When a kid twists her ankle at a Saturday afternoon soccer game, she may wind up in a nearby emergency room sitting next to a stabbing victim.

But if there's an urgent care clinic in the area, her family has another choice, one that may be a growing force in the debate over health care reform in the next few years.

Health care providers are increasingly using alternative primary care settings, especially urgent care clinics, to capture an after-hours market and divert traffic from emergency rooms to control rising medical costs.

In the Sacramento region, Sutter Health is currently opening a network of urgent care clinics that offer after-hours care, while Kaiser Permanente is performing triage treatment in its waiting rooms and beefing up its advice phone line. Mercy hospitals have started a pilot program to refer emergency room patients to a primary care doctor or clinic.

Sutter Urgent Care, Elk Grove, opened its doors this month in the Sutter Medical Group's existing medical office campus to treat relatively routine cases, such as colds and flus, fractures and rashes. The 2,000-square-foot clinic has two attending physicians, and access to X-rays and labs. The clinic is open 365 days a year, including holidays, and no appointment is necessary.

Elk Grove has had privately operated urgent care clinics for many years, but this represents the latest in a coordinated campaign by a health care organization to channel patients away from emergency rooms. Sutter opened similar clinics in Roseville in January 2011, and in Sacramento in November.

"Nationwide, we're seeing a debate on health care costs being too expensive," said Eric Rasmussen, director of growth and development for Sutter Medical Foundation. "These clinics are an affordable alternative to get treatment without going to the emergency rooms."

Sutter also operates urgent care clinics in Davis and Yuba City. The foundation plans to convert extended-hour clinics in Fairfield and Auburn in 2012.

"It's a good model, and can be replicated based on future demand, as the population of greater Sacramento grows and expands in different directions, especially to the south, and east along Highway 50," Rasmussen said.

While the foundation has had extended-hour clinics for about 10 years, the urgent care clinic model offers more consistent hours and types of services, Rasmussen said.

Emergency departments nationwide are seeing a marked increase in use, said Maribeth Shannon, director of the Market and Policy Monitor program for California HealthCare Foundation. But contrary to the popular belief that emergency rooms are full of uninsured patients, she said the increase is primarily driven by insured patients who do not have true emergencies.

Uninsured cut ER use

"Uninsured people can't be flooding emergency rooms because they usually have to pay for the services, so they cut back on ER use," Shannon said. "Instead, we find more people who are insured, but have trouble getting in to see their primary care doctors. Doctors' offices are impacted and there's a shortage of primary care physicians overall. Doctors sometimes even encourage patients to go to emergency rooms because they can't fit them in."

Emergency room visits are generally three to four times the cost of trips to a doctor's office, Shannon said.

Shannon said a 2006 study found that 50 percent of patients in U.S. emergency rooms would have gone to urgent care clinics, but didn't know where they were, what kind of treatment would be covered or what the hours are.

"Everyone knows that emergency departments are open all the time," she said. "Hospitals and physicians need to communicate with patients better to let them know their options in advance of an emergency."

A more recent study published in the September issue of the journal Health Affairs found that 27 percent of hospital emergency room visits are not emergencies and could take place at less expensive urgent care centers and retail clinics. Non-emergency conditions include minor infections, strains, fractures and lacerations.

ER overcrowding leads to higher costs for providers and insured patients, creates longer waits and increases the chances that the emergency room won't be able to deal with real emergencies, Shannon said.

Kaiser ER visits grow

Richard Isaacs, physician-in-chief and chief of staff at Kaiser Permanente Medical Center, south Sacramento, said emergency room visits there have risen. The center is open for service 24/7, which makes it attractive for after-hours use.

The staff about four years ago developed a model for dealing with the influx of ER patients, Isaacs said.

"It's kind of a failure of the primary care system that all these patients are coming to emergency rooms," he said. "We started having a physician-led team treat patients in the waiting room. We believe this is best way to handle this."

The team treats lower-acuity cases in small rooms near the waiting room, reducing the number of patients that go to the emergency department. Isaacs said the center treated 80,000 patients last year, with a significant portion of those being treated in the waiting room triage.

Isaacs said Kaiser's phone system also allows patients to talk to a nurse or doctor after hours to get medical advice and decide if they need to make a trip to the emergency room. Kaiser also provides patients with same-day appointments with their physician.

Patients do not need to have a physician affiliated with Sutter Health to receive care at Sutter Urgent Care. If a patient has a physician affiliated with Sutter Medical Group or Sutter Independent Physicians, they will receive a treatment report that connects automatically to their electronic health record and their physician's office. Most insurance plans are accepted.

"Our patients have told us many times in surveys, they want services at times that are convenient to them and their work schedules and family activities," Rasmussen said. "The other benefit is that it offers an opportunity for our organization to grow. People who don't belong to Sutter but use our urgent care clinic, and have a good experience, may choose a Sutter physician during open enrollment."

Dignity uses referral plan

Dignity Health, formerly known as Catholic Healthcare West, which operates Mercy hospitals and clinics in the Sacramento area, does not have urgent care clinics, but is in a pilot program to refer emergency room patients to clinics and doctors.

Thirty percent of Mercy's emergency room admissions could be averted if patients had access to basic care, said Rosemary Younts, director of community benefits for Dignity's Sacramento region. She said Dignity is exploring extending hours or opening on Saturdays at its clinics.

The system launched its Community Health Referral Network about a year ago, which matches emergency room patients with services at a primary care site. In one year, the program referred 2,000 patients, and 80 percent of those have not returned to the emergency room for treatment.

"Over the last three to four years, we've seen a significant increase in our ER admissions," Younts said. "It's a direct result of the economy, lost jobs and insurance and the fact there's only one primary care clinic in the county. It has created a lot of confusion and it's really hard to find after-hours care in our region."

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