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Saturday, February 13, 2010

My encounter with an urgent care clinic

I have had frequent encounters with the medical care system through my children recently. Today, my college aged son came home with complaints of a severe sore throat, fever, and adenopathy. Student Health at his school is not open on Saturday leaving me with the option of treating him empirically, taking him to the Emergency Department at my own institution, or visiting a local urgent care center. I have driven past this urgent care center for at least a year, always wondering who  staffed this operation and how busy they were. I decided it was worth a try to get an evaluation and perhaps a rapid strep or monspot test.

It was the right decision. We were able to drive right up to the building and park. We enrolled quickly and our insurance information was processed immediately. After a brief wait, we were evaluated by an efficient staff and the Emergency Medicine trained physician quickly identified the suppurative pharyngitis which I missed with my flashlight exam at home.

I got to speaking to one of the owner operators regarding his business and his clients, which included patients sent by a number of prominent department chairs at my own institution. Basically there is no way large integrated healthcare systems to deal with mundane yet urgent medical matters without both substantial costs and inconvenience of patients. Most of us actually realize this. The local urgent care centers have a defined value added model and operate in lower cost real estate. They can truly handle the mundane, generally non-life threatening scenarios better, faster, and cheaper. If we are advocates of our patients, why would we not utilize such resources?

This is an example of what David Ricardo, the famous English economist of the early 19th century described as the law of comparative advantage. the definition on Wikipedia is as follows:

In economics, the principle of comparative advantage refers to the ability of a party (an individual, a firm, or a country) to produce a particular good or service at a lower opportunity cost than another party. It is the ability to produce a product most efficiently given all the other products that could be produced.[1][2] It can be contrasted with absolute advantage which refers to the ability of a party to produce a particular good at a lower absolute cost than another.
Comparative advantage explains how trade can create value for both parties even when one can produce all goods with fewer resources than the other. The net benefits of such an outcome are called gains from trade. It is the main concept of the pure theory of international trade.
In short what this means is that one does not try to grow pineapples in  Nome, Alaska. The environment is just not right and although you can invest resources to change that environment, it makes more sense to grow the pineapples where the environment is right. Similarly, dealing with mundane but urgent medical problems in an environment constructed to deal with life threatening emergencies is like trying to grow pineapples in Nome. It can be done but is very expensive and does not work well.

The arguments against the development of convenient urgent care centers focus on the need for cross subsidies to support the missions of conventional emergency rooms. If the urgent care centers bleed off the simple patients which so happen to be most lucrative, where does that leave the emergency rooms? That argument might have some merits, but the problem is not with the urgent care centers. It is with the payment system which uses administrative pricing formulas and  sets the prices wrong. No subsidies would be needed if the payment for true emergency room services was actually correct. As long as they are set by administrative fiat, they will always be wrong.


  1. Hoohaaa...someone who gets it!

    Peter Lamelas, MD, MBA, FACEP
    Medical Director, MD Now Urgent Care Walk In Medical Centers, in Palm Beach, Florida.

  2. I am surprised that hospitals across the country are not setting up Urgent Care Centers adjacent to ERs, so that patients can be triaged there, rather than gum up the acute care ER. While this would make ER care more efficient, it would draw business from surrounding primary care and Urgent Care Centers. Every reform hurts someone.