Urgent care in the HMO: evolution of a system in Washington, D.C.

In 1961, Group Health Association, a large, non-hospital based, prepaid group practice in Washington, D.C. established an after-hours walk-in clinic on its premises for the care of medical problems requiring prompt attention. Within a year, this clinic's operation was extended to daytime hours for the use of the consumer-member at his own discretion. After 10 years, in the plan's main health center, the volume of adult visits to the acute care/walk-in center exceeded the number seen in the Department of Internal Medicine; most were of a routine rather than urgent nature. More visits to the acute care service were made during the day, when the full range of ambulatory services were available by appointment, than were made after hours. The choic of immediate first-come, first-served care over the conventional care-by-appointment by so many members was felt to have resulted in discontinuous suboptimal care, segregation of the membership along socioeconomic lines, as well as unnecessary and very costly duplications of service. The background of organizational behavior and community medical practices contribuing to this pattern of utilization are explored. Compared to traditional fee-for-service medicine, demands for outpatient services in the HMO tend to be greater. Acceptable alternatives to off-line channeling of patients with unexpected or acute conditions can be designed. In the general community today, utilization of medical services is strongly influenced by imbalances in available resources and by financial factors which are under no central control. In the HMO, all costs are prepaid and services are planned for a membership of known size. Even so, consumers' use of services in prepaid plans tends to follow the patterns seen in the community. More appropriate distribution of demands requires an active and ongoing system of patient education. A commitment by the HMO's providers and managers toward this goal is indispensable.