I don’t routinely blog about the work of AHCJ board members (which doesn’t mean you shouldn’t read Charles Ornstein’s latest on Florida’s slow reaction to physicians who treated and prescribed drugs under Medicaid “amid clear signs of possible misconduct.”)
But I’m making an exception to my self-imposed rule for Julie Appleby’s recent Kaiser Health News piece “The Walmart Opportunity: Can Retailers Revamp Primary Care?“
I’ve read other pieces about the future of retail clinics, including their potential for treating chronic disease. But I thought Appleby did a terrific job of asking – and often answering – many interlocking questions about the delivery of primary care, the management of chronic disease, the quality of care and what this all has to do with health reform.
While asking big-picture questions, she also wove in details that gave the story texture and made it a good read. If you saw my tweet, you’ll know I was particularly taken by the bit about how long-distance truckers can pull up in the parking lot of more than 600 centers to get their mandatory federal checkups.
As Appleby noted, the clinics – which sometimes lose money but bring customers into the stores – started with the low-hanging fruit, the “relatively healthy patients looking for convenient, low-cost care for simple problems.” The next stage is to try to start treating more expensive chronic diseases, such as diabetes and heart disease, which are big drivers of health care spending. Treating chronic disease, however, is definitely a problem in search of a primary care solution. As her story said:
“It’s sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible,” says Jerry Avorn, a professor of medicine at Harvard. “We should not be surprised if someone outside of our world comes in and does it for us.”
Some of the retail clinics are already venturing into aspects of chronic care: diabetes management, weight-loss programs. (I think we can safely say that primary care physicians have not solved the U.S. obesity problem). Some employers are using the clinics for wellness and routine screening programs.
The costs tend to be lower. Appleby cited a study in the American Journal of Managed Care that costs are 30 percent to 40 percent lower than in the doctor’s office and 80 percent cheaper than in the emergency department. Consumers like the predictability and transparency of the costs (although insurance can also pay) . They don’t get pricing clarity up front at the doctor’s office or hospital.
Several provisions of the federal health law may further spur interest in the clinics. For instance, small businesses will have incentives to offer worker wellness program. The clinics may help fill in some gaps in primary care which are expected to get worse before they get better because of the pent-up demand for care that may burst out when coverage expands under the health law starting in 2014. The Association of American Medical Colleges estimates a shortfall of 21,000 primary care doctors by 2015. Not everyone agrees that there is an across-the-board shortage, as opposed to a shortage in specific underserved areas.
How clinics make the jump from flu shots and throat cultures to the far more complex task of monitoring chronic disease is not completely clear. Remember that patients, particularly older patients, often have multiple chronic diseases (i.e. diabetes and hypertension and congestive heart failure and arthritis, etc.). Some questions remain: Will the clinics turn out to be good at managing relatively stable patients in the early stage of disease – where the convenient locations and evening and weekend hours may enhance compliance? What about with the more advanced illnesses? Will the retail clinics add to fragmentation and miscommunication? Or will the clinics somehow form relationships with “new, integrated collaborations between doctors, hospitals and insurers?”
I don’t want this post to get longer than Appleby’s article so, when you read it, pay attention to the other issues she raises, and think about how they are playing out in your community:
- Scope of practice. What is the role of nurses/nurse practitioners/physicians assistants versus physicians? Turf battles can produce good sources and good stories.
- Does your state have laws about clinics directly employing physicians?
- Will clinics “skim off” healthy patients from physician practice and leave them with all the sickest and most expensive ones, without greater reimbursement? Or, by taking on some routine medical tasks, will clinics allow physicians to spend more time doctoring?
- Who are the patients? (Other than truck drivers and high school students needing sports physicals.) Are clinics just a convenient way for insured middle-class people to get routine care? (I’ve taken my son in for a throat culture at 7 p.m. when he’s feeling scratchy and I know there’s strep in his class. It’s way better than waiting until the next morning to go to the pediatrician when he might be sicker, and he has to miss school and I have to miss work. And, if he does need antibiotics, I’d have to go the drug store anyway.) Or are the clinics avoiding poorer neighborhoods, meaning the underserved stay underserved?
- Appleby didn’t mention this explicitly but it’s worth adding to the mix: To the extent the clinics are in underserved communities, are they helping low-wage hourly workers who don’t have paid sick leave or the flexibility to take an hour or two off in the middle of the day to get their kid (or their mother-in-law) to the doctor?
- Are any of the clinics – anywhere – starting to share information with patients’ primary care physicians? Or, in the case of diabetes, heart disease, etc., are they sharing information with specialists? It can be as simply as faxing something, sharing electronic medical records or using secure email. If I take my kid for that throat culture, it’s really not a catastrophe if I forget to tell his pediatrician (and I don’t need to bother if it’s negative). But for things like immunizations, or A1C levels for diabetics, or blood pressure spikes or changes in medications – someone needs to keep track of the big picture. Of course, communication isn’t all that great right now between doctors without the clinics but, since health reform has some incentives for improving coordination, where do the retail clinics fit in?
That question about integration, which Appleby raised, doesn’t yet have a clear answer. Could the clinics end up having some kind of relationship with the “medical home” or the “Accountable Care Organization” or other models of integrated care? I am not sure of all the legal or contractual problems. If someone has written about this, please chime in. But I can envision ways that clinics can be brought into the coordinated or accountable care loop. It may turn out to be in everyone’s interest – patient, physician and clinic – to do the looping.