Emergency Rooms vs. Urgent Care Centers: Differences in Services & Costs

View the vast difference between Emergency Room and Urgent CareThe debate over receiving treatment at a hospital emergency room versus treatment from an urgent care center is worth having for anyone concerned about medical debt, especially families, who may have a lot of “emergency” and “urgent” needs facing them every year.

There are many sides to the debate, but the generally agreed upon guidelines for deciding between an emergency room and urgent care center are:

If you have a non-urgent condition – fever, flu symptoms, allergic reactions, minor cuts, animal bites, broken bones – urgent care centers are far better for time and cost.

If you have an extreme medical condition – stroke, heart attack, severe burns, electrical shock – the resources and services available at hospital emergency rooms make that a far better choice.

Unfortunately, if you are looking for timely data to support either argument, the debate is over. Nearly all the information on emergency room care is from 2012 or earlier and the data for urgent care centers is by observation from the American Academy of Urgent Care Medicine.

Emergency Rooms

According to the Centers for Disease Control and Prevention (CDC), Americans made 136.1 million visits to one of the country’s nearly 5,000 emergency rooms in 2012. Approximately 20 million of them arrived by ambulance. About 43% of all hospital admissions originate in an emergency room.

Normally, emergency room patients receive one of five levels of care. Level 1 is for minor problems, such as an earache. Level 2 may be for a cut that requires stitches, while level 5 is for more severe problems, like a broken bone. Levels of care exist for critically ill patients that are even higher.

The main reason that so many emergency room visits are for non-urgent care is that hospital ERs are required by federal law to provide care to all patients, regardless of their ability to pay. Since they can’t be turned away, patients without insurance, or the necessary funds to pay out-of-pocket costs, often utilize emergency rooms as their main health care provider. This puts tremendous strain on ERs, and limits their ability to attend quickly to health emergencies.

It is estimated that more than $18 billion could be saved annually if those patients whose medical problems are considered “avoidable” or “non-urgent” were to take advantage of primary or preventive health care and not rely on ERs for their medical needs.

What Are Urgent Care Centers?

Urgent care centers are a valid bridge between your primary care physician and emergency room services. They evolved in the 1990s to serve the 73% of Americans who say they have no access to their primary care doctors at night or on weekends.

There is no appointment necessary at the estimated 9,300 urgent care centers in the U.S. They usually are open seven days a week until 9 p.m. or later. The centers are staffed primarily by family care and emergency room physicians and can duplicate nearly all the services offered in the traditional doctor’s office or emergency room with two major exceptions:

  • They don’t keep medical histories like you expect at a primary care doctor’s office.
  • They do not have the sophisticated medical equipment and staff expertise found in hospital emergency rooms to handle life-threatening conditions.

Urgent care centers do have x-ray machines, lab testing and most of the equipment needed for treating medical conditions ranging from simple things like flu shots or blood-sugar tests to more sophisticated treatment like casting broken bones.

Nearly all their procedures are covered by insurance and the average cost is about $150 per patient.

Walk-in clinics are similar to urgent care centers, only they are typically are staffed by nurse practitioners instead of doctors. That limits the services they can offer, but generally speaking, if you need a shot, treatment for a cold, flu or slight sprain, you could get it at a walk-in clinic. The walk-in clinics are located in pharmacies, grocery stores and retail outlets.

Choosing Emergency Room Or Urgent Care Center

The discussion of whether to go to an emergency room or urgent care center to receive after-hours medical treatment should revolve around cost and the severity of a patient’s condition, but surprisingly, the ultimate decision is often made for convenience.

People want medical treatment at whatever time and whatever place they can get it. With 5,000 emergency rooms providing treatment 24 hours a day, 365 days a year, emergency rooms are the most convenient choice.

The most recent data available on costs, time, resources and effectiveness of emergency rooms is more than three years old. Still the numbers from 2012 are just as frightening in 2015.

The Center for Disease Control and Prevention (CDC) said there were more than 136 million visits to emergency rooms in 2012. While the American College of Emergency Physicians reports that 92% of emergency visits are from “very sick people who need care within 1 minute to 2 hours,” the National Hospital Ambulatory Medical Care Survey estimates that one-third to one-half of all ER visits are for non-urgent care.

The New England Health Institute said 56% of emergency room visits were “totally avoidable.” It didn’t say how much of the remaining 44% could have been treated at urgent care centers, but several studies suggest many of these cases could have been handled in urgent care. In fact, the top three reasons for ER visits in 2012 were sprains and strains (6.1 million visits), upper respiratory infections (5.9 million) and superficial cuts (5.8 million).

Thus, the decision to receive treatment at an emergency room is one of the many reasons Americans spent $3 trillion on healthcare in 2014. It’s also a factor for why more than 75 million people complained they were having problems paying off medical debt, which happens to be the No. 1 cause of bankruptcy in the U.S.

Some of the debt problems could be avoided if people knew more about emergency rooms, urgent care centers and walk-in clinics and how they serve those in need of medical attention.

When To Choose Emergency Room

The real question that should be answered when deciding between urgent care centers and emergency rooms is: Why am I going?

If the answer is: “Because I have life-threatening injuries or symptoms,” then the choice is simple: Go to an emergency room. Otherwise, an urgent care center should do.

The problem is that some ailments and symptoms straddle the line and only a trained medical staffer could make the call. If it’s too close to call, common sense dictates going to an emergency room.

There is no definitive list of ailments that demand to be treated at emergency rooms. Generally speaking, if the condition can permanently impair or endanger your life, it is an emergency.

Some of the most common reasons to go to an emergency room are:
  • Severe chest pain
  • Severe abdominal pain
  • Wheezing or shortness of breath
  • Paralysis
  • Intestinal bleeding
  • High fevers or rash, especially among children
  • Vaginal bleeding with pregnancy
  • Repeated vomiting
  • Poisoning
  • Severe head or eye injuries
  • Allergic reactions
  • Unconsciousness

Typical Ailments For Urgent Center Care

There also is no defined list of conditions that suit urgent care centers. The rule of thumb should be that if the condition is not life threatening, but needs treatment today, head to an urgent care center.

The conditions most often associated with that include:
  • Fevers, flu or cold symptoms
  • Ear infections
  • Animal or insect bites
  • Seasonal allergies
  • bronchitis
  • Sprains and broken bones
  • Cuts and bleeding that may require stitches
  • Vomiting or diarrhea
  • Breathing discomfort, such as moderate asthma
  • Urinary tract infections
  • X-rays and lab tests
  • Abdominal pain
  • Minor back pain

Again, if the situation is life threatening or the patient is showing symptoms for life-threatening condition such as difficulty breathing, unconscious or unresponsive, call 9-1-1 and let an ambulance take them to the emergency room. They could receive medical care while riding in the ambulance that could mean the difference between life and death.

Time & Cost Favor Urgent Care

The cost difference alone should be enough to encourage people to go to urgent care centers. The average urgent care visits range from $50 to $150, depending on the patient’s co-pay and level of treatment, according to Dr. Franz Ritucci, President of the American Academy of Urgent Care Medicine.

Dr. Ritucci said that 70% of patients at urgent care centers use health insurance and their only cost is a co-pay. Uninsured patients face additional charges for things like x-rays, shots, lab tests or casting a broken bone. As a result, the costs for their care can be much higher.

Average emergency room costs vary wildly based on treatment, but a 2013 National Institute of Health study put the median cost at $1,233. Other estimates push it to as high as $2,168.

Then there is the time factor. Patients at urgent center care are seen on a first-come, first-serve basis and average less than 30 minutes from the time they arrive until they depart.

Emergency rooms treat patients based on the severity of condition. Patients with life-threatening injuries go first. The average time from arrival to departure is 2 hours, 15 minutes.

Cost Estimates for Emergency Rooms vs. Urgent Care Centers

The following estimated costs were prepared by Medica Choice Network for nine of the most common reasons people visit the ER. They were determined by calculating the average number on claims submitted in 2010 to the Medica Choice Network, a system of more than 4,000 medical offices, clinics and hospitals across four Midwestern states

Condition Emergency Room Cost Urgent Care Cost
Allergies $345 $97
Acute Bronchitis $595 $127
Earache $400 $110
Sore Throat $525 $94
Pink Eye $370 $102
Sinusitis $617 $112
Strep Throat $531 $111
Upper Respiratory Infection $486 $111
Urinary Tract Infection $665 $112

The Annals of Internal Medicine study found that the average cost of an urgent care visit for three common illnesses — middle ear infection, pharyngitis and urinary tract infection — was $155. Other estimates place the average urgent care visit at anywhere from $71 to $125. The bottom line is that an urgent care visit is substantially cheaper than an emergency room visit.

Prudent Layperson Standard

There is one other major factor that consumers need to consider when deciding whether to go to an emergency room or urgent care center for treatment: Prudent Layperson Standard.

The short definition of the Prudent Layperson Standard (PLS) is: “Any medical or behavioral condition that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the severity of their condition would result in death or harm to a physical organ.”

Insurance companies use the PLS as a barometer to determine whether a trip to the emergency room was really necessary and how much, if any, of the bill they are going to pay.

Insurance companies have denied coverage to patients who went to an emergency room for non-urgent procedures like a cough, sore throat or sprained ankle. If you could have received treatment at an urgent care center or walk-in clinic, this may not be covered by insurance and you would have to pay for your treatment out of your own pocket.

That could mean more credit card debt, or taking out a personal loan to cover an expense that would have been paid for by insurance, if you had visited an urgent care center.

The Prudent Layperson Standard does allow for discretion in borderline cases. If you are experiencing symptoms related to a severe condition – shortness of breath, rapid heartbeat, dizziness or fainting – and went to an emergency room, the claim should be covered, even if the final diagnosis was that it was not a severe condition.

This is another step by insurance companies to reduce emergency room claims for frivolous medical condition. However, if you believe your claim is a legitimate visit to an emergency room – and it still gets denied – there is an appeals process. A 2011 study by the Government Accountability Offices showed that 39-59% of appeals were successful.

How Emergency Room Costs Add Up

The recent introduction of high-deductible insurance makes it possible that individuals and families could take on severe medical debt if they have to use an emergency room.

The Kaiser Family Foundation says that 87% of Americans are insured, but many are in high-deductible plans. The average high-deductible plan required patients to pay an average of $1,217 before insurance coverage kicks in. Many high-deductible insurance policies are closer to $2,000 for individuals and $4,000 for families.

If a visit to the emergency room requires x-rays, an MRI, lab tests or complicated procedures, the total cost could easily exceed your deductible and, depending on your coverage, some portion of the remaining bill will be your responsibility.

And that’s if you drove yourself to the emergency room!

If you had to use an ambulance service to get to the emergency room, you could be charged anywhere from $25 to as much as $1,200, depending on whether you have insurance and what type of plan you have.

There is also a chance that the emergency room you choose is out-of-network. Even if you chose an in-network hospital, you may be treated by a physician who is out-of-network and have to pay that cost. The uninsured would have to tackle the entire bill out of pocket.

7 Tips For Paying Emergency Room Bills

So what should you do if the bill for a visit to the emergency room is more than you can afford?

Here are some suggestions to deal with the problem:
  • Ask for itemized accounting. Mistakes happen on emergency room bills. It could be for medications that were never given, procedures not done, etc. Ask your primary care doctor or nurse to look at the bill and see if all the items make sense for the procedure you went through.
  • Talk to the billing department. There are several sets of costs for the same procedure at most hospitals. Ask them to bill you at the lowest cost available.
  • Ask for a payment plan. Hospitals don’t want the bill to go to a collection agency. Tell them how much you can afford to pay every month and see if they will work with you.
  • Financial aid programs. Ask the hospital if they are aligned with any charities that offer financial aid for people who can’t afford their bill.
  • If you can’t make a deal with the hospital, then try making a deal with the collection agency. They probably paid as little as 5 cents on the dollar for the bill and would be glad to recover anything close.
  • Crowdfund the bill. There are crowd funding sites online like Giveforward.com, Fundly.com and youcaring.com that are specifically aimed at helping people manage medical debt. If the bill gets into the five-figure price range, put your story out at a crowdfunding site and see how people are willing to help.
  • Consider bankruptcy. There is a good reason medical debt is the No. 1 cause of bankruptcy. If you go to an emergency room for a catastrophic situation and are hospitalized, the debt load quickly can become unmanageable. Consult with a bankruptcy attorney. Medical debts are unsecured and can be dismissed in a successful bankruptcy filing.
Bill Fay

Bill Fay is a journalism veteran with a nearly four-decade career in reporting and writing for daily newspapers, magazines and public officials. His focus at Debt.org is on frugal living, veterans' finances, retirement and tax advice. Bill can be reached at bfay@debt.org.

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