As urgent care centers expand, small hospitals feel the pinch

  • Michele Winham, of Plainfield, N.H., takes a few deep breathes for Kaitlyn Jennings, a certified physician assistant at ClearChoiceMD urgent care center in Lebanon, N.H., on Wednesday, Dec. 18, 2019. Winham was at the center because of a persistent cough. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Chris Ramos, of Gaithersburg, Md., and Janet Wong, of Lebanon, N.H., spend time in the waiting room at ClearChoiceMD urgent care center in Lebanon, on Friday, Dec. 20, 2019. Ramos was in the area visiting for the holidays, and he was waiting to see a clinician. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • After cutting his hand on a piece of sheet metal, Jack Molloy, of Grantham, N.H., is helped by friend Baleigh Clark, of Lebanon, N.H., with filling out his paperwork at ClearChoiceMD urgent care center in Lebanon. Molloy is left-handed. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Mike Wilds, an advanced emergency medical technician at the ClearChoiceMD urgent care center in Lebanon, N.H., retrieves paperwork from Sandy Tisdale, of Hartford, Vt., during her visit on Friday, Dec. 20, 2019. Tisdale, a retired nurse, was having problems with her throat. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Jonathan Snow, left, and Kaitlyn Jennings, both certified physician’s assistants, with Mike Wilds an advanced emergency medical technician have a discussion at ClearChoiceMD urgent care center in Lebanon, N.H., on Friday, Dec. 20, 2019. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

Valley News Staff Writer
Published: 12/28/2019 10:49:45 PM
Modified: 12/28/2019 10:49:33 PM

LEBANON — Michele Winham decided it was time to see a doctor after she noticed the mucus resulting from a persistent cough had changed its hue.

The 49-year-old Winham, who moved to Plainfield from Maui this fall when her husband took a job at Kimball Union Academy, has not yet found a primary care doctor in the area, but called Dartmouth-Hitchcock Medical Center on Wednesday hoping they might have her records on file from her daughter’s birth there two decades ago.

Unfortunately, they did not — and she learned her options for being seen quickly for her respiratory problem were to wait to be seen in the emergency department, go to walk-in evening hours in D-H’s primary care or make a trip to the ClearChoiceMD urgent care center on Route 4 in Lebanon.

“I didn’t want to put it off,” she said, nor did she think her condition was serious enough for a trip to the emergency room.

So Winham walked in the door of ClearChoiceMD, which is in a shopping plaza along the Miracle Mile, mid-morning on Wednesday. She got in within minutes of her arrival, and after a paramedic took her vitals, she saw Kaitlyn Jennings, a certified physician’s assistant. After examining Winham and listening to her lungs, Jennings recommended a breathing treatment with a medication called albuterol, which a paramedic then brought into the exam room for Winham to inhale through a tube attached to a nebulizer, which converts liquid medicine to vapor.

Overall, Winham said she felt the visit, which also included a chest X-ray, was “handled well.”

Visits like these have increased in the past decade as the number of walk-in clinics in New Hampshire has more than quadrupled, from 15 in 2009 to 62 today. They aim to fill a niche between primary care and emergency departments, at a lower price to patients and insurers, with shorter wait times and evening and weekend hours.

But at least two critical access hospitals in rural parts of New Hampshire say that for-profit urgent care centers threaten their revenue streams, making it more difficult for them to continue to provide lower-revenue services such as obstetrics, mental health care and addiction treatment.

While all involved seem to agree that there’s a need for urgent care in some form, they have not yet pinned down how best to provide that care, while sustaining the range of health care services people and communities need.

“All share the desire for lower-cost health care, but lower-cost health care cannot come at the expense of a health care delivery network that only a hospital can represent,” said state Sen. Jeb Bradley, R-Wolfeboro, according to the record of a March hearing of the Senate Executive Departments and Administration Committee. Lawmakers and stakeholders gathered to discuss a bill he proposed that would have changed the way the state reviews license applications by standalone health care facilities near critical access hospitals.

As health care costs have continued to rise in recent years, patients, employers and insurance companies have become increasingly cost-conscious, said Dr. Marcus Hampers, ClearChoiceMD’s CEO and founder.

Hampers, a Plainfield resident who is trained in internal medicine and critical care, came to DHMC in the 1990s and worked there in the emergency department and in intensive care until about five years ago. He left because he saw that many of the needs of people coming to DHMC’s emergency room could be met in a less costly setting, he said.

“One … trip to the emergency department could bankrupt a family,” he said.

Since opening the first ClearChoiceMD center in 2014, Hampers’ New London-based company has grown to include 13 clinics across New Hampshire, Vermont and Maine, many of them near interstate exits.

“We feel like urgent care is only going to continue to flourish,” Hampers said.

Urgent care centers, though varied in their capabilities, generally treat acute minor illnesses or injuries, such as ear infections, colds, flus, sprains, minor broken bones, cuts, asthma or dehydration, Hampers said. They are open 8 a.m. to 8 p.m. daily and also provide services for employers such as drug screenings.

They are not set up to treat chronic conditions such as diabetes or depression, which Hampers said are better managed through a long-term relationship with a primary care clinician. Similarly, they are not equipped to treat the most serious emergencies such as heart attacks, strokes, uncontrolled bleeding, a drug overdose or a newborn with a fever.

Also, unlike nonprofit hospitals, for-profit urgent care centers can turn away patients who are unable to pay either out of pocket or through their insurance.

For those who can pay, an average visit to urgent care costs roughly 10% of the cost of an emergency department visit. In 2018, the average walk-in visit for non-emergency care at an emergency facility cost $1,600, while an average visit at a walk-in clinic is $196, said Lisa Guertin, the president of Anthem Blue Cross and Blue Shield, during the March Senate committee hearing. Meanwhile, the average deductible is $3,000, she said.

“This is not just a problem (for) employers, but also for the consumers,” Guertin said at the hearing. “This has been changing in the southern tier with alternatives appearing, but it is not changing up north.”

Another alternative may be on the horizon for the Upper Valley. The Portsmouth-based ConvenientMD is looking for a location along Interstate 89 in West Lebanon. Though the company withdrew a recent Zoning Board application seeking a waiver for additional signage for an Interchange Drive property it was planning to lease, the company’s CEO Max Puyanic said they are “working hard to find an alternate site” due to the Upper Valley’s higher than average emergency room utilization.

Puyanic said ConvenientMD provides a broader range of services than other urgent care providers, such as intravenous therapies for dehydration, chronic obstructive pulmonary disease exacerbation, asthma, migraine headaches and cellulitis (a bacterial skin infection), as well as complex wound repair.

He said the goal is not to undermine other providers, such as critical access hospitals, but to collaborate with them by sending them referrals for specialty care.

“Ultimately, I believe that the health care system is stronger by us entering those communities,” he said.

Several supporters spoke in favor of ConvenientMD’s coming to the Upper Valley at a November Zoning Board hearing.

Wendy Parker, executive director of the Concord-based HealthTrust, which provides benefits to public sector employees around the state, including employees of Lebanon and of Grafton County, said she would like to see more lower cost options available in the state’s rural areas, especially in the North Country.

HealthTrust is “always looking for opportunities to have organizations come to those areas to help provide some relief on the cost of medical care,” she said, according to an audio recording of the hearing.

In addition to saving money in health care costs, Parker said the convenient evening and weekend hours mean that employees can have their needs met without having to take time away from work, which also is a benefit to the public employers she represents.

Similarly, Grafton County Commissioner Wendy Piper, an Enfield resident, spoke in favor of ConvenientMD’s presence both in Lebanon and in Littleton, N.H. Rising health insurance costs for county employees “inflates the tax rate” for Grafton County taxpayers, she said.

In a Sept. 9 letter to the board, Paula MacKinnon, the president-elect of the New Hampshire School Nurses’ Association, said ConvenientMD has worked with the association to develop a “School Nurse Partnership” program that includes free care and sports physicals for children referred to the facilities by school nurses; free flu shots for students, faculty and families; free vaccines to students under 18; concussion baseline testing for $10 or less; help obtaining free Epi-Pens; and phone triage and continuing education for school nurses.

“In short, ConvenientMD’s outreach and support of the local communities it serves is truly unprecedented, and they provide a tremendous service to the communities they serve,” MacKinnon wrote. “You would be fortunate to have them in Lebanon.”

But some disagree. At least two critical access hospitals in rural parts of New Hampshire recently filed complaints with state regulators, saying ConvenientMD clinics near them threaten their revenue streams.

“Having duplicate services just down the street will have an adverse effect on our ability to provide our full range of health services,” Littleton Regional Healthcare CEO Robert Nutter said in a news release earlier this month.

The Littleton hospital, an important provider in northern Grafton County of obstetrics and behavioral health services, said that it stands to lose $3.2 million annually to the ConvenientMD in town.

“While we believe competition is generally good, this situation assumes a for-profit entity that provides very specific services is the same as a nonprofit critical access hospital,” Nutter said in the release. “This is clearly not the case.”

Grafton Superior Court Judge Lawrence MacLeod Jr. this month dismissed a suit the Littleton hospital filed against the New Hampshire Department of Health and Human Services that asserted that the department should not have granted ConvenientMD a license to set up a clinic just miles from an urgent care clinic operated by the hospital. MacLeod said his court did not have jurisdiction in the case.

The other critical access hospital in New Hampshire that has disputed DHHS commissioner’s approval of licenses allowing for-profit urgent care centers to locate near them is LRGHealthcare’s Franklin (N.H.) Regional Hospital, which has objected to DHHS’s approval of a license for a ConvenientMD in Belmont, N.H.

Central to the dispute is a process instituted by a 2016 law passed when New Hampshire’s certificate of need process sunsetted. That law requires the health commissioner to make a “material adverse impact” determination before approving licenses for new health facilities near critical access hospitals. But Commissioner Jeffrey Meyers, who left the post earlier this month, said that he didn’t have the ability to conduct a review, so he approved all applications he received.

Bradley’s bill last session, SB 97, initially set out to require a third-party review, but ended up creating a committee to study the issue instead.

In Vermont, urgent care clinics are considered physicians’ offices and therefore are not subject to a certificate of need review by regulators. ClearChoiceMD operates four clinics in Vermont in South Burlington, Berlin, Rutland and Brattleboro. ConvenientMD does not yet have any clinics in the state.

Puyanic said his company has set up clinics “where insurance companies asked us to go.” He hasn’t “had that communication yet from the insurance companies in Vermont.”

Several hospitals around the region, including Valley Regional Hospital in Claremont and Springfield (Vt.) Medical Care Systems, operate their own urgent care clinics in an effort to meet patients’ needs for same-day access without sending them to the emergency department.

Lebanon’s critical access hospital Alice Peck Day Memorial Hospital, which has been trying to encourage more people to visit its emergency department, said in an email that so far, “We haven’t seen any great variation in the number of (emergency department) patients we care for since other urgent care centers have opened in our region.”

ClearChoiceMD first opened on Miracle Mile in 2014. Hampers said his approach is collaborative.

It “has to be a collaborative for it to really benefit the community,” he said.

ClearChoiceMD does not offer infusion therapies that are revenue-generators for critical access hospitals, he said. ClearChoice also shares ownership of some of its clinics with hospitals.

“Services that we provide are no threat to the hospitals,” Hampers said.

Puyanic, ConvenientMD’s CEO, said that it’s unfair to consumers to deny them a cheaper alternative just to shore up hospitals’ finances.

“If we as a system are only looking to try to maintain the status quo by charging unfair prices … that’s not going to help us,” he said.

Though she had never been to an urgent care clinic before this year, Winham found herself turning to them more than once. She made a couple of stops during a recent trip back to Hawaii, including for a sinus infection of her own and for her son’s pneumonia. She was glad to find that they saw the same clinician each time.

“Some things I was afraid of going in didn’t manifest,” she said.

Valley News Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.




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