SEE RELATED ARTICLE , P. 397 .

In this issue of Annals , Martsolf et al assess how emergency department (ED) visits for low-acuity conditions change after nearby retail clinics open. In more than 2,000 EDs across 23 states from 2007 to 2012, they correlated changes in low-acuity ED visit rates with retail clinic penetration within a 10-minute drive. In the end, more retail clinics did not translate to fewer low-acuity ED visits; however, greater clinic density did correlate with a modest reduction in the subset of low-acuity visits among the privately insured. To estimate what this means: with 40,000 annual ED visits and 50% private insurance, there would be approximately 8 fewer visits per year for each 10% increase in retail clinic density. They concluded that retail clinic growth has not led to a real reduction in low-acuity ED visits.

A prevailing theory and frequent claim by groups that promote “convenience settings” is that they reduce ED visits. Convenience settings are those that provide episodic care outside of hospitals such as retail clinics, urgent care centers, and direct-to-consumer telemedicine. Conceptually, the ill and injured with conditions potentially treatable in these settings would choose them over the ED because of greater accessibility, shorter waiting times, and lower costs. For payers, the use of convenience settings is desirable. Assuming equivalent service is delivered by a lower-cost provider, it’s a better value. One study reported that 13% to 27% of US patients attending the ED could be treated in urgent care and retail clinics, with an estimated cost savings of $4.4 billion.

Unfortunately, theory and reality do not always align. The study by Martsolf et al challenges the notion that convenience settings substitute ED visits. In actuality, the predominant effect is “new use,” meaning that visits to convenience settings are mostly additive, rather than substitutive. Specifically, many people who would not have otherwise received treatment seek care in convenience settings because they’re accessible and available. A separate study found that 58% of retail clinic encounters are new use as opposed to care by another outpatient provider, such as a primary care physician. (The study did not examine ED visits.)

Convenience settings create new use for 3 reasons: they meet unmet demands for care, motivations for seeking care differ in EDs and convenience settings, and groups of people who are more likely to use EDs for low-acuity conditions do so because they have little access to other types of care, including convenience settings.

When it comes to unmet demand, the desire for episodic acute care often exceeds the supply of physicians or facilities in many communities. This demand is conveniently met by the opening of convenience settings. Imagine the wayward patient with a nagging cough or sore throat who is driving by a shiny minute clinic, or who has a supereasy application on his or her iPad, who thinks, “Maybe I should just get it checked out. Why not?” And poof! there is a provider. Convenience settings step in to deliver the desired service, with minimal time investment (eg, travel, waiting). In contrast, the long ED waits in some communities can effectively ration care through inconvenience.

In economic terms, this is “supply-sensitive care,” in which demands are not directly determined by actual medical needs of the population. Convenience settings do not save lives; rather, they deliver services that make people feel better or reassure them that they are taking the right steps to get better. According to theory, use of “supply-sensitive care” is largely capacity driven and requires a supportive payment system, specifically, fee for service. Convenience settings create new use through improved access, which lowers the threshold to seek care.

There is also price transparency in convenience settings, particularly retail clinics and telemedicine. Armed with price information, people make decisions about whether it’s worth it. Similar to rationally shelling out $5 for a frothy mocha cappuccino, people pay $50 for peace of mind about whether they have pneumonia and for guidance for over-the-counter decongestants.

In contrast, ED charges are not transparent to patients or the emergency physicians who dole out services. Yet despite murky pricing, people increasingly pile into US EDs. One possibility: people are not particularly price sensitive when they think they’re having an emergency. To generalize, in comparison to reasons people use convenience settings, the majority of people who use EDs think they might actually be having an emergency. This reasoning is validated by studies that actually ask people why they use the ED.

This narrative runs contrary to the popular belief that most people commonly use EDs for minor illnesses when they think nothing’s seriously wrong. In fact, people coming to EDs often have potentially serious complaints that sometimes turn out to be a minor illness. But oftentimes symptoms end up being serious, and not infrequently, people are admitted for what seemed at the beginning to be a minor problem. In short, people select the setting they think can best care for them. Most people know that if they are really having an emergency, the last place they should be is a convenience setting. The result is that convenience settings don’t really directly compete with EDs.

Nevertheless, some groups do have relatively higher use of EDs for low-acuity conditions more regularly, including ED superusers and those with Medicaid. However, these groups do not commonly use convenience settings. Medicaid populations have less access to convenience settings because they tend to locate in affluent areas in which most Medicaid patients don’t live. Even so, many Medicaid plans don’t even cover convenience settings. ED superusers also commonly have Medicaid insurance and infrequently live in affluent neighborhoods. They also have complex medical or mental illness in which the resources needed to care for even simple complaints can exceed the capacities and capabilities of providers who work in convenience settings.

Given that convenience settings don’t prevent ED visits, what can be done in an era in which looming government reforms may soon restrict the very payments that support them? The answer is not to build more convenience settings but to improve the value of existing settings by increasing the connectivity among providers and with longitudinal care. When people get sick and injured, there should be a system rather than the piecemeal network we have today in which each player is selling its own “service.”

An example of such a system is Kaiser Permanente, which is paid for by capitated premiums that come from its members. Kaiser’s system includes EDs, convenience settings, and longitudinal care connected with the goal of efficiently managing both acute care needs and population health. Kaiser leverages convenience settings such as telemedicine so that people can access advice about when and where to seek care. Then, they are efficiently directed to the most appropriate setting, be it urgent care, the ED, or their own physician. Furthermore, there is always follow-up to ensure that patients receive the care they need. Kaiser’s “secret sauce” is the contractual relationships that align incentives for efficiency across providers, facilities, and their insurance arm. There are fixed resources (eg, monthly premiums per member), and the system is designed so that each entity (eg, provider, facility, insurance) benefits when the other is efficient and everyone loses when another entity exceeds its budget. Along with shared governance, efficiently meeting patient needs aligns with improving everyone’s bottom line.

Yet this model is challenging to replicate. In much of the rest of the system, providers, facilities, and insurers are linked with contracts in which incentives are misaligned: each tries to maximize its own profits rather than efficiently manage population health. In economic theory, this is the “tragedy of the commons”: each user within a system of shared resources acts independently in his or her own self-interest and consumes resources contrary to the common good of all users. So ultimately, until the right incentives are implemented to promote integrated systems of care to respond to patient needs, we will continue to see studies such as that by Martsolf et al, and the costs of acute, unscheduled care will increase unabated.