Consider adding this service to the orthopaedic patients in your community
As patient care moves to less-acute settings, orthopaedic urgent care (OUC) is becoming more common.

One of the most common reasons for emergency room care are musculoskeletal, and OUCs are a great opportunity to provide better access, better quality, and better value for their patients and communities.

The move toward OUC
There are many big-picture reasons to consider adding an OUC center to your practice. At a health system level, it can provide huge savings. Physicians must be good stewards of healthcare spending. With $20 billion spent annually on urgent care, the opportunity for savings is significant.

Patients are going to demand that this cost savings be passed on to them. Their tolerance for cost inefficiency has plummeted with the meteoric rise of health insurance deductibles. They are becoming true consumers of health care when the problem is not emergent. In markets with multiple options, they will do more research on where they get best quality for their money.

Bruce Cohen, MD, of the Charlotte, N.C.-based OrthoCarolina, said the practices’ OUC facility has “proven to be a valuable service line to OrthoCarolina and the community. For our practice, it’s a vehicle for helping patients who otherwise would have to go the emergency room or a hospital-owned urgent care facility. Lastly, OUC centers have proven to be financially successful. As for the community, we offer an opportunity to be evaluated by an orthopaedic specialist at convenient hours while only charging an office visit.”

In addition to cost, the consumer-driven market will expect healthcare dollars to be spent on quality care.

One of the key components of quality is the provider’s skill and knowledge. Some emergency department providers do not have extensive experience musculoskeletal injuries. There can be significant variability in the care provided both in hospital emergency rooms and general urgent care centers. Many orthopaedic surgeons have seen missed diagnoses or inappropriate treatment of musculoskeletal injuries. OUC enables orthopaedic surgeons provide more direct management of these problems.

OUC centers can help practices balance a busy clinic while accommodating urgent patient needs. Many presenting complaints can be treated without exceeding a patient’s deductible. This scenario opens the door for out-of-network care without adverse financial consequences for the patient. These satisfied patients are more likely to advocate for their surgeons to their primary care providers. Urgent care also provides a patient stream without the burden of hospital emergency room call. Furthermore, most musculoskeletal injuries do not require acute hospital service and are ideal candidates for the urgent care setting.

Practical considerations
Fully developed urgent care centers often partner with hospitals. For those severe injuries requiring acute hospitalization, the time to the time to arrange this higher level of care is before the patient arrives. To ensure the best patient care and protect the center from liability, OUC centers should develop transfer agreements with local facilities. Staff will be more comfortable knowing they have an acute outlet, if needed.

Any level of orthopaedic care is often dependent on timely and accurate imaging services. Additionally, imaging takes up a large part of healthcare spending and is a key point of cost containment in the urgent care setting. Having providers with experience and surgeon access allows OUC centers to maximize value on imaging. Getting direct access to definitive orthopaedic care can bypass the process where inappropriate and expensive advanced imaging is ordered. The imaging that is ordered is more likely to have the correct views and quality. Even with surgeon control, approximately 25 percent of patients in an OUC center still will require advanced imaging. If structured appropriately, these imaging services can provide an additional ancillary revenue stream.

Urgent care clinics can take many different forms. Some practices establish a walk-in option for patients to see the surgeon in the usual office setting. This approach—the face-to-face exchange between patient and surgeon—is often a patient expectation in competitive markets. The obvious downside is the unpredictable nature of the clinic schedule for the surgeon. As a precaution, it is beneficial to have the on-call doctor as the urgent care provider. Schedules can be adjusted to free up the assigned surgeon. Contingency plans are necessary in case a surgeon is called to the emergency room or surgery.

Another option is to have OUC in the office and staffed by a provider other than the operating surgeon. The arrangement can be a midlevel team member such as a physician assistant or nurse practitioner. Nonsurgical physicians—such as primary care sports medicine, occupational medicine, or physical medicine and rehabilitation—can also serve in this role. A final option is an orthopaedic surgeon who chooses to only work in an office practice.

Dr. Cohen stressed, “It is critical to identify enough providers to consistently staff [the OUC center]. Using nonorthopaedic trained providers have not been a successful model. Patient volumes need to be analyzed on a frequent basis to determine staffing levels and avoid extended wait times and poor service.”

Site selection and sizing
Some practices have placed OUC in geographically diverse locations. This method increases points of care and patient convenience. For example, retail commercial areas provide more walk-in patient traffic.

These remote locations are more efficiently staffed with midlevel providers. In almost all cases, a well-trained physician assistant with direct access to a surgeon can provide final patient disposition and definitive care. This approach provides cost savings for the patient and avoids unnecessary visits with a surgeon.

How big an area is needed to sustain an OUC center? Alejandro Badia, MD, chief executive officer and chief medical officer of OrthoNOW, an OUC clinic franchise, feels that a drawing area population of 100,000 is ideal. In a less dense rural setting, the target could drop to as little as 50,000. In an urban setting, the drawing area should be approximately five miles in radius from the center. Location relative to competitors substantially influences the ideal placement of a facility.

Another important aspect for remote offices is facility size. The answer, of course, is dependent on the market and expected traffic. Dr. Badia has found that about 2,200 sq. feet is required for a viable remote clinic to meet demand of a market with a population of 100,000.

In the spirit of fast service, a greeting room, instead of a waiting room, is ideal. Four to six exam rooms should provide enough space to keep pace with patient flow.

Space should be identified for imaging early in the development stages as lead wall requirements are common and can be expensive to build. Although the bare minimum requirement is radiography, ultrasound is becoming more useful in this setting. Medicare requires digital radiographs for reimbursement. Requirements for radiology technician certification vary by state.

Linking the imaging to the surgeon is crucial to maximize efficiency. The flow of patient information from imaging to the provider is key to an efficient decision-making process.

Finally, it is important to understand community and state regulations regarding urgent care services. These regulations can vary and thus impact billing procedures, staffing, and the minimum square footage of the clinic.

Is OUC for you?
As patients increasingly view health care thru the consumer lens, providers must focus on opportunities to create value. OUC centers are one path to high-quality, cost-effective, and convenience. The rapid growth and diversity in OUC demonstrates the important flexibility this business model has in fitting your individual practice needs. It is worth your time to understand how OUC can help you expand your practice and add service to the orthopaedic patients in your community.

Jared Abel, JD, MHA, is the orthopaedic service line director for OrthoKansas and the administrator for the Lawrence Surgery Center.

Neal Lintecum, MD, is a partner at OrthoKansas in Lawrence, Kan. He just completed his second term on the AAOS Health Care Systems Committee.