Quick clinics find niche in health market
From the October ACP Observer, copyright © 2006 by the American College of Physicians.
By Ingrid Palmer
A patient who normally sees her primary care physician decides instead to go to a grocery store health clinic for a minor illness and is prescribed an antibiotic for a urinary tract infection (UTI). What the treating medical professional might not know, however, is that the patient’s last few UTIs were resistant to the antibiotic prescribed.
That's part of the problem with the burgeoning trend of health care clinics now treating patients for minor illnesses in grocery and drug stores and even shopping malls, say concerned physicians.
“Retail health providers don’t know if a patient is resistant to certain drugs,” said Lawrence Klein, FACP, an internist in Washington, D.C., referring to the many health care clinics opening in stores like Wal-Mart, Rite-Aid and CVS, which are staffed primarily by nurse practitioners and physicians’ assistants. “A regular doctor often has information about patients that can impact [their care]," he said.
Not only don't the in-store practitioners know the patient's background and may thus miss what's really going on, these clinics also could add another blow to continuity of care, raise issues of conflict of interest and begin to compete with office-based internists for lucrative, quick medical services.
What in-store clinics do offer are convenience—evening, weekend and even holiday hours are common—competitive prices and access to a health care system that doesn't work for everybody.
While some physicians say the impact on their practices will be minor, others consider the growing trend a wake-up call for physicians who are seeing the trend reach into their communities and their practices.
Meeting a need?
Though these in-store clinics—with names like MinuteClinic and RediClinic—have been around since 2000, they are steadily growing in numbers and locations around the country as demand for quick, convenient and affordable care grows. Most of them have huge expansion plans for the coming years (see "Huge expansion plans for in-store clinics").
Much of the clinics' popularity—each company touts greater than 90% consumer satisfaction rates—is due to having evening and weekend hours. The clinics know this and use it heavily in their marketing. For example, MinuteClinic, which was purchased in June by CVS/pharmacy, sells its services as “quick, convenient and affordable treatment for many common illnesses.” Its motto? “You’re sick. We’re quick.”
Solantic, whose clinics are open every day, including weekends and holidays—a big draw for today’s busy families—also emphasizes convenience. “Just Walk in—no appointment is ever needed” boast their ads.
The convenience factor is one answer to today's access problems, said Uwe E. Reinhardt, PhD, professor of health economics at Princeton University. “The American medical profession hasn’t made it particularly easy for even insured consumers to get access to them. It’s all on the doctor’s terms,” he said. “Illness is not a nine-to-five affair.”
Statistics from Wal-Mart, which currently leases space to 12 clinics, uphold the theory that this trend may alleviate pressure on the overall health care system. Twenty percentto 40% of surveyed customers said they would have used an emergency room had the clinic not been available, and another 10% to 20% would have gone without treatment entirely, perhaps causing more serious and more costly problems down the road.
Though several clinics reported that the percentage of uninsured patient visits was low (20% for both MinuteClinic and Solantic), the number of uninsured patients visiting clinics in Wal-Mart stores was substantially higher (25% to 40%).
Insurance companies in general support the clinics as a great way to save money on health care. Blue Cross/Blue Shield saves so much money on each patient visit to a retail clinic that in Minnesota, the carrier waives co-pays for its own employees who choose to go there instead of to their regular doctor.
Even without that help, the clinics' prices, clearly posted on menu boards, are hard to beat. Solantic, one of the few companies that guarantees a doctor on site at all times, offers three levels of visits, costing $55, $90 or $150 depending on the treatment needed. Services include in-house lab tests, X-rays, immunizations, sutures and medication.
Most clinics make a profit much the same way a doctor’s office does—through insurance and cash payments from the customers—while others save on low overhead, primarily because the clinics concentrate on a narrow set of issues.
“The take-home pay for NPs is less than it is for doctors,” said Jan Hennings, a spokesperson for Blue Cross/Blue Shield of Minnesota. "And supplies not only cost less, [the clinics] don’t need as many.”
But all the convenience in the world doesn't guarantee that the care at what skeptics call “fast-food clinics” is good for patients, their relationships with physicians or health care costs in the long run. Concerns include the following:
Quality of care. The chief concern is that retail store health clinics will decrease quality of care because patients are being taken care of by someone who doesn’t know them or their history, Dr. Klein explained. For example, many patients on multiple medications frequently forget to mention one or more of them, said Robert M. Lubitz, FACP, Governor of ACP's Indiana Chapter. They also forget about allergies, genetic predispositions, failed medications and test results. “This puts the patient in jeopardy and raises the risks of potentially dangerous reactions,” he said. The clinics note that they refer patients with more serious conditions to a primary care doctor or an urgent care center.
After-hours and follow-up care. Cutting office-based physicians out of part of the loop can make it that much harder to care for those patients when they call later with reactions to or questions about a treatment prescribed by someone else. “Medically and legally, you’re trying to figure out over the phone what’s wrong with the patient,” Dr. Klein said. “The doctor didn’t see the patient, doesn’t have a feeling for what’s going on, and doesn’t even know what tests were run or what the results were.”
The clinics note that they are doing what they can to connect with their patient's regular physicians. For example, MinuteClinic's patients are handed an information packet at discharge that includes a patient-provided medical history plus results of tests done in the clinics, information that is also faxed or mailed to the physician's office, said chief medical officer James Woodburn, MD.
MinuteClinic also offers patients a 24-hour hotline. Solantic follows up with a phone call to patients within three days of their visits. "We inquire about their condition and, secondly, we want to know if we met their needs from a patient satisfaction standpoint,” said Barrett Cook, a company spokesman.
Fragmenting care. Despite contentions that the days of one doctor taking care of a patient 24/7 are over anyway, critics contend that in-store clinics are pushing that trend, bringing with it the problems of fragmented care.
“By providing services outside of the patient’s medical home, patients may be subject to redundant tests and treatments, needless referrals and loss of continuity of care and health records,” Dr. Lubitz said. Doctors are missing opportunities for counseling on preventive measures, medication refills and continued growth of the doctor-patient relationship.
Yul Ejnes, FACP, Chair of the College's Board of Governors, is worried that these clinics will further fragment what he sees as an already dissected health care system. “Every time we see someone new come in and take a piece of the patient’s care away, it’s troubling,” he said. “A lot of physicians are taking this as a wake up call, for instance, by extending their hours.”
The real costs. Retail clinics are being promoted as a way to save costs in the health care system, but some doctors say that because they undermine the medical home and increase missed opportunities for peripheral and preventive care, the long-term cost may be substantial. “In the long term, if one could measure it, it probably doesn’t save money,” Dr. Klein said. When he sees a patient for an illness, he explained, he follows up on other aspects of that patient’s care and may make an impact on, for instance, the patient's heart disease—and associated costs—in the future.
Conflicts of interest. Although there usually is no direct financial link between in-store clinics and their pharmacies it is not only convenient for patients to fill their prescriptions there, but it also could lead to problems, some say. “The placement of clinics within facilities with pharmacies creates the potential for a financial conflict of interest in prescribing treatments,” Dr. Lubitz said.
For now, the clinics say it's not an issue. Kevin Gardner, a specialist for health clinics with Wal-Mart, emphasized that the only revenue Wal-Mart receives from the clinic-tenant relationship is a rental fee.
And CVS doesn't influence how or what the clinic's staff prescribes, said MinuteClinic's Dr. Woodburn. “We are not motivated to generate prescriptions for CVS. And we will not write a prescription if it’s not warranted.” He added that MinuteClinic does not share patient information with CVS. “We will never do that. Patient privacy comes first.”
Competition. Experts say the retail clinics are siphoning away some of the quick and lucrative medical services needed by doctors to offset the chronic care and follow-up visits that are more time-consuming and not well reimbursed—services the clinics are not pursuing.
“Consumers now have the choice to go to doctor and pay $100 or go to a retail clinic, which will only set them back $40,” Dr. Reinhardt said.
Facing the music
But competition is not necessarily a bad thing. Some of the patients who go to in-store clinics may actually end up in a physician's office—for the first time, Dr. Reinhardt noted.
“There are a lot of patients who wouldn’t go near the health system at all, but they will go to a MinuteClinic—and they may be referred to a doctor,” he said.
Plus, the clinics do fill a need—for now, Dr. Klein acknowledged. “There are some physicians’ practices where patients can’t get seen for days; in that case, going to a retail clinic is certainly better than a patient not being able to get treatment,” he said.
Nonetheless, some physicians remain on the fence. “I could see the MinuteClinics as being potentially good or bad, depending on how people use them,” said Caitilin Kelly, FACP, Chair of the Indiana Chapter's Health and Public Policy Committee and a trustee for the Indiana State Medical Association. “The potential concern would be if people started using them as their sole source of health care. This would make it more likely that basic screening tests might not get done and problems like obesity would be less likely to be addressed.”
Still others say that even with in-store clinics opening shop around the corner, the impact on their practices will be slight. “"These clinics will have little impact, certainly less than urgent care centers which have been in operation for years,” said Michael Burgin, MD, who works in a suburb of Columbus, Ohio, not far from a CVS-based MinuteClinic. As for concerns about quality of care from non-physicians seeing and treating patients, he maintained that since "these clinics must follow state medical board guidelines and likely use well-proven triage protocols and treatment algorithms, the patients' care should be no worse than what is delivered by less-trained individuals over the phone from some doctors' offices everyday."
But those who say the writing is on the wall are meeting it head on. In Connecticut, for instance, ProHealth Physicians, the state’s largest group of primary care doctors, is opening its own walk-in clinic in a Putnam Price Chopper supermarket. It plans to expand statewide if the initial venture is successful. Other physicians groups have contracted with local retail clinics in agreements to refer patients to each other. And some doctors provide medical oversight to retail health companies for a fee.
Just coming up with a plan is an appropriate first response, according to Dr. Reinhardt. “Doctors should ask, 'How can I compete with these clinics? How have we failed the consumer to allow this gap to come about?'” he said.
In the long run, he said, physicians are just going to have to accept that the trend of in-store clinics is going to be a reality. “Try not to control or patronize it,” he cautioned. “Cooperate with the clinics. See if you can turn [the trend] to your advantage. But don’t fight it; it’s a losing battle.”
Consider what might be opening up in your neighborhood:
MinuteClinic. The Minneapolis-based model already has a strong national presence, operating 83 clinics with plans to open 250 more by the end of 2006. Most clinics are in CVS stores, but some are in Bartell Drugs, QFC and Cub Foods, among others. Geographic locations include Florida, Georgia, Indiana, Kansas, Maryland, Minnesota, North Carolina, Ohio, Tennessee, Washington state and Washington, D.C.
Solantic. This company currently runs 13 clinics throughout Florida, and plans to open as many as 1,000 more nationwide over the next five years. Located in North, Central and South Florida, Solantic has a mixture of free-standing clinics and clinics located inside Wal-Mart Supercenters.
Houston-based RediClinic plans to grow from 75 to 500 locations in the next three years.
RediClinic. This Houston-based model will grow from 75 locations to 500 in three years. Located in Wal-Mart and other stores in Arkansas, New York, Oklahoma and Texas.
Take Care Health. This Conshohocken, Penn.,-based company will grow from 16 clinics to 1,400 by the end of 2009. Located in Walgreens and Rite-Aid stores in Kansas, Missouri and Oregon.
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