Robert W. Morrow, M.D.
A couple of weeks ago, the New York Times took a stab at documenting one of the radical transformations that is happening in the delivering of healthcare in the US, i.e. the advent of the store-front urgent care facilities. This is how they introduce the topic:
“Is the doctor in?
“In this new medical age of urgent care centers and retail clinics, that’s not a simple question. Nor does it have a simple answer, as primary care doctors become increasingly scarce.”
In the sub-head to the article, the authors announce that:
“Big corporations — giant retailers and health insurance companies — are teaming up to become your doctor.”
Are they really? And why? The story behind the story is a bit involved, but it is not complicated to see that it has less to do with doing any doctoring, than with having your name on a list that allows them to claim you as a patient. Here’s how it works…
A Family Practitioner in the Bronx
My patient Paolo’s wife had diabetes. Together, with some guidance from me, they lived together happily and managed her diabetes for years. One day, however, she had a small stroke and was admitted to the hospital where the doctors did not know her or her history. Soon, she was moved to a rehab facility where, no surprises here, no one knew her either. Worse, none paid attention to her and her complicating factor, i.e. diabetes. Thanks to cutbacks and profit taking, the rehab facility had only a skeleton staff.Early in the morning after a few day in the facility, Paolo’s wife entered insulin shock and died. No staff was watching, there was no appropriate monitoring, nothing. Just another dead patient.
I had worked with the two of them on their various medical problems over the years, and this outcome could have been avoided. After she died, her husband also became ill with multiple major, but preventable problems. I was able to work closely with subspecialists and see him frequently. He has survived many complications, and we meet regularly to tweak his medicines and lifestyle.
I don’t do miracles, but I work with my patients and community, which is complex and challenging, but also great fun and rewarding. Even after many years, however, I get a little bit of my heart taken when one of my patients dies, especially unnecessarily.
But as the New York Times article correctly reports, I’m part of a dying breed. My practice is squeezed from every direction. The payments I receive for my work are so restricted, and the administrative work so complex, that I gross far less than I did 15 years ago. My net income from this business is kissing zero.
The Urgent Care Center “Fix?”
If you live in NY State and have diabetes, then the risk that you will end up with an amputated foot increased from 2016 to 2017. Expect with the lack of solid primary care those numbers will get worse. More feet in buckets, when not one should need amputation.
That’s in spite of the blossoming of urgent care facilities around the State heralded by the Times article.
An urgent care center is not an effective replacement for effective primary care. Sure, a primary care physician like myself gets a fair number of patients with coughs and colds and various other types of conditions that do not require long-term monitoring. Nor does every patient visit require giving eating and lifestyle guidance based on a long-term view of the patient.
But, we have substantial evidence, not only from around the world but also from experiments in the US, that independent primary care, like my practice, slashes costs and improves outcomes.
Follow the Money
So what are urgent care centers doing, and how do they make money for investors, which a primary care practice like mine is being financially squeezed out?
The ideal scenario for an urgent care facility is to attract relatively healthy, relatively young people that they can treat, bill and send home in a very short period of time. When they do this successfully, they are actually stealing those patients from the traditional primary care physicians.
And that leaves us with the the relatively less health, relatively older population to deal with. That’s a challenge because treating their complaints takes more time and is more poorly reimbursed.
If the problem here sounds familiar, it is because you have heard this before in the debate about Obamacare. The reason for the personal mandate that everyone needed insurance is to spread the costs across the entire population, including the young and healthy who rely much less on the system.
Once an urgent care facility has established itself with a population of mostly young and otherwise healthy people, it become a valuable property that can be packaged up and sold on to other investors. They, in turn, can squeeze out more profit for less care, something which will make my practice suffer even more.
The Contrary Perspective 
Reblogged this on The Secular Jurist.
Thank you, Dr. Morrow, for this series, your thoughtful approach, and your honesty. What a great statistic for “The Greatest Nation on Earth Now, That There’s Ever Been, or Ever Could Be” to crow to the world about: an increase in foot amputations for diabetics!! Let’s add this to life expectancies slipping backward for certain segments of the population! Let’s all wave the glorious ol’ Red, White & Blue vigorously! Hey, at least that’s a form of exercise, right?!?
Health care vs Medical industry care–big issue in my book. While the medical industry has never been about health, this article demonstrates so clearly how the public is totally objectified for profit. Deaths like this diabetic woman’s are a clear example, too, of the participation of the medical industry in the national goal of depopulation. And there people profiting mightily from this. Many doctors like this author do try to be caring and ethical but they cannot as their system is toxic and not designed for cure. Thank goodness our body is self healing on so many health condition and we can avoid falling down the medical rabbit hole. Best solution in the immediate is to take full responsibility for learning how our body/body works in synch and learn how to take care of our own health with holistic care for prevention. The biggest problem I have seen is not money (which is a big issue for many), but undoing the co-dependency that has been intentionally created by Big Pharma and the Medical industry at large.
Dr. Morrow, Urgent Care has become so popular not by “stealing ” healthy people from Primary Care, but by providing acute care to a population who either don’t have a primary care provider or can’t be serviced by their provider in a timely fashion(which is what an acute problem needs). The young healthy people who work 50-80 hours a week don’t want to wait 2-14 days, or even 3 hours, to get care for their medical issue, they want it now. In the Urgent Cares I have worked in since 1987, we are always telling our patients to followup with the appropriate specialist whether it be their PCP for their out of control diabetes and hypertension or the Orthopedist for their ankle fracture. Every Urgent Care I have worked for has developed and vetted a list of specialists to refer our patients to. We are always looking for PCPs to handle the patient with a chronic illness who either doesn’t have a PCP or doesn’t like their PCP. I would encourage all specialists including PCPs to reach out to their local Urgent Care to build a relationship for referrals that goes both ways. The monetization of healthcare has created many problems which are only going to get worse. While Urgent Care may be a result of some of these forces, it has certainly diverted a lot of trivial Emergency Department visits. In poor communities like the Bronx where the culture has been “go to emergency for any health issue”, we are changing that culture to one where patients can get prompt care and get solid advice about followup. Unfortunately many HMO’s don’t allow us to send a patient directly to the specialty care they need without going though their PCP. Urgent Cares are here to stay, so let’s work together to improve healthcare outcomes. As always, you and I can continue this discussion on the mighty Hudson River, the river that flows both ways.
Reply from Dr. Morrow:
Thanks, Todd, and other commenters. Disclosure-Todd is a close friend of mine, and one of the most ethical physicians known to me.I am confident he sews folks up better than I do.
He illuminates my key point about the macroeconomics of health care, which is the role of finance capital in support of transactions in health services, as opposed to the role of actual continuity health care, both acute and chronic.
How can a small hospital system own 22 hospitals in short order? From where does the money come? If monopoly systems cost more and lead to worrisome outcomes, why do investors support them? If urgent care pays large rents and salaries, but are rarely busy, why do new ones keep opening? With rapidly changing ownership?
And what happens when a community has many urgent care centers in the context of thin primary care?
From the money side, urgent care makes money for someone, somehow, that merits investment in a competitive market in which each individual ‘sale’ [medical visit] has virtually no margin. Indeed, these centers appear side-by-side, with three cheek-by-jowl near Executive Boulevard in Northeast Yonkers, NY, where I live. They support expensive marketing programs.
The transactional model in the not-for-profit world explains this phenomenon with the best fit–relatively healthy young attributed lives provide a marketable package. In the last flurry like this in the ’90’s, most investors at a low level got fleeced when the sites went bankrupt and were sold at basement prices to health systems, which commonly closed them after trialing specialty centers. And that was before the value of attributed lives or a ‘value based payments’ system.
But much of this data is categorized as trade secrets in the not-for-profit sector, and hard [at least for me] to get. It is plausible that urgent care centers can negotiate higher fees than independents, and this is particularly relevant but complex in pharmacy based-primary care. In some cases, enhanced facility fees play a role in improving balance sheets.
The other piece is the size and anonymity of the bond market, which finances this activity. That market, which now is far larger than the stock market, is quite opaque in the not-for-profit world, but appears to make money for investors, through various collateralized debt instruments.
So the key is to look at the forces driving primary care [off a cliff!] We know these forces harm the public, which had become used to a large network of culturally appropriate primary care providers who were available and knew their patients. With personal relationships, these providers could use current techniques to manage chronic illness efficiently. But they ‘steal’ attributed lives from over-extended health systems.
When transactional fees beat out community based continuity care fees, the ‘Invisible Hand’ is helping investors while slapping down needed continuity care.
More feet in buckets
These financing schemes look to me suspiciously like Ponzi operations. If you’re gonna invest, get in and out quickly, before the floor drops out from under the whole charade!!
It seems that Dr. Morrow is ahead of the curve on this one. Here is the Guardian’s take on the same issue: https://www.theguardian.com/commentisfree/2018/apr/22/america-golden-age-corporate-medicine-health-insurance
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