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Payers and urgent cares must be partners in value-based model

As healthcare payment models shift their focus from volume to quality of service, healthcare providers and payers are facing increased pressure to improve patient outcomes in an efficient, cost-effective way.

When included in networks, urgent care centers play a key role in helping payers meet the Centers for Medicare & Medicaid Services’ Triple Aim goals – the pillars of the value-based model – while also working toward MACRA requirements.

Urgent care centers create significant savings for both payers and patients. Nearly half of all visits to urgent care centers result in an average charge of less than $150, compared to $1,354 for an emergency room visit, according to a 2011 Medical Expenditure panel survey. A 2010 article published in Health Affairs noted that up to 27 percent of all emergency room visits could take place at an urgent care center or retail clinic, generating potential savings of approximately $4.4 billion a year. More recently, a Colorado Health Access Study (CHAS) identified $800M in savings after concluding that roughly 40% of all ED visits should have been seen in a lower cost setting, including urgent care centers.

Urgent care centers also support the patient-centered medical home (PCMH) by caring for episodic illnesses and injuries while allowing medical home providers to focus on the chronic patients who comprise 80 percent of the cost of care. And they can provide this integrated care in the ways patients value most: on a walk-in basis, including evening and weekend hours.

Greater access is key. These benefits are only realized when urgent care centers are included in payer and provider networks.

Strong, beneficial partnerships are forged between urgent care centers and payers by following these best practices:

Meet MACRA goals together. Creating a value-based reimbursement model is one of the main goals of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). To achieve this, there must be strong coordination among healthcare organizations, payers and patients. The MACRA measurement criteria for payers and providers are very similar, underscoring the value of interoperability and data-sharing between industries. Furthermore, payers can help educate patients on the cost of care and different treatment options available, which in turn improves patient safety, clinical outcomes and total costs.

Maintain open lines of communication. When evaluating a provider, payers look at value, scope and intent — often through online applications. The format makes it challenging for urgent cares to provide adequate details on these areas, causing payers to not see — and potentially lose out on — the full benefits of comprehensive care, including in-house laboratory and radiography, offered by urgent care facilities. Urgent care providers are an important part of the solution when it comes to the delivery of much needed primary care. Barriers to network access and contractual limitations on the scope of care create barriers to patient access and services.

Rethink reimbursement. Payers and urgent cares must work together to ensure urgent care reimbursement accounts for the costs to staff facilities for walk-in hours, attract staff and providers to work nights and weekends, and provide the additional services that current Urgent Care Association of America studies show occur during 70 percent of visits. By receiving a fair reimbursement, urgent care centers have the incentive to provide even higher-level services, thereby alleviating overcrowded EDs.

Create plan alignment to reduce ED visits. Patient co-pays for urgent care services have continued to rise. This increase can cause patients to not seek care for an illness or injury, making the condition worse and leading to more costly emergency room visits and even hospital admissions or readmissions. Encouraging urgent care visits through co-pays that are aligned with those of primary care providers fosters better outcomes for patients and lower costs for payers.

Consider urgent care for acute primary care, wellness and screening services. Urgent care centers are often pigeon-holed as destinations for exclusively non-emergency illnesses and injuries. However, a growing number of patients are turning to urgent care centers for acute primary care in lieu of other options, including the ED. In addition, at least 20 percent of the urgent care population is unaffiliated with a medical home and an even greater percentage rarely frequent their medical home due to access issues. In response, urgent care centers can play a vital role in lowering the cost of healthcare through models that support screening and care coordination, yet these services are often denied under existing payer agreements.

We urge payers to recognize the unique value urgent care centers bring to networks. We want to be your partner in improving the patient experience of care and the health of populations, while reducing the costs of healthcare. These are goals we can all get behind.

Laurel Stoimenoff, PT, CHC, CEO of the Urgent Care Association of America.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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