With regard to Urgent Care Center utilization, many cases are already being seen in this setting when such facilities are available and thus never become ED cases in the first place. Other, more complex, cases are seen in the ED following evaluation in such centers and referred on for higher level evaluation and management. Still others correspond to patient choice based on perception of quality of care where use of an ED instead of an Urgent Care Center is considered preferable. Thus there is no precise answer to the question as posed.

In general, as pointed out by Smulowitz’ study, “…although seemingly ‘low hanging fruit,’ diverting minor injuries or illnesses to other settings would not be expected to result in substantial cost savings, even with diverting up to 50 percent of visits, The cost of these visits is responsible for a small proportion of the 2 percent to 4 percent of total health expenditures accounted for by the ED.”

Finally, there is no objective answer to the question of what percentage of ED cases seen are considered emergencies. The previously cited recent work by Smulowitz et al categorizes 10-16 percent of ED cases as “emergencies,” that is, almost always requiring hospital admission. However, these “emergencies” would still account for only 20-25 percent of all admissions; thus, the vast majority of patients admitted through the ED would come from a category that the authors characterize as “Intermediate/complex conditions” whose evaluation and management generally require the resources of a full service ED to determine both the severity and most appropriate disposition for the presenting complaint. While some number of ED presentations might have been handled as non-emergencies in other venues, there is no statistical tool that has the power to deal with the inherent complexities of the question itself. And, as noted, attempts at retrospective analysis based on discharge diagnosis lack sufficient correspondence with clinical outcomes and actual need for emergency care to be practically utilizable as an assessment of “emergent” versus “nonemergent” cases. As noted by Dr. Maria Raven, principal author of the JAMA article cited above, “Currently, there is no possible way to determine the outcome of the visit in advance, and our study has shown that it’s not good policy to do so after the fact. Insurance companies should not treat these two patients differently. Patients should never be burdened with the task of diagnosing themselves out of fear that their potential emergency isn’t covered by insurance.” Further, as alluded to in the introduction, under EMTALA provisions all patients at the time of presentation are “emergencies” until proven otherwise by hands-on evaluation, and after the fact no statistics are kept, other than in cited research studies, on those that might otherwise have sought care elsewhere.