The Urgent-Care Boom
Capital New York
October 29, 2014
By Dan Goldberg
The new urgent care center on Broadway between 102nd and 103rd doesn’t look like a doctor’s office and definitely doesn’t look like a hospital.
With its open floor plan, plush chairs and oddly placed modern art, it looks like a upmarket lobby, in part because the designer has a background in hotels.
The waiting room at Cure Urgent Care is meant to provide a sense of calm, as is the logo out front—a green medical cross with a smile underneath.
“It’s supposed to convey the idea that it’s not supposed to hurt to get better,” said the company’s C.E.O., Jake Deutsch.
The center is open until 10 p.m. on weekdays and 9 p.m. on weekends, far later than the typical physician’s office, because, according to the sign outside, “life doesn’t wait for you to feel better.”
This is the public-facing part of New York’s recent boom in urgent care centers, as they compete for patients who once might have spent hours waiting to be X-rayed in an emergency room, or days for an appointment at a doctor’s office. Most anyone can stitch your finger, so clinics have to offer a little something extra, a certain ambiance, shorter wait times, if they are to change consumer behavior and lure patients away from traditional care.
This is, in many ways, a very positive development—as the centers compete to provide convenience and value, they’re also keeping people out of the emergency room, potentially saving hospitals and patients thousands of dollars on each case, and allowing E.R. personnel to focus on true emergencies.
But the flood of urgent-care entrepreneurs into New York’s wide-open market brings with it a new level of public risk.
The government’s ability to regulate the centers—as opposed to a much more limited number of hospital emergency rooms—isn’t keeping pace with their rapid proliferation, thanks in part to a medical group’s successful effort to beat back legislation in Albany that would have strengthened oversight.
And as this relative lack of regulation facilitates the creation of ever more centers, New York’s emergency-case scheme diverges ever more sharply from one of the primary goals of public health officials, who encourage consolidated care from primary physicians over episodic, drop-in care.
“This is potentially enormously disruptive to the primary care model and the historical ways of seeking care,” said United Hospital Fund director of innovation strategies Greg Burke.
Burke said he believes the new clinics serve a real consumer need. But he added, “If you are talking about the core of health reform being really robust primary care … this is not necessarily supportive of that. This isn’t a medical home. It’s a medical motel. You check in and check out.”
Most experts believe that the multi-billion dollar business still has room to expand, thanks to the undeniable efficiency of the new model.
Clinics can provide an effective place to stitch a wound, or X-ray a bone without the overhead of an Emergency Room, which must also be able to handle births, strokes, ear infections and gunshot wounds. And clinics can be open during nights and weekends, when most physician practices are closed, to care for children with the flu or a sore throat.
For patients, they mean more proximity and shorter wait times, at lower cost for patients with high-deductible plans, steep co-pays or no insurance at all.
“I know what people need,” said Jacob Gerlitz, Director of QualityFirst, which recently opened in Bensonhurst. “This clinic is designed with that in mind.”
The major health systems see an opportunity to expand their brand and reach patients who had been outside their traditional service area in a lower-cost setting, which is both good for the patient and for the health system.
Earlier this month, North Shore-L.I.J. announced plans to open two urgent clinics (Forest Hills and Massapequa) this November, and over the next four or five years plans to open 50 more clinics in New York in partnership with Access Clinical Partners.
N.Y.U. Langone Medical Center has opened dozens of ambulatory centers over the last few years. Mount Sinai and New York Presbyterian are in the game as well.
Meanwhile, pharmacies such as CVS and Walmart are stepping in with “retail clinics,” which offer the chance to diagnose, treat, prescribe and pick-up all in one location. PriceChopper now offers diabetes management.
And then there are the new, unaffiliated urgent clinics such as CityMD, Cure Urgent Care and QualityFirst, that are popping up at a rate New Yorkers usually associate with Starbucks rather than health care.
Their owners see a niche they can fill, at least, for some of them, until they’re bought out by the larger health systems.
“We view ourselves as an E.R. alternative,” Gerlitz said.
CityMD recently opened a new location in Williamsburg, its fourth franchise in Brooklyn. It has nearly three dozen more in Manhattan, Queens, Long Island, Westchester and the Palisades.
It’s hard to say precisely how many clinics there are in New York at the moment because no one, officially, is counting.
Urgent clinics do not need an Article 28 license the way hospitals do. They do not require a “certificate of need” from the health department. They are treated by the state as physician’s practices, which are more loosely regulated.
“New York State does very little regulating of your doctor’s office,” said New York State Assembly health committee chair Richard Gottfried. “Your local restaurant is visited more often by the health department than your local doctor’s office.”
This poses a challenge in terms of what public health officials call “care coordination,” in which the goal is to have one doctor quarterbacking care for a given patient, allowing that doctor to be aware of every encounter the patient has with the medical system, and every prescription, and every complaint.
The clinics mitigate against that model.
“This potentially decreases continuity of care,” said Dave Chokshi, assistant professor of population health and medicine at N.Y.U. “For complications related to chronic diseases that can be a real problem. Often treatment plans evolve and it takes evidence-based experimentation to come to the right set of therapies, and if you don’t have that knowledge, of what’s been tried in the past, even though the care provided may be less expensive on a per-access basis, it may lead to patients seeking more care.”
Most urgent care clinic operators will say that the hypertensive diabetic with a mental health issue is not their market, and that care coordination isn’t important if all a patient has is a sprained ankle. That’s true, but the data on who is using urgent clinics is so sparse that it isn’t clear which patients are using the service for which ailments.
Some clinics have electronic medical records that can help keep track of past experiences, some do not. Some have X-Ray machines, some do not. Patients can’t know what to expect unless they’ve done some research before walking in.
Most everyone assumes that clinics affiliated with L.I.J. or N.Y.U. will be of a certain quality, because it’s in the institutions’ economic interests to guarantee that that’s the case. That’s also true, to an extent, of retail clinics, such as those run by CVS.
There is, necessarily, less certainty when it comes to unaffiliated urgent clinics. They often provide care and prescribe medications which can be, and often are, invisible to the patient’s regular doctor, or other providers from whom the patients are receiving care.
That potential inconsistency from clinic to clinic has led to calls for regulation from both inside the medical profession and out. The idea is to ensure the clinics are connected with other providers so everyone who comes into contact with the patient is aware of past problems, treatments, prescriptions and recommendations.
Health policy experts advocate at least a set of minimum standards so patients know what to expect from these clinics.
“The first step is to develop a sophisticated taxonomy and measure and track what the proliferation of convenient care options looks like,” Chokshi said. “What is the payer mix they accept? Are these convenient care options only for the relatively affluent? There needs to be some bare minimum standards, which don’t exist right now.”
That kind of regulation would be welcome, said Deutsch, the co-founder of Cure Urgent Care.
“A lot of people call themselves urgent care and they’re just practices with extended hours,” said Deutsch. “They don’t have X-rays. They don’t have physicians who can stitch. I think like anything else that expands rapidly. … Once that expansion triggers problems among people and concern from regulators, then standardization is necessary, and I think that’s a good thing.”
Payer mix is also a growing concern, particularly among public officials, who worry that clinics will be a convenient option for the relatively affluent, mostly healthy patients, leaving hospitals, especially public hospitals, to treat the poorest and sickest.
Another issue is location. Urgent clinics, like most health-related business, tend to open in more affluent neighborhoods. CityMD, for example, is well represented on the Upper East and Upper West side, but it offers nothing above 88th Street. It plans to open one clinic in the Bronx—in Riverdale.
The Centers for Disease Control and Prevention reports that higher income is linked to lower rates of several chronic diseases, including obesity. That means clinics are often drawing from a healthier pool, reducing costs and wait times in well-to-do neighborhoods and leaving the emergency room only for those who can’t afford to pay, and, by law, can’t be turned away.
CityMD takes certain health insurance plans, but for those without an accepted insurance plan, the charges start at $125, according to the company’s website.
CVS’ Minute Clinics—there are six in the state—accept several insurance plans as well but also offer an extensive price list on its website. Have acne or ringworm? That will cost between $79 and $99. As of this writing, sports physicals are on sale for $39, according to its website.
The economics of these models encourage a volume-based business—the more patients come in, the more fees for service can be billed—at the very time everyone in public health says we need to move away from volume based care and emphasize value-based care.
Earlier this year, the state’s Public Health and Health Planning Council made extensive recommendations, including standardizing nomenclature for services and public signage to reduce consumer confusion, and preserve continuity of care, particularly with patients’ primary care practices.
The council also recommended that each urgent care site must have an X-ray machine and crash cart supplies and medications, and that its staff must be ACLS (advanced cardiovascular life support) and PALS (pediatric advanced life support) certified.
Their recommendations were included in Governor Andrew Cuomo’s 2014 executive budget but were stripped by the legislature after outcries from the Medical Society of the State of New York, which assailed the “costly and burdensome accreditation requirements.”
“An urgent-care practice is a medical site that is essentially indistinguishable from any other office-based medical practice, staffed by appropriately licensed and credentialed physician,” the medical society, which represents 25,000 physicians, said at the time. “Physicians operating urgent-care practices do so in a safe and effective manner and there have been no demonstrated examples of public-safety risk that justify a need for new mechanisms of oversight.”
During a budget hearing, Elizabeth Dears, senior vice-president and chief legislative counsel for the medical society, told the Assembly that accreditation could cost thousands of dollars, too great a burden for physicians looking to open up a new urgent care center.
“Many urgent care practices are small physician businesses which simply cannot absorb the costs necessary to secure and maintain accreditation,” she said. “In our opinion, market forces should be the deciding factor in whether a physician owned urgent care practice should seek accreditation.”
New York does not allow publicly traded companies to operate medical facilities, but most get around that by setting up a landlord-tenant relationship, meaning a practice simply rents space inside a publicly traded company such as CVS. The governor’s budget would have created a special category called a “limited service clinic.” The law would have allowed corporations to own a facility in a retail location, with a limited scope of allowed services.
MSSNY opposed that as well, arguing “the limited service retail clinic model raises a number of concerns, including the potential conflict of interest posed by pharmacy chain ownership of retail clinics which provides implicit incentives for the nurse practitioner in these settings to write more prescriptions or recommend greater use of over-the-counter products than would otherwise occur.”
“These clinics are usually staffed by nurse practitioners or physician assistants and focus on providing episodic treatment for uncomplicated illnesses such as sore throat, skin infections, bladder infections and flu,” Dears said during her testimony. “Physicians feel strongly that retail-based clinics pose a threat to the quality of patient care and to the ability of physician practices to sustain financially and should not be allowed to propagate in New York.”
That concern is shared by some in the Assembly including Gottfried who worries about the the creeping corporatization of health care.
“This is a major policy question as to whether we want health care to evolve into something you go to CVS or Walmart or the Texaco station to get as opposed to going to a doctor’s office, a clinic or a hospital, and I think we are quite possibly on the verge of heading down a path of Walmart or CVS or any number of big corporations being the deliverers of our care.”
One of Gottfried’s concerns is that the trend could end the traditional primary care practice at the very time when public health officials are claiming the country needs more primary care.
If CVS can handle your checkup, why go to a traditional practice? If the sniffles and sprains can be treated at the urgent clinic, what business is left for the raditional primary care provider?
And if those doctors begin to close shop, are there mechanisms in place to prevent the pharmacies from pressuring doctors, who could be their tenants or their employees, to over-prescribe?
“While Toys R Us could not own a pediatric practice, there is nothing preventing them doing almost the equivalent in New York and renting space to a physician practice that would be financed, managed and largely controlled by Toys R Us,” Gottfried said. “And it would have enormous financial and marketing power that all the other pediatricians in town could not dream of. And if the result is most other pediatricians are put out of business by a Toys R Us clinic, that’s a policy development that New Yorkers certainly have not discussed and has serious consequences. And what I’ve just described is today perfectly legal for Toys R Us or Walmart to do.”