The growth of retail clinics and urgent care centers, both in Massachusetts and around the nation, represents an effort to provide alternative, convenient points of access to health care beyond the traditional hours and sites of physician offices, community health centers, and hospitals. Greater access to these alternative care sites holds the promise of reducing avoidable and costlier emergency department (ED) visits. Previous HPC analysis has found suggestive evidence that retail clinics may reduce ED use, though literature studies to date have been mixed and more research is needed to definitively establish a link.
Retail clinics (or “limited service clinics,” as regulated in Massachusetts) are typically staffed by nurse practitioners, are located within large pharmacy chain stores, and provide a limited scope of care including vaccinations, diagnosis, and treatment for conditions such as upper-respiratory and sinus infections and yearly wellness exams. They are specifically prohibited from providing surgical services, dental services, physical rehabilitation services, mental health services, substance use disorder services, or birth center services. Urgent care centers, on the other hand, usually include physicians on staff who provide diagnosis and treatment for more pressing conditions, including broken bones requiring x-rays and care for more complex chronic conditions that are not life-threatening. One analysis has found that urgent care centers could safely treat 27% of visits that currently take place in EDs and that retail clinics could manage around 13% of these visits.
In this eighth DataPoints issue, the HPC analyzes growth in these alternative care sites in Massachusetts over time, the geographic areas in which they are located, and the types and costs of services they typically provide. The HPC identified urgent care centers using a number of sources including licensure data from the Massachusetts Department of Public Health  data from the Centers for Medicare and Medicaid Services, insurers’ online directories of providers, and the websites of the clinics and their affiliated organizations. For purposes of this analysis, an urgent care center serves at least all adult patients on a walk-in (non-appointment) basis, and has hours of service beyond normal weekday business hours. Retail clinics are easily identified through their licensure as limited service clinics with the Massachusetts Department of Public Health and because CVS Minute Clinics are the only retail clinics currently operating in Massachusetts.
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Trends in Numbers of Urgent Care Centers and Retail Clinics
The numbers of urgent care centers and retail clinics serving Massachusetts residents have both grown strikingly since 2010, though at different rates.
The number of retail clinics nearly tripled from 20 clinics in 2010 to 57 in 2015 and remained at that level through 2018. The number of urgent care centers grew even more dramatically over this period, accelerating eight-fold from 18 in 2010 to 145 by the end of 2017.
In 2010, most urgent care centers were affiliated with hospitals, but by 2018, most (61%) were part of non-hospital-based chains such as American Family Care (with 21 centers) or Carewell Urgent Care (with 16 centers as of 2018). A handful of them were community health centers that met the definition of urgent care centers as described above.
Nevertheless, in 2017, the number of new hospital-based urgent care centers surged, with 15 new centers opening compared to 11 non-hospital-based centers.
By 2018, Partners HealthCare System owned the largest number of urgent care centers among all hospital systems (16) compared to five each for Southcoast, Steward, and Wellforce. Of all hospital-based centers, some are located on or near hospital campuses (17%) but most are distant from the hospital campus, often located in shopping centers or other suburban areas.
Geography of Retail Clinics, Urgent Care Centers, and Emergency Departments
The next two maps illustrate the locations of urgent care centers and retail clinics as a point of comparison both in 2010 and 2018. The following map shows EDs as well for 2018.
The growth in urgent care centers and retail clinics between 2010 and 2018 is particularly noticeable in the Springfield and Worcester areas, and in the areas outside Boston.
Considering the populations of each area as well, the resulting distribution of EDs, retail clinics, and urgent care centers remains uneven across the state.
Urgent care centers are most prevalent in the areas surrounding Metro Boston, while EDs are more prevalent in Boston and the North Shore. At the extremes, the Norwood and South Shore regions have more than six times as many urgent care centers and retail clinics combined than EDs, while the Upper North Shore and Berkshires have roughly the same number of EDs as urgent care centers and retail clinics combined.
The HPC examined the level of income of the communities in which urgent care centers and retail clinics are located and found that, while urgent care centers were more broadly distributed, the majority of both types of sites are located in higher income areas: 58% of urgent care centers are in zip codes with above-median income while 72% of retail clinics are in these zip codes.
Costs and Care Provided at Urgent Care Centers, Retail Clinics, and Emergency Departments
The next graph illustrates the most common patient diagnoses treated at retail clinics and urgent care centers.
Almost one in five retail clinic visits is for acute pharyngitis (sore throat), with acute sinusitis accounting for another 11% of visits. Urgent care centers see a wider range of patient conditions, with the top two (acute pharyngitis and acute upper respiratory infection) comprising only 13% of visits. Pains, wounds, and ankle sprains make the top 20 list for urgent care centers, but are not typically treated at retail clinics.
Visit costs, including patient cost-sharing, vary significantly by care site.
The average amount paid by insurers and patients combined for an ED visit is just over $1200 with the patient copayment averaging $164, compared to $172 (total) and $35 (patient copayment) at urgent care centers and $69 and $20, respectively, at retail clinics. Even when examining a common set of minor conditions that can be treated at all settings, the average cost difference between an ED visit and retail clinic is similar, with total costs and patient copayments averaging $899 and $162 at EDs, $166 and $34 at urgent care centers, and $78 and $26 at retail clinics. 
 A discussion of quality of care across these different sites is outside the scope of this brief, although findings in academic literature tend to show similar quality for episodes within the scope of all settings. For example, see Mehrotra, Ateev, et al. "Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses." Annals of Internal Medicine 151.5 (2009): 321-328.
 Not all urgent care centers are individually licensed by the Massachusetts Department of Public Health. For example, independent physician-owned and operated facilities may be licensed under the physician’s medical license. Additionally, urgent care centers may be satellites of a hospital.
 Specifically, the HPC required that an urgent care center be open 1) at least 8 hours beyond normal business hours (defined as between 9am and 5pm on weekdays) in a given week, or 2) at least 1 extended weekday hour and 5 weekend hours to be considered for this analysis.
 The 2018 figures here and throughout this brief reflect data through early 2018. There are a number of activities underway that will impact the data presented here by the end of 2018 including a new non-hospital chain (ConvenientMD) entering the Massachusetts market with several urgent care centers under construction in 2018. In addition, the HPC received notice on August 1, 2018, that South Shore Health System proposes to acquire five Health Express urgent care sites. After the transaction, those urgent care sites would become hospital-affiliated.
 “Near” is defined as within a 10-minute drive time to the hospital.
 For example, see Rudavsky, Rena, Craig Evan Pollack, and Ateev Mehrotra. "The geographic distribution, ownership, prices, and scope of practice at retail clinics." Annals of Internal Medicine 151.5 (2009): 315-320.
 Cost figures were updated in December 2018, to include additional payments associated with visits including facility charges, labs, tests, and other procedures.
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