The demise of St. Vincent's Hospital in Greenwich Village two years ago has led to a struggle for health care supremacy in some of New York's most distinctive neighborhoods, offering a glimpse, in the process, at what might be the future of urban medicine.
Michael Appleton for The New York Times
Dr. Shari Stirling, a physician who practices out of a Duane Reade pharmacy at 40 Wall Street, sees a patient for a leg injury.
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Michael Appleton for The New York Times
Dr. Leslie Miller, left, and Dr. Alicia Salzer at Medhattan, an urgent care center near ground zero in Manhattan.
Without building a hospital, one large chain, Continuum Health Partners, is establishing a beachhead in Chelsea and the Village by connecting with outpatient clinics, trying to dominate the market and create a feeder network for its hospitals in other neighborhoods. It is joining forces not just with traditional clinics but also with newer experiments like doctors working out of drugstores. A competitor, NYU Langone Medical Center, is expanding its physician practices downtown, and like Continuum, it has hired dozens of stranded St. Vincent's doctors.
Several walk-in "urgent care" centers have also rushed into the vacuum left by St. Vincent's in Lower Manhattan, hoping to show that they are more efficient and consumer-friendly than a hospital-based system, but some have already begun to form relationships with the hospitals.
"We are still trying to figure out if we are a threat or an asset to each other, and we are probably both," said Dr. Alicia Salzer, co-founder of Medhattan, an urgent care center that opened in 2011 near ground zero at Liberty Street and Trinity Place.
The immediate fight is to win market share, the loyalty and business of the area's many affluent and well-insured residents. But the demise of St. Vincent's has also turned Lower Manhattan into a laboratory for health care reform. The new clinics and the maneuvering by large chains are anticipating an expansion of the number of people with insurance and changes in the way that health care is delivered and paid for. And they are testing the notion, long held by health planners, that the city can survive with fewer hospitals.
Many doctors and some Village residents were dismayed when St. Vincent's went bankrupt and closed, and consider the new health care choices in the area to be less than adequate.
"As a physician and general internist, other than a laceration, I would never send a patient to the urgent care center," said Dr. David Kaufman, who trained at St. Vincent's and spent more than 30 years working there.
But in its waning days, St. Vincent's was filling far fewer beds than it did during the AIDS crisis, and as is the case at other hospitals, many patients using its emergency room did not need emergency care, driving up costs.
While it is impossible to know whether local residents are worse off without the hospital, one 2009 study by analysts for the RAND Corporation found no adverse impact on quality, and significant cost savings, in the newer models of care.
The study looked at patients in a large Minnesota health plan who received care for sore throats, ear infections and urinary tract infections — common complaints at retail clinics like the ones in drugstores. It found that the cost of care was 30 percent to 40 percent lower in those clinics than in physician's offices and urgent care centers, and 80 percent lower than in emergency departments, mainly because of lower reimbursement rates and less laboratory testing. It found that the rate of preventive care and overall quality of care was actually worse for patients who patronized emergency rooms for those ailments.
The researchers did raise concerns that the proliferation of urgent and retail care might lead people who otherwise would nurse minor illnesses at home to seek medical attention, raising the costs of health care to society. And they suggested that without good communication between different types of care, the health system might become even more fragmented.
"So you have more cooks over the pot, and that lack of continuity is a real frustration," said Dr. Ateev Mehrotra, a policy analyst at RAND, an associate professor at the University of Pittsburgh School of Medicine and the lead author of the study, published in the Annals of Internal Medicine.
As for worries that urgent care or retail clinics might miss serious diseases like cancer, Dr. Mehrotra said that the rarity of complications made that concern hard to assess, but that "there would be a lot of malpractice suits, and we haven't seen that."
Executives at Continuum, which runs five hospitals in New York City, say they expect their expansion into the community to form the foundation of an accountable care organization, a new model of care supported by the federal law that seeks to move patients out of hospitals as much as possible, and to reward health care organizations for working together to improve quality and cut costs.
From Eighth Street in the Village to 26th Street in Chelsea, between Ninth Avenue and Union Square, a patient can now choose from a dozen clinics or medical practices that have been opened or expanded by Continuum or are affiliated with it.
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