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.
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