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Retail-based clinics and their place in primary care
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The issues raised during the past decade by retail-based clinics are varied and complex. Given the current pace of change in our system of health care, it is also not surprising that passions about these same issues are becoming even more heated.
To be sure, one only needs to look at the AAFP recent policy revision on these clinics to see the rapid evolution of concerns. In 2010, the AAFP revised its own 2005 policy stating that retail-based clinics (RBCs) may be complementary to family and other primary care physician office-based care to now reflect the academy’s opposition to the growing expansion of scope of service offered at many such clinics. Furthermore, the AAFP ended its practice of entering into formal agreements with retail clinics that accepted its prototypical guidelines for retail-based care. When not so prevalent and care presumed was limited to sore throats, urinary tract infections and ear infections, there were seemingly fewer objections — either practical or philosophical.
The AAP has taken a tougher stand. Its policy statement dates to 2006 and clearly opposes RBCs as an appropriate source of care for infants, children and adolescents and discourages their use, while emphasizing the importance of the medical home. Both the AAP, and now the AAFP, define their opposition based on the medical home model of care, with the AAFP clearly concerned with the expansion of RBCs into the realm of chronic disease management. Both organizations focus their concerns over quality issues, which include but are not limited to: fragmentation of care; episodic care of special needs individuals; follow-up of test results; after-hours access; provider level of training; and the risk of communicable disease in retail settings.
Despite these concerns, the two organizations acknowledge the likely expansion of RBC care and elaborate a new set of guidelines they hope RBCs will abide by in the future. These principles refer to support for the medical home model; acknowledgement of the infectious disease risk; adoption of electronic health records; use of evidence-based medicine; and the establishment of communication of care and referral systems with the medical home office. The AAP specifically argues against insurance companies waiving or lowering co-pays or providing other financial incentives for visits to RBCs, and thus undermining the primary care medical home.
Future of primary care
As I sit in my office on a weekend in which eight of 10 visits were related to sore throats or ear infections, I cannot help but note that at the heart of the controversy is our individual, or organizationally collective, vision of the future of primary care. I ponder about who will provide the care and what their training will be, as well as how quality and cost will be accounted for. Questions regarding how the medical home model will really play out and whether accountable care organizations will solve the nation’s health care woes also come to mind.
RBCs are almost certainly here to stay. Clearly, there is profit to be made in their operation. As a Red Sox fan, I expect I will continue to see the MinuteClinic (CVS Pharmacy) logo adorn the Green Monster. It is likely that there will be areas within medicine where there will be cooperation between RBCs and primary care, but conflicts will undoubtedly remain. There is institutional support and an acceptance of RBCs that appears to be self-sustaining. The National Retail Clinic Summit, co-sponsored by the Convenient Care Association and Jefferson School of Population Health, convened a year ago to establish a forum for discussion of RBCs in both the marketplace and the health policy domains. One must remember, or hope, that a purely marketplace-driven model of care is vulnerable to a rapid shift in that same market.
Stay focused
For pediatricians, we need to remain focused on the needs of our patients and their families, and acknowledge the demand for accessible, quality care. That care should be provided in our offices at the times and in the manner that meet those requirements. We must realize that cost is a major concern for all parties in health care; however, the ability of certain health care organizations to cost shift between specialty and primary care and to capture facility charges distorts the discussion and often confuses policy leaders.
In Massachusetts, MinuteClinic can provide a visit for $79 to $89. If strep testing is needed, the cost is an additional $23 to $30. For many offices, this is half of the usual charge (not reimbursement) and at least one-third of the cost for an ED visit. Unfortunately, the current economics of primary care practice results in charges for reimbursable acute care visits to compensate for the often poorly reimbursable longitudinal care that we must, and want to, provide. For us to be part of the solution, we must as physicians, either individually or as organized units, better understand the complexities of our current care and reimbursement systems and the implications of proposed changes as we move forward. Otherwise, those of us in the office setting will relinquish our voices to politicians, business people and organized medicine to define the future.
We live in interesting times.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.
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