Docs Want Retail Clinics Closed
A number of doctor groups have called on the American Medical Association to seek a ban of all in-store health clinics.
The physicians are claiming that the facilities, largely staffed by advanced practice nurses, put patients at risk for a number of reasons including what the groups see as a lack of government regulation and oversight.
Dr. Rodney C. Osborn, president of the Illinois State Medical Society, described what he saw as primary differences between the relationships patients have with doctors or nurse practitioners in retail store clinics on a MedPageToday podcast from the AMA convention: “The patient relationship with the physician – the patient comes in and they’ve had a 10, 15, or 20 year history. The physician may recognize the cough for what it is, a symptom perhaps of a lung cancer. In a retail clinic, a mid-level practitioner may believe the cough to be associated with an acute viral or bacterial infection and treat it thus and not follow through on what’s been a long-term history of medical care for that patient. There have been examples of that given. There have been examples of additional problems with misdiagnosis of breast cancer (and) cervical cancer for women where the appropriate care by that midlevel practitioner isn’t delivered.”
Dr. Osborn also suggested that the basic mission of doctors and retail stores offering clinic services makes physicians the better choice for consumers. “The basic business mission (pharmacies) is one of selling products and prescriptions. The medical mission is the patient’s care, the patient’s health, the patient’s safety. Our members are very concerned about that aspect.”
When asked if he had specifics to back up his assertions about patients at risk, Dr. Osborn said, “There hasn’t been time to obtain objective study. There will be on the care given in a series of settings versus the standard physician office setting will be evaluated. Right now, the evidence is anecdotal and there are stories. So, I can’t point to a study because this is such a new animal.”
A Chicago Tribune article addressed concerns by pediatricians over parents bringing small children to clinics for care. While most in-store clinics do not treat children below 18 months of age, many pediatric groups believe kids should be at least three.
There’s no doubt that physicians also have financial concerns about the impact that clinics that are open seven days a week and do not require an appointment may have on their practices.
Walgreens expects to have 400 clinics operating in its stores by the end of 2008. Company spokesperson Michael Polzin said, “We would be disappointed if the AMA adopted a policy that is counter to what patients are demanding, which is more accessible and affordable health care that reduces overall costs. It would be hard to argue against those principles. The bottom line is, retail clinics are improving health care access and health outcomes while keeping the patient’s doctor informed as the patient desires.”
Dr. Peter Carmel, an AMA board member, told The Associated Press, “If we believe in consumer-driven medicine, if we believe that it is the responsibility of medicine to respond to the needs of our patients and if there is a strong consumer demand, then we in fact are going to have to compete in this arena.”
Discussion Questions: What is your reaction to the strength of opposition, including calls for an outright ban, to in-store clinics from physician groups? What actions should the retail industry and in-store clinic operators be taking to address this reaction from at least some elements of the medical community?
It is interesting that doctors would take this position without looking at their own practices.
What about the nurse practitioners who handle a larger portion of the office visits for doctors.
I remember nearly 40 years ago when nurses and paramedics were little more than gophers not allowed to do anything without being micro-managed by doctors. Maybe a lot of people reading this aren’t old enough to remember the “Emergency” Television series where the paramedics had to call a doctor to do the simplest of procedures. I’m old enough to remember the days when the doctor actually gave the injections (which is rarely the case today) and even did house calls (never done today).
Most of the time when a patient calls the doctor with what appears to be an illness, he is told to go to the local emergency room, another place where the doctors on-call do not know the patient anyway.
Time and experience have shown that nurses and paramedics can handle a range of procedures effectively.
We do not need additional governmental control because the states already have strict laws regarding what doctors and nurses (and more recently nurse practitioners can do) and have licensing authority for medical practitioners.
I view this doctor’s comments as nothing more than attempting to protect his business interests.
I think we are starting to seem that the free enterprise system–a large basis of what this country is founded upon–is starting to work in an industry (let’s face it, it is an industry) that is long overdue for reform.
HMOs and insurance companies have forced many MDs to become more like patient mills moving them through as quickly as possible. Health insurance costs are skyrocketing out of control and way too many people have no coverage at all. I don’t think that anyone is touting these clinics for a place to diagnose or treat serious illness, but they do seem a logical place to stop for minor complaints.
And just maybe, a little competition will bring the market back into sync.
“Me thinks they doth protest too loudly!”
While I’m certainly no Michael Moore fan, the juxtaposition of this week’s press releases from the AMA and the pre-release publicity appearances for Moore’s “Sicko” is just too ironic to ignore. The Tribune article also included a quote from one of the presenting physicians which, paraphrased, said something to the effect of “…if we don’t stop this now, in fifteen years the chairs in this room will be filled with Walgreens and Wal-Mart executives.” That makes it pretty clear what the AMA is really afraid of.
Another telling statement was Mr. Polzin’s “keeping the patient’s doctor informed as the patient desires.” Note that he did not say “as the physician desires.” It occurs to me that there are three basic approaches to healthcare. “As the physician (or read “healthcare industry”) desires”. “As the government desires” (state run or “socialized” healthcare). And finally, “as the consumer desires.”
From what I’ve read and heard, few are willing to put themselves down as “fans” of either the U.S. or other “state run” healthcare systems. They each have flaws. From our collective perspective as a group of businesses and individuals dedicated to filling consumer needs, maybe we are in in better position to see the advantages of a consumer driven system–something neither the U.S. or other countries have yet. But the advent of retail clinics, Health Savings Accounts and portable health insurance are headed in that direction. This could be a very good thing.
We have been tracking the health care field for 40 years, and it does not appear that some of the claims made in opposition to this trend may be accurate:
– A 10, 15, or 20 year history. 88% of consumers report they either have no primary care physician, they don’t know who that person is, or they have had their current physician for less than a year.
– Correct/incorrect diagnosis. As judged by outcomes, 73% of all diagnoses are either completely incorrect or are incomplete enough to result in a “failed” outcome.
– Mission. Just because an entity makes money doesn’t mean that making money is its ONLY, or even primary, mission. This is a common mis-assumption about business organizations. Note that, obviously, physicians also make money–but does that mean money-making is their primary mission? Pharmacies make money, but that is obviously not their ONLY mission. Also, how many poor physicians have you ever met? And on the other hand, take a look at how many pharmacies donate either their time or money or resources to charity.
The physician groups in this country do not appear to have a pristine reputation of selfless lobbying efforts. These groups have many, often conflicting, interests. There are certainly many selfless physicians out there (I have four physicians in my family), but their professional groups may not be serving the same goals.
Medicine is VERY big business and the doctor groups highlighted in the article appear to be looking out for number 1: themselves.
The fact that these groups have already approached the AMA without, admittedly, gathering objective and scientific analyses of their claims, speaks volumes over what is motivating them.
These groups of doctors may not be contemplating the possibility that if the clinics weren’t an option many of these people would not have been able to afford to see a physician and would go untreated versus mis-diagnosed.
The last thing that this country needs is more government intervention and regulation of what appears to be a fresh and exciting approach to bringing affordable health care within reach of millions.
Obviously there are real concerns here and real vested interests at work. In-store clinics aren’t supported by all the testing equipment found in a traditional medical center nor are nurses doctors. The danger here is that some customers might rely on the in-store clinics as their primary or sole medical care facility and that more complex diseases may go undiagnosed or misdiagnosed.
If I were a retailer, I would think twice about an in-store clinic for two reasons. First I’m not sure I’d want a clinic attracting sick children and adults to my store. The danger of spreading certain diseases is high enough as it needs to be in many public places. Next, if a serious condition is missed and a patient dies or suffers significant damage, I’m willing to bet it wouldn’t be too good for business.
Of course, on the other hand, some of the indignation on the doctors’ part may come from a desire to stifle competition.
In my mind the jury is still out on this one.
Dr. Osborn’s comments seem to me to be a glaring example of attempted turf/revenue protection. When someone comes in with a cough, the most obvious cause is generally not lung cancer. There are lots of less serious things that physicians would treat or rule out first. And, if a walk-in patient gets treated for a cold, allergies, flu, etc. first for a week and then gets diagnosed with lung cancer, I don’t think the clinic has done anything wrong. If the patient were to call his/her doctor for an appointment to treat a cough, there is a good chance they would have had to wait at least a week anyway.
Previously protected businesses don’t seem to like it when the free market becomes a factor.
It is unfortunate that there are many Americans without health care insurance that have no choice but to seek alternate heath care options. When you couple that with the tradition of some ethnic groups to seek their medical advice from the pharmacist, it makes all the sense in the world to set up and expand retail health care clinics. The major retailers will be the primary influencers of this trend and possibly place nurse practitioners in a similar “high demand/high compensation” mode as we currently see with pharmacists.
If the AMA wants to take control this situation then they will need to lead an effort to provide either low cost health insurance or low cost health care to this growing segment of the population!
My reaction to the medical opposition is in part the observation of this being a “CYA” move based on the shortcomings of the medical and health delivery system in at least the U.S. and possibly more broadly than that where clinics are being introduced. Obviously, medical practitioners perceive they have much to lose if their business heads elsewhere. Some of the most profitable work for doctors is in vaccinations and wellness appointments, and there may be a reduction in that work as patients head to cheaper alternatives.
As I have stated previously though, the idea of KNOWINGLY co-mingling over the grapes, baked goods, sandwich meats, or even breakfast cereals with someone who is coughing, sneezing, and obviously sick as they wait for their turn in the clinic or to have their prescription filled would be reason for me to NOT shop that store. I am not naive and understand it happens now without my knowledge anyway when people DO shop while ill, and do breathe the same air as me while they await their prescriptions–but I do not want to voluntarily go into an environment where sick people are encouraged to congregate.
Retailers are opportunistically seizing a chance to better serve customers and prospects and I applaud that. Doctors are using their muscle to claim that they alone have the insight to administer to the health of patients. Shoppers are fed up with the pricing, lack of service, and poor results of their health care experiences. The system is in need of overhaul. I just don’t want to allow the business end of tending to someone’s bronchial distress to lead to my now needing to seek medical attention because I stood too long next to someone squeezing cantaloupes or who did not have the sense to use a tissue when they sneezed before they returned the 2-liter CSD from their cart to the shelf right before I picked it up.
The AMA does make a good point. Many people may go to these clinics under the false impression that they could actually get treated for a serious illness. Before the AMA goes overboard, let’s let the marketplace decide on the future of these clinics. If they are not successful, then they will close. I’ve seen a lot of these clinics and so far all I’ve seen is the nurse sitting around reading a magazine with no patients.
I recently ran across my primary care physician of 10 years outside the office. He obviously didn’t know who I was so I introduced myself. ‘Nuff said.
Many people have no real relationship with an MD. They go to emergency rooms or they see an MD who is in their insurance provider network, who’s being paid minimally for the visit and can’t spend the time for a complete medical history. Years ago, the AMA tried to prevent Medicare. Today, most MDs love Medicare, compared to insurance companies. The AMA hasn’t used its political power to end the hazing of medical students, forced to work 24 shifts, who couldn’t possibly be giving decent patient care. Sure, seeing an MD might be better than seeing a nurse.
Physicians are the ones with a clear financial concern about the impact that clinics with may have on their practices. Doctors who see their patients in an urgent care setting have no better approach than the the clinic. These clinics are not designed to replace the family doctor and in fact, refer patients back to them. However, if you have a relatively straight forward condition such as a cough, cold, ear infection, urinary tract infection etc., why not be able to access convenient health care? Additionally, a nurse practitioner working with a pharmacist can offer enhanced care and accessibility for patients.
It’s too bad the AMA is so much of a monopoly that it can’t be trusted. There are probably some in-between answers like having the nurses supervised by online–even visiting–physicians and frequent referrals. There could even be doctor’s offices in the store or nearby. Without a doubt though, the AMA would resist as they only want what is easiest and most profitable for themselves.
There is no “sacred turf” any more. If more doctors gave tremendous service to all of their patients, then the patients would not leave them for this alternative. How many times have we sat in our doctor’s office for up to 3 hours just waiting, because patients are stacked like cordwood? The old days of the corner store, the local butcher, the malt shop, the feed supply, the local druggist, and restaurant are all gone.
Our country now demands the lowest price on everything and there is a price to pay for that. I hope the clinics do what is right for the patient, and I also believe it would be smart for a Walgreens to marry-up with a local hospital or doctor’s office for referral or consult. That way, everybody wins, and less serious cases would get expedited without further cost.
Hey doc!!! Stop whining and make your patient care better than ever, and you’ll still be able to ski in Aspen next winter.
I think Phil Straniero has raised the most important point of all. Too many Americans have no or insufficient healthcare coverage and so walk-in clinics, emergency rooms, etc. become their primary (and, for that mater, exclusive) source of medical care. Al is right about the cough but for the uninsured or underinsured that cough may be a symptom of something worse which shouldn’t just be masked by an OTC remedy. As Phil notes something should be done to help the poor or working poor or self-employed get adequate medical coverage. But, that said, I’m still not sure the answer is a checkup at A&P.
Certainly gathering some data on patient experience and results would help determine what actually happens to patients at these clinics. For any person seeing a doctor for the first time, a cough will not necessarily be a symptom of cancer on the first visit. Given the number of people who visit emergency clinics or who do not have a regular physician, an initial visit with a cough is most likely going to be treated in a similar way as it would be treated at a clinic.
The question is what happens when the patient returns and still has a cough. My understanding of the clinic guidelines is that if initial treatment does not work successfully, the patient is referred to a physician.
How is this process different from getting an appointment with the nurse practitioner in a physician’s office because the physician is too busy to see patients for routine issues? When the problem does not go away, then the individual may eventually see the physician.
This issue is part of the whole health care issue. If people actually have access to health care for basic, routine issues and get referrals for more complicated problems, these clinics appear to be a useful part of the process.
Dr. Peter Carmel of the AMA has it right. This is a consumer-driven element of a business which has not been consumer-driven since the dawn of HMOs and PPOs. As a former health care practitioner, this may be the chink in the Health Insurance armor which has prevented true consumer-driven health care in favor of cost-shifting from employers to employees.
Retailers are jumping on this trend without thinking through the ramifications. Wait until they receive the first lawsuit as a result of an incorrect diagnosis. No matter how many waivers the “patient/consumer” signs, the fact is that when a patient visits an in-store clinic, and has a critical outcome resulting in death due to a missed problem, the lawyers will sue the retailer, because the retailer is the one with deep pockets. Is every retailer prepared to have medical malpractice coverage as part of his or her corporate insurance policy?
Contrary to what they say, retailers are not looking at this because customers are demanding it. Retailers are looking at this concept because it is an opportunity to make more money. If the same companies spent more time being great retailers, and great merchandisers, I have to believe that they would generate higher profit margins from the square footage they are giving up for the clinics, than they will from the clinic revenues. Be a great retailer, and the increased foot traffic will come.
This is clearly a small group of physicians who is trying to protect their own personal stake. These clinics offer basic medical care for folks who are unable to afford it in a reasonable location, at a reasonable price. This is desperately needed by many of the nation’s poor and economically restrained. Their medical care is largely unavailable, or prohibitively expensive. This is being put in place to meet these needs on a low-cost, initial visit basis so that folks can get some fundamental health care where before they had none. There is nothing wrong with this model so long as it is self-sustaining. Any objections are clearly self-serving and frankly despicable in light of the medical community’s ethical oath and position on health care.
“There’s no doubt that physicians also have financial concerns about the impact that clinics that are open seven days a week and do not require an appointment may have on their practices.”
Well, yes. That having been said, the AMA is, perhaps, not without a point: medical care is one of those areas where there is a high probability of market failure: patients–“customers”–often lack the information/expertise to make informed decisions (and mistakes can be costly…in every sense of the word!) But in a purely practical sense, this issue comes down to one question: are these clinics being used in place of a traditional MD, or in place of nothing at all?
It would seem that from today’s comments there are several perceptions at play among us: 1) doctors want to control all health care even though they do not not always offer immediate accessibility to treat us: 2) far too many people don’t have affordable access to health coverage and in-store clinics offer them some relief; and 3) supermarkets and drug stores are trying to further extend their reach with consumers by providing in-store health clinics.
All these perceptions have some profile, but does eliminating in-store clinics solve anything else? Or do in-store clinics provide quality medical care for more serious sicknesses that many may rely on them for? Or do healthy retail shoppers want nasal-dripping or obvious germ-spreading shopping companions intermingling with them in the stores where they shop?
There is no single seemingly solution available for these various dilemmas and opportunities. But personally I find myself not wanting to buy my groceries or toothpaste at a hospital someday and thus it would seem that emerging in-store clinics are partially related to the other side of that coin. Meanwhile, the doctors will use their considerable clout to maintain control–and little else gets resolved by anyone anywhere.
Who Moved My Cheese?…A great book that maybe a few in the medical profession should take the time to read and apply to themselves. This debate is about protecting the status quo. Health care in the US is broken, and the only way to change is it to think outside the box and find different ways to deliver medical services in a manner that is affordable and non-threatening. I’m sure in light of the movie “Sicko” being released this Friday, the topic of making health care affordable is only going to become more of an issue.
I am still dismayed to see the comments of “sick people in my store” or even the one comment about knowing there are sick people coming in. A number of stores have prescriptions–you cannot really think that sick people are not coming in shop at the same time as you are. Just my two cents worth on the ways some people will try to justify something they do not like. Just come out and say–I do not want to shop with anyone outside of my circle….
I agree with the other posters–the AMA and the doctors cannot compete so they want to squash the clinics. I am lucky to have a primary care physician with whom I have a great relationship and can get in to see quickly. I know I am in the minority–my wife called her doctor and was told that because she had not come in for more than 2 years (darn her for not getting sick enough to come in) that they would not see her and told her to go to a local first care clinic. It’s this personal experience and those of friends and family that make me cheer for the clinics to succeed. Perhaps then, doctors and the AMA will get the kick they have needed for a long time.
I believe that we need to develop ways for patients to access medical services more efficiently. Our emergency rooms, in particular, are overflowing with uninsured patients, many with minor ailments that could be effectively treated by a qualified nurse practitioner in a more cost-effective venue. Of course, the execution must be done with clear definitions of what can be treated in these clinics and there must be monitoring to ensure quality.
How many of these doctors actually ever see their long term patients? Every time I go to my doctor–the one I have had for the last ten years–I see the nurse practitioner. I’m always billed as if I saw the doctor, though. Let’s make an appointment with each of the doctors who are fighting the clinics and take a survey on how many actually personally see their patients. I am willing to bet that over 90% of the time their nurse practitioner is the one who administers to the client’s needs.