How Higher Visit Volumes are Reshaping Urgent Care

On October 21, 2021, Experity hosted a webinar reviewing our UCQ visit volume data and explained how these trends impact clinics and the future of urgent care.

Joining our President of Strategic Initiatives — Alan Ayers — were Experity’s Chief of Staff Joe Goken, VP of Finance Brooks Pidde, and RedMed Urgent Care’s CEO Ben Morris.

During the webinar, we received a lot of great audience questions.  We’ve included those most widely applicable below for long-term reference.

Could the increase in volume seen in the morning be related to the influx of patients trying to be seen prior to clinics reaching “capacity” each day? If capacity was unlimited, would we still think mornings were expected to be higher?

I saw this early in the pandemic. Patients would arrive starting at 4:30 am to be among the first in line when we “opened” at 8:00 am. But the switch to Clockwise made this unnecessary…as soon as we closed the night before (8:00 pm,) we’d open up registration for the next day. So then patients got conditioned to wait until 8:00 pm to be seen first the next morning. But even if capacity were infinite, I do believe mornings will always be busier. Patients who feel ill at night will typically try to “sleep on it,” coming in the morning if they still don’t feel better. Additionally, people can be late for work but can’t miss work, they need an excuse for work, they need a drug screen or fit-for-duty clearance, or they otherwise want to be seen and get on with their day. So urgent care has always been busiest in the morning.

My advice to centers looking to expand hours is to look at first hour (i.e. 8:00 am) versus last hour (i.e. 7:00 pm) arrivals. If, say, 8 people arrive at 8:00 am, the center is already one hour behind if the provider can see 4 per hour. By opening one hour earlier, the center can spread those eight arrivals over two hours, lessening the backlog at opening.  But regardless of what time a center opens, there’s likely to still be people wanting to get in/out. Change the open from 8 am to 7 am and now you have people standing outside at 6:45 am. And given that negative rapid COVID-19 tests are often required for return to work/school, there’s likely more impetus to get a COVID-19 test first thing in the morning.

Based on the number visits per time-of-day data, is the slower time of day a reflection of actual demand or more of a reflection of appointment availability?

I would say it’s a function of how patients have historically utilized urgent care. See the response to question #1 above. Historically afternoons are the slowest time of day in urgent care, so if afternoons are busier, I’d say that’s reflective of either A) centers reaching capacity, or B) an effective queuing system that paces arrivals evenly across opening hours. However, given the data is showing afternoons are slower, that probably means queuing systems have not been fully adopted and there is opportunity to better use that open capacity in the afternoon. 

How do you determine when to cut off walk-in patients?

If you take walk-ins, I believe they need to be taken during all posted hours. Meaning, don’t say you’re open from 8 am to 8 pm but you take your last patient at 7:30—in that case you “close” at 7:30!  

If the concern is paying OT, the incremental revenue from each additional patient should exceed the cost of OT. If the concern is burning out staff, then schedule shifts longer than the posted center hours to allow staff to finish their tasks and get home on time. If the center is backed up with patients waiting, then you can communicate at whatever time there are sufficient patients in line to occupy the staff until closing. For example, at 6:00 pm if you have 12 people waiting, you could tell non-emergent new arrivals “we’re at capacity…you’ll need to return tomorrow.”

Is there a strategy to limit the number of patients that book a visit,  and then cancel or remove themselves shortly before their appointment time?

I have not seen this, and to my knowledge this is not a current capability of any system. To accomplish this, the patient would have to first log into an account using a distinct username and password (so they could be identified) and while some retail websites and apps are designed that way, it’s not how queuing is currently designed in urgent care.

Is there an ideal advanced appointment option to reduce no-shows and cancellations?

No-shows and cancellations are a problem. Unfortunately in urgent care we can’t easily impose penalties as in other practices (see this.)

The problem is people grab spots at various locations and then go the first place they can get in. The prevalence of these no-shows can be reduced with the use of eRegistration. Patients who are fully registered — who have provided a scan of their ID and insurance card — are more likely to show up (or call to cancel if unable) than someone who can book several locations without providing further information. I’ve found it effective for staff to call or text people who joined the queue online 2-3 hours before their arrival time to confirm they intend on coming in, to reiterate it’s not an appointment (check-in time subject to change — watch your texts) and to ask them to complete their eRegistration. If someone says they’re not coming or it’s a bad phone number, then your front desk can release that patient from the queue thus opening the slot to someone else or a walk-in.

How can you balance quality AND quantity to help prevent patient complaints, patient conflicts, etc.?

Quality should never be sacrificed. The ethical duty is to provide quality medical care to patients. Period. Throughput should be adjusted to enable sufficient time to adequately see and treat patients. Generally, this is to determine the average number of patients per hour a provider can see and use the queuing system to align patient arrivals to the provider’s productivity. Meaning…if the provider can see 4 patients per hour, then enable 4 “appointments” or “slots” per hour. 4 patients per hour is a good rate although some providers are able to function effectively at 6, and doing COVID-19 only, some providers are able to rock at 8-9 per hour. Other factors determine the number of patients per hour including the efficiency of back-office workflows and provider charting.

How can you incentivize your providers to handle larger volumes and acuity?

My experience is a base level of compensation by hour or shift with a bonus paid for each patient per hour above a threshold. Now this primarily considers volume and not acuity, therefore the risk is that higher acuity patients get sent to the ER so the provider can see more low acuity cases. While RVUs would better balance quantity and acuity, the problem with RVUs in urgent care is “case rate.” When every visit pays the same global rate, RVUs can incentivize services that the urgent care often can’t get paid for.

Are the demographics of new patients different from the traditional urgent care demographic?

Typically, an urgent care draws from a trade area so the demographics of the urgent care are likely reflective of the patients available in the community. I did observe early in the pandemic at one center I was pulling very heavily from the Hispanic community because there was an outbreak in that specific community, but once that initial rush subsided, we saw fewer of the Spanish-speaking patients. I think that was a function of that one specific center’s location. It would be interesting to see in Experity’s database whether COVID-19 introduced a younger or older demographic, or changed the payer mix of urgent care. 

How do you show appreciation to those running your clinics?

There are a great variety of ways you can express appreciation to staff:

• Spending time in the centers, personally listening to the staff/acting on their concerns, and thanking staff for their service.
• Small acts of kindness like handwritten notes, flowers or balloons, or unannounced meals (pizza or Panera tray) delivered.
• Stocking the breakroom with a variety of packaged and healthy snacks, both shelf-stable (Raman noodles, Nabs, graham crackers, chips) and in the refrigerator (fruit, yogurt, hot pockets, ice cream bars.)
• Gift cards for a nail salon, chair massage, or other “simple indulgences.”
• COVID bonuses to paychecks.
• Being adequately staffed and eliminating other barriers to their jobs such as replacing broken equipment or fixing dysfunctional processes to make their jobs go more smoothly.

How is telemedicine being done? Are the same providers performing clinic work or other providers assigned to handle telemedicine calls?

Urgent care has embraced telemedicine several ways:

• As a replacement for in-person visits and/or to compete against national telemedicine platforms like MD Live, Teledoc or health system and insurance company options.
• To provide the medical screening component for COVID-19 exams enabling drive-up swabbing.
• Inside the exam room to “staff” pop-up clinics where no provider is on-site, to cover for provider callouts or absences, or to increase patient per hour capacity (adding a “virtual provider”) at a center.
• To offer urgent care services in remote locations like employer worksites or school nurses offices.

While it is possible to queue up in-person and virtual visits to utilize a provider working in the clinic, my concern is that it would detract from throughput in the clinic. If an urgent care has scale in multiple locations, the telemedicine is typically provided by a dedicated provider in a separate queue. 

More from Experity

If you haven’t seen the webinar or would like to watch it again, it’s available on-demand:

▶ Urgent Care Data: How Higher Visit Volume Is Changing Your Business

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