Wednesday, May 02, 2007

I vote "yes" on storefront clinics

Liz Kowalczyk writes in the Boston Globe about plans by the CVS pharmacy chain to open storefront medical clinics to provide certain primary care services to the public. Walmart and others have done the same.

We can expect that there will objections to this from people representing established health care practices or institutions. You can be sure that those objections will often be phrased in terms of protecting the public from substandard or uncoordinated care. That is always the first refuge of people concerned about protecting market share for established players. I have seen it before in many industries.

I think this kind of objection also stems from a belief that primary care must be provided by doctors. Yet, physician assistants and nurses can provide excellent and appropriate care for many issues. Their doing so may actually free up time for primary care doctors, who are in short supply, to handle more complicated cases.

Rather than objecting to this convenient approach to providing care, established providers should open their arms and do their best to make it easier to coordinate with CVS and others.

39 comments:

Rob said...

And how ironic is it that a percentage of the "continuing care" crowd resists EMR as too costly, or getting in the way of care, or cramping their style?

Can't continue care if you leave the patient to rattle off what s/he's had done to him/her instead of actually knowing. Sometimes I really wish we could send doctors through a simulator so they can see how profoundly frustrating and scary it is to rely on the memory of someone who's obviously too busy to treat you as a person, to harried to have the right records, and too focused on the next case.

I can't help but think that relieving the time pressure on Docs can only improve thier ability to, well, doctor.

BC said...

I think the clinics popping up in retail stores are likely to make a very significant positive contribution to the primary care segment of our healthcare system.

As a patient or potential patient, the benefits include: (1) the ability to be seen right away or after a short wait, (2) low cost, as compared to a PCP, and (3) price transparency for the limited array of services the clinics offer. I made a recent trip, out of curiosity, to a nearby CVS clinic and learned the following: (1) if the patient needs something the clinic is not equipped to provide, he is advised to see his PCP; (2) if he doesn't have a PCP, the NP at the clinic can offer a referral to one, and (3) if it's an emergency, she said "we know how to call 911."

As these clinics proliferate, PCP's may find themselves with plenty of capacity to see patients. Moreover, the number of non-emergency visits to ER's should decline significantly, which would be a good thing from both a system cost and ER overcrowding perspective.

Patient Dave said...

While I lived in Minnesota I used Minute Clinic, which was in my grocery store - even better than a pharmacy. (People *use* resources that are in their ordinary traffic pattern, and grocery stores are visited far more commonly than pharmacies, especially with kids in tow.)

I checked in and got a restaurant-style beeper. I continued shopping and when I was beeped I came in, got my 15 minute visit and a prescription, went to the pharmacy counter, and that was that.

Were it not for the Minute Clinic, I probably would have waited out my flu without seeing anyone.

The conventional "make an appointment and wait" approach is stupid by comparison. (And I don't say "stupid" often.)

I already heard that some association of physicians' offices was objecting... I'd suggest that they radically improve their concept of customer service! :-)

Anonymous said...

One of the many reasons that the French system is rated so highly by WHO is that pharmacists diagnose, treat and prescribe for many minor problems, put on bandages, provide triage and referral. We were in St. Barts on a Sunday when my wife developed a skin problem - the pharmacist looked at it, said a physician would need to review. Sunday 11 am two were open - we walked in and my wife was better in 15 minutes.

Emily DeVoto, Ph.D., said...

If CVS can give me a patient medical record that I can carry around on a card (including all my prescriptions of course) with all the information on my interaction with the storefront NP, and that I can bring back to my primary care doc, I'm all for it. But that's a ways down the road because of (I think overblown) fears about HIPAA. I'm just worried that, currently, such enterprises contribute to the fragmentation of care that we suffer from. (And I'm not a provider worried about market share.)

Airwick said...

I see this as a great thing for those of us with PCP's and good insurance as well - but are on the grey area of whether it is "worthy" of a doctor's visit. For example - is this just a cold that I've had for 2 weeks, or has it truly crossed the line to a sinus infection that deserves antibiotics (insert discussion of when antibiotics are ever necessary or not here if you want).

As BC said ... as long as the providers are smart enough to know when to refer to a more appropriate level of care (ie PCP/ER) (and corporate policiesof both MinuteCare and the retail host allow them to do so), things should work out okay in my mind.

I'd love to be able to just get a quick walk in opinion on stuff ... saving my Doc's time for 'real' patients.

Anonymous said...

It's sad that you frame this is as a simple turf issue.
You couldn't design a better way to finish off primary care than this. It picks off the last thing that PCPs can make money on, leaves the unprofitable stuff behind.
Or maybe this is a good way to get even with the docs who want to set up ambulatory surgery centers?
Careful what you ask for. ... they'll end up in your emergency room.

Jon said...

I also think that these clinics are great for a number of uses, including things like childhood vaccinations, minor urgent care (cold/flu, diarrhea), and may also be a good way to get people who don't take advantage of preventative medicine to do so.

Perhaps if you can get your cholesterol checked at a quick and convient time and place, for cheap, you'll do it! I don't worry at all about market share; there are more than enough people in America that need primary care. I do worry about fragmented care... it would be so wonderful if these places could tap into a national medical record database.

Imagine if you went to one and wanted to start medicine for high cholesterol or high blood pressure. How can you integrate these new meds with your current PCP, or what if you move, etc? Perhaps more likely, what if your kids have a couple vaccinations at a pediatricians, then a couple at Walmart... we know they keep paper records, but good luck getting that sorted out. If only there was a simple, national medical record database-- like the VA-- to save time, hassle, and unnecessary expense.

Anonymous said...

No. Certainly physician assistants and nurse practitioners can do many of the primary care tasks. But they should be linked into BIDMC Health Associates or other organized entities if we are to preserve quality of care. At the same time that we are talking about computer medical records and all the benfits of new technology we are going to have individual practitioners outside the system at CVS. Talk about fragmentation!

p a kenney said...

This is one debate that could get rowdy. Are we becoming a drive through culture?
In the dim, distant past I remember the neighborhood GP. In the latter years of his practice he often tended to the grandchildren of patients he had delivered, whose appendix and tonsil removals he performed. He remembered a patient's medical history because he had written it. Of course, our family's GP was a college classmate of my father so loyalty trumped all else and we were always told to arrive at 1:00...even though we usually waited hours in an overheated waiting room to see the man. He set our broken bones, listened to our hearts and lungs, found our early back problems, did our school physicals and was the shoulder where people went to cry. Today's technology delivers wonders, but the neighborhood GP is sorely missed. Luckily, my four kids here on the Cape have a D.O. who is a true family practitioner...and the world's reigning medical center is still only 75 miles away. Who needs CVS?

Tom Leith said...

Seems to me the neighborhood GP isn't missed any more than the neighborhood is. People sleep in the neighborhood (zoned residential) and do practically everything else at some kind of mall (zoned commercial). There is no neighborhood any more. The comment about traffic patterns is spot-on.

And just try to find a GP having hours that mesh with two wage-earner schedules, after school activities, and all the rest. Some (most?) docs refuse to advertise late hours even one day per week. The clinics will succeed by being good enough, and available.

It seems to me physicians are essentially ceding primary care to nurses. This is probably fine for relatively healthy people, but I wonder how well the elderly with multiple comorbidities will fare. Of course, they'll probably go see a specialist at one in the afternoon — a Gerontologist. If they can find one.

I do not see walk-in clinics as being particularly cheaper. A cash-only physician practice could work fine on a $50 basic fee, and my understanding is this is about what the clinics will charge.

People who don't live in a rich neighborhood like the Cape need CVS. Only 3% of GPs locate in rural areas, but Wal-Mart is everywhere, and I bet there are any number of nurses who'd be happy to work for 10 or 20 hours a week at the Wal-Mart they normally shop at.

t

Anonymous said...

This is a huge conflict of interest: Providers who are being supported by CVS will be seeing patients and writing prescriptions that are filled under the same roof.

Anonymous said...

Now from a healthcare marketing point of view. I saw the comment that this is the best way to finish of PCPs. Well, if PCPs are willing to step up to the plate and treat their patients in a flexible accomodating manner, provide excellent care in a timely manner, and market to their patients; then PCPs are in trouble.

PCPs need to start managing their pracitices more like a business and realize that consumer driven healthcare is here. My daughter's pediatrician offers late and Saturday hours, I am able to email nurses and physicians on simple questions and is timely with appointments.

We are tired of waiting days to see a PCP and then waiting in reception and then a observation room. COMPEITION WILL BE THE DRIVING FORCE TO CHANGE PRIMARY CARE! Hopefully PCPs will accept the change, because it is coming whether they want it or not.

MAK said...

I look at it the same way as airwick and jon: As a former paramedic and current adminstrator involved with emergency medical services, I see the overuse of the hospital emergency department as a problem. A lot of that is patients who use the ER as their primary care provider because they can get care without regard to ability to pay. Those people will not go to CVS oe Walmart unless states (or public opinion) impose a certain charity care requirement on them. However, for an employed, insured individual like myself, if I can get the blood pressure or cholesterol test at 7 pm while I pick up a birthday cake or some shanpoo, I don't have to take a half day off of work to do it. If I think I have a sinus infection or flu, I don't have to wait til next week, or force my doctor into squeezing me in and therefore inconvienancing all of his other regularly scheduled patients to see me (and that karmically comes back to my convenience when I schedule a regular appointment, doesn't it?)

It's really about customer service, which is often lacking in medicine. The controversial area here are: 1. fragmentsed care and records. So, set up a policy that the patient must provide the identiy of the treating physician(s) and the visit notes are emailed or faxed to those providers by the end of the day. 2. ERs will lose these paying non-emergecny patients i their "immediate care" tracks, with no concomitant reduction in non-paying patients. How do we address that?

p a kenney said...

"...rich neighborhood like the Cape...?" WOW!
I guess our current county budget struggle over human services' next budget is a fiction. Perhaps the food pantries covering all Cape towns are actually free health food stores and our rising tide of homelessness is just a media conspiracy. 10% of Cape Cod's population is Brazilian...and 80%-90% of them are undocumented aliens...no taxes, no insurance, slave wages, etc. Barnstable's high school has the second largest number of students with no fixed residence address of ALL municipalities in Massachusetts.
Dennis-Yarmouth High School is
close behind. Do not let our artificially elevated property values fool you; poverty is very much a part of the Cape's social landscape. Perhaps a visit to one of three district courts or our emergency rooms, even during the off-season, would enlighten.
By the way, Cape Cod is not rural. Hyannis and its surrounding area is officially designated a Statistical Urban Area by HUD. Our new EIGHT STORY HOSPITAL says it all.

Tom Leith said...

> This is a huge conflict of interest

Nonsense; it's good service to the patient. Doctors have always dispensed medications in their offices (causing great consternation among apocatharies). With better IT and an almost friction-free trade in generics, I expect in-office dispensing to make a bit of a comeback; it's an easy revenue stream for the doc and people want the convenience.

t

Maxine said...

Wow, all the ideas, etc. I think storefronts will get a lot of people who don't use PC's or who can't take time off work to see one. You know, if I could get a flu shot or quick check whether it's a cold, allergy, or sinus infection, and not have to schedule time off work to see my PC, I would use a store front clinic myself. And I am a loyal patient of BIDMC. I would then probably email my doctor about it -using patient site of course. When my kids were little, they were always getting something or doing something to themselves on weekends. my mantra then was "We'll go to the local ER for now and go to a real doctor on Monday." I think that would be my feeling about storefronts.

David Harlow said...

Paul, I would certainly agree that there's a fair amount of turf protection going on here among opponents of the MinuteClinics. However, I don't think that means that all reservations about this model should be so easily dismissed.

See my HealthBlawg post on yesterday's news. One point linked to in that post (at the very end) is a list of issues identified by the academy of pediatrics, which also recommended a code for retail clinics . . . I think the recommendations were actually endorsed by one of the retail clinic operators.

Good old-fashioned physician practices and Boston teaching hospitals can display lack of coordination and communication just as well as the retail clinics (I speak from personal experience), so that's not necessarily the most salient difference betwwen the two models.

I believe that Massachusetts has a licensure category of "nurses' clinic." Perhaps with appropriate tweaking that's where the MinuteClinics would fit best.

The issue remains -- if we push in on the balloon at this point, what part of the balloon will pop out on the other side?

ObGynThoughts said...

Occasionally I read about a strange concept called "physician shortage". This concept is extremely difficult to understand to anybody who thinks in economic terms. One of the most basic, most simple rules of economy is that "Supply and demand determine the price of a product or service". Somehow too many of our colleagues refuse to believe this. Since the mid eighties the true physician income has plummeted to roughly a third.
Based on this we have an OVERSUPPLY, not a "physician shortage". Should our income truly go back to what it was an beyond, yes, then I would believe those rumors about a physician shortage.
But, to come back to the topic at hand, the health care kiosks, booths or whatever you want to call what is happening at WalMart is one way to increase availability. Training more nurse practitioners would be another way. This way we would not have so much routine, but some more unusual and interesting days...
It is hard to predict the future. Remember those predictions from the 1960s about the cars we would have in the year 2000? Big cars, with fins, some looking like rockets, most self driving...,yes, we have all that. The future is unpredictable, even for people who try...Predicting an increased "need" for physicians in the future based on an aging populations could be easily offset by .. the above and by developments such as a genetic cure for obesity - whihc would have millions of positive effects, a genetic cure for hypertension, diabetes etc. What do we do with a huge oversupply of physicians then?

So, take it easy, let the true developments show us the way. Don't overdue it with the calls for "more physicians". Do not open more medical schools. Train some more nurses and nurse practitioners.

I suspect the group with the most vivid interest in training as many physicians as possible are our friends, the HMOs.

What could be worse then physicians having enough patients and simply "firing" the worst paying HMO each year? What an unimaginable diaster! The million size bonuses that HMO CEOs have come to expect would have to be reduced...

The HMOs clearly have the most interest of keeping the numbers of physicians high - to keep us working for less and less. Think about it. It is supply and demand. Adn I do not see the reimbursement going up significantly yet...

JS said...

I certainly understand the benefits of having easy access to prompt care for minor acute issues. However, what concerns me is the potential for medical errors. For example, what about the elderly lady or man who walks in to one of these clinics who is on 20 different meds but can't remember the names of half of the medicines let alone what their medical conditions are. how can someone treat them without knowing their meds and history? Even a dose of sudafed can be extremely dangerous in a frail patient with risk of cardiac issues or stroke. I would hate to see some serious medical errors come out of this.

JS said...

One more thought: It is not that I vote "no" on the issue. The benefits may well outweigh the risks. I just hope that they are careful with it.

Dr. Kenneth Peelle said...

At first glance, these “mini-clinics” may seem like a good idea: convenience, extended hours, multiple locations, no long lines in emergency departments, no long waits for appointments with primary care physicians.

Not so fast.

Concern #1: Safety. I' worried that medical care will be delivered without the knowledge of the patient's primary care physician and without the knowledge or availability of a patient's medical history. This raises the risk of medical error. Elderly persons with multiple chronic conditions, on multiple prescriptions, are even more challenging.

Concern #2: They could kill our fragile primary care system. Our primary care network is already in crisis. Allowing mini-clinics to skim the easy, less complex patients might be the death knell of primary care, and our community health centers, too. Who would pick up the slack if that happens? Our emergency departments, of course, which are already over capacity. In other words, these clinics could replace what already exists -- with something worse.

Concern #3: Conflict of interest. It’s an inherent ethical conflict when a pharmacy is located at the same site as a primary care clinic, owned by the same company. There’s good reason why most doctors can’t dispense drugs in their own offices; the same reasoning applies to mini clinics like these.

I don’t think the Department of Public Health should allow mini-clinics to cut corners on good standards that serve the public well. If such organizations want to establish clinics, they should be subject to the same rules and regulations that govern other, designated sites for medical clinics.

Kenneth Peelle, MD

Anonymous said...

I have read that these clinics have strictly defined "scripts" dictating what they may treat and how, and when to refer a patient. However, any physician knows that eventually someone will come in with misleading symptoms and have a bad outcome, just as can happen in a doctor's office or ER. We shall see what happens when the first lawsuit is filed involving one of these clinics.

Paul Levy said...

Although Dr. Peelle and I had a chance to discuss this a little bit on Emily Rooney's Greater Boston show on WGBH last night, I think his points deserve a little more commentary.

I am most surprised by #2, mainly in the extent to which he thinks this could do some much damage to the primary care system. Let's put aside the point that many people cannot get a primary care doctor because of the shortage of them. And let's put aside the fact that most PCPs do not provide service on weekends or after hours. The services provided in the stores would be the lowest level of care, the items for which doctors receive the poorest reimbursement. Are those really the items that make the difference to the profitability of an office? Let's hear from those doctors.

I think CVS can offer these services and make it worthwhile is because people will, on average, spend money on more profitable other items like shampoo and conditioner while they are in the store. I can't imagine the fee they charge for the medical care is enough to make much of a profit on the care itself.

Paul Levy said...

Now, let's turn to his point #2, lack of coordination of care with the patient's PCP. A good point for sure, but often equally true in an Emergency Room. Because of lack of interoperability of electronic medical records -- or the nonexistence of EMRs in many PCP offices -- that happens now.

For example, if I were to go to the ER at the Newton-Wellesley Hospital near my house, the MDs there have the same access to my medical record at my PCP at BIDMC as does CVS, i.e., none whatsoever. Unless, in either case, I authorize my doctor to release it to them.

So, the way to solve this problem is for CVS and the primary care networks to figure out a way to cooperate -- to "push" medical information from the PCPs to the CVS clinics upon authorization of the patient.

Paul Levy said...

On his third point, why is it any more unethical for a CVS clinic to prescribe drugs than for a PCP practice or other ambulatory clinic in a hospital that hosts a pharmacy to do the same?

Anonymous said...

This is a GREAT discussion. Thanks for bringing it to the table Paul.

We are learning as a nation that there are many ways to get our health needs met outside the scope of physican based care. This evolution in our understanding of health care reflects itself in the concept of clinic based care (CVS clinics)

This can pose an obvious threat to medicine. If patients can meet their healthcare needs without a visit to a doctor where does that leave the discipline?

Are doctors the gatekeeper to healthcare?

If other healthcare disciplines provide interventions that create positive outcomes what is the hold up on allowing these disciplines to maximize their influence?


Simply put doctors are potentially threatened because pharmacists and NP's are offering quality care to people that need it. Frankly, I prefer to see my NP over my MD because I feel that my concerns are met with a different sort of awareness.

I am grateful for the expertise that physican's offer. I just don't feel that I should have to wait 4 days to get a Z-pack for a upper respiratory infection! Why not go to a clinic (CVS) and see a qualified NP who can help me out.

Anonymous said...

Unfortunately, this sort of "assembly-line" type of medical care is all too common nowadays. While it's probably OK for relatively minor things, such as a sprained ankle, or a cut, etc., it's way too risky for major medical care.

Paul Levy said...

A comment from my friend Jim Hunt:

According to a recent study, people who receive routine medical care are better able to prevent sickness, manage chronic illnesses and avert emergency room visits and hospital stays than are people without a regular source of primary care – a health care home.

Last year, the state’s 52 community health centers provided a health care home for more than 700,000 state residents, providing them with regular check-ups, help in managing their asthma and diabetes, nutrition counseling and a range of other medical and social services. Such quality, consistent and comprehensive care has an added bonus for all Commonwealth residents: Effective health care generates savings for Massachusetts’ entire health care system.

So what does that mean if Massachusetts were to be flooded with "MinuteClinics?"

While the primary care physician shortage is real and demand is expected to grow, the only way MinuteClinics could offer respite is if they form referral relationships with experts like community health centers and other providers that are integrated into the overall healthcare system. They must commit to communicating with primary care providers when they care for their patients, and they must appropriately refer patients for on-going care when they identify such a need.

Massachusetts is making a significant investment to make health care affordable and accessible and encourage residents to establish a health care home. It would be a shame to undercut that effort – and its opportunity to get a handle on health care costs -- by creating a parallel, non-coordinated system of care through MinuteClinics. And if located in retail outlets, let's make sure these clinics are positioned far away from the cigarette racks!

Sincerely,

James W. Hunt Jr.
President & CEO
Massachusetts League of Community Health Centers

Paul Levy said...

Accroding to CVS,

"MinuteClinic health care centers are located in Atlanta, Austin, Baltimore, Charlotte, Cleveland, Columbus, Detroit, Hartford, Indianapolis, Jacksonville, Kansas City, Las Vegas, Miami, Minneapolis-St. Paul, Nashville, Northern New Jersey, the New York City metropolitan area, Orlando, Phoenix, Providence/Woonsocket, Raleigh/Durham, Seattle, Southern Connecticut, South Florida, and the Maryland suburbs of the Nation’s Capital."

Before we get overly worried about the possible impact here, is there anyone from one of those cities who would like to give us a sense of negative and positive impacts there? MA can't be all that different from these areas.

BC said...

I live in the NYC metropolitan area. While I have not used CVS yet, I have used a nearby urgent care clinic on numerous occasions over the past several years even though I have a "health care home" in NYC. I have generally accessed the urgent care facility for colds, sore throats, and other minor problems on weekends and evenings when my primary care doctor does not have hours (and is not nearby).

Providers at the urgent care facility, which is staffed by both doctors and NP's, always want to know what medications I take, and I am always able to tell them. Interoperable EMR's or, at least, PHR's that patients could carry with them would be helpful in this regard.

As healthcare costs continue to rise faster than inflation, I am increasingly frustrated and impatient with doctors who try to thwart or resist sensible systemic changes when they perceive a threat to their monopoly power to provide healthcare. They don't like P4P either because they don't want to be measured, and they resist electronic records, in part, because they don't want to have to learn a new way to do business.

NP's and PA's can handle many minor problems perfectly well. If doctors don't like it, what's their answer besides pay us more money? Our current healthcare model is unsustainable. Doctors should be leading the way toward sensible reform of the healthcare system. Unfortunately, they look more like a longstanding and persistent obstacle to it.

Anonymous said...

Very interesting comments. I always enjoy reading views and opinions of others, whether I agree or disagree, as it broadens my perspective.

As a hospital administrator, I am currently in a wait-and-see mode with the varied concepts being thrown out into the public arena. Although I must admit, it appears to me that the primary motive for WalMart, CVS and other retail companies entering into the healthcare market at the clinic level is nothing less than pure profit; not so much profit from a store clinic but from filling prescriptions and allowing customers to shop for other non-drug items. The while-you-wait-with-a-beeper customer will tend to shop for other items, which is what any sophisticated retail operator wants.

It will be intersting to see how self-insured hospital systems and payors view this model. Will they view store clinics as "in-network" or "out-of-network" for purposes of copay? The latter means a much higher copay for the customer. Using "out-of-network" pharmacies is already costing the customer more out-of-pocket for copay, and this trend will continue.

In any event, let's wait and see how these store clinics handle non-paying customers who require care, maneuver liability issues for bad outcomes or outcomes attributed to their care or lack of care, and 9-1-1 calls.

Just know for sure, there will be a time where a 9-1-1 call is made and EMS stops, with red lights blinking on the ambulance, in front of CVS or WalMart while the EMS tech runs into the store pushing a stretcher through the store to attend to a patient and then wheels that patient through the store and out the front door and into the ambulance.

How the general public responds to this scene will be interesting.

Jen M. Gorman said...

Paul -

Thanks for one of the best posts (and subsequent discussions in the comments section) I've yet to read on the topic.

I think your point about extra dollars consumers will pull from their wallets after "running in to get a quick check up at the Minute Clinic" is well taken - I'd be far more likely to 'remember' I need Diet Pepsi, gum, trash bags, oh, and some new scented lotion at a retail clinic located within a store than I would waiting in an ED or Urgent Care center (granted, the acuity may have some influence on clarity of thought here).

Anonymous said...

Walmart plans on 2,000 in-store clinics. Partners or any hospital should team up with a retail chain and in the process have the ability to oversee the quality issues. Home health services are already a major service line and this is a reasonable extension. May help with staffing also.

jnicholas said...

My anecdotal sense is that many primary care physicians depend on a certain number of "easy patient encounters" for 2 reasons:

1. Although they are reimbursed at a lower rate, many encounters can be seen/billed during the same time as a single complex visit. I'm pretty sure this produces an overall financial gain to the practice.

2. These encounters are a necessary emotional/intellectual counterweight to complex patient office visits.

Of course, I think getting medical care should be as effortless and convenient as possible. I do fear the consequences on our disastrously fragile primary care system. The number of physicians willing to manage complex, complicated patients is dwindling (I think)

Anonymous said...

Paul Levy wrote "The services provided in the stores would be the ... items for which doctors receive the poorest reimbursement. Are those really the items that make the difference to the profitability of an office? Let's hear from those doctors."

I am one of those doctors. I am a pediatrician, and I believe that the cases that will be siphoned off by the Wal-Clinics are clearly the money makers for a primary care pediatrician.

As a pediatrician, I provide a fair amount of service for which I am underpaid or not paid at all. I typically make about 10 phone calls to patients a day, each of which might take 10 minutes, and for which I collect no money. (A lawyer may charge $400/hr or more for phone time; I charge zero.) I also answer several Emails from patients, again being paid nothing. I may also spend "non-face time" helping my patients by Emailing a consultant, looking up labs, or researching the medical literature. Again, no pay.

I generally enjoy these unpaid parts of my job -- they make me feel that I'm being a good doctor -- but obviously I want to make a living as well.

So, how do I finance these 2 hours or so a day of unpaid work? By being relatively overpaid for some other work I do. When I see a patient with Strep throat, I get paid $60 to $80 from the insurers. An easy visit like this may take me only 10 minutes. If I can see 6 such patients an hour, I can generate $360 to $480 of revenue.

On the other hand, if I see a patient with ADHD and spend an hour talking with him and his family, I may get paid $100 or $120.

Before you get started on how overpaid doctors are, please recognize that my professional fees (and those of my colleagues) are the only source of income for our entire practice. We pay the rent, the electricity, the staff salaries, the computer costs, etc., from the fees I receive. Considering that, $120 per hour isn't enough revenue to keep us going.

I enjoy spending an hour working with a patient to really get to the heart of the issue. I also enjoy looking stuff up, Emailing consultants, etc. But the reason I can afford to do this is because I make a profit on the quick and easy cases.

For pediatricians in particular, I believe these convenient Wal-Clinics are a major threat. My advice to patients and parents: "Be careful what you wish for."

Paul Levy said...

Thanks for writing. Any others out there?

The payment problem for PCPs is real and serious and, I suspect especially so for pediatricians. But perhaps we should work on getting insurers to pay you for the real value of all those other services rather than hoping to make up the difference on the ones you fear losing to CVS.

Anonymous said...

Paul, do you know that you are being quoted by John Auerbach as favoring Retail Clinics. As a Massachusetts pediatrician I must respectfully but bluntly tell you that you do not know what you are talking about. Of more consequence, since you are a not an expert on this topic, I hope that you ask John Auerbach to not reference you on this subject any sooner than he might reference me on how to run a hospital.

My concerns are with your position being used as an authority to support Retail Clinics. The areas where I believe that you are in error are the following:

1) Any pediatrician will affirm that medical diagnosis for even so-called "minor illnesses" is extremely complex and takes great care and expertise to do properly. I can easily teach a smart high school graduate to do 90% of what I do. But to safely identify and reliably distinguish the other 10% is where I make a critical difference every day. To sort out the 90% and accurately identify the 10% takes years of in-depth training in the classroom and in the hospital. It may surprise non-PCP's to really comprehend that the years of learning in the classroom, the training on the wards and in the ICU, and the assisting in the OR make a very big difference in handling what Retail Clinic advocates call "minor problems".

2)Over the years I have worked with many superb, dedicated, and experienced PNP's. However, it still amazes me at how much better any pediatrician is compared to any PNP in evaluating children's illnesses. The PNP who has genuine, immediate access to a supervising pediatrician is a great asset to medicine. However, if you do not appreciate the risks of having an unsupervised NP treat children, you do not understand how a easily a sore throat can mask lymphoma, a sore foot can be the only symptom of leukemia, or a pink eye actually can be an escalating iritis. My mentor and hero at the BI, Dr. William Silen (who is also one of the very best physicians Boston has ever seen) would say "there is no such thing as minor surgery, there are just minor surgeons." By analogy, there is no such thing as a minor illness , just people who think there are minor illnesses that can be reliably identified by an unsupervised NP --- and those people are called investors in Retail Clinics.

3) Why are you not advocating against granting Retail Clinics waivers from meeting the same standards expected of medical offices? Sinks, exam tables, legal and ethical responsibility for parents following through with a plan of care for their children - not to mention not benefiting from the prescriptions you write - are all minimal quality expectations for pediatric offices. Somehow Retail Clinics should be exempt??

4)It is naive to think that NP's will forever be able to resist the inevitable pressure to prescribe meds preferred by the parent corporation. The American health care system has many problems and bad actors, but I am confident that the ethos in the average medical office - especially in the pediatric office - far exceeds the pure profit motive driving CVS or Walmart. Retail Clinics will only exacerbate the problems impeding proper delivery of health care.

4) As a previous pediatrician said on this blog, treatment of what you call "minor illnesses" are what support PCP's to be able to provide all the other non-profit services that patients receive every day from our offices. The relatively high revenue for time spent for these office visits help pay for the uncompensated hours spent treating other conditions and fears that must be properly attended to by any quality physician who gets up every day to serve patients and not the bottom line.

5) As is true for most pediatric practices, we work very hard to serve our patients 7 days per week, 52 weeks per year. We are open every day of the year, and we are available 24 hours per day without exception. We consider it a failure if our patients end up in the ED for a non-emergent condition. Retail Clinics will decrease the practice revenue that allows us to serve patients at this level while also providing all the other non-renumerative services that children need and receive from our office.

6)Without doubt, Retail Clinics will further fragment medical care, negatively impact the coordination of services, and contribute to the McDonaldization of medicine. For that matter, what does CVS or Walmart offer that McDonald's cannot. Logically why not lower the standards of the whole system and get some french fries in the bargain?

Massachusetts is a leader in health care in the country. Paul, I am afraid that your promotion of the Retail Clinic model has a potential impact far beyond our borders. I hope you reconsider your advocacy for the slow-motion train wreck that Retail Clinics will bring to provision of health care for children.

Anonymous said...

I am by no means an expert either in medicine or in hospital administration. What I do understand is what the business model of Walmart and CVS is designed to do. With massive inventory and low profit margin on products and massive gross sales numbers they snuff out the smaller qualitative business operations with the cheap quantitative alternative.

If this is consistent with all of their other products, why argue that they have decided to change their business model as they add medical services to their list of markets niche's to dominate?

Many of you have Ph. D's and almost all of you are probably more intelligent than I. I think that if you look at this situation from a neutral standpoint as I am having no connection to the medical field other than my fiance is becoming a nurse practitioner in a couple years you will see that this truly is the case.

Of course the dynamic of this situation involves many factors most of which have been discussed by you all who have extensive personal involvement in these matters, look at the heartbeat of Walmart's business model you'll find this is how they operate, it generates a profitable revenue, makes the stockholders happy and puts a fat check in their bank so they aren't going to stop doing it.

Its time for the medical world to recognize that and quit being a parallel to the Western World Pre-WWII bickering about the intentions of a heartless regime. We'd be speaking German and Japanese right now if hadn't had a wakeup call in Pearl Harbor. Don't make that same mistake for the good of my children and their children's health care.