How Urgent Is ‘Urgent’ Healthcare?
As walk-in urgent care centers spread, so do questions about their expertise. One thing for sure: They’re not emergency rooms.
When Mandi Patterson noticed her 8-month-old son Abbott was having trouble breathing, she rushed him to Oswego Health Urgent Care in upstate New York, expecting the kind of quick medical attention that happens at emergency rooms.
The infant wheezed, coughed and made barking sounds. A physician treated him for asthma. It was January 2010, and Patterson took him back three more times during the next nine months. The boy’s breathing difficulties would not go away.
The 36-year-old mother was seeking acute medical care at the kind of place where more Americans are going: an urgent care center. More and more medical practices across the country are rebranding themselves as urgent care centers. Nationwide, there were an estimated 9,000 such centers as of 2012, up from 8,300 in 2008, according to the Urgent Care Association of America. They sound like places promising the kind of medical attention offered at emergency rooms. As a marketing tool, the phrase “urgent care” is luring patients with an implicit promise of fast treatment.
The reality is that these facilities face much less oversight, and many are not required to have even the basic equipment common in emergency rooms. That is triggering a growing debate in state governments and among health care policy experts over how to regulate urgent care centers. Some states have already responded by instituting tougher regulations to ensure patients get proper care.
All of this, lawsuits show, is happening against a backdrop of medical mishaps. In New York, where Mandi Patterson wanted care for her son, there are no rules specifically regulating medical standards at urgent care centers, though there are plenty covering emergency rooms. Among other requirements, hospital emergency departments must have laboratory and X-ray equipment available at all times, for example, as well as an attending physician on duty who is trained in emergency services. In Albany, state officials have begun discussing whether to increase oversight of medical practices that do not have to offer services beyond the level of any family practice. Such oversight could help patients expecting acute care avoid confusion or delayed treatment from professionals who aren’t prepared to offer emergency services.
For 8-month-old Abbott Patterson, the cure finally came nine months after his first visit to Oswego Health Urgent Care. A physician’s assistant at the clinic ordered an X-ray. It showed that the infant had swallowed a quarter still lodged in his throat.
Abbott underwent surgery at Upstate Golisano Children’s Hospital in Syracuse to remove the coin. It was black when the surgeon dislodged it. The family sued Oswego in 2012 and the case was settled out of court for an undisclosed sum. Now Abbott is doing well, said Patterson, who declined to comment on the case due to a settlement agreement. Oswego Health Urgent Care also declined to comment.
There are different levels of urgent care centers — some staffed with trained emergency physicians and others with physician assistants or nurse practitioners. And a lack of oversight has produced inconsistent levels of care. Some patients receive the quality, acute care they expect from emergency physicians, while others are given the fastest, simplest, cheapest medical solutions.
Mistakes can be fatal. On April 4, 2013, 17-year-old Jessica Erin Hart was taken by her mother to MedExpress, an urgent care facility in Roanoke, Virginia, to be treated for a severe sore throat. The girl was given a painkiller called Dilaudid. But the dose administered was 4 milligrams, more than twice the prescribed amount. She died before she arrived home that day, according to case files reported by the Roanoke Times.
Those who treated Hart were publicly reprimanded by the Virginia Department of Health Professions, according to documents.
The family filed a lawsuit against the urgent care center and it was settled for $1.5 million in June.
The number of urgent care centers has grown rapidly in New York and other states.
Across the nation, two-thirds of today’s centers opened in the last five years, according to calculations by Concentra, a health care provider. In New York State, according to incorporation records examined by the CUNY Graduate School of Journalism in December 2014, two-thirds of 188 health-care facilities — those labeled “urgent,” “immediate” or “walk-in” that claimed to offer acute care — were incorporated in the last five years. Eighty-five percent were incorporated in the last 10 years.
The new centers cater to the greater number of patients insured under the Affordable Care Act. Dr. Franz Ritucci of the American Academy of Urgent Care Medicine also attributes the growth to a “McDonald’s society.”
“You want something, you want it now, and you don’t want to wait,” he said.
Some standards for urgent care centers exist, but they vary widely. At least nine states — Arizona, Florida, Maryland, Minnesota, New Hampshire, Utah, Kentucky, Delaware and Illinois — have legislation that defines urgent care. Arizona requires special licenses for urgent care facilities.
Trade organizations promote differing standards. Some, like the Urgent Care Association of America, want the centers to have onsite X-rays available daily and medical oversight by a licensed professional, among other standards. Other groups, including the American Academy of Urgent Care Medicine, call for centers to provide health care services for at least six months before they can be accredited.
Interviews with those in the industry reveal several defining standards. Centers typically open seven days per week, accept patients without an appointment, and are set up to diagnose and treat a vast range of medical conditions, including infections, viruses and injuries. Many are run like any family practice. Some offer a variety of specialties from pediatrics to psychiatry to geriatrics. But they typically refer patients with severe traumas and life-threatening conditions to an emergency room.
“Our job is not to be heroes,” said Dr. Marc Salzberg of StatHealth, an urgent care chain in Long Island. “We don’t take chances with people’s lives.”
Unlike emergency rooms, urgent care centers can decide whom they want to treat. They can accept those with insurance or patients who can pay up front. They can turn away patients who cannot pay.
This changing health-care landscape can be confusing to navigate.
When Samantha Patterson, 25, injured her arm moving furniture in her Harlem apartment one February night in 2014, she wasn’t sure whom to call. (She is not related to Mandi and Abbott Patterson). She considered going to the emergency room. But her mother in Florida offered another suggestion: Go to an urgent care center.
Patterson arrived at a Manhattan clinic at 8 p.m. and was out the door in 40 minutes, with instructions to ice her arm and see an orthopedic specialist in the morning.
“I realized it wasn’t as urgent as I thought,” said Patterson. “But I still didn’t know if it was fractured, sprained, broken.”
Still, Patterson was thankful to have saved herself a trip to the emergency room. The specialist later told her she had a hairline fracture that would heal without a cast.
Some governments now are considering whether to create or expand rules for these new health-care centers. Arizona has defined “a freestanding urgent care center” as an outpatient facility that’s open 24 hours a day, provides unscheduled medical services not regularly available at primary care practices, brands itself as a center for urgent, immediate or emergency conditions, or regularly provides unscheduled medical services for more than eight straight hours, among other conditions.
The New York State Department of Health has issued a non-binding “official paper” suggesting oversight on how medical facilities get named urgent care centers, as well as their hours of operation, accountability and services. Under proposed standards, private physicians’ offices would apply to use the name “urgent care” and be accredited by an approved national organization.
“It’s an attempt to recognize and smooth out what’s happening to the public,” said Dr. John Rugge, chair of the committee that made the recommendations. He said the urgent care recommendations are part of a broader initiative to understand ambulatory care. “As we recognize its importance, we ought to gear up and take a closer look, … and make sure there’s not an opportunity for abuse.”
Many in the industry argue that urgent care centers can develop their own regulations. “[The government] has created a solution to a problem that doesn’t exist,” said Jonathan Halpert, president of the Northeast Regional Urgent Care Association. He acknowledged instances of negligence and malpractice, but said they are “exceptions to the rule,” and are not indicative of the quality of care at the majority of urgent care centers.
His group opposes the New York committee’s recommendations because they limit the types of patients urgent care centers can treat, preventing them from treating such patients as children under 3 years old, or patients with mental health problems. The centers also would be required to treat Medicaid patients.
Halpert said that new state regulations would set a dangerous precedent. “That would be the top of a slippery slope,” he said. “We are physician practices. We just are open extended hours.”
The regional association does have its own guidelines for urgent care centers that include having a physician onsite or available for consultation at all times, and opening for extended hours. Halpert said the organization, which started in 2013, is not a governing body with the ability to enforce rules. Its standards are not binding. But he believes its members favor these provisions, the industry can regulate itself, and successful businesses are those that treat patients well.
“We want to be the beacon,” said Halpert. “There are always going to be people out there that have different practice standards, but we feel like we built a better mousetrap.”
While Halpert’s group does not accredit members, other industry organizations do offer certification for urgent care. Representatives of the Urgent Care Association of America, which launched its accreditation program in 2014, visit facilities and check their scope of services. That includes checking whether X-rays and blood analyses are done onsite. Accredited urgent care centers must be available to patients seven days a week, be overseen by a licensed physician, and, in emergencies, have the ability to stabilize patients and arrange transportation.
One hundred and three centers nationwide have this accreditation, according to the Urgent Care Association of America’s website. That is about 1 percent of the estimated number of urgent care facilities in the nation. Accreditation is valid for three years, and so far no organization that applied has been rejected, the organization said.
That doesn’t make the critics any less uneasy. Pulse of New York, a Long Island-based patient-advocacy group, runs workshops about office and hospital visits twice a year. Urgent care centers have come up in nearly every seminar for the past three or four years, said president Ilene Corina. “[Patients] don’t know what to expect going in there” because nobody is scrutinizing these centers, she said, adding that patients should research their urgent care center before visiting, just as they might a primary care physician.
“[People] assume that it’s regulated in some way and that it must be safe because it’s operating,” said Suzanne Mattei at New Yorkers for Patient and Family Empowerment, another patient-advocacy group. “The reality is that these things have really taken off in a way that wasn’t really predicted in the past,” she said. And regulators are scrambling to keep up.
