Convenient care clinics merit a closer look by physicians

AMA Leader Commentary. By Edward L. Langston, MD, May 5, 2008.

A message to all physicians fromEdward L. Langston, MD, chair of the AMA Board of Trustees.

There is something new happening out there. Have you noticed the birth of convenient care clinics, also known as retail clinics? Most are located in a facility that houses a pharmacy.

This phenomenon is around four years old and starting to grow. In 2007, approximately 800 convenient care clinics were up and running across the United States.

Many physicians and physician organizations have asked: Why? How can these convenient care clinics (CCCs) work successfully? Are they regulated like most health care facilities and physician’s offices? What should physicians do?

Reasonable questions.

The AMA House of Delegates has endorsed an American Academy of Family Physicians set of principles, now codified as AMA policy H-160.921.

Many physicians have voiced concerns regarding quality of care, appropriate supervision of those providing the care, whether the facilities were in harmony with state regulations and even questions about scope of practice.

In response to all these concerns and questions along with activity in many states and locales across the United States, an attempt has been made to determine how these clinics work, what is their premise of care and what is their underlying business model.

Currently there are three major CCC entities: MinuteClinic, RediClinic, and The Little Clinic. Wal-Mart also has about 75 to 80 clinics in their stores that currently are operated by a leasing organization. They have announced plans to increase that number by 400 over the next two years.

The CCC business model for these clinics is based upon a quick turnaround time of 12 to 15 minutes per customer. Most clinics, if not all, have a limited number of conditions they are prepared to treat. All seem to have physician-developed protocols for evaluation and treatment, and defined referral plans for follow-up. The CCC concept is not designed for long-term or follow-up care.

Some states are closely watching and monitoring return visits to these CCCs, for instance.

More importantly, the need for more intensive and immediate medical care has resulted in templates for those who fall outside the adopted protocols for care. Anyone who falls outside the protocols of care requires immediate referral to a qualified medical care facility with appropriate physician staffing.

The predominant business model is based upon protocol-driven care in a limited range of medical conditions. To provide a more in-depth level of care, the increased costs associated with providing that care run counter to the overall business model and limited revenue possibilities. Therefore, unlike the urgent care model, more in-depth care is counterproductive to most CCCs and thus the need for a defined referral system.

The preliminary data on customers seen in convenient care clinics suggest that up to 40% do not have an identified primary care physician and a third or more are uninsured.

The majority of CCCs are staffed by nurse practitioners. Some CCCs are staffed by physician assistants where state laws allow the practice under physician supervision. An overwhelming majority of patients are pleased with the convenience and quality of the care provided in the narrow range of conditions treated.

Many state medical organizations, responding to their unique state characteristics, have proposed legislative and regulatory responses to address concerns regarding quality of care, supervision and facility issues. Since each jurisdiction is unique, specific issues can and should be addressed.

Perhaps, as physicians, we should take a closer look at this model. If the CCC, with appropriate safeguards, meets the needs of some individuals’ immediate, nonemergency care that we know costs less than emergency and urgent care facilities, then it might be a reasonable option for some.

Certainly, for many patients who cannot get in to see their own physician in an immediate care situation, an alternative other than the ED or urgent care might prove to be more useful.

There is opportunity for physicians and medical systems to be important forces in the CCC movement through supervision opportunities, protocol development, follow-up care and providing immediate referral medical care services for acute and more complex medical needs for those falling outside of the model’s protocol of care.

There is also the opportunity for ownership of the CCC, as demonstrated by the Sutter Clinic in California.

A case can be made that the model may offer an entry into the health care system. Needed follow-up care or recognition of immediate and more intensive care will drive the customer to seek further care in a more appropriate facility. The CCC is not designed to provide critically needed follow-up care.

A measured, critical assessment is the appropriate response to the CCC movement.

In a recent AMNews article (“Ask questions before working at retail clinics,” April 7), Scott Miller, MD, chair of the ethics committee at Allegheny Hospital in Pittsburgh, outlined critical questions physicians may want to explore if contemplating engagement with a CCC.

This seems prudent.

As Dr. Miller noted, these clinics seemingly are here to stay. From the physician point of view, it certainly appears the convenient care clinic has created challenges and opportunities for the traditional office practice model.

If physicians cannot create a pathway within their practice model for immediate and convenient care for low-complexity medical problems, then the concept will probably continue to grow.

It will be interesting to watch.

Time will demonstrate whether they answer more questions than they create.

Certainly food for thought.

Dr. Langston is a family physician in private practice in Lafayette, Ind. Learn more about Dr. Langston at the AMA’s bio page or contact him by e-mail.

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