A new report calls attention to the lack of regulation surrounding urgent care clinics—a popular source of COVID-19 tests during the pandemic—and implores states to boost their oversight.
Not-for-profit consumer advocacy groups Community Catalyst and the National Health Law Program found that there's no way to ensure low-income patients are able to access and afford services at urgent care clinics or retail health clinics. Most states don't license the facilities, and don't require them to serve uninsured patients or those with Medicaid.
It's a relatively new phenomenon, although the clinics gained attention during the pandemic, having provided more than 725,000 COVID tests. The report found the number of urgent care clinics nationwide grew 33% to 10,000 clinics between 2015 and 2020. The number of retail health clinics, those located in drug stores or retail outlets, almost tripled to 2,700 between 2013 and 2019.
"To the extent these urgent care clinics and retail clinics are expanding, we want them to be expanding access as well—not just to patients that can pay out-of-pocket but to have some kind of broader community responsibility for those who are on Medicaid or other public health insurance programs," said Amy Chen, a co-author of the report and senior staff attorney at the National Health Law Program.
The Urgent Care Association, a membership association for the sector, did not respond to requests for comment on the report.
In the 40 states that don't issue facility-specific licenses, the report found most urgent care centers are operated under an individual physician's license or hospital license. Even so, the report said they're generally able to evade scrutiny by state health departments.
Connecticut, by contrast, requires urgent care centers to undergo state inspections every three years. New Mexico requires potential urgent care operators must submit letters of intent to the state describing the services they'll offer.
The report recommends reforming state licensing requirements and Certificate of Need programs to consider urgent care clinics specifically. Thirty-six states plus Washington, D.C. have CON programs, which require providers to apply with states before adding certain types of services and facilities.
"States don't need to reinvent the wheel," Chen said. "There are some models they can look at."
The report focused on state regulation as opposed to federal because states license medical facilities and operate CON programs. Lois Uttley, co-author of the report and director of Community Catalyst's Women's Health Program, said she's also interested in any action the federal government might consider.
The report urges states to require the facilities to accept uninsured patients and those with Medicaid, and to require those patients comprise a certain percentage of their business. Right now, Vermont is unique in that it forbids urgent care centers from discriminating on the basis of insurance status or type of coverage. The state also has a working group examining possible changes to its licensing requirements for those facilities.
"We want to make sure that these urgent care clinics are in fact serving everyone, not just people with commercial health insurance," Uttley said.
The report raised questions about the availability of certain reproductive and sexual health services at religiously-affiliated clinics. Four large Catholic health systems together run 342 urgent care centers that are likely to be subject to church healthcare rules that bar them from providing services like contraception, abortion and infertility services, the report found. One system, Chicago-based CommonSpirit Health, operates 115 urgent care clinics, including retail clinics located in Hy-vee grocery stores, where the report said reproductive and sexual health services are not offered.
CommonSpirit said its clinics in Iowa and Nebraska are walk-in clinics focused on minor medical conditions such as ear infections, strep throat and sports physicals. "They would not be the appropriate level of care for women's reproductive health services," the statement said. "We are committed to meeting the unique health needs of women in our communities, and our providers and care sites will always direct a patient to the appropriate care setting if we don't offer a particular service."
A large Catholic system, Livonia, Mich.-based Trinity Health, recently acquired a majority stake in a privately-held urgent care company with more than 70 locations in nine states and growing.
In 2016, Community Catalyst and the National Health Law Program did a secret shopper study to find out what services were offered at 18 Catholic urgent care centers compared with 20 non-Catholic ones. None of the Catholic centers could help a patient experiencing symptoms of early miscarriage, compared with roughly 70% of the secular clinics. Just over one-quarter of Catholic clinics could help a patient obtain birth control, compared with more than half of the secular clinics.
Uttley said a big issue is simply confusion around what services are and are not offered at urgent care clinics, especially compared with emergency rooms. A lot of people don't understand that urgent care clinics don't offer the same intensity of services as ERs. New York lawmakers considered a measure that would have required urgent care clinics to remove the word 'emergency' from their signs, she said.
The report recommends states require care coordination among urgent care centers, retail clinics, primary care services and hospitals. It also says health advocates should try to encourage more equitable distribution of the facilities in low-income neighborhoods rather than just in upper- and middle-class ones.
The report did not explore the effects of private equity ownership of urgent care clinics, but Uttley said it's a subject of future study. Investment firm Warburg Pincus made waves in 2017 with its acquisition of a majority stake in CityMD, and the trend has continued since then.
