Industry Watch

Hybrid model: The Urgency Room center in Eagan.

A sense of ‘urgency’

Why hybrids of emergency rooms and urgent care centers are gaining traction in Minnesota

In the fall of 2010, Twin Cities health care consumers were introduced to a new type of clinic when Minnetonka-based Emergency Physicians Professional Association (EPPA) opened its first Urgency Room in Woodbury  one of the first of its kind in the nation. A hybrid of an emergency room and an urgent care center, the Urgency Room is designed to offer emergency room–level care at lower urgent-care prices.

Last October, EPPA opened its second Urgency Room in Eagan, and it expects to open its third next month in Vadnais Heights.

The hybrid model seems to be gaining traction. Several other Twin Cities providers have opened similar ER/urgent care clinics. As a result, Twin Cities patients who need same-day walk-in care for illness and injury have more choices.

In late April, Robbinsdale-based North Memorial Health Care opened the North Memorial Urgency Center at Blaine Medical Center, in partnership with Multicare Associates, a Fridley-based physician group. The facility is staffed by board-certified emergency medicine physicians from North Memorial's Level I Trauma Center who focus on high-acuity cases. Multicare, which has a primary care clinic on-site, can provide urgent care services to some patients suffering from less-severe conditions. The center  has some equipment more often found in emergency rooms, including CT scan, ultrasound, and MRI machines, which makes it a hybrid ER/urgent care center, similar to the Urgency Rooms. Patients needing to be admitted to a hospital can be transported by ambulance to an appropriate facility.

Another freestanding ER and urgent care facility is Ridgeview Medical Center's Two Twelve Medical Center, which opened in 2011 at Highways 212 and 41 in Chaska.

In January, Abbott Northwestern, part of Allina Health and one of Minnesota's urban hospitals, opened an ER at its WestHealth campus in suburban Plymouth  where it also offers urgent care. The facility behaves like a freestanding ER, but it's physically attached to WestHealth.

Because care provided by emergency rooms tends to be relatively expensive, health insurers have expressed concern that a proliferation of freestanding ERs might drive up health care costs. Having both urgent care and ER care at the same or nearby locations is a way to prevent costly over-reliance on emergency care, providers say.

WestHealth has set up a system to "triage" every patient  determine whether urgent care or ER care would be most appropriate and direct them accordingly, says Ben Bache-Wiig, president of Abbott Northwestern Hospital. "In some places, if you go to an ER at 3 a.m. for treatment of a strep throat, you are charged with an ER visit; at our facility, that would be considered an urgent care visit," and therefore be less costly.

What's the difference between urgent and emergency care? Urgent care is intended to "manage a fairly limited set of problems, and they are rarely 24-hour-a-day operations, and rarely equipped to handle ambulances," Bache-Wiig says. Typically, fewer than 1 or 2 percent of urgent care patients would require transfer to another facility. Most of the care is provided by physician assistants or nurse-practitioners.

Emergency departments are required to be open around the clock and staffed by at least one board-certified emergency-medicine physician. As many as 5 to 10 percent of ER patients may require hospitalization, according to Bache-Wiig.

WestHealth has also partnered with Children's Hospitals and Clinics of Minnesota, which provides pediatric care at the WestHealth ER.

Abbott Northwestern doesn't have plans to open any more freestanding urgent care or ERs "at this point," Bache-Wiig says, although Allina is considering opening a freestanding emergency facility, using WestHealth as a model.

One challenge for health care facilities not located on a hospital campus is making sure that staff and other resources are in place to handle whatever comes in, Bache-Wiig says. "When you have an ER in a hospital, it's easy to shift resources as needed. So, it's been challenging to build a new (freestanding) model and make it work. But it's gone very well."

While providing more convenient access to walk-in care is the primary goal, Twin Cities providers are also responding to competition and other changes in the health care marketplace, according to Stephen Parente, a University of Minnesota health care economist.

They're adding outpatient centers to prepare for the impact of the Affordable Care Act in adding new, insured patients to the nation's health care system in 2014, when the law takes full effect, says Parente, who is director of the Carlson School of Management's Medical Industry Leadership Institute and a professor in the finance department, as well as the Chair of Health Finance at the Minnesota Insurance Industry.

Health systems want to make sure they have care-delivery networks in place and that they can provide care for less than their reimbursement, thereby making a profit. "There's enough ‘commoditization' of some services clinics offer to make it worth their while," Parente notes.

The impact of the Affordable Care Act was not a primary driver for WestHealth, Bache-Wiig says. For the inner-city hospital, opening the suburban facility is a response to consumers' desire to receive care close to home.

One reason urgent care provided at standalone centers is less expensive than in-hospital care is a difference in billing practices. Hospitals typically charge both a facility fee and a professional fee. Standalone centers do not charge facility fees. And, using non-physician practitioners to deliver routine care means the cost to patients "can be a little lower," Parente says.

Providers are also responding to new competitors in the form of walk-in retail clinics, such as those operated by Target.

To compete, urgent care centers are staying open longer hours to accommodate the needs of families juggling work and child-care responsibilities, Parente says.

"Providers have realized that a 9-to-5 clinic is a nice idea, but a lot of people are working longer hours, are single-parent families with (childcare) responsibilities at different hours." By staying open longer, providers "are going to find a whole new set of people trying to get in for care on a ‘catch as catch can' basis, just like at the retail clinics."

The trend is also being driven by a cultural change, Parente contends: younger consumers' acceptance of having a "retail-like" relationship with care providers, as promoted by the in-store walk-in clinics. Studies indicate that about 25 percent of patients who seek care at ERs don't have a primary care physician, according to Bache-Wiig. "We try to make sure that those patients get referred into a primary care clinic."

While baby boomer-and-older patients may be accustomed to having a designated primary-care physician, "a lot of younger folks haven't established relationships with primary care physicians," Parente points out. "Providers are realizing that (outpatient) primary care can be a gateway to establishing longer-term relationships."

Is it possible the Twin Cities market will reach a saturation point in the next few years? He doesn't think so. "The market will probably identify what makes sense or doesn't."

As in most other health care trends, the Twin Cities area "is probably a bit ahead of the curve" nationally in its proliferation of freestanding centers, Parente says. With many physician practices owned by hospitals  and a number of large, independent practices "we have a more integrated delivery system than most other communities."

Eric Hoag, senior director of provider contracting for Blue Cross and Blue Shield of Minnesota, declined to make a blanket statement on the cost-effectiveness of the standalone urgent care/ER model that can triage patients through a dual track of services. "It does provide more up-front ability to assess proper acuity" as patients come in, he says. "As an organization, we are always looking for opportunities to ‘drive' affordable care; our interests and those of providers are aligned on that."