Health Care

Green Mountain Care Board gives ClearChoice the green light for urgent care centers

The Green Mountain Care Board ruled Tuesday that a New Hampshire urgent care company does not need further review of its plans to operate centers in Vermont.

The New London, N.H., company ClearChoiceMD had requested that the board make a determination whether its plan to open five centers in Vermont would trigger the certificate of need process.

ClearChoiceMD owner Marcus Hampers. Photo by Jennifer Hauck/Valley News
ClearChoiceMD owner Marcus Hampers. Photo by Jennifer Hauck/Valley News

In a letter to ClearChoice attorneys, the board concluded that the urgent care centers proposed by ClearChoiceMD do not trigger Certificate of Need (CON) thresholds “and as such are not subject to review.”

Urgent care facilities provide a lower-cost alternative for people with non-life-threatening injuries or illnesses, such as fevers, infections or fractures, who can’t get in to see their primary care doctor and don’t want to seek care in a hospital emergency department.

A shortage of primary care doctors throughout the United States has increased demand for urgent care services.

ClearChoice has already leased properties in Rutland, Burlington, Brattleboro, St. Albans and Barre. The company intends to open the Barre and St. Albans locations in June.

Central Vermont Medical Center in Berlin will open its own urgent care center in May. The hospital was not required to obtain a certificate of need either, because the standalone facility does not meet cost thresholds to trigger the oversight process.

The two urgent care centers in Barre would be just a short distance from one another on the Barre-Montpelier Road.

Northwestern Medical Center has plans to open an urgent care center in St. Albans as well, meaning the city will also have two centers. Fletcher Allen Health Care also operates a urgent care center in Burlington.

Hospital executives say they want the process to be regulated to ensure there will not be a duplication of services that will drive up health care spending because of fixed system costs.

ClearChoice executives say that without competition, hospital-owned urgent care centers have no motivation to lower prices.

Advocates for universal health care and hospital executives are concerned that ClearChoice requires upfront payments for care and will turn away those who can’t pay.

Hospital-owned urgent care centers would not turn away people who can’t afford their services.

Rep. Mike Fisher, D-Lincoln, recently introduced an amendment that would require urgent care centers to obtain a certificate of need from state regulators before opening new clinics in Vermont.

The House was expected to vote on the amendment late Tuesday night.

It’s unclear if the amendment passes whether it could be retroactively applied to block ClearChoice’s entry into the Vermont market. ClearChoice has made clear that they believe it can’t and are prepared for a legal battle.

Fisher, who chairs the House Health Care Committee, said his proposal doesn’t reflect an opinion on whether ClearChoiceMD or anyone else should be allowed to enter the market.

The certificate of need process is in place to ensure an intentional and reasoned build-out of the state’s health care system, and he believes that should apply to urgent care centers, Fisher said.

Valerie Mullin of Monkton is a candidate for state representative. Courtesy photo
Valerie Mullin of Monkton is a candidate for state representative. Courtesy photo
Monkton resident and Republican candidate for state representative Valerie Mullin says Fisher’s proposal would stifle competition in the health care industry and limit choice for Vermonters.

Mullin, 55, is a small business owner and first-time candidate. She intends to run on a property-tax reform and health care choice platform.

She is running for one of the two seats in the Addison-4 district, currently held by Fisher and Rep. David Sharpe.

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Morgan True

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  • Matt Fisken

    I’m pretty sure one of the reasons the cost of visiting a traditional hospital is so expensive is because they’ve needed to compensate for all the uninsured patients who cannot pay their bills. This is similar (not exactly the same) as a store which experiences a lot of theft. They have no choice but to raise their prices in order to avoid losing money. If a business can guarantee that all their customers will pay for the products they receive, it seems only fair that they should pass lower prices along to the customers. As long as the products are worth paying for in the first place.

    • Karen McCauliffe


      It is not only some of the uninsured who are not covering the full cost of receiving care in hospital emergency rooms (ERs), as both Medicare (over 65) and Medicaid (lower income) reimbursements often do not fully cover the cost of hospital health care services. This results in a cost shift onto Vermont private insurance as hospitals charge the private insurance companies more to cover the losses from the low Medicare and Medicaid payments.

      Vermont’s demographics with over 15% of its citizens now on Medicare (to be 25% by 2030) and currently 27% on Medicaid (as of Feb 2014) will cause a bigger cost shift to private insurers.

      A high percentage of Medicaid patients use the ERs throughout the nation. This is a costly place to be seen for minor urgent care problems, to not mention time consuming for the patient as they wait in line for triage care.

      Clear Choice stated that they accept all payers including Medicaid, but require payment at time of service. The state should attempt to work out a “deal” with Clear Choice MD to obtain a waiver for the Medicaid and Medicare patients that they do not have to pay up front. What is wrong with empowering the Medicaid (lower income) patient? Often the Medicaid patient is seeking care at the ER as they have no other options.

      The cost savings of Medicaid and Medicare patients using non-hospital based urgent care centers instead of ERs (or hospital based urgent care centers that add facility fees) would be substantial, and the savings could be used to offset the cost of caring for the uninsured.

      In Rutland, we need an urgent care center. The situation is so dire that sometimes even during normal clinic hours that the privately insured, the uninsured, both the Medicare and the Medicaid patient must bounce into the ER to be seen that day as no same day clinic slots are available.

      At all the urgent care centers and ERs in Vermont, we need to see the charges (fee list) posted up front, including the extra facility fees are that are charged at hospitals, but not at non-hospital based urgent care clinics. Florida passed legislation to show the costs up front. The Vermont legislature should act similarly.

      “Hospital ‘facility fees’ boosting medical bills, and not just for hospital care…
      Charges also added for hospital-owned urgent care centers, medical practices; Medicare budget-cutters want changes…

      After Vermont hospitals started buying up the medical practices of local physicians, state Sen. Kevin Mullin of Rutland, began hearing complaints that prices some patients were paying for routine medical care had soared.

      One family accustomed to paying about $120 in out-of-pocket costs for doctor visits and other medical services was outraged when they ended up forking over more than $1,000 for similar visits, Mullin said, mostly for seeing doctors whose practices had been bought out by a local hospital.

      “The only thing that was different was the office was [now] hospital-owned,” said Mullin, a Republican. “All of a sudden everything was charged differently.”

      “After her 8-year-old daughter was nipped by a dog, she took her to a local [hospital owned] urgent care center and left with a bill for more than $500. The child was treated with antibiotic gel and a simple bandage during her 15-minute visit, according to the South Florida Sun Sentinel, which reported on the incident last year.

      Because the center was owned by Baptist Health South Florida, the hospital-based system slapped a $275 facility fee on top of the $233 doctor’s bill. The woman’s insurance refused to pay half the fee and Romaniello argued she would have gone elsewhere had she known about the extra fees beforehand. Florida has since passed a law requiring urgent care centers to post prices and all its clinics do so, a Baptist spokesperson said.”

  • Dave Bellini

    Why would anyone oppose ClearChoice? Vermont has a shortage of Doctors and the state of Vermont wants to keep it that way. One way to lower costs is to limit the number of Doctors like Canada. IT’s GOOD that ClearChoice is opening care centers. GMCB approved it this time but in the future other providers may be shut out.

  • Bob Zeliff

    I do not understand the Green Mountain Care’s board thinking on this approval.

    Because all of Clearchoice patients will be screened for ability to pay before treatment and they will not be giving treatment for those who can not prove they can pay, they will not experience the risks and cost that hospitals are now exposed.

    The effect of ClearChoice taking only patients who can pay, In fact, will INCREASE the number of patients, who can not pay, the Vermont hospital will see in the future. This will have the effect of making the hospital MORE expensive, less competitive.

    How can this be fair?

    How can this be justified?

    Will this drive our hospitals to take the same position as Clearchoice and only accept patients who can pay?

    Will some one for Clearchoice explain why my thinking is flawed?

    Will some one on the Green Mountain Care board explain their thinking?

    • Walter Carpenter

      “The effect of ClearChoice taking only patients who can pay.”

      This does make me nervous as well. People who cannot afford it will be turned away. The only ones who will have any choice in the matter are those with the ability to pay. Otherwise, well, you out of luck, and your illness or whatever is your problem. And, as this is a private business, we could see all kinds of rapacious practices to get the positive cash flow necessary to sustain it.

  • Steven Farnham

    “Monkton resident and Republican candidate for state representative Valerie Mullin says Fisher’s proposal would stifle competition in the health care industry and limit choice for Vermonters.”

    Fisher’s proposal might also stifle high prices set by a for-profit cartel. What is the point of busting the insurance mafia’s grip on healthcare financing, if we’re going to leave the providers up for profiteering grabs by the same or similar crooks?

    • Walter Carpenter

      “What is the point of busting the insurance mafia’s grip on healthcare financing, if we’re going to leave the providers up for profiteering grabs by the same or similar crooks?”

      Good point, Steve.

  • Gail Graham

    Matt, Your comment about the need for traditional hospitals to compensate for the losses with the uninsured patients is so true. This is one of many issues that most people have no idea about all of the factors affecting hospital budgets. This is one of the many reasons I have been concerned about the GMCB becoming so involved with regulating hospital budgets. I have been hoping that the nurse, who is most recent member of the Bd., will be able to share some logic in all of this. So pleasantly surprised about their decision about ClearChoice.

  • Jeanne Keller

    “In a letter to ClearChoice attorneys, the board concluded that the urgent care centers proposed by ClearChoiceMD do not trigger Certificate of Need (CON) thresholds ‘and as such are not subject to review.’ ”

    In other words, the Board did not “approve” the the Centers; the Board determined they do not have jurisdiction to review the Centers because the capital and operating costs are not high enough to “trigger” a CON review.
    Therefore, the board never had the opportunity to review the questions raised by commenters to this article – they did not review it and approved it; they ruled they don’t have authority to review it.

    The cost threshold (or trigger) for review is set in statute by the Vermont legislature. (It is currently $1.5 million for facilities, and $1 million for equipment.) If you want to see things like this reviewed, then either they must be explicitly defined in statute as reviewable (per Rep. Fisher’s proposal), or the threshold should be lowered to make more expenditures in general reviewable.

  • Valerie Mullin

    More of what I was saying….ClearChoiceMD has said they will be able to offer Vermonters affordable services such as chest x-rays for $50 VS the $300-$600 currently charged by emergency rooms at hospitals.
    “I’m concerned that Rep. Fisher’s amendment to force urgent care clinics like ClearChoiceMD to apply for a Certificate of Need from the Green Mountain Care Board is beginning a dangerous precedent of keeping doctors “in their place” and not being able to choose freely where, when and what they practice. This will put VT doctors at a disadvantage and keep more from choosing to practice here. In addition, it limits Vermont consumers from seeking affordable care and the care of their choice. Does Rep. Fisher really want to limit Vermonters ability to “shop” for their health care needs”?
    Vermonters will be more apt to seek the health care that they need if they have an affordable choice. Consumer choice is important now that Exchange Insurance requires high deductibles and co-pays to be paid in addition to high insurance premiums. It is important for those seeking care to get affordable care, so if a consumer can get a chest x-ray for $50 VS $300 -$600 at a hospital, that choice should be available.
    “If we truly want to get health care costs under control and have a healthier Vermont population, then empowering Vermonters with opportunities to make the best health care choices for themselves and their families through competition and choice is a great start. I would strongly urge Representative Fisher to withdraw his amendment and for the Green Mountain Care Board to stay out of the way of over regulating choice and competition”

  • Walter Carpenter

    In addition, it limits Vermont consumers from seeking affordable care and the care of their choice. Does Rep. Fisher really want to limit Vermonters ability to “shop” for their health care needs”?

    I must admit that I did not know that people who need health care, which is all of us, were “consumers.” This is one of the things so wrong with our current approach to health care. We are people; we are not “consumers” out buying an ipad or something where our health care is a commodity to buy and sell. And, as someone who has had to “shop” before for health care in a dysfunctional system which deals with health care as a commodity, almost in the same way as it does a used car, and deal with negotiating prices before while I was dying, this is no way to think of health care. Rep. Fisher has the right approach, both to this and to GMC. Health care is not something for merchants to compete over. It is a public good for all of us.

    • Jim Christiansen


      Interesting take. How would you propose Vermont provide other essentials for life such as food, water, clothing, shelter, etc.?


      • Paula Schramm

        Jim, Maybe you should think this out a bit for yourself…it’s worth mulling over.
        I think food, clothing and shelter can fit the “commodities” model better than health care, as long as these needing these things is not an emergency situation. When it is an emergency, in most civilized societies, we try to provide them to the person who is in dire straits. We even ,together as a society, contribute through taxes to a “social safety net” so that there is access to food ( food stamps), and a minimal fund for basics such as clothes & shelter ( welfare). We even as a basic human right, together provide the infrastructure & teachers for education for all through high school, for roads and transportation infrastructure, and for a military for common defense. It’s not that these things are free – together we all pay for them, but we try to make sure that everyone has access and can benefit from them. It makes for an equitable, highly- functioning society.
        Water is perhaps even a better example of how systems break down when you start commodifying an essential need so that only those with enough money can get it. When water is “privatized”and taken away from those who cannot afford to pay to drink, a society does not thrive. Imagine a future where you must pay to breathe air.
        The trouble with looking at us as “consumers” of health care is that often when sickness hits it is more like an emergency situation than a shopping trip. We all need to contribute to the infrastructure, equipment and medical professionals so that they are there when we need them.

        • Renee Cantwell

          Considering that VTMCC spent something like $25 million for the name change from Fletcher Allen to VTMCC, I doubt that ‘we the people’ need to ‘help’ our medical organizations at all. 30 years ago we had outstanding care. Clinical presentation and thorough exams (remember those?) were the norm. EBM (Evidence Based Medicine) is now being used fairly often. We do not need to ‘help’ or ‘contribute’ to medicine; medicine needs to make better QA and QC decisions and review internally on a tighter basis. So you have any idea how many third world countries deliver better quality healthcare than we do? As I taught my children: Don’t say ‘can’t’ when what you mean is ‘won’t.’ They can improve quality of care, and I bet they would really swiftly, if their reimbursement of payment was predicated on whether they provided appropriate care. e.g. Not having to go to a doctor’s six times when one time should have sufficed. You can try, but any medical malpractice attorney will tell you that you can’t legalize and validate willful negligence or malpractice.

  • Dave Bellini

    “…they will not experience the risks and cost that hospitals are now exposed.”
    That’s because they are NOT A HOSPITAL.
    ClearChoice is just a Doctor’s office open at night. It’s not a hospital. It’s not a trauma center. It’s not for treating life threatening situations. It’s not for surgery. It’s a Doctor’s office.

  • James Haslam

    This is a terrible decision. Walter Carpenter nails it: “Health care is not something for merchants to compete over. It is a public good for all of us.”

  • Al Giordano

    Well said, Dave.

    We all ask for doctors to provide convenient hours and provide off hour coverage. True, ClearChoice is “for profit”. Wake up! So is every healthcare entity out there! CEOs of tiny hospitals earning in excess of $300K? That’s not profitable?

    When was the last time you told your vet you couldn’t pay? Or your manicurist? Hmmm…

    Hospitals do well on Medicaid. In fact, have been feasting on it for years. As for the “uninsured”, Mr Obama has rendered that issue moot,right? Why do the pro hospital folks never mention bad debt and charity pools, disproportionate share pools and federal discount drug programs (from which they make millions) when crying the blues? And, oh, yeah…… Read their mission statements. One of the main reasons they EXIST and pay no taxes is their mission to treat the poor.

    • Dave Bellini

      I think folks read “urgent care center” and they think of an emergency room at a hospital. The name “urgent care center” is not accurate. There is already one tiny “urgent care center” in Berlin VT. To the best of my knowledge it’s one P.A. and they’re only open from 8-4:30. Hardly competition for the hospital. No one is protesting it either.
      I doubt ClearChoice would even bother to locate in central Vermont if CVMV had an after hours clinic already running. I wonder if they got the idea after they learned ClearChoice was going to open? There’s a real need for more Doctors in the Barre Montpelier area. Many primary care Docs are closed to new patients. My prediction is the demand is high so the new CVMV “urgent care” and ClearChoice will both do a brisk business. I don’t understand why some supporters of changing the current health care system still support the use of expensive emergency rooms over after hour clinics. Even if some after hour clinics only take people with insurance it still saves overall money by not using the ER.

    • Renee Cantwell

      I concur. And I wish to add that CMS payments are the MEAT of the profits for any hospital, nursing homes, or medical center. Its time to stop the fraud. It is time for quality of care. Making it affordable won’t matter if we remain the #1 in healthcare costs and number #37, #38, #39 in the three major areas of critical care, according to W.H.O. It isn’t the money, it’s the quality of care and availability. ALEC which is the legislative body that writes law in the US Congress wrote the ACA along with insurance companies and every other entity that has a profit motive, and this is the result.