Monday, January 25, 2016

The doctor is in -- in a storefront

Dr. Danielle Ofri calls this trend the ‘Mall-ification’ of Medical Care. The health funder Robert Wood Johnson Foundation reports on Retail Clinics. Their trade association uses the label "Convenience Care". I first noticed them while walking around the city. Apparently these facilities are becoming a significant presence in the U.S. healthcare non-system.

The Center for Advancing Health published a clear description of how these facilities function.

Most retail clinics operate something like this: Appointment times are guaranteed, but up to 90 percent of patients just walk right in. They start by choosing their problem from the clinic's menu of common complaints — think bronchitis, ringworm, ear infections. Many clinics also offer services such as childhood and adult vaccinations, pregnancy tests, and seasonal items such as flu shots and school and camp physicals. There are set prices for all of these services, displayed at the clinic's entrance. Patients then sign up to see a health care specialist, who could be a nurse practitioner, physician's assistant or even an M.D. in some cases. Most consultations take less than 15 minutes.

The short wait was a big draw for Tim, a Tucson, Ariz., college student who suspected he had a sinus infection. He visited a retail clinic housed in a nearby drugstore: "I got an appointment with my regular doctor last year for this same thing, and I ended up seeing a nurse practitioner there anyway. So I thought I would go where I knew I could probably get the same experience in less time and with less hassle."

Nancy Dawson, a nurse practitioner and manager of operations for Minute Clinic in Tucson, says convenience seems to be a big factor in whom the clinics attract. Parents with young children and young adults are some of the heaviest users, "although we see all age groups," she says. "It depends on the time of year, whether it's flu season, time for seasonal allergies, or with our younger population, time for physicals."

...The retail clinics keep their costs down by limiting their services and their space — exam rooms are about the size of a walk-in closet in most places. There's no room for an X-ray machine or ultrasound, lab, or other expensive equipment.

No need to plan a visit days or weeks in advance, no long waits, and a published price list -- the fact that these might be disruptive innovations in healthcare delivery speaks the truth that the shape of the U.S. system was forged around interests other than those of patients.

There are detractors who may have some valid concerns. The American Academy of Family Physicians opposes management of chronic conditions through these facilities.

Protocol-based decision and diagnostic models are used in most non-physician led retail clinics, resulting in a missed opportunity to address more complex patient needs. These missed opportunities range from preventive care services to critically important diagnoses which may not be specifically covered in the pre-generated protocol decision program. The AAFP is committed to the development of a health care system based on strong, team-based patient-centered primary care – defined as first contact, comprehensive, coordinated, and continuing care for all persons.

Care delivered in retail clinics can be a component of patient-centered care, but must work in coordination with the patients’ primary care physician to ensure that care is not further fragmented. Fragmentation and unaccountable silos of care are in direct opposition to achieving continuous whole-person care with improved health outcomes for both the individual and society.

In plain English, that means that these doctors think patients need their expertise to manage complicated, interacting illnesses. And since medical records don't easily flow between systems, they fear subsequent providers will never learn about a convenience care user's prior conditions and care. This seems realistic.

In 2008, the journal Health Affairs reported on a study that addressed the continuity of care issue.

... We found that three-fifths of patients did not report having a PCP [Primary Care Physician], so for these patients there is no relationship to disrupt. ... Most independent retail clinic providers can provide patients with a printed visit summary from their electronic medical records (EMRs), or the clinic can fax the record to a physician upon the patient’s request. However, we do not know how often this occurs and whether the pattern of communication is better or worse than what is seen between other care providers.

I've never availed myself of a retail clinic. By accident of past employment, I've been ensconced for 20 years in the nation's largest, and probably best, managed care plan, Kaiser Permanente. I can see a doctor within a day if I need one and they insistently chase me down for immunizations and preventative tests. But if I didn't have Kaiser, I'd probably explore these cut rate options for simple conditions.

Does anyone who reads here use these clinics? Any experiences to share?

1 comment:

Hattie said...

I'm with Kaiser too,thank goodness. We have gone to walk in clinics in Seattle and had OK.experiences. Ballard in Seattle has a walk in neighborhood clinic in a church basement that was signing people up for Obamacare on a day when I was visiting.