Thursday, Jun. 11, 2009

Getting Well While You Shop

If there's one thing most patients lack, it's patience. And who can blame them? When you're burning up with fever or your child has an earache or that sore throat you've been nursing doesn't seem to be going away, the last thing you want to hear is that your doctor's next open appointment is a month from now.

Good thing then that there's a supermarket or pharmacy nearby. Need to buy some shampoo or pick up a few things for dinner? Why not see the doctor — or, more accurately, the nurse practitioner or physician's assistant — while you're at it?

For all the complexities of the U.S. health-care crisis, most Americans experience the problem in a straightforward way: it's just too hard to schedule face time with your family doctor, and it costs too much when you finally get in the door. Of the approximately 1 million physicians working in the U.S., just 30% provide primary care. If you do get an appointment during the week, you'll probably have to take off time from work and carve out at least a few hours to sit in a waiting room. And if you get sick on a weekend, good luck.

That, of course, is assuming that you have a doctor in the first place, not a given in a country where up to 50 million people lack health insurance. Even for the insured, ever changing corporate health plans may mean that a physician you see one year is not available to you the next. In times of illness, more and more people just show up in emergency rooms, which increases crowding and slashes revenues as bills to the uninsured go unpaid. In the past 13 years, at least 190 ERs have responded by shutting their doors.

Enter the retail health clinic. In the past decade, more and more pharmacies like CVS and Walgreens, supermarkets such as Kroger and Publix and big-box stores like Wal-Mart have made space for clinics that treat minor ailments, administer vaccines and examine kids who need medical forms to enroll in camp. In those nine years, storefront clinics have logged at least 3.4 million visits. Today there are about 1,200 such clinics, pulling in some $550 million in annual revenue, by one estimate. Doctors, worried that the clinics will dig into their bottom line, are resisting the trend, but it's hard to argue that the innovation wasn't needed.

Early Detection
The cornerstone of prevention is early detection. Minor problems caught right away — from infections to mild hypertension to a suspicious lesion — may never blossom into major problems. But the inaccessibility of doctors makes early detection more difficult.

Among the new ranks of providers filling the void is the Little Clinic, a company that operates 99 in-store clinics in nine states. The Little Clinic experience is an unabashedly retail one. You can get in and out in 15 minutes during hours that extend into evenings and weekends. Prices are clearly displayed, as is the menu of ills the clinic can address, such as strep throat, sinus infections and flu. There are also preventive services like cholesterol and hypertension screening.

And the cost? For basic acute ailments, an uninsured person will spend about $60 (without tests) at a retail clinic, compared with $60 to $110 at a doctor's office or hundreds more in an ER. And while the retail-clinic model launched on a cash-only basis, most outlets now accept insurance, used by about two-thirds of patients, according to a study by the Rand Corp. published in 2008.

There are some practical benefits to combining the place where you see your health-care provider with the place where you shop. "I can walk [patients] out of the clinic and show them a nutrition label," says Sabrina Freeman, a nurse practitioner and manager at the Little Clinic. Everyone agrees physicians should stress prevention, but during an appointment, "you probably spent five minutes with somebody talking about those things."

Nobody has any illusion that clinics are in the business as an act of altruism. The companies make money — money consumers might not otherwise have spent on health care. The Rand study showed that 90% of adult visits to retail clinics are for 10 common, often minor, reasons. But the same kinds of patients represent only 13% of traffic in doctors' offices. While some are migrating from their doctors to the clinics, others would have sought no medical help and would have gotten better on their own.

Doctors have emerged as the biggest critics of the new trend. "The most profitable part of a family physician's practice is exactly what retail health clinics are going after," says Dr. Ted Epperly, head of the American Academy of Family Physicians. A family doctor treating the same conditions can see five patients an hour. Take away this revenue and doctors will be left with only complicated cases that yield less profit.

But there are less mercenary concerns too. In 2007, the American Medical Association called for an investigation into retail clinics, arguing that drugstores, which position clinics directly adjacent to pharmacies, have a conflict of interest. For instance, floating above the pharmacy counter at many CVS stores are cardboard bubbles reading think minuteclinic, raising the worry that the clinics have an incentive to write too many prescriptions, which will then be filled at the pharmacy. (No AMA investigation took place.)

Family doctors also argue that retail clinics undercut the concept of a "medical home," a care provider who knows your history and can act as a director for all your medical needs. The clinics counter that with as many as 60% of their patients reporting that they don't have a primary-care provider, there's not much to undercut.

Nonetheless, clinics insist that they don't want to be anyone's medical home. They say they refer many patients — particularly people who come in too often, which may indicate a chronic illness — to doctors in the community. For uninsured patients who need more substantive treatment, a referral list includes low-cost community health centers or physicians who offer sliding-scale fees. "These clinics are a portal to the health-care-delivery system," says CVS's Chip Phillips, president of MinuteClinic.

That's important. Many clinic patients come in with an acute problem and, while there, learn they have a chronic one. "We catch a lot of things in people who just don't go to the doctor. Maybe they have high blood pressure and don't know it," says Anne Pohnert, a nurse practitioner and manager of MinuteClinics in Virginia. A retail clinic is not equipped to manage chronic hypertension, but spotting the problem is a first step.

Some retailers take this concept further, working with local health systems and hospitals. This eases ER crowding and helps a hospital extend its brand. The Cleveland Clinic is partnering with CVS in Ohio, and the Mayo Clinic has an outpost at a grocery store in Minnesota.

Despite the misgivings of doctors, retail clinics are changing the way family practices operate — and possibly for the better. Surveys show that many family doctors are now lengthening their hours and leaving more appointments open on a first-come, first-served basis.

In times of economic crisis, the ability of the free market to solve problems may come into question. But in one vital corner of the economy, a little creative capitalism is helping fill a gap.