Thursday, June 21, 2007

More on storefront clinics

Several weeks ago, I wrote in support of the establishment of storefront clinics in the state. That post generated a lot of back-and-forth and good discussion. I recognize and respect the full set of views. It is an interesting public policy question.

Since then, the state DPH has held a hearing on the matter and also received lots of comments. Most recently, a letter was sent in from several groups outlining their list of suggested requirements for these clinics. The signers included representatives from the MA Medical Society, the MA Academy of Family Physicians, the MA Chapter of American Academy of Pediatrics, the MA League of Community Health Centers, and MA Hospital Association.

I hold no brief for the applicant -- other than joining with lots of friends and neighbors who this is a good idea for the public -- but I have to think that many requirements the opponents would seek to impose on the clinics would make them uneconomical or impractical. The letter writers would surely state that their only interest is insuring the public health. But the nature of the comments suggests more than that -- that the protectionist view I thought would come to the fore has indeed done just that.

I can't go through the whole letter here, but here is a sample comment.

"There is also large concern about the mix of patients that the MinuteClinic will take and the impact on the health care system as a whole. While the representatives indicated an intent to care for all patients regardless of their ability to pay, there is no indication that they will be established in an area with public transportation or a concentration of indigent patients. The Department should also strongly review the referral patterns and payer mix of these stores to ensure that if they have a full clinic license they will have the capacity to respond to the needs of all walk-in patients from the community and not just those that generate low risk and complexity visits."

Heads, we win. Tails, you lose. Previously, some commenters were worried about the effect of the clinics on the community health centers, which are often located in areas with public transportation and a concentration of indigent patients. Now, with the applicant avoiding those areas and focusing on the suburbs, they are essentially criticized for not competing with the health centers.

And what is a "referral pattern" for a walk-in clinic in a drug store? And how would you review such a pattern for clinics that do not yet exist? Would you look at who recommended that people buy their shampoo at this drug store? Or which doctors submitted prescription orders?

And, why should the clinics have the capacity to respond to the needs of all walk-in patients, when they are designed specifically not to do that? They made clear that they would quickly and helpfully make referrals to emergency rooms and doctors when they were presented with medical problems beyond their capability.

In summary, these clinics have worked in other states. Why are my colleagues so averse to letting Massachusetts give them a try, too?

[Disclosure: I recently was asked to join the Board of the MHA, but I was not involved in the decision of MHA to participate in this letter nor in its decision to take the position it has on this issue.]


Anonymous said...

Sigh. Doctors have a long history of trying to stifle competition and protect their power and turf. Sometimes I think their attitude boils down to: pay us our fees promptly and don't question or interfere with our medical decisions.

Retail clinics are for profit businesses that pay taxes. They are not charities. They have the potential to not only reduce costs for the healthcare system, individual patients, and insurers as well as take some pressure off overcrowded emergency rooms. Isn't that a good thing? How frequently are Boston area ER's on diversion? How good is the ER care when doctors are overworked, over stressed and, more often than not, have no prior history with the patients they are treating. If the ER's have more patients than they can handle, some relief should be welcome. The same is true for the clinics.

As Paul said, these have worked elsewhere, and there is no reason they cannot work everywhere assuming they can generate enough volume to sustain their business model. If they can properly and consistently refer out patients who present with medical issues beyond the clinics' capability, what's the problem aside from some incremental competition for primary care doctors?

Unknown said...

What bothers me about this is that they will try and put these Doc in a Box in places where the 'indigent' gather or live, and thus keeping the rest of the poor population out of the loop, just as Mass Health has done with pediatric dentistry. The clinics for pediatric dentistry that will take Mass Health are in Roxbury, Lawrence and Lowell. That leaves pretty much every struggling working class family out of the loop. If you're poor in Natick, where are you going to take your kids to the dentist that takes Mass Health. Good luck with that.

It sounds like they're planning to do the same thing, the ghettoization of healthcare for the poor, assuming that poverty is only in a few places. It's unrealistic and it's dead wrong.

I think they will work just fine if they are accessible. I tried to make appointments today for 3 doctors. The soonest we could be seen was Sept 19th. And I've got chronic and life threatening illnesses. Medical care in MA has fallen apart, and we DO need places where you can go in, get seen, and get

Unknown said...

Personally, I believe these are a good idea. After having spent numerous hours in the ER, with my son who has asthma, I noticed many "bad colds" and "sore throats" utilizing precious ER space designated for true emergencies. MGH has a walk in clinic used for those who cant get a PCP appt and arent sick enough for the ER, though it is only open limited hours. Why wouldn't hospitals
consider a similar model to what is proposed? Clearly there is a need, and with hospitals expanding toward the suburbs, space may not be as limited.

posted by JoAnn said...

I agree with rny, as a former urgent care director in a clinic in the inner city, these clinics if owned and operated by hospitals would be a benefit to all as long they are under a hospital unbrella with the same regulatory standards.

Wade said...

I'm always surprised at the opposition from people in the healthcare field to these kinds of clinics. They have the potential to take many of the treatments for which the chance of reimbursement is the lowest out of hospitals, while leaving heavily-reimbursed major activities there. This seems like a good deal for everyone involved -- patients get quicker care, they pay in cash, reducing the load on Medicaid, and emergency rooms are left for emergencies.

The fact is, there's a shortage of health care in this country for many people. Adding capacity won't harm any existing players, because all of the growth can be new.

Anonymous said...

I think RNY hit the nail on the head at least twice. It's silly to have colds/coughs taking up ER space and lengthening the wait; and Paul, why on earth wouldn't hospitals get into this game??

As I said before, I used one of these clinics when I lived in Minnesota, and it was a breath of fresh air.

The competitors' "concerns" strike me as disingenuous, just as when Shaw's supermarket wanted to enter Salem NH, a town dominated by the the DeMoulas / Market Basket family. The family submitted a big hand-wringing brief about the horrible effect it would have on traffic in town if there were another grocery store. Fooey.

Anonymous said...

Hospitals might very well get into this game if they were permitted to "waive" the requirements that are being considered for MinuteClinics. To date, the types of waivers being considered for this "new entry" into the health care delivery system have NOT been liberally granted to the existing hospital and community health center industry. If the Department of Public Health believes their existing regulations should not apply to this type of care, that information should be communicated to the hospitals and community health centers. They would be happy not to spend all the money they do on accessible bathrooms, waiting rooms, ensuring patient confidentiality, medical records retention and incorporation of the care rendered to patients into their broader system, all of which drive up the cost of the health care they deliver. If the MDPH wishes to have a "demonstration project" which waives the regulations for the establishment of these "rapid treatment" clinics, it should occur first within the existing care delivery model and not in the middle of a retail pharmacy that has not yet established nor proven itself as a clinical care delivery site. Also, Mr. Levy indicated a "hearing on the matter" was held. This is in fact not true, but is exactly what the MA Medical Society, MA Academy of Family Physicians, MA Chapter of the American Academy of Pediatrics, MA League of Community Health Centers and the MA Hospital Association requested in their letter.

Anonymous said...

It's also important to note that not all physicians oppose storefront clinics. While physicians as a group aim to uphold strong professional standards, they aren't homogenous in opinion. It's rather unfair to portray all doctors as money-grubbers. Many do support and try to spearhead efforts to improve access to health care outside of the hospital setting.

There are many issues to consider from a critical perspective. Will the providers running these clinics have any oversight? Will they coordinate care with hospitals, or simply shuffle patients to the hospitals and not followup? Will the providers be physicians, nurse practitioners, or physician's assistants? If not physicians, will these providers have the necessary sensitivity in diagnostics to be able to identify early symptoms of acute infections and diseases?

From the perspective of a patient who has been seen by dozens of NPs and physicians, I wonder whether the average NP-run storefront clinic will be most useful as a provider of medical care or merely as a buffer for hospitals. Arguably, both are useful, but as a patient, I'm generally less confident in the care provided if the NP who has seen me hasn't consulted a physician. I have had excellent NPs care for me, but they have always worked as part of a team led by a physician. A storefront clinic run by an NP can, if operated well with the appropriate connections to other facilities and resources, be an excellent resource. If not run well (i.e. as an isolated unit), it might simply delay and trap patients in eddy currents, potentially leaving them in worse shape when they finally do arrive in a hospital for medical care.

Anonymous said...

In assessing the potential value of retail clinics, I ask the following question from an individual patient perspective: Am I net better off from a medical outcome standpoint if I (1) go to a retail clinic and see an NP immediately, (2) wait 2 or 3 or 4 days to see my PCP or (3) go to the ER?

On a macro basis, I believe the net cost to the healthcare system (including patient out-of-pocket payments) would be considerably lower if thousands of patients chose to see the NP at the clinic instead of selecting options 2 or 3 even if a small percentage of them are misdiagnosed or otherwise receive less than stellar care.

If the clinics didn't exist at all, the only option aside from #2 or 3 above would be to not seek care at all and hope the problem resolves itself. Bottom line: I think it is highly likely that the clinics will make a significant positive contribution toward both more timely access to a medical professional for minor problems and lower systemwide healthcare costs.