By Lachin Hatemi M.D.
For years, South Carolina’s urgent-care market has been shaped by a powerful combination: a dominant health insurer and a large urgent-care network that the insurer itself owned.
That network was Doctors Care, which grew to 52 locations across the state. In November 2024, BlueCross BlueShield of South Carolina sold Doctors Care’s parent company, UCI Medical Affiliates, to North Carolina-based Novant Health for approximately $79.4 million. The transaction included 52 Doctors Care urgent-care clinics and 20 Progressive Physical Therapy locations.
The sale changed the ownership—but it does not erase the questions about how the market operated before the sale.
When an Insurer Also Owns an Urgent-Care Chain
BlueCross BlueShield of South Carolina has historically been the dominant commercial insurer in the state. An earlier National Institute for Health Care Reform analysis estimated that BlueCross held about 60% of South Carolina’s commercial insurance market at the time.
That creates an unusual competitive dynamic when the same organization also owns a major provider network.
For an independent urgent-care operator, being excluded from the dominant insurer’s network can be devastating. Patients with BlueCross coverage may face higher out-of-network costs or simply choose another clinic.
And South Carolina has already seen several public disputes over this issue.
MEDcare: A Public Fight Over Network Access
In 2014, MEDcare Urgent Care, led by Dr. Radwan Hallaba, publicly fought BlueCross after the insurer moved to remove MEDcare from its network.
MEDcare said BlueCross had “de-selected” the company despite its previous participation in the network. After a highly publicized dispute involving patients, businesses and political leaders, BlueCross reversed the decision and MEDcare returned to the network.
This was not simply a contract dispute.
For an urgent-care company, network status can determine whether patients can afford to walk through the front door.
Nason and American Family Care
Nason Medical Center in the Lowcountry faced a similar confrontation. In 2014, BlueCross announced that Nason was scheduled to leave its network, but the two sides reached an agreement allowing Nason’s five urgent-care centers to remain in-network.
Four years later, another dispute received significant attention.
American Family Care, a national urgent-care operator, complained that several newer South Carolina locations were being excluded from BlueCross’s network. State Representatives Mike Burns and Bill Chumley asked to meet with BlueCross over allegations that the insurer was restricting competition.
According to the Journal of Urgent Care Medicine, five AFC locations initially faced rejection from the BlueCross preferred-provider network. The controversy became particularly interesting because some of the rejected locations were reportedly within three miles of Doctors Care locations.
BlueCross rejected allegations that it was acting anticompetitively, describing the accusations as unfounded. In 2019, BlueCross and several AFC locations ultimately reached an agreement to join the network.
But they demonstrate that network access can become a major competitive weapon in the urgent-care business.
The Bigger Problem: Reimbursement
Network participation is only half of the equation.
The other half is how much an insurer pays different providers for the same service.
I have obtained and analyzed what I believe to be a comprehensive set of BlueCross BlueShield of South Carolina negotiated fee schedules covering urgent-care providers across the state. My analysis identified approximately 56 urgent-care companies and roughly 250–300 locations, although some contracts cover multiple locations.
One of the most commonly billed urgent-care codes is CPT 99213, representing an established-patient office or outpatient visit.
The reimbursement differences in the data are striking.
For 99213, the negotiated rates in the data range from approximately $36 at one independent urgent-care provider to more than $145 at a hospital-affiliated urgent-care provider.
That is roughly a fourfold difference for the same CPT code.
The lowest figure in my analysis was associated with Broken to Better Urgent Care in Rock Hill, while one of the highest was associated with Lexington Medical Center’s urgent-care clinics.
These numbers require additional independent verification and contract-level analysis before they can be presented as proof of discriminatory conduct. But if the figures are accurate, they raise an obvious question:
Why should two clinics providing the same service receive dramatically different reimbursement simply because of ownership or affiliation?
The Pattern Is Bigger Than One Clinic
The providers appearing toward the bottom of my analysis include:
Broken to Better Urgent Care in Rock Hill (Closed One Location)
Carolina Health Urgent Care in Greenville (Permanently Closed)
Kid Care Pediatric Urgent Care
Urgent Care LLC in Florence (Permanently Closed)
Gaffney Urgent Care
Gold Star Urgent Care in Florence
Bella Clinical Care in Columbia
Johns Island Urgent Care
Several of these businesses have reportedly closed locations, reduced hours or experienced financial difficulties.
But reimbursement is one of the most important variables in the economics of an urgent-care clinic. Most of the clinics on the lowest paid list, is either closed or financially struggling.
If an independent clinic receives $36 for a service while another provider receives $145, the difference is not theoretical. It can determine whether the clinic can hire another physician, remain open evenings and weekends, purchase equipment or survive another year.
A Market That Rewards Consolidation
This creates a powerful economic cycle.
Independent clinic enters the market → struggles to obtain favorable insurance contracts → receives lower reimbursement → loses money → closes or sells → hospital system acquires more providers → hospital system becomes larger and more powerful.
The cycle benefits consolidation.
And once a hospital system owns primary-care practices, urgent-care centers, specialists, imaging facilities and hospitals, it can capture revenue at multiple stages of a patient’s healthcare journey.
That is why the urgent-care market cannot be viewed simply as a competition between medical clinics.
It is a competition over patients, insurance contracts and the downstream healthcare revenue those patients generate.
The Doctors Care Sale Changes the Story—but Not the Question
BlueCross’s sale of Doctors Care to Novant Health was an important development.
Today, Doctors Care operates under the Novant Health umbrella. Novant acquired UCI Medical Affiliates in November 2024 and subsequently rebranded the 52 Doctors Care locations as Novant Health Urgent Care.
But the fundamental question remains:
Was South Carolina’s urgent-care market ever truly competitive when the state’s dominant commercial insurer also owned the largest urgent-care network?
That question deserves serious examination by regulators, legislators, employers and patients.
Because if an insurer can determine who gets into the network and how much each provider gets paid, while simultaneously owning a major provider network, the potential conflict of interest is obvious—even if no law has been violated.
Patients Ultimately Pay the Price
The consequences go beyond individual doctors.
When independent urgent-care clinics disappear, patients have fewer choices.
When reimbursement becomes inadequate, physicians stop opening clinics in smaller communities.
When independent practices close, physicians often have only one realistic alternative: go to work for a large hospital system.
And when independent competition disappears, healthcare becomes increasingly concentrated in the hands of a few large organizations.
The question South Carolina should be asking is not simply whether BlueCross complied with its contracts.
It is whether the state’s healthcare marketplace provides a level playing field for independent physicians.
Because a healthcare system cannot claim to promote competition while simultaneously making it economically impossible for independent doctors to compete.
Patients need more choices, not fewer.
And South Carolina needs an urgent-care market where a physician-owned clinic has a genuine opportunity to compete with a hospital-owned clinic—based on quality, access, efficiency and patient satisfaction, rather than simply on who controls the insurance contract.
No comments:
Post a Comment