Bruce A. Auerbach, M.D., president-elect of the Massachusetts Medical Society, delivered these remarks today (July 25) at a public meeting of the Board of Registration in Medicine on the application of Minute Clinics to open a limited health clinic at a CVS store in Weymouth:
The Medical
Society and the physicians of Massachusetts welcome innovations in health care.
We need innovations in our health
care. We all know that much in our current health care delivery system is
dysfunctional. Therefore, the only intellectually honest position to take –
especially in a state which is committed to making care accessible to everyone –
is to support innovation. But those innovations must ensure safety, improve the quality of care, and deliver care efficiently and in a coordinated manner.
My brief comments today will focus on only two areas – the supervision of the care delivered and
the continuity of care after a patient encounter at one of these facilities.
First, on the supervision of care:
The business model of the Minute Clinic is to have nurse practitioners deliver all,
or almost all, of the care. Certainly, for the limited scope of conditions that
these clinics are designed to accept, this is not inappropriate, on its face.
Nurse practitioners have adequate training to treat many of the conditions outlined
in the original application to DPH. I have great respect for and
value the skills of nurse practitioners. In fact, they are used extensively in
the delivery system in which I practice.
Training is not our issue – collaboration and supervision is. The original application by
Minute Clinics outlined – and I stress “outlined” – an arrangement that does
not appear to ensure the integrated high-quality care for which we strive.
In what most consider the ideal model, the one that ensures quality, safety and
continuity, the nurse practitioner has constant, ready access to their supervising physician. The patient also knows with which physician their nurse practitioner has a supervising relationship and to whom they can turn for issues beyond the scope of the nurse practitioner.
In other words, there is a physician-patient relationship and accountability. In many cases, these providers are in practice in close physical proximity to each other, again supporting the collaborative, consistent relationship and the consultative, supervisory role. This type of model supports quality, safe
practice.
Patients do not present with a diagnosis, similar to the list of “accepted” problems for
the retail clinic. They present with complaints. Every patient who presents
with a sore throat does not have Streptococcus pharyngitis. Every patient
presenting with red eye does not have simple conjunctivitis. Having the ready,
consistent access to a physician colleague helps ensure that the sore throat
that is a peritonsillar abscess and the red eye that is a herpes lesion are not
missed. My 25 years of experience working alongside physician assistants and
nurse practitioners has provided me with more than anecdotal examples of
similar cases.
The Minute Clinic model does not attempt to mirror this ideal model nor does it appear to even
meet the standards that this Board has supported in other instances when
physicians who are not always on site are called upon to supervise care by nurse
practitioners. The current standards not only create a mandate for a consistent
supervisory relationship with the nurse practitioner, but support the link
between the patient and the supervising physician.
This does not appear to be the case with the Minute Clinic model, where the physician seems
to be responsible for only a sampling audit of the nurse practitioner’s activity.
There does not appear to be any attempt to establish a relationship with the
patient or be available for consultation. We believe the relationship intended
by the Board’s standards is the one that is in the best interest of safe, high
quality patient care. It should not be altered.
Second,
some comments on how these clinics should relate to the rest of our health care
system.
One of the historic scourges of our health care delivery system has been its fragmented
nature. Thankfully, we are starting to make some headway in reversing this
direction. Chapter 58 promises to bring us even closer to our objective of
providing care along an effective, efficient continuum to every resident of our
Commonwealth.
One example is the concept of the Advanced Medical Home, proposed by the American College
of Physicians. It’s an excellent step in the right direction. It includes a
large role for nurse practitioners in settings like this – but in close
association with the physician’s practice. A number of pilot programs for the
Advanced Medical Home could be implemented in the Commonwealth within the next
year.
Some questions that might be posed are:
- Who will be responsible if the patient worsens after their Minute Clinic visit?
- How will the entity assuming any follow-up care, scheduled or otherwise, be made aware of the evaluation and treatment rendered by the clinic.
- Will records at the, now closed, retail-based clinic be available for those providing after hours follow-up care?
- How will follow-up or more extensive care be facilitated if the patient does not have a primary care physician?
This is just a small sampling of the types of issues that concern provider groups with
the proposed model. To reiterate, these are all issues with the potential to
impede our progress towards the most integrated, comprehensive, coordinated,
safe and high quality health care system we can devise.
Without significant changes in its
plans for physician supervision and connecting to the larger health care
community the Minute Clinic model would be a step backwards, in the wrong
direction -- towards more fragmentation, and away from collaboration and
continuity of care. This model would undo much of the progress that the Board,
our hospitals, and our physicians have made to ensure that care is not only
effective, but efficient, coordinated and patient-centered.
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