known as the emergency department, is the definitive immediate-need healthcare option. This is the place patients can go for any level of a medical condition, regardless of how severe or benign. Emergency departments are also the most expensive option.
An ER visit bill will almost always be north of a grand. A trip to the urgent care center or to a doctor’s office, on the other hand, is likely to be two or three hundred bucks, tops. It’s important to understand the differences—and educate patients on the difference—so that they can make a better decision.