As some urgent care centers try to open up new businesses or expand, some operators say are being shut out by insurers who may not want to have any new urgent care centers in an area because of perceived over-saturation.

Urgent care centers thrive on treating a patient’s cough or checking out that bruised elbow or twisted ankle.  But insurers keeping them out of certain networks appear to be giving them a big headache, some urgent care operators tell me in a story I wrote for athenainsight.

The story notes: “A lot of urgent care providers are facing a narrowing of networks,” says Laurel Stoimenoff, CEO of the Urgent Care Association of America, which represents 2,700 urgent care centers in the U.S. and abroad.

Those rules hamstring “the entrepreneur who wants to build an urgent care center right now,” Stoimenoff says. “You may have spent a million dollars on the place, even before applying for a contract. Then you apply to one of the major payers and they say, ‘sorry, we’re not accepting more urgent care clients. We have enough of them in our network.'”

In a follow-up email exchange with Stoimenoff, she said payers add more requirements on urgent care centers that they might not otherwise impose on primary care physician offices. That may effectively shut out an avenue for urgent care centers, although the insurers may not actually say they are narrowing their networks, she says.

That is a confusing situation, she says. “(Urgent care centers)  practice acute primary care so we are perplexed as to why UCCs are being held to standards in excess of (primary care physicians),” Stoimenoff says.

Some contractual language written into urgent care center contracts also are problematic, she adds.  Stoimenoff gives the following scenario:

Say a patient goes to an urgent care center and it is determined that patient has pneumonia. A follow-up would seem to make sense, but contracted language with the insurer prohibits follow-up care “as the insurer (would try) to ensure that the urgent care is only providing care for singular episodic visits,” Stoimenoff says.

That could create logistical problems for patients. “A patient may be 2,000 miles from home and/or without a primary care doctor,” Stoimenoff says. “Who then is to follow that patient who has a condition that medical best practice would say needs follow up?” she asks.

Urgent care centers are also limited in prevention practices. Stoimenoff offers this scenario as an example: Someone works in an area that is  “high risk for tetanus,”  and wants a tetanus vaccine from an urgent care center because that person didn’t have one for a decade or more. The urgent care center would have to tell the patient: “We couldn’t give you one and get paid by the payer in most cases because they consider it ‘wellness’ versus ‘episodic illness or injury,” says Stoimenoff.

Baffling, no?

Such scenarios — i.e. real life – seem to go against the idea of having an open marketplace for the full spectrum of a patient’s needs. That is a crucial part of the conversation as the government again moves in some possibly new direction in healthcare.

Franz Ritucci, MD, President of the American Academy of Urgent Care Medicine, agreed with Stoimenoff’s assessments, saying some urgent care centers “are having difficulty contracting with insurance carriers,” he told me for the athenainsight story.

Despite obstacles, urgent care centers believe they are finding their rightful place in helping patients, according to Stoimenoff.

The “issue of receiving the right care in the right place at the right time is likely to finally get attention as we move into value-based care models and there are financial incentives to do the right thing,” Stoimenoff says. “There are numerous studies that support the fact that many patients being seen in emergency departments do not need to be there.”

Change may rest on patient education and advocacy along with physician discussion.

Healthcare is tough: there’s no question it’s scary when someone faces a 3 a.m. sharp pain and doesn’t even think twice about going to the emergency department. It’s another issue for the patient who has a cough and sniffles, then maybe it’s  time for urgent care instead of an overcrowded, expensive emergency department.

One person at a time, it becomes a national issue about cost and quality of care.

“If there is an opportunity to save what is undoubtedly in the billions (of dollars) we should all be open to problem-solving,” Stoimenoff says.

— Joe Cantlupe