Mini-Clinic Review

The AMA's Back to Squash Innovative Delivery of Healthcare

Back in the day...1847 that is, the AMA decided to prohibit corporations from practicing or influencing the practice of medicine with what became known as the Corporate Practice of Medicine Doctrine.  The formation of Doctrine was to protect the AMA from losing control of patients, methods of treatment and diagnosis, patient relationships and, oh yeah...income.  The Doctrine was put in place based on three emerging trends: 1. businesses hiring physicians to provide care for employees, 2. general corporations that hired physician staff to provide services to the general public and 3. the creation of hospitals by public agencies and private philanthropists. A really outstanding overview of the Doctrine is here.

Now read this: AMA to seek probe of U.S. retail health clinics 

The AMA wants state and federal agencies to investigate retail health clinics like MinuteClinic based on their fear that these clinics are operating with a conflict of interest (read: making money). 

It seems to me that we're  back in 1847 again.  We have a new disruptive innovation that consumers are attracted to (Of the 5% of 2,441 U.S. adults polled who said they have used the clinics (WSJ Poll from March 07)  (I've heard this number is now 11%)) and are satisfied with:  A study($) titled Retail Clinics: Primary Care Evolution or Revolution? released in April 2007 by healthcare researchers Market Strategies, Inc. documents consumer acceptance of—and in some cases reliance on—these programs for the delivery of primary care.  The director of the study stated that "We were somewhat shocked to find that 12 percent of households with a primary care physician said that minute clinics replaced those physicians for routine care”. 

All in all there is very good evidence that these clinics are providing a valuable, quality service to consumers.  And the AMA is now on high alert that this new healthcare delivery model could impact their business.  It's not surprising that they've been roused.  It was only a matter of time and momentum.  The questions is whether or not we will see a "New and Improved" Corporate Practice of Medicine Doctrine that will attempt to smother this innovation.   

My bet is not.  The world is a different place today with highly connected and motivated consumers.  That kind of scenario didn't exist in 1847.  Today it's about the consumer.  If the medical establishment doesn't change to accommodate the consumer, the consumer will go to and demand services that do.  In this case it is the miniclinic.

The Empire Strikes Back

A couple articles today (Chicago Tribune & Massachusetts Medical Society Weblog)speaking about physicians taking issue with mini-clinics.  This is certainly to be expected as we see the rise of mini-clinics and their acceptance by consumers put pressure on the traditional health care model.  The themes are generally the same as we have seen in the past: Safety and Quality of Care.  Plus some new ones that mini-clinics could kill the primary care system as we know it and even make it worse with conflicts of interest.  (Are docs going to try and suppress this (r)evolution in health care delivery with somthing akin to the Corporate Practice of Medicine Doctrine that they brought to bear at the turn of the last (19th) Century?) Everything that I have seen and read to date mitigates these concerns with empirical evidence that supports safety and quality. Not to mention the overwhelming belief that safety and quality is of the utmost priority with mini-clinic providers.

The more interesting, and again, not surprising theme is that physicians are worried that these clinics will take dollars out of their pocket.  They will.  Because they are more efficient and cater to customers needs.  And since customers...patients...are shouldering more and more of their own health care dollar they are going to spend that dollar where they get the best service.   The traditional primary health care system needs to cooperate with mini-clinic providers and adopt this new model of health care delivery, not fight it or we will continue to have the health care system we have today where when my kid has an ear infection on the weekend, I have to wait until Monday to see a doc...or go to the ER for 4 hours.

It's the Consumer Stupid

I've been in a few meetings over the past few weeks and it is becoming abundantly clear that while the government and industry continue to squirm and wrangle over what to do with the maelstrom we know as healthcare, consumers are taking the lead.

The fact that Walmart is on the road to open mini-clinics in 2,000 locations is a good leading indicator that this is happening. Consumers want accessible, convenient care and Walmart is looking to fulfill that demand.  I believe we'll continue to see consumers demand and get better quality of care and we will see new businesses pop up that will cater to this.  Firms like Chronicity, operating under the name of ADD Health and Wellness Centers, provides integrative treatment for Attention Deficit Hyperactivity Disorder (ADHD) and related conditions.  Firms like this will offer a one stop shop for specialized care for ailments and conditions that consumers will gladly pay for out of pocket.  As I've stated before, the Boomers are not going to go down easy.  They will demand the highest levels of care and they will pay for it...whether in whole or in part.  As a result, we won't have to wait for "Healthcare Canadian Style" to reach the US.      

Walmart: From Pilot to Roll Out

Walmart announced yesterday that it intends to open 400 more in store mini-clinics.  It will do this in partnership with hospitals and third party mini-clinic providers.  A couple interesting points from the Walmart press release that bear noting:

“We know that customers like and want these clinics. At existing clinics in our stores, about 90 percent of patients report being satisfied or very satisfied. They appreciate the fast, easy and convenient experience,”

"Scott notes that surveys in existing clinics revealed more than half of those who visited a clinic said they were uninsured. Nearly 15 percent of customers said they would have gone to a hospital emergency room for their care – thus increasing the burden on already strained community health care institutions – if they could not have gone to the clinic inside a Wal-Mart."

What this says to me is that it's all about increased access to affordable convenient healthcare. And people like that... 

 

Intel Inside the Mini-Clinic?

There's a story in today's SFO Cron. in which the CEO of Intel, Andy Grove, is advocating "a vast network of walk-in clinics that would allow people to receive relatively minor treatment from a nurse practitioner."  He sees it as a way to decrease health care costs by helping the uninsured get access to health care at affordable prices.

Retail Health: The PCP's Specialty

Matt Winn over at Punctuative has an interesting post that looks at the results of a new  study on retail care from Market Strategies regarding the decentralization of care for common ailments.  Based on this, and some other references,  he makes the correct point about that the PCP physician specialty as we know it is disappearing.  For a new doc coming out of med school it just doesn't make economic sense to generalize and make $162K vs. specializing and making $297K a year according to Winn.  Unlike radiologists and urologists, for example, PCPs just don't have the business opportunities or procedures to make extra income beyond the patient visit. 

Our point is that there is an opportunity for physicians to become a part of the retail health solution by participating in it's growth through investment.  Currently independent companies like MinuteClinic own and operate mini-clinics which are staffed by NP's.  PCP's could easily participate by owning and operating their own mini-clinics.  They could then utilize them as satellites to their main office i.e. distributing care to the common ailments to the edge, at pharmacies and other retail locations, while maintaining their main office for more complicated cases that require more time. In this fashion they could collect revenue from multiple locations while easing their case load.  We've run the numbers on this and we believe it would be possible for a PCP to essentially double his yearly income and thus reach a "specialists" salary while at the same time increasing access for patients, and attracting more patients to the practice. 

Couple other links Matt has noted:  The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care  and The Primary Care-Specialty Income Gap: Why It Matters

Mini Clincs: It's Getting Better All the Time

A new Wall Street Journal Online/Harris Interactive health-care poll shows Americans are pretty satisfied with mini-clinic healthcare.  It also shows that consumers have become more comfortable with issues surrounding quality and they are less concerned about the potential of missing a more serious condition.   However, we're still early in the adoption of these clinics as only 5% of the 2,441 adult respondents stated that they have used a clinic.

Retail HealthCare's Role

David E. Williams over at Health Business Blog has written up a nice summary piece on the role of retail in healthcare. My take is that the mini-clinics are forcing the traditional medical establishment to become more customer service oriented.  And that's a good thing.

AAFP Sets the Foundation For Mini-Clinics

With the continued growth in retail miniclinics, the AAFP has drafted a policy to establish a foundation on which retail mini-clinics should be built.  The report can be found at: "Desired Attributes of Retail Health Clinics." 

The main points, from the AAFP, are as follow:

 

1. Scope of Service -- Retail clinics must have a well-defined and limited scope of clinical services.
2. Evidence-based Medicine -- Clinical services and treatment must be evidence based and quality improvement-oriented.
3. Team-based Approach -- The clinic should have a formal connection with physician practices in the local community, preferably with family physicians, to provide continuity of care. Other health professionals, such as nurse practitioners, should only operate in accordance with state and local regulations, as part of a "team-based" approach to health care and under responsible supervision of a practicing, licensed physician.
4. Referrals -- The clinic must have a referral system to physician practices or to other entities appropriate to the patient’s symptoms beyond the clinic’s scope of work. The clinic should encourage all patients to have a "medical home."
5. Electronic Health Records -- The clinic should include an EHR system sufficient to gather and communicate the patient’s information with the family physician’s office, preferably one that is compatible with the Continuity of Care Record supported by AAFP and others.

That's a big 10-4 for Miniclnics

Mini-clinics continue to proliferate the landscape.  Today in the Tennessean it is reported that a new firm, The Professional Drivers Medical Depots, is opening up clinics at truck stops along interstates near Knoxville.