HD45 - Commercial Walk-In Medical Clinics in the Commonwealth
Executive Summary: The lifting of regulatory restraints and the unleashing of market forces in the early 1980s created unprecedented growth and diversification in the provision of outpatient health care services in Virginia and throughout the nation. A significant part of this growth is the proliferation of walk-in medical centers (WIMCs) that provide primary health care services to an increasingly broad segment of the population. These consumers require and demand services organized and delivered to appeal to their special needs for convenient, essentially episodic care. While the growth of WIMCs throughout the decade has been dramatic, there is current evidence of market saturation and decreased rates of growth. Nonetheless, freestanding, walk-in medical centers comprise a significant and permanent part of the health care delivery system. Many services can be provided cost effectively in these centers, and both patients and third party insurers are increasingly willing to pay a premium for convenience. During the past decade, policymakers have identified legitimate public protection concerns related to the operation of WIMCs. These concerns focused especially on centers owned or operated by corporate or commercial interests, often located far from the point of service delivery and from local or state oversight. The diversity of organizational arrangements in the current market, however, frustrates any effort to pinpoint centers that are "commercial" in character. Industry studies document a changing profile of ownership and operation of walk-in centers. While most WIMCs were originally owned and operated by physicians, there is a pronounced trend toward ownership by hospitals and for-profit corporations. At one end of a continuum of ownership and service provision are the primary or specialty care practices of physicians or groups of physicians on an extended schedule of hours, often on a "no appointment required" basis. At the other end of the organizational continuum are hospital-owned or corporate-affiliated centers that provide true emergency services, or specialty services such as imaging, ambulatory surgery, dialysis or cardiac catheterization on an outpatient basis. Many variations of ownership and operation exist between these points. The literature documents that WIMCs may be owned by individual physicians or groups of physicians, laymen or groups of laymen, corporate franchisers or franchisors, secular or sectarian hospitals or chains of hospitals, public or private corporations, venture capitalists, and governmental, scientific, charitable and other public, quasi-public, and private concerns. Physicians, nurses, pharmacists and other licensed health professions in the Commonwealth are regulated by boards within the Department of Health Professions, regardless of practice setting. Some centers that function as hospital satellites are regulated by the Department of Health, but there is no coordinated regulatory program that extends to all WIMCs. As a consequence of public protection concerns and the lack of a coordinated regulatory program, House Joint Resolution 303 of the 1989 Session of the Virginia General Assembly requested the Department of Health and the Department of Health Professions to study the need to regulate commercial walk-in medical centers as an approach to ensuring greater consumer protection. The most prevalent concerns related to WIMCs include: • misleading advertising of facilities and services as "emergency" or "urgent care," and the potential for harm that may result from public misunderstanding of the true nature of services available in WIMCs; • the quality of episodic care, generally, including specific concerns for patient record keeping and transfer, adequacy of staffing and equipment, and the coordination and integration of WIMC services with attending physicians, specialists, and community emergency services; • access to WIMC services for the medically indigent, recipients of publicly funded health services, and others with limited ability to pay; and • the potential for WIMCs to (a) shelter health practitioners with histories indicative of incompetent or unscrupulous practice; and, (b) inadvertently contribute to prescription drug addiction or abuse problems. • difficulty in determining accountability due to ownership characteristics and the mobility of employed physicians, nurses, and other professional staff. In response to HJR 303, an interagency task force studied these issues with the assistance of expert individuals and organizations and the general community of health care providers and consumers in Virginia. The objectives of the review were to determine: • the degree to which these concerns are valid and unique to specific segments of the health care enterprise; • the adequacy of voluntary efforts within the health care industry to address these concerns; and, • the need for state regulation as a means to address unresolved concerns. The task force was governed in its review by statutory and administrative policies that restrain the use of the regulatory authority of the Commonwealth, unless it can be clearly demonstrated that regulation is required for public protection. While the task force found a potential for public harm to exist in some WIMC operations, it also determined that this potential extends beyond WIMCs to the larger general arena of outpatient health care. It is not possible to relate the potential for harm to specific characteristics of WIMC ownership or operation that are amenable to effective state regulation. It was also clear to the task force that problems identified early in the decade of the 80s have been addressed by voluntary, private sector quality assurance initiatives. These initiatives are prompted by existing and emerging standards for third party reimbursement, by the forces of competition, by increasingly influential accreditation and peer review programs, and by the possibility of governmental intervention should voluntary efforts fail. Regulation invariably increases the cost of services and may hinder innovation in the marketplace. Only a small number of states have proposed or implemented regulatory approaches to the resolution of concerns related to WIMCs, and several of these have abandoned or withdrawn their initiatives. The task force found no evidence that those few regulatory programs that have been implemented have been sufficiently effective in protecting the public to warrant regulatory costs. Indeed, there is no evidence available to demonstrate that state regulation offers greater public protection than voluntary compliance with industry, accreditation, or reimbursement standards. Notwithstanding these observations, participation in voluntary standard-setting programs is not universal. While competition may eventually eliminate risky or exploitative practices in the health care marketplace, the Commonwealth has a legitimate concern in monitoring WIMCs to assure continued safe practice. To this end, the task force has prepared recommendations to address concerns identified in its study. Identifying and Classifying Walk-in Medical Centers It is in the interest of the Commonwealth that an inventory and classification system for walk-in medical centers be established. The Task Force recommends that the Department of Health initiate a voluntary registration program for walk-in medical centers in the Commonwealth. A voluntary registration program can contribute to sound health planning and policy through a systematic inventory and classification of primary and other health care resources in Virginia communities. Assuring Quality and Continuity of Health Care Virginia citizens are entitled to quality health care services that are appropriately marketed and coordinated with other community resources. The Task Force recommends that the Department of Health distribute this report to all known walk-in medical centers in the Commonwealth to encourage their participation in private sector quality assurance programs, including those programs that set standards for staffing and equipment, marketing, and coordination with community resources appropriate to the level of service actually provided within these centers. Access to and Payment for Services Walk-in medical centers represent a unique point of access to the larger health care delivery system and make important contributions to the provision of primary health care in Virginia communities. Increasingly, services provided in these centers are reimbursed by public and private third party reimbursement plans. Standards established by insurers are important elements in assuring access, quality and coordination of services provided by walk-in centers. The Task Force recommends that the State Health Planning Board, the Virginia Department of Health, and the Department of Medical Assistance Services receive this report and consider walk-in medical centers in their approaches to the more general problems of geographic access to primary health care and to health care for the uninsured, underinsured, and medically indigent. Licensed Practitioners and Controlled Substances Special efforts are required to ensure that walk-in medical centers do not inadvertently shelter problem practitioners or contribute to prescription drug diversion or abuse. The Task Force recommends that the Department of Health Professions request the U. S. Department of Health and Human Services to include walk-in health centers explicitly in the requirement for participation in the National Practitioner Data Bank. The Task Force also recommends that the Department provide all known walk-in health centers with statutes and regulations governing controlled substances and the practice of physicians, nurses, pharmacists, and other licensed health care providers. The Department should also encourage centers to make readily available to patients the procedures for complaints involving licensed professional practice. Ensuring for Continued Safe Practice While the task force concludes that the regulation of walk-in medical centers is not currently warranted, a method to monitor continued safe practice within these centers is necessary. The Task Force recommends that the Department of Health survey all known walk-in medical centers in the Commonwealth by 1992 and periodically thereafter to assess the degree of compliance with private sector standards for safe and appropriate care. The Task Force also recommends that all agencies of the Commonwealth that receive and adjudicate health care complaints remain vigilant in the detection of problems related to walk-in medical centers. |
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