Over the past few years, big box retailers like Wal-Mart and pharmacy chains like CVS/Caremark and Walgreens have opened health clinics in hundreds of their stores across the country. Staffed primarily by nurse practitioners — registered nurses with advanced training — the clinics provide immunizations, health screenings and treatment for common ailments like sore throats, earaches and pink eye.
Open evenings and weekends, and with visits usually taking no more than 15 minutes — eliminating the need for appointments — the clinics have proven very popular with the public. The Convenient Care Association estimates the clinics, which now number around 900, have served over 2,000,000 patients since the first opened in 2000. And the clinics claim a 98 percent satisfaction rate.
Insurers have largely embraced the clinics as well, although they were initially concerned the clinics would increase the frequency of subscribers’ medical visits. Usage patterns didn’t bear that out, but they did show that the clinics could save insurers money. Blue Cross Blue Shield of MINNESOTA, for instance, found that, on average, the 22,956 visits its subscribers made to MinuteClinics between June 2004 and June 2005 cost about half of what doctors’ visits did ($43 versus $87).
Clinic patients with health coverage increasingly incur a co-payment similar to what they pay at their primary-care doctor. For them, convenience is the attraction. It’s the uninsured, who lack a regular doctor, and who are generally able to obtain treatment for less than $65 per visit, who benefit most from the clinics. According to a 2007 Harris poll, 22 percent of clinic patients fall into that category.
Retail clinics’ success in the marketplace prompted Grace-Marie Turner, director of the Galen Institute, a free market think tank, to suggest last May that they could be the “disruptive innovator” in America’s health care system. She said that “as consumers get a taste of what consumer-friendly health care is like, they may well demand that the top-down, centralized health care delivery of the 20th century give way to a system more in tune with the demands of 21st century consumers seeking greater value and efficiency.”
Richard Datz, senior vice president of business development for CareClinic in Montvale, NEW JERSEY, offered a similarly favorable, if slightly more humanistic, view: “Look at how everyone is talking about universal health care. Certainly these clinics could be part of the solution.”
Not everyone sees it that way, however.
“We’ve got big problems in health care, and this is not the answer,” Dr. Rick Kellerman, president of the American Academy of Family Physicians, told The New York Times last summer. He went on to say that retail clinics “are a response, they are a niche market and an economic opportunity….”
Some of the criticism of retail clinics is simply on principle. For instance, Dr. Bruce Auerbach, chief of emergency medicine at Sturdy Memorial Hospital in Attleboro, MASSACHUSETTS and president-elect of the MASSACHUSETTS Medical Society, told state officials there last year that with the cramped quarters in which retail clinics operate, “You’re crowding people who may be sick, not to mention potentially exposing someone who’s just trying to buy Doritos.” And Dr. Edward J. Volpintesta, a family physician in Bethel, CONNECTICUT, called the clinics “the ultimate commodification of health care.”
But primary care physicians have also repeatedly raised pointed questions about the quality of care in-store clinics provide. While acknowledging nurse practitioners’ qualifications for treating minor illnesses, they’ve expressed doubts about NPs’ ability to catch early signs of serious health problems, particularly when the NPs don’t have established relationships with their patients like primary care physicians do.
“Every patient who presents with a sore throat does not have Streptococcus pharyngitis,” or strep throat, says Dr. Auerbach. “Every patient presenting with a red eye does not have simple conjunctivitis.”
Some primary care physicians maintain that retail clinics actually disrupt the continuity of care that enables the physicians to know when something is seriously wrong with a patient, and, making matters worse, the clinics aren’t set up to provide follow-up care.
Then there’s the conflict of interest issue, which heated up significantly last summer, when the American Medical Association — the nation’s largest physician group — announced at a meeting in Chicago that it would urge state and federal investigations of the relationships between retail clinics and their host stores. The group said its decision had been spurred by statements from retailers indicating that in-store clinics “help drive additional store traffic, which can increase sales of lucrative prescription drugs and other non-health related products.”
Commenting on the subject, Peoria anesthesiologist and ILLINOIS State Medical Society President Dr. Rodney Osborn said, “Our primary focus is patient safety and patient care, and the retail clinics have a different mission of selling products and prescriptions.”
Some doctors urged the AMA to impose an outright ban on the clinics. The association backed off taking that hard a line, but physician groups have pushed in other directions, including supporting state legislative efforts aimed at tightening regulation of the clinics.
For example, the ILLINOIS State Medical Society, representing over 13,000 doctors, has thrown its weight behind HB 1885, which would require every in-store clinic to obtain a permit to operate.
“These retail storefront clinics, if you will, should face standards just as there are for hospitals, surgery centers and doctors’ offices,” said Dr. Osborn.
The retail-clinic, or convenience-care, industry has spent a good deal of time stating its case too, at times just as bluntly as its toughest critics.
“The real reason physicians oppose retail clinics has nothing to do with patient safety or quality care. Rather, it is pure profit-driven, anti-competition greed,” said Edie Brous, a nurse and lawyer in NEW YORK who represents nurses on licensing issues.
But supporters have directly addressed the specific concerns raised by physicians as well. Speaking to the quality of care issue, for instance, clinic operators say their NPs know their limits, and what they do, they do well. According to an internal MinuteClinic review published in The American Journal of Medical Quality last year, 99.15 percent of the 57,311 patients treated for sore throat at MinuteClinics in MINNESOTA between September 2005 and September 2006 received proper care. In contrast, an article in the October 2007 issue of The New England Journal of Medicine reported that children nationwide receive appropriate ambulatory care less than 50 percent of the time.
Clinics have responded to physicians’ continuity of care complaints by developing referral relationships with local physicians and hospitals. They also now forward patients’ records to their primary care physicians, if they have them.
There is also anecdotal evidence to suggest that conflicts of interest might not be as much of a problem as they are presumed to be. BlueCross BlueShield of TENNESSEE reported that, based on analysis of six months of claims data, pharmacies with in-store clinics wrote fewer prescriptions than those without clinics. Clinic operators say that’s because they follow strict “evidence-based” guidelines in diagnosing and treating patients.
Additionally, the industry says it benefits the medical community by offering evening, weekend and holiday hours when most doctors’ offices are closed; by reducing the burden on emergency rooms; and by providing a point of entry to the health care system for those who don’t have primary care providers.
Caroline Ridgway, senior policy associate for the CCA, thinks much of the resistance to retail clinics is the result of misperception about what they’re trying to do. She says when people actually visit the clinics, they realize the clinics are “trying to complement traditional medicine, not replace it.”
“There’s nothing mystical about this industry,” adds CCA Executive Director Tine Hansen-Turton. “It’s providers that are already regulated in the states who just happen to be providing more limited services than they’re actually educated to do and doing it in a retail setting.”
Hansen-Turton also made the point that “with 47, or 48 now, million uninsured, and another 30 million underinsured, we need more access. And, certainly, policymakers get that.”
Undoubtedly, they also get that retail clinics offer an opportunity to expand access in a way that doesn’t place the burden on their cash-strapped states. And those considerations, and the industry’s other arguments, have apparently swayed some state lawmakers and regulators.
CALIFORNIA, WASHINGTON and WEST VIRGINIA are considering, and PENNSYLVANIA Gov. Edward Rendell (D) has signed, legislation (CA AB 1643 and SB 809, WA HB 2497 and SB 6267, WV SB 59, and PA HB 1253, respectively) aimed at expanding “scope of practice” regulations for NPs, concerning such matters as their prescribing authority and physician oversight requirements.
The CALIFORNIA Senate’s Republican minority has also proposed a bill (SB 236) that would allow NPs to operate primary care clinics, a privilege currently reserved exclusively for physicians under the state’s “corporate practice of medicine” law, which has discouraged clinic operators from entering the state.
MASSACHUSETTS and NEW YORK, meanwhile, have introduced measures (MA HB 921, SB 1226 and SB 2418, and NY AB 5477, AB 6342, SB 3093 and SB 3094) mandating that health insurers cover services provided by nurse practitioners.
MASSACHUSETTS’ Public Health Council also voted last month to modify the state’s regulations governing ambulatory care to accommodate retail clinics, a big step for a state where health care has long been dominated by large group practices and non-profit hospitals.
“If [retail clinics] are well-run and they stay within certain parameters, they fill a need,” said Ronald Preston, a former top MASSACHUSETTS health official and current faculty member at the University of MASSACHUSETTS Medical School. “My issue with them is what they say about the whole healthcare delivery system: The primary-care delivery system in this country is dying. The reason why these things have become important is because there’s this big hole in the delivery system.” (WALL STREET JOURNAL, CHICAGO TRIBUNE, NEW YORK TIMES, BOSTON GLOBE, US NEWS & WORLD REPORT, NEWSWEEK, BCBS.COM, CONVENIENCE CARE ASSOCIATION, CHCF.ORG, MINUTECLINIC.COM, BUSINESSINSURANCE.COM, STATE NET)
Source: StateNet
Original Publication Date: February 6, 2008
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