Urgent care centers and the debate over advanced practice providers

“How many people are aware that you will rarely (if ever) see a physician in an urgent care?”

In February, Dr. Mitch Li, an emergency medicine physician at Cherokee Indian Hospital and the owner of Thrive Direct Care in East Asheville, raised this issue in the Mountain Maladies Facebook group, where people share their experiences of, and concerns about, the quality of local health care. His question points to a growing trend in urgent care center staffing: fewer physicians and more advanced practice providers, which include nurse practitioners, physician assistants and other licensed nonphysician practitioners like certified nurse midwives, according to a 2019 article in the American Journal of Managed Care.

According to a recent article in The New Republic by Dr. Niran Al-Agba, up to 80% of such clinics nationwide “rely on nurse practitioners or physician assistants to oversee care, under what can only be assumed are varying levels of oversight by physicians.”

As of April, 26 states and the District of Columbia had granted nurse practitioners full practice authority — the ability to diagnose and treat patients without physician supervision — according to the American Association of Nurse Practitioners. And if the N.C. General Assembly passes the SAVE Act, North Carolina will join that list. The bill, reintroduced in March 2021, is currently in committee and has bipartisan support.

Supporters of the law say the supervision that’s currently required is so lax that getting rid of it wouldn’t make a big difference. Although advanced practice providers in North Carolina must be supervised by a physician, this can be done via telehealth. Speaking to the General Assembly’s Joint Legislative Committee on Access to Healthcare and Medicaid Expansion March 29, Vincent Guilamo-Ramos, dean of the Duke University School of Nursing, stressed that, under current conditions, the physicians providing supervision aren’t “working hand in hand at all times with patients.”

The way Li sees it, the reason physicians are so scarce in urgent care centers boils down to this: corporate interests prioritizing profits over quality of care.

“The commoditization of medicine, where an external investor or owner profits off of the labor of health care workers while effectively making medical decisions, has transformed the profession of medicine,” he maintains. In response, he founded Take Medicine Back, which advocates against the corporatization of health care, in May 2021.

Nonetheless, urgent care centers are booming. Between 2013 and 2019, their numbers grew from 6,100 to more than 9,600, according to the Urgent Care Association of America. As of 2019, these facilities were handling roughly 89 million patient visits a year, including almost 30% of all primary care visits, noted CEO Laurel Stoimenoff. More recently, a 2021 article in Modern Healthcare set the total number of urgent care centers at 10,400.

Bottom-line medicine?

For many patients, the model’s biggest selling points are affordability, ready access and location. With rapid growth, however, has come criticism, and some of those critics share Li’s concerns.

As of 2019, 40% of urgent cares were at least partly owned by hospitals, 35% by insurers and 6% by private equity firms, according to an article in Modern Healthcare magazine. In 2008, physicians owned 54% of all such facilities nationwide; by 2015, that number had fallen to just 26% — and that includes urgent cares owned by physician investors who don’t provide services at the facility.

Complaints about the corporatization of health care aren’t limited to urgent care centers. Across Western North Carolina, corporate ownership of key facilities has sparked concerns about the quality and accessibility of care.

Since HCA Healthcare acquired Mission Health in 2019, the local hospital system has seen an exodus of doctors. And last August, six area residents filed a class-action lawsuit against HCA alleging illegal monopolization of health care.

Urgent care centers receive less oversight than hospitals, however, which could mean fewer safeguards against bottom-line-fueled decisions with the potential to affect quality of care. And if a situation escalates to an emergency, urgent care — which healthcare.gov defines as “care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care” — may be less well equipped to handle it, critics charge.

Because the rise of urgent care centers is recent, not much data is available concerning malpractice claims against them, but pediatrician Al-Agba’s New Republic article cites several children’s deaths following misdiagnoses by advanced practice providers.

Li, meanwhile, doesn’t pull his punches. “Patients trust society to ensure standards in training and competence,” he says. “But this trust is being betrayed in the interest of corporate profits. Misaligned incentives and cutting corners on training can result in catastrophe.”

Limited oversight

According to a study by the Community Catalyst/National Health Law Program, North Carolina does not require urgent care centers to obtain a facility license from the Division of Health Service Regulation as hospitals, nursing homes and other medical facilities must do. They are therefore not subject to state Department of Health and Human Services inspections.

Although some providers must obtain a certificate of need, that document’s purpose is to lower health care costs by preventing duplication of services in a given area rather than to ensure patient safety. And last August, Gov. Roy Cooper signed a law that makes it easier for clinics to bypass this requirement by increasing the amount they can spend on equipment and facilities before a certificate is mandated.

Range Urgent Care is the Asheville area’s only physician-owned facility. The breakdown for the remaining local providers is as follows: FastMed, the nation’s sixth-largest urgent care operator as of 2016, is owned by ABRY Partners, a Boston-based private equity firm. Centra Care (14th-largest) is owned by AdventHealth. And HCA Healthcare owns both My Care Now and Mission Health. Mission spokesperson Nancy Lindell describes its My Care Now facilities as “walk-in primary clinics” rather than urgent care centers. Xpress reached out to FastMed and Centra Care for comment but hadn’t heard back when this issue went to press.

The Asheville area is also home to multiple CVS MinuteClinics. Lacking equipment such as X-ray machines, these in-store facilities typically provide fewer services than do urgent care centers.

Following the money

A key reason for the increase in corporate ownership is that individual urgent care clinics have low profit margins, according to a 2018 article in Medical Economics. As a result, they need a high volume of patients to be viable. The article quotes Stoimenoff advising doctors who want to open urgent care facilities to look for locations with at least 30,000 people living within 5 miles of the target site. A 2016 study by two San Francisco-based physicians found that only 22% of urgent care centers were located in rural areas, even though those have been the places most affected by hospital and emergency department closures.

In Burnsville, a small Yancey County town, the lone urgent care center is run by the Roman Catholic Sisters of Mercy, which operates eight nonprofit facilities in the region. “We have locations in areas where other people wouldn’t dare to go because it’s not very lucrative,” Mercy Urgent Care President and CEO Rachel Sossoman explains. “We exist to serve the need.”

But with the trend toward corporate ownership has come a shift in staffing, notes a 2021 report by the USC Brookings-Schaeffer Initiative for Health Policy. And advanced practice providers cost employers far less than physicians.

In the Asheville area, the average earnings are as follows: $244,100 for family medicine physicians, $115,500 for physician assistants and $113,140 for nurse practitioners, according to 2021 Bureau of Labor Statistics figures.

Who’s in charge?

The debate about whether nurse practitioners and other such providers should have full practice authority is contentious, and the evidence is not clear-cut. As Al-Agra noted in his New Republic article, “There is, unfortunately, little research to bolster the claims of either camp.”

In January, an article in the Journal of Nursing Regulation recommended that nurse practitioners in emergency departments be supervised due to a lack of standardization among the profession’s degree programs. The analysis didn’t include urgent care centers, however. And the American Association of Nurse Practitioners cites studies that found no difference between the diagnosis and treatment provided by nurse practitioners and by physicians.

Indeed, for every study like a 2013 Mayo Clinic investigation, which found that physicians provided more accurate referrals to specialists than did nurse practitioners and physician assistants, there is one like a 2020 review by University of Washington researchers that found no statistically significant difference in clinical outcomes for patients seen by those different types of providers.

At the same time, however, an issue brief from the Primary Care Coalition, a Texas-based partnership of physician advocacy groups, notes a vast difference in the number of training hours physicians receive compared with those for other practitioners. Family medicine doctors must accumulate at least 15,000 hours of clinical training before they’re allowed to operate independently, the paper states, while nurse practitioner programs require anywhere from 500 to 1,500 hours.

Bridging the gap

Another factor that’s driving current staffing patterns is a national shortage of primary care physicians, says Sossoman of Mercy Urgent Care. And according to the Robert Graham Center, which conducts research and advocates on behalf of family medicine policy, North Carolina has fewer primary care physicians per total population than the national average.

Six physicians work across Mercy Urgent Care’s eight locations, with one always on-site at its West Asheville facility. Each of Range Urgent Care’s three locations is staffed with a team of care providers, and co-owner Dr. Stephanie Trowbridge, an emergency room physician, is available to consult by phone or through the company’s electronic medical records.

In an email, however, Range Urgent Care co-owner Mathew Trowbridge strongly disputed the idea “that advanced practice providers are inadequate in providing care to patients,” calling it “inaccurate and frankly offensive. At Range we wholeheartedly and unabashedly believe in the abilities of advanced practice providers to provide evidence-based, appropriate care. We strongly support the role of advanced practice providers in the health care system and would like to emphasize that without them, our system would cease to exist. Advanced practice providers are perfectly qualified to provide care and navigate the health care system for our patients and are vital in helping patients heal while avoiding the expense and discomfort of the emergency department.”

For her part, Sossoman believes the state’s current rules on physician supervision provide “robust safeguards.” Mercy Urgent Care, she says, “has no position on the SAVE Act and no plans contingent on any legislative outcomes related to it. All decisions regarding Mercy’s clinical structure are based on standards of safety and quality for our patients. Those standards are nonnegotiable.”

Old-school medicine

Li, however, sees the very need for urgent care centers as a reflection of more fundamental problems.

“Urgent cares wouldn’t be necessary if we had a functioning primary care system,” he maintains. “A functioning primary care would be able to get you in the same day, and you’d be seeing your doctor.”

To that end, Li prefers the direct primary care model, in which physicians charge a monthly membership fee that enables them to bypass insurers and corporate overhead costs. In Asheville, these fees range from $45-$109; in exchange, patients receive same- or next-day appointments and on-demand remote communication with their doctor. Prices for tests and prescriptions are also often much lower than when they’re obtained through insurance.

The big difference between direct primary care and urgent care is that in the former model, patients have an ongoing relationship with a single practitioner who is always a physician. Perhaps the best analogy, says Li, is having a doctor in the family: someone who knows the patient’s medical history and lifestyle and can factor that information into diagnosis and treatment. Li and other advocates maintain that this form of preventive medicine reduces the need for both urgent care and emergency room visits, where patients have little control over who will treat them.

Satisfaction vs. patient safety

Range Urgent Care recently hired a family medicine physician, Dr. Anna Quinn Harrelson, adding direct primary care as a complement to it other offerings, which include house calls. The latter service exemplifies what makes urgent care so popular: It’s affordable, convenient and focused on patient satisfaction.

However, a 2012 study reported in JAMA Internal Medicine concluded that regardless of clinical setting, patient satisfaction doesn’t always equate to better quality of care. Although patients in the study who reported greater satisfaction received the most discretionary treatments (things like prescriptions, MRIs and other tests), they had a greater mortality risk than did less-satisfied patients.

A 2018 study in the same journal found that urgent care clinics overprescribed antibiotics for respiratory illnesses significantly more than did medical offices, emergency departments and retail clinics.

“We get this in the ER all the time,” says Li, who works at Cherokee Indian Hospital. “‘I didn’t get a prescription,’ or ‘I didn’t get my CT scan or MRI; I waited seven hours.’ You feel ripped off.”

Urgent care centers offer a more affordable alternative to traditional emergency and primary care, and most of the time they fill that gap safely.

“When it’s working well, it is a very beautiful and much-needed service to the community, economically,” says Sossoman.

Some believe the industry needs greater transparency, however. A 2018 study in the Journal of General Internal Medicine found that up to half of respondents weren’t aware that physician assistants can diagnose illnesses and prescribe medications, and one-third didn’t know that this was true for nurse practitioners.

Clearly, the deeper issues in the American health care system — including physician shortages, ever-increasing costs and unequal access to care — aren’t likely to be resolved anytime soon, and precisely where and how urgent cares and advanced practice providers fit into the bigger picture remains an evolving question.

Still, proponents of those approaches say they have complete confidence in them.

“My primary care doctor growing up was a nurse practitioner,” notes Dr. Meredith Ward, a podiatrist at Moore Foot & Ankle Specialists in Asheville. Ward sends her patients to urgent care centers for lab work all the time, she says, and local centers frequently refer their patients to her practice when more in-depth care is needed.

Sossoman agrees, saying, “I would trust any one of our providers with mine or my family’s health care.”