Mini-Clinics: Not So Fast!

CVS has announced plans to open 20 to 30 "mini clinics" throughout the state.

At first glance, these “mini-clinics” may seem like a good idea: convenience, extended hours, multiple locations, no long lines in emergency departments, no long waits for appointments with primary care physicians.

Not so fast.

Concern #1: Safety. We’re worried that medical care will be delivered without the knowledge of the patient's primary care physician and without the knowledge or availability of a patient's medical history. This raises the risk of medical error. Elderly persons with multiple chronic conditions, on multiple prescriptions, are even more challenging.

Concern #2: They could kill our fragile primary care system. Our primary care network is already in crisis. Allowing mini-clinics to skim the easy, less complex patients might be the death knell of primary care, and our community health centers, too. Who would pick up the slack if that happens? Our emergency departments, of course, which are already over capacity. In other words, these clinics could replace what already exists -- with something worse.

Concern #3: Conflict of interest. It’s an inherent ethical conflict when a pharmacy is located at the same site as a primary care clinic, owned by the same company. There’s good reason why most doctors can’t dispense drugs in their own offices; the same reasoning applies to mini clinics like these.

We don’t think the Department of Public Health should allow mini-clinics to cut corners on good standards that serve the public well. If such organizations want to establish clinics, they should be subject to the same rules and regulations that govern other, designated sites for medical clinics.

Kenneth Peelle, MD
MMS President

Comments

[ALM]

“Concern #1: Safety. We’re worried that medical care will be delivered without the knowledge of the patient’s primary care physician and without the knowledge or availability of a patient’s medical history.”

Oh, my...someone leveraging "patient safety" as a business defense? Never! This rationale is old, old, old.

Retail care environments assess and treat a very finite list of common ailments with the goal of providing, fast, affordable diagnosis and/or relief using protocols that are based on best practices: http://minuteclinic.com/en/USA/Treatment-and-Cost.aspx

First, I must ask whether it matters in the long run if my PMD knows I was evaluated and offered relief for athlete's foot or swimmer's ear.

Second, are we not trying to encourage a "system" (health care "system" is an oxymoron) wherein patients are "empowered" to be part of the health care "decision making team"? Is this just rhetoric? Might that team approach include a responsibility to share with your PMD that you were treated for strep throat? Or telling a MinuteClinic CNP that you have an allergy to sulfa drugs?

When I switched from one local health "system" to another about two years ago, I'm pretty sure my records never did make the transition. Or at least I am unaware. Heck, I ship packages all the time and am e-mailed of delivery progress every step of the way. But my medical history? Faa! Who knows? I digress...

Bravo, retail clinics! Traditional medicine: No more tired excuses. Time to step up and compete like you mean it.

Best,

Andrew
Former Paramedic
Former Health Plan Business Professional
Former Hospital Business Professional
Currently Fed Up, Out of Health Care and Glad to Be

[Ken Higgins]

It would seem the PCP's real concern is keeping out the competition - through use of the same tired scare tactics that have traditionally been used by those seeking to protect their monopoly. Mini-clinics provide a service consumers desire: quick, efficient and quality service for routine and minor ailments w/ convenient locations and hours of service - something the medical profession simply has not provided - nurse practitioners are perfectly capable of delivering these services and triaging more complex cases back to the physician community - isn't it a better use of highly trained physicians' time to focus on more complex cases rather than vaccinations, colds and sniffles? Nationwide there is a shortage of primary care physicians - the "mini-clinics" offer an interesting, albeit partial, solution to this problem, which is good for consumers, the healthcare system and, ultimately, primary care physicians.

[Gordon Kuntz]

Sorry, but the arguments herein do not hold water. Many minute clinic visits are made for convenience reasons more than cost. Given the limited scope of treatment offered by these clinics, the risk inherent in not knowing about a patient's past history seems limited. Patients, especially the elderly, with multiple chronic conditions seem unlikely candidates for using these services since most understand their fragile condition and the value of connecting to their history.

Secondly, the concern about "killing our fragile primary care system" seems misplaced. How about the "fragile primary care system" learns from these market innovators how to provide a simple strep test for less that $100? If they are that fragile, I would suggest that the group that will be around to pick up the pieces won't be the emergency room, but more likely an expanded minute clinic role.

Lastly, the least valid point is that the co-location of the minute clinic with a pharmacy creates a conflict of interest. Guess what is on the first floor of my primary care clinic? A pharmacy, owned by the same health system as the clinic.

Patients - the term is "customer" in any other industry - want quality, convenience and reasonable cost. In any other industry it is called "value". In healthcare it called almost impossible.

[Kevin]

As a consumer/patient, I really like the idea of a convenient "Minute Clinic". I just visited my PCP and he literally spend "minutes" with me. I was then prescribed an ointment and Lipitor. I went to the basement and picked up the meds.

These centers make all the sense in the world to me. I have an HSA, so I can save money and get taken care of quickly and conveniently. As long as PCPs provide little in the form of time/customer service, I will seek out this alternative. I have a strong feeling that I'm not the only one who feels this way (not a rocket-science thought since Walmart and Walgreens are hopping on the bandwagon). Healthcare is a messy business. Walmart and Walgreens are well-oiled machines. Maybe they can motivate positive change!

[flea]

I'm unconvinced by your objections.

Even if I were, the complaint is unseemly. We (including myself) created the niche that retail-based clinics are filling. We refuse to make ourselves available to patients. We triage them to emergency departments for non-emergencies. We educate them to the effect that all minor illness requires the intervention of a health professional.

In short, we created the demand for minute clinics. It's too late to bitch about it now. We made this bed - now we damn well have to lie in it.

I don't know about my fellow MMS members, but this flea plans to partner with CVS when they move into his community. I suggest you do the same.

best,

Flea

[RJS]

You can complain all you like from your ivory towers. Until PCPs start competing with these MinuteClinics on the same terms, it's just a bunch of hot air.

"It’s an inherent ethical conflict when a pharmacy is located at the same site as a primary care clinic, owned by the same company. There’s good reason why most doctors can’t dispense drugs in their own offices; the same reasoning applies to mini clinics like these."

This is completely wrong. The NP doing the prescribing won't see a dime in extra compensation if s/he prescribes a certain volume of medications. Just like the pharmacist doesn't receive meaningful extra compensation if his volume jumps by 80 prescriptions a week. ($1000 for a year's worth of an extra 80 scripts/week is zilch when you're pulling in over $120K/year.) All the RPhs I know would rather forgo the higher volume in favor of not having to work as hard.

In fact, I'd be more worried about bonuses for the NP seeing a certain number of people per day. More patients=more money. But then again, that's just the way medicine works in private practice, now isn't it?

In any case, your assertion that a doctor having his own pharmacy is also a conflict of interest doesn't hold water. My doctor's office, in NH, has a pharmacy in the basement that he and his partner own. So physician-owned pharmacies can, and do, exist. Just (apparently) not in Massachusetts. By your reasoning, this is unethical.

[Frank A. Howard, M.D.]

One year in the past, the Harvard Medical Students performed a critical skit about medical care. The name of their speedy service was "Jiffy Med." As a retired primary care physician, my concern about good primary care for myself and my family is not about speedy care at CVS or elsewhere. It is qualiy care!