Alan A. Ayers, MBA, MAcc is Practice Management Editor of JUCM, serves on the Board of Directors of The Urgent Care Association of America, and is Vice President of Strategic Initiatives at Experity.

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, payor reimbursement, and the branding impact of after-hours accessibility.

As urgent care operators look to the coming holiday season while beginning their strategic planning for the New Year, many are faced with the question of how they should approach holiday operating hours. Specifically, should a center open its doors on days such as 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 espouse and incorporate. 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. However, 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 attempting such extensive hours.

Why Holidays Can Be Busy Times for Urgent Care
When considering holiday hours, an urgent care center can start by examining anticipated patient demand. First, because primary care offices are closed on major holidays, people with emergent medical needs have their options narrowed to two: the Emergency Room (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, to general carelessness around outdoor grills. Lacerations, ostensibly from carving meat, are also increasingly seen on holidays.
  • Decorating – Knee, ankle, and hip sprains from slips and falls due to scaling roofs to hang holiday paraphernalia (i.e. Christmas lights, July 4 bunting, etc.), and climbing stools and ladders to adorn trees, bushes, and awnings with decorations.
  • Heartburn/Indigestion – Overindulgence in food and drink that leads to gastrointestinal issues, which can induce chest pains that mimic a heart attack in some patients.
  • Food-borne illness – Undercooked meat, mishandling of raw meat (salmonella, coli exposure), improper storage or thawing of holiday cuisine (e.g. foods prepared with eggs, mayonnaise), or cross-contamination.
  • 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 an unexpected injury.

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 filling the gap between primary care and the ER, and that 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 balance said 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 Table 1. To identify the number of patients required to “break even,” divide incremental operating costs by incremental revenue per patient.

Table 1
Single-Day Profit and Loss Statement to Evaluate Financial Contribution 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. Only include expenses that would not otherwise be paid if the center had closed on the holiday.

Incremental Cost of Opening on a Holiday
Incremental costs are costs that would not be incurred if the center were closed for the holiday. Fixed costs such as rent and equipment leases are thus excluded from the analysis. 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, as calculated using the following equations:(Number of patient encounters TIMES average net collections per patient) MINUS costs attributable to specific patient encounters, including billing fees, supplies, x-ray over-read fees, etc. EQUALS Incremental revenue
Incremental Patient Revenue DIVIDED BY Number of Patients EQUALS Incremental Revenue Per Patient encounter
Incremental Cost of Opening MINUS Incremental Patient Revenue EQUALS Profit or Loss on Holiday Operations
Incremental Cost of Opening DIVIDED BY Incremental Revenue Per Patient Encounter EQUALS Break-Even Volume for Holiday Operations

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

Payor 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 a center that doesn’t realize a profit will still reap long-term benefits from offering holiday hours, so occasional operating losses can be accepted within the context of a broader marketing strategy. Nonetheless, lobbying payors 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 the holiday.

Current Procedural Terminology (CPT) codes 99050 and 99051 are add-on codes that medical practices can use to bill payprs to help compensate for the additional cost of being open extended hours, such as evenings, weekends, or holiday hours:

  • 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 payors will reimburse these “extended hours” codes—especially if an urgent care center is contracted at a flat reimbursement per encounter as opposed to fee-for-service—but many payors do recognize the value of extended hours and will indeed compensate, even if only occasionally.

A starting place should be to evaluate whether payors 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 payors using the 99051 code on federal holidays, while others have found that payors are 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 payor 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, means increased costs for the insurance company.

Clearly, when patients choose an urgent care center for treatment, payors realize considerable savings from what they’d have to pay out 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 payors can be enlisted to help steer patients to the center on holidays.

Holiday Hours Toward Executing Branding Goals
Going beyond single-day profitability and payor 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 positions a center’s brand in such a way as to be associated with the “Wal-Marts” and “McDonald’s” of the world—synonymous for their convenience and availability.

In addition, consider the competition when evaluating holiday operations for an urgent care brand. It’s universally known that the ER is always open, but what about competing centers within the community? A 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, an urgent care brand that puts patient convenience above all positions itself to attract more business in the long run.

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

  • Historic Utilization – Burns, cuts, and lacerations are generally the most common causes of 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 – Because primary care is rarely available on the holidays, an open urgent care center will undoubtedly capture patients who can’t see their primary care physician (PCP) and don’t want to utilize the ER.
  • Consumer Behavior – Has the center set the expectation within the patient base that urgent care will always be accessible, even on the holidays? Does the center operate within a cultural and/or religious patient base that’s less likely to observe certain holidays and to interpret closings on occasions other than those 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-mid-afternoon coverage accomplish the center 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 that they don’t know is open, so a holiday-specific advertising campaign serves to contribute to the overall awareness of the center within its market and to help drive patient volume.
A sample holiday urgent care advertising schedule is outlined in Table 3. As the holiday draws closer, the promotional activities are ramped up, community awareness gains traction, and momentum builds toward peak holiday utilization.
Table 3
Holiday Marketing Activity Checklist

1 Month Out

– Schedule should be completed with medical and non-medical staff committed to working on the holiday

2 Weeks Out

– Poster in every patient room advertising that the center will be open on the upcoming holiday
– Sign on tables at community events informing public of holiday business hours
– Notification of referral 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 (i.e. Wal-Mart, hotels, airport)
– Email blast to occupational medicine clients promoting the holiday hours

1 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 that they’ll post a message on their answering machine instructing patients to utilize the urgent care when PCP offices are closed
– Email blast by the PCPs and/or posting to the PCPs’ Facebook pages/groups
– Notification on the center’s Facebook page; prominent notification on the homepage of the center’s website

Day of Holiday

– Advertisement in the local daily newspaper indicating that the center is open today– Participation in/sponsorship of community holiday event (e.g. 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

Advertising that a center is open on a specific holiday can help drive utilization on that one day, but 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, a hospital-affiliated urgent care center 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, payors, 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 and, as volume increases, open earlier and close later. It’s always better to add hours than to reduce them. Persistence is key because 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 4 parade–the center should be open during the event. Otherwise, it undermines the brand to communicate “We’re open to serve you–except right now.”
  • Add a tagline to 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. Patients 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 who have more traditional beliefs. Centers near tourist destinations also may see an increase in holiday traffic.
  • For multi-location centers within a specific market, cross-promote the open location at other centers 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, staff can be added later. If holiday volumes are low, not only does over-staffing 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 holiday traffic by offering ancillary services that tie into 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 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. The promotions can be marketed using guidelines similar to the previous example, so when the calendar turns to January 1, the center is primed and ready to take advantage of the resulting patient influx.

Conclusion
Deciding whether to offer holiday urgent care services involves evaluating several factors, all of which should balance the needs of the patient base, providers, and staff, and the profitability of the business. 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–an 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 among 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 holidays operations are chosen, aggressively marketing to ensure that patients arrive at your door–no matter the season.

Practical Considerations for Urgent Care Holiday Hours

Alan A. Ayers, MBA, MAcc

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