Lee A. Resnick, MD, FAAFP
If history repeats itself, then we just may be in big trouble. Many of us remember the doc-in-the-box days of the early 80s, when the first urgent care boom occurred. There was a wild proliferation of urgent care centers, driven mostly by physician entrepreneurs looking to make a quick buck. By 1985, in excess of 3,000 centers dotted the country. The following decade brought significant contraction within the industry, before the rebound we are now witnessing that began in the late 90s.
I believe that there were two factors contributing to lean years in the industry.
First, was managed care. Urgent care centers did not fit into the managed care model very well, and despite the lower cost of care vs. the emergency department, declining reimbursement and capitated payment methods made it very difficult for urgent cares to generate enough revenue. With high site development and labor costs, a number of centers went bankrupt or sold out to large healthcare organizations. While, perhaps, no one predicts a complete re- turn to the managed care days, hints of the same (e.g. “Ac- countable Care Organizations”) are beginning to re-surface. Less discussed, but no less important, was a failure of quality control. With a limited physician workforce amid efforts to staff the centers for extended hours, urgent care centers were increasingly turning to less skilled physicians and residents. Moonlighters from numerous specialties, from orthopedics to urology, and residents of all levels were staffing the urgent cares and delivering sub-par care outside of their expertise. Quality control and standards of care were disregarded in favor of fast money and convenient staffing. A crisis in quality was quickly followed by a crisis in confidence, and the once promising industry went into a tailspin. Urgent care was then, and remains now, attractive to in- dependent-minded physicians looking to apply standard business practice to a healthcare delivery model. Exceptional customer service, strong financial management, cost control, marketing, and retail conveniences are often applied.
I have no issue with applying a “retail” standard to urgent care, but consider this: If urgent care is a retail business, then what is our product? And how do we ensure that product is of high quality, and delivered in a consistent manner? If Star- bucks served bad coffee, it really wouldn’t matter much that they pick the best real estate or have the friendliest baristas; they would fail.
Urgent care is no different. The urgent care “product” is the provider–patient encounter. It is a clinical product dependent on the knowledge and expertise of the provider across the core competencies of the discipline.
It is worth noting here that urgent care providers do not receive consistent training across the spectrum of urgent care core competencies. There are only a handful of formal clinical fellowships, ultimately representing a tiny fraction of the urgent care workforce. Urgent care centers are staffed with physicians from multiple specialties along with physician assistants and nurse practitioners, all with variable expertise and all with variable gaps in competency. And yet, only a small number of urgent care practices make much of an effort to thoroughly assess competency and offer focused training and education opportunities to fill gaps.
This represents the perfect storm for a crisis in quality. The success of the urgent care model cannot be predicated on access, convenience, and customer service alone.
Our “customer” is not ignorant. As were the ghosts of urgent care past, we too shall be judged on the quality of our product. And if we fail to consistently deliver a quality clinical product, our industry will fail, regardless of how we pick real estate or how friendly our baristas are.