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    Linda Ratner, RN, BSN, MBA, CMPE

    Lack of access to medical care continues to drive the growth of urgent care clinics (UCCs) nationwide.

    Just three years ago, I did not see any urgent care clinics in the Boston area despite being on the lookout. By autumn 2018, I saw one in every neighborhood I visited and near all heavily traveled highways.

    Urgent care centers have become more prevalent nationwide, as well. According to the Urgent Care Association’s 2017 Benchmarking Report Summary, there has been an increase of nearly 40% UCCs since 2014 — and 90% of those UCCs anticipate growth.

    This growth has been good news for patients who visit an emergency department (ED) with life-threatening conditions. Access to high-acuity treatment has dramatically improved with the availability of UCCs for lower-acuity illnesses and injuries. Additionally, both patients and insurance companies have experienced significant cost reductions by shifting lower-acuity work to UCCs.

    Entering this arena of healthcare requires many considerations. For real estate investment purposes, the location of a UCC is significant. Factors to consider include:

    • The population within three- and five-mile radiuses
    • The traffic count directly in front of a selected building (available from retail analytics firms or shopper marketing analysts)
    • The decision on a standalone building or operating as part of a retail center.

    Start with a robust strategic plan consisting of solid core values and a strong mission/vision statement that promotes alignment and accountability within the organization while supporting quality care. It is imperative to identify the target market early on and address pain points more effectively than the competition can (hint, read the competitions’ reviews and work to address complaints). For example, can you provide a virtual queue so that your patients can rest at home, thereby perceiving a shorter wait? Be innovative to differentiate the clinic from others in the area.

    Income considerations are also important in today’s high-deductible health plan climate. Are there any established UCCs in the preferred area? What do their customer reviews reveal about them? It is crucial to understand the competition and how you can enter the market to ultimately be successful.

    Keep in mind that patients have choices. It is not enough to provide quality care. Today’s medical practices must provide a high level of service, taking into consideration patients’ needs and building strong relationships between staff and providers and their patients to ensure continued patronage. UCCs competing for patients must treat them with respect and empathy and provide a high level of customer service for patients who expect convenience, efficiency and economy.

    Engaging physicians is also vital. A new UCC may be seen as a threat to a practices’ bottom line or cause concern about a loss in continuity of care. Meet with surrounding physicians to create collaborative relationships; one idea is to have the urgent care’s medical director and manager meet with doctors and their management teams to assure them that the clinic is an extension of their practice by offering evening, holiday and weekend hours. Explain that a copy of the medical report will be forwarded to the practice (if patient requests) to maintain continuity. A UCC can also handle practice overflow as needed to better serve patients. Remember that urgent care does not replace primary care or other specialties; building a solid relationship with those providers will allow the center to refer new patients to their practice as well.

    Other areas that require careful examination are those related to expenses and level of care provided. How will the center be staffed? Staffing ratio and optimization of the clinical personnel’s skill set is essential. For example, it is quite common to cross-train X-ray techs to manage the front desk and/or provide clinical care to patients to reduce labor costs, which represent a large percentage of monthly expenses. Thoroughly analyze payer contracts, if they are available, and understand what net revenue per patient visit (NRPPV) will look like. Will it be enough to sustain a doctor-only model or will you need to staff with a combination of extenders and providers? Hours of operation are also a huge consideration — optimizing staff and provider schedules for patient visits can save thousands of dollars per month.

    Provider staffing considerations will help dictate the level of care provided. Will the center be staffed with physician extenders most of the time or will the model be based exclusively on physician care? Also consider how emergency care will be provided at the center. How will transfers to the emergency department be coordinated? The clinic will be held to a higher standard based on how much equipment is available to sustain life. For example: A UCC without a full crash cart or required medications would not be expected to intubate and resuscitate a patient using advanced cardiac life support measures (ACLS). The level of equipment and care will dictate the level of training for staff in the event that there is a respiratory or cardiac event. Create policies and procedures to support the decision and set aside time to spontaneously practice a mock event.

    A robust financial process is needed, complete with oversight and tight financial controls. Urgent care is episodic care, and time-of-service (TOS) collections deserve the owners’ attention and must become a priority. High-deductible plans and increasing patient responsibility necessitate proper insurance verification. Today, front desk collections may account for up to 40% of the clinics’ revenue and require more attention. The opportunity to collect at a future date is drastically reduced once the patient is treated and discharged. Procedures designed to provide reliable and consistent oversight of account receivables must be actualized. Because of the nature of insurance verification, the front desk collections process will not be 100% accurate. In this case, a consistent means of post-service statements, collection calls, claim denial adjudication supported by prompt-pay laws and a partnership with a collections firm must be created and tightly managed.

    Finally, consistent and regular oversight of key performance indicators (KPIs) is an indispensable part of operations and financial supervision. Without this level of constant care, finances can go off the rails quickly. Deciding which KPIs to monitor depends on the center’s goals, but revenue, NRPPV, patient satisfaction, door-to-door time, patient count, TOS collections and employee retention are among the most important to measure.

    Further considerations include:

    • What type of in-house laboratory certification will be utilized (CLIA-waived or moderate complexity)?
    • Will compliance programs and services such as billing, coding and HR be outsourced?

    Many complicated moving pieces need orchestration, such as insurance negotiations, clinic construction, staff training, services offered and provider credentialing. If this intricate dance isn’t done properly, it takes place in the care setting, to the detriment of patients, staff and providers. For those willing to brave it, the rewards can certainly outweigh the work required to bring this project to fruition.

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