Starbucks locations outnumber urgent-care clinics in Westchester at the moment, but that may not be the case for long. The walk-in medical-care facilities are popping up like morels after a spring rain, with 17 in the County at press time and a dozen more in various stages of development. If some providers have their way, it won’t be long before you can get your scraped knee stitched up anywhere, anytime. Who knows? Maybe even at Starbucks…
That’s either good or bad—or both—depending on whom you ask and what their interest is in the business of medicine. Andrew Sussman, MD, president of MinuteClinic, which operates two walk-in clinics in Westchester CVS Pharmacy locations, says, “Our healthcare system today needs easy access, low cost, and quality care.” CVS has 650 MinuteClinics nationwide and plans to have 1,500 by 2017.
“There are a few positives, but a whole host of negatives,” says Thomas Lee, MD, chairman of the board of St. John’s Riverside Hospital and immediate past president of the Westchester County Medical Society. “You are increasing access and convenience at the price of good care, quality, and outcomes.”
From a different perspective, Scott Hayworth, MD, president and CEO of Mount Kisco Medical Group (MKMG), observes, “For a large, multi-specialty physician group like ours, it just makes sense. It’s an extension of the care we provide.” MKMG, with 300 physicians and 300,000 patients, operates two centers, in Yorktown Heights and Carmel, New York, with one slated to open this fall in Bedford Hills.
Ron Nutovits, MD, chairman of Emergency Medicine at Hudson Valley Hospital Center (HVHC) in Cortlandt Manor, is not a fan of the phenomenon.
“If the urgent-care centers are only going to be picking the paying customer,” he says, “it will contribute to more deficits for hospitals that are already struggling with the new healthcare economy.”
Contributing to (or confusing) the discussion is the variety of service-offerings that fall under the definition of “urgent-care provider.” The designation encompasses retail clinics like those in CVS that provide—at least now—a limited range of services administered by nurse practitioners; doctor-owned clinics sometimes referred to as “doc-in-a-box” offices; and full-service walk-in facilities operated by major group practices like MKMG and WESTMED Medical Group as part of the spectrum of care they provide. Blurring the lines are fast-track units set up by six Westchester hospital emergency rooms, including both Hudson Valley and St. John’s Riverside Hospital. Basically, all aim to serve the patient who can’t see a personal physician for one reason or another, but who doesn’t require (or wants to avoid) intensive, expensive, emergency-room treatment.
From the consumer’s standpoint, the argument probably doesn’t matter. When you’re sick, you want care—now. As Annette Choolfaian, chair of the Department of Health Policy and Management at the New York Medical College School of Health Science and Practices points out, “These things have popped up and been relatively successful because they fill a need that traditional practices and emergency rooms have not filled in the past.”
As the business of urgent care grows, it’s drawing more and more players. Jason Lupow, MD, is one of five board-certified ER doctors who trained and now work together at Montefiore Hospital in the Bronx. “We all moonlight or work extra shifts for the hospital, so we decided to do something for ourselves,” he explains. “We saw urgent care popping up everywhere, especially in Florida and Long Island. They all seem to be doing pretty well.” The group opened MDxpress in Mamaroneck in March and is already thinking about expansion. “The reception has been great. We’re seeing easily 30 patients a day, and we have a lot of repeat visits.”
One of the biggest needs everyone points to is the declining number of primary-care physicians, the traditional go-to guy or gal who takes our temperature, puts that chilly stethoscope on our chest, and cures most of what ails us—pretty much on demand. “It’s very hard to find primary care doctors,” says Hayworth. “Even an organiztion like ours has trouble hiring them.” While exact numbers for Westchester aren’t available, there’s plenty of anecdotal evidence that points to a shortage of independent doctors who practice family medicine, internal medicine, general pediatrics, and OB-GYN. Have you tried to get a same-day doctor’s appointment lately?
Then there’s the problem of physician access. “Just because you have primary-care physicians practicing,” says Jean Moore, director of the Center for Health Workforce Studies at the School of Public Health at SUNY Albany, “it doesn’t mean they are available to everyone in the community. In Westchester, you’re not likely to find geographic shortages, but, for people who don’t have insurance or are on Medicare or Medicaid, some of them don’t have much choice other than to go to the emergency room for their primary care.”
Lee, however, believes it is disingenuous to say that the rise of walk-in care is due to a shortage of primary-care physicians, since physicians staff the urgent-care centers as well: “You’re just shifting them to another location.”
Regardless, consumers really like the convenience of walk-in medicine. Vera Luthra, who manages Urgent Care of Westchester, says the message has been spreading since she and her husband, Jay Luthra, MD, an ER physician in the Bronx, opened their first center nine years ago. They now have eight in the NewYork metro area, including one in Tarrytown, and hope to open two or three more in the very near future. “The most important message is that we are open seven days a week,” she says. “People like the fact that they can just walk in any time.” You can do that at an emergency room, too, she points out, “but the environment [at Urgent Care of Westchester] is much less scary. You won’t see some guy next to you with a gunshot wound.”
Sussman says half of CVS MinuteClinic patients come in on weekends or evenings. In addition, he says, “about half of our patients don’t have a personal physician, so we give them a list of doctors in their area who are accepting new patients.”
Urgent care is usually less expensive care, too, at least as compared to emergency-room services. As Hayworth explains, “Patients like the fact that the copay to go to urgent care is, in many cases, a lot less than for the emergency room.” Obviously, insurance companies also like the lower charges.
How do walk-in-care charges compare with non-emergency-care charges from a doctor’s office? Apples-to-apples comparisons are difficult to make, but a 2009 study by the RAND Corporation and published in the Annals of Internal Medicine looked at 2,100 patients in Minnesota with three common acute conditions (ear infections, soar throats, and urinary tract infections) as they were treated at retail clinics like CVS MinuteClinic versus at doctors’ offices, urgent-care centers, and hospital emergency rooms for the same conditions. It found retail-clinic overall costs were about 30 percent lower than urgent-care and doctors’ offices costs and 80 percent lower than emergency-room costs. What’s more, quality scores were basically identical across the board.
For WESTMED patients, there’s another advantage to urgent-care service, according to Jason Shuker, MD, managing physician for WESTMED’s four ugent-care centers. Co-locating urgent-care facilities with the group practice’s full-service offices, he says, “essentially provides one-stop shopping. It’s somewhere you can go to get all your stuff taken care of in one place.” If you come to them with abdominal pain that turns out to be appendicitis, for example, WESTMED Urgent Care will confirm it by examination, CAT scan, and lab work before contacting a surgeon—which may well be one of theirs. “In that situation, because the surgeon is already aware, the patient can avoid the emergency room completely.” Because WESTMED’s urgent-care clinics are located within their existing facilities, testing and imaging are immediately available and specialists are oftentimes found just a short walk down the hall.
That patient’s treatment will also become part of WESTMED’s electronic medical records system, an important advantage that’s unique to them and MKMG among the local urgent-care providers. Clinics that don’t have that capability typically rely on faxes or even the patients themselves to hand-carry treatment records to their personal doctors. It’s analog procedure in a digital world.
Which is a major problem, according to Robert Amler, MD, dean of the New York Medical College School of Health Science and Practices. “The patient, or customer, is looking at a trade-off,” he says. “They are gaining the immediacy of care but losing the continuity of knowledge about their current medications, past medical history, family and social history, and so forth.” That lack of history cuts both ways. “The doctor or nurse practitioner in the urgent-care facility has to deal with the absence of information that can be extremely important.”
Lee bluntly adds, “There is discontinuity of care. People, many times, don’t pass on information to their physicians or primary-care providers. In a healthcare environment where we’re trying to consolidate and integrate care, this is actually a massive disintegration of the communication chain.”
The effects of urgent care on the business of medicine in Westchester aren’t being felt very strongly—yet. Sole practitioner Michael Fusco, MD, says, “Even though I’m within a couple of miles of urgent-care centers, I’m busier than I ever have been. Generally, the way my office works, I cover my patients, myself, 24 hours a day anyway. But I’m the exception, not the rule.” He says he doesn’t hesitate to send a patient to an emergency room or urgent-care center if they call him and he feels they need immediate assistance that he can’t provide right at that moment.
Westchester hospital emergency rooms are also busier than ever. From 2005 to 2010 (the latest year with available data from the New York State Department of Health), ER visits jumped nearly 25 percent at County hospitals. St. John’s Riverside Hospital Emergency Department currently sees 38,000 patients annually in a space built to serve 25,000, and its volume is continuing to grow at more than 3 percent per year. The new Flanzer Center for Emergencies and Critical Care at White Plains Hospital provides emergency and critical care for more than 48,000 patients annually.
While urgent-care centers may be relieving some of that pressure, it’s probably going to get worse before it gets better when the Affordable Care Act takes full effect next year. As Fusco points out, “The Affordable Care Act is insuring millions of new people, but it doesn’t say who’s going to take care of them.”
Urgent-care providers are hoping to fill that gap, but even they know there’s more to the opportunity than meets the eye. “People without insurance today are reluctant to go to doctors because of the expense. They wait until the last minute,” explains Dan Purugganan, director of operations at Doctors Express, an urgent-care franchise that opened in Hartsdale in 2011 and is actively seeking more locations.
“When they are covered, they will go more often. That will flood the ERs and put even more pressure on primary-care physicians.”
How bad will it be? When the Massachusetts universal-coverage law went into effect, the state experienced a 4-percent rise in ER visits, according to a 2011 study published in the Annals of Emergency Medicine.
But even with universal coverage, there are profitable patients, and then there are unprofitable ones. HVHC’s VP of Finance Mark Webster points out that people who get insurance from the controversial exchanges—a set of government-regulated healthcare plans from which people can purchase health insurance—will probably have high-deductible policies that require substantial out-of-pocket payments for much care. On top of that, the Congressional Budget Office estimates that more than a third of those receiving insurance for the first time will be covered under Medicaid, which reimburses doctors at lower rates than other forms of insurance. A 2011 study by the journal Health Affairs found nearly a third of doctors unwilling to accept new Medicaid patients.
The urgent-care facilities we talked to report that around 90 percent of customers/patients today have insurance and that the rest receive substantial discounts for out-of-pocket payment. No one mentioned the patients who have no means to pay but need care—and who represent as many as 5 percent of the ER patients at Hudson Valley and other hospitals. Several urgent-care providers state clearly on their websites that they don’t accept Medicaid. Hospitals typically don’t have that option.
“It appears that the urgent-care centers are profiteering by taking in patients who are well-insured or can pay and leaving the rest to us,” says William J. Higgins, MD, vice president and director of Medical Affairs for Hudson Valley Hospital Center.
Choolfaian agrees. “The primary people who go to urgent-care clinics are those with insurance or who are able to pay out of pocket,” he says. “The hospitals are left with those who can’t pay. They are skimming the cream from the top.”
“We are here 24 hours a day, seven days a week, 365 days a year to provide care,” says HVHC’s Webster. “For the urgent-care centers, they are there to make a dollar. Patient care is a side benefit.”
To be fair, however, that’s part of the dichotomy of medicine in a free-market economy. “If insurance companies and the government want more primary-care physicians, they have to adjust how they reimburse them,” offers Purugganan of Doctors Express. “As a business person, I feel there needs to be a balance.” What does the future hold? WESTMED’s Shuker says, “We see an expansion of services we can provide to patients on the day of their visit, but, perhaps more important, a more facile way of getting them back to their primary physicians and usual specialists who take great care of them year-round.”
For better, worse, or otherwise, the rapid growth of urgent-care clinics reflects the continual state of flux in the Westchester healthcare industry. Dr. Fusco has practiced medicine for 20 years in Port Chester, taking over from his father, who emigrated from Italy in 1959 and opened the office in 1964. As Fusco says, “The delivery of medicine is multi-faceted. You have to move along with the times.”
Dave Donelson lives in West Harrison and is the author of eight books, including the Dynamic Manager Guides and Handbooks.
