Curbside Consult with Dr. Jayne 8/22/22

In many ways, I’m still recovering from the years I spent as an in-person urgent care physician, especially during the COVID pandemic. The organization where I spent a good chunk of my career was a well-run practice when I joined, but a series of events led to an ongoing downward spiral that resulted in tremendous staff turnover and contributed at least in part to loss of more than one life.

An event that finally convinced me to leave was the acquisition of the organization by a private equity firm and the subsequent chaos that change introduced. My former partners and the PE firm are still suing each other years later and the practice is in shambles. Staff members who were relocated to other states to grow the business by developing new locations were stranded when those sites were put on pause.

I was gratified to learn that there is an organization that keeps an eye on these things. The Private Equity Stakeholder Project (PESP) released a recent report that looks at the impacts of PE firms acquiring urgent care facilities. To be honest, private equity is everywhere in frontline healthcare delivery these days. Ambulatory surgery centers, dermatology practices, OB/GYN practices, and ophthalmology practices are big targets due to their revenue streams.

The PESP issue brief notes how urgent care centers benefit from a lax regulatory environment that allows them to escape the level of scrutiny that is paid to hospitals and other healthcare providers. Only 10 states require facility licenses for urgent care clinics, while in the rest, they operate under an individual physician’s license or a hospital’s license. Not surprisingly, private equity was involved in approximately 50% of all urgent care transactions from 2012 to 2020.

Additionally, the report notes that recent surprise medical billing regulations may provide loopholes for urgent care centers that will negatively impact patients. It’s no surprise that patients are drawn to urgent care centers, which can treat a variety of non-life-threatening conditions more quickly and economically than the emergency department. The brief notes that as of 2019, it was estimated by the Urgent Care Association that urgent care visits counted for 23% of primary care visits and 12% of all ambulatory physician visits. That’s a significant amount of primary care that is potentially being delivered in environments that don’t have the same supports in place as a traditional primary care practice, or by those who are not actually trained in delivery of high-quality primary care. I’ve used several EHRs that are specifically marketed to urgent care practices and those systems lack the content that is needed to manage chronic conditions or to ensure that preventive care is being delivered.

It goes on to note the tactics used by PE firms to improve cash flow, including adding service lines, reduced staffing, expanding the use of unlicensed staff, and pushing unnecessary high-dollar procedures. I’ve had a front-row seat to all of these, and unfortunately, it’s often reinforced by patient perceptions of technology and its role in good care. For example, patients often place more value in a CT scan than they do in a physician’s clinical skill. They specifically ask for laboratory testing and x-rays when they’re not clinically indicated, and physicians who don’t order the studies anyway are often penalized with poor reviews. Technology has become a proxy for experience and skill. That approach not only raises costs, but can lead to worse outcomes when there are slightly abnormal incidental findings on the tests that weren’t needed in the first place, which in turn leads to more testing, patient anxiety, and costs.

Prescription medications and polypharmacy are also part of the equation, especially when clinics are running their own pharmacies and dispensing medications on a cash basis. One urgent care I consulted for actually maintained a metric on their providers, scoring them on how many prescriptions they issued per visit. Leadership dinged them if they sent scripts to an outside pharmacy where patients could use their insurance. This was all supported through elaborate “talk tracks” that the staff was forced to memorize and use.

The process went like this. First, all prescriptions were filled in-house without asking the patient their preference. When the clinical associate went into the room to discharge the patient, they carried the medications with them and walked the patient to the checkout counter with no mention of the fact that the prescriptions had been filled on a cash-pay basis. When the patient arrived at the checkout counter, they were asked to “please sign here to indicate you received your medications” without explanation that the sheet was approval to charge for the medications.

If the patient complained, the checkout team had a speech about “filling the medications here as a convenience” without mentioning that some of the commonly used generics were more than four times more expensive than pharmacies charge cash-paying patients. When you have providers giving four or five questionably-indicated medications per urgent care visit, that really adds up.

If patients still balked, there was a speech about how important it was for patients to be compliant with all the provider’s treatment recommendations, and that failing to do so could place their health at risk. While that’s  generally a true statement, using it to coerce patients into purchasing prescription versions of medications they can buy over the counter or might already have at home is quite a stretch. There were a couple of additional talk tracks that staff could use at that point. 

If the patient still refused, the staff would take the medications and the billing sheet and walk them back to the clinical area to try to find a provider who could send the prescriptions to the pharmacy. The practice refused to install the capabilities needed to legally prescribe controlled substances electronically, so  those had to be manually printed and signed. Patients who had been to the practice before and knew the game and knew their insurance coverage or how to get the cheapest medications in town were savvy enough to tell the provider to preemptively send the prescriptions to the pharmacy versus going through the whole in-house pharmacy charade.

There are times where having a prescription filled in-house is worth an upcharge for convenience. A couple of those situations might include treatment of an infection requiring antibiotics that is diagnosed at 7 p.m. when many pharmacies are closed, or filling a prescription for a harried parent with four children in tow who doesn’t want to deal with lines or delays at a short-staffed pharmacy. Still, it should be the patient’s choice, and for many of us, ethics dictates that they should understand their options before choosing. That takes more of someone’s time at the bedside, whether it’s a licensed individual or a clinical associate, and practices simply aren’t willing to expend those resources.

I’m not sure what the answer is, but the continued growth of for-profit care delivery organizations is only going to fuel more sticky situations. Patients will continue to be left holding the bag, and clinical care will continue to be diminished in the name of profits.

I’m interested in what readers think about this situation. As a patient, how do you feel about being treated by for-profit entities? Are there any advantages? Leave a comment or email me.

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