“Your time is valuable,” reads an advertisement I found in my mailbox recently. “On Monday, Pam’s eyes were red and she couldn’t stop sneezing. On Tuesday, she went to Indigo Urgent Care. On Wednesday, she’s giggling like a schoolgirl. Who knows what Thursday will bring?”
Indigo, part of the MultiCare Health System in Washington, is opening up in Wallingford. It joins dozens of other Urgent/Immediate/Express/Convenient Care Clinics open in our state. Such clinics attempt to fill a perceived gap in healthcare, available for folks who have healthcare needs that don’t rise to the level (in both time and cost) of an emergency room visit, or when it is inconvenient (or impossible) to see their primary care doctor (if they have one).
In the case of some larger institutions such as MultiCare, Urgent Care Clinics (UCCs) can capture patients in their healthcare network, in the event they need additional care after their urgent care visit. This is a financial incentive that may or may not be in the patient’s best interest.
This article defines UCCs, and describes both the healthcare providers who work there and the patients who choose to get their healthcare from them. Finally, this article examines the potential medical/legal issues associated with these clinics.
**What They Are**
UCCs provide walk-in care for illnesses and injuries that need immediate attention but do not rise to the level of an emergency.1 With extended hours, availability of unscheduled appointments, and the range of services they provide, UCCs are “uniquely positioned within the healthcare system to address the overflow of acute care patients from primary care as well as low- to mid-acuity emergency department patients.”2
Urgent Care Clinics likely began in the late 1970s as an alternative when patients could not get in to see their regular physician.3 Over the past decade, alternative care settings for nonemergency care like UCCs have grown in number.4
Recently there has been a rapid expansion of UCCs, which is attributed to such factors as long wait times for primary care appointments, crowded emergency departments and patient demand for more accessible care, including after-hours appointments.5
There are now nearly 7,100 UCCs in the US, and approximately 160 UCCs and Walk-in Clinics in Washington State.6 This includes UCCs operated by large healthcare institutions, like CHI Franciscan, Multicare, Group Health, UW, and Providence. It also includes other similar entities, such as “Immediate Clinic,” “ZoomCare,” and “US Healthworks.”
Typically, UCCs are freestanding physicians’ offices with extended hours; with on-site x-ray machines and laboratory testing; and with an expanded treatment range, including care for fractures and lacerations.7 UCCs are different from other healthcare facilities in that, typically: 1) there is no appointment necessary to see a medical provider; 2) there are evening and weekend operating hours; 3) there is an x-ray machine on site; and 4) they are capable of performing simple procedures like suturing and casting.8
There are a number of organizations devoted to the practice of Urgent Care Medicine. This includes The American Academy of Urgent Care Medicine (AAUCM), the Urgent Care Association of America (UCAOA), Urgent Care College of Physicians (UCCOP), and the American Board of Urgent Care Medicine (ABUCM). Such organizations may be helpful in building your case if the healthcare provider in question belongs to any of these organizations, as some publish materials that may be relevant to the care of which your client is complaining. For example, UCAOA and UCCOP publish the Journal of Urgent Care Medicine.9
The Joint Commission, which is the nationally recognized main body that accredits a range of healthcare organizations, includes UCCs in its Ambulatory Healthcare Program. In addition to the Joint Commission, there are other voluntary accreditation processes, such as those run by the Urgent Care Association of America, the National Urgent Care Center Accreditation, and the American Academy of Urgent Care Medicine.10
Currently, the Urgent Care Clinic model is a generally unregulated form of healthcare delivery. The use of the term “urgent care” itself is generally unregulated with the exception of Illinois and Delaware. In those states, UCCs adopt alternative, interchangeable names such as “immediate care” or “convenient care” that connote the delivery model and scope of services offered in compliance with the states’ marketing and signage restrictions.11
In other states, UCCs follow rules in place for the opening of any regular medical office.12 Although there is no specific urgent care license in Washington, there are guidelines for the specific design and construction of freestanding urgent care facilities.13 The guidelines mandate that “[t]he functional program for the facilities must clearly describe a scope of services that are appropriate for urgent care . . .”14
**Who Staffs Them**
Healthcare providers serve similar roles as ER doctors and primary care doctors. They are on the ‘front lines’ of medicine, so they need to be proficient in evaluating and caring for – at least initially – any patient who walks into an urgent care medicine center or urgent care clinic.”15
Although UCC doctors don’t care for admitted patients or provide continuing medical care for chronic medical problems, they do many other things that overlap with both primary care and emergency medicine. With primary care doctors, there is a shared broad scope of caring for patients of any age with any complaint. With emergency medicine doctors, there is a shared primary focus on acute medical problems (instead of chronic, ongoing ones), albeit on the lower end of the severity spectrum.16
UCCs are typically staffed by physicians, generally with backgrounds in either primary care (with board certification in internal medicine or family practice medicine) or emergency medicine. Some have physician assistants working under doctor supervision.17 In addition, UCCs may also be staffed with medical assistants, nurses, and x-ray technicians.18
There is currently no AMA-recognized board certification for Urgent Care Medicine, but the AAUCM, in cooperation with the American Medical Association, was successful in having “UCM” (Urgent Care Medicine) established as a self-designated/practice specialty code by the AMA.19 Notwithstanding the above, ABUCM offers certification in UCM to qualified candidates.20
**Who Treats at a UCC**
As discussed above, UCCs have elements of primary care and emergency medicine. As a result, two distinct subgroups of people tend to visit UCCs: “those without a regular source of healthcare who wish to avoid the emergency department (ED), often because of the perceived inconvenience, and those with a primary care provider (PCP) who feel they do not have adequate access to their physician, although more serious health concerns issues might prompt waiting for a PCP visit.”21
In such circumstances, when a patient needs healthcare but cannot see their PCP, and is faced between going to the ER or to a UCC, there are a number of appealing reasons some patients choose the latter. Healthcare consumers like UCCs because they are often quicker to see a doctor at a UCC than at an ER. While the wait time for an ER visit is often hours, 90% of UCCs offer a wait time of 30 minutes or less to see a provider, and 84% of UCCs visits result in an entire visit time of 60 minutes or less.22 In addition, visits to a UCC tend to be cheaper. The average cost of an urgent care center visit is $150 – compared to the average cost of an ER visit at $1,354.23
Some experts have opined that UCCs can play an important role in improving primary care, especially when UCCs partner with primary care provider offices to provide care during off hours.24 This helps patients avoid unnecessary ER visits, and hopefully with good communication (including shared Electronic Medical Records), the UCC can be a valuable after-hours primary care tool.25
**Conditions Treated at a UCC**
The Urgent Care Association of America counsels that urgent care is not emergent care, and should not be a substitute for true emergent situations, nor for ongoing primary care. However, UCCs can “bridge the gap” for patients by treating them for any non-life threatening medical illness or injury that the patient deems urgent.26
UCCs commonly treat conditions seen in primary care practices and retail clinics, including ear infections, strep throat, and the flu, as well as some minor injuries, such as lacerations and simple fractures.27 Other conditions typically treated at UCCs include: upper respiratory infections, musculoskeletal conditions, dermatological conditions, symptoms without a specific diagnosis (abdominal pain, headache, unclassifiable symptoms), urinary tract infections, chronic illnesses, psychiatric conditions, lower respiratory conditions, and other minor conditions, such as allergies, insect bites, rashes, contact dermatitis, conjunctivitis, constipation, and eye injuries.28
**Medical/Legal Issues**
Depending on the severity of the harm resulting from alleged negligent medical care at a UCC, liability insurance (or lack thereof) can be a threshold question when evaluating such claims. Sometimes, like with “Indigo,” the clinic is affiliated with a large institution. In such circumstances, discovery may reveal that there is sufficient available coverage for almost any injury.
However, for smaller entities, the only liability coverage may be the policy that the doctor holds. An investigation into whether the entity itself has any additional sources of recovery may result in finding that there is no additional coverage, and few if any assets to liquidate. Space and equipment are often leased, leaving the doctor’s policy as the only available asset.
Knowing where the coverage lies can tailor your discovery to target the responsible entity with assets to recover. If the target is the entity or institution itself, one possible theory of negligence is that it is staffing its clinic with the wrong type of doctor. We have found clinics staffed by radiologists and physical rehabilitation doctors, physicians who may very well be competent in their particular field, but do not have the same breadth of experience as a family practice, internal medicine, or emergency physician.
Clinics may also be liable in certain circumstances if harm arises because the clinic is giving a false impression to the public that it can provide emergency care when they cannot. Having “emergency” or “ER” in the name will only add to this confusion, and possibly give rise to liability.29 Other liability could include the entity not having robust policies and procedures in place that cover communication (with the patient and with his or her providers), referrals, and discharge instructions.
Providers can fall below the standard of care in a number of ways particular to the UCC setting. Patients “self-triage” by going to a UCC in the first place, which can make a doctor less likely to diagnose more serious issues. As articulated above, there is a business interest in treating a patient at the UCC. Still, the physician must make the best medical decision for that patient, including whether to send a patient “up” to an emergency department, “down” to a primary care physician, or “out” to a specialist.30 If the doctor decides the best course is to treat the patient at the UCC, and provides treatment, the standard of care in many situations requires a re-evaluation during the visit.
Communication is another possible pitfall of UCC care. Communication with the patient is vital, particularly if other care is indicated. Discharge instructions should allow the patient to leave with an understanding of the diagnosis and treatment given, and with clear instructions to the patient of what to do if the situation does not improve or gets worse.
Even more important is the “care coordination” that needs to occur in the event other providers need to know information generated from the UCC visit. If the patient is being referred to another provider, that provider needs to have access to the records of the UCC visit, including in particular the results of any diagnostic tests. A subsequent doctor – either an emergency room, primary care, or specialty doctor – needs to have this information to be able to appropriately treat the patient. If a patient suffers harm because the UCC does not have adequate policies and procedures in place for care coordination, that may also give rise to liability.
**Conclusion**
With possible primary care physician shortages and an increase (for now) in the number of insured patients due to the Affordable Care Act, UCC visits may become even more common. To the extent UCCs can release some of the burden placed on emergency rooms, and fill in for PCPs off hours, they can be quite useful to patients. However, it is important to the safety of all Washingtonians that such institutions have a clearly defined scope of practice, and that providers working in UCCs appropriately refer patients to necessary care when indicated.
*Tyler Goldberg-Hoss is a partner at Chemnick Moen Greenstreet, which limits its practice to medical negligence claims. He is also active in WSAJ as an EAGLE member, Board Member, and current Vice President of Publications.*
1 Yee, et al: The Surge in Urgent Care Centers: Emergency Department Alternative or Costly Convenience? http://www.hschange.com/CONTENT/1366/.
2 Weinick, et al: Urgent Care Centers in the U.S.: Findings from a National Survey, BMC Health Services Research (2009), 9:79.
3 Urgent Care Association of America, Industry FAQ: http://ucaoa.site-ym.com/
?industryFAQs#Range%20of%20Visit%20Levels.
4 Weinick, et al: Many Emergency Department Visits Could be Managed at Urgent Care Centers and Retail Clinics, Health Affairs 29 No. 9 (2010): 1630-1636.
5 Yee, supra.
6 Urgent Care Locations. https://www.urgentcarelocations.com/wa/washington-urgent-care.
7 Id.
8 UCAOA FAQ, supra.
9 www.jucm.com. AAUCM also offers an “E-Journal” to its members.
10 Weinick, et al, No Appointment Needed: The Resurgence of Urgent Care Centers in the United States, Prepared for: California HealthCare Foundation (2007); www.ucaccreditation.org.
11 UCAOA FAQ, supra.
12 Id.
13 WAC 246-320-500, -600.
14 Id. at WAC 246-320-600.
15 AAUCM – What is Urgent Care? http://aaucm.org/about/urgentcare/default.aspx.
16 Id.
17 Yee, supra.
18 UCAOA FAQ, supra.
19 AAUCM. http://aaucm.org/.
20 ABUCM. http://www.abucm.org/index.html.
21 Shamji, et al: Improving the Quality of Care and Communication During Patient Transitions: Best Practices for Urgent Care Centers, The Joint Commission Journal on Quality and Patient Safety, Vol. 40, Number 7 (July 2014).
22 UCAOA Media Infographic. http://c.ymcdn.com/sites/www.ucaoa.org/resource/resmgr/Media/UCAOA-Infographic-UCvsER_FIN.pdf.
23 Id.
24 Shamji, supra.
25 Id.
26 UCAOA Media Infographic, supra.
27 Yee, supra.
28 Weinick, et al: Many Emergency Department Visits Could be Managed at Urgent Care Centers and Retail Clinics, Health Affairs 29 No. 9 (2010): 1630-1636.
29 Newman, Benjamin. Reducing Liability in Urgent Care: A Defense Lawyer’s View. http://www.gray-
robinson.com/articles/newman5410.pdf.
30 Id.
