Presenting a live 90-minute webinar with interactive Q&A Urgent Care Centers: Key Legal and Business Considerations Complying With Corporate Practice of Medicine Laws, State Licensure Requirements, EMTALA Mandates, and Reimbursement Laws WEDNESDAY, SEPTEMBER 21, 2016 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific Today’s faculty features: Jon M. Sundock, General Counsel and Chief Administrative Officer, CareSpot Express Healthcare , Brentwood, Tenn. David F . Lewis, Esq., Butler Snow , Nashville, Tenn. The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10 .
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Forming Urgent Care Centers: Addressing Complex Legal Challenges September 21, 2016 David F. Lewis Jon Sundock Butler Snow CareSpot and MedPost 5
What is an Urgent Care Center? No universal definition • • Provide services that fall in between primary care and emergency department Can also include some primary care services and could branch into other • areas, e.g., weight loss, allergy care, wellness, etc. Urgent Care Association of America: • • The delivery of ambulatory medical care outside of a hospital emergency department on a walk-in basis, without a scheduled appointment Generally focused on episodic, acute care rather than • on long-term management of chronic illness or preventive care 6
Common Features of Urgent Care Centers Retail healthcare High focus on customer convenience No appointments required and short wait times Extended hours, including weekends and evenings Broad list of services beyond primary care offices X-ray EKG Onsite lab for CLIA waived testing Ability to perform minor procedures like laceration repair and splints 7
Why the Growth in Urgent Care Centers? Growth spurt began in mid-1990s and has continued • • Since 2008, the number of urgent care centers has increased from 8,000 to more than 11,000 Why the continued growth? • Acceptance by the public • Lack of access to primary care (no access or delayed access) • Overcrowding in Emergency Departments (ED) • Affordable Care Act has not slowed growth in ED visits • Long wait times at other providers (EDs especially) • • Convenience of longer hours and walk-ins Emphasis on high-quality care • Increased healthcare consumerism spurred by • high-deductible plans 8
Current State of Urgent Care Centers Over 150 million patient visits to urgent care centers each year in the United States By 2018, total urgent care industry revenue is projected to exceed $18 billion There have been significant transactions in the urgent care industry Tenet Healthcare’s purchase of CareSpot Express Healthcare Wellpoint’s purchase of Physicians Immediate Care Dignity Health’s purchase of US Healthworks 9
Current State of Urgent Care Centers Would anticipate additional consolidation in the industry More health systems acquiring urgent care centers and developing additional urgent care centers Continued interest by private equity players in having interests in urgent care companies Various strategies remain viable: Urban focus Rural focus Pure play urgent care Hybrid models primary care focused Telemedicine 10 10
Current State of Urgent Care Centers 2015 UCAOA Benchmark Report Nearly 90% of urgent care centers saw an increase in the number of patient visits from 2013 to 2014 Nearly 25% of all urgent care centers are owned by hospitals or health systems Approximately 20% of urgent care centers are owned by two or more physicians About 27% of all emergency room visits could take place in urgent care centers (with approximate cost savings of $4.4 billion) By 2019, large metropolitan areas could support two to three times the number of current urgent care centers 11 11
Current Distribution of Urgent Care Centers 12 12
Key Legal Considerations Corporate Practice of Medicine Staffing Models State Licensure and Permits Documentation and Coding Other Focus Areas Medical Director Accreditation EMTALA Other Compliance Matters 13 13
Corporate Practice of Medicine The corporate practice of medicine doctrine prohibits employment of clinical personnel by corporations Purpose is to protect the integrity of medical profession by keeping it separate from corporate interests State laws vary on the doctrine Strict prohibitions Some Limitations No prohibitions 14 14
Corporate Practice of Medicine Certain states are very strict - any corporation employing a licensed physician to treat patients and receive fees for those services is unlawfully engaged in the practice of medicine Texas, New York, California, and Illinois are examples of states with strict corporate practice of medicine perspectives Employee-physician subject to disciplinary action or license revocation In strict states, structuring arrangements carefully is very important. 15 15
Strict Prohibition Against Corporate Practice of Medicine Narrow exceptions could apply: Professional corporations formed by physicians – this is a common permitted corporate structure in states Texas utilizes the “501(a)” structure as a unique exception California permits the use of a “foundation” model The “Friendly PC Model” is commonly used in strict corporate practice of medicine states Physician owned professional corporation is managed by a corporate entity for a fair market value management fee. 16 16
Less Strict Approach to Corporate Practice of Medicine Permits physician employment as long as the terms of relationship do not violate statutory requirements: “Entity does not direct or control independent medical acts, decisions, or judgment of the licensed physician” Most physician-entity employment relationships permitted as long as physician’s professional medical discretion is preserved Indiana and Florida are examples of states with this approach. 17 17
Urgent Care Staffing Models Common staffing models for urgent care centers: Physician-only staffing Primarily physician staffing supplemented on a limited basis by mid-level providers Primarily mid-level staffing with supervision provided by physicians most often through “indirect supervision” Considerations for choice of staffing models: Economic considerations Public perception considerations Availability of staffing to meet needs 18 18
Urgent Care Staffing Models Here are some 2014 statistics on staffing models used at urgent care centers: 11% are physician only Will this percentage decrease over time? 29% have a physician and midlevel working together 54% have physician supervision with the physician not onsite 4% have no physician supervision (permitted by state regulation) For non-clinicians, over half of the urgent care centers use medical assistants (40% used RNs) and nearly all urgent care centers (93%) use X-Ray Technicians 19 19
Urgent Care Staffing Models Direct Supervision versus Indirect Supervision Direct supervision - when the physician is working at the same time in the same building with the mid-level provider Indirect supervision – when the physician and the mid-level provider are not working at the same time but the physician is available for consultation State requirements impact supervision arrangements Scope of practice for nurse practitioners and physician assistants may not be the same Supervision requirements for NPs and PAs may not be same State requirements may be harder to satisfy 20 20
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