IDNs get serious about urgent care
Integrated health systems are in a unique position to capitalize on the opportunities in the urgent care market…if they can recognize them, says Ulana Bilynsky, assistant vice president, MedStar Ambulatory Development. Bilynsky made her comments at the recent National Urgent Care Convention in Chicago, sponsored by the Urgent Care Association of America.
MedStar – which owns 10 hospitals in the DC-Baltimore area – is serious about ambulatory care, explained Bilynsky. Since 2007, the IDN has increased the number of physician office locations it owns from 36 to 155, and physical therapy sites from 31 to 48. The IDN employs about 1,500 physicians and has an insurance product for its employees.
Urgent care is a key ingredient of MedStar’s ambulatory care plan, she said. Eight years ago, the IDN didn’t have any urgent care centers. Today it has 10 MedStar PromptCare locations, with plans to open four more in the coming year. One of those centers is a freestanding building, while others are located in strip malls or retail spaces. Typically, each is between 3,500 and 4,000 square feet, with six or seven exam rooms.
“What does it mean to be an urgent care center in an IDN?” asked Bilynsky. “Sometimes it’s an obligation, and that may create challenges from an urgent care business perspective. But often, it’s about identifying opportunities, and focusing on the opportunities that come with being part of a much larger health system. Freestanding urgent care centers don’t have some of the luxuries that we as a large system can bring to the table.” Flexibility, staffing and referrals are just a few.
For example, a couple of MedStar PromptCare sites have excess space, which the IDN makes available to some of its orthopedists, cardiologists, sports medicine specialists and others whom the IDN employs. One ambulatory care center – in Federal Hills – encompasses 25,000 square feet, enough for PromptCare urgent care, a primary care practice, physical therapy, a cardiology practice, and a women’s practice, with space left over for “session time” from various specialists.
“We look for situations that make sense from a referral standpoint,” said Bilynsky. Orthopedists are happy to carry on their practice at least part-time in the PromptCare facilities, because many of the patients who visit the facilities have some kind of injury, and can be referred to the orthopedist for followup treatment. Conversely, the orthopedists and other specialists appreciate that MedStar has an urgent care center that can treat their patients when the specialists’ offices are closed.
MedStar tries to group its sites in a compact geographic area, so they can share staff and other resources when necessary, said Bilynsky. With PromptCare facilities nearby, MedStar’s primary care physicians are relieved of the pressure to maintain late-evening and weekend hours, she added.
Another advantage of being IDN-owned is the fact that MedStar’s PromptCare locations use the same electronic medical record system as its employed physician practices (both primary care and specialty), said Bilynsky. “So, when the patient comes in to PromptCare, and they happen to be a patient of one of our physicians, the doctor in the urgent care center has information about the patient in front of them.” They have the ability to “see” more than they would without that historical information.
What’s more, the PromptCare sites acquire medical supplies and equipment through the IDN’s corporate supply chain division.
Unique opportunities
“We’re in a competitive market,” said Bilynsky. That makes site selection very important.
MedStar considers several factors when selecting urgent care sites. Which competitors, if any, are in the area? What are the key demographics? Is the site a strategic fit with the IDN? Do people in the area recognize the MedStar name? If MedStar were to open a PromptCare site in that location, would it serve the needs of MedStar’s own employees who may need urgent care?
Once it selects a location for a PromptCare site, MedStar can take advantage of unique opportunities, including:
- Sports medicine. The urgent care centers offer many opportunities for MedStar’s sports medicine primary care physicians.
- Healthcare screenings for the community.
- Pre-employment screening and vaccination programs for MedStar employees.
- Occupational medicine.
- MedStar is considering giving physicians in some of the urgent care sites the opportunity to conduct virtual visits with patients.
As an integrated health system that employs many physicians, MedStar has a definite advantage over independent urgent care centers when it comes to recruiting physicians. For example, it can offer young physicians a career path. “We can offer them more flexibility to pursue things that might be of interest to them,” said Bilynsky.
“It’s important as a network to look at the things that you have that your competitors don’t, and then capitalize on them,” she said.
Urgent care’s niche between primary care and the ED
Why are patients increasingly turning to urgent care centers? With high-deductible plans proliferating, people want access to affordable care. They want clarity on pricing. They want proximity and immediate availability of care, tailored services and, of course, quality. Meanwhile, emergency departments are expensive and inconvenient.
In Boston, for example, patients can wait up to 65 days to see their primary care doctor, explained Evan Berg, M.D., associate medical director, urgent care, Newton-Wellesley Hospital, Waltham, Mass., speaking at the recent National Urgent Care Convention in Chicago, sponsored by the Urgent Care Association of America.
For all these reasons, IDNs – including Newton-Wellesley Hospital – are anxious to open urgent care centers. The IDN operates an urgent care center on the first floor of a satellite campus in Waltham. It is one of four urgent care centers operated by Partners HealthCare, of which Newton-Wellesley is a part.
To more rapidly expand their presence in the urgent care market, in December 2014, Partners and MedSpring Urgent Care formed a joint venture – Partners Urgent Care – with the goal being to roll out a dozen or more facilities in eastern Massachusetts.
The opportunity
The nine-bed unit in Waltham has a staff of front-end personnel (registration, greeting); and back-end personnel, including physicians board-certified in emergency medicine, family medicine and internal medicine, nurses (RNs and LPNs), and medical assistants. The center occupies the bulk of space of the “Waltham campus” of Newton-Wellesley Hospital, approximately three miles from the main campus, Berg explains. Included in this space is X-ray, ultrasound, phlebotomy, a family medicine practice and rotating OB/GYN practices. “We routinely utilize X-ray and ultrasound services during our operating hours, but those services are also available – as is the lab draw/phlebotomy station – for primary care providers and/or specialists in need of outpatient studies.”
The competition in eastern Massachusetts is substantial, said Berg. But so are the opportunities. “There’s a huge opportunity in the market for consumer-directed services,” he said. “Consumer-directed” involves more than convenience and affordability, however.
“People are seeking more meaningful interactions” with healthcare providers, said Berg, who is certified in emergency medicine. Retail clinics can’t provide it. Neither, in most cases, can the emergency department. An extra 15 or 20 minutes with a patient can make the difference, he said, and urgent care centers can deliver it.
It’s true that independent operators of urgent care centers enjoy some advantages over IDN-owned facilities, he said. For example, they tend to have ideal locations and more robust social media and digital marketing programs. In many respects, they tend to be more nimble organizations.
However, when compared to IDN-owned sites, independent centers and retail clinics typically suffer from lean staffing, a narrow scope of service, an inconsistent specialty referral network, inconsistent followup with primary care physicians, disjointed electronic medical records systems, and an absence of a hospital-based credentialing process. Meanwhile, the IDN or hospital that owns and operates an urgent care center benefits by limiting “leakage,” that is, the loss of patients and potential patients to other hospitals, retail clinics or independent urgent care centers.
Spreading the word
Since opening the Waltham urgent care center, Newton-Wellesley has taken care to enlist the support of the hospital’s primary care physicians, said Berg. Initially, some physicians were threatened that the urgent care center would take away patients and income. Berg met with all the primary care doctors to explain the mission of the center. “It has been well-received, because the primary care physicians see they can offload their weekend and evening schedule to us,” he said. “They can spend more time with more challenging, complex patients,” potentially keeping them out of the ED. What’s more, the primary care doctors benefit from the referrals from the Newton-Wellesley Urgent Care Center, as many patients who visit the center lack a primary care doctor.
Likewise, Berg and the urgent care team have met with the hospital’s specialists, who also have come to embrace the urgent care concept. “They are the first ones who said, ‘I don’t want to do I&Ds in my office; I’d rather be in the OR,’” he said.
The urgent care team has ventured into the community, attending community events, such as expos, races and wellness fairs, and visiting local employers. The many colleges in eastern Massachusetts also represent opportunity, as many college students lack a primary care physician, and are at a loss as to who to see when they sustain an injury. Consequently, the Newton-Wellesley urgent care team has formed solid relationships with college health centers and athletic departments.
The urgent care team is also ramping up its marketing efforts, expanding into local TV and social media.
Population health management
Most important for the future, urgent care centers can play a valuable role in population health management, said Berg. That’s particularly true as governmental and commercial payers continue to make the transition to reimbursing for value instead of volume.
Population health management means delivering “the right care at the right place at the right time at the right price,” he said.
“I am an emergency physician, but the ED isn’t always the right place for treatment. The ED is the ideal location for higher-acuity, more complex, critically ill patients – including med/surg and mental health issues – given its staffing mix and necessary resources. However, for lower-acuity conditions not in need of emergent testing, a qualified urgent care venue, where the physician is not being pulled towards the higher-acuity, more critically ill and more complex patients, is a setting where the provider can spend the extra time at the bedside doing an assessment and addressing any concerns/questions, thereby potentially limiting testing that might otherwise occur if you didn’t have the benefit of time and order.”
IDN vs. independent center: Who’s got the upper hand?
In many markets, hospital systems and independent urgent care operators compete fiercely for market share. But increasingly, the two are making the decision to approach the market in tandem, in the form of partnerships and joint ventures. Why? And who’s got more to gain? More to lose?
A panel of experts tackled the topic at the recent National Urgent Care Convention in Chicago, sponsored by the Urgent Care Association of America.
Why partner with a hospital?
Independent urgent care companies see two reasons for partnering with hospitals: growth and opportunity, said Jeff Ward, chairman of AppleCare Immediate Care, Brunswick, Ga. The independent operator may lack the name recognition of the hospital system, he said. Tapping into that recognition “is a great way to bring patients to your door.” What’s more, through its strong negotiating power, the hospital may enjoy more favorable reimbursement from commercial payers than the independent operator. And as hospitals form so-called “narrow networks,” the independent operator may find it difficult or impossible to capture market share on its own.
Ward is also the CEO of Tristan Medical, Raynham, Mass., which operates primary and urgent care centers. While Tristan is not currently active in a hospital joint venture, that approach is highly likely to be part of its future strategy, he said.
Tom Charland, founder and CEO, Merchant Medicine, Shoreview, Minn., pointed out that private-equity-backed urgent care operators who lack a familiar brand in a market may seek a partnership with a local hospital or hospital system in a order to “shorten the runway” to gaining a foothold with the local population. The independent operator can also benefit from the hospital’s long-standing marketing efforts in its community, and in so doing, direct some dollars that would have been invested in marketing to other endeavors, such as opening new centers.
What’s in it for the hospital?
But the benefits go both ways, according to the panelists. Hospitals are feeling a need to get into urgent care, and partnering with an independent operator may be the best way to do so.
“Low-acuity mass-market has all of a sudden become very strategic for hospital systems,” said Charland. Already, an estimated 25 to 30 percent of the nation’s hospitals operate at least one center, many driven by a sense of threat. Perhaps an independent urgent care operator, a competing hospital system or a private-equity-backed urgent care operator has entered the market. If a patient visits a competitor’s urgent care center, that patient may seek follow-up, “downstream” care from a competing practice or hospital, noted Charland. That “leakage” can lead to market share erosion.
Charland pointed to Optum’s recent decision to acquire MedExpress as a prime example of the threat facing hospitals wishing to capture a share of the urgent care market. MedExpress currently operates 141 full-service neighborhood medical centers in 11 states, and plans to accelerate its expansion by opening 25 to 30 additional centers in 2015 in states in which it currently operates as well as additional states. MedExpress centers are open 12 hours per day, seven days a week.
The competitive threat may explain IDNs’ desire to get into urgent care. But what about partnering with an independent operator?
Hospitals and hospital systems usually form joint ventures and partnerships because they want to – need to – move quickly, said Charland. “If they are capable of doing it on their own, and can have 100 percent equity, they should do that. But the truth of the matter is, they are not always capable of competing at the level of a nimble, private-equity-backed urgent care operator. Even with the best consultants on earth, a lot of hospital systems lack the depth or skill or people to move quickly. Therefore, they look at a joint venture.”
It’s a typical outsourcing decision, added Ward. “People are always looking to outsource what they aren’t expert at.” Operating an urgent care center may be simpler than operating an acute-care hospital, but the fact is, hospitals aren’t used to it. That’s why they seek help from independent operators. What’s more, in some markets (such as Savannah, Ga., where AppleCare has a presence), busy EDs are losing commercial patients to urgent care, as patients are increasingly unwilling to face the long wait times and expense of the typical emergency department. “So it’s catchment and control of the patient, and the desire to grow quickly,” he said.
One potential sticking point in partnerships between IDNs and independent urgent care operators? A lack of understanding and tolerance of each other’s cultures, according to panelists.
Hospital systems seek partnerships with competent urgent-care operators, who have an established track record, said Charland. Many non-hospital healthcare providers view hospitals, as large, clumsy, bureaucratic and slow to act. That attitude can negatively impact any potential partnership. “It would be nice if that operator understood the dynamics and complexity of the hospital system,” he said.
Even so, added Ward, “You have to strike a balance between understanding where [the hospital] is coming from, but not getting sucked up in it to a point where you lose sight of why you were engaged in the first place – which was to operate the center as the urgent care expert.”