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Matters of Urgency: Imaging, Urgent Care Centers and the Growth of Choice

– By Matt Skoufalos

In 2013, there were about 6,100 urgent care centers operating in the United States, according to the annual benchmarking report from the Urgent Care Association (UCA) of Warrenville, Illinois. In just six years, that count is approaching 10,000 (9,616), having climbed almost 10 percent year over year, the agency reported. As of March 2020, “an estimated 27 percent of all primary care visits and 14.9 percent of all outpatient physician visits take place in urgent care,” UCA reported, citing data from the Centers for Disease Control and Prevention (CDC) National Ambulatory Medical Care Survey and its own 2019 Benchmarking Report.

As those centers continue to expand the array of treatment options they provide, where do medical imaging modalities fall in their continuum of services, and who’s performing those studies?

Tracey Dennewitz, head of product marketing and operations for the X-ray products business of Siemens Healthineers North America, sees the growth in urgent care centers as being driven by patient demand, the convenience of care provided at those centers, and the ongoing search in health care for greater cost controls.

Amid the explosion in urgent care center growth, Dennewitz also notes a shift in their ownership: five or six years ago, such centers were established by physician-led practice groups; today, they’re being opened by large health systems and investor-backed companies, he said.

They’re also picking up patients who don’t have primary care physicians. The lowest participation in primary care practices has been seen among Americans aged 18 to 34, as nearly 20 percent of American women and 30 percent of American men do not have primary care doctors, Dennewitz said.

“At the end of the day, patients that are seeking medical care don’t want to wait long periods of time in ERs, or deal with the hassle of primary care scheduling,” Dennewitz said. “It’s an on-demand society, and that’s a need that urgent care centers fill.”

As urgent care centers expand the array of services that they provide to include medical imaging, they will bear the cost of owning and maintaining the staffing and technology that delivers those services, Dennewitz said – even though, in most cases, patients still need to visit a primary care doctor to get their results interpreted. Given the versatility of mature, commodity technologies like digital X-ray and ultrasound, the question of incorporating those services into an urgent care environment becomes largely arithmetic.

“To me, it’s a capital investment equation,” Dennewitz said. “X-rays aren’t just for broken bones. Urgent care centers use digital imaging to diagnose a number of complications – pneumonia, joint dislocations, bowel obstructions, kidney stones, fluid in the lung, foreign bodies – or to rule out the need for additional procedures. Most centers offer routine general X-ray, either DR or CR, and ultrasound. And clearly, there’s growth in the market. We’ve seen a steady increase over the years in this segment.”

As digitalization of health care continues to expand, Dennewitz foresees additional, “higher-end” imaging services could be added to those on offer in urgent care centers, be they mammography, CT, fluoroscopy and so on. If Americans continue to seek lower-cost care at urgent care centers instead of at hospitals or private-practice imaging centers, “urgent care centers will need to evolve and enhance their capabilities,” he said.

Likewise, Tracy Bury, senior vice-president of marketing, sales, and communications for ultrasound at Siemens Healthineers, believes in point-of-care ultrasound, or POCUS, as a growing market beyond urgent care center operations. The attitude “is perfectly matched with the urgent care philosophy of addressing non-life-threatening procedures and events for patients,” Bury said.

With total visit times at most urgent care facilities averaging less than an hour, including wait times, “it’s so much more convenient for patients than going to an ER, where they have to wait and constantly be put behind the more urgent cases,” she said. And as ultrasound is useful in reliably evaluating a number of conditions, from pregnancy to shock and trauma, it’s easy to imagine its broader use in the catchall business that urgent care facilities do.

However, the adoption of ultrasound modalities in urgent care clinics has lagged that of X-ray technologies, in part because of the skill level required of its operator. Urgent-care practitioners have to be broad generalists, and unless their clinics are being staffed with ultrasound technicians as well, the biggest shortfall in broader adoption of the technology lies in technical education.

“The U.S. differs from other countries in that we have a sonographer-based workflow in most hospitals and private physician offices,” Bury said. “Most of these physicians have not had sonography experience in school.”

“Ultrasound is a subjective art,” she said. “There are skill levels. I feel the education hurdle is a big one for physicians. More are becoming familiar and educated, even to the point of expertise with ultrasound equipment; many vendors recognize this and focus on education in modules.”

But even as ultrasound classes are filling up, there’s still “a long learning curve for these physicians specifically because they do everything,” Bury said. The biggest hurdle might be the time it takes to develop proficiency with the modality in the broader context of all the other demands on their time.

“People graduating now have had exposure to ultrasound, whereas more and more years ago, they didn’t,” she said. “I feel this is growing symbiotically with the technology and the skill set.”

“As more digital education is available, more remote learning, more physicians will practice this,” Bury said. “As it becomes more portable and the workflow is easier to use, it will enable them to do it.”

Katrina Catto, CEO of Urgent Care Occupational Health and Employment Services Division at Banner Health in Phoenix, Arizona, said that most urgent care centers are built upon a case-rate model, in which everything done in the office is covered under a single fee. Putting basic radiography under that umbrella is effectively a decade-old expectation, Catto said. X-ray studies are widely performed at urgent care centers, in large part because after-image digital systems can fine-tune a study once it’s been captured, and not all states require that only a licensed X-ray technician may obtain the image, she said.

Yet although some 90-percent of urgent care centers offer X-ray services, Catto said ultrasound is only available at about 10 percent of them, and CT at less than 2 percent. She believes those umbrella payment arrangements are another factor that will keep more centers from investing in higher-cost imaging equipment, as even with increased reimbursements, volumes are low in that environment.

“There aren’t enough CT studies that really come through the urgent care to make the purchase of a large machine really show on ROI,” Catto said. “I see urgent care branching out into other types of service lines where accessibility is needed. There’s a lot of work around fusion and dialysis that patients will continue to drive out of the hospital space. I don’t see any increase of the level of imaging provided in urgent care centers any time soon.”

Beyond broadly expert physicians needing to develop their facility with imaging equipment, additional barriers to rolling out higher-level services at urgent care centers include access to imaging technicians, the availability of radiology professionals to interpret the results of imaging studies performed, and patient access to primary care providers to review them (which most people making use of urgent care centers may not have). But even if urgent care facilities don’t expand their imaging offerings, Catto doesn’t necessarily believe that patients are going to turn to hospitals for outpatient imaging services given the out-of-pocket cost.

“How imaging fits into a landscape like ours is really about creating continuity of care through our services: medical records, payment services, high-level care,” she said. “It’s a matter of having the best radiologists doing it. Convenient access and that high-quality experience are very important within that continuum.”

“The consumer is really going to be the one that makes that change and drives the need for additional locations and availability of imaging services,” Catto said. “There will continue to be opportunity in that space for continued growth. There aren’t imaging centers in a number of places; people still go to hospitals for those studies. As consumers manage where that spend is going, it’s going to drive a lot of that business out of the hospital.”

Alejandro Badia, co-founder and chief medical officer of OrthoNOW and the Badia Hand to Shoulder Center of Doral, Florida foresees growth in “specialty urgent care,” particularly orthopedics. Such facilities are particularly dependent upon imaging, “and that’s going to be an opportunity for the imaging market,” he said. Practices like Badia’s see many cases that are not always urgent in terms of their acuity, but may be the result of untreated chronic conditions flaring up.

“The analytics we have show that 70 percent of people walking into our urgent cares are not even that urgent; it just might be some arthritis or tendonitis that has nothing to do with injury,” he said.

Providing urgent orthopedic care “decompresses the entire system” in the same way that primary care and other urgent care centers do, providing a safety valve that relieves overall pressure on the system, Badia said. Patients who go to emergency rooms for treatment of their orthopedic injuries could be back-burnered there depending upon the volume of patients waiting to be seen and the severity of their cases.

“If you have knee pain, you don’t want to be sitting next to someone with a hacking cough,” Badia said. “Still, people will go to a general urgent care all the time with their knee pain.”

As a specialty urgent clinic, Badia’s practice locations all make use of digital imaging, from X-ray to diagnostic ultrasound to miniature fluoroscopy, which Badia describes as one of his most powerful resources. Going forward, he believes mini-fluoro is the next advanced modality to which physicians at freestanding practices like his will turn.

“I use mini-fluoro every day,” Badia said. “If you do sports medicine, every knee and shoulder surgeon will need an MRI. You’re going to see more clinicians, even solo, having these in-office machines that are much smaller and not as powerful, but useful if you have a good technician.”

Orthopedic urgent care centers like Badia’s fulfill a specific role between those of hospitals and primary care physicians; however, he is careful to say that there are limits to the types of cases that should present there, optimally.

“If something’s really severe and acute, that’s what hospitals are for,” Badia said. “We don’t want to go the other way either and bring everything to a patient walk-in center; you may need an ICU bed.”

Beyond urgent care centers and standalone imaging facilities, Badia also pointed to the presence of standalone emergency rooms as another option for patients in several parts of the country. From Texas to Florida, the growth of facilities like these reflect the degree of competition among large health systems and hospitals throughout America. Amid that pressure, the quality of available imaging services and imaging-guided procedures will oftentimes be a differentiator for customers with multiple options in a marketplace. And as customers have more options available to them, “the problem is, where are we as physicians going to be?” Badia said.

“If physicians want to remain independent, they’re going to need a little more business savvy,” he said. “They’re going to have to realize they’re going to have to make an investment, and the investment is imaging.”

Rather than worrying whether devices will pay for themselves over their lifespan, Badia said physicians should consider what their ability to offer imaging services does for their practices when deciding to purchase.

“Walk in with shoulder pain, walk out with a definitive diagnosis, and I’m already on your surgery schedule to fix my rotator cuff,” he said. “What physicians are going to make that jump and offer those services to their patients?”

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