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Urgent care centers proliferate in Mass., but fewer low-income patients have access

CareWell Urgent Care operates 16 centers in the state, including this one in Framingham.
CareWell Urgent Care operates 16 centers in the state, including this one in Framingham.(Barry Chin/Globe Staff)

Need an X-ray and stitches to go along with your burrito and office supplies?

Urgent care centers, walk-in clinics that treat a range of pressing medical issues, are proliferating in crowded shopping centers and along busy roads across the state, especially in affluent suburbs. One 2-mile stretch of Route 9 will soon have four urgent care centers, the newest next to a Chipotle and a Staples in Natick. Chestnut Hill has three within a 15-minute drive, and Cambridge, four.

But no companies have rushed to open urgent care centers in Dorchester, Roxbury, or other lower-income neighborhoods in Boston.

The explosion of the urgent care industry is reshaping the health care landscape in Massachusetts and across the country. A state commission counted 150 urgent care centers last year, up from 18 in 2010. And more are coming this year.

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The centers lure patients with convenience: They don’t require appointments, and they typically are open until 8 or 9 p.m., and on weekends. They promise to treat almost any non-life-threatening medical issue — at a fraction of the cost of hospital emergency rooms, and without the long wait.

What they don’t tend to prioritize is care for the poorest. Most firms operating urgent care centers report that only a small percent of their business comes from patients on Medicaid, known here as MassHealth.

And it remains unclear what effect these centers have on the overall health care marketplace. Do they help contain spending by diverting patients from emergency rooms? Or do they add to costs by encouraging new visits?

“There are a lot of issues around these urgent care centers that trouble me,’’ Massachusetts House majority leader Ronald Mariano said. They “are changing the face of health care in an extremely short period of time.’’

MassHealth insures more than one-quarter of the state’s residents.

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But at two of Massachusetts’ largest urgent care operators, American Family Care and CareWell Urgent Care, just 11 percent and 2.5 percent, respectively, of patients are on MassHealth.

In another type of walk-in medical clinic that provides more limited services and is located in CVS stores, just 5 percent of patients are on MassHealth.

MassHealth patients, meanwhile, still rely heavily on chaotic and expensive hospital emergency departments, though in some urban neighborhoods, community health centers offer expanded hours for urgent medical needs.

Data from emergency rooms make that clear: Nearly half of visits to the three emergency departments run by Cambridge Health Alliance, in Cambridge, Somerville, and Everett, are by MassHealth patients, according to state data. At MetroWest Medical Center emergency rooms in Natick and Framingham, MassHealth patients account for more than 18 percent of visits.

Even the national urgent care lobbying group acknowledges the disparity.

It estimates that 30 to 40 percent of centers refuse to treat Medicaid patients, saying the public program has onerous requirements and does not pay enough to cover their costs.

“We are not trying to cherry-pick, but we have to be sustainable,’’ said Dr. Gene Green, president of South Shore Health, the parent company of South Shore Hospital that recently bought six Health Express urgent care centers. About 2 percent of the centers’ patients are covered by MassHealth.

Some hospital systems, such as Cape Cod Healthcare, are building their own urgent care centers as part of a strategy to attract and retain patients in their networks.

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Compared with competitors, Cape Cod Healthcare sees a relatively higher share of MassHealth patients at its urgent care locations — about 20 percent.

“That’s our population,” chief executive Michael K. Lauf said. “Do I think the odds are stacked against us [financially] because we do that? Yes.”

MassHealth pays health care providers much less than commercial insurers. CareWell, for example, said it receives an average of $74 for each urgent care visit from a MassHealth patient; commercial insurers pay CareWell at least double that — an average of $150 to $200 per visit.

That gap is one factor that pushes some providers to target middle- and high-income patients.

An analysis by the state’s Health Policy Commission found that 58 percent of urgent care centers and 72 percent of CVS’s MinuteClinics are located in ZIP codes where residents earn above the median income.

“They are going to get a higher reimbursement by getting people with commercial insurance. Therefore, it’s in their financial interest to be in communities with higher-income patients with commercial insurance,” said Dr. Ateev Mehrotra, a professor at Harvard Medical School who studies walk-in clinics.

Massachusetts now has 59 MinuteClinics, up from 46 five years ago.

A CVS spokeswoman said the company selects locations based on a variety of factors, including store size and regulatory requirements.

Jim Brennan, area executive for American Family Care in Massachusetts, said his company’s method for choosing urgent care locations is proprietary.

But executives generally search out retail centers with heavy pedestrian and car traffic, and neighborhoods with busy families consisting of two working adults and teenagers who play sports — and face sports injuries.

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“Those people value their time,’’ American Family Care spokesman William Koleszar added. “We want it to be as easy to come to urgent care as it is to pick up their dry cleaning.’’

While AFC executives said their urgent care centers in low-income communities like New Bedford “do very well,’’ they said the state makes it harder for lower-income people to use them.

For those enrolled in MassHealth managed care plans — about 1.2 million people — the state generally will not pay for an urgent care center visit unless the patient has a referral from a primary care doctor.

Urgent care companies say the referral rules are dated and burdensome and prevent them from treating larger numbers of low-income patients. They want the rules lifted.

“We can be turning away dozens of [MassHealth] patients a day because we don’t have referrals,” said Shaun Ginter, chief executive of CareWell, which operates 16 urgent care centers in Massachusetts, from Worcester to Peabody to South Dennis.

But Massachusetts Health and Human Services Secretary Marylou Sudders said she is concerned about MassHealth patients going to urgent care centers that are not connected to larger health systems; encouraging treatment there would be “antithetical’’ to the state’s plan to manage care for MassHealth patients by requiring them to stay within specific networks of health care providers.

State officials are considering licensing urgent care centers. “They are a growing part of health care. We need to take a prudent look,’’ Sudders said.

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MinuteClinics began opening in Massachusetts more than a decade ago and are already regulated by the state, which requires them, for example, to provide a list of primary care doctors for customers who don’t have one.

Urgent care centers are still new enough to Massachusetts that the state has no official definition for them, nor specific rules for how they operate or what illnesses they can safely treat.

While most states do not specifically license urgent care centers, their oversight has grown with the expansion of the industry.

Urgent care centers can range from small offices staffed by nurse practitioners to large facilities run by emergency physicians, with expensive imaging equipment and blood-testing laboratories. Their hours vary.

Some centers are set up as doctor’s offices and charge similar prices, while others are licensed as hospital outpatient facilities and charge additional hefty fees that often come as a surprise to patients.

“There still needs to be education about what kinds of services urgent care centers actually provide to the community, and who can actually access their services,” said Senator James Welch, cochairman of the Legislature’s Joint Committee on Health Care Financing.

Welch and Mariano expect lawmakers to work on health care legislation this session that includes regulations on urgent care.

Dr. Scott Weiner, president of the Massachusetts College of Emergency Physicians, said patients don’t always know where to go.

Weiner, who works in the Brigham and Women’s Hospital emergency department and its urgent care center in Foxborough, said he often sends patients from Foxborough to the hospital because they need more extensive testing, for example, or need to be admitted to the hospital overnight for chest pain.

“I don’t think patients fully understand the differences in services between the two sites,’’ he said.

“We need to do a better job educating people.’’


Liz Kowalczyk can be reached at kowalczyk@globe.com. Priyanka Dayal McCluskey can be reached at priyanka.mccluskey@globe.
com. Follow her on Twitter @priyanka_dayal.