Wednesday, September 10, 2008

Health Care and Retail Clinics

Commonly referred to as "Doc in a Box," retail health clinics have been getting a bad rap this year from the American Medical Association, certain government agencies, and other critics. Companies like Walgreen's and Wal-Mart have embraced the concept wholeheartedly and are on a campaign to increase penetration in the health care marketplace with easily accessible locations for consumers to receive certain health care treatment at an affordable price. Largely due to the number of uninsured in America, the retail health clinic does meet a specific need. And, many of them also do actually accept most insurance plans. Critics claim that patients cannot get the same quality of care as in a private physician's office or fully staffed medical clinic. However, the public usually sees this complaint as sour grapes because of the amount of money that doctors are losing due to overpriced procedures. Americans want access to medical care, but they don't want to pay a fortune for it.

According to the website Salon.com, the medical establishment is opposed to drop-in clinics in Wal-Marts and other retail stores. But self-interested doctors need to get over their archaic ways of doing business. According to the StarTribune.com in Minneapolis-St. Paul, MinuteClinic is the first and still the biggest chain of retail clinics, where nurse practitioners treat common ailments in a retail setting. According to the article, going to a MinuteClinic is cheaper for patients than going to a physician's office or urgent care. A study published in the journal Health Affairs found prices charged by all providers rose by double digits over the four years tracked, a trend that went against the conventional wisdom that more providers leads to more competition and lower prices. The study is the first to compare costs per episode of care -- which includes not just the medical exam but also lab and pharmacy costs -- for sore throats, ear infections, sinus infections, pinkeye and urinary-tract infections.

However, the report issued this week by Health Partners on Pioneer Press suggests patients get their money's worth when they use MinuteClinics instead of family doctors for the treatment of sore throats, ear infections and other common maladies. Some critics have argued they end up increasing overall costs because many patients go to them first but go to their family doctors later for the same problems. Researchers looked at the total cost of care a patient received for an entire "episode" or individual illness rather than an individual procedure or treatment. The result: The total cost of a patient treated at a MinuteClinic for one of five basic illnesses was $51 cheaper on average than a patient treated at urgent care and $55 cheaper than a patient treated by a primary-care doctor. Pharmacy costs were also slightly lower for the patients using MinuteClinics. One key difference is that patients with chronic conditions such as asthma or diabetes were much more likely to see their regular doctors. The cost difference won't mean much to most insured patients who simply pay copays for basic medical visits. But it is significant for employers and insurers who pay the bills and for the growing number of patients with health savings accounts who benefit financially when they seek cheaper care.

Retail health clinics provide simple, nonemergency services to walk-in patients, regardless of insurance status. They are much cheaper than a traditional doctor's visit because they're generally staffed by nurse practitioners and/or physicians assistants. These clinics have extended hours including nights, weekends, and sometimes even holidays. They charge a set price for common services, everything from sports physicals to treating ear infections. Currently, there are about 1,000 such clinics in the United States, according to the Convenient Care Association, but that number is expected to increase to as many as 1,500 by the end of this year as reported by the ConsumerReports.org website. Supporters of retail clinics, like the Convenient Care Association, say they help take pressure off primary care physicians and emergency rooms by taking care of simpler cases and that retail health clinic services are limited to routine physicals and simply treated illnesses and injuries, referring more complicated cases to traditional health care providers. And, supporters also say retail health clinics empower consumers by providing additional transparency, convenience and choice.

However, doctors are naturally nervous about the rapid growth of retail clinics, according to feedback on Salon.com. Many medical groups, like the American Academy of Family Practice and the American Academy of Pediatrics, have published position papers opposing retail clinics. Their basic argument is that retail clinics run counter to the concept of "a medical home," a place where patients receive care for any and all of their problems. They worry that patients will have no sensible place to follow up their test results, and that putting a clinic in a mall or a Wal-Mart could expose shoppers to people with a contagious illness. The medical community needs a second opinion. Retail clinics are good for American healthcare. By giving doctors a run for their money, they force doctors to do something they don't do well: innovate. At their best, retail clinics can make doctors look like smart entrepreneurs instead of a self-interest group futilely trying to protect archaic ways of doing business.

Retail clinics are thriving according to Salon.com. They provide excellent access. After all, what's more convenient than showing up any day, night or weekend to have your sore throat checked? No telephone time spent on hold trying to make an appointment, no shuffling your personal schedule to get there. Then there's cost. Retail clinics operate on a fee-for-service basis. Most charge a maximum of $50, which is significantly cheaper than the $100-plus your insurance company (or you, if you carry an increasingly popular high-deductible insurance plan) will pay when see your doctor for the same concern. That relative savings makes retail clinics a great place to go if you're uninsured and have a minor medical problem. This desire to pay out of pocket is a not-so-subtle sign that consumers are asserting their purchasing power in the health sector, just as they would with other goods and services. A 2005 Wall Street Journal/Harris poll confirms this: Eighty percent of retail clinic users expressed satisfaction with the cost of services; 89% were satisfied with the quality of care; 88%, with the staff's qualifications (usually nurse practitioners).

Salon.com also reports that the success is due to a few reasons. First, retail clinics don't do everything. Literally, a customer has to choose what he or she wants from a menu of choices posted on a marquee. Choices are limited to simple, easy-to-handle medical problems like sore throats, allergies and cold sores or a request for routine flu or pneumonia vaccinations. No acute medical problems, like injuries or asthma, are addressed. All decisions are made using very strict decision trees, leaving no room to treat issues beyond or outside of them. Also, Clinics make no claim to be a medical home. Statistics support the safety of this approach. there's nothing complicated about communicating with a patient's primary doctor. Specialists and emergency rooms routinely send letters or faxes to primary care offices to inform them about a patient, his or her diagnosis, prescribed treatments and a follow-up plan. Retail clinics have made efforts to do the same. So rather than writing position papers opposing retail clinics, medical organizations ought to use them to encourage bold innovation. Technology is also helping. An increasing number of offices are adopting an electronic medical record, one that allows patients to e-mail their doctor or chat live over video.

Of course, there are potential pitfalls. Should walk-in clinics expand to become a medical home by offering physical exams and other comprehensive services like treating injuries, they stand to do patients a disservice. Time will tell whether the rate of errors is any different than in standard practice; but as long as the clinics continue to keep services strictly limited, this risk will remain relatively low. Regardless of those red flags, though, retail clinics in their current format have found a unique and useful niche in medicine. Competition in the marketplace makes us better business people, better consumers, and better Americans.

Until next time. Let me know what you think.

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