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.

Will MinuteClinics be a Wash?

We have blogged several times, (most recently here, here, and here) about one of the latest health care fads, in-store 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.

A lot of people have objections to this concept. My concerns center around how the clinics will be able to manage patients whose problems are not so simple as they first seem.

Sometimes what a patient thinks is a simple problem is not. For example, a patient may come to the clinic for the treatment of a sore throat, but actually have an exacerbation of chronic obstructive pulmonary disease.

Sometimes a patient with a simple problem has other, not so simple problems of which they are unaware. For example, a patient with a bladder infection may also have undiagnosed, but uncontrolled diabetes.

Why would in-store clinics not cope well with such patients? One reason is that nurse practitioners, no matter how able and well intentioned, do not have as extensive training and experience as most primary care physicians. They may not know all the possible causes of common complaints, and not recognize subtle symptoms and signs that indicate more complex problems.

Another reason is that the people who developed the in-store clinic model may not understand the health care context well enough to appreciate these issues. Many people pushing in-store clinics seem to be business executives with no on the ground health care experience. For example, we previously noted that Michael Howe, the CEO of MinuteClinics, a subsidiary of CVS Caremark, was "recruited for his leadership experience," but this experience mainly seemed to be in the restaurant business. Howe was the former CEO of Arby's Inc./Triarc Restaurant Group, and before then an executive for KFC, according to this article in the Minneapolis/ St Paul Business Journal.

My concern about how well the people designing in-store clinics understand the health care context was highlighted by today's Boston Globe article that described how Massachusetts state regulators have just cleared CVS Caremark to open MinuteClinics in the state. Here are the crucial two sentences:

The panel's members also wanted hand sanitizer available at the clinics and restrooms adjacent to the facilities so that patients don't have to walk across the store. All these provisions were incorporated in the regulation adopted yesterday.

This article implies that CVS Caremark MinuteClinics will not have any plumbing within the clinics proper. They will not have sinks and soap dispensers, and they certainly will not have toilet facilities. How adjacent such facilities would be is unclear.

Why is this a big problem?

Take a look at the list of conditions which MinuteClinics claim to be able to treat. They include "bladder infections," "pink eye and styes," and a variety of skin infections.

Diagnosis of bladder infections requires a urinalysis, and usually a urine culture. How will MinuteClinic patients provide urine samples? If patients are required to go out into the CVS store to find a bathroom, produce their sample, and go back to the clinic, how many would refuse out of embarrassment? If patients with bacterial urinary tract infections fail to provide urine samples, they might not get needed treatment. If patients without such infections fail to provide urine samples, they might get unneeded antibiotics. Also, would waiting for patients to provide urine samples slow down patient flow so that MinuteClinics become HourClinics?

It gets worse. "Pink eye" is often caused by viral conjunctivitis, which can be highly contagious. Health care professionals can cut down on its spread by thorough hand washing after seeing affected patients. (This is one of many reasons that you will almost never see an American doctor's office examining room without a sink and soap.) But MinuteClinic nurse practitioners will not have a sink and soap within their clinic, and will have to go out of the clinic, and wash their hands in whatever facilities CVS provides. Because of this inconvenience, and the time pressure inherent in the MinuteClinic concept, would the nurse practitioners sometimes fail to wash their hands when indicated? If they would not wash their hands, they would be at risk of transmitting viral conjunctivitis to other patients, and acquiring it themselves.

It gets still worse. MRSA (methicilin-resistant staphylococcus aureus) infections have been on the rise. MRSA can cause skin infections that are not specific in appearance. It is likely that some patients going to MinuteClinics for one of the common skin infections that the clinics are supposed to be able to treat will really have MRSA. For the reasons above, would the nurse practitioners fail to wash their hands after every such patient they see? If they would not wash their hands, they would be at risk of transmitting MRSA to other patients, or acquiring it themselves.

The failure of the executives of MinuteClinics to make sure that every one of their clinics has an in-clinic sink and toilet suggests that these executives really do not understand the health care context well enough to appreciate what they are getting into. I worry about what unrealistic assumptions have gone into the development of the in-store clinic concept.

The common business school notion that an executive does not need to know anything specific about the nature of the business he or she leads will continue to plague health care, maybe this time, literally.

The Rush to In-Store Health Clinics

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.

MinuteClinics

One of the latest ideas in the brave new world of the health care biz is "MinuteClinics." As described here, MinuteClinics operate rapid-service, walk-in clinics located in such venues as CVS pharmacies, Target and food stores. The clinics are staffed by nurse practitioners and physicians' assistants, and treat a limited range of minor illnesses, such as "strep throat, pink eye, and bronchitis." As described by ABC News, patients are seen in a "tiny kiosk with a nurse practitioner inside."
The American Medical Associaton is wary of MinuteClinics because they do not provide continuity of care. One of our local physicians wrote an op-ed challenging their effects on the "efficiency" of primary care.
My biggest concern is that some people with apparently simple problems, even sore throats and bronchitis, actually have serious ailments. Will a nurse inside a "tiny kiosk" be able to identify them? The nurse may have a good protocol (although the contents of the protocols they use have not been made public), but I wonder how nurses in tiny kiosks can do adequate physical examinations, even for simple complaints. If they can't do a good chest examination, for example, they may miss the heart murmur that suggests a patient with a sore throat might merit antibiotics even with a negative rapid strep test, or they may miss the signs of pulmonary congestion that suggests a patient with "bronchitis" might have pneumonia or congestive heart failure.
But MinuteClinics also provide a telling example of how health care is now lead. This article provides a brief biography of MinuteClinics new Chief Executive Officer (CEO), Michael Howe, who was, it says, "recruited for his leadership experience." Howe is the former CEO of Arby's Inc./Triarc Restaurant Group, and had previously had executive positions with KFC. These days, leadership in selling fast food is now considered equivalent to leadership in health care. Would you like fries with that rapid test for strep?