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Congressional Newsletter
Monthly updates to Congress on RAND's work in health policy

Some Visits to Emergency Rooms Could Be Handled by Retail Clinics and Urgent Care Centers

entrance to emergency room

Facing long waits for appointments and limited options for after-hours care, growing numbers of Americans are visiting hospital emergency departments (EDs) seeking care for nonemergent conditions. Frequently, the cost of treating such conditions in EDs is substantially higher than in other settings, and many EDs are overburdened. The past decade has also seen significant growth in alternative care settings, such as retail medical clinics and urgent care centers. Retail clinics, located in pharmacies or grocery stores, are typically staffed by nurse practitioners and a treat a small number of health conditions, such as sore throats or urinary tract infections. Urgent care centers are freestanding facilities staffed by physicians and treat a broader range of conditions, including minor fractures and lacerations. There is some evidence that both settings provide less expensive care than EDs at similar levels of quality. Could these alternative settings treat some share of patients who are currently seen in EDs?

To answer this question, a RAND team led by Robin Weinick analyzed information about people who visited retail medical clinics and urgent care centers and compared it to profiles of patients who visited hospital EDs during 2006. They examined issues such as the types of illnesses seen in EDs, as well as the volume and mix of cases seen when alternative care settings are open. Based on these comparisons, researchers found that about 17 percent of all visits to hospital EDs across the United States could be handled by retail clinics or urgent care centers, potentially saving $4.4 billion annually in health care costs. Conditions that could be treated safely outside EDs include minor infections, sprains, fractures, and lacerations.

The study provides evidence about the number of cases that could be managed outside EDs; however, the analysis did not evaluate whether retail clinics and urgent care centers currently have the capacity to handle higher numbers of patients. In addition, more evidence is needed to understand whether patients are able to decide safely when it is appropriate to visit a retail clinic or urgent care center instead of an ED.

READ MORE: Some Hospital Emergency Department Visits Could Be Handled by Alternative Care Settings

Physician Cost Profiling: How Reliable?

prescription, stethoscope, and money

Physician cost profiling is a recent approach to controlling health care costs. Physician cost profiles are summary measures that health plans and other purchasers have developed based on physician spending patterns. These cost profiles, along with quality profiles, are used as the basis for categorizing physicians into value tiers (for example, “high,” “average,” and “low”). The reasoning behind this approach is that physician decisions about care—such as ordering tests, writing prescriptions, making referrals, and performing procedures—drive a great deal of medical spending. By giving consumers incentives to seek out physicians with relatively lower cost profiles, health plans hope to contain spending. To date, however, there has been limited evaluation of the reliability of these profiles or the methods used to create them.

A RAND Health team assessed the reliability of physician cost profiling methods. The researchers analyzed aggregated claims data on 1.1 million adults age 18–65 who were continuously enrolled in four Massachusetts commercial health plans in 2004 and 2005. The study sample included more than 13,700 physicians. The researchers examined the methods for constructing physician cost profiles and assigning physicians to cost categories. They then measured the reliability of the assignments to these categories and the chances that a physician could be miscategorized.

The team found that 59 percent of physicians overall had unreliable cost profile scores, according to one widely used reliability threshold. Moreover, reliability varied substantially for different specialties. The analysis also found that, with common cost profiling methods, about 22 percent of physicians could be inaccurately categorized. These high rates of miscategorization raise a caution flag. If a substantial percentage of physicians classified as lower-cost do not really fit that profile, then health plans’ ability to control costs by directing patients to lower-cost physicians could be undermined.

The results suggest that current methods of physician cost profiling need improvement if they are to contribute to containing health care costs.

READ THE RESEARCH BRIEF: Is Physician Cost Profiling Ready for Prime Time?

RESEARCHER PROFILE

Robin M. Weinick

Robin M. Weinick

Robin M. Weinick is a senior social scientist at RAND. Her research focuses on improving the quality of medical care in the United States, with a special emphasis on practical tools for use in the health care system. She is interested in the development and use of measures for monitoring the status of health care and how such tools can be used to drive improvement, in the organization and delivery of health care in a variety of settings, and in providing technical assistance for implementing change programs and the evaluation of such efforts. She is particularly concerned with systematic barriers that cause health and health care disparities by race, ethnicity, and socioeconomic status. Weinick’s work includes a focus on care delivery sites that affect access to care, such as urgent care centers, retail clinics, and emergency departments.

Read more about Robin M. Weinick »


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