Thursday, January 10, 2008

Thank you, PHC

Stephen Smith at the Boston Globe reports that the state Public Health Council voted to allow storefront clinics in Massachusetts. (I had written in support of this vote last week.) CVS, the original proponent, apparently plans to open more than two dozen. Now, having gotten permission, CVS needs to carry this concept in a manner that will set a high standard and prove the wisdom of the PHC vote. I wish them well in introducing this innovation into the MA health care delivery system.

23 comments:

Anonymous said...

There is no question that the medical system is in dire need of repair. But when has throwing more money (or in this case more clinics) at a problem ever resolved the real issue?

I look at it this way, would opening more schools solve the education crisis?

Increased morbidity among the lower SES population is not related to a lack of access to medical care.

The issue at hand is not access. Opening store front clinics is not the answer. CVS isn't doing this out of good will, their goal is profit.

We can do a better job at solving these problems.

MES @ MSSM

Ian M said...

Anonymous,

I disagree with you that store - front clinics are not part of a broader health care solution. Access to care is absolutely an area that could stand to see some improvement. These clinics are designed to treat minor conditions and problems. So long as they are used properly, they will ease the burden on other treatment facilities.

As far as your analogy to the school system: When a school system becomes overcrowded, more schools should be, and in many cases are, opened. Opening more schools does not alter the curriculum, but it does increase access to education.

Opening 2 dozen minute clinics will not cure the common cold, but it will increase your access to treatment for it.

stewie said...

increased mobidity among the lower SES population is not related to a lack of access to medical care? i would argue that it is! specifically a lack of access to AFFORDBALE care. it may not be the entire cause, but it certainly is a part.

will these clinics provide free care, take medicaid/medicare, or offer payment plans scaled according to income?

Roy M. Poses MD said...

Since you are a fan of hand-washing, note that the clinics won't have sinks (or toilets), and that at best, according to the new regulations, plumbing facilities might be somewhere nearby.

If the planners of in-store clinics didn't understand enough about health care to realize they needed to install plumbing so practitioners could wash their hands, what else didn't they think about.

See my post on Health Care Renewal:
http://hcrenewal.blogspot.com/2008/01/will-minuteclinics-be-wash.html

Jean said...

President Levy, why aren't you concerned like your colleagues at Atrius that these non-integrated clinics will interfere with the management of care of your patients? Do you think your PCPs will encourage or discourage their patients to use these clinics?

Paul Levy said...

Lots of these issues were considered by the PHC and dealt with in an appropriate way, in my view. (And Roy, they are required to have hand sanitizers at the point of care. That is all that is used by PCPs in many hospital and office settings.)

Jean, I think these clinics will attract people who have minor problems who cannot get quick access to their PCPs. They may also attract people who would otherwise show up for unnecessary visits at emergency rooms. And, of course, for the thousands of visiting tourists and businesspeople who come to MA, they would be an excellent choice for minor problems -- with the only alternative being the ERs, or trying to reach a PCP back in DC or CA or wherever they came from.

BIDMC-affiliated PCPs might encourage people to go for minor issues like bee stings, poison ivy, and the like. Or, they might not. That is up to the individual doctors. More likely, the consumer might not even bother the PCP for such minor things and just go to the clinic.

I am surprised, in all the comments here, that no one recognizes the efficacy of these clinics in other state. Why is it that you think this concept would be so awful here when it is so widely accepted in other states?

Patient Dave said...

> I am surprised, in all the comments here, that no one recognizes the efficacy of these clinics in other state.

Well, it's Mr. Broken Record here, saying I used it and it was excellent. So far, if I recall correctly, I haven't heard from a community or individual that allowed 'em and had a problem. Perhaps we will hear.

Zagreus Ammon said...

Paul, I must strongly and vociferously disagree. This represents nothing more than an ER diversion effort on the part of hospitals and ends up hurting the community health centers that your city relies upon so much for it's community's care. If the CHC's were not providing sufficient convenience, they could have been engaged and partnered with. I am aware of multiple CHC's and FQHC's in multiple markets that have tried and failed to work with regional hospitals to provide just the kind of service levels that would keep people out of ER's and in convenient clinical settings. I perceive two reasons for the failure: some ER's benefit financially from the needless traffic (frequently critical-access hospitals in rural areas) or just sheer ignorance of the role of an FQHC/CHC.

This is not going to benefit the health of Boston's population. It is not efficacy which I dispute. It is the law of unintended consequences which I am invoking.

More at:
http://executivephysician.blogspot.com/2008/01/retail-clinics-versus-public-hospitals.html

Paul Levy said...

Zagreus,

Please provide some evidence that these storefront clinics have had this effect in the several other states where they have existed.

You also fail to talk about the many parts of the state where there are not community health centers, where people have no option but to go to ERs with minor acuity cases when they can't get access to a PCP.

Anonymous said...

The implicit issue being raised seems to relate to the assumption that most everyone believes that they are entitled to the best medical care. While the fact remains that we all can't have a Harvard Medical School graduate quarterbacking our individualized treatment plan, knowing what you know (i.e. how zebras often first appear to be horses) and family vacations aside, is this where YOU would send a family member?

Zagreus Ammon said...

Paul,

I too, sometimes like to challenge someone else's assertion in the full knowledge that there is no evidence one way or another. There is no "evidence" that retail clinics help, but certainly anecdotal accounts of places where they have worked well from a business perspective. (Multiple Medline search this morning revealed only three article, moslty reportage or opinion. No data.)

Nobody has yet looked at appropriate end points regarding the distribution of providers and above all, the impact on an already fragile primary care infrastructure. There has probably not been enough time for such studies to have meaning.

I suspect the distribution of retail clinics will parallel the distribution of the middle-class population. In Massachusetts, areas without FQHC's are more likely than not to be areas without much population. It is one of the most "blessed" states in the Union.

In the absence of certainty, leaders also question the consequences of their being in error. How difficult will it be to roll back 5000 retail clinics in one or two years time, should we discover that, indeed, they are a problem?

You understand that I want to compete, but I want to do it in a way that the outcome of competition is improved health for the population. It does not take much imagination to visualize a half-dozen adverse consequences of retail clinics, most of which will manifest in the fullness of time and not within a six-month study window.

Paul Levy said...

Dear anon 9:32.

Not only would I send a family member, but I would go myself. There have been times when my family and I went to an ER or waited till the next weekday to see our PCP for some minor thing that could have been well treated at this kind of clinic. It would have been faster, more convenient, and not imposed on the valuable time of the doctors and nurses in the ED and in the PCP practice.

Zagreus,

So, if I am reading you correctly (and maybe I am not), first the objection was to competition with health centers. Now, the objection is that these clinics will mainly go to middle class areas where there are no health centers.

You want to compete, but you want to close out one type of competition. Which types would you permit?

jean said...

Sorry for keeping coming back to this topic....

I understand the on-the-spot benefit of taking care of minor health problems in this kind of peripheral delivery settings; but it does bear the question whether this is a progress or departure from the ultimate care model that we are all working towards --- where care is integrated and any touch point with the patient is recorded, coordinated, and managed in the context of the overall health history of the patient. At the very least, I will be very concerned if these clinics don't make an effort to join the larger healthcare system in the development of electronic medical records, which allows the mainstream providers to track the care being delivered...
Or, taking a further step back, rather than having a for-profit drug store chain play the role of mending primary care, why don't the integrated delivery systems build out their primary care functions (which I think BI has done a wonderful job with), in presumably consumer-friendly, cost-effective, and ultimately, profitable ways?

Paul Levy said...

There is no reason these clinics can't be integrated into hospital electronic networks. (By the way, right now, most community based pratices of doctors in MA are not integrated that way!)

Ian M said...

You cannot perform all of your banking via an ATM, but ATMs are a convenient interface to your financial institution. Minute Clinics (or any store front clinincs) could operate the same way, if they adopted appropriate EMR policies.

I think too many who oppose these clinics are losing sight of just what level of treatment they are going to be providing.

Dave said...

A few quick thoughts if this thread is still alive..

I think Retail Clinics are going to have a solid place in our overall delivery model. If we continue to move towards more competitive healthcare where the 'best' people/places for a particular procedure are chosen over what is 'in network' then this will happen throughout the lifecycle.

Addtionally, I would forsee the capabilities of Large Institutions such as BIDMC to have the ability to integrate or push data between the large scale PHRs (Google, Microsoft or Dossia).

I would hazzard a guess that retail giants Walmart and CVS who know how to capture and handle data would be able to provide these integration points to Hospitals or national PHRs alike.

This would be a higher level of collaboration than some current CHC's, PCPs, or small provider groups have available to them today.

Best Regards,
Dave

Patient Dave said...

> too many who oppose these clinics are losing sight
> of just what level of treatment they are going to be providing.

Well heck yes!! Next time I get renal cell carcinoma, I ain't going to the Minute Clinic.

I see a continuum of care options coming - simple solutions for simple needs, bigger solutions for bigger needs, go-out-of-town solutions for major needs.

When I broke my leg in May, I initially got it set in Nashua where I live, then they brought me to BIDMC (because the surgery required scooping cancer out of the femur and I wanted my oncologist involved).

Now, if the real objection is that we don't trust patients to have a lick o' sense, then that's a different issue. But to me it's quite like the continuum of medication options: OTC for most headaches, prescriptions for more serious things, all the way up to in-hospital treatments for the risky things like the HDIL-2 I received (high dosage Interleuken-2).

Will there be cases where a patient doesn't have the sense to escalate his/her care when necessary? I'm sure there will, just as some people I've known have taken aspirin for years when they had a serious problem that should have been treated. But we surely shouldn't require doctor visits for every ache and pain.

Y'know what it'll come down to? If Minute Clinics etc aren't worth it, people will tell each other: "I went to one of those and it was a total waste of time." So if you think these clinics really won't work, please hunt down an associate or relative who lives in such an area (a lay person, not a medical professional) and ask if they're regarded as junk or perfectly okay.

Zagreus Ammon said...

Paul, I am more concerned with the diversion of resources, i.e. competition for providers.

We are in a world of limited resources. Allowing a net drain on the system (which is how I regard retail clinics) makes it harder for CHC's and primary care providers to contain costs via primary care. Primary care has an exceptionally broad evidence base when it comes to positive outcomes for a population. It is amazing how often the evidence-base is ignored because some people have trouble getting appointments. Maybe that is a manifestation of mis-allocation of resources because of how regulation distorts the playing field.

If there is a general shortage of primary care providers to provide cost-containment and medical homes for the bulk of the population, providing an incentive for convenient urgent care clinics to proliferate, could it be that supporting primary care homes is a better and more efficient use of resources than the diversion of that limited manpower to retail clinics?

Anonymous said...

This week, a group of exchange students from China was visiting. One of the kids developed an ear infection. The teacher took the child to Children's and sat until the middle of the night to be seen.

Use of the ER at night -- and even of the doctor during the day -- is too often using a machine gun to kill an ant. We need a sore throat checked for strep, not a heart transplant. This isn't going to hurt the community clinics, it's going to help them to deliver care to people who need it the most. Let all of us sore throats be seen at CVS.

Paul Levy said...

Zagreus, I totally agree that primary care deserves better support, but that is a matter of the amount that insurance companies, medicaid, and medicare have chosen to pay them. Until more progress is made on that front, young doctors are understandably making choices to go into other part of medicine. As the comment below yours indicates, though, that still leaves lots of situations that are more appropriately handled by this kind of clinic.

Paul Levy said...

Another quarter heard from:

AIM COMMENDS PUBLIC HEALTH COUNCIL DECISION ON LIMITED SERVICE HEALTH CLINICS (1-11-08)

Boston, Mass. - Associated Industries of Massachusetts (AIM), the state's largest employer association, applauded the decision yesterday the state's Public Health Council to allow limited service clinics to operate in the Commonwealth.

Richard C. Lord, President & CEO, stated that, "A major cost driver in health insurance premiums is the use of emergency rooms for routine health care needs. These limited service clinics, typically operational within pharmacies or retail stores, provide a cost-effective safe way for residents of Massachusetts to get routine health care services in a non-emergency room setting. It is also a convenient alternative for the many two-parent working families across the Commonwealth and we applaud the Public Health Council for allowing such innovative alternatives as one small way to begin to drive health care costs down. AIM looks forward to partnering with public officials on a series of health care cost-containment initiatives, as the cost of health care continues to be a primary concern of Massachusetts employers."

Anonymous said...

Paul, I am an RN working at BIDMC and happen to have excellent health insurance (not thru hospital) but I would use one of these clinics in a heartbeat for minor things.... doesn't it seem you always get a sore throat/cough on weekends? And then there's the time I got a nasty rather large splinter in a finger in a late afternoon -- tried to treat it myself due to the hour, then when my husband came home, had to have him saw off my wedding ring - went to ER next day where I waited for hours for someone to see me....

I have an ongoing serious health concern with CAD - I would not expect to have a storefront clinic treat that, but colds and splinters... yep!

Zagreus Ammon said...

Our goal is to distribute resources to achieve an optimum health outcome for the population at large. Of course we have problems with inappropriate ER use and a need for minor care at odd hours. It is sometimes difficult to find care given an imbalance in the supply and demand of skilled, licensed providers ,and yes, CMS reimbursement has much to do with creating these imbalances in the first place.

But is it appropriate for a progressive state like Massachusetts with a regulatory method to counteract these imbalances (i.e. requiring regulatory clearance) to open the floodgates?) Will it achieve the real goal of the PHC (i.e. safeguarding the health of the Commonwealth's residents)?

As usual, policy-makers have opted for a knee-jerk response to address the problem shoved into their face by whomever. So their decision addresses that problem without any consideration for the larger system forces that created the problem (and will probably continue to perpetuate the problem after a brief period of adjustment.)

Even if we have successfully addressed the problem of inappropriate ER use, have we created another problem somewhere else?

The price of cutting-edge technological medicine is one of the major factors affecting the current US health system. Pushing those costs are demographic factors and the small incremental costs of chronic disease management in the outpatient setting representing a huge chunk of tomorrow's health care dollar in the aggregate.

So we have a sweet little exchange student who got treatment for an ear infection. I am truly happy. But is she a seal-cub for a new generation?

Imbalances in the distribution of health providers, now exacerbated by a drain from retail clinics may be associated with only a 0.1 or 0.2 drop in average Hemoglobin A1c for a couple of hundred patients.

It's up to you to decide if you need to rev up your cath labs.

But at least an ear infection was treated and we all feel better.

Let's leave it here. I object based on assessing that the overall outcome is more likely to be negative. The assumptions are 1) the supply of providers will not rise fast enough to meet the increased demand 2) there are perverse incentives on provider performance imposed by the pharmaceutical industry's involvement in retail clinics.

(Please don't use the euphemistic term "limited service clinic", since every specialist's office is a limited service clinic.)

You can't just pull just one noodle out of a bowl of spaghetti without making a mess.