Monday, May 14, 2007

Quick In-Store Health Care Clinics: "You're Sick. We're Quick!" but Will You Really Get Better?

There has been a lot in the media lately about quick in-store health care clinics, an issue which we blogged about previously here and here. In Illinois, as reported by the Chicago Tribune, the state medical society is pushing for more regulation, which is predictably not making clinic operators happy.

The Illinois State Medical Society, which represents more than 13,000 doctors, is pushing a proposed law to more closely monitor hundreds of in-store clinics being opened by retail giants Wal-Mart Stores Inc., Walgreen Co. and CVS/Caremark Corp.

The doctors claim the clinics, staffed by advanced-degree nurses and physicians' assistants, are largely unregulated and therefore put patients' health at risk.

The potential loss of business for doctors is great because most health insurance companies are beginning to cover retail clinic procedures.

Doctors say they are concerned about the quality of care if the clinics uphold their promise to treat patients in less than 15 minutes. The doctors said that is not enough time for consultation, and that follow-up may not be adequate.

Facing off against the doctors' powerful lobbying organization are the powerful pharmacy and retail industry lobbyists, who are trying to block the proposed legislation. Retailers say the clinics are staffed by licensed health professionals who track their patients' health in medical records and make referrals.

'Increased regulation has the potential to restrict access to these health-care services and create more costs to patients,' Walgreens spokesman Michael Polzin said. 'That would work against the growing concern over affordable, quality health care that our Health Corner Clinics are directly addressing.'

There is a paean to quick in-store clinics in a today's Wall Street Journal by free market health care booster Grace-Marie Turner.

It's Friday evening and you suspect that your child might have strep throat or a worsening ear infection. Do you bundle him up and wait half the night in an emergency room? Or do you suffer through the weekend and hope that you can get an appointment with your pediatrician on Monday -- taking time off your job to drive across town for another wait in the doctor's office?

Every parent has faced this dilemma. But now there are new options, courtesy of the competitive marketplace. You might instead be able to take a quick trip on Friday night to a RediClinic in the nearby Wal-Mart or a MinuteClinic at CVS, where you will be seen by a nurse practitioner within 15 minutes, most likely getting a prescription that you can have filled right there. Cost of the visit? Generally between $40 and $60.

These new retail health clinics are opening in big box stores and local pharmacies around the country to treat common maladies at prices lower than a typical doctor's visit and much lower than the emergency room. No appointment necessary. Open daytime, evenings and weekends. Most take insurance.

Much like the response to Hurricane Katrina, private companies are far ahead of the government in answering Americans' needs, this time for more accessible and more affordable health care. Political leaders across the country seeking to expand government's role in health care should take note.

This industry is in its infancy and will hardly register in our nation's $2 trillion-plus health care bill. But just as Nucor overturned the steelmaking industry with a faster-better-cheaper way of making low-end rebar, these limited service clinics could be the disruptive innovator in our health-care system. Package pricing for more complex treatments, like knee replacement surgery, may not be far behind.

Government can get in the way, of course, with protectionist policies that throw up more regulatory barriers to entry. But retail clinics could be just the beginning of consumer-friendly innovations....

What bothers me about all this? It seems to me that in-store clinics (of this type) could embody what goes wrong when the business managers and bureaucrats who are now in charge of health care treat health care as a commodity, a standardized service that can be provided quickly in a formulaic way by "mid-level providers." But won't the service be quick, cheap and to the point?

My concern is that health care is rarely as simple as it seems, especially to people whose health care training was reading financial statements from health care companies. Let's look at an example. One of the maladies which the quick clinics advertise they can treat is the common sore throat. I have actually done some research on this problem, and what I have learned from reading the clinical literature, and my own clinical and research experience is that even this seemingly simple health care problem isn't.

Sure, most, maybe the majority of people with sore throats just have self-limited viral illness, and only need symptomatic treatment (aspirin or the like, maybe throat lozenges, maybe cough syrup, maybe an anti-histamine, fluids and rest). Such people do not even need to visit a clinic. The first problem is that neither the patient nor the practitioner can reliably determine from the patient's symptoms and physical exam whether the patient just has a viral sore throat, or streptococcal pharyngitis (strep throat).

Strep throat can at times lead to serious complications if not treated with antibiotics. Yet the antibiotics used in treating it can have side effects. So even for the "routine" sore throat, the health care professional needs to look at the probabilistic balance of benefits of treatment and harms of treatment. The relevant probabilities, and the importance and value of the particular benefits and harms will vary for different patients. To some extent, this balancing can be rendered formulaic (although the formula may not be simple.) But a failure to understand that the problem is actually somewhat complex and probabilistic could lead to trouble: a patient with a viral sore throat getting a needless antibiotic complication, a patient with strep throat not getting an antibiotic and getting a complication of the disease.

Things get even more complex for a patient with another condition which may affect the likelihood of complications of strep, or of antibiotics. Some common examples of such conditions are asthma, diabetes, chronic obstructive lung disease, and heart valve problems. There are other, less frequent problems on the list. If a health care professional fails to appreciate that the patient with a sore throat has one of these problems (and patients with these problems are not always fully aware of them), then the potential for something major going wrong is even higher. It becomes much harder to set up a formulaic approach that would efficiently screen for such problems, especially because not every patient with them knows he or she has them.

And then there is the issue of rare causes of sore throats....

Other "simple" problems, like urinary tract infections and ear infections, may not always be simple either. And we physicians feel we really earn our money by figuring out when an apparently simple patient isn't.

My real concern about the "quality of care" delivered by quick health care clinics is that the "mid-level providers," good, well-intentioned people with substantial training, but still years less of training than that given to physicians, operating in isolation with corporate pressure to do things quickly and cheaply may miss some of these not so simple patients. And that would be quite bad for the patients. (And when the lawyers figure it out, it would be quite bad for everybody involved.)

Again, those concerned with decreasing costs and improving access might better first focus on the really expensive parts of health care (look at Health Care Renewal and the blogs on our blogroll for some examples). But of course those costs will be heavily defended by vested interests. And the relatively poor, beleaguered primary care docs probably won't make such a fuss about quick quick health clinics, that is, until there own patients end up having bad experiences resulting from such clinics' care.

Of course, it may be possible that quick in-store clinics are just a symptom of larger social ills, and hence may be hard to stop. Let me conclude with quotes from a recent column by Brian McGrory in the Boston Globe:

Oh, I know, I know, every harried mother and overwrought father within Route 495 is undoubtedly thinking that these fast-serve clinics are a going to be a godsend in their mile-a-minute lives. The kid has a rash -- head out to see the nurse practitioner at the CVS, and hey, pick up some Tide while you're at it.

Because that's all we have time for these days, impersonal drive-through treatment centers offering medicine by slogan. As the chief executive officer of MinuteClinic said, 'You're sick. We're quick!'

What's next in their ad campaign? How about 'You've got ills. We've got pills!' And conveniently, you can fill the prescription written by the nice CVS nurse practitioner with the equally nice CVS pharmacist.

It wasn't all that long ago when the average Jane and Joe would take the time to establish relationships with their doctors, who would get to know them inside and out, and doctors would take the time to nurture relationships with patients.

But now look what's happened. Modern technology was supposed to free people up, to give everyone more time.

We can have all the information in the world, but rather than creating the luxury of time, it's causing a constant frenzy. Technology hasn't allowed people to leave their responsibilities behind; it's made people bring their obligations every single place they go.

And thus, the MinuteClinics, guaranteed to be as popular as they are impersonal. So back to my first question: They are merely a symptom, not a cause.


Anonymous said...

News flash. The retail clinics are not the only ones using midlevels providing "Your sick, Were quick" medicine. Your local ER might be doing the same thing.

Where I work a patient is Triaged upon arrival by a PA, Obvious critical patients are routed to the main ER and seen by a MD. Minor appearing complaints never see a MD and are treated and streeted, sometimes after a 30 second exam by the PA. The longest wait is getting registered. This model provides quick care to the patients who least need it in the ED. With the emphasis on patient satisfaction and scores administration gets a bigger bang for the buck by providing rapid treatment to this group of patients since they are the largest group and the really sick paitents usually do not fill out their surveys

I support the clinic approach to keep this miniute medicine out of the ER's.

ERMurse said...

I find it amusing that some vested interests in the medical profession are trying to squash this type of care. Very self serving. For the working uninsured the retail clinic concept makes basic healthcare affordable.

Unknown said...

An interesting take that the process of a patient being cared for in a "doc-in-a-box" is simply an economic adventure; it shows the self-serving focus and fears that some providers are voicing, loss of revenue.
Easing allergies symptoms, testing for and if appropriate, treating strep or influenza, evaluating sinus infection, providing vaccines, evaluating an ear infection, these are a great service to a community, and the fact that we are earning money in the process is not wrong. It is a process that is highly coordinated with the primary care provider and patients are aware to follow up there.
FNP, New Jersey

Anonymous said...

I am on medications that reduce clotting. I got a minor stab wound in the leg (accident with a swiss army knife) and needed more bandaging than I had at home. For a lack of such clinics I got to go to the ER at a hospital and wait 4 hours not being treated before giving up and going home again. The bleeding stopped by the next morning.

Yes some minor injuries or illnesses are symptomatic of bigger but harder to diagnose problems. Most aren't. When the *only* available mid-level care is a hospital's ER room everybody loses. The ER standards, equipment, and level of training are expensive overkill for minor complaints, and the lines to access them are an an expensive loss of productive time for those forced to use them. There needs to be a mid level mid priced alternative.

Roy M. Poses MD said...

I certainly agree that we need to make care for relatively minor acute problems more accessible. It used to be that such care was often available in physicians' offices and hospital clinics. But primary care is now sinking under the weight of ever increasing bureaucratic requirements driving up overhead costs, and reimbursement that fails to keep up with inflation. I would argue that the best way to make primary care accessible is to stop this strangulation. To do so, maybe we need to rethink how much we spend on management and bureaucracy and on procedures and high-technology. See our posts on wooden-headed reimbursement here:
and on the increasing gap between primary care and cognitive vs procedural reimbursement here:

Note that quick in-store clinics are only designed to treat a few specific problems, and only their simplest versions occuring in patients who are otherwise healthy. I don't think they most would treat a fresh, even minor stab wound. So as a substitute for primary care they can go only a little way.

And treating some simple upper respiratory infections (mostly those that would improve without medical care) and a few other simple problems, but avoiding all other problems, and patients with chronic diseases is not likely to provide much of a community benefit.

Finally, I am happy working with nurse practitioners and physicians' assistants. I think they do great work in settings like Emergency Departments, clinics, and office practices, where they have adequate back up. But I worry about what they can do when they are set up in isolated quick in-store clinics with no backup other than computer screens full of protocols.

Anonymous said...

The discussion against quick medical treatments by mid-level providers in a coporate setting is not valid.

I have recently been interviewing for nurse practitioner positions at a variety of "Family Practice" Groups. I am finding that the expectation of those practices are no different than the Minute clinics and Solantic groups. The expectation is that I would see a patient for no more than 5 to 10 minutes, take a history, make a diagnosis, order treatment, and discharge nearly in the same breath.
Family practice is no more personal than a minute clinic and certainly no more thorough when treating acute illness. Granted the patient may return for additional services at the practice. However,the working poor are in desperate need of quick services and may be the only medical treatments they ever recieve.

The abuse of emergency room services for routine problems is both economically draining and inappropriate utilization of medical staff.

The real argument, as always, is a turf war between the AMA and other health care providers. NP's are well trained to provide acute care services and recognize serious illness that require referral. We are held to the same evidence based practice guidelines and medical standards as are physicians. Thus the argument is clearly null and void, and once again a disguised AMA protest against turf invasion.

Anonymous said...

It looks as though the family doctors and the AMA will have the model of the future and answer for retail clinics in MeD thru Express Clinics.
Credible care, location, visibility, technology, continuity of care etc.
Family physicians providing access today that is interactive and based around the patient.
Family physician

Anonymous said...

"We are held to the same evidence based practice guidelines and medical standards as are physicians."

Thats a lie. Nurses are NOT held to the same standard of care. If a medical malpractice lawsuit is filed against an NP, then ONLY an NP can testify against them. Doctors are stricly barred from testimony about NP mlapractice.

The same is true for med mal cases against doctors. NPs are not allowed to testify about any malpractice by a doctor.

In fact if you bohtered to read the state nursing board statutes you will see clearly and plainly that they claim to practice NURSING, not medicine. In fact, thats the only way they ever got prescription privs in the first place was thru this loophole.

Nurses define all their activities as the practice of "nursing" and therefore are free and clear of any regs by the state medical board. Its all a sham, but the American Nurses Association and all the state nursing boards deny that nurses are held to the same accountability/standards as doctors. If they were, that would be the practice of medicine and they would be guilty of breaking the law.

Anonymous said...

May need to review your proof of assumption prior to writing it. Keep sucking up to the AMA:
(6) "Approval to Practice" means authorization by the Medical Board and the Board of Nursing for a nurse practitioner to perform medical acts within her/his area of educational preparation and certification under a collaborative practice agreement (CPA) with a licensed physician in accordance with this Section.
A nurse practitioner shall be held accountable by both Boards for the continuous and comprehensive management of a broad range of personal health services for which the nurse practitioner is educationally prepared and for which competency has been maintained, with physician supervision and collaboration as described in Rule .0810 of this Section. These services include but are not restricted to:

(1) promotion and maintenance of health;

(2) prevention of illness and disability;

(3) diagnosing, treating and managing acute and chronic illnesses;

(4) guidance and counseling for both individuals and families;

(5) prescribing, administering and dispensing therapeutic measures, tests, procedures and drugs;

(6) planning for situations beyond the nurse practitioner's expertise, and consulting with and referring to other health care providers as appropriate; and

(7) evaluating health outcomes.

Anonymous said...

Being an RN for 16 years and using these clinics many times, I've found them to be a God-send. Dr. PCP HAS NEVER helped me out on the week-ends or evenings. These clinics have been my saving grace for the Sunday morning strep throat illness or the sick child on the week-ends whose ped won't do ANYTHING but say go to the ER and sit with all those sick people for 8 hours or more. Some things like cold symptoms and fevers are too bothersome to live with for the whole week-end, but not serious enough for the ER.
Not only that, I've never in my life been to my PCP where they've spent more than maybe 5-7 minutes with me...if not less. Including visits with the pediatrician. I have never worked with or for any docs that would spend longer than a few minutes with their patient. The doctors are the WORST pill poppers!!! Anything to get the naggy patient off their backs. The nurse practioners I've seen were more knowledgable, more compassionate and took wayyyy more time with me and my children than any dr. has. Plus I don't have to sit in an ER for hours.