Massachusetts Allows In-Store Clinics

With national health care spending exceeding 16% of the GDP and rising at over 6% annually, some experts have suggested that the use of in-store clinics may provide a mechanism to curb health care expenditures. Although they are relatively sparse presently, some experts predict there will be approximately 2,000 such clinics in 2009 (subscription required).

One of the major battleground states for these clinics has been Massachusetts, a hotbed for medicine with many leading medical institutions and research labs. The state’s Public Health Counsil just approved a proposal that will allow these in-store clinics. (Thanks to the WSJ Health Blog for bringing this story to our attention.)

In-store clinics essentially function like McDonald’s for patients where nurse practitioners (NPs) or physician assistants (PAs) treat various common medical problems. They typically cover non-life threatening problems like allergies, athlete’s foot, and wart removal in addition to services like pregnancy testing and vaccinations. I do not have price lists for all of the in-store clinic firms, but Minute Clinic (one of the largest firms in the field) offers price lists that vary by location. Prices tend to run between $30 and $110 with most treatments between $49 and $69. Approximately 2/3 of patients receive prescriptions from the NPs or PAs. These charges are typically only $10-$20 because they are covered by local health plans. According to a 2005 Medical Economics article, the charges at MinuteClinic are significantly below that of a doctor’s visit or a trip to the ER:

According to MinuteClinic, which charges $48 to treat strep throat (plus $14 if an overnight culture is required), the average cost at a doctor’s office is more than $100, and more than $300 at an ED.

It seems reasonable to assume that even if the spread has decreased in the past 2 years, MinuteClinic still manages to be less expensive.

One caveat with in-store clinics is that they will not deal with complicated medical conditions or serious injuries.

“We treat common medical conditions that can be handled with one visit, and don’t require a full workup or follow-up care,” say Debra Benoit, an NP who supervises the company’s Baltimore area clinics. “For instance, we treat minor cuts and abrasions, but we don’t treat wounds that need sutures, or orthopedic problems that require X-rays. If the patient has high blood pressure, we won’t prescribe medication; instead, we’ll refer him to a primary care doctor.”

This is probably due to a combination of legal/medical malpractice issues, economic reasons, and the simple fact that the staff (NPs and PAs) simply aren’t trained to handle those issues. Although state laws typically require that a group of clinic is supervised by a local board-certified family medicine physician, he or she is rarely called upon because the NPs and PAs follow a specific set of clinical guidelines and protocols. This may serve an added purpose since if they follow clinical guidelines, they will have a stronger argument against any malpractice claims.

Despite the positive aspects of these in-store clinics such as relieving overcrowding in ERs and providing relatively cheap medical particularly for the uninsured, several groups have stated their objection to the clinics. One of the leading groups is doctors who argue about the quality of care delivered by these clinics. They believe that what appears to be a relatively small problem may mask a very serious condition that the simple heuristics used by the clinics may miss. In addition, they claim that the clinics disrupt continuity of care such as colonoscopies or mammograms that a regular doctor’s office provides. Many of the attendings that I have worked with in Massachusetts have brought up these arguments and have even criticized NPs and PAs as not qualified to handle patients despite the fact that these same physicians utilize the services of NPs and PAs in their own practices. However, I feel that a larger component that these physicians are not comfortable speaking about is that the in-store clinics may be skimming patients. By taking away these patients who present with relatively simple problems that can be treated very quickly, the in-store clinics are taking money away from these physicians.

The first couple of arguments against in-store clinics are certainly valid. The rare diagnosis argument appears to be a bit weak to me as physicians routinely miss diagnoses. The continuity of care is probably the best argument against in-store clinics since NPs/PAs probably will not ask about preventative measures or to see if a patient is continuing to take their medication (or perhaps if they are even on any medications, which may lead to issues with drug interactions). In my opinion, it is the last reason (skimming) that is drives much of the physicians’ resistance to these clinics as I believe they can offer an excellent option in today’s medical system where patients have to deal with overcrowding and outrageous charges. Of course, this depends on the in-store clinics operating the way they are intended to function. If NPs and PAs start trying to do more than they are qualified or trained to do, patients could run into serious problems. Because of this, perhaps the state or federal governments should create a body to oversee these clinics to ensure they maintain a certain level of care and do not overstep their original intent. This will certainly raise costs, but I believe they would be relatively small compared to the benefits of having these clinics available to patients/consumers to allow them to make their own decision on where they would want to be treated.

In the end, it becomes an issue of how much quality of care are you willing to sacrifice for increased access to care. Certainly, an in-store clinic will not provide you with the same level of care as a concierge/boutique medicine practice would, but you only pay a very small fraction of what you would in that practice

For a more detailed look at in-store clinics, I would suggest you check out Richard Bohmer’s excellent discussion in the New England Journal of Medicine.

Tags: CVS, In-store clinics, Massachusetts, MinuteClinic