The Urgent Care Center Charade

This recent article in the NY Times, about urgent care centers, is really interesting.  It’s called The Disappearing Doctor: How Mega-Mergers Are Changing the Business of Medical Care and it is full of irritating stuff.  Let me explain.

I did a transition year in an urgent care center before I did my DPC practice.  It was in a massive chain now owned by an insurance company.  I will give my opinions about it in a second, but here are what some of the “experts” said in this NYT piece:

  • Dr. Mark J. Werner, a consultant for the Chartis Group, which advises medical practices, emphasized that convenience of care didn’t equal quality or, for that matter, less expensive care. “None of the research has shown any of these approaches to delivering care has meaningfully addressed cost,” Dr. Werner said.
  • “The quality of care that you see at a retail clinic is equal or superior to what we see in a doctor’s office or emergency department,” said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School, who has researched the retail clinics. “And while there is a worry that they will prescribe antibiotics to everybody, we see equal rates occurring between the clinics and doctor’s offices.”

Let’s go to the first point.  I agree it is not cheaper.  Why?  Each visit at the urgent care I worked at came was automatically billed with an E/M code level of 4 or 5.  These were way too expensive and over-billed and there was nothing I could do to override the computer to make them lower.  The computer EMR gamed the billing system for optimization. Second, I would see full families coming in and say that little “Jimmy has a cough but why don’t you see all of us just in case?”.  Now, why would they do that?  Because they had Medicaid and didn’t pay a dime!  In conclusion, there is no way urgent cares are saving anyone money.  They over-bill and up charge and see an endless amount of people without any triage.

Now the second point, which is the most distorted.  The ivory tower professor, who is NOT a primary care doctor, talks about equal or superior care?  I call absolute bullsh%t on this.  Show me those studies!  Were they on reading strep tests?  A 9 year-old can do that?  Or reading a urinalysis? A monkey can do that.  In my year at that urgent care chain I saw physicians working there who had a litany of board complaints against them.  I saw a pathologist (yes, a pathologist!)  there seeing patients all the while doing a side hustle of answering online requests for antibiotics.  I saw another doctor who was so bad that I cringed when I heard he was in our local facility because I knew the fallout would be horrible. This guy would work anytime or anywhere so he became their shining star.  He later was found to be having multiple affairs with staff and performing girl sports physicals “alone”.  In my opinion, 50% of the doctors were atrocious.  The midlevels?  About the same.  Some were really good and some were literally seeing 40 patients a day a week after graduating.  One PA was doing so much malpractice that I threatened to leave and go home if she was on my schedule.  She once told me that she will do whatever she wants with patients and just have some other doctor at corporate sign her notes.  This including endless antibiotics and narcotics.  She was a walking disaster but was never fired.  In fact, she was later promoted.

Oh, let’s not forget the prices.  The place I worked at had a sign that a visit costs around $120.  A little more with procedures but never more than $199.  That’s even with stitches or x-rays.  Impressive, right?  It was a lie.  That was if you paid cash. If you gave your insurance card then the insurance was billed at those codes mentioned above.  My nurse’s daughter-in-law got a bill for over $300 for a UTI.

How about consistency of doctors?  I left this clinic after a little over a year. It truly scarred me and gave me PTSD.  The two other doctors, who I had started with and were very good, left before me. The turnover was massive but nothing like the other urgent care clinic they owned across town.  I was later told by a nurse who worked there that their clinic had 80 doctors and midlevels cycle through in 3 years.

And lastly, about the idiot stating urgent cares don’t give more antibiotics.  Who are you kidding?  Everyone with a URI gets an antibiotic at these places.  Every….last….one.  Sometimes the doctor may be honest and say that it is viral but he will still give them an antibiotic to fill in 3 days only if it gets worse.  You have to please the patient, you know.  How many patients you think waited those 3 days?  I once refused to give an abusive patient an antibiotic because it was an obvious virus.  She went ballistic and reported me to the board of medicine. It took months but the case was eventually thrown out but not without work and worry on my part.

The NY Times’ authors of this piece don’t know enough to call out bullsh%t.  They also didn’t mention direct primary care, which is changing the game.  They appropriately expose the concerns about insurance companies owning these chains and that’s good. If my experience is any example (and that was 14 months of seeing up to 70 patients a day) then these places are NOT the answer to our broken system.  They are just money-making slot machines for the corporate bad guys who are already raking it in.

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  11 comments for “The Urgent Care Center Charade

  1. cassandra
    April 22, 2018 at 2:50 pm

    Thanks for a concise and accurate analysis of the blood-sucking assembly line, prescription pushing, and morally bankrupt Urgent Care industry. But one of your comments really struck me:

    “Each visit at the urgent care I worked at came was automatically billed with an E/M code level of 4 or 5. These were way too expensive and over-billed and there was nothing I could do to override the computer to make them lower. ” If this urgent care factory sees Medicare patients, this behavior is textbook fraud and abuse.

    1) There is no way that they could have even 25% of visits legitimate level 4 and definitely NOT level 5. Level 4 and 5 visits are by definition are for patients requiring “complex” diagnosis and medical management. On the other hand, Urgent Care by definition is a place to obtain care for non- emergent, and very basic primary care. There are of course a few exceptions, but these should be outliers.

    2) ONLY the treating physician (or other treating clinician) is permitted to assign billing codes. The fact that they override your professional judgment and coding assignment is flat out illegal. Perhaps some doc should turn them into the DOJ and collect some of the fines via a qui tam suit. I can’t think of a better outcome for the bloodsuckers!

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  2. Bridget Reidy
    April 21, 2018 at 9:00 pm

    If you’ve already told your patients what a cold is and why antibiotics don’t work, they don’t come back for every cold. You might have the occasional visit where you have to say “Yes they can last over two weeks” or such but usually they’re coming in because they already crossed what line you drew in the sand last time. So to say we prescribe in the office as many antibiotics per respiratory visit or whatever is ridiculous. We don’t see people with simple colds anymore as the urgent cares do. And there’s nothing easier (ie more profitable) than giving opiates for musculoskeletal conditions. None of those patients wine about how their problems persist or how physio doesn’t work or they need more imaging or referrals. They just have another acute musculoskeletal problem that doesn’t take any effort if they heard you won’t do opiates for chronic pain, or tell you how well they are doing with the meds and how horribly without otherwise.

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  3. Jennifer Hollywood
    April 16, 2018 at 1:45 pm

    I get notes all the time from urgent care. They read: CC sore throat. Rapid strep neg. Abx given. WHY? Vitals all normal and physical exam normal. Clearly viral. Why even do the test if you are going to treat anyway? Patients also come to my office AFTER going to urgent care for Acute Bronchitis because they want their antibiotic changed because they are still coughing and feel the first antibiotic is not working. It takes a lot of time to explain to them about viral infections and antibiotics, which is even harder AFTER they already were given antibiotics. Best I can figure out is that IF you give people lots of medicine (even though its not needed) THEN they will return the next time they get sick. If you teach them that there is nothing that needs to be done, then next time they stay home and the UC doesn’t make money that way–even though it’s better health care.

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  4. Soccerdoc11
    April 15, 2018 at 5:56 pm

    In my area a visit to one urgent care with multiple offices, a chief complaint of “cough” gets this treatment: three page note of negatives, nebulizer treatment, IM ceftriaxone, IM steroids, CXR, CBC, antibiotic du jour, oral steroids, inhaler, and codeine cough med. Both MD and mid levels do this. Saves money and good medical care. Also there is no regulation requiring them to send notes to the primary even though they ask for PCP name. We never know about these visits unless the patient mentions it–even though I have spoken to the MD owner requesting records routinely.

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  5. Stephen O'
    April 15, 2018 at 12:16 pm

    The greater problem is how we Americans bundle propaganda, advertising and entertainment together. That problem is far more massive to even touch upon here, but it applies in medicine.
    We are indoctrinated to trust unknown talking heads, and accept them with honor and familiarity, when they broadcast to the millions; but we are indoctrinated to mistrust those who are familiar to us, and to mistrust any dispassionate personal dialogue.
    Tacking it down to the problem with medicine, we pour our absolute trust onto Dr. Oz, the famous TV doctor known and beloved to the millions whom he has never met. He shills some nostrums that he claims are beneficial. 15% of his claims contradicted medical research and the remainder of Oz’s advice were either vague banalities or unsupported by research.McCoy, Terrence (December 19, 2014), Washington Post “Half of Dr. Oz’s medical advice is baseless or wrong, study says”.
    At least he is a doctor. Many of the images and ideals about what quality medical care truly is are drawn from the images offered us by screenwriters in movies and TV. The examples are endless, and people love them – Emily Owens, M.D., The Mob Doctor, The Night Shift, Code Black, Chicago Med, Heartbeat, Pure Genius, The Good Doctor, The Resident, House M.D., Gray’s Anatomy, back to Marcus Welby MD of the ancient days. Every one of these makes a permanent and defining image of the American doctor, and offers to peel back the wall that separates us from the public. It is amazing nonsense. It is conceptualized, written and acted, edited and broadcast by people, almost none of whom have the slightest clue about medicine. I’d recommend a break to see the famous adventurer, Scott of the Sahara, as put up by Monty Python, with the warning – this is not instructive about how to be a real adventurer.
    People see that this is not about fighting with lions. They do not see that The Resident is not about medicine. Therefore, people learn expectations about “Real Medicine” that are harmful.
    In one instance, a patient came in claiming malaise (yes) and splinter hemorrhages (no) and insisted upon an echo and hospitalization for acute infectious endocarditis, which she did not have, based on the lack of correlation between examination and the fact that people with IE are sick as shit.
    In Real Medicine, we got on the topic of why she thought she had IE, and it turns out that her 22 year-old niece died of it, which “came from nowhere.” The niece was the pride and joy of the family, and graduated Stanford. The suggestion that she may have been an injection drug user was offensive to the family, and this sort of thing “just comes out of nowhere.” And then followed 20 minutes of grief and confusion and shame over the loss of this young woman.
    Yes, I know how to run around and be grim, and order blood cultures STAT and let’s get a TEE STATand gated cardiac MRI STAT. Underneath, of course, was a patient who desperately hoped unconsciously that she could also die of IE “from nowhere,” and exonerate her beloved niece’s reputation.
    True human therapy takes a few visits, is very dull and boring interpersonal work that does not upcode easily, or televise well. And the American audience/patient demands what they see on TV, which is after all the fundamental purpose of TV and the Internet and movies. You are expected to demand something that 30 seconds earlier you never heard of. And all too often we are left with angry customers in the clinic interaction, rather than suffering people. They have been sold what they want, and antibiotics or opiates are the product they want STAT.
    I find this inutterably sad, and see people controlled by so many inhumane forces, and just ask why?

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    • Perry
      April 16, 2018 at 3:19 pm

      Modern health care is basically screwed.

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  6. Michele Parker
    April 15, 2018 at 10:54 am

    You can also add that the system running the urgent care benefits by hiring mid levels at cheaper cost, who then order more labs and X-rays, and referrals, and that feeds money into the system better than a doc who examines the patient and solves the problem

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    • Sir Lance-a-lot
      April 15, 2018 at 6:11 pm

      This is absolutely true. Everywhere I’ve worked, they’ve had PAs or NPs, generally seeing exactly the same patients (sometimes with slight limitations regarding age or acuity), and routinely ordering every test in the book. I try hard not to order tests I don’t need (ie: the outcome won;t affect the treatment), but they are constantly getting CBCs and CXRs for the common cold or gastroenteritis.
      Sometimes they will present a patient to me and ask my opinion:
      “Well, since it’s pretty clear the patient has X, I’d just treat him for X and send him on his way.”
      “You don’t think we should get an X-ray?”
      “I wouldn’t, but I’m not treating the patient.”
      “I think I would feel more comfortable…”
      “Okay, then knock yourself out, and let me know if you find anything different.”
      They never do, but the company makes more money from the lab tests and X-rays.

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  7. MLP
    April 15, 2018 at 10:00 am

    I’m a PA …worked in a privately owned UC and lasted a year….was lured by larger salary, but soon realized, I’d been had. Saw unsafe numbers of patients with inexperienced med assistants and LPNs, who were also expected to clean the bathrooms and exam rooms. Seeing the “most” patients in a shift was celebrated, not scrutinized….absolutely no backup for high volume days…illness…etc…to bring in extra revenue…expected to adminster extensive pre employment screening tests and sign off on them with no training whatsoever…..absolutely pressured to give the patient what they want…including reams of unneceasary antibiotics…..books concerned with inproving customer service were assigned and required reading…we were constantly advised to show the patients around the facility..especially the media room…where movies played constantly.. (I still can’t listen to the theme song from Nemo)….time off was discouraged and often impossible to take for lack of staff coverage….I once worked excessive hrs…got sick…went to work sick…and was criticized for lying on a stretcher for 5 min (I was told I should have put my head down on my desk)….the owner doc, and doc VP were susposed to be available by phone anytime….often could not be reached, or would return calls hours later…certain staff blatantly favored over others, and spying and reporting to management was encouraged…absolutely the most toxic atmosphere I’d ever worked in….. of course the unsuspecting public knows none of this….and equates convenience with good care.

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  8. John Chamberlain
    April 15, 2018 at 9:37 am

    Doug,

    You and I both know that the driving force today in our sickcare system is not about patient care, it’s about the Benjamins.

    How to game the system, optimize coding, insurance companies like UHC buying physician practices and surgery centers. (33,000 doctors now! Really).

    Fully 1/3 of the $3.3T spent on health “Care” adds no value, in fact, it extracts value. When the annual cost to bill for one physician is $99,000, something is seriously wrong.

    And yet, we have these bozos sitting above the fray writing as if they know what goes on in the real world.

    I am so absolutely over it and there are several of us doing something about it.

    Please check out Citizen Health citizenhealth.io

    You and your DPC colleagues have been a bright light in this dark world of health?care.

    Thank you.

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  9. Sir Lance-a-lot
    April 15, 2018 at 9:06 am

    I’m a family practice doc who’s been doing urgent care for ten years now, and I absolutely hate it, though I haven’t seen anything as bad as you describe, Doug, probably because almost all of that time has been with a non-profit hospital and with a doctor-owned “multispecialty group,” and not with a large corporate practice.

    Why do I continue doing this if I hate it? Plenty of annoyance, but still less BS than I would have to put up with doing regular primary care. Ask a few questions, do a quick exam, maybe give a speech about the importance of this or that, and Goodbye. If I could make a similar amount of money doing something else, I would, but I can’t, and if I quit medicine now, my med school will not give me a refund or forgive my loans.

    DPC? I tried this over ten years ago, before it had a name, and failed miserably, with over $100,000 in debt (in addition to med school loans). The problem is, you need to get patients in to pay the bills, and, at least where I was, there just weren’t enough people who wanted to drop a chunk of cash every month for quality medical care, when they could just go somewhere that is covered by insurance, or, if they have no insurance, they can skip it altogether, until they get really sick and need to go straight to the hospital. Now they’ve also got the option of stopping by the urgent care if they have a minor problem every year or two, so, for me at least, I won’t be doing DPC.

    As far as antibiotics, yeah, some of my colleagues prescribe way to much, but I genuinely try to avoid prescribing unnecessarily. I won’t bang my head against a brick wall, though, so, when I can tell that that is the one thing they want, I tell them that they are wrong and they don’t need them, and then I prescribe them. It’s just not worth the time, effort, or stress, and, frankly, I really don’t care anymore. I will agree with the article, though, that (as visible in the chart) primary care doctors are at least as bad with unnecessary antibiotic prescriptions as the urgent care doctors. I will generally point out that since their primary, or the doc they saw last week in urgent care, prescribed an antibiotic and it didn’t work, we need to try something else now, and most of the time, they will go along with that.

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