The Wall Street Journal published an interesting article (subscription not required) about what appears to be the latest fashion in US commercial health care, "in-store health clinics."
The major players include the pharmacy chains. "Rite Aid Corp., Brooks Eckered Pharmacy and Osco Drug - have announced plans to open health clinics in the coming months. All three have partnered with a Pennsylvania-based health care start-up called Take Care Health Systems LLC that will lease space inside the pharmacies and operate the clinics." "CVS and Target are working with Minneapolis-based MinuteClinic.... Wal-Mart is working with InterFit Health and other companies...."
The motivation, of course, is money. "While the retailers don't profit directly from the new services, the hope is that the clinics will boost business if patients fill their prescriptions at the store pharmacy, or pick up other items on their way out."
US health insurers seem to "have embraced the concept because the clinics promise considerable savings. While a typical doctor visit for a basic illness costs an insurer about $110, a visit to one of the clinics usually costs under $60." "Some insurers are actively encouraging patients to use the clinics by lowering the co-pay. In Minnesota, companies including Blue Cross Blue Shield of Minnesota and Graco Inc. have reduced or eliminate co-pays for employees who opt to use a MinuteClinic instead of a doctor. Take Care has deals in place with several insurers in Portland."
It is revealing that "the management teams behind both of the leading companies in the field - Take Care and MinuteClinic - have experience in other consumer focused industries. MinuteClinic's new chief executive officer (CEO), Michael C. Howe, is the former president and CEO of the Arby's fast-food chain, and previous worked for KFC. Hal Rosenbluth, chairman of the board of Take Care, is the former CEO of Rosenbluth International, a travel company acquired by American Express Co...."
Take Care, run by the former travel agency executive, is pioneering novel use of computer technology, "a computer software program will be involved in actually diagnosing illnesses. The patient's sign-in information will be transmitted electronically to a computer terminal inside the treatment room.... The software system will eventually generate a diagnosis and recommend course of treatment. If the nurse practitioner disagrees with the computer-generate diagnosis, he or she can opt to over-ride the system."
Some patients seem very happy with the whole concept. The Wall Street Journal quoted on Terri Whitesel, a 56-year old marketing consultant in Minneapolis. "I didn't want to go to the doctor and sit around waiting with a bunch of people who are really sick."
But Edward Hill, President of the American Medical Association, tried to throw some cold water on the concept. "Serious illness sometimes presents with simple symptoms. A cough may be something as simple as a cold, or something as serious as congestive heart failure. The ability to ferret out the 20% of serious illnesses that present with simple symptoms is what we went to medical school for."
I have posted about MinuteClinics before. Dr. Hill's concern that even apparently simple complaints may sometimes stem from serious problems is a real one. It is amplified if, as reported in the earlier post, the in-store clinic may not have adequate facilities for the nurse practitioner to do some basic parts of the physical examination. It is further amplified if the diagnosis and decision making will actually be entrusted, not to a nurse practitioner, but to some piece of computer software, whose accuracy and reliability are unknown.
This report again emphasizes how managed care companies and insurers are quick to try to save money at the expense of primary care, when they seem reluctant to confront high prices of drugs, devices, and procedures, especially those that are seemingly high-technology, regardless of their effectiveness. (Some recent posts about such prices are here, here, here, and here.)
Finally, this attempt to siphon off the least sick patients may further disrupt an already fragile primary care/ generalist infrastructure in the US. Yet in most countries, primary care is the bed-rock of the health care system. In the US, we have less and less capacity to take care of the patients with more than one real illness, or with undiagnosed problems. Will patients with five chronic illnesses (who are not rare) have to go to five different sub-specialists? Will patients with chest pain have to guess whether their problem is cardiac, pulmonary, gastro-intestinal, or musculoskeletal before they can figure out what doctor to see? How will a system without primary care cope with health care crises from terrorist attacks, to hurricanes, to avian flu?
These aren't, of course, the sort of questions likely to be asked by former executives of fast food companies and travel agencies, until they become the patients in question. And by then, it may be too late.