Published on

 URGENT MESSAGE: Whether an urgent care center should be open 365 days per year or close on major or minor holidays depends upon factors that influence profitability, such as patient demand, competitive positioning, staff availability, payer reimbursement, and the branding impact of after-hours accessibility.

Alan A. Ayers, MBA, MAcc is Practice Management Editor of The Journal of Urgent Care Medicine, serves on the Board of Directors of the Urgent Care Association, and is Vice President of Strategic Initiatives for Practice Velocity.

 As urgent care operators look to the coming holiday season while simultaneously laying strategic plans for the new year, many are faced with the question of how they should approach holiday operating hours.
For example, should a center open its doors on Thanksgiving, Black Friday, Christmas, New Year’s Day, the Fourth of July, or Labor Day? And if so, are full-day operations in order, or should a center offer truncated hours in the interest of keeping operating costs down?

Ideally, a best-in-class urgent care center will be open for business 12 to 14 hours a day, 7 days a week, 365 days a year, reinforcing the “care when you need us” ethos that successful urgent care brands strive to embody. Thus, holiday hours serve to underscore the dual value propositions of urgent care—that fast, convenient medical care is accessible even when primary care isn’t, and that substantial cost/time savings can be realized by foregoing the emergency room for minor injury/illness.

Conversely, the difficulties of provider holiday scheduling, the desire for staff to enjoy time off with their families, and the need to maintain profitable operations can discourage some centers from offering holiday hours.

 Why Holidays Can Be Busy Times for Urgent Care
When considering holiday hours, an urgent care operator may start by examining anticipated patient demand. First, as primary care offices are closed on major holidays, people with emergent medical needs have their options narrowed to two: the ER, or an open urgent care facility/walk-in clinic.
Second, unexpected illness and injury don’t take a holiday just because we do; in fact, many urgent care centers report increased patient encounters on holidays due to causes such as:

  • Injuries from cooking accidents―These run the gamut from burns caused by dangling sleeves over hot stoves, haphazard rushing to remove meals from ovens, or general carelessness around outdoor grills. Lacerations, presumably from carving meat, are also seen more often on holidays.
  • Decorating―Knee, ankle, and hip sprains from slips and falls due to scaling roofs to hang holiday decorations (eg, Christmas lights, July 4th bunting, etc.) and climbing stools and ladders to adorn trees, bushes, and awnings with decorations put many celebrants on the wrong end of gravity.
  • Heartburn/indigestion―Overindulging in food and drink can lead to gastrointestinal issues, which can also induce chest pains that mimic a heart attack in some patients.
  • Food-borne illness―Undercooked meat, mishandling of raw meat, improper storage or thawing of holiday cuisine (eg, foods prepared with eggs, mayonnaise), or cross-contamination can result in salmonella, E coli exposure, and other hazards.
  • Holiday events―5/10k fun runs, days at the lake, golf tournaments, and other physical activities tend to occur on holidays, and physical activity always presents risk of unexpected injury.

So, whether it’s a youngster awakening Christmas morning with pinkeye, or a weekend warrior who overdoes it at the annual Fourth of July festival, an open urgent care center can expect a steady stream of patients on the holidays. After all, urgent care centers are marketed as physician-centered medical facilities that fill the gap between primary care and the ER, and this is never truer than on the holidays.

 Building a Financial Business Case for Holiday Hours
Once holiday patient demand has been clearly established, a center should next attempt to correlate demand with profitability. To do so, an owner/operator can create a single-day profit-and-loss statement designed to reconcile the incremental cost of business operations on a holiday against the incremental revenue anticipated from patient encounters, as illustrated in Exhibit 1. To identify the number of patients required to break even, divide incremental operating costs by incremental revenue per patient.

 Exhibit 1: Single-Day Profit-and-Loss Statement: Financial Consideration of Opening on a Holiday
Holiday hours can be considered profitable if the incremental revenue generated on the holiday exceeds the incremental cost of opening.

Incremental Cost of Opening on a Holiday
Incremental costs are costs that would not otherwise be paid if the center had closed on the holiday. Fixed costs such as rent and equipment leases are thus excluded from the analysis because they’re the same regardless of whether the center opens. Variable costs of opening include:
· Direct hourly cost of providers and staff working on the holiday, including overtime and/or holiday pay
· Prorated share of benefits, paid time off, incentive pay, and other variable staffing costs per hour worked
· Costs of advertising the holiday opening (distinct from any regular, ongoing marketing program)
· Janitorial services, courier, security, and other services incurred on days the center is open
Incremental Patient Revenue Generated by Holiday Hours
Incremental revenue is simply the net cash generated by patient encounters on the holiday. This takes into account:
· Number of patient encounters multiplied by average net collections per patient, minus costs attributable to specific patient encounters, including billing fees, supplies, x-ray over-read fees, etc.
Incremental revenue per patient encounter = incremental patient revenue / number of patients seen
Profit or loss on holiday operations = incremental cost of opening – incremental patient revenue
Break-even volume for holiday operations = incremental cost of opening / incremental revenue per patient encounter

 Put simply, a center must see more patients than needed to break even to recoup the cost of opening and realize a profit on the holiday. Because overtime, holiday pay, and holiday advertising costs are not incurred on normal operating days, however, the incremental costs of a holiday opening will necessarily require a higher patient volume than on a typical day. Centers that truncate their holiday hours or serve a community with a smaller patient base will likely struggle to achieve break-even volumes.

Conversely, larger urgent care centers and multilocation operators who appoint a single center to handle the local holiday patient load from its other sites can often reach or exceed break-even volumes.
Regardless, single-day profitability, while relevant in the short-term, should not be the lone consideration when deciding whether holiday hours can benefit a center.

Payer Reimbursement for Extended Hours
With staffing costs being the greatest variable expense for an urgent care center, paying team members time-and-a-half, overtime, or even double-time in the absence of higher-than-normal patient volumes means the center loses money for that day. But because a center that doesn’t realize a profit on a given day will still reap long-term benefits from offering holiday hours, occasional operating losses can be accepted within the context of a broader marketing strategy. Nonetheless, lobbying payers to compensate extended holiday hours is one oft-overlooked way to help defray staffing costs that might otherwise persuade a center to shutter its doors on a holiday.
Current Procedural Terminology (CPT) codes 99050 and 99051 are add-on codes that medical practices can use to bill payers to help recoup the additional cost of being open extended hours, such as evenings, weekends, or holidays.

  • 99050: Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday, or Sunday), in addition to basic service
  • 99051: Service(s) provided in the office during regular scheduled evening, weekend, or holiday office hours, in addition to basic service

Not all payers will reimburse these “extended hours” codes—especially if the urgent care center is contracted at a flat reimbursement per encounter (ie, case rate) as opposed to fee-for-service—but many payers do recognize the value of extended hours and will indeed compensate, even if only occasionally.

A starting place should be to evaluate whether payers have expectations—by way of contracting as an “urgent care center”—that the center be open on certain holidays and if they do not, to identify whether they will reimburse “after-hours” codes. Urgent care centers (place of service=20) have reported success with some regional payers using the 99051 code on federal holidays while others have found payers unwilling to reimburse an urgent care center for any after-hours service. Centers contracted as “physicians offices” (place of service=11) have reported greater success using the codes with fee-for-service contracts. Also, note that Medicare and Medicaid will never reimburse these codes.

When facing payer denials of CPT 99050 and 99051 reimbursement, the trick seems to be presenting a compelling case that by offering holiday hours, the center effectively diverts patients who would otherwise visit the more expensive ER for treatment—which of course would mean increased costs for the insurance company.
When patients choose an urgent care center for treatment, payers realize considerable savings from what they’d have to pay for a comparable ER visit. Hence, some billing experts advise that a center bill 99051 or 99050 for all federal holiday services―whether they are compensated or not―and if necessary, bring the compiled archive of claimed charges to the next contract negotiation. It’s also worth exploring ways that payers can be enlisted to help steer patients to the center on holidays.

Holiday Hours’ Role in Center Branding
Going beyond single-day profitability and payer reimbursements, a center whose doors are open 365 days a year elevates its brand immeasurably. Being known as the urgent care center “that’s always open, even on the holidays” helps engender highly coveted top-of-mind awareness, as people experiencing holiday mishaps recall right away that the center is indeed open—irrespective of the season, or the particular holiday being observed. In a sense, being open every single day, including holidays, brings to mind attributes not typically thought of outside the retail sector, and certainly not in the realm of medical services. Urgent care centers have little in common with Walmart, but operators could do worse than having a brand synonymous with convenience and availability.

Additionally, consider the competition when evaluating holiday operations for the urgent care brand. It’s universally known that the ER is always open, but what about competing centers within the community? An urgent care competitor who is open sets a consumer expectation that “urgent care includes holidays,” and it’s best to follow suit. If competitors are closed, however, being open differentiates the brand significantly, and lends it a competitive advantage. Even if there’s insufficient local demand to justify holiday hours from a single-day profitability standpoint, the urgent care brand that puts patient convenience above all positions itself to attract more business in the long run.

How to Determine Optimal Holiday Hours
After the decision is made to provide holiday services, an urgent care center should follow standard guidelines in determining hours of operation, considering factors such as staffing and expected utilization, as outlined in Exhibit 2.

Exhibit 2: Key Factors in Determining Holiday Hours

· Historic utilization―Burns, cuts, and lacerations are generally the most common reasons for a holiday urgent care visit. Therefore, typical factors such as seasonality, time of day, historic peaks and troughs, and service type may deviate from the norm on holidays.
· Profitability of extended hours―Considerations include market size and expected utilization. Should a center offer truncated hours, which serves to provide limited holiday care while keeping staffing costs under control? Is the center only handling episodic encounters, or are other holiday-based ancillary services being promoted?
· New business attributable to extended hours―A center may indeed capture new patients who utilize a center on the holiday due to competing centers being closed, coupled with untenable wait times at an overcrowded ER.
· Competitors―As mentioned, holiday hours can be a key differentiator from competitors who forgo offering holiday services, and critical in achieving top-of-mind awareness within a market.
· Primary care availability―As primary care is rarely available on the holidays, an open urgent care center will undoubtedly capture patients who can’t see their PCP and don’t want to utilize the ER.
· Demographics―Assume the center has set the expectation within the patient base that urgent care will always be accessible, even on holidays. However, does the center operate within a cultural and/or religious patient base that’s less likely to observe typical Christian holidays―thereby interpreting a center’s being closed for the holidays as not truly serving them?
·         Provider/staff scheduling―Does a center have providers and staff willing to sacrifice time off with family and friends to help promote the value proposition of holiday hours? Note: A center should employ a rotating holiday schedule so that the same clinicians and staff members don’t have to work every holiday.

Taking these factors into account, each individual center operator can then determine the most favorable time slot. Would early morning to midafternoon coverage accomplish the center’s goals, or is a full-day schedule the better option for serving the community?

Marketing Holiday Hours
Whether attempting to boost profitability or simply furthering its branding goals, an urgent care center should actively advertise that it’s open for business on the holidays. Consumers won’t use a center if they don’t know it’s open, so a holiday-specific advertising campaign serves to contribute to the overall awareness of the center within its market and help drive patient volume.
A sample holiday urgent care advertising schedule is outlined in Exhibit 3. As the holiday draws closer, the promotional activities are ramped up, community awareness gains traction, and momentum builds toward peak holiday utilization.

Exhibit 3: Holiday Marketing Activity Checklist

One Month Out
· Schedule should be completed with medical and nonmedical staff committed to work on the holiday
Two Weeks Out
· Poster in every patient room, advertising that the center will be open on the upcoming holiday
· Signage at community events informing public of holiday business hours
· Notification of referral primary care physician (PCP) offices; craft signage for PCP office to display at registration window or in waiting room
· Direct phone call to large occupational medicine clients known to be open on the holiday (eg, Walmart, hotels, airport)
· Email blast to all other occupational medicine clients promoting the holiday hoursOne Week Out
· Advertisement in any weekly neighborhood papers (shoppers) indicating the center’s upcoming holiday hours
· Temporary exterior signage such as vinyl banners, sandwich boards, or plastic yard signs announcing to passers-by that the center is open on the holiday. Note: Holiday hours should be included on the signage.
· Signage on the center doors stating the center will be open on the upcoming holiday
· Signage at check-in/checkout counters, reinforced by staff mention
· Email blast to opt-in patient newsletter list
· Partner with PCPs so they’ll post message on their answering machine, instructing patients to utilize the urgent care when PCP offices are closed
· Email blast to the PCP’s distribution and/or posting to the PCP’s Facebook page/group
· Notification on the center’s Facebook page; prominently displayed notification featured on the center’s website home page

Day of Holiday
· Advertisement in the local daily newspaper indicating that the center is open today
· Participation/sponsorship of community holiday event (eg, July 4 parade, Thanksgiving Turkey
Trot, Christmas Festival of Lights, etc.)
· Promotional table in movie theater, shopping mall, or other high-traffic venue
· Mascot appearance at parks/lakes or stores/malls attracting and engaging holiday visitors
· Yard signs, flags, or mascot standing outside the center holding “We’re Open Today!” signage

While advertising that a center is open on a specific holiday can help drive utilization on that one day, keep in mind that an investment in holiday-specific advertising serves the dual purpose of raising awareness of the center, which contributes to volume on all other days.

For instance, in mid-November, a hospital-affiliated urgent care sent out a cute, attention-grabbing postcard featuring a gingerbread man with his arm “eaten off” and in need of urgent care to raise awareness of its Thanksgiving, Christmas, and New Year’s availability. The center experienced visit lift attributable to the direct mail campaign during the entire month of December.

Additional Holiday Considerations
Key to devising a successful holiday strategy is to take a holistic approach that considers the perspectives, needs, and options of all relevant audiences—patients, payers, occupational medicine clients, and your providers and staff. Thus, additional recommendations include:

  • Start out with limited holiday hours and expand the hours over time. A center that is open 10 am to 4 pm can easily meet patient needs on the holiday, then open earlier and close later as volume increases. It’s always better to expand hours than reduce them. Persistence is key, as it takes time for patients to learn when and how to use an urgent care center.
  • If participating in community events or grassroots activities related to the holiday―such as marching in a July 4th parade―the center should be open during the event. Otherwise, to communicate “We’re open to serve you—except right now” only serves to undermine the brand.
  • Tagline on year-round advertising indicating “Open 7 days per week, 365 days per year, including holidays.”
  • Consider the religious and cultural traditions of the center’s patient base. Patient populations in large urban areas are likely more diverse, less likely to observe Christian holidays, and may have greater expectations of 365-day availability than patients in more conservative communities of the “Bible belt” or of more traditional beliefs. Also, centers near tourist destinations may see an increase in holiday traffic.
  • For multilocation centers within a specific market, cross-promote the open locations with signage on the closed center’s doors, and change the closed center’s voicemail system redirecting patients to the open location.
  • Staff the center with a “skeleton” crew. To reduce the incremental cost of a holiday opening with expected slow foot traffic, a center should consider staffing with just a provider and a cross-trained front-/back-office specialist who can also take x-rays. When holiday volumes increase later, staff can be added then. If holiday volumes are low, not only does overstaffing increase operating losses, but it also kills morale as bored team members quietly lament the time they could be spending with friends and family if they weren’t “stuck” at work.

 Promoting Ancillary Services on the Holiday
In addition to the expected episodic patient encounters, urgent care centers can stimulate additional holiday traffic by offering ancillary services that tie in to the specific holiday. This requires a bit of creativity on the part of the marketing team/owner-operator, but it’s a tried-and-true method to drive holiday patient volume.
Take New Year’s Day, for example. Holiday revelers have packed on a few extra pounds, and the new year is typically when folks are dusting off their well-worn weight-loss resolutions, determined to get fit. A center that offers weight management/nutrition/diabetes services should be ready to capitalize on that initial thrust by offering discounts, specials, and various other promotions for New Year’s Day sign-ups to their programs. The promotions can be marketed using guidelines similar to the previous sample, so when the calendar turns to January 1, the center is primed and ready to take advantage of the resulting patient influx.

The decision to offer holiday urgent care services (or not) should be based on several factors, taking into account the needs of the patient base, providers and staff, and the profitability of the business. And when short-term profits aren’t necessarily a limitation, positioning a center as the community’s go-to medical provider on holidays can strengthen its brand significantly, which pays dividends in the long run.
Even if a center loses money on its first open holiday—a distinct possibility—the urgent care operator shouldn’t view that as a reason to discontinue future holiday hours. To the contrary; cultivating an “always open, always here to serve” image within a patient base—combined with clever and creative holiday marketing—should eventually lead to a center bustling with patients, regardless of the day of the year. In sum, it comes down to committing to a game plan one way or the other and, if holiday operations are chosen, aggressively marketing to ensure patients arrive at your door—no matter the season.

Making a Business Case for Urgent Care Holiday Hours

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine