The Closure of Urgent Care and Orthodontics

If Whittier is to improve services for patients, the re-opening of Urgent Care and Orthodontics would be good first steps. They were both closed without any prior discussion with staff and the true reasons for their closure are still murky, though the expulsion of union supporters who staffed those departments was likely a consideration by management.

Urgent Care

A recent front-page article in the Boston Globe (1/13/19) and follow-up column (1/15/19) reported on the relative lack of urgent care programs in lower-income neighborhoods of Boston, even as they’ve been spreading to the suburbs (https://bit.ly/2ssxhsn and https://bit.ly/2H5mU7k):

At the time of its closing, Whittier had a popular Urgent Care program in place that served its community well. It wasn’t closed for financial reasons, since the higher reimbursements CHCs receive from MassHealth, compared with freestanding Urgent Care centers, makes their operation at CHCs financially viable.

The main reason given for the closure was to improve the integration of patients into Primary Care, in particular so that they could be seen by their own primary care providers.

However, few patients at Whittier are actually seen by their own primary care providers in walk-in slots, for a variety of reasons. Also, patients with more complicated acute problems must now be seen within shorter appointments slots, which has incentivized their referral to hospital emergency rooms. And patients aren’t routinely screened by clinical staff, increasing the risk that emergencies will be missed before patients are seen by a provider. In one case that we’re aware of, a patient with a bad cough was scheduled by front desk staff into an appointment slot on future day, and when she finally arrived was diagnosed with pneumonia.

If the goal is to better integrate our walk-in patients into Primary Care within an Urgent Care department, intentional measures can be taken in the Urgent Care intake and exit processes to make sure these connections are made. Urgent Care departments tend to attract many patients who have no primary care providers, and so they have the potential of channeling many patients into comprehensive care who would otherwise be lost to other facilities and emergency rooms.

A reopening of the department would also reduce the stress on providers in the Primary Care departments, whose schedules can barely accommodate their own continuity patients, due to the drop in the numbers of providers over the past two years.

Orthodontics

The Orthodontic program at the WHSC was founded in 1970 by the City of Boston’s Health Department, when Whittier was in its early years. Since then, thousands of inner city Boston children and young adults with severe handicapping malocclusions have received life-changing improvements in their appearance and health. At the time of its closure, in October 2018, the clinic was the only orthodontic program within a CHC in Boston, a true jewel of a program for residents of inner city Boston.

It was very disappointing that the Massachusetts Department of Public Health conducted a site visit on January 17, in response to a safety complaint, yet reported no problems. DPH only spoke with management during the investigation, not with the staff who provided care for these now-abandoned patients. Here are their conclusions and the facts they missed:

1) "Orthodontic services underwent a planned closure ..."

Response: Whittier changed closure dates, with only 3 months' notice given

— In late July 2018 staff were told, without any prior discussion, that Orthodontics would close on December 31, 2018. This would have given the orthodontist time (albeit brief) to help arrange referrals for patients. But at the end of September, the date was changed to October 31 2018. Patients continued to receive letters as late as 10/16/18 stating, in error, that the clinic would close on 12/31/18. Many were therefore lost to follow-up.

2) "... due to significant financial constraints"

Response: Orthodontics generated positive revenues; fiscal misinformation provided by management

— As a justification for closure of Orthodontics, management erroneously claimed to staff that it only received partial (40%) payment for orthodontic services from MassHealth, when it in fact it has always received 100% of the MassHealth payment, as was confirmed by MassHealth to the Whittier’s orthodontist.

— Departmental cost/revenue reports distributed to staff in 2018 showed the Orthodontic department to be one of the few cost centers that was revenue positive at Whittier

— Whittier made a decision to hire a second orthodontist in 2016 (who subsequently left in 2018) because the need was so great; this hiring was inconsistent with a department that was purportedly in financial distress.

— Whittier had 19 new patients ready to begin treatment at the time of clinic closure, representing a loss to the health center of $82,000 in foregone revenue, which alone would have covered 1-1/2 years of the cost of the entire Orthodontic staff.

3) "Appropriate staff and patient notification and transition was provided"

Response: There were some significant problems in transitioning of patients; many patients still have no reasonable follow-up or treatment options

— The Whittier orthodontist was not given an adequate opportunity to communicate treatment plans and transfer protocols to new providers for the vast majority of the 70 patients still in active treatment at the time of clinic closure. Many of these patients were receiving highly specialized treatment plans, employing techniques that even many other orthodontists would not understand without a clear communication. The remaining general dentists at Whittier aren’t trained to evaluate and communicate orthodontic treatment plans to other orthodontic specialists. Typically abbreviated orthodontic records also don’t suffice for communication about ongoing patient treatment.

— Patients were told to find new providers by searching the internet, or to go to a dental chain Kool Smiles, which was convicted of Medicaid billing fraud in 2018, for which they were fined $24 M. A number of patients we’re aware of weren’t accepted by Kool Smiles and couldn’t find other providers.

— After the clinic closed, some patients were able to reach the Whittier orthodontist through his personal phone, desperate for help, feeling abandoned and unhappy, unable to get follow-up.

— Whittier has already received the full payments from MassHealth for an estimated 25 patients who still require further treatment, with hardware still on their teeth (with continuing progressive modeling of bone and teeth in process). They have no insurance mechanism for completion of their treatment (since Whittier has pocketed the full payments received before these patients completed their treatments). However, Whittier Street could reimburse patients, if they chose to, for the care they still need to get. They have done so for a few self-pay patients who were persistent, but not for any MassHealth patients.

The closure of Orthodontics is a sad case of a poorly planned and unnecessary closure of an important program at Whittier. It should be reopened in order to, at a minimum, complete the care of those stranded patients whose treatment was begun at Whittier and who have no reasonable remaining options for follow-up. We would like the DPH to re-investigate the Orthodontic closure, and in a more impartial way.

February 22, 2019