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Urgent care industry grows nationally and in NH, under the shadows of the Affordable Care Act

  • Christina Ericson plays with her son Giovanni and her nephew Andrew Abair while Andrew's mother seeks treatment at the Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.<br/><br/>(SAMANTHA GORESH / Monitor Staff)

    Christina Ericson plays with her son Giovanni and her nephew Andrew Abair while Andrew's mother seeks treatment at the Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.

    (SAMANTHA GORESH / Monitor Staff)

  • Kathy Lemieux watches her great-great-granddaughter Laylin while they wait for Laylin's parents at The Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.<br/><br/>(SAMANTHA GORESH / Monitor Staff)

    Kathy Lemieux watches her great-great-granddaughter Laylin while they wait for Laylin's parents at The Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.

    (SAMANTHA GORESH / Monitor Staff)

  • Nurses Harald Brown (right) and Sandra Pinette look over patient records at the Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.<br/><br/>(SAMANTHA GORESH / Monitor Staff)

    Nurses Harald Brown (right) and Sandra Pinette look over patient records at the Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.

    (SAMANTHA GORESH / Monitor Staff)

  • Christina Ericson plays with her son Giovanni and her nephew Andrew Abair while Andrew's mother seeks treatment at the Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.<br/><br/>(SAMANTHA GORESH / Monitor Staff)
  • Kathy Lemieux watches her great-great-granddaughter Laylin while they wait for Laylin's parents at The Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.<br/><br/>(SAMANTHA GORESH / Monitor Staff)
  • Nurses Harald Brown (right) and Sandra Pinette look over patient records at the Horseshoe Pond Urgent Care Center in Concord; November 30, 2012. New Hampshire is poised for a 20 percent increase in walk-in and urgent care centers in the coming months.<br/><br/>(SAMANTHA GORESH / Monitor Staff)

A woman with one foot in a brace and a crutch to help her around eased up out of her chair and through the door held open by a waiting nurse at Concord Hospital’s walk-in clinic at Horseshoe Pond. Another woman, younger, wore a surgical mask that hid all of her face except her tired eyes as she shuffled out from the exam rooms to talk to her family.

Their widely differing ailments are just two of the many the walk-in clinic saw on Friday. In an average year, the clinic sees about 21,000 patients. The emergency room at the hospital on Pleasant Street treats an additional 40,000 or more, according to hospital data.

A Portsmouth-based venture capital fund is betting it can siphon some of those patients to a new walk-in center, called ConvenientMD, due to open on Loudon Road this spring.

Another new urgent-care center opened yesterday, attached to and run by Lakes Region General Hospital in Laconia.

The urgent-care industry is growing quickly here, but even more so nationally, said Steve Norton, executive director of the New Hampshire Center for Public Policy Studies, a private nonprofit and nonpartisan think tank.

“We are a little bit behind the curve because as a state we have a highly integrated health care system, where a lot of doctors’ offices have been bought by the hospitals,” Norton said. “There are other parts of the country where you’ve seen more intensive competition, but the difference is only in a matter of degree.”

There are a number of reasons the urgent-care clinic industry is growing, but experts agreed that the largest is patients’ inability to get care from a family physician, whether because they don’t have insurance or can’t wait for an appointment. National surveys estimate there are thousands fewer primary care physicians available than currently needed.

Where experts disagree is what effects urgent-care centers could have on hospitals near them, and how they’ll be affected by the federal Affordable Care Act and its mandate that every person in the country carry medical insurance.

Giving more people insurance and access to the preventive care found at doctors’ offices without adding doctors could make it even harder for people to get appointments when they’re sick or injured, some said. Others said that eventually, the federal law will make primary care, typically a lower-paying specialty, more attractive for medical school graduates, and reduce the need for urgent-care centers.

Gareth Dicken, president of ConvenientMD, sees long-term growth potential for the urgent-care industry. The company’s first urgent care location is due to open in Windham on Wednesday.

“Basically, if more people are covered, whether it’s through a private health plan or a universal plan, that just means there’s going to be more demand, and a greater burden on the health care system overall,” he said.

“We can’t have more people going to emergency rooms. They are already busy, and they are very expensive. Lower-cost alternatives have to be sought.”

Urgent-care facilities offer lower-cost treatment because they don’t have many of the fixed costs that hospitals often do: large staffs, multiple operating rooms, specialty departments and more. The private clinics can also refuse treatment to customers who don’t have insurance, which nonprofit hospitals can’t.

The broadest definition of urgent care, as defined by the Urgent Care Association of America, is health care provided on a walk-in, no-appointment basis for acute illness or injury that is not life- or limb-threatening, and is either beyond the scope or availability of the typical primary care practice or retail clinic. As of September 2011, there were approximately 9,000 facilities in the United States that meet this definition.

Under New Hampshire law, walk-in care centers are facilities where a person can walk in off the street without an appointment and without having an established relationship with the provider, and without intent to establish one. There are 20 centers currently licensed, with at least four more working toward opening, according to John Martin, manager of the licensing division of the Department of Health and Human Services.

To get a state license, the centers have to pass two inspections each year, and have at least one licensed practitioner on site while they’re open. Licensed practitioners include medical doctors, physicians’ assistants, advanced practice registered nurses (APRN), doctors of osteopathy and doctors of natural medicine.

The medical director for urgent-care facilities, who can oversee multiple sites, must be a physician or an APRN.

Clinics within the walls of retail stores like Walmart or CVS, often called “minute clinics” or “a doc in a box” by industry insiders, fall under the same state regulations. None of those have applied for licenses, but Martin said he’s “heard through the grapevine” that some are interested.

Neither urgent-care clinics or retail clinics are subject to review by the state’s Certificate of Need legislation, usually because the investment required to open one doesn’t reach the financial threshold limiting the board’s jurisdiction. The threshold, which is set in statute and revised through a formula including inflation, is currently $1.98 million. ConvenientMD estimated its facility in Concord will require an investment of about $980,000, according to the company’s only filing with the Certificate of Need board.

The growth of facilities outside the board’s jurisdiction, and continuing conversations about whether to keep the board at all, “raise the question of if we have a responsibility to manage the cost, quality and access of health care, then what does that regulatory system look like?” said Norton.

“The over-arching problem is we don’t yet have a good sense of how we are balancing the trade-offs. We have no way of saying, how much of an impact does this have if we have 10 new ambulatory care centers. Do they lower costs? Do they erode hospitals’ ability to provide access to uncompensated care?”

Concord Hospital CEO Mike Green said that’s not keeping him up at night.

“I worry a little bit whether it is going to be an issue of lack of continuity if their primary care provider is not going to be informed of the care they are receiving, if their primary care doctor is in the hospital system and they go elsewhere. . . . It could have a financial impact on the hospital, but given the scale, I don’t think the impact will be material,” he said. “If it is, we would find a way to compete even more aggressively.”

The new center in Laconia is part of the hospital, located in a bright yellow hallway just off the main lobby. The hospital spent less than $100,000 of general budget funds to renovate a former lab space into five exam rooms, where they expect patients to be seen and able to leave within an hour of arriving. Waiting time in the emergency room, where 32,000 people visit each year, could often be multiple hours, they said.

Patients with unclear symptoms, like abdominal pains, that could require a complicated exam, will be referred back to the emergency room, said Deb Livernois, the director of emergency services.

But mostly, “we hope to see this decompress our emergency room, which will increase access there to more people,” said Ellen Wolff, chief nursing officer and senior vice president for patient care at LRGH.

Primary care doctors in the hospital’s system will be able to access records of care their patients receive at the clinic, Livernois said.

Coordinating with the primary care system may help an urgent-care center stay open and attractive for patients beyond the full health care reform implementation in 2014, said Ned Helms of the Institute for Health Policy at UNH.

Stand-alone, for-profit urgent-care clinics are “band-aids that I think in time will yield to a fundamental restructuring,” he said. “They’re historical artifacts of a system out of a balance.”

People use emergency rooms, and will use urgent care facilities, because they lack access to traditional primary care. The primary care physician shortage, however, could start to reverse as federal reimbursements for preventive care and primary care increase under the health reform law.

“A lot of the fundamental inadequacies of our system, the high expense and lack of access, are going to be solved collaboratively,” he said. “It’s going to take some time, but the good news is we won’t be simply working on short-term expedience, we’ll be looking at long term. And long term, you don’t want to base a system on people using emergency care. You want them to have a primary care doctor.”

Dickens, president of the ConvenientMD group, said even in light of the presidential election ensuring the future of the Affordable Care Act, his company is looking for more locations in New Hampshire and southern Maine.

(Sarah Palermo can be reached at 369-3322 or spalermo@cmonitor.com or on Twitter @SPalermoNews.)

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