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Urgent Care Centers Seek Payment for Wider Scope of Practice

from AIS Health

Author: UCA Admin/Wednesday, September 18, 2019/Categories: Industry News

(from AIShealth.com)

September 16, 2019


On the surface, health plans and urgent care centers should be on the same team — after all, insurers are increasingly nudging their members to choose urgent care over the emergency room for less-serious issues like strep throat or a broken wrist.


Yet in a lengthy statement issued Sept. 9, the Urgent Care Association (UCA) made clear it has a major bone to pick with payers: It says they often refuse to reimburse urgent care centers for providing follow-up care and wellness care, like immunizations, despite patient demand for such services and many centers’ willingness to meet that demand.


Laurel Stoimenoff, CEO of the association, tells AIS Health that the main issue is “a disconnect between our reality working in urgent care and what’s being written into contractual language.”


“We’re either treating people who have no PCPs [primary care physicians], in many cases, or who are geographically displaced from their PCP,” she says. As an example of the latter situation, Stoimenoff points to a person who lives in Los Angeles but is traveling for work in Philadelphia and visits an urgent care center to be treated for pneumonia. If that patient needs follow-up care while still traveling, the center might hesitate to provide it out of concern that a payer won’t reimburse for that care, she says.


Stoimenoff also highlights the fact that UCA’s 2018 benchmarking report found 35% of patients seeking care in an urgent care center are unaffiliated with a PCP or medical home. One problem is there aren’t enough PCPs; in fact, the UCA notes that the Association of American Medical Colleges predicts a shortfall of between 14,800 and 49,300 primary care physicians by 2030. (Urgent care centers, meanwhile, are proliferating: a 2018 FAIR Health study of insurer claims found that urgent care center utilization grew by 1,725% from 2007 to 2016).


But another reason is likely that many primary care practices operate during business hours Monday through Friday, when potential patients have to work, Stoimenoff points out.


The result is that urgent care centers — which are often open on nights and weekends — report patients are calling to ask if they can schedule an appointment for a physical or immunization, and because of reimbursement limitations, the centers can’t always provide those services. Or, patients have to pay out of pocket for those services — something some opt to do, which “tells you there’s a need,” she says.


The major trade group representing health insurers, though, doesn’t see it that way.


“While urgent care centers are an important venue for care and can be an efficient and cost-effective alternative for an emergency room, for example, they are not [a] substitute for a person’s ongoing relationship with their primary care physician,” an America’s Health Insurance Plans (AHIP) spokesperson tells AIS Health. “We will continue to work closely with all types of care providers, including urgent care centers, to ensure patients have access to quality, affordable and comprehensive care.”


So which side has the more valid argument?


To Joseph Paduda, a principal with Health Strategy Associates, LLC, health insurers that refuse to reimburse urgent care providers for non-urgent care “are well within their rights to do so.”


“Payers reimburse urgent care for just that — emergent care,” he says via email. “Follow up care should be provided by the patient’s primary care provider. If the Urgent Care providers want to become primary care providers, they should seek to contract with health plans.”


Yet Fred Bentley, of the consulting firm Avalere Health, says he can see where the UCA is coming from.


“I think there is a legitimate argument or question about, why is it that health plans are restricting access and really trying to, in some instances, keep urgent care centers in a box — in terms of, ‘You deal with urgent issues, you don’t do wellness, you don’t do preventive services, you don’t do screenings, you don’t do follow-up care,’” he says. “It’s a really old way of thinking.”


While the UCA’s position statement takes aim at payer policies, the real “tug of war” is between urgent care centers and primary care practices, which would argue that they are better equipped to provide continuous care to patients rather than “episodic, disjointed, fragmented services,” Bentley says.


Indeed, AHIP’s statement to AIS Health says that at the center of a patient’s care “should be an ongoing relationship with a primary care physician, who knows the patient, can help patients navigate the system, and ensure they receive care that meets their specific needs.”


Payers May Fear Pushback From PCPs

Because there’s such demand for primary care services — and generally not enough supply — allowing urgent care centers to provide such services likely won’t be much of a business threat to PCPs, Bentley argues. But payers are still likely concerned about the pushback they’d receive if they expanded urgent care centers’ scope of practice, given that “the bedrock of any provider network” is primary care, he says.


“I also think there’s just a utilization control component to this — a concern on the part of payers [that] ‘We need to really tightly manage these urgent care centers,’ some of which are for-profit chains,” he adds. “There’s just a concern that they’re going to be ginning up utilization and running up the tab.”


A March 2016 study published in the journal Health Affairs made such a case about retail clinics, analyzing data from Aetna Inc. and finding that between 2010 and 2012, 58% of retail clinic visits for low-acuity conditions represented new utilization. It further concluded that retail clinic use was associated with a $14 per person per year increase in spending.


Stoimenoff says she’s heard the argument against on-demand providers that “sometimes you’re creating too much access for care.” Yet she points to a 2017 study of Blue Cross Blue Shield of Texas claims data, which found a 60% overlap in the 20 most common diagnoses at hospital-based emergency rooms and urgent care centers — despite the ER being 10 times more expensive on average. “To me, that’s proof” that urgent care centers can be part of the solution to creating more health care value, she says.


ER, Primary Care Are ‘Overburdened’

UCA appreciates that insurers are educating members about choosing urgent care centers over the ER to treat less-serious conditions, Stoimenoff says. She also notes that urgent care centers frequently advise patients to affiliate themselves with primary care doctors to get a chronic condition like diabetes under control. But both the ER and primary care are overburdened systems, and “we sit right in the middle of them and have capacity in many cases,” she continues. “That’s what I’m saying; let’s leverage that capacity.”


So far, though, payers have shown little interest in taking the UCA up on that offer. “We have tried to have discussions with some of the other associations, and we really haven’t gotten very far,” Stoimenoff says. “That’s why we wrote this position statement; it’s almost a cry for help.”


To get insurers to actually change how they reimburse urgent care centers, it would probably take “a groundswell of their members saying, ‘What do you mean I can’t go in for an immunization, what do you mean I can’t get the school physical here?’” Bentley says. “They are service organizations; they respond to their customers.”


However, the onus is also on the urgent care sector to present data to payers that shows they should “be thinking more expansively” about what that branch of the care continuum can do, in the interest of preventing downstream ER utilization, he contends.


In many ways, primary care already is evolving — for example, with the rise of staffing models that elevate the role of advanced practice nurses, Bentley points out. “So you could imagine in five to 10 years’ time, the line that we think is such a bright line between a PCP’s office and an urgent care center and a retail clinic, those really start to blend.”


Read the Urgent Care Association’s statement at https://bit.ly/2kcAyeM. Contact Stoimenoff via Mary Velan at mvelan@lcwa.com, Paduda at jpaduda@healthstrategyassoc.com and Bentley at fbentley@avalere.com.


by Leslie Small


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