Sense of Urgency
Edition: January 2013 - Vol 21 Number 01
Physicians can get frustrated competing for scarce resources in hospitals. For 20 years, emergency-room physicians Mark Melrose and Neal Shipley dealt with that frustration while working in Manhattan. “We saw that in many ways, because of the competition for resources, we were unable to provide timely and quality – in a customer-service-sense – service to patients in the hospital,” says Melrose. What’s more, they saw a tremendous need to provide services to patients who needed immediate attention, though not ill enough or injured enough to go to a hospital emergency room. Such patients might be suffering from a broken bone or laceration, an allergic reaction, a urinary tract infection; or they might need preventive work, such as blood work, vaccinations, a pre-employment physical or CLIA-waived lab testing.
“We saw an opportunity,” he says. “We saw we could work in a better professional setting and provide emergency or immediate care when people needed it. So there was a huge customer service element.”
Manhattan lacked such a facility, partly because of the exorbitant cost of real estate. Then the market collapsed a few years ago, and with it, the real estate market. “Rents came down and made it an affordable enterprise,” says Melrose. So, he and Shipley pooled their money, got a Small-Business-Administration-guaranteed loan, and, in November 2010, opened Urgent Care Manhattan on the Upper West Side. And they couldn’t be happier.
“We’re the bosses of our own business,” says Melrose. “There’s no longer any hospital hierarchy and administration to attend to.
Only patients are customers
In the hospital, everyone is your customer; now, only our patients are our customers,” he says. “We have as many resources as we need to take care of patients the way we want to take care of them. We can be much more dedicated to providing great medical care and customer service. It’s enormously satisfying.”
Urgent care began in the late 1970s, says Laurie Stoimenoff, interim executive director of the Urgent Care Association of America (UCAOA). Growth was slow in the ’70s and ’80s, but the concept of seeing a “doc in a box” gradually gained popularity. “Over the next 20 years, the industry continued to expand and to gain respect as a viable place to receive healthcare when one could not get into one’s ‘regular’ physician,’” she says.
Growth slowed down in the late 1990s and early 2000s, according to Kaiser Health News. But it has picked up since then.
Today, approximately 9,000 centers provide urgent care services, says Stoimenoff. And the industry is growing by almost 500 centers each year.
The slowdown of the ’90s and early 2000s was driven by changes in insurance reimbursement, according to Stoimenoff. Payers failed to recognize the urgent care operating model, and hence, only offered providers primary-care contracts. “But evening and weekend operating hours, retail-accessible locations, marketing/advertising, and volume fluctuations of a walk-in model mean that urgent care has higher operating costs than conventional primary care practices with scheduled appointments,” she says. “Today, insurance payers realize the benefits of members having a place to go and the savings realized as an alternative to the emergency room for their immediate healthcare issues, and they are now offering urgent care contracts that cover these increased operating costs.”
Over the past five years, growth has accelerated, as consumers experience an increasingly difficult time gaining access to primary care providers, and wait times in emergency rooms have climbed. These developments have caused the private equity community to invest in the growing sector, says Stoimenoff.
Hospitals are showing more interest in opening urgent care centers of their own. A 2010 survey of UCAOA members shows that approximately 28 percent are hospital-owned, as opposed to 25 percent in 2008.
Hospitals have multiple reasons to invest in urgent care, says Stoimenoff. Urgent care centers can alleviate overcrowding in the emergency room by moving lower-acuity cases to a more appropriate setting. In addition, such centers can enable the hospital to expand its service area to new communities without the cost and timeline of building a new facility.
Hospitals can use urgent care centers to capture new patients and drive business to their imaging, laboratory, physical therapy and ambulatory surgery centers, she adds. “Downstream revenue generated to a hospital system is often a multiple of the profitability of the urgent care center as a freestanding entity.”
There’s one more reason a hospital might want to open an urgent care center, she says. Such centers provide practice opportunities and equity participation for the hospital’s affiliated primary care or emergency medicine physicians.
What do they do?
The typical urgent care center is staffed with physicians trained in either emergency medicine or primary care. That said, urgent care targets sick and injured workers and consumers, but should not be confused with the care provided by trauma centers, when injury threatens life or limb, says Stoimenoff.
Urgent care centers typically have X-rays, perform CLIA-waived lab tests, and have a procedure room for casting, suturing, wound debridement, abscess drainage, foreign body removal, and other minor medical procedures. They also typically have an automated external defibrillator for resuscitation of people with cardiac arrest, although once stabilized, such patients are transferred by ambulance to a hospital emergency room.
Urgent care centers are self-limiting in terms of the acuity of their patient’s illnesses or injuries, says Melrose. “No urgent care centers accept ambulances. To get here, you have to be largely able to walk, maneuver on crutches or get to our door so we can scoop you up in a wheelchair.
“For the most part, the people who come here are unsure of what’s wrong with them. If we have to send them off to the hospital – which we do a couple of times a week – it’s because they [misdiagnosed themselves]. What they thought was abdominal pain was really appendicitis; what they thought was a urinary infection was a kidney infection that needed to be treated in the hospital; what they thought was indigestion was a heart attack.”
Word to suppliers
The outlook for urgent care centers is strong, says Melrose. Due to healthcare reform, “there may well be as many as 40 million people who didn’t have access to care, who over the next five years will get insurance. That’s a great opportunity for every healthcare entity.”
And as the squeeze on primary care continues, urgent care centers offer patients some options. Still, questions remain. “We provide people with easy and convenient access to care,” says Melrose. “Even for those who are fortunate enough to have primary care doctors, it’s not so easy to get an appointment when you need one. The acceleration in proliferation of urgent care practices around the country will continue to be the case for years to come. The challenge will be, where do we get the doctors to staff them?”
Repertoire readers should note that urgent care operators are looking for practical advice, says Stoimenoff. “Don’t sell ‘products,’ but rather, sell ‘solutions to problems.’ Demonstrate to the urgent care operator how products/equipment will generate revenue, improve patient flow, reduce costs, improve medical outcomes, reduce medical risk, or meet some other clinical or business need. This requires a solid understanding of the urgent care operating model and research into the client’s specific business.”
Says Melrose, “As a business entity philosophy, we’re happy to talk to anybody or anyone in a professional capacity who may be helpful to us. When the question is, ‘Can you meet with me?’ our answer is ‘Yes, because we don’t know what opportunity you can provide us.’
“Our rep, no matter who they represent, has to provide us with timely service and quick turnaround time of whatever it is we are requesting. Pretty much, we want them to treat us the same way we treat our patients, so we can serve our patients’ needs.”
Urgent care setup: Med/surg items
• Cast cutter
• Cast spreader
• Dermal curette
• Dermal punch
• Dispenser, ear speculum
• Forceps, alligator
• Forceps, bayonet
• Forceps, biopsy
• Forcep, splinter
• Forcep, nail splitter
• Forceps, tenaculum
• IUD extractor
• Laryngoscope, handle, blade, light source
• Laryngeal mirror
• Nasal specula
• Oto/opthal scope
• Oxygen regulators
• Peak flow meter
• Ring cutter
• Scissors, bandage
• Shears, utility
• Sponge forceps
• Vaginal speculum (multiple sizes w/illumination system)
• Valve mask (resuscitator), adult
• Valve mask (resuscitator), pediatric
Source: Urgent Care Association of America, www.ucaoa.org
What do urgent care centers do?
For pediatric and adult patients, Urgent Care Manhattan on New York’s Upper West Side provides care for common illnesses and injuries, X-rays, wound repair, and a variety of minor emergencies. Following is a list of services provided, as listed on the facility’s website.
• Allergies and allergic reactions.
• Back problems.
• Colds and flu.
• Ear aches/infections.
• Gastroenteritis or stomach ailments.
• Gynecological emergencies.
• Headaches/head injuries.
• Pink eye.
• Rashes, poison ivy.
• Respiratory infections.
• Seasonal allergies.
• Skin infections/problems.
• Sore throats.
• Urinary tract infections.
• Abrasions, cuts, bruises.
• Broken bones, fractures.
• Lacerations, suturing or stitches.
• Lyme disease, tick bites.
• All blood/lab analysis.
• Cholesterol screening.
• Diabetes screening.
• Vaccinations – flu shots, tetanus shots, etc.
• Alcohol and drug testing.
• Pre-employment physicals.
• School/summer camp physicals.
• Rapid strep, flu, mono testing.
• HIV and STD testing.
Source: Urgent Care Manhattan, www.urgentcaremanhattan.com