Urgent care is filling the gaps primary care can't

Nearly 40% of Gen Z patients do not have a primary care physician. Millennials are not far behind. And by 2036, the country could be short by as many as 86,000 primary care physicians. Against that backdrop, urgent care has quietly become something it was never designed to be: the first and sometimes only point of contact between Americans and the health care system.

That shift is forcing a harder conversation about how urgent care and primary care coexist — whether the two settings can function as coordinated parts of a system or whether they will continue operating in parallel, each absorbing patients the other cannot reach.

Medical Economics sat down with Andrea Giamalva, M.D., FAAFP, chief medical officer at Experity, a leading platform for on-demand health, about what urgent care is actually handling today, where the relationship with primary care breaks down, and why she believes artificial intelligence (AI)-enabled technology may finally give clinicians the tools to direct patients to the right setting before care gets fragmented.

The following transcript has been edited for style and clarity.

How has the role of urgent care in the American health care system changed over the last decade, and where do you see it heading?

I’ll actually start a little further back. Urgent care really started in the 1970s, but it became more formalized and standardized as an industry from the 1990s into the 2000s. So it is not a young industry, but it is not an old one either. That said, it has proven to be one of the most innovative in its time.

It started mostly with emergency medicine physicians, but over time it pivoted to a broader spectrum of training. Now we see many more physicians from family medicine, internal medicine and pediatrics going into the urgent care space. I would say this, combined with the national shortage of primary care and shortages in many specialties, has really led to urgent care becoming the front door to health care for many Americans.

That means patients are showing up for more than a cough, cold, scrape or cut. They are coming through urgent care doors, or maybe through a telehealth visit, with a question that could lead down many paths. Is it really an urgent care visit? Is it more of a primary care visit? Does it need to pivot to specialty care? Does the patient just need ancillary services? That is really the crux of the change we are seeing.

At the same time, many clinics are changing what they offer. Some are doing employer-paid services, per-member-per-month models and other adjacent services like weight loss therapy, hormone therapy and mental health services. So it is no longer just the cough-and-cold clinic. It is a multichannel digital front door where patients can come with a need and be guided to the right path forward.

How much of that growth reflects genuine consumer preference for convenience versus patients who simply cannot get in to see a primary care physician?

Without a direct-to-consumer survey, the best way to answer that is to look at the market data we do have. There is clearly a generational shift happening in whether patients choose to have a primary care physician at all.

Around 10% of baby boomers do not have a primary care physician. Among Generation X, that gets closer to 20%. By the time you get to millennials, it is around 30%, and they have a strong preference for what we would call retail clinics, which can include urgent care. Then you get to Generation Z, and the data show that nearly 40% do not have a primary care physician.

So some are choosing not to have one, and others likely do not have access. The access problem is real. Some studies estimate that shortages of primary care physicians could range from 20,000 to 80,000 by 2037. We are only about a decade away from that, and we are already feeling the pain now. There are also health care deserts across the country, and interestingly, those are often the same places where urgent care has a stronger presence.

Then you have to look at patient expectations. We are living in what I call the Amazon-Uber-DoorDash world. That expectation has been created culturally, and this may be one of the first times health care is really trying to step up and meet it. Patients want convenience and access, and urgent care has responded to that while still providing quality care.

And from a cost standpoint, while insurance plans vary, there is no question that urgent care is far more cost-effective than an emergency department visit. So when patients are deciding between the emergency room and urgent care, the cost comparison is often obvious. It is just much harder for primary care to respond to that same on-demand expectation because of the pressures the specialty is under. As a family medicine physician who managed a panel of nearly 3,000 patients, I understand that firsthand.

In a well-designed system, how should urgent care and primary care work together? Where does that relationship work well, and where does it break down?

I think one of the hardest things for health care to grasp is getting the right patient to the right place at the right time. If we are truly coming into a major supply-and-demand problem in American medicine, then we have to recognize that some patients really need the full breadth and scope of a primary care practice — chronic care management, preventive care, consistent follow-up and that ongoing relationship — while other patients are relatively straightforward, otherwise healthy and may be a better fit for more on-demand care.

We are at a point in time where we have to leverage technology to make that right patient, right place, right time trifecta happen. If we can do that well, then primary care and urgent care can each meet the needs of the right patients instead of getting the urgent care patient in primary care or the primary care patient in urgent care.

Ideally, some primary care services can happen outside a traditional primary care office if places like urgent care have the tools and support necessary to manage chronic disease, preventive care needs, anticipatory guidance and even know when to escalate the patient to a higher level of care. That is a tall order for the average urgent care setting today, and more work still needs to be done.

In practical terms, the more complex, time-intensive visits should probably remain in primary care, while the more straightforward patients may be manageable in urgent care. That could help primary care meet demand in a way that just is not realistic under the current supply constraints.

What could a well-run urgent care infrastructure realistically take off primary care’s plate without simply creating more fragmentation?

Communication is key. There has to be a clear conduit so everyone caring for the patient can see what is happening across the entire journey and the patient context stays clear.

And you are right that primary care physicians are stretched incredibly thin. One study from the last few years found that it would take 27 hours a day for a primary care physician to fully manage the panel of patients they are expected to manage. That is simply undoable.

So the real question is what tools can be put in the hands of the providers seeing those patients. When the patient is in front of you, how can you help close care gaps? How can you deliver the right care to the right patient without overstepping into the very complex cases that need the case management and broader longitudinal support of primary care?

Urgent care should be a partner in that process. Enough of the “their world” and “our world” mindset. It is all our world when it comes to taking care of patients.

Patient expectations around access and convenience have clearly changed. What does that mean for urgent care and primary care as they think about patient experience?

Expectations are really high. And when you step back and think about it, the stakes are higher in health care than in almost any other industry. We should be holding ourselves to a very high standard around patient experience because it can directly affect outcomes.

If patients have a poor experience, if they do not trust the provider or the process, they may not follow through on the recommendations they are given, and that can lead to worse outcomes. Health care has lagged behind for a long time when it comes to that experience.

There is also a cultural shift happening in how we think about patients. It is uncomfortable in medicine, because the patient-physician relationship is unique and special, but patients are also customers. They have a choice. They can choose where they go. So we have to think about how we engage with them in a way that helps them have the best possible experience and the best possible outcome.

We have developed tools like Care Agent, which is an agentic tool that helps walk alongside the patient through the entire journey. I compare it to ordering a pair of shoes and getting text updates along the way. Why shouldn’t patients have that kind of visibility in health care too? That is really what we have been trying to build.

Then there is the in-clinic experience. With things like artificial intelligence scribes, we can start transforming office visits back into more human interactions while still delivering strong documentation, patient insights and follow-up plans. That humanness has been chipped away for too long by data entry and administrative burden.

Are there operational or technology-driven efficiencies that urgent care has developed out of necessity that primary care could realistically adopt?

A lot of the technology could cross over, but primary care still faces that supply-and-demand constraint in a very different way. A lot of practices are just trying to dig out from under a deep hole of work and administrative burden. So there are certainly tools that can help, but there is still a structural issue there.

One thing urgent care has always had is more flexibility in scheduling. It has always been ready for the patient expectation of care in this Amazon era because it has always had more of a retail health care model. Its DNA has always been, “The doors are open. Come in when you need to.”

That gives urgent care a head start. I think an area primary care could learn from is a more hybrid approach, where patients are more intentionally risk-stratified to the right place at the right time. Then the care can proceed in a way that is timely, effective and right-sized for that patient’s needs.

As a family physician, I can relate to feeling relieved when I looked at my schedule and saw some easier patients for the day. But the reality is that I was probably most needed for the more complex chronic patients, and some of those more straightforward patients could likely have been cared for somewhere else. If we are approaching a significant supply-and-demand issue, then we have to start right-sizing the visit type and directing patients to the most appropriate setting.

When you talk about getting the patient to the right place, does that include telehealth as well?

Absolutely. It could mean a telehealth visit. It could mean an urgent care visit. It could mean a more robust primary care visit. I think of it as levels of care, where we recognize which level best fits the patient’s need at that moment.

Again, I cannot help but think about primary care schedules where some patients really needed the full context and some did not. If we are entering a time of serious supply-and-demand strain, then patients are going to get forgotten or lost in the shuffle unless we do a better job matching the visit type to the right provider setting.

How should urgent care and primary care think about their respective lanes as advanced practice providers take on larger roles in both settings?

Advanced practice providers are absolutely taking on larger roles across health care, and that is exciting. But it also means we need to step back and make sure the right tools and support are in place.

In primary care, it may make sense to have a lead physician working with a team of advanced practice providers, where that team becomes an extension of the physician’s expertise and care model. In urgent care, if we are moving toward caring for more than coughs and colds, we should also be thinking in terms of a team-based model.

That does not mean urgent care should try to become full primary care for extremely complex patients. But it does mean that urgent care teams should be equipped to care for very common, more manageable conditions — diabetes, hypertension, hyperlipidemia, thyroid disease, common women’s health issues, common men’s health issues and so on.

The key is clarity. Practices need to be very clear about provider and staff expectations. Once that clarity exists, we can be much more certain about where the patient should be seen and how that care should be delivered.

When a patient keeps using urgent care but does not have an established primary care relationship, what responsibility does urgent care have to help close that gap? And what gets in the way?

It is a really interesting question because there are multiple parts of the patient journey and patient context to consider.

First, the patient has to be willing to engage in that kind of care-gap closure. They have the final say in the care they want. If they come in with a sore throat and all they want to discuss is whether they have strep, we have to be careful not to push them so far beyond that expectation that they leave not wanting to see a doctor again. First, do no harm. We do not want to create a situation where the patient feels uncomfortable returning for care.

Second, there are very specific payer relationships in urgent care. In some contracts, urgent care clinics are prohibited from providing preventive care or certain primary care services, including care-gap closure. That is a real barrier, and it has to be addressed either through contract negotiation or broader recognition in the market that urgent care may sometimes need to step into that role.

Third, many providers entered urgent care with a certain expectation about the kind of care they would be delivering. If organizations want urgent care clinicians to do more around care-gap closure, then they also have to think about culture, provider expectations and whether their teams are truly comfortable with that more primary care-directed work.

So the opportunity is huge, but there are definitely operational and contractual constraints that have to be addressed to make it work well.

Is there anything we have not talked about that you think is important for physicians and practice leaders to keep in mind?

I think the big thing is that artificial intelligence-enabled technology is more than just the latest fad. For the first time in a long time, I really think we can use technology to bring humanness back into the patient-provider experience.

For too long, technology has chipped away at human interaction and created more burden, more administrative load and in some ways less capacity to actually see patients and get the work done. I really think the time is now, and it is an exciting moment for what is coming next in health care.