Wednesday, September 17, 2014

A bit harsh on Minute Clinics

I really admire Shannon Brownlee, but I have to take issue with the parts of her Providence Journal article in which she takes CVS to task for running Minute Clinics in their stores.  But perhaps we end up in the same place anyway!

In summary she argues:

For-profit retail clinics are a bad sign to anyone who understands the special role of primary care in providing good health care to a very sick nation.

Primary care is one of the few places remaining in the medical system where physicians and patients have direct personal relationships that last longer than any particular treatment or illness.  

But CVS and other companies diving into primary care aren’t interested in building relationships. Patients are customers, not vulnerable human beings, and the health professionals who work for them are employees, not caregivers. For these companies, health care isn’t about caring or healing — it’s a product — and their interest in providing it is aimed at the bottom line. In the future, your relationship with your doctor will be about as meaningful as your relationship with the local barista at Starbucks.

By siphoning the easy cases and easy revenue away from primary care offices, retail care further undermines their financial stability.

But then she points out the problems in maintaining traditional primary care practices:

You can’t blame retailers for jumping into the business of offering primary care services. The fact is, primary care doctors have failed to provide services that patients need: fast care for minor ailments, and care that’s available in the evenings and on weekends.

For the sake of all those who have a chronic illness now, or who are destined to get one as they grow old and frail, the nation had better figure out a way to support primary care practices. 

I don't think we should blame the retailers for filling a gap in the healthcare system nor should we demonize them or their clinical staff by saying they really don't care about people's health. Where Shannon and I appear to agree, though, is on a key point:  If the country really wants to support primary care, there are ways to do that, starting with fixing a perverse reimbursement system.


Nancy Thomas said...

I couldn't agree more with your response to the editorial published today...CVS is meeting an unmet need - giving customer service to the masses who have had their pleas gone unheard forever, in the area of minor primary care issues and emergency care. As the great hospital systems are so good at saying, "competition breeds better quality", then this should help primary care and hospital systems improve themselves to the point where people will not need to go to a "drugstore" for their medical care. But until whatever generation that happens, I am ready to take my little ear infection to a Minute Clinic - and I will see a PA - which is what I would have seen anyway as my primary care only will see me, personally, once a year... Go, Minute Clinic - the people are behind you!

nonlocal MD said...

I think we have to be careful not to force a vision of primary care perhaps rooted in the past onto the current state of affairs, reimbursement issues notwithstanding. A system in which the patient runs to his primary care doctor for every broken toenail (unless he is diabetic or hemophiliac) is not an efficient nor cost effective one either. What if, for instance, there were Minute Clinics for the very minor issues as Nancy suggests, urgent care centers or same-day ortho appointments (which we have here in MD) for acute but non serious injuries and early diagnostic triage, ER's for trauma and true emergencies, and M.D.-level team primary care for its most important current function - management of the increasing set of chronic diseases, for which knowledge of the patient's history and comorbidities is imperative. Those few diagnostic dilemmas which remain can start at primary care, but by then they would have the time to sit down and address them, rather than a knee-jerk referral to a specialist for lack of time and/or knowledge produced by low pay and low incentives for the critical continuing education needed.

Jon Hurst said...

I don't see in store clinics as in anyway trying to be "primary care," rather they are affordable, convenient, high quality alternatives for certain immediate health care needs. And if we can get some of those non-emergencies out of the emergency rooms, then let's do it.

Charlotte said...

Why is it bad to see someone who doesn't know me for an ear infection, but it is good to see someone who doesn't know me (a hospitalist) for a life-threatening problem?

e-Patient Dave said...

Since I know and like both you and Shannon (hi Shannon!), I hesitate to comment here, but if I tried to set up a three-way call that fits all our schedules, it might be a challenge... the same as the dilemma of the patient in this comment on the Providence Journal article:

"There is a shortage of primary care physicians. I just spoke with a patient who said she sought care at her primary doctor's office but was unable to be seen because the PCP was just returning from vacation and was "booked solid". She contacted her ENT who also could not see her for a few days.

"She decided to seek the convenient, affordable, accessible care of a CVS MinuteClinic and was provided with the high quality care that she needed when she needed it. ..."

I know first-hand, and from many others, that one of the top reasons people don't get recommended care is that it isn't AVAILABLE when they need it. Like "dial-a-nurse" services, retails clinics are a tier of care, not a total replacement.

Here's my ultimate rebuttal these days, and I wonder what Shannon would think.:-) ----

In mid-2013 I had the thrill of speaking at the same event as the famed surgeon and author Atul Gawande. In his remarks he touched on retail clinics, and you know what he said? Paraphrasing from memory:

"At first I was skeptical [about the clinics] - who needs this?? But then when the time came to get my own flu shot, I could get it in my own workplace [his hospital] - I didn't even have to go somewhere else - but I could never find the time. So as time passed, I realized - I'll just get it at the Minute Clinic in my neighborhood."


Cleary Squared said...

Hi Paul!

I've been to the CVS MinuteClinics twice and for the price of a co-pay, they are well worth it for minor procedures, flu shots, etc.

Both times, I went to the MinuteClinic in Porter Square, Cambridge (as then-Mayor Menino was fully against them and blocked them in Boston) for blocked ears. The NP who worked there did a short history workup, cleaned my ears as best as she could (the PCP had to finish the procedure at the office) and that was it.

Providers should embrace these entities as helpful assistants and stopgaps, not try to protect their own interests by blocking them. Even if it's a "hey Doc, can you look at this" procedure, a MinuteClinic could probably give them a fair assessment at any time, without the long wait at the ER (or the doctor's office).

It would also prevent minor incidents from becoming major ones - such as the scrape that becomes cellulitis, which requires ER intervention, and then inpatient admission, which costs tons of money in copays.