Stick your foot with a nail while doing that long-awaited garage repair (was that rust or just dirt)?
Got the “crud” that’s being passed around your kid’s 3rd grade classroom (or is it something more serious)?
Often, it’s obvious when a trip to the ER is in order, but it may not so clear when to visit the urgent care or your primary care physician.
When you experience an accident or illness you may have more questions than answers. But the first question you need to answer is where to go to get medical care.
When it comes to your family practitioner, urgent care, retail clinic, or the emergency room, what you select could make a big difference in terms of cost, convenience and care.
So what’s the best option?
Where to obtain medical care – Quick decision guide
|Service Provider||Types of Services||When to Go||Cost||Who You’ll See||Insurance to Use|
|Doctor’s Office||Diagnostics, Prescriptions, Preventive Care, Illness Treatment, Disease Management Referrals||Non-acute symptoms, managing existing conditions, preventive care||$$||MD (General Practitioner)||Major Medical
Short Term Medical
|Walk-In Clinic||Diagnostics, Prescriptions, Preventive Care||Non acute symptoms of common illnesses or skin conditions, screenings, vaccinations||$||Nurse Practitioner, Physician’s Assistant||Major Medical
Short Term Medical
|Urgent Care||Diagnostics, Prescriptions, Minor Injury Treatment, Illness Treatment||Non life-threatening conditions that need to be assessed the same day||$$$||Nurse Practitioner, Physician’s Assistant||Major Medical
|Emergency Room||Anything relating to triage/diagnosis + stabilization of a serious or critical injury or illness||Life threatening, sudden-onset pain, acute injuries||$$$$||ER MD, trauma surgeon, Paramedic||Major Medical
Short Term Medical Hospital Insurance
When to go to the ER
In 2015, 139.9 million people visited the emergency room.1 Could some of those patients have visited the urgent care or retail pharmacy clinic?
Possibly. But it turns out that people are pretty good at assessing when to go to the emergency room and are generally not using the ER for routine care.
According to a 2017 study by the International Journal for Quality in Health Care, the rate of unnecessary ER visits may be as low as 3.3%.2
You should go to the ER for the following acute, sudden-onset symptoms and conditions, or traumatic injuries:3
- Severe physical trauma, such as from a car accident, broken bones or dislocated joints
- A sudden and severe headache
- Severe flu or cold symptoms
- Any severe pain, especially in the abdomen or starting halfway down the back – it could be appendicitis requiring emergency surgery
- Symptoms of a heart attack: including sudden or persistent chest pain, the feeling of a heavy weight on your chest, pain radiating down one or both arms as well as any of the lesser known symptoms of heart attack that women more commonly experience
- Severe shortness of breath, difficulty breathing, severe heart palpitations
- Sudden clumsiness, loss of balance or fainting (for no apparent reason such as during physical exertion)
- Sudden difficulty speaking, trouble understanding speech, weakness or paralysis especially on one side of the body
- Sudden vision change, including blurred vision, double vision or full to partial vision loss
- Sudden testicular pain and swelling
- Vaginal bleeding during pregnancy
- Seizures without a previous diagnosis of epilepsy
- Severe and persistent diarrhea or vomiting
- Any head or eye injury
- Newborn baby with a fever (a baby less than 3 months old with a temperature of 100.4 degrees or higher needs to be seen immediately)
- Coughing up blood, blood in vomit or bright red blood in stool
- Deep cuts that require stitches (especially to the face) – serious bleeding that doesn’t stop after 10 minutes will require stitches
- Altered mental status or confusion, including suicidal thoughts
When to call 911 – When in doubt call an ambulance. You should not drive yourself to the emergency room if you’re experiencing chest pain, severe bleeding, dizziness or nausea (or any other signs of head trauma). If you believe your injuries or symptoms are life-threatening or may become life threatening within a few minutes, call 911.
Pros + cons of the emergency room
- They can handle anything and everything, with a full complement of medical doctors, nurses, nurse practitioners, anesthesiologists and lab technicians and the necessary medical equipment in a hospital setting
- You may not wait as long as you think – According to ProPublica, the average emergency room wait time across the US is 22 minutes.4Priority is given to critical patients, so if you’re there for severe or life-threatening symptoms you’ll be seen very quickly
- There is usually no access to prior medical history or records that could help ensure safe and effective treatment (e.g., avoiding medications you may be allergic to)
- Emergency rooms are the most expensive health care option available
How much does the ER cost?
And what about the cost of an emergency room visit without insurance?
$2,209 to $6,936 or more is what you can expect to pay out of pocket for an emergency room visit for a complex problem.5
$762 to $2,929 or more is what you can expect to pay out of pocket for a emergency room visit for a severe problem.6
Keep in mind that if you have health insurance that covers all or part of your emergency room visit you will pay less out of pocket (or nothing).
Get health insurance to cover emergency room visits
Major Medical Insurance – All major medical plans include emergency services among the 10 essential health benefits that ACA-compliant coverage must include. Which emergency rooms are in-network and how out-of-network emergencies are covered will vary by plan, so check your policy or contact your health insurance provider for details.
Learn about special enrollment for major medical plans.
Short Term Health Insurance – If you need treatment from the ER, a short term plan will typically include benefits to help cover the cost. Of course, you will need to read the plan brochure and your policy to learn more. If you can’t tell or have questions, call the plan’s member services to get answers.
Hospital plans – Hospital plans provide specific, limited benefits for certain medical care related to hospitalization, surgery, chemotherapy and more. You may be able to select a plan with benefits for emergency room treatment – the Care Access Plan available through Health eDeals includes that option. Get a quote for hospital coverage by calling the number on your screen.
When to go to urgent care
Urgent care centers are for patients whose illnesses or injuries don’t present as life-threatening, but who can’t wait until a primary care physician can treat them.
Go to the urgent care for the following kinds of symptoms and conditions:7
- Fever without a rash
- Non-life threatening allergic reactions
- Ear pain
- Painful urination
- Persistent diarrhea
- Sore throat
- Minor trauma, like sprains or shallow cuts
When to go to urgent care vs. your doctor: If you experience a non life-threatening health problem during your doctor’s office hours, contact them. In the event of a recurring medical condition, such as a UTI or ear infection, they may be able to fit you in for a quick same-day appointment in order to begin a course of treatment you’ve previously had. Visit your urgent care if you require same-day care and your doctor is unable to accommodate you or their office is closed (e.g., on the weekend).
When to go to urgent care vs. the ER: While there is overlap in the kinds of conditions urgent cares and ERs treat, ERs are located in fully functioning (24/7/365) hospitals. If you have symptoms of a potentially life threatening condition such as a stroke or heart attack, or are experiencing acute or severe symptoms of an illness, you should go to the ER instead of the urgent care.
Pros + cons of the urgent care
- Evening and weekend hours are available
- Walk-in appointments are common, though some urgent care centers have optional online appointment scheduling to reduce your wait time
- Though wait times vary, on average, walk in patients can expect to wait for around 24 minutes to be taken back to an exam room8
- You’re likely to see a nurse practitioner or physician’s assistant rather than a medical doctor
- You likely do not have health history established at your urgent care facility
How much does urgent care cost?
And what about going to the urgent care without insurance?
$119 to $330 or more9is what you can expect to pay at the urgent care out of pocket unless you have health insurance to cover all or part of the visit.
Urgent care facilities accept cash, credit cards and health insurance.
Health Insurance to use at urgent care
Be sure to use the closest in-network urgent care center covered by your health insurance (it may not be the one closest to your home or workplace). And as always, check your specific plan’s benefits statements as coverage may vary.
Major Medical Insurance – Your major medical plan includes urgent care benefits, as long as you stay in network. For out-of-network benefits, be sure to contact your plan to see if (and how) a trip to urgent care is covered.
Learn about special enrollment for major medical plans.
Hospital Plans – While this coverage may be designed for medical care related to hospitalization, surgery, chemotherapy and radiation services, there are plans such as the Care Access Plan at Health eDeals, which include optional health maintenance benefits that cover urgent care visits.
What does a hospital plan cost? Call the number on your screen for a quick quote.
Telemedicine allows you to skip the urgent care altogether! Telemedicine can provide many of the same kinds of diagnostic and prescribing services as an urgent care, making them a convenient and cost-effective alternative for contagious conditions like the flu, recurring conditions like sinus infections, skin dermatitis and more.
When to go to the doctor (your primary care physician)
Family doctors play a vital role in the healthcare system. In 2015, around 192 million people visited their general and family care practitioner. That’s about 19.5% of all physician’s office visits for the year.10
Go to your primary care physician for the following kinds of symptoms and conditions:
- Cough, cold, flu
- Ear infections and sore throat
- Minor injuries like sprains, bumps and bruises
- Skin problems
- Urinary tract infections
Your primary care doctor can also coordinate your care for chronic conditions like:
- Allergies and asthma
- Heart disease
- High blood pressure
- Diabetes and obesity
- Substance abuse
Primary care physicians most commonly perform the following kinds of health care services:
Diagnostics and screenings – Your primary care physician is a generalist, patient educator and care coordinator. If you go to your primary care doctor reporting symptoms they will ask you questions, perform a physical examination, order up lab work or possibly X-rays, and write prescriptions to help manage symptoms. Then refer you out for further testing and treatment if necessary.
Referral to specialists – Your primary care doctor may not be current on the latest research into treatment of sciatica pain or be able to perform hernia surgery, but they can send you to a specialist who can. And even if you’re sure your foot pain is caused by plantar fascitis, you may still need to go through your primary physician to be referred to a podiatrist.
Preventive health care such as annual wellness visits – While you may only visit an urgent care center or ER when you need acute care, your family doctor’s role includes preventive health services such as annual wellness exams, vaccinations, cholesterol and cancer screenings.
Pros and cons of going to the doctor’s office
- Your family practitioner has access to your medical records and health history, which can help ensure you get appropriate, consistent care.
- You may need to wait a week or more to obtain medical services depending on how busy your doctor is.
How much does a doctor’s office visit cost?
Your out-of-pocket costs for a doctor’s office visit will vary depending on:
- your health insurance coverage
- where you live
- why you’re seeing the doctor (e.g., preventive care or illness visit)
- what tests or treatment is required
- and even the amount of competition in your area, number of insurers, and availability of services
Additional costs may come in the form of prescription drugs and treatment by specialists.
$48 to $13111is what you can expect to pay out of pocket for a 15-minute office visit with your existing physician for a moderate problem requiring counseling and treatment, or that may require coordination of care with other providers.
$66 to $15212is what you will expect to pay out of pocket as a new patient for a 20-minute office visit.
Physicians offices accept insurance, cash, check and credit cards for services if you’re uninsured.
Health insurance for doctor’s office visits
Doctors offices accept major medical and alternative health insurance. Make sure to check your plan’s benefits statement to verify the covered services, and ensure that your preferred provider is in your network before scheduling your visit.
Major Medical– Major medical health insurance covers certain preventive care at no additional cost. Major medical plans must also include healthcare services as outlined in the ACA’s 10 essential health benefits categories.
Review your plan or plans you’re considering closely as visits for care related to injury or illness aren’t considered preventive care and you may be responsible for a percentage of costs related to those visits out of pocket until your deductible is met.
Short Term Health Insurance – Temporary plans often include benefits for visits to the doctor, and there is a small selection of plans on the market that include limited benefits for preventive services. If you’re unable to obtain major medical right now, short term medical may be a helpful alternative.
Learn more about what short term plans cover + get a quote!
Hospital plans – While a hospital plan provides specific, fixed benefits for hospitalization , surgery, chemotherapy and other inpatient services, you may find a plan with optional outpatient benefits that cover physician office visits, wellness and preventive care and diagnostic testing.
When to go to the walk in doctor (e.g. Minute Clinic)
Retail clinicsare located inside of major retailers like Target or at pharmacies like Walgreens or CVS.
Go to the walk in doctorfor the following kinds of symptoms and conditions:13
- Sore/strep throat
- Minor to moderate flu-like or cold symptoms
- Pink eye and styes
- UTI, bladder infections and yeast infections
- Heartburn + indigestion
- Sinus infections
- Bug, tick bites + stings
- Minor cuts, blisters, and wounds
- Suture and staple removal
- Cholesterol screening
- Skin conditions like athlete’s foot, shingles, sunburn, and lice
- Vaccinations and general wellness physicals
4 Tips for using the pharmacy clinic:
- Call ahead or check online to validate hours of operation and wait time – often, clinic hours are more limited than the retail store hours.
- Many pharmacy clinics allow you to book an appointment online (including same-day) for select services. Doing so can help you avoid long wait times in the store.
- Bring along any personal health records that you maintain. If you don’t maintain them yourself, bring a list of:
- medications you take (dosage and frequency), including over-the-counter, prescription drugs, vitamins and supplements
- allergies you have, especially allergies to medication or latex
- previous medical procedures or surgeries you’ve had, including dates and names of treating physician or hospital
- Lastly, consider Telemedicine (virtual doctors visits) as a convenient alternative to many of the healthcare services provided at the pharmacy clinic.
Pros + cons of convenience care clinics
- No appointment needed – just walk in
- On-site pharmacy for convenience
- Most accept insurance to cover all or part of the costs of a visit
- Hours often coincide with retail store hours, meaning some evening and weekend availability
- Price transparency – retail clinics often post the prices of their services on their website
- Less expensive than other health care providers for many of the services they provide
- You won’t be seen by a doctor as convenience care clinics are generally staffed by physician’s assistants and nurse practitioners
- Unless you’ve previously used the clinic, you will need to provide an accurate health and medical history to ensure quality care
How much does the retail clinic cost?
You can expect to pay approximately the following for these types of services at the walk in clinic:14
- $99 to $129 for minor illnesses, injuries, and skin conditions
- $69 to $109 for wellness exams and physicals
- $59 to $129 for health screenings and monitoring
- $45 to $109 for vaccinations and injections
Walk-in clinics accept cash, credit cards, and insurance.
Health insurance you can use at the retail clinic
While one of the major benefits of the walk-in clinic is affordability, they also accept most types of insurance.
Major Medical Insurance – Your major medical insurance might cover a visit to a walk-in clinic, but check with your plan for a list of in-network providers before you go. Need major medical now?
Short Term Medical Insurance – Not typically subject to network restrictions, temporary plans should be accepted at most clinics. You’ll want to check with your plan and the clinic, though.
Telemedicine is a convenient alternative to the pharmacy walk-in clinic. Skip the waiting room! You can access care most anywhere, 24/7 – stay in your pajamas, don’t leave your desk, forget network restrictions.
Summary + Next Steps
Understanding when and why you should visit a doctor’s office, urgent care center, walk in retail clinic or emergency room is important for maximizing the effectiveness of the care you receive and minimizing your out-of-pocket expenses.
If you don’t currently have health insurance coverage for the emergency room or urgent care, consider obtaining an alternative health insurance policy to help defray the costs of unexpected illness or injury.
Short term health insurance is a good option if you’re between major medical plans.
Telemedicine, though not insurance, can be a good option to obtain diagnosis and treatment of routine illnesses from the convenience and comfort of your home.