Urgent care centers have become a staple in American society. After their introduction in 2000, millions of people began to realize how large a role convenience plays in medical care. If you're not facing a true medical emergency but require somewhat immediate help (and therefore can't wait two weeks to see your primary care provider), urgent care clinics offer an easy and affordable solution. For the insured, under-insured, and uninsured alike, urgent care centers offer practical, on-demand medical services.
As such, starting your own urgent care center has become a lucrative business. With the proper urgent care business model -- in addition to some help from urgent care consultants -- you can tap into this profitable market. While there are a number of important factors that come into play in your urgent care business model, location is one of the most influential. Let's take a look at the two main aspects of choosing a good location for your urgent care center.
Establishing an effective urgent care business model begins with a simple piece of real estate. Find the right one in the right area, and you'll be helping the community as much as profiting from it.
It's easy to associate the word startup with the innumerable tech firms dotted around Silicon Valley and posturing themselves as the next best thing. We also know that most tech startups seeking funding never reach the coveted status of unicorn.
The good news for startups in the healthcare industry is that healthcare is universally essential (unlike the millions of useless apps out there). However, just because healthcare is universally necessary, that doesn't mean the business plan supporting it can be lacking. With saturated hospitals and a record number of Americans with health insurance, we've since seen a marked rise in retail medical centers, urgent care clinics, and other healthcare facilities with similar structures.
Throughout 2018, the number of retail medical clinics actively operating in the United States has been about 14 times higher than it was a decade ago. It's safe to say the idea of an urgent care startup is currently en vogue, but we want to make sure that they don't become a dime-a-dozen and poorly operated to boot. Here's what you should be thinking of before you attempt to start an urgent care center.
Remember, Patients Are Always First
This is your duty as healthcare professionals. In every consideration you make for your urgent care startup, think of the potential patients. Have you secured enough space to serve them properly? Are you in an easily accessible, convenient location? Will you have ample medical staff to provide exceptional care? Can you partner with other healthcare facilities in the area? All of your initial urgent care startup considerations should end up being patient-oriented. Because without them, you've already failed.
What Does It Cost To Start An Urgent Care Clinic?
You cannot escape the question of the cost of an urgent care startup. Aside from literally having the financial capability to open an urgent care center, you must consider its scalability. After you've gotten your initial logistics of patient care and the ability to provide the best possible service, it's vital to consider how your urgent care will grow as a business. Your urgent care business model should look to the future and factor in growth, hardship, and how it'll maintain an edge. Healthcare is a notoriously volatile industry where patients continuously have a growing pool of care options. Make sure you have plans in place that attract patients from day one to day 10,000 and beyond.
Consider Consulting For Urgent Care Centers
Urgent care business consulting is an important element to consider, especially if you're a group of medical professionals foraying into the business world for the first time. It's important to remember that excellent medical treatment and the business side of an urgent care startup are very different things. Be sure to opt for guidance when needed and even when not needed. You never know where a fresh new idea might come from.
We'll tackle more specifics in future blogs, but since you've been bitten by the urgent care startup bug, we want to make sure you don't catch the fever. There's a reason the word care is in healthcare. We don't do anything haphazardly, medically or otherwise.
Intuitive Health and Riverview Health Break Ground in Fishers, Indiana, on the First of Four New Dual Model ER & Urgent Care Facilities
FISHERS, Ind., October 30, 2018 (Newswire.com) - Intuitive Health, a Texas-based company that is a leader in the dual model ER and urgent care under one roof, has broken ground with partner Riverview Health on the first of four new facilities in the Hamilton County area north of Indianapolis. Surrounded by key board members, partners and city officials, Seth Warren, CEO of Riverview Health, and Thom Herrmann, CEO of Intuitive Health, delivered details of the venture and the positive impact the facility will make to the families and economy of the county.
Fishers, which was recently voted the No. 1 place to live by Money Magazine, will be home to the first location. The site is located adjacent to the new Top Golf and will feature both a full-service emergency room and urgent care under one roof. The facility is designed to be welcoming with easy in-and-out access and will feature over an acre of green space.
"Patients want convenience, immediate access to care, better customer service and greater transparency into the billing process," said Thom Herrmann, CEO of Intuitive Health, a company that pioneered the combined emergency care and urgent care model in Texas over 10 years ago and whose facilities now rank in the top one percent of global retailers in customer satisfaction. “Bringing urgent care and emergency care to the families of Fishers allows us to meet many of their expectations.”
In addition to Fishers, Intuitive Health and Riverview Health are building three additional locations in Hamilton County. The four clinics will be designed to simplify how patients access immediate, appropriate care while lowering their out-of-pocket costs. All of the facilities will be located in attractive retail settings and by offering emergency care and urgent care in one facility, the patient will no longer have to choose where to go to access the right care in their time of need.
The Fishers facility will be open by the end of 2019 and the remaining facilities are expected to open in early 2020.
Presbyterian Healthcare Services partners with INtuitive Health to introduce 24/7 emergency and urgent care clinics in New Mexico
ALBUQUERQUE, N.M.- Presbyterian Healthcare Services, a national leader in innovative integrated health systems, has announced its partnership with Texas-based INTUITIVE HEALTH to bring a new venue of care – 24/7 combined emergency and urgent care clinics – to New Mexico.
The four clinics will be designed to simplify how patients access immediate, appropriate care while lowering their out-of-pocket costs. The facilities will be located in typical retail settings and by offering emergency care and urgent care in one facility, patient will no longer have to choose where to go to access the right care in their time of need.
"Patients want convenience, immediate access to care, better customer service and greater transparency into the billing process," said Thom Herrmann, CEO of INTUITIVE HEALTH, a company that pioneered the combined emergency care and urgent care model in Texas over 10 years ago and whose facilities now rank in the top 1% of global retailers in customer satisfaction. “Bringing urgent care and emergency care clinics to a new market allows us to meet many of their expectations.”
The new clinics will eliminate the need for patients to decide if their symptoms require a visit to urgent care clinic or an emergency room by providing a location that offers both.
“Across the industry, insurers and providers are trying to help guide consumers to the appropriate level of care. Instead of asking patients to self-diagnose and determine the right venue on their own, Presbyterian and INTUITIVE saw the opportunity to improve the patients’ experience and decrease their guesswork by creating a single venue with 24/7 access to both services,” said Clay Holderman, executive vice president and chief operating officer, Presbyterian Healthcare Services.
At the walk-in clinics, each patient will be assessed by a clinician and then treated. This approach makes care more affordable by avoiding the higher costs of emergency care if patients require urgent care. The clinics will also offer 24/7 access to urgent care, which is typically only offered through the early evening.
The facilities are expected to open by the end of 2019.
About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. Presbyterian is a locally owned, not-for-profit healthcare system of eight hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with more than 11,000 employees.
About INTUITIVE HEALTH LLC.
Founded in 2008, INTUITIVE HEALTH changed the way patients accessed ER and urgent care services by providing emergency and urgent care services under the same roof, accessed by the same entrance and offered in highly convenient retail locations. INTUITIVE has built an exceptional customer service model, with industry-leading satisfaction ratings. Intuitive saves patients, payors and employers millions of dollars each year by eliminating inappropriate emergency room utilization. INTUITIVE partners with leading health systems nationwide to build, operate, and launch combined ER & UC retail-located healthcare facilities. Please visit IHERUC.com for more information.
Today we’d like to introduce you to Dr. Jay Woody.
Thanks for sharing your story with us Dr. Woody. So, let’s start at the beginning and we can move on from there.
While working a successful career as a board-certified ER physician in some of Dallas’s busiest and most prestigious emergency rooms, I began to notice a disturbing trend – many of the people I treated on a daily basis did not need emergency level care. These people did not have many options at the time, so they went to the hospital which leads to overcrowding, long waits and large bills for those non-emergent cases.
In 2007, we came up with a concept for a full-service emergency room and urgent care all in a retail setting. At this time the concept of free-standing community-based emergency rooms or urgent cares was not an industry, and there were no rules or regulations surrounding this concept. Many believed this to be a very risky endeavor because gaining patients’ trust to receive care in a retail setting would be a challenge. This would also be the first and only Emergency Room and Urgent Care under one roof ever created. This would allow us to provide all the services of an emergency room but bill patients that did not need ER level care at urgent care rates. At the time, we did not know how this would work, but it absolutely resulted in cost savings! We saw 85,000 patients in 2017 with 84% being billed at the urgent care level thus saving over $20,000,000 in unnecessary ER charges for North Texans and their employers.
We opened our first location in the bustling suburb of Frisco Texas in 2008. At the time our location was surrounded by open fields and the promise of new retail locations to come. Our close proximity to the rapid housing developments was our greatest asset. We set out to gain patients’ trust by caring for the people of Frisco one by one and introducing them to this unique model. By not being affiliated with any hospital or health system and knowing the only referral patients will typically receive to come in would be friends and family, customer service and loyalty was our main marketing. We knew we could create a new standard for the level of service in healthcare. Patients were used to long waits, confusing billing, and most of all a less than stellar level of service. We hatched a novel plan to train all of our staff in customer service and eliminating all of the typical healthcare stereotypes – for instance, there is no glass partitions in any of our locations, but rather a concierge type open concept. We invite patients to come in, ask questions and to always get a smile.
The next complete change in patient perception would be the expectations of the time. We created a proprietary process that alleviates the typical long waits and door to door times by keeping patients moving. Most of our Urgent Care level patients are getting back into their cars within 35 minutes. Even on our busiest days, patients will only be in our reception area for less than 5 minutes. In these busy North Texas communities, time and money are the biggest factors for customer loyalty and this dual model and attention to customer service have created a recipe for success.
Has it been a smooth road?
Starting Legacy ER & Urgent Care came with many of the same entrepreneurial challenges as starting any business, combined with the massive government regulations and hurdles of healthcare. In healthcare, there are multiple state and federal government oversight committees for everything from insurance to oversight of care. There are loopholes and opportunities to take advantage of that could bypass some of these initiatives, but we set out to be 100% transparent and by the book as we were in this for the long haul. Even to this day we are under constant review and are required to abide by the many laborious and sometimes, in my opinion, unnecessary rules required by various State and Federal agencies. The biggest issue being many of these rules disrupt our model of efficient and fair billing.
As a disrupter, we knew many of our processes would come under scrutiny but as insurance companies began to see the benefits of the dual billing model we gained key allies in the insurance companies. Saving patients and communities millions in unnecessary ER charges benefits everyone, and we have continued to gain acceptance and even have advocates from the third party payors.
Another challenge for us was the rapid growth of competition that started with the passage of legislation in 2009 allowing free-standing emergency rooms to be built without an affiliation to a hospital. This lead to fast and furious growth in this new healthcare sector. Consumers being confused by the rapid growth of the free-standing ER industry and our unique model has been a real challenge to overcome. Patients quickly realized a Freestanding ER is the same as an ER and would cost them the same regardless of the level of care they required. Negative consumer reactions quickly followed and a warranted backlash followed from the press. Legacy was lumped in this Freestanding ER category and even though we are the complete opposite of that and have an in-network strategy we have to continue to educate our patients and the media about our highly efficient model.
As of 2018, many of these competitors, including the nation’s largest private ER Company, have gone out of business thanks to consumers becoming more educated. Meanwhile, we are in our 10th year with continued year over year growth and expansion nationally underway.
So, as you know, we’re impressed with Legacy ER & Urgent Care – tell our readers more, for example, what you’re most proud of as a company and what sets you apart from others.
Legacy ER & Urgent Care is the largest provider of both Emergency Room and Urgent Care services under one roof in the country. Our mission is to set a new standard of care, service, and honesty in health care. Changing the way families receive and pay for healthcare is at the core of everything we do and it is a part of our company’s culture. Also, a part of the culture we practice is servant leadership. The executive team sits on the bottom of the paradigm supporting the patient experience and providing all of the tools necessary to continue our mission. This dedication to service has put Legacy in the top 1% of global retailers with a Net Promoter Score of 82. Over 30k patients a year provide detailed feedback on where we did well or where we need to improve via a short survey. Patients are either detractors (rating the service 0-6) Passive (7-8) or promoters (9-10). Over 87% of our responses are promoters. To put this in perspective Starbucks, Southwest Airlines, and Apple are in the 60s and 70s. This has helped us retain and promote some of the best healthcare talents in Texas and we are proud to have them on our team. This has been instrumental in our growth outside of Texas as well.
Legacy is a full-service emergency room and urgent care under one roof. This means, we can treat everything from allergies to a heart attack in the same facility. Our value and difference are that the patient will only get billed for the level of service they received. We staff with an ER trained physician, ER trained Nurse, Paramedic techs, nurses, radiology professionals, and administrative staff at all of our facilities. Every patient regardless of the level of care needed will see our full line up including an ER physician which gives people a piece of mind.
The future is bright for Legacy ER & Urgent Care and leads us to create INtuitive Health (INtuitiveHealthERUC.com) as our expansion brand. INtuitive brings our concept of retail health to health systems nationwide. In 2019, we will be opening several new facilities around the country as an extension of the health systems hospital outpatient services. We recently announced a relationship with Riverview Health in Indianapolis with our first facility to open in Money Magazine’s #1 Place to Live, Fishers Indiana. We will open an additional 3 locations in the Indianapolis area and will soon be announcing several more new relationships throughout the US. Patients are demanding better service, better billing, and better access – and Legacy ER & UC is providing this in one of the most competitive healthcare markets in the country. I am excited that we are bringing all of this to several other states in the very near future.
Let’s touch on your thoughts about our city – what do you like the most and least?
Dallas is full of opportunity – probably considered the ‘land of opportunity’ right now. Jobs, good weather, great housing all come with the package. Those same things have made for challenges as well – low cost of entry has created overcrowding, an exceptional amount of competition and created difficulty recruiting.
INtuitive Health, a pioneer in retail healthcare, with their Legacy ER & Urgent Care locations in North Texas, announces expansion into the Indianapolis market in partnership with Riverview Health. The newly formed joint venture will build four new retail clinics that offer both 24/7 emergency services and extended hour urgent care under one roof. These facilities will be built in highly convenient retail locations, offering patients easy access to treatment for everything from the common cold to a life-threatening emergency. Patients will only be billed for the level of care that they need, thus saving patients, employers, and payors millions in unnecessary ER costs while alleviating long waits at local hospital emergency rooms.
"Patients are demanding better transparency into the healthcare billing process, quicker care, and better service. We have focused on these specifics since 2008 and are now rated in the top 1% of all retailers in customer satisfaction. We are excited to partner with Riverview Health and bring this model to northern Indianapolis & Hamilton County," said Thom Herrmann, CEO of INtuitive Health. “Riverview Health is a leading healthcare provider in Hamilton County which shares similar characteristics to our home market in North Texas. Our North Texas locations have become the go-to option for patients seeking high quality, convenient, immediate care and we believe the residents of Hamilton County will value our service the same way. The northern suburbs of Indianapolis are home to a lot of young families, as well as a healthy economy and great schools. Several of the communities are ranked nationally as highly desirable places to live. Fishers, Indiana was recently chosen as Money Magazine’s #1 place to live in the United States.”
"Partnering with the INtuitive team makes perfect sense for Riverview Health. We have a strong reputation for service and commitment to our community, and building these customer service oriented facilities will be a great fit,” said Seth Warren, President, and CEO of Riverview Health.
The four facilities will be built in north Carmel, west Carmel, Fishers and the Nora area of Indianapolis. Construction will begin in the spring of 2018 with all the facilities slated to open in 2019. There has been no name decided for the joint venture, and the financials of the deal have not been disclosed.
About INtuitive Health
Founded in 2008, INtuitive pioneered retail healthcare, with their Legacy ER & Urgent Care brand, and was one of the nation’s first healthcare facilities to offer both urgent care and emergency room treatment options under one roof. INtuitive is building an exceptional customer service program, with industry-leading ratings by providing transparent billing, and creating welcoming clinical environments with one-on-one access to board-certified, emergency-trained physicians. INtuitive partners with health systems nationwide to build, operate, and launch these retail healthcare facilities. Please visit INtuitiveHealthERUC.com for more information.
About Riverview Health
Riverview Health is comprised of a full-service, 156-bed hospital and 25 primary, immediate and specialty care facilities located throughout Hamilton County. Together, we provide comprehensive healthcare services in 35 medical specialties and have frequently been recognized for our clinical and service excellence. For more information, visit riverview.org.
Before the mid-1980s, there were few options when it came to getting quick medical care on an outpatient basis. From unbearably long emergency room wait times (and the associated large bills) to the growing difficulty of actually finding or booking an appointment, there was a mounting frustration in the healthcare space. Ultimately, this gap led to a rise in what we now call “urgent cares”, and an emphasis on providing a better patient experience.
Legacy ER & Urgent Care has expanded this model further, offering dual emergency room and urgent care locations to meet the needs of patients in the United States. Today, they are the largest dual provider of both emergency and urgent care services in the country, and a leader in delivering superior patient experience.
News of their success and innovative business model has garnered a high volume of interest from major healthcare providers and hospital investors looking to provide similar access to communities across the country. To ensure a high standard of patient satisfaction and retention through their continued expansion, Legacy ER & Urgent Care implemented CustomerGauge—a Net Promoter System® that helps them track and improve patient experience- across their locations.
Getting Started with a Net Promoter System
Before partnering with CustomerGauge, Legacy ER & Urgent Care found that one of the biggest hurdles when it came to focusing on their patient experience was that the healthcare industry simply wasn’t built for it. Prior to CustomerGauge, Legacy ER & Urgent Care always paid close attention to patient feedback, but did not have the detailed processes for improvement and tracking they do today.
That all changed in 2016, when Legacy ER & Urgent Care implemented CustomerGauge, which enabled them to track and respond to patients in real-time and analyze satisfaction. Chief Marketing Officer, David Apple, attributes the success of the implementation to first and foremost, employee buy-in of the system and its value,
“We streamlined the process by empowering our leaders, on both the care and administrative side, to lead the NPS program and really hone in on not just the bad experiences (we have a workflow process for that), but also to celebrate the wins. It was spreading the word about our promoters that got everybody excited.”
By establishing buy-in with their employees, Legacy ER & Urgent Care built out their Net Promoter System across their locations, which enabled them to track patient satisfaction.
Closing the Loop to Improve Patient Satisfaction and Retention
As part of their CustomerGauge workflow process, Legacy ER & Urgent Care uses consistent survey best practices. Patients are sent surveys about their experience within 24 hours of their visit via email. If they do not receive a response within 36 hours, they send out a secondary email reminder, which has led to improved response rates and higher retention within their patient base.
“We’ve taken everything that healthcare typically does [when it comes to patient satisfaction and patient experience] and thrown it out the window. " - David Apple, Chief Marketing Officer
Once a patient has submitted a survey, as part of their follow-up workflow, leaders at each location are notified of detractors or passives in real-time via email using CustomerGauge’s issue escalation. At this point, the clock is ticking. To ensure dissatisfied patients are contacted ASAP, every facility has designated ‘first-responders’, such as a nurse or physician leader, to reach out for solutions. Legacy ER & Urgent Care will not consider a case closed until the issue is resolved.
In addition to care-based first responders, billing and insurance-related issues also include separate first-responders—meaning issues are always designated to the right person in the company. Issues are processed and closed in no more than 36-48 hours of notification. When asked if this process has noticeably improved their patient experience, CMO David Apple stated:
“100%. Knowing how important promoters are to our business, we implemented improvements as issues arise. For example, if we see any consistent issues in billing, co-pay, or other procedures, we make changes in our operational process to improve based on that patient feedback.” - David Apple, Chief Marketing Officer of Legacy ER & Urgent Care.
Best Practices for Winning Patient Experience and NPS
Proper employee training, good survey procedures, and streamlined follow-up are just a few of the best practices that Legacy ER & Urgent Care have employed over the last few years. Since investing in patient experience and retention, Legacy ER & Urgent Care has experienced a 15-point increase in their NPS score overall. But how did they get there?
For Legacy ER & Urgent Care, following the status quo didn’t cut it:
“We’ve taken everything that healthcare typically does [when it comes to patient satisfaction and patient experience] and thrown it out the window. It’s a complete transition away from a typical healthcare experience. Our NPS score and patient experience comes from the whole package. Before patients are even done checking in, somebody is greeting them in the room and bringing them in. We’re aware that a majority of the people we see are probably having a bad day, so it’s important to set that initial tone very high, even when people first walk in.”
Legacy ER & Urgent Care employ numerous best practices to ensure success within their NPS program to increase satisfaction and grow their business:
• Employee buy-in, encouragement and thorough training of the tools and procedures
• Fast and proven survey process and follow-up
• Consistent patient/customer experience procedures across multiple locations
• Tying revenue to a patient/customer experience program to justify investments
"Knowing how important promoters are to our business, we implemented improvements as issues arise."
With CustomerGauge, Legacy ER & Urgent Care hopes to continue delivering consistent, outstanding patient experience, and tie their efforts to revenue and growth as they continue to expand.
According to NPSBenchmarks.com, the average Net Promoter Score for the health care industry—from primary care to physical therapist—is 75. However, according to a third-party survey of N. Texas Free-Freestanding ERs and Hospital
EDs, the industry benchmark is even lower. Healthcare has been slow to adapt NPS or any customer feedback tools. Legacy ER & Urgent Care’s NPS score of 81 is a significant achievement considering it is on par with top retailers and customer service-oriented brands.
By the end of the year, Legacy ER & Urgent Care expects revenue from existing patients to grow by 200%. Given both their ability to justify their patient experience program via revenue and the value in their business’ dual model, Legacy ER & Urgent Care is looking forward to an exciting year of expansion and growth:
“There’s going to be a seismic shift in healthcare across the country. People are looking for better access and experience. As such, we are looking to expand. We have a lot of major hospitals and healthcare systems around the country that are interested in partnering with us to deliver our model to states that don’t have any community access care that. We’re in a good position to grow rapidly, and we have the people and the system [CustomerGauge] in place now to help us with this expansion. It’s going to be an exciting year.”
CustomerGauge is a software-as-a-service platform that improves customer experience using the industry-standard Net Promoter System. The system helps companies automatically measure and analyze feedback in real-time, act to reduce churn through close-loop tools and grow their bottom line.
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About Legacy ER & Urgent Care
Legacy ER & Urgent Care is the largest dual provider of both emergency and urgent care in the country, and runs on one simple premise: there has got to be a better way to deliver emergency services while providing extraordinary customer experience and only billing for the care you need.
The landscape of healthcare is changing. Better access, better service, and honest billing have become patient directives because it makes sense - it's intuitive. The team who developed the hybrid retail care model and built the chain of successful, North Texas-based, Legacy ER & Urgent Care facilities, is now launching Intuitive Health. Intuitive Health will serve as an expansion brand to partner with health systems around the country.
Joint venture partnerships have been in the works since the second quarter of 2016, but efforts have recently been accelerated due to consumer request and a heightened interest from health systems. “North Texas has provided an exceptional proving ground,” said Thom Herrmann CEO of Intuitive Health. “The ability to meet our patients' needs, while maintaining a high level of customer service and providing honest billing, has been the winning combination for us.” The state of Texas is a semi-regulated state, which allows ownership of freestanding emergency departments independent of hospital systems. “The perception that free-standing emergency rooms and urgent care facilities are on every corner is not exactly untrue. However, this incredible rise has also seen a continued sell-off, as consumers continue to understand the costs associated with an emergency department and owners understand the expense of operations,” Herrmann continued. “In comparison, our facilities have seen a consistent level of growth since 2008, regardless of the 500 percent increase in competition. This is a direct result of our hybrid retail care model and relentless pursuit of customer service.”
As expansion continues, Intuitive Health will remain dedicated to the support and operations of their Legacy ER & Urgent Care locations. The executive team will remain in place, with the addition of healthcare leadership veterans to the board of directors and the business development team. “We have an accomplished team of healthcare specialists, advisors and capital partners in place,” Herrmann stated. “We are excited to bring our hybrid retail care and customer service model to quality health systems around the country.”
About Intuitive Health
Intuitive Health partners with health systems nationwide to build, operate and launch hybrid retail healthcare facilities that provide urgent care and emergency services under one roof. Intuitive’s convenient care facilities drive patient acquisition, increase visibility and deliver the high-level customer service patients demand.
About Legacy ER & Urgent Care
Founded in 2008, Legacy ER & Urgent Care is one of the nation’s first healthcare models to offer both urgent care and emergency room treatment options under one roof. By providing transparent billing, a welcoming clinical environment, and one-on-one service with board-certified, emergency-trained physicians, Legacy has built an exceptional customer service program, with industry-leading ratings. The hybrid retail care model gives patients access to immediate care at a full-service, on-site emergency room 24/7 and urgent care center level services from 7A-9P daily, allowing patients to only pay for the level of service needed.