Urgent Care? ER? Your Doctor? Which Medical Issue Where?
There are emergencies and there are emergencies. Horrible chest pain or a sick baby are capital “E” emergencies. Back pain that kicks in while on vacation, a hard-to-reach sliver of glass, or a sprained wrist generally require medical attention, but might not mean rushing to the emergency department.
Once upon a time, patients had two choices when meeting their medical needs -- a visit to their own doctor, or a visit to the local emergency department. But today, the choices have multiplied. Besides a personal doctor and the ER, there are urgent care clinics, retail clinics and online services. So, it begs the question: How can a person know where to go?
“The terminology gets really confusing,” explained Ateev Mehrotra, MD, MPH. Dr. Mehrotra is an associate professor of Health Care Policy at Harvard Medical School. Dr. Mehrotra talked to Medical Daily about retail clinics, telemedicine and e-doctors.
How can someone tell if they are looking for a retail clinic or an urgent care? There are three big differences, starting with location. “A retail clinic is located within the confines of a retail store, while an urgent care center is usually freestanding, so you’ll be in a drive-in plaza, or some other office building,” Dr. Mehrotra explained.
The second thing is the differences in what each offer. “The retail clinics have their menus online and they'll say exactly, ‘these are the things we treat, these are our prices.'" The clinics usually have fewer services than at a primary care office.
As for an urgent care center, the breadth of their offering is wider. "For example, urgent care facilities can insert IVs, take X-rays and CT scans and even sew up big cuts," Dr. Mehrotra said. In comparison and depending on the practice, an urgent care center could offer more services than the average doctor’s office.
And the third difference?
Is the type of healthcare provider you will see.
"At a retail clinic, you'll see a nurse practitioner almost all the time, at an urgent care center, you'll see some combination of nurse practitioners, but mostly physicians,” he said.
Retail clinics and urgent care centers price their services differently. According to Dr. Mehrotra, a retail clinic could be 30 to 40% less expensive than an urgent care, which will likely cost about the same or a bit more than a doctor’s office.
The retail clinic
Retail clinics are inside bigger stores like CVS, where they are called MinuteClinics, and Walmart and Walgreens. The CVS clinic can offer up to 125 services, while Walmart clinics offer about 40. Currently, Walmart only has clinics in Arkansas, Georgia and Texas.
Angela Patterson, DNP, CVS' chief nurse practitioner, said CVS has 1,100 clinics spread across 33 states and Washington D.C., in an interview with Medical Daily. She said appointments at retail clinics can be either walk-in or scheduled. There will likely be an appointment cost, and any lab tests can be extra. Dr. Patterson explained that "...there are a few services where state regulations may create variances. These differences typically surround minimum patient ages for delivering specific services and age restrictions for administering vaccinations.” So, for patients looking for a specific immunization or procedure, it is best to check first.
Retail clinic patients aren’t necessarily first-timers who are having a minor emergency. Dr. Patterson explained, “It’s not unusual to see a patient 2 to 3 times a year for a variety of different services – a series of vaccinations or treatment for common acute illnesses.” Minute clinics are connected, just like the healthcare providers with a system. This means clinics in other areas can access a patient’s records, making retail clinics very useful for people who are traveling.
Who should not go
“The minute clinic is not appropriate, [however], for more urgent medical matters that should be handled by emergency rooms and urgent care centers,” said Dr. Patterson. She also said they are not right for young children under 18 months. People who might be a bit older, or have multiple serious conditions, might consider a different treatment option, she added.
Show me the money
A big plus with a retail clinic is price transparency. With a retail clinic, although the services are limited and patients are likely to see a nurse practitioner or a physician's assistant, visitors will have a good idea of what they will be paying.
The pharmacy
Although they are not retail clinics, pharmacies also can be an option for some types of health care. Sometimes they are inside grocery stores or stores like a Target. These pharmacies do not do as much as retail clinics. According to a representative from the Wegmans grocery store, pharmacies can offer vaccinations, but can also do other services like vision tests for driving or providing Naxalone, a drug used to reverse opioid overdoses. A pharmacist will probably be the healthcare provider, the pharmacy often will take insurance, and all this can happen during a shopping visit.
Other options
Dr. Mehrotra discussed online health options, which were available even before the pandemic made them ubiquitous. The telemedicine providers include a patient's own doctor and new companies like Teladoc, Amwell and Doctor on Demand. E-doctors like Lemonaid or Heydoc are also available. Patients will fill out a survey or maybe talk to a doctor, and they can get medication if appropriate. Lemonaid's FAQ explained that "Some states require you to have a short video consultation with our team, other states require a phone call, some states don’t require a video or phone call!" Expect slightly different rules depending on where the call is coming from.
A new problem
“We're asking patients to self-triage," said Dr. Mehrotra. Patients are now responsible for working out how serious their issue is, and then picking the best option for care. That is a lot more complicated, and a lot more work for patients, then the old 'emergency room or doctor' decision. To make today's self-triage process easier, Dr. Mehrotra suggested calling either the healthcare center where the person has gone before, or to one's own doctor.
Calling in the experts
People with a primary care doctor can get some help with this decision. Kate Cronan, MD, Division of Pediatric Urgent Care, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, said, “If I had something, relatively speaking, that was not that serious, I might call my doctor, or the doctor on call, and see what they thought.” According to Dr. Cronan, doing so can help keep the patient’s doctor in the loop. It isn’t necessary, but it can be useful. “...They may advise you to go to an urgent care or say, ‘you know what, we can see your first thing in the morning.'"
An added bonus of calling the doctor is that if the medical situation occurs after the practice has closed for the day, the nurse or doctor on call will have access to medical records and review the patient's chart. Seeing a patient’s chart can help medical practitioners give good advice, whether to stay home, come in for an appointment, go to urgent care or the ED.
The emergency department
When do people actually need to go to a hospital's emergency department? While it might not be obvious if the situation warrants immediate attention, if it feels like an emergency, do not hesitate, go to the ED, Dr. Cronan said. Experiencing the symptoms of a heart attack -- bad chest pain in the middle of the chest, or in the arms -- she said, lend an excellent example.
They could be first-time symptoms, or symptoms they have had before. "But now they're having really bothersome pain in their chest, and they're feeling really lousy, they should go to the ER,” advised Dr. Cronan. The pain could indicate a heart attack has occurred or is about to occur.
The other emergency is a stroke, which occurs when an oxygen-carrying blood vessel en route to the brain is either blocked by a clot or has burst. Because the brain is deprived of oxygen and other nutrients, the brain tissue deprived of oxygen and other nutrients begins to die, as do brain cells.
The American Stroke Association (ASA) has a quick achronic for the symptoms of a stroke.
F - Face drooping
A - Arm weakness
S - Speech difficulty
T - Time to call 911
If it is a real emergency, call for an ambulance. The ill person shouldn't be in a car. Dr. Cronan said, “time is of the essence, so they really need to get [to the ED].”
Where does it hurt?
For babies and children, things are a little different. Dr. Cronan said for babies under three months, a fever probably means a trip to the doctor or the ED. As for kids, Dr. Cronan explained that most of the time, even though urgent cares may see fewer children than adults, it is fine to take a child there. But, families can always call their pediatricians for advice. “I don't want to pat us [pediatricians] on the back, but I'm saying pediatric ER doctors and pediatricians in general, we've been trained to read the patient." A young child might not be so good at explaining what hurts, for how long it has hurt, or exactly where it hurts. A call to the family doctor might help sort out where to go get the best treatment.
The urgent care
An urgent care center falls somewhere between an ED and a retail clinic. Just like medical centers have levels, so do urgent cares. Dr. Franz Ritucci, MD, is the physician liaison for the urgent care accreditation organization, National Urgent Care Center Accreditation.
A level I urgent care, the highest level, is a freestanding ED. Most urgent cares are level II or higher. A level II facility is your typical urgent care. Most have physicians, physicians' assistants, and nurse practitioners, Dr. Ritucci said. The level II facilities can take X-rays, treat lacerations, see children. "They have equipment to evaluate [from] pediatric to geriatric clientele," Dr. Ritucci explained. A level III urgent care would be a lot like a retail center, like those in a Walgreens or CVS.
Level III facilities have nurse practitioners and therefore are limited in the type of conditions that they can tend to. A computer-based program spells out which medical conditions they can treat. If the situation is beyond that scope, then the practitioner has to tell the patient to either go an emergency department or an urgent care center for evaluation, Dr. Ritucci said.
“By and large, a lot of people will go to a retail clinic because it's convenient, it's close,” said Dr. Ritucci. “They'll go to the pharmacy [to buy] a Band-Aid [and realize] oh, the clinic is here, let me go check about condition A, B, or C.’ " If the situation doesn't get better, the next stop is an urgent care center, he said.
For people wondering where an urgent care ranks, the NUCCA ranks them. These are voluntary rankings and so a particular center might not be on the list. But, Dr. Ritucci said people can always call and find out who staffs the urgent care. Dr. Ritucci said his first question would be."Is a physician physically present?’
Primary care?
Dr. Ritucci did have a word of warning for patients. Urgent care centers, more or less, will handle a medical need that requires immediate care but isn't an emergency. "They will patch you up, and then get you back to your provider.” These centers, he continued, aren't the ideal spots to handle a chronic condition.
Freestanding ED or trip to the hospital?
For people considering a freestanding ED -- the highest level of urgent care -- Dr. Mehrotra has some advice. Patients who go to these places, he said, expect to pay a certain amount, but end up paying a lot more. “We find that patients go there thinking this is [just] an urgent care center, [with] a certain cost point in their mind, [but] they'll pay 10 times more for care." Also, people should be careful to identify how much it will cost, if it takes their insurance and if it will be able to provide all services necessary.
In research from 2019, Dr. Mehrotra found that urgent care clinics that converted to freestanding EDs often saw the same patients they did before, in the same manner, for more money. However, the Centers for Medicare and Medicaid Services is now allowing some of the facilities, on a temporary basis, to see Medicare and Medicaid patients, due to the pandemic.
The doctor is in
Finally, there is primary care and special types of primary care. In an emergency, there might not be time to make an appointment, but, sometimes it is worth calling to check. Apart from private practice primary care, there are also specialty care nonprofits, like Planned Parenthood, which often offer fixed services on a sliding price scale, and federally qualified health centers (FQHC). FQHCs exist to provide low-cost care to people who might not otherwise have access. For patients looking for more than one-time treatment, FQHCs could be a long-term solution.
Bottom line
So, where should someone go for care? Each person needs to weigh time, price, and their need for care. In the case of a true emergency, the ED is the best option. People can always call ahead and ask who might see them, if the condition can be treated there, and so on. For serious but minor injuries such as burns, scrapes, and the like, an urgent care might be a quick, easy option, but so could retail clinics, telehealth, and e-doctors.
Sabrina Emms is a science journalist. She got her start as an intern at a health and science podcast out of Philadelphia public radio. Before that she worked as a researcher, looking at the way bones are formed. When out of the lab and away from her computer, she's moonlighted as a pig vet's assistant and a bagel baker.
