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.
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.
Continuum has also taken over the former St. Vincent's cancer center on 15th Street, and it has established a clinic with a focus on H.I.V. patients on 17th Street, renovating several floors and filling them with colorful pop art. Half of the doctors at the clinic, called the Center for Comprehensive Care, were hired from the old St. Vincent's H.I.V. program.
"Urgent care centers are opening at the pace of Starbucks, and we are affiliating with as many of them as we can," said Adam Henick, senior vice president of Ambulatory Care and Medical Enterprise for Continuum.
Continuum has also become affiliated with doctors practicing out of 13 Duane Reade drugstores in Manhattan and Brooklyn, and has a contract to expand to 20 within the next year or so, and to 50 within four years, said Dr. James A. D'Orta, chairman and chief executive of Consumer Health Services, which manages the practices in the pharmacies.
No money changes hands in the Duane Reade affiliations, Mr. Henick said, but there are indirect benefits for both sides. The hospital system checks doctors' credentials and provides — and bills for — laboratory, radiology and imaging services prescribed by the Duane Reade doctors. The system also gets a potential trove of patients referred by the clinics. The Duane Reade clinics earn the cachet of being associated with major hospitals, and as with other affiliated practices, the Duane Reade patients are given expedited access to Continuum specialists and direct access to hospital admission if needed.
While one goal of the federal health care overhaul is to move nonemergency patients from hospitals to cheaper outpatient care, there is significant cost variation among clinics, even among those that are part of Continuum's loose network. In a byzantine patchwork of state and federal law, some specialized clinics — especially those treating H.I.V. or geriatric patients — can be reimbursed several times as much for a patient visit as are private practices and urgent care centers.
Officials at NYU Langone Medical Center on the East Side said that they, too, were trying to expand their downtown market.
"Everything is intensely competitive and everyone is everywhere," said Dr. Andrew W. Brotman, its senior vice president and vice dean for clinical affairs and strategy.
The hospital system with perhaps the most to lose from the competition is the North Shore-Long Island Jewish Health System. It is renovating the 160,000-square-foot O'Toole building, across from the old St. Vincent's, as a free-standing emergency room, which expects to handle 50,000 visits a year. It will operate as an extension of Lenox Hill Hospital, a North Shore affiliate on the Upper East Side.
But the emergency room is not scheduled to open until 2014. Over the summer, North Shore was forced to close an interim clinic it had opened in Chelsea with a $9.4 million state grant. The clinic attracted an average of only two patients a day, which a hospital spokesman, Terry Lynam, attributed to its limited hours and "the proliferation of urgent care" in the neighborhood.
Michael J. Dowling, chief executive of North Shore, said he believed there was room to work collaboratively with Continuum and other health care providers in the neighborhood.
"Good hospitals are important, but you don't need more than you need," Mr. Dowling said. "In many cases, we've been addicted to inpatient beds. We can't be addicted to them in the future."
Word of the new options is trickling out, and some patients say they are not mourning St. Vincent's.
Michelle McKenzie, a social worker, said going to the St. Vincent's emergency room often meant hours of waiting and, in recent years, run-down facilities. She found Medhattan, the urgent care center, advertised on the bulletin board at Public School 3, where her 7-year-old son, Ian Etheridge, is a student. She has gone there to be treated for an allergic breakout of hives, and her husband took their son there a few months ago when he cut his forehead on the playground and needed stitches.
"I was seen immediately," Ms. McKenzie said. "It wasn't crazy chaotic like St. Vincent's was. I only had to tell my story once, and I was treated by the same physician I told my story to."
Dr. Charles Carpati, former chief of intensive care at St. Vincent's, now at Lenox Hill Hospital, said the community seemed to be coping without the old hospital.
"It's been very hard to show that people are dying because St. Vincent's is no longer there," Dr. Carpati said.