Urgent Care vs Emergency Room

Differences in Urgent Care vs Emergency Room Costs Services

Seeking medical care outside of an office visit to a primary care physician invites a long-term side effect common to the patient experience in America: sticker shock.

In our haste to get immediate help for an injured or sick loved one, or for ourselves, cost isn’t always the first consideration. The major worry comes later with the arrival of a sometimes indecipherable and almost always eye-popping bill.

The decision to go to a hospital emergency room or an urgent care center likely depends on factors other than cost: convenience, time of day, seriousness of the problem and medical vulnerability of the sick or injured person.

In any case, it’s good to know what we’re paying for when we seek medical care at a hospital emergency room or an urgent care facility and what services each facility provides.

“An ER visit often costs up to 10X the rate of an urgent care center or primary care provider (PCP) and often includes a long wait time,” said Dr. Ben Aiken, a family medicine physician and VP of Health at Decent, a health benefits company.

“If you are not sure what you’re experiencing is an emergency, try contacting your PCP first for guidance. If they are unavailable, try the nearest urgent care center or virtual care/telemedicine resource if you have access, as each of these can help you make a more informed decision on whether to go to the ER.”

Cuts, bites, broken bones, fever, flu symptoms and allergic reactions are often more quickly (and economically) treated at an urgent care center. More extreme medical conditions such as stroke, heart attacks and serious accidents call for a trip to the nearest emergency room.

The average wait by state in emergency rooms ranges from 1:44 to 3:48.  One study, a National Hospital Ambulatory Medical Care Survey from 2018, showed that only 12.4% of emergency room visits resulted in hospital admissions.

Overall, if you have a non-life threatening condition, urgent care centers can handle it cheaper and quicker. If it’s life threatening, better you should go to an emergency room.

Emergency Rooms

The Center for Disease Control and Prevention (CDC) estimates 130 million Americans made visits to the nation’s emergency rooms in 2018. More recent data is skewed by the Covid-19 pandemic.

The Library of Medicine, for instance, estimated emergency room visits in a targeted study of an Arizona medical center decreased by 20% in 2020 compared to the same time frame in 2019. While Covid-related emergency room visits increased, pandemic mitigation strategies reduced non-Covid ER visits.

Of the 130 million emergency room visits in 2018, only 16.2 million resulted in hospital admission. Approximately 35 million were injury-related visits.

ERs aren’t exactly what you see on TV. Many visits to the nation’s ERs are for non-urgent care but sprained ankles and ear infections don’t make for high-level drama.

The reason so many ER visits are for non-urgent care? The law requires hospitals to provide care for all patients regardless of their ability to pay. The same applies to urgent care facilities owned by hospitals.

The cost of an average emergency visit can range from $623 (Maryland) to $3,102 (Florida). Much depends on the level of care.

Level 1-5 covers everything from an earache to a broken bone. Broken bones requiring surgery can result in as much as $10,000 in emergency care costs.

Emergency departments are staffed with physicians, physician assistants, nurse practitioners and nurses trained in round-the-clock emergency care. They have diagnostic and laboratory services, access to specialists in several fields including cardiology. If you think you’re having a heart attack or stroke, an ER visit is for you.

Aiken said those resources alone lead to a higher operating overhead and that the cost is “passed on to both patients and insurance companies.”

What Are Urgent Care Centers?

Urgent care centers are that middle ground between primary care physicians and emergency rooms.

Unless you have a doctor who encourages you to call him or her at home any time of night and twice on weekends, you probably know why urgent care centers became a popular alternative for Americans in the 1990s.

Some urgent care facilities have physicians on staff though the centers are typically staffed by physician assistants, nurse practitioners and nurses. They also typically order labs (basic labs at least) and imaging tests. But while they’re open seven days a week, they aren’t usually open 24 hours a day and are not as extensively equipped as ERs.

They often treat an established list of conditions. All of that translates to urgent care visits being less expensive than emergency room visits.

The Urgent Care Association’s 2019 benchmarking report estimated there were 9,616 urgent care centers in the U.S, a 9.6% jump from the previous year.

Nearly all their procedures are covered by insurance. What you’ll pay often depends on your insurance coverage and whether the facility is in or out of network.

Walk-in clinics are similar to urgent care centers, except they are typically staffed by nurse practitioners instead of doctors. That limits the services they can offer, but generally speaking, if you need a shot or 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

Data suggests urgent care centers have reduced the stress on hospital emergency rooms, at least as far as non-emergent care goes. In a six-state survey, the National Library of Medicine in 2021 found that an open urgent care center in a ZIP code reduced the total number of ED visits by residents in that ZIP code by 17.2%. But ERs are still overused.

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. 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 (and expensive) choice.

The most recent data available on costs, time, resources and effectiveness of emergency rooms is dated.

The Center for Disease Control and Prevention (CDC) cites 130 million visits to emergency rooms in 2018. Those numbers come from the National Hospital Ambulatory Medical Care Survey that also estimates one-third to one-half of all ER visits are for non-urgent care.

The Department of Health and Human Services Office of Health Policy issued a report to Congress in 2021 that studied the utilization of emergency departments. The Office of Health Policy cited the “potential overuse or inappropriate use of emergency departments (EDs) for non-emergent care” as a long–running concern.

The study concluded that despite good intentions the efforts to decrease the number of patients that visit the ED each year “have not had a large impact on total numbers.”

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 2019 were chest pains (4.3 million visits), upper respiratory infections (2.5 million) and urinary tract infections (1.5 million).

National health expenditures grew to $4.1 trillion in 2020, an increase from the $3.65 trillion spent just two years earlier. It’s also a factor for why more than 75 million people complained they were having problems paying off medical debt, which is the No. 1 cause of bankruptcy in the U.S.

Some debt problems could be avoided or lessened 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

When should you choose an emergency room visit over an urgent care visit? Other than when you hit the lottery?

The first question 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.

Obviously, the answer is not always that clear-cut and you want a trained medical staffer to evaluate your condition. In that case, common sense dictates going to an emergency room.

There is no definitive list of ailments that demand treatment 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

When to Choose Urgent Care

Do a quick Google search of urgent care centers in your geographical proximity. You’ll likely find they’re open six or seven days a week. But accidents and illnesses don’t always happen during banker’s hours.

Many urgent care centers close in the early evening – 7:30-8 p.m. – during the week. On weekends, the majority close even earlier. So, in part, the decision to visit an urgent care center versus a hospital emergency room might well be contingent on time of day (or night.)

Time of day considerations aside, urgent care visits are almost always the preferred route in non-emergency situations.

The rule of thumb should be that if the condition is not life threatening, but needs treatment attention today, or before your primary care physician can see you, head to an urgent care center.

The conditions most often associated with urgent care visits are:

• 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 conditions involving difficulty breathing, lapses in consciousness or unresponsive behavior, call 9-1-1. Medical care while riding in the ambulance, could mean the difference between life and death.

Cost Estimates for Emergency Rooms vs. Urgent Care Centers

The cost of a hospital emergency room visit can be 5-10x the cost of an urgent care visit, and the majority of hospital visits are considered non-emergency.

American Family Care, a franchise of urgent care centers founded in 1982, estimates the average urgent care visit at between $100 and $200.

Average emergency room costs vary wildly based on treatment, but a Health Care Cost Institute study put the average cost at $1,389 in 2017. Citing “new data,” the Institute estimated in a 2021 report that spending per person on ER visits increased 51% from 2012-2019 and that out-of-pocket costs increased 85%.

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 of 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.

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.

Then there is the time factor to consider. Patients at urgent care centers 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.

“If the illness or acute concern happens after-hours and without access to your primary care provider, an urgent care center, online self-assessment resource, or virtual care service are alternatives that can help avoid ER visits,” said Aiken. “Of course, for emergencies, the ER is absolutely necessary and a critical resource for our communities.”

What Is the Prudent Layperson Standard?

There’s another major factor consumers should consider when deciding whether to go to an emergency room or urgent care center for treatment: Prudent Layperson Standard.

The PLS says: “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 the necessity of an ER visit and how much, if any, of the bill they’ll pay.

Insurance companies have denied coverage 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, your ER trip may not be covered by insurance. You’d have to pay for your treatment out of 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 is a patient protection that 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.

A “My Emergency My Choice” online petition urging people to ask Congress to protect their rights is aimed at stopping insurance companies from eroding the standard.

Insurance companies look to reduce emergency room claims for frivolous medical conditions. 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.

A 2020 report issued by the Centers for Medicaid and Medicare Services estimated that HealthCare.gov consumers filed successful appeals 37% of the time. Industry experts estimate the successful appeal rate at greater than 50% in employer plans that are self-insured.

Going to the Hospital Without Insurance

The legal obligation for emergency rooms to treat you whether or not you’re insured shouldn’t be confused with free treatment. You’ll be charged afterwards, whether you can pay or not.

The Emergency Medical Treatment and Labor Act (EMTALA), a federal law passed in 1986, requires anyone coming to a hospital emergency room to be stabilized and treated, regardless of their insurance status or ability to pay. It applies to all hospitals that accept Medicare and since nearly all hospitals do, it effectively includes them all.

A Medicare note: just because Medicare covers your hospital ER visit and urgent care visit doesn’t mean cost shouldn’t be a consideration.

“It’s important to note that Medicare only pays for 80% of the costs of any visits for unexpected illnesses or injuries that a doctor would consider serious enough to warrant an urgent care visit or treatment in the emergency room,” said Ari Parker, co-founder of Chapter, a technology-driven Medicare advisory organization.

“Beneficiaries are still responsible for 20% of the costs of all their medical care. Most people choose to get supplemental insurance coverage for this gap but the exact cost each person needs to pay out of pocket varies by the specific plans they choose.”

According to Consumer Health Ratings, uninsured patients making emergency department visits in 2019 had an average cost of $1,749. For people aged 45-64 the average expense was $2,285.

Who foots the bill for the treatment if you don’t have insurance?

“Hospitals must make up for the cost of uncompensated care,” Aiken said. “One of the ways they do that is by raising prices for patients and insurance companies, though there are other tools they can use to offset this expense, including funding from local and federal groups to cover the cost.”

However, uninsured patients aren’t off the hook. They will still be charged and, in many cases, have the medical bills turned over to collection agencies, who will try to recover at least some portion of the bill.

Can I Visit Urgent Care Without Insurance?

If you failed to accurately measure the risk of climbing that ladder in high winds to take down your Christmas lights, and that’s the reason you’re at an Urgent Care Center, an even greater risk is seeking treatment there without insurance.

While you can go to an Urgent Care Center without insurance and be treated, if you can’t afford to pay, they could turn you away.

Urgent Care Centers that aren’t owned by hospitals are not bound by the Emergency Medical Treatment and Labor Act and most require some form of payment at the time of service.

Costs for an uninsured person visiting an urgent care range from $80-$280 for the most basic (Level 1) care and could cost as much as $440 for an advanced Level II visit, according to a Mira research survey of out-of-pocket costs at 1,229 urgent care clinics across 43 states.

Mira reported the average urgent care visit involving imaging services such as X-rays or ultrasounds could add as much as 50% to the cost.

How much you are expected to pay depends on the level of treatment you receive. Many Urgent Care Centers post a list of prices so you know the cost in advance. Some will offer discounts if they know you don’t have insurance.

How Emergency Room Costs Add Up

The recent introduction of high-deductible insurance raises the odds that individuals and families will take on severe medical debt if they have to use an emergency room.

The Kaiser Family Foundation 2021 survey of employer health benefits said workers, on average, paid $5,969 toward the cost of their coverage. The average annual deductible just for an individual was $1,669.

A previous Kaiser Foundation survey put the percentage of insured Americans at 91% but many are in high-deductible plans. Some high-deductible insurance policies are closer to $2,500 for individuals and $5,000 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.

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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 find out later (often when the bill arrives) that you were 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:

• Talk to a nonprofit credit counselor. It’s generally not a good idea to consolidate medical debt unless you owe other creditors. Credit counseling agencies might be able to consolidate all your debts into one payment.
• 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. Then ask about other types of concessions they might be able to make.
• 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.
• 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 need help with medical bills.
• 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.

Get Help Managing Your Medical Debt

Medical bills are quite often more debilitating than the injury or illness that prompted your trip to the hospital emergency department or urgent care center.

Medical debt is often unavoidable and can sabotage your best intentions to pay down other debt. What can you do?

Certainly, a loan from a family member or friend could be a lifeline but many of us don’t want our family and friends to know the extent of our debt.

Other options such as transfer balance credit cards are appealing but they require good credit and they come with a catch: if you don’t pay them off during the introductory offer period the interest rate soars. And if you use them to charge anything, you’ve defeated your purpose.

Whatever the options you’re considering, nonprofit credit counseling is one of the most impactful steps you can take to manage debt.

Nonprofit credit counselors can assess your situation over the phone, online or in person and get you in an affordable program to pay down your debt. Credit counseling agencies offer free consultations. With credit counseling, you’re a 30-minute phone call away from tackling the problem.

It’s possible to reduce your vulnerability to medical debt by choosing an urgent care center over a hospital emergency department. But the bills can still add up.

Don’t be sheepish about seeking help to manage medical debt. It’s not as if you maxed out your credit cards on items you couldn’t remember purchasing and no longer even need six months later.

Getting help managing medical debt might be the best treatment available for the side effect of health care sticker shock.