By Scott Scanlon – Refresh Editor
Dr. Mark Pundt has spent more than 20 years as an emergency room doctor in the Western New York medical field.
The North Tonawanda native and Lancaster resident has watched emergency medicine change since his early medical years – and has reacted to the transformation by looking to help fix the logjam in in the region’s emergency rooms.
He did so by becoming an early pioneer in the urgent care movement in the region – one that has arrived, and mushroomed, with its critics.
Today’s “In the Field” feature in WNY Refresh focuses in part on what prompted this new segment of health care and, generally, how urgent care centers operate.
Pundt and I talked on Monday morning in the MASH Urgent Care site on Transit Road in Clarence, The 8,000-square-foot center is a sort of flagship of the seven-site MASH Urgent Care network that Pundt leads – find all the locations at mashurgentcare.com – but it shares a similar model and flow to all the others.
He compared it to a Tim Horton’s. “You know what you’re going to get when you walk in.”
The flooring is a hardwood-style laminate, the walls neutral in color. The patient exam rooms are clean, warm and quiet, with small flatscreen TVs. The goal is to get patients into one of these rooms within five minutes of arrival. An attending nurse or medical assistant then wheels a laptop and credit card payment machine into the room, takes general information – including for your malady and insurance – and handles things quickly.
If blood is needed, it’s drawn ASAP. Nurses and radiation technologists have been cross-trained to conduct the testing ASAP. If a cut needs to be closed or a sprain or fracture X-rayed, the procedure room is right around the corner.
The setup allows for efficient flow, Pundt said, and 95 percent of patients are in and out within an hour.
This Clarence site also has an in-house pharmacy staffed by Mobile Pharmacy Solutions, and other sites also are served by the company, so patients in need of prescriptions can have them filled on-site, or delivered to their homes at no additional charge. An occupational therapy office also sits at the back of the site for workers comp cases and pre-employment testing.
The regional medical establishment was hestitant at first about places like this, particularly primary care doctors who saw the concept as a professional threat. Many still do. But in the decade since Pundt and a group of nine other ER docs founded MedFirst, the concept continues to gain steam.
Pundt today is CEO of the medical side of the MASH Care Network, which MedFirst folded into in 2012, as well as Professional Emergency Services, which staffs three regional emergency departments and helps several medical groups with billing.
He wants the medical consumer to understand this – patients will bear a greater portion of their health costs in years to come, so it benefits them to make good wellness choices and plug into a system designed to address access, efficiency and cost when it comes to necessary care.
During our interview, he talked in detail about the transformation of emergency care. He also answered concerns that the growing number of urgent care centers in the region threatens primary care providers, which was the subject of a recent front page story by Buffalo News Medical Reporter Henry L. Davis.
“The standard urgent care model, other than us locally or nationally, is a walk-in center that does compete with everyone else in the region – the primary care doctors, the hospital emergency docs, other urgent cares, specialists,” Pundt told me. “Our model is collaborative. We approach other primary care doctors to act as an extenstion of their practice.”
Below are excerpts from our interview.
What was your experience like working as an emergency room doctor back in the mid-1990s compared to what it’s like now as you’re helping to staff emergency rooms?
As emergency medicine became recognized as a profession – it didn’t become a medical board specialty until the late ‘80s – more and more of the initial treating and screening and testing was done in the emergency department. When I was training, my first few years out, you would take care of everything you could treat and discharge. But other patients you would triage, stablize and admit, and the admitting doctors would do all the testing.
Over the last 20, 21 years, now in the emergency department, someone comes in and all the initial testing and treatment is started before it’s handed over to the inpatient doctors. That is why there’s greater slower through-puts, because before, if someone was short of breath, we’d do a quick X-ray and say, ‘Yes, they have pneumonia’ and admit them,’ or ‘Yes, they have congenital heart failure’ and admit them. Now, we’ll do CT scans if we need them, MRI scans if they need them, and have to start all the antibiotics and initial treatments in the emergency department before they go into the inpatient side, so emergency care is much more involved...
They’ve decreased the number of beds in inpatient settings through the Berger Commission, so there’s a greater backup of admitted patients in the emergency department. There’s not beds to move them to because we can’t move them out and up.
So at some point, you saw an opportunity?
As the amount of work we had to do on the inpatients increased, we saw that the less ill, or the ones we knew would be treated and sent back home, were waiting longer because you have to take care of higher acuity cases in the emergency department or you’ll have worse outcomes.
So we said, ‘Can we create a venue we can move patients through much more efficiently, and maintain or enhance the quality of an emergency department?’ At that point, we realized that medicine was going in the direction that if we don’t do something about it, it’s going to injure the economy, locally and beyond. So we started to look for ways to lower the cost of care and provide that care at not only a more efficient time frame for the patients but a more efficient cost to the (health insurance) payers, the community and to the patient.
How did you go about gathering physicans who felt the same way to invest, as well as convincing insurers and health agencies this was a good idea?
The physicians were straightforward. We had started the staffing company for emergency medicine, we had all worked as a group of about 10 of us at the time who were co-owners of the staffing company, and we all agreed we would take some time and staff the urgent care. They all worked with me and saw the need as I did.
From the standpoint of the health insurers, they were trying to develop more of the after-hours care models in primary physicians' practices. They were concerned, at first, with trying to start an alternative venue of care. However, because we were working in partnership with some of the primary doctors, as well as looking at reducing costs, they agreed that the model made sense to them.
We also approached our partners at the time, and started our first MedFirst site (at the Dent Tower) in September of 2004.
This particular realm in health care has snowballed since. Why?
Part of the growth is because of convenience and part is the affordable costs. As we hit the Affordable Care Act days, that’s going to grow.
Part of the problem with emergency departments is, very simply, they are the safety net of medicine. When a patient cannot get care anywhere else, they go to emergency departments, whether they need it or not. If they need care with a primary doctor, don’t have one or can’t get an appoinment, the old default was the emergency department. Now, there’s a new default: urgent care. The public also is being educated that if they don’t need an emergency department, urgent care is there.
It will continue to grow because as the Affordable Care Act enrolls more and more people in insurance, they’ll want more and more care but we will have a greater and greater shortage of primary care doctors. It’s either going to go to the emergency department or urgent care. With the growth of urgent care networks in the country and in the region, urgent care networks will become that safety net for non-emergencies.
Are you involved in more than urgent care?
The MASH Care Network also has non-emergency medical transportation, which does transportation to and from hospitals, doctors offices, dialysis units. We do a lot of work with the developmentally disabled, getting them to their work and home. We have a division that manages the transportation not only for our non-emergency transportation vehicles but others in the region. The emergency medicine practice is part of the MASH Care System as well, MASH Emergency Services. The last subsidiaries are the MASH Physician Services (ER docs and billing) and the Occupational Health Division of MASH Urgent Care.
There are about 150 employees n the MASH Urgent Care sector of the 600-worker MASH Care Network.
Can we talk about ownership?
The MASH Care Network is a group of physicans I started with a holding company, and that holding company owns half of the MASH Care Network; Snyder Corp. owns the other half of the network. They brought in the transportation side and we brought in the medical entities. That occurred March 1, 2012. That was another reason we rebranded (from MedFirst), to get all of this under one network. My role is CEO of the medical division, which is overseeing the urgent care, the emergency medicine side and the shared services that supports the medical groups.
What kind of doctors do you have at MASH Urgent Care?
We have a blend of emergency doctors and family practice doctors, board certified. The reason we choose those is they’re educated in their training from conception to end of life, so they can take care of any age patient who walks in. It’s probably staffed about 50-50 by both.
What percentage of the docs you have in here are working somewhere else at least part of the time?
About 50 percent. Our emergency docs pick up both and then we have some family docs who moonlight with us. Most of the family practice docs are urgent care only.
What are your hours?
We open at 8:30 a.m. and provide medical care from 9 a.m. to 9 p.m.; it functions like a restaurant, as long as you walk in by 9 p.m., you’re seen. And that’s 365 days a year across all seven sites. (A “global fee” of $135, which covers all services offered in-house is charged to those without insurance; those with insurance see a co-pay generally one-third to one-half of emergency room co-pays).
What have you discovered to be the busiest times of day?
We find it’s early in the morning until about 11 a.m. and it ramps up again from 4 o’clock until close, when people are coming home from work and school.
What about the busiest days of the week?
Generally Friday through Monday.
Some primary care doctors express concern that urgent care centers are trying to replace them. Do you see yourself as an extension of the primary care office?
The standard urgent care model, other than us locally or nationally, is a walk-in center that does compete with everyone else in the region – the primary care doctors, the hospital emergency docs, other urgent cares, specialists. Our model is collaborative. We approach other primary care doctors to act as an extenstion of their practice. We work with them so they will communicate to us ahead of time if a patient is coming in, what they’re coming in for – their allergies, medications, previous medical problems. We will see the patient and if they’re acute we will communicate verbally with that primary care doctor and make a plan to treat. If it’s something more straightforward, once we close our encounter documentation, it immediately is routed to that primary physician, either by fax or electronic medical record, so they have the information of what we did for the patient.
We also use their referal patterns, so if a patient comes in and needs an orthopedic doctor or an ear, nose and throat specialist, or admission to the hospital, we follow the pattern of the primary care doctor, so we act as an extension of their practice.
With that collaboration, primary care doctors see us as a partner. What they’ve experienced is that although the larger practices can afford to stay open after hours or on weekends, most of the smaller practices (find it more difficult). When primary care practices do that, they only attract patients from their own practices, therefore they’re adding overhead without much more patient flow, so it becomes difficult for them to survive, so they need partners who can provide this after-hours service, but they need collaborative partners. So we work patients to call their doctor first, to go to their doctor with the sore throats and sinus infections. When their doctor directs them to us, or if their doctor is unavailable, we’re here.
Are you involved with any particular groups or primary care docs?
We have a pilot project with some of the Catholic Medical Group doctors (seven practices and 30 physicians). We also collaborate with the Buffalo Medical Group ... (and) the Primary Connection out of Independent Health.
With that collaboration, are there financial incentives?
No, it’s all clinical incentives. It’s for the clinical care for the patient.
What would you say to a primary doctor who says, ‘I just went to medical school, put up all this money and put up a shingle and now I’m going to be losing some of my patients to urgent care?’
I tell them the facts. The first fact is they want a lifestyle that is more than work. If they’re keeping their office open all hours, guess who has to staff it? Guess who’s getting calls through the night when they’re trying to have family time? We’re trying to offload that and make their lifestyle better. We’ve even had some practices call and say, ‘We’re very busy today, we don’t have any slots in our schedule, can you cover any of these unanticipated calls, can I send them to you?’ So we help them with that.
On top of that, there’s a lot more work that’s spent these days in a primary care office on chronic disease and preventative care, so they have less time for episodic, unanticipated, unscheduled care.
The literature shows that primary physicians have lost 1 percent of their patient volume to urgent cares but there’s 10 times as many patients waiting for chronic management doctor visits; 30 percent of our patients do not have a primary care doctor, so we can help build a practice. We need primary care doctors to refer to so we can help build a practice, as well.
With that type of collaboration, we make their lifestyle better, their practice life better – and by the way, you get paid more for a chronic disease visit than an episodic care visit – so you actually can enhance your practice income, not directly by giving them money but how we can help the patient flow.
The other thing we can do is increase patient satisfaction because they now have seven sites they can go to – eight when their doctor’s office is opened.
So you don’t tell patients, ‘You can come back for a well patient visit?’
We do the opposite. We refer those type of things to the primary care doctor. We sometimes do sports physicals, that type of thing, if the patient doesn’t have a primary care doctor or if the primary care doctors, like pediatricians at the beginning of school, will call us asking for help.
So the bottom line is you saw a need and filled it.
We found a need, filled it, and we’re being asked to fill other niches, as well. We saw the transporation niche. We’re filling the occupational niche. But we’re doing it in collaboration and we’re helping build a new medical delivery system that has more access, high quality, but is more cost-effective and time efficient than the previous model.
Collaboration is the key thing. We have strong relationships with the big three local payers. We meet monthly for sure, sometimes weekly. They’re very happy with our ways to fill that niche.
Looking out five years, do you think most urgent care centers are going to be using the model you’re using now, and what is health care going to look like then in Western New York?
From the beginning, we derived the urgent care part of our network plus our transportation as being the glue to something called the ‘patient centered medical home’ or the ‘accountable care organization.’ Being the glue to support getting the people where they need to be, see people when it’s unanticipated when they need care.
Today, the urgent care network is looking for the dominant platform. It hasn’t found one because the other platforms are all competing with the provider platforms and other stakeholders in the community. We believe our platform will be the model of the future because it’s integrative and collaborative. It creates a new delivery model that creates greater access, high quality care at a lower cost. We believe this will be the model not just regionally but beyond.
The payers are all in, the health systems are all in and more and more community doctors are finding out what we’re all about.