This is the transcript of my recent podcast interview with Concentra Chief Medical Officer, Dr. Tom Fogarty. David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog. I’m speaking today with Dr. Tom Fogarty. He is Chief Medical Officer at Concentra, which operates hundreds of clinics that combine urgent care with other services. Dr. Fogarty, thanks for speaking with me today. Dr. Tom Fogarty: Thank you. I appreciate being here. Williams: What is an urgent care center? How does it differ from other options like emergency rooms or primary care physician offices? Fogarty: An urgent care facility is more of a walk-in facility to take care of immediate problems as opposed to a family practice or a primary care practice where the physician has a long-term relationship with the patient for chronic health and wellness. The biggest difference between urgent care and emergency room is generally the level of care that they are designed to take care of and the cost associated with the delivery of that care. Statistics show that 84 percent of ER visits are a lower acuity than what an emergency room is designed to take care of, but unfortunately the charges are still pretty high for those patients that are seen. Urgent care is designed to take care of those patients that don’t need the high level of acuity that an emergency room is designed for. Williams: Is it straightforward for a patient to tell in advance which sort of facility they should go to? For example, if somebody thinks they may have a broken arm, is that a clear cut case for one type of facility over another? Fogarty: Well I think that’s part of the issue with the average patient. Most patients don’t understand the level of care that can be delivered in different facilities. Emergency rooms are for life threatening issues that you might need to be hospitalized for. Most other types of conditions can be taken care of in an urgent care setting. Fractures is the one that you mentioned. Obviously if you have major traumatic fractures you should go to the emergency room, but a lot of minor fractures can be taken care of in urgent care. Even in the emergency room, if it’s a displaced fracture, you’re going to be referred to an orthopedic surgeon, and the same can take place in an urgent care. Williams: Let me ask you about a couple of other kinds of less traditional facilities that have emerged in recent years, one being retail store clinics and the other one being freestanding emergency rooms. How do those fit into the equation? Fogarty: The freestanding emergency room, from my understanding, is kind of in between the urgent care and emergency room. They can take care of more severe things. Myocardial infarctions, they advertise that they can take care of those. I’ve not been in one so I really can’t address specifically what their level of acuity that they can care for. The retail facilities are a much lower level than urgent care as far as what they take care of. They generally are designed for immunizations, upper respiratory, very minor issues. So they’re usually staffed by a midlevel, either a nurse practitioner or a physician’s assistant working under the guidance of a physician that is not onsite. They don’t have x-ray facilities, they don’t have lab capabilities. It’s really more of a very low acuity they’re designed for, but they do provide a service for entry into the system. Williams: Let’s talk a little bit about reimbursement. I’m curious about how urgent care centers are reimbursed by commercial health plans and by Medicare and Medicaid. Do they fit right in between a physician’s office and an emergency room as they do for acuity of injuries? Or are there some peculiarities about how reimbursement is done and also perhaps what the patient responsibility is? Fogarty: In our facilities about 20 percent of our patients are cash pay so they don’t really use insurance. The insurance companies and Medicare and Medicaid, you have to be approved. Some of the payers in certain parts of the country don’t even have a classification for urgent care. So you could say it’s an educational process even on the payer side about what an urgent care’s role and function is. The schedule for the reimbursement is more along the lines of the outpatient versus the emergency room. Again, the difference is in the cost. An emergency room bill is a very specific thing. The cost is much higher than when that same service is billed for in an outpatient setting. Urgent care is more in line with the primary care practice as far as reimbursement goes. Different payers recognize urgent care in different fashions and some of them don’t recognize them at all. It’s part of the process of educating the payers on what those services are and what their capabilities are. Williams: Despite the moves towards transparency, it’s hard for a patient to figure out what they’re going to be charged when they go to the doctor’s –and never mind to an emergency room or hospital admission. You mentioned that 20 percent of your clientele are self-pay. Do they have any sense up front of what the cost is going to be? What’s the experience like for them when they get the bill? Fogarty: We post some standard pricing in our facilities so it’s pretty apparent when the patient comes in. We have some standard pricing for three different levels of care: minimum, medium and more extensive. Patients kind of know what that pricing is up front with what it’s going to cost them. That gets into the whole side of people taking responsibility for their health care. I think transparency of pricing and knowing what services and things cost are a key component of that. We, in our facilities, handle that by posting some pricing up front when the patient comes in. Williams: I understand that probably the best use for an urgent care center is the type of acute issue that can be taken care of in a single visit, but how do you tie in more broadly to the health care system to deal with some of the continuity of care issues? Fogarty: That really is an issue. When you talk about health care from more of a global perspective, part of the solution to our health care needs really is an integrated primary care based delivery model that helps a patient coordinate their care through the system. In our urgent care facilities when patients come in, one of the questions we ask them is ‘Do you have a primary care physician?’ If you do have a primary care physician then getting the results of our visit to those primary care physicians is a critical step. If we can get information from them, which doesn’t happen very often, it’s beneficial. If they don’t have primary care physicians then we try to help them, especially if they have a condition that is more chronic in nature. We help facilitate that patient to get into a primary care physician so they can have continued care. It’s not good for somebody to take care of their hypertension or diabetes in an episodic fashion. It’s much more beneficial for the patient and it’s much less expensive for health care in general for those patients with chronic conditions to be taken care of in a coordinated fashion from a primary care physician. The urgent care facilities provide a very good opportunity for patients to access a primary care system, versus an emergency or hospital based system, to help coordinate their care and make sure that they get tied in with the folks that can help them take care of their health on an ongoing basis. Williams: So perhaps the way an emergency room is often the front door to the hospital admission, urgent care in some cases could be the front door to someone getting into a primary care environment? Fogarty: Yes, most definitely. In an ideal system you would have in a community a network of primary care clinicians that provided the vast majority of care. As you well know patients that have a medical home –that have coordinated primary care– end up in better health, taking less medication, having fewer hospital admissions and therefore decreasing the total cost of care. And the good side of that is the patient gets better health care. Williams: There appears to be strong momentum for patient centered medical homes. In that environment, is there a formal role for your urgent care clinics? Could they be part of the patient centered medical home network or ‘neighborhood’? Fogarty: I definitely see it as part of the medical home or neighborhood. The reality is patients don’t always have medical issues that occur during office hours. So you have patients that need care outside of office hours. Also, if a clinician has a full schedule and can’t see patients, what is the alternate methodology for those patients to be seen for an acute episode? Urgent care is a great model for delivering that kind of care. The reality is not everybody has a medical home, so it is an entry point for patients that never had a need to develop a medical home; it’s an entry point for them to take care of an episode. Then in an ideal coordinated fashion, that would be an opportunity for the system to help patients maneuver into a primary care setting that can help them on their long-term care. So yes, I see it as a very integral part of the delivery methodology. Emergency rooms historically have functioned in that capacity. The problem with emergency rooms is the cost associated with them and being part of that integrated process. Williams: Tell me about Concentra’s business. I know that your centers don’t tend to be just urgent care centers and that you also have some, worksite centers. Can you describe the philosophy and share the contours of these clinics? I’d also be interested in your staffing model. Fogarty: Concentra has been around for about 30 years. We stared here in Texas back in the late ‘70’s, early ‘80’s. Our primary practice in our facilities was occupational health. We worked with employers focusing on health and wellness, focusing on treatment of work-related injuries. When you look at urgent care and work-related injuries, about 70 percent of the ICD9 diagnoses cross over between the two. It’s a lot of musculoskeletal issues, upper respiratory, etc. As our practice developed it focused on providing the best medicine to the patient but also decreasing the total cost, because we’ve always focused on the total cost of the case and have been very successful in establishing relationships with patients and employers to provide that care. A couple years ago we looked at adjacencies to our practice and started expanding into urgent care at the request of employers. They had employees that would get medical issues; colds, illnesses, stomach aches and things like that that happened and they were looking for someplace for those patients to receive their care. So we took an adjacency approach and expanded into urgent care. At the same time, we started focusing on the patient experience. Customer service in health care has not been the best in the world, so we started focusing on the patient experience so that patients, when they come to our facilities, have a good experience. They feel like people care about them, which assists in the healing process. Another part of our business, as you mentioned, is onsite clinics where we are actually in an employer’s physical location, providing some form of health care. We have about 250 worksite clinics around the country with medical personnel in a company’s facilities. We provide a different range of services, depending on what the employer is trying accomplish with their health facility: whether it’s health and wellness, taking care of work-related injuries or a full-blown family practice. It takes care of all the medical needs of their employees. So we’ve got a broad range in the 300 [non-worksite] facilities that we have around the country. We’re within about a ten-minute drive of 35 percent of the workforce in the country. So we have an exposure out there that provides care to primarily the working folks in society but we also provide the urgent care to those folks and to their families when the need arises. Williams: I’ve been speaking today with Dr. Tom Fogarty, Chief Medical Officer at Concentra. Dr. Fogarty, thanks so much for your time. Fogarty: I appreciate you having me here to discuss the issues of health care.