Friday, January 18, 2008

The Business-Think Rationale for In-Store Clinics

An urban legend that has haunted health care in the last 20 years, to its great detriment, is that the application of business-like thinking, business-think for short, to health care (not just financing health care), will yield enormous improvements.

One of the latest health care fads generated by business-think appears to be in-store clinics. We have blogged several times, (most recently here, here, here, and here) about these clinics. Such clinics are situated in retail stores, such as drug stores, staffed by nurse practitioners, but usually not doctors, and claim to treat a limited number of ailments quickly for reasonable prices. They have been touted as the latest business-like solution to the decline of primary care.

My biggest concern is that these clinics may fail to provide good care to some of their patients, particularly patients who have more serious problems masquerading as or accompanying one of the limited ailments which the clinics claim to handle.

KevinMD just put it more graphically.

I've said it before and my stance hasn't changed. In their zeal for speed, convenience, and profit, someone will screw up.

A 'bronchitis' will actually be a PE [pulmonary embolism]. Chest pain caused by an 'anxiety attack' will be an MI. The inevitable malpractice suits against a retail clinic will no-doubt put a damper on things. Bet on it.

I am afraid that the people touting in-store clinics and similar business-think based fads are too preoccupied with the brilliance of their business models to appreciate how the health care context may make the model unworkable. For example, I noted that the initial designs of the MinuteClinics proposed for Massachusetts including no plumbing in or adjacent to the clinics. No doubt eliminating plumbing would cut construction and maintenance costs. However, in an era when practitioners are urged to always wash their hands to prevent the spread of new, contagious, and treatment-resistant infectious diseases, neither practitioners nor patients in these clinics would have easily been able to wash their hands. And some of these nasty new contagious diseases could masquerade as some of the limited ailments the clinics claim to handle.

The Boston Globe just published a commentary by Steve Bailey that (probably inadvertently) disclosed some more of the fallacious thinking used to justify the concept of in-store clinics. Selective quotes from the article are below, in sequence, and I don't believe out of context,

In the business schools, the personal computer and Southwest Airlines are taught as case studies of what has come to be known as 'disruptive innovation.' Now, with CVS Corp. poised to open as many as 30 medical clinics in their stores in the Boston area alone this year, local primary care doctors and neighborhood health clinics worry they could be next. They may be right.

America spends more money per capita on healthcare than any nation, but continues to lag behind many less affluent countries when it comes to benchmarks like infant mortality and life expectancy. The problem, says Harvard Business School professor Clay Christensen, is that so much of the money goes to maintain the status quo because it is given to organizations wedded to their current solutions, including the old delivery models.

Christensen literally wrote the book on the kind of disruptive innovation that the PC and Southwest Airlines represent. His landmark 1997 book, "The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail," turned Christensen into a rock star of the start-up revolution during the dotcom boom. Now in a book due out in August, Christensen and coauthor Jason Hwang examine how the disruptive innovation model can be used to cure what ails our healthcare system.

CVS's MinuteClinics get an entire chapter in the book. Physicians' associations typically oppose MinuteClinics on patient-safety grounds, Christensen and Hwang write. In about half the states, the business model is illegal because regulations mandate that doctors supervise nurse practitioners and physicians' assistants. But the regulations haven't caught up with the science, they say. Today, the diagnoses for a host of illnesses - from sore throats to ear infections to the flu - are precise and the therapies predictably effective.

'These regulations now trap care in high-cost models when there are much more affordable and accessible business models available,' they write. 'About $15 billion is spent each year in high-cost physicians' offices for the care of acute, rules-based disorders. Delivering even half of this care through a disruptive business model such as the MinuteClinic could easily save $7 billion a year. . . . A billion here and a billion there soon amounts to serious money.'

Maybe it is too snarky to being a "rock star" of the dotcom boom, which became, of course, the dotcom bust, does not seem to be a good credential to tout as a redesigner of health care.

Moreover, the commentary exposed Christensen's fallacious thinking: in-store clinics are a disruptive innovation that will improve quality and save money by using the latest cutting-edge technologies that are not available in old school physicians' offices.

His notions of the capabilities of the latest cutting-edge technologies, however, are seriously misguided. Christensen declared that the diagnoses of illnesses such as sore throats, ear infections, and influenza are "precise" and their treatments are "predictably effective." That's plain wrong.

One reason medicine is still a challenging profession is that the situation is exactly the opposite. There are no practical, quick and accurate diagnostic methods for these diseases.

Let me use sore throat as an example. Most sore throats are are self-limited, and are probably due to a variety of pathogens, most viral. Streptococcal pharyngitis ("strep throat") is caused by a specific bacteria, can last longer, and rarely can produce severe complications. There is no way to quickly and accurately diagnose strep throat. Signs and symptoms do not clearly differentiate strep. Using multiple signs and symptoms in a statistical diagnostic model (most notably the "Centor model") can categorize patients by their risk of strep, but can neither rule it in nor rule it out. The various rapid strep tests are not very accurate. The throat culture is generally thought to be specific, but it takes at least 24 hours to provide results. (References for all the above provided on request.)

Similarly, there are no quick, practical, accurate ways to diagnose bacterial ear infections There are rapid tests that can diagnose influenza, but they have variable and imperfect sensitivity and specificity.

Furthermore, there are no "predictably effective" treatments for sore throats, ear infections, or influenza. Antibiotics at best may shorten symptom duration and decrease the likelihood of complications from strep throat, but have side effects. There are no specific treatments for "viral" sore throats, or most ear infections, or "flu-like" illnesses. The newer antiviral agents for influenza can shorten symptom duration, but only on average by one day.

I'm sure such details about the imperfections of existing diagnostic and therapeutic technology might seem tedious to a "rock star" like Christensen. The sort of business-think he embraces seems to demand a big-picture view that neglects all the devils lurking in the details. But his notion that in-store clinics will bring miracle technologies to "customers," that the dinosaur physicians in their offices do not use is just nonsense, to use the most polite term.

I still hope that exposing the dubious logic and evidence underlying the in-store clinic movement will slow it down before, as KevinMD feared (see above), the malpractice suits start.


Anonymous said...

Good, fast and cheap-pick any two.

InformaticsMD said...

But the regulations haven't caught up with the science, they say. Today, the diagnoses for a host of illnesses - from sore throats to ear infections to the flu - are precise and the therapies predictably effective.

Abraham Flexner must be rolling in his grave.

Anonymous said...

hmm, I've had a go at Christensen blong before you made it trendy Roy, but you're being overly simplistic and overly defensive here.

For a bunch of reasons (that we agree on) primary care has become very user unfriendly. Instore clinics are answering that problem. And the better ones are trying to link to the rest of the system in using the continuity of care record, etc. This is NOT something most physician PCPs do.

And to be realistic NPs can handle 90% of the work of GPs. The rest they should be able to refer on. Not every sore throat needs to be treated by a team in a large AMC, despite the possibility that it can be something else.

Roy M. Poses MD said...

With all due respect, Matt, I don't think I am the one being simplistic here. I may be a bit defensive, but if we don't start defending primary care adequately, there won't be any primary care left, at least in the US.

In-store clinics are at best a partial answer for a very limited sub-set of patients. To get an idea how limited, simply look at:

I challenge your statement about what proportion of primary care problems nurse practitioners can handle. Do you have any evidence to support your statement? By the way, the relevant comparison would have to do with family practitioners, general internists, and/or general pediatricians, since there are almost no general practitioners left in the US. Also, since the argument is about in-store clinics, the evidence would have to be about nurse practitioners or physicians' assistants working in free-standing settings without the opportunity for physicians supervision other than over the telephone.

I do admit that from my own experience, some patients who come to see me (I'm a general internist) don't really need to see a physician, or could do well with a physician extender. Those are mainly patients with minor upper respiratory infections, or patients who just need their blood pressure checked, or medications refilled. However, a lot more than 10% either have multiple chronic diseases that require often complex management decision making, or present diagnostic issues beyond those of sore throats.

Are you suggesting that nurse practitioners should be referring patients directly to sub-specialists? That might mean all patients with chest pain go to cardiologists. That hardly sounds cost-effective. Moreover, since cardiologists (like all specialists) are used to their patients being pre-screened, the result might be lots of patients with gastrointestinal, pulmonary, musculoskeletal etc causes of chest pain getting unnecessary cardiac catheterizations.

Finally, the comparison should not be of an NP with an in-patient visit to an academic medical center. Suggesting patients with sore throats (leaving out those rare ones with gonococcal pharyngitis, diptheria, leukemia presenting with a sore throat, etc,) are being managed by large teams in academic medical centers is a straw-man argument.

Anonymous said...

Since I am a nurse practitioner and NP-driven care is always the underlying tone of such opposition to retail clinics, I think it would be fair to have a comment from one. With all due respect, I do have research evidence that talks about high-quality care given by nurse practitioners. You can look here,, here, and here (I have more if you'd like to see them).

You mention "physician supervision" when in fact supervision is the practice model in 15 states. Most states either use the collaborative practice or independent practice model. The vast majority of nurse practitioners are practicing autonomously and in collaboration with physicians. This means that physicians aren't watching over our shoulders or co-signing every note. We realize our limits and know when patients need a higher acuity of care and patients are then referred thusly.

You also can't have your argument work both ways -- in one sense you refer to the limited sub-set of patients and in the next breath you talk about multiple chronic diseases and more complex decision making. From what I understand, these clinics aren't seeing those patients so I can't really follow your rationale. If the clinics are really that limited and won't have much impact, why are you so vociferous against them?

If you are implying that nurse practitioners aren't capable of diagnosing strep throat while not being aware of a differential that includes peritonsillar abscess, diphtheria, mono, gerd, and gonococcoal etiology (to name just a few) then you must not be that all familiar with NP practice.

We aren't the bad guys here and it's sad how other professionals look to smear or slander our hard work. Advanced practice clinicians such as NP's and PA's are known for providing wholistic, high-quality and cost-effective care in conjunction with other members of the healthcare team. Therefore, patients have a broader entry to access care – one of the real problems that faces healthcare today.

Roy M. Poses MD said...

I have tried to focus my comments on the business models of in-store clinics. I intended no disrespect of NPs and PAs who staff them.

I agree that NPs and PAs can provide good quality care, but have limits, and need to practice within a framework that compensates for these limits. My concern is that the framework provided by in-store clinics may not compensate so well, because of lack of on-site physicians, but also because of the physical design of the clinics (as mentioned in an earlier post, MinuteClinics were originally designed with plumbing), and probably most importantly, but not much discussed, the protocols the practitioners must use. Presumably those protocols are influenced, if not designed by corporate executives whose main concern is profits.

Anonymous said...

We aren't the bad guys here and it's sad how other professionals look to smear or slander our hard work.

Well I'm not so sure about that, they do play a role.