Urgent Care Centers Delay Emergent Surgical Care Based on Patient Insurance Status in The United States

Walter R. Hsiang, BS; Daniel Wiznia, MD; Laurie Yousman, BS; Michael Najem, BS; Alison Mosier-Mills, BS; Grace Jin, BA; Siddharth Jain, BS; Akshay Khunte, BS; Kimberly A. Davis, MD, MBA; Howard P. Forman, MD, MBA; Kevin M. Schuster, MD, MPH


Annals of Surgery. 2020;272(4):548-553. 

In This Article

Abstract and Introduction


Objective: Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition.

Methods: Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types.

Results: A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09–1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63–9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19–12.29).

Conclusions: Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.


Demand for urgent care services has grown significantly in the last decade as patients increasingly seek convenient and affordable health care services.[1] Over the last 5 years, the number of urgent care centers (UCCs) has increased approximately 30%,[2] and a total of 8000 to 9000 UCCs are now estimated to be operating in the United States in 2020.[2,3] Additionally, the number of patient visits to UCCs has more than doubled over the last 10 years.[1] UCCs offer an attractive alternative to emergency departments (EDs) due to lower out-of-pocket costs, shorter wait times, and improved patient experiences.[1,4] However, access to UCCs is not guaranteed for all types of patients. UCCs may deny services based on a patient's finances or insurance status, whereas EDs must provide services to all patients regardless of their ability to pay, as required by the Emergency Medical Treatment and Active Labor Act (EMTALA). To date, 2 small investigations have shown that UCCs may deliberately select which patients to treat based on insurance status and deny or restrict care particularly for Medicaid patients.[5,6] Because these studies have only measured the acceptance of insurance by UCCs in a limited geographic setting, little is known about how insurance status affects patient management, such as triaging and referrals, at UCCs across the United States.

Additionally, patients may present to UCCs with an emergent condition that might require a higher level of care, but how UCCs manage such patients, and whether insurance status affects the management of these patients, has yet to be described. Given the for-profit nature of many UCCs[7] and the fact that UCCs have a tendency to position themselves in areas with higher household income levels and increased rates of private insurance,[8] UCCs may have a commercial incentive to establish a patient encounter even if the patient's condition warrants an ED or hospital evaluation.

Using a secret shopper methodology, we called UCCs across the nation with a simulated clinical scenario to determine how patient insurance status impacted triage and ED referral rates at UCCs. We hypothesized that when presented with symptoms consistent with an incarcerated inguinal hernia in the simulated clinical scenario, UCCs would selectively triage patients to a higher level of care based on insurance coverage type. We also explored whether ED referral rates for Medicaid patients at UCCs were affected by a state's Medicaid reimbursement rate.