They're coming whether we like it or not, so you might as well get used to them.
That seems to be the feeling of family physicians when it comes to retail health clinics that are popping up in drugstores and supermarkets across the country.
“We can't stop it, so we might as well try to work with them and turn it to our advantage,” said Kerry Gonzales, executive director of the Oregon Academy of Family Physicians in Portland. “We're going to wait and see how it works.”
In addition to pharmacies and grocery stores, retail health clinics also are appearing in corporate headquarters, shopping malls, chain discount retailers, and universities. Their menu of services includes treatment of minor problems such as ear infections, bladder infections, strep throat, and bug bites as well as some preventive services such as vaccinations. The cost for treating a minor illness runs around $44.
The Oregon AFP cosponsored a resolution that was adopted by the American Academy of Family Physicians (AAFP) Congress of Delegates in San Francisco; the resolution asked the academy's board of directors to “investigate the growing phenomena of retail health clinics and educate members … regarding, but not limited to, patient access, ethical issues, third-party payer reimbursement, legislative impact, midlevel provider relationships and statutes, and continuity and quality of care.” It also asked the board to develop a model for a retail health clinic that will ensure continuity of care and a medical home.
“Some health insurance plans are providing preferential treatment of the clinics by waiving patient copayments for clinic visits, but not for visits to family physicians,” according to testimony given in one of the Congress’ reference committees. It's that aspect of the clinics that has some Minnesota family physicians concerned.
Dr. David Thorson is part of a 34-physician, seven-site family medicine practice. He practices in White Bear Lake, Minn. To respond to patients’ demand for more convenience, “we're trying to stay open for our patients from 7 a.m. to 7 p.m.,” he said. “We also offer urgent care from 5:00 to 8:30 p.m. Monday through Friday, and 9 a.m. to 4 p.m. on Saturday and Sunday. How much more expansive can we be?”
Even with those hours, some of his patients still end up at the MinuteClinic, either because it's 7 p.m. on a Sunday night, “or sometimes we're open but they're going shopping at Target now and don't have a copay” if they go to the MinuteClinic, he said.
A spokeswoman for BlueCross BlueShield of Minnesota confirmed that the plan waives the copay for its own employees if they visit the clinic.
To respond to that financial incentive, the practice decided to start a pilot program at one clinic that would give away generic antibiotics to the patients who needed them.
“So if you have a urinary tract infection, you would go to the MinuteClinic [with no copay] and then you get a prescription and pay at the pharmacy. But if you come here, you get evaluated by your own doctor and receive a course of treatment and have no pharmacy copay,” Dr. Thorson explained.
The pilot program costs about $6-$8 per patient for the generic drugs, which the group buys in bulk from the pharmacy. The practice distributes the prescribing information that the pharmacy normally would provide. “We've been eating the cost, and it's working out very well,” he said, noting that the group is ready to expand the project to its other clinics.
Dr. Thorson is quick to note that he doesn't think that retail health clinics are all bad. “I don't think they're necessarily practicing bad medicine,” he said. “I just think that oftentimes people who come to our clinic for acute intervention have other things picked up.” For example, a diabetic patient who comes in for an acute illness may trigger the physician to look at his chart and realize that he hasn't had his blood sugar tested in a while.
Dr. Larry Fields, AAFP president and a family physician in Ashland, Ky., said that the academy has already partly addressed the retail clinic issue in its Future of Family Medicine project. “We recommended in our new model of practice that our members address this point of accessibility and cost to make a more patient-centered, patient-friendly environment,” he said. “We have promoted this sort of idea in the private office—extended hours, open-access scheduling to get a same-day appointment without problems, and no waiting times.”
But Dr. Fields also said that AAFP was concerned that the clinics “might eventually become the only source of care for a particular patient, which is not good because they are not set up to be a regular source of care. You need your own family physician and a medical home.”
Dr. Jim “Woody” Woodburn, chief medical officer of MinuteClinic, in Minneapolis, said he agreed with the medical home concept. “Everybody needs to have a primary care provider,” he said. He noted that since 30%-40% of patients who come to MinuteClinic say that they do not have a primary care provider, “we provide a list of physicians and clinics that are accepting new patients.”
Dr. Fields also expressed concern that retail health clinics may expand to provide an inappropriate level of medical care.
“It's important that these entities confine themselves to a very small set of problems and don't try to do follow-up visits or complicated diagnoses,” he said. “If someone has to come for a second visit, it may be something that needs further attention.”
Dr. Thorson agreed. “If they branch into screening stuff, it could be very disastrous, in my opinion,” he said. “If you're a person who has a family history of heart disease, and you get a ‘normal’ result on a cholesterol check, will you get the counseling you need about a genetic factor which means a normal result may not be normal?”
Dr. Woodburn said that MinuteClinics previously performed several screening tests, including cholesterol, glycosylated hemoglobin, and bone densitometry tests, but the company has decided to stop doing them for the time being.
“Many patients weren't coming to us for those services; it wasn't meeting a lot of patient needs,” he explained. “Also, when you don't do a lot of these tests, sometimes your skills get a little rusty, and with all the other ongoing training we do, training [for the tests] was getting harder for us to do. And we were getting feedback from physicians that maybe that's a domain we shouldn't be in at this time.”
MinuteClinic may get back into the screening business at a later date, he added. “If we can provide a value to the community to allow them a different place to get these screening tests done, that's something we all need to think about.”
The AAFP board of directors has formed a task force to look into retail clinics’ effects on medical care. “What are these things doing? What's the spectrum out there?” Dr. Fields said. “It's hard to make any recommendations without having all the facts. We want to see how we can interface with these things to make them actually a piece of the medical system rather than an outlier.”
For example, there are some family physicians that are having the clinics refer patients to them for follow-up or supervising the nurse practitioners who run the clinics in cases where that is required, said Dr. Fields. “That would be an appropriate way for a family physician to interface with these things.”
Dr. Woodburn advised family physicians to make their peace with the clinics. “This is an industry that I very much believe is permanent,” he said. “So an awareness of what it is we do and don't do is important, and it's reflective of a very strong patient need that's not being met in the current delivery system. “That is not a criticism [of physicians],” he added. “I understand the limitations every clinic's facing. But doctors need to look at their patients and continue to work on being patient-centric.”
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