Virtual urgent care in an integrated value based healthcare system

Abstract

Virtual urgent care (VUC) is not well understood when delivered through an integrated value-based healthcare system. The Southern California Permanente Medical Group operates Get Care Now (GCN), a VUC program complementing its urgent care clinics (UCC). Quality and patient experience dimensions are included in this study, comparing GCN and UCC patients. Females and Hispanics/Latinos were predominant in both groups and proportions of patients with chronic conditions were nearly identical within the leading 30–49 age band. Wait times for GCN were 21.19 min lower than for UCC, and positive patient survey results align with GCN’s average Net Promoter Score of 87. 3-day return rates to the ED (2.53% GCN vs. 3.26% UCC) and to UCC (5.44% GCN vs. 2.42% UCC) were comparable between GCN and UCC utilizers. Findings demonstrate that 24/7 VUC sustainably supports meeting patient demand for urgent care services in an integrated value-based system.

Introduction

The concept of virtual urgent care (VUC) is becoming mainstream, as substantiated by the proliferation of direct-to-consumer healthcare vendors like Amwell, Teladoc, and MD Live, all striving for consumer buy-in and market share in this growing field. Nationally the direct-to-consumer telehealth services market was valued at $1.47 billion in 2023, and it is projected to grow at a compounded annual growth rate of 30.3% between 2024 and 2030¹.

VUC offers on-demand care for non-life-threatening acute conditions that is accessible via synchronous video or phone interactions with providers. It draws on two well-established care delivery models, namely urgent care and telemedicine, both of which experienced surges in utilization due to circumstances tied to the COVID-19 pandemic. From 2019 to 2020, urgent care centers managed a 60% increase in per-center patient visits² and the pandemic catalyzed the rapid adoption of telehealth³, which has demonstrated favorable impacts on quality compared to in-person provider visits along numerous measures⁴. In this tumultuous environment in which payment parity regulations took hold and created more opportunities⁵, VUC platforms would expand, offering the benefits of both urgent care and telemedicine. The growing prevalence of VUC would suggest a prominent role for it to play moving forward.

The Southern California Permanente Medical Group (SCPMG), a care delivery arm of Kaiser Permanente, serves 4.8 million patients as part of an integrated value-based healthcare system. In October 2021, it launched a VUC program named Get Care Now (GCN), which offers 24/7 on-demand virtual visits. Capable of conveniently addressing an array of acute conditions, GCN today offers a ripe opportunity to evaluate a functioning VUC model that has already delivered over 1.3M patient visits. See Fig. 1 for an overview of the GCN process. All SCPMG patients may access GCN, regardless of empanelment status or payor profile; and no special fees apply.

Fig. 1. Overview of the Get Care Now (GCN) Process.

GCN is available on the patient portal, accessible 24/7 via webpage and mobile app; nurses and queue managers support the GCN process, which culminates in the launching of a Video or Phone Visit with a Provider.

We showcase how GCN’s incorporation into the infrastructure of an integrated value-based healthcare system creates a steady synergy benefiting patients and the organization. GCN is unique in this respect; non-value-based delivery systems predominate in the literature, with none resembling GCN. Existing research on VUC covers a wide range of subjects including time and cost analyses⁶, impacts to preventive care⁷, and quality and safety⁸; and highlighted settings often include academic institutions^9,10 or direct-to-consumer entities¹¹. In each case, however, the featured delivery system is not comparable to SCPMG’s integrated value-based delivery structure. The latter is grounded in a patient-centric approach emphasizing care quality and total well-being, sharply contrasting with many fee-for-service contexts that contend with incentives to drive higher volumes. Interestingly, in a post-pandemic era, many VUC platforms are challenged to evolve and maintain their valuations in an oversaturated market¹².

GCN, however, is positioned to endure, providing 24/7 VUC within an integrated value-based model. It sustainably complements in-person urgent care clinic (UCC) encounters and alleviates pressure on other segments of the care delivery system, while meeting patient expectations.

Results

SQL query using the Clarity database identified a total of 1,393,425 GCN patient encounters and 5,772,406 UCC patient encounters during the study period of October 1, 2021 to September 30, 2024. Encounters coded as completed with no other completed encounters by the same patient in the preceding 72 h constitute index visits. Only index visits are included in this study: 1,195,512 for GCN (74.30% via phone, 25.70% via video) versus 5,343,465 for UCC. The digital adoption rate for SCPMG patients (defined as % of patients with an online account for the patient portal) was at 83.9% as of October 2024.

Patient demographics

The age band of highest prevalence covers those 30–49 years of age, with greater representation for GCN (39.71% GCN vs. 29.89% UCC). Females were the predominant users in both cohorts, with a higher proportion for GCN (61.63% GCN vs. 54.87% UCC). For reference, 52% of the 4.8 million patients served by SCPMG identify as females. As expected, most users were adults, i.e., at least 18 years of age (79.51% GCN vs. 85.31% UCC); and GCN use among those Medicare-eligible (>65 years of age) was low (7.22% GCN vs. 17.17% UCC). Hispanics were most prevalent in both groups: 35.68% Hispanic, 29.28% Caucasian, 9.96% Asian, 6.75% African American in the GCN arm vs. 41.31% Hispanic, 24.50% Caucasian, 8.88% Asian, 7.63% African American in the UCC arm. For reference, the patient population for SCPMG is characterized as: 42.9% Hispanic, 29.8% Caucasian, 12.6% Asian, 8.4% African American, and 5.5% multi-ethnic. Table 1 displays the demographic information.

Table 1.

Demographic characteristics of GCN and UCC patients

	Patients, no. (%)	Patients, no. (%)
Characteristic	GCN (n = 631,349)	UCC (n = 2,381,452)
Age
<18	138,807 (21.99%)	424,765 (17.84%)
18–29	121,095 (19.18%)	425,450 (17.87%)
30–49	250,689 (39.71%)	711,851 (29.89%)
50–64	84,608 (13.40%)	485,387 (20.38%)
65+	45,608 (7.22%)	408,856 (17.17%)
Sex
Female	389,073 (61.63%)	1,306,674 (54.87%)
Male	242,127 (38.35%)	1,074,366 (45.11%)
Ethnic background
Hispanic/Latino	225,283 (35.68%)	983,798 (41.31%)
Caucasian	184,831 (29.28%)	583,363 (24.50%)
Asian	62,884 (9.96%)	211,474 (8.88%)
African Americans	42,624 (6.75%)	181,616 (7.63%)
Other	89,219 (14.13%)	311,550 (13.08%)
Top 5 diagnoses
(1)	URI, 65,857 (10.43%)	COUGH, UNSPECIFIED, 183,150 (7.69%)
(2)	COUGH, UNSPECIFIED, 49,099 (7.78%)	URI, 150,110 (6.30%)
(3)	COVID-19 DISEASE, 47,417 (7.51%)	FLU VACCINATION, 105,031 (4.41%)
(4)	THROAT PAIN 27, 984 (4.43%)	UTI, 94,522 (3.97%)
(5)	SINUSITIS, 26,807 (4.25%)	ABDOMINAL PAIN, 82,600 (3.47%)
Complex patients
Age 30–49	50,663/250,689 (20.21%)	133,926/711,851 (18.81%)
Age 50–64	35,602/84,608 (42.08%)	208,557/485,387 (42.97%)
Age > 65	30,475/45,608 (66.82%)	298,261/408,856 (72.95%)
Patients w/ chronic conditions
All ages	290,881/ 631,349 (46.07%)	1,287,117/2,381,452 (54.05%)
30–49	122,487/250,689 (48.86%)	344,468/711,851 (48.39%)
50–64	66,479/84,608 (78.57%)	385,595/485,387 (79.44%)
>65	43,052/45,608 (94.40%)	393,770/408,856 (96.31%)

URI upper respiratory infection, UTI urinary tract infection

Chronic medical conditions (Supplementary Table 1) were higher in the UCC cohort, as expected given the higher percentage of elderly patients (65 years of age and older) in the UCC arm. When comparing the predominant 30–49 age band, however, the proportions of patients with chronic medical conditions were nearly identical (48.86% GCN vs. 48.39% UCC). Also, those in that age band encompass similar proportions of complex patients (20.21% of GCN vs. 18.81% of UCC). Of the documented primary diagnoses, respiratory ailments (coughs, upper respiratory infection, COVID) and urinary tract infection (UTI) were among the most common; they constitute 29.91% of GCN diagnoses vs. 20.97% for UCC.

82.01% of GCN users had commercial insurance compared to 71.10% of UCC users. Proportions for Medicaid coverage were similar between both arms (15.24% GCN vs. 14.69% UCC). To uncover a potential digital divide¹³ in our population, we analyzed broadband usage according to zip code in California¹⁴. Broadband use overall was similar between the two groups (55.6% GCN vs. 56.5% UCC), which indicates that in-person urgent care continues to serve a need for SCPMG’s patient population, even when digital care pathways are available. This underscores the importance of facilitating access to UCC services, which was a driver behind the design of GCN.

Quality

For the GCN cohort, the 3-day return rate to the ED was lower (2.53% GCN vs. 3.26% UCC, p < 0.001), but the 3-day return rate to Urgent Care was higher (5.44% GCN vs. 2.42% UCC, p < 0.001). The specialty referral rate (2.87% GCN vs. 9.25% UCC, p < 0.001), image ordering rate (1.94% GCN vs. 7.11% UCC, p < 0.001), and Dr. Advice rate (0.22% GCN vs. 0.43% UCC, p < 0.001) were significantly lower on the GCN arm. Dr. Advice is a primary care-to-specialty communication tool utilized in SCPMG that is designed to address simple specialty-related questions or concerns that do not warrant a full consultation between the patient and a specialist. Table 2 displays the quality metrics.

Table 2.

Statistical comparison of quality performance metrics between GCN and UCC visits

	Visits, no. (%)	Visits, no. (%)
Measure	GCN (n = 1,195,512)	UCC (n = 5,343,465)	P-valuea
Antibiotic prescription rate	289,653 (24.23%)	1,667,441 (31.21%)	<0.001
3-Day return rate to ED	30,280 (2.53%)	174,281 (3.26%)	<0.001
3-Day return rate to UCC	65,018 (5.44%)	129,177 (2.42%)	<0.001
Specialty referral rate	34,338 (2.87%)	494,175 (9.25%)	<0.001
Dr. Advice request rate	2684 (0.22%)	23,033 (0.43%)	<0.001
Imaging study order rate	23,251 (1.94%)	379,776 (7.11%)	<0.001

^aFor the null hypothesis that the rate for GCN is the same as the corresponding rate for UCC.

Despite higher proportions of patients being seen at GCN for respiratory ailments and UTI, the antibiotic prescription rate was lower for GCN (24.23% GCN vs. 31.21% UCC, p < 0.001). This is salient given the context of studies indicating that VUC provided by direct-to-consumer vendors is associated with higher rates of prescribing antibiotics^15,16.

Also, SCPMG promotes proactive office encounters (POE), the key metrics for which are successful opportunity rates (SORs) for addressing care gaps. SORs (as percentages) indicate the extent to which preventive care actions that were outstanding at the time of a visit are successfully addressed within 30 days after the visit. The aggregate SOR covering 11 care gaps for the 36-month study period (Supplementary Table 2) was low for each arm (12.11% GCN vs. 16.90% UCC, p < 0.001), prompting an emerging campaign to address preventive care actions with patients while they are waiting in queue for their GCN visit to begin. This effort exemplifies how the larger care system offers resources to benefit VUC patients.

Patient experience

Visit volumes grew steadily since program inception; total visits completed in the first three quarters of 2024 alone (590K) surpass the total number of visits completed in all of 2023 (481K). Also, GCN’s Net Promoter Score for each of its first 12 quarters falls within the 86–89 range, which is typically recognized as highly favorable¹⁷. Supporting evidence of GCN’s appeal to patients also came in the form of qualitative patient feedback. A sentiment analysis engine driven by Natural Language Processing technology reviewed 75,574 patient feedback entries collected through post-visit surveys and determined that 89.3% had a positive tone, 2.3% had a negative tone, while the remaining 8.4% were characterized as mixed as they reflected a blend of positive and negative sentiments (e.g., “Awesome however there was a glitch where I wasn’t able to see the doctor’s face”). This distribution of positive and negative comments aligns with the average Net Promoter Score of 87.

Patient survey results also reveal the alternative pathways patients would have pursued in the absence of GCN (Fig. 2). Those who complete a video visit are offered the opportunity to respond to a survey immediately upon the conclusion of the visit. To the question, “If you did not have this video visit, what else would you have done for care,” 55% responded with in-person “Urgent Care.” This underscores how GCN alleviates pressure on UCCs, which operate between the hours of 7 a.m. and 9 p.m.

Fig. 2. Responses to the survey question on alternative pathways.

Surveys sent to video visit recipients asked them what they would have done in the absence of GCN; their responses suggest that GCN effectively diverted a substantial volume of patients away from in-person Urgent Care Clinic (UCC) services.

More objectively, the average daily wait time from October 2021 to September 2024 was significantly lower in the GCN group compared to the UCC group (47.70 min GCN vs. 68.89 min UCC, p < 0.001). Excluded from the UCC wait time are the minutes spent traveling to and from the clinic, which if factored into the calculation would result in a starker contrast favoring GCN.

Discussion

With the pandemic’s effects waning, telemedicine remains an important part of healthcare delivery. Yet uncertainties still abound as they relate to procedure-intensive specialties, concerns about reimbursement rates, perceived quality of care, and lack of seamless technology integration, all of which continue to hinder widespread adoption.

However, a hybrid model that strategically integrates virtual and in-person care seems to offer a sustainable approach moving forward. Traditional in-person urgent care services will remain a fixture in healthcare delivery systems, but VUC can effectively complement the former, especially in an increasingly consumer-centric environment where patients expect a digital experience that offers convenience and ease of use¹⁸. At minimum, 24/7 online access helps fill the after-hours gap left by in-person urgent care; and during daytime hours VUC can address many patient concerns that do not require an in-person visit, which consequently conserves access to the urgent care clinic for those who truly need it. We presume GCN alleviates some pressure on Emergency Departments and primary care clinics, thereby conserving access to those other care venues as well, although likely to a lesser extent. In any case, demand for GCN has been so great that SCPMG has had to allocate more provider resources to support it, a task marked by difficulties exacerbated by physician recruitment challenges.

Also, when VUC is situated within an integrated value-based system, there are distinct competitive advantages over third-party telemedicine providers. They include independence from payment parity regulations and a unified telemedicine platform that integrates seamlessly with legacy electronic health record (EHR) systems, ensuring continuity of care across both virtual and in-person settings. Additionally, as is the case with GCN, providers are invested in their patients’ long-term well-being, which distinguishes them from many third-party telemedicine service providers who are moonlighters without the same vested interest. By upholding the patient-centric values of SCPMG, the organization to which GCN providers belong, they foster meaningful encounters with patients that cannot be replaced by the transactional approach of third-party providers. GCN providers, for instance, follow-up on lab and imaging orders they place and then reach out to their patients where appropriate. They also refer patients to specialists, who will review the GCN providers’ notes.

While the complementary relationship between in-person urgent care and VUC can create synergy in a value-based system, noteworthy is the fact that GCN and UCC do not represent the same patient population and thus should not be directly compared without understanding selection bias and confounding factors. Referral rates to Orthopedics are illustrative. As expected, the volume of referrals to the Orthopedics department (as a proportion of all specialty referrals in the cohort) is greater for UCC visits (22.67% UCC vs. 7.77% GCN). A patient who suspects a broken bone, for instance, would expectedly favor going to an in-person UCC visit over a VUC visit. Also, because such cases typically involve imaging studies to inform diagnosis and treatment plans, we find to no surprise lower imaging order rates for GCN. GCN providers undergo monthly reviews and education on the appropriateness of referrals and imaging studies using evidence-based guidelines, all of which drive consistency of care and reduce duplication of efforts; this further explains the difference in imaging order rates.

On the financial front, measuring the impact of GCN on per capita costs is challenging in an integrated delivery system, as GCN is just one of several offerings in a comprehensive care package. Because GCN is situated within a value-based model, one in which multiple services along the care delivery spectrum come together to serve patients across time, there is no simple way to quantify how GCN influences cost. Studies in the literature, however, point to how VUC lowers costs. Lovell et al. found VUC to be of lower cost compared with urgent care, with no associated increase in overall follow-up rates¹⁹. Gordon et al. found each virtual visit was $153 and $1735 less costly than an urgent care visit and an ED visit, respectively²⁰. Nord et al. estimated the net cost savings per virtual visit to be in the range of $19–$121²¹. Such studies demonstrate that VUC is a financially sound model.

A strength of the study is its direct accessibility to EHR data covering a large and diverse population representative of Southern California. We thus ensured high accuracy in analyzing patient and encounter data across a 36-month time horizon, to produce findings that are reliable.

Limitations to the study, however, include the following. First, data were limited to a single vertically integrated health system, and this may introduce selection bias. Our data thus may not be directly generalizable, especially for healthcare systems that utilize a fee-for-service model. Second, due to the omission of direct cost analyses, we rely on the literature for evidence of the potential for cost savings. Third, inherent biases of patient surveys could not be accounted for when presenting subjective satisfaction data. Fourth, primary diagnosis measures capture a limited set of visits as many encounters lack the information, especially for the GCN arm; this is likely attributable to a lack of incentives for providers to enter such information. Fifth, because broadband comparisons were calculated based on publicly available data on the URL provided, we were not able to internally verify the accuracy of the datasets. Lastly, we were unable to control for the number of visits between UCC and VUC as this was not a prospective study.

Our principal finding is that GCN sustainably complements conventional urgent care services, within an integrated value-based care delivery system, through 24/7 accessibility via a convenient online patient portal. Key metrics, including the 3-day return rates to ED and UCC, are comparable between the two study arms, and therefore acceptable. As a proven viable care path, GCN has matured into a permanent fixture for SCPMG in the post-pandemic era.

Methods

This study assesses GCN visits delivered by SCPMG, which serves a geography encompassing 16 hospitals and 197 medical office buildings. Extracted from the EHR were deidentified data for October 1, 2021, to September 30, 2024. The study was deemed exempt by the Kaiser Permanente institutional review board; informed consent was waived owing to the use of deidentified data. This study is reported following the Standards for Quality Improvement Reporting Excellence (SQUIRE) guideline²².

Measure selection

Patient demographics (Table 1) encompass age, sex, ethnic background, and diagnoses. Complex patients are those with at least 6 diagnoses that appear on their EHR’s problem list and who are taking over 6 active medications. Patients with at least one chronic condition are distinguished as well; qualifying chronic conditions are outlined in Supplementary Table 1.

For the quality dimension (Table 2), the patient return rate is calculated by dividing the total number of index visits that were followed by one or more visits to the ED or UCC within a specified time frame by the total number of index visits. Similarly, specialty referral rate, imaging order rate, antibiotic prescription rate, and Dr. Advice rate are all calculated by dividing the respective number of visits during which an action was taken by the provider (entry of specialty referrals, entry of orders for imaging studies, entry of antibiotic prescriptions, and requests for Dr. Advice) by the total number of index visits.

Related to SCPMG’s promotion of proactive office encounters (POE) are successful opportunity rates (SORs). These metrics, covering a multitude of care gaps, are detailed in Supplementary Table 2. Patient satisfaction metrics are explained in the “Results” subsection “Patient experience”.

Cohort study design

For patient demographics, two patient cohorts were studied: patients who had an index visit via GCN, and patients who had an index visit in UCC. A given patient may be included in both cohorts, but not more than twice within a cohort (to eliminate the effects of artificially inflating demographics variables resulting from frequent utilizers, while allowing for appearing in another age segment as a result of aging during the study period). Patients counted twice in this manner were few (3.01% GCN, 3.31% UCC).

For quality metrics, the two patient cohorts being analyzed—GCN utilizers in one arm, and UCC utilizers in the other—are also limited to index visits, but data are based on encounters as opposed to patients. This means if a patient has many index visits in GCN, for instance, then the GCN utilizer cohort will account for each of those index visits.

Time frame selection, bias controls, and variables

We selected an uninterrupted 3-year timeframe, from the GCN go-live date of October 1, 2021, through September 30, 2024. All metrics of Tables 1 and 2 pertain to index visits, which refer to visits not preceded by another encounter for the same patient for 72 h; focusing only on index visits brings GCN in-scope volume to 1,195,512 visits and UCC in-scope volume to 5,343,465. Non-index visits, however, are counted as part of calculating return rates.

Statistical analysis

All reported significant differences were tested using a two-proportion z-test with a two-tailed p-value threshold of <0.001, performed with the SciPy.Stats package (version 1.14.1) in Python.

Author contributions

K.N. and D.N. conceived the study and designed the study. A.E., S.L., J.C., Y.B., and R.T. designed and ran the study. F.J., T.S., C.W., and M.K. performed data analysis. S.L. and K.L. wrote and edited the manuscript. All authors read and approved the final manuscript.

Data availability

The patient data that support the findings of this study are not available due to privacy reasons, but they may be discussed with the corresponding author upon request.

Code availability

Not applicable.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s41746-025-01590-6.