Most shoppers everywhere crave convenience, and their habits and attitudes have been noted. Especially in the United States, large department stores and behemoth retail centers that boast of “having everything you need in one place” have replaced countless small retail shops. This change was guided largely by the principle of keeping shopper traffic at one site to assure multiple sales across several product sectors and to limit competition.
Now shopping malls are threatened by the even greater convenience and often more economical choice of online shopping, and retail outlets like chain pharmacies are expanding their scope of services to include walk-in clinics. The intent is to convince consumers that all of their needs, health care included, can be handled at one location. Another goal is to solidify the retail sales of health-related items including prescription medications, medical equipment, and personal care items.
Welcome to health care in retail.
On the surface this concept seems like a good idea. Compared with the option of making a doctor’s appointment, going to the office, and spending time in the waiting room for who knows how long, this new model allows people to fulfill many tasks in one, set time slot. But does this model have some undesirable outcomes? To answer that question, let’s look at the role of the primary care physician (PCP) today.
The PCP and the patient
Individuals who are young and healthy may view a PCP as someone they see once a year for a physical or wellness check-up, or as a convenient option for addressing an immediate health problem. It’s easy to see how this group would also view a retail health clinic as a perfect fit.
The truth, however, is that PCPs are under increasing pressure to be proactive in performing, documenting, and recording health claims while following a set of specific measures (like a checklist) that the government and insurance companies now require. The purpose of the measurers — which increase in number every year — is to collect population data, which can then be analyzed.
The PCP, and in many instances the medical group he or she belongs to, and the insurance carrier that contracts with the group, ultimately receive a score based on how well the doctor complies with these measures.
These measures can include:
- HbA1c (diabetes)
- Urine microalbumin
- Eye exam
- Foot exam in a patient diagnosed with diabetes
- Assuring that patient is taking prescribed medications
Documentation of "care for adult" (seniors) measures can include screening for falls and depression, having a conversation about advanced directives for end-of-life, and taking time out during the visit for reconciliation of medications (or ensuring that medication is compatible).
The role of the PCP requires a full-time familiarity with the patient’s history, as well as a commitment to ongoing follow-up.
More (and more) technology
What is also required, and somewhat new to doctors, are technology skills to help them achieve a score that will fairly reflect the work done by the physician provider. In other words, doctors have to spend quite a bit of time navigating computer programs. Unfortunately, some doctors who are excellent with regards to the measures, and doctors who are incredibly good historians and communicators, may not be proficient with the ever-evolving software the new measures demand. At the same time, clinics that have skillful computer personnel can essentially receive higher scores for meeting the measures, while really not spending sufficient quality time with the patient.
Value vs. volume
This medicine model is part of the new trend set by the government to reward “value” rather than “volume” of services. Value is measured by outcomes. Outcomes are more positively reflected by those who have access to a robust information technology machine. If you go to a doctor in a retail setting, is he meeting those guidelines and measures? Are you getting standard of care as set by the government?
If the model in that setting is “quick visit and resolution of acute problem,” then clearly they are not going to meet the standards of the new measures. The setting in these retail health clinics is a private examination area and the ability to dispense prescriptions on the spot.
With their limited mandate (in a retail clinic setting) and goal of treatment, you can assume that walk-in clinics will only fulfill the purpose of providing a quick service for a specific problem and not much more. To be a part of the larger health care environment, they would have to meet the guidelines and measures described above. The retail community (corporate owner) would not be interested in expanding beyond quick visits and solutions since meeting the measures requires an entirely different set-up, i.e., one far more costly to create and maintain.
Risks of the ‘quick fix’
The public at large is likely unaware of the difference between seeking help at a retail-based health clinic and establishing a relationship with a PCP. I have personally seen many patients who visited doctors in a walk-in type of setting, and were told that “everything is fine.” If the patient is young and in good health, there’s probably no significant downside. But if the patient has risk factors or undiagnosed disease and it’s missed at the time of this acute visit (due to the lack of extensive screening services), then the patient and the health care system are both losers.
And if the patient has ongoing chronic disease that requires regular visits, interactions and monitoring, then again, the retail health care setting will fail him.
Problems of payment
One big issue that the patient needs to contend with is payment. Many, if not most, insurance plans are now contracting with groups or have in-network or out-of-network protocols for payment. The consumer will likely have to pay cash for these clinic visits, as well as any lab work or diagnostics utilized. Medicare may still cover these visits, but even its coverage is changing.
If you need an urgent care visit for a sudden illness, and visiting a clinic makes more sense than going to an emergency room, the retail health visit may be appropriate. Pharmacists are also great at tracking medications and explaining proper use, interactions, and side effects. Utilizing a licensed dietician at a retail clinic setting is also acceptable -- but by no means should it replace a relationship with a PCP.
Doctors also have to disclose conflicts of interest like a relationship with a pharmaceutical company. Your retail healthcare center has no mandate to disclose any conflicts of interest. This is definitely a case of "consumer beware — and be smart."
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Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music. Find him on Twitter @Lung_doctor.