Is health care shifting towards convenient retail clinics?

Mark Perry provides an interesting inference from two news stories: a WSJ article that suggests consumers are using less health care and another that reports a big jump in MinuteClinic volumes.

Consumers aren’t necessarily consuming less health care like the WSJ suggests; rather, they are shifting their demand for health care away from expensive, conventional physician offices with limited hours to affordable and convenient retail clinics.  Especially when consumers are spending their own out-of-pocket money for health care and they have a choice, they prefer market-driven, consumer-driven options like affordable, convenient retail clinics over conventional physician offices.

I think Perry is on to something. It’s hard to get people out of their established habits. They have a relationship with their own doctor, they accept the long wait for appointments and even treat it as a proxy for high quality (if my doc is so busy he must be great), and just suck it up when it comes to co-pay’s and deductibles. They want access to high tech exams and the latest drugs.

But all these things change over time. MinuteClinic and its ilk are well-positioned to take advantage of these trends in the long run. To take them in turn:

  • Relationships aren’t what they once were. Your doctor may or may not remember you. If you have something routine (or even if not) you may be shunted off to see a “physician extender, ” such as a nurse practitioner. At least when you go to MinuteClinic that’s who you expect to see
  • Wait times for appointment can be lengthy. Under health reform they are likely to get worse, especially since open access scheduling is slow to catch on
  • We’ve now reached the breaking point for co-pay’s and deductibles. Even insured people are nervous about going in for treatment and want to save money. They realize it’s only going to get worse
  • High tech exams (like MRIs) and drugs have lost some of their allure. Cost is part of it, but the continued news stories of safety problems with drugs are taking a toll, too. I think Americans are finally realizing that when it comes to health care less is often more

Finally, especially for routine issues, MinuteClinics do as well or better for quality. The reason is pretty simple: nurse practitioners are more likely to follow protocols than doctors, and the standardized MinuteClinic model represents a more disciplined approach to operations than the typical physician office.

It will be interesting to see if the substitution of MinuteClinic for the physician office is a trend that holds up over time.

David E. Williams is co-founder of MedPharma Partners and blogs at the Health Business Blog.

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  • Highmark Rates

    Also…as preventive benefits are more utilized, the number of random office visits will decrease. And as patients take better care of themselves and have a vested interest in the health care dollars they spend, usage should reduce.

  • Winslow Murdoch

    Minute clinics are only approved to evaluate and treat the most common simple conditions. If a patient has any complicating factors, is outside of a certain age or has significant co morbid diseases, their protocol is call your doctor or go to the ER

    Your doctor is paid usually far less than the minute clinic to deal with the more complex cases, so minute clinic cherry picks the easiest and most profitable cases.
    I would suggest minute clinic to select patients, but realize this is not really ideal primary care but an expensive adjunct to a failing primary care delivery system.
    Winslow a family doc

  • Wellescent Health Blog

    While minute clinics do offer fast affordable, access, they are targeting those relatively quick and easy problems that pay disproportionately well. As Dr. Murdoch pointed out above , this leaves the primary care physician having to deal with the more problematic and comparatively lower paying medical issues. Over time, this will be another negative that reduces the already low number of doctors in primary care. Taken to an extreme, the minute clinic becomes most people’s primary care provider and anything even slightly complex will have to be referred to a specialist.

    As a whole, this trend demonstrates that health care isn’t well served in all cases by standard market approaches that always attempt to seek the markets of greatest return. Health care has to serve the medical needs of all patients and not just those who have simple medical problems.

    • HJ

      “Health care has to serve the medical needs of all patients and not just those who have simple medical problems.”

      That’s socialism.

      • Healthcare Observer

        That’s humanity.

        • HJ

          Providing health care for everyone would cut into profits.

    • Alina

      …anything even slightly complex will have to be referred to a specialist.”

      Newsflash….that how many PCPs practice medicine right now. That’s the reason why the FM practice lost its status over the years.

  • Alina

    It really depends where you are. Over the past few years I’ve lived in two different areas. One where the PCPs spend more time with you, on average 20 minutes per visit. In the other region, PCPs would spend 5 minutes on average. Both large metropolitan areas with very close costs of living. The region that spends less time with the patients also has a higher reimbursement. Totally backwards.

    If I’m in the second region (5 minutes/visit) I may not see a reason to go to a regular practice and therefore I could go to a walk-in clinic. In both settings I get the same impersonal “care.” There is of course a third option to go search for that physician who is true to the profession and does the right thing. I know I would chose the latter.

    “long wait for appointments…is a proxy for high quality.” Unless that physician is the top one in the region and country, why would I want to have a long wait to go see this person?

  • Devon Herrick, PhD National Center for Policy Analysis

    Retail clinics have traditionally had a limited scope of practice. But, increasingly, they are extending the boundaries into chronic care. This only makes sense. Why should the chronically ill (who arguably need access to a care provider more than their worried well counterparts) not be able to swing by MinuteClinic to have their PB, cholesterol checked and the info sent electronically to their primary care doctor?

    • family practitioner

      The chronically ill tend to be on medicare, medicaid. If they just “swing by” to have their cholesterol checked, this may add to unneccesary testing, because they may have had this done just last month. In other words, the clinic may profit, but the public foots the bill.

      What is PB? Lead? Only children need to have this done routinely, and even those guidelines are debatable.

      • Primary Care Internist

        I think he meant “BP”, but in any case, why should a primary care physician have the “info sent electronically”??? To field the liability without any of the payment (which went to the undertrained and undermotivated NP at the minuteclinic)?

        Most people just don’t understand that just declaring oneself a primary care doctor does not get them some regular chronic management fee. So if a patient i saw once, two years ago, has called (or had walgreen’s fax) for med refills for cozaar and lipitor, while i complied and even did prior auth calls etc., then saw the minuteclinic for a flu shot and perhaps a mild ankle sprain in the interim (or whatever), I have made ZERO in that two years. This is why primary care is dead (not dying, but DEAD). Minuteclinics are just another nail in the coffin.

      • Primary Care Internist

        Also, i think it’s a shame that the National Center for Policy Analysis doesn’t understand these basic issues. Hopefully they aren’t funded by our tax dollars (although I am sure that at least indirectly they are, through nonprofit status).

        Much like Obama doesn’t understand that:
        a) pediatricians don’t perform tonsillectomies at all, let alone because the fee schedule says that’s more profitable than “giving an allergy pill” (actual quote)
        b) it doesn’t make sense to make head of HHS (Sebelius) a lawyer – did it ever occur to him that it might be better filled by a DOCTOR???

        • Alina

          Then give your patients a reason to stay with your practice. It’s that simple.

          • Primary Care Internist

            The reason to stay with a practice rather than a minuteclinic is simple – developing a long-term relationship with a DOCTOR who knows you.

            The fact that this needs justification is to patients is very telling. That is why primary care is dead – because too many people will just never appreciate that. When patients are in their 50′s and older, generally, and develop a chronic condition and get shuffled from specialist to specialist for useless testing etc., the smart ones will realize the value of a good primary care doctor.

    • ninguem

      Devon Herrick, PhD – “…..Why should the chronically ill (who arguably need access to a care provider more than their worried well counterparts) not be able to swing by MinuteClinic to have their PB, cholesterol checked and the info sent electronically to their primary care doctor?……”

      I’d say, for the same reason I can’t walk into a restaurant with a coke and sandwich in my hand, sit down at their table, eat my carry-in lunch, and expect them to clean the table after I leave.

      Why should you expect the MinuteClinic to run the test (the nearby Wal-Mart clinic charges more than I do for the lipid panel), AND charge an office fee close to mine for a blood pressure check, AND expect me to deal with the results for free?

  • Bruce Hopper Jr MD

    If communication technologies (email, texting, instant messaging, videochat) are utilized properly, then 67% of primary care office visits are unnecessary. Of course, you must have an established relationship with your doctor in order for this to work.

  • Bruce Hopper Jr MD

    Excuse me, Primary Care Internist, I hear your frustration, but why do you sign an insurance contract with a pathetically low fee schedule that requires insane amounts of unreimbursed paperwork?

    • Primary Care Internist

      You are right, and I have stopped doing so, particularly since the “negotiations” with insurance companies are completely one-sided.

      Concierge practice is an option, but I would like to stay away from things I really don’t believe in, e.g. acupuncture. And i think the majority of patients feel, rightly or not, that having insurance entitles them to not pay an additional fee for primary care, and therefore this model will be difficult to sustain for most. I have seen concierge practices struggling even in very affluent areas (greenwich ct)

      • medstudent

        Primary Care internist,
        As a med student interested in direct-pay primary care practice, I would be interested to hear about the struggling practice you talk about, perhaps there is something to learn from that set-up.

  • Jackson MD

    True, but of course, that would be accompanied by a 67% pay cut. And you are also right about the established relationship helping facilitate care. A couple of years ago I stopped taking new patients. My practice is very enjoyable now. My practice is eight years old and I know my patients pretty well. Taking care of them is a joy. If someone calls with symptoms of a bladder infecton, it’s ok with me if they drop off a urine and pick up a script. My office knows their mamograms are up to date and their bone density is current. We know their history and allergies, prescriptions, etc. I don’t get paid for treating that bladder infection, but I know it hasn’t been that long since the patient was in and that they will be in again soon. It’s an optimal relationship, but only because of the years of rapport we’ve built up. Occasionally I still have someone wanting this free care who hasn’t been in in a year or so. Our office policies are given to the patients at every visit and they are very clear. If you have not been seen in the past six months, you must make an appointment. We’ll see you the day you call, but you may have to wait. If the patient raises cain, they can go and not make/keep appointments with someone else. Negative interactions of that nature will devour all of a physician’s energy, and potentially affect the care given to other patients (we’re human). I realized a couple of years ago that primary care docs are a dying breed. It is not my job to save the world. I have to take care of my own well being first, in order to better care for my patients. So I no longer waste my energy trying to appease unreasonable patients.

    • ninguem

      I second that.

  • HJ

    “The reason to stay with a practice rather than a minuteclinic is simple – developing a long-term relationship with a DOCTOR who knows you.”

    I have multiple health care issues. It’s hard to develop a relationship with a doctor when they shuffle your care to a variety of physician extenders. My previous PCP may have been a great doctor, but I hardly knew him. Only one out of seven visits were with this doctor. Perhaps this doctor felt he had a relationship with my chart.

    And as a good consumer and to support efforts to lower prices, I should go to the MinuteClinic because it’s cheaper.

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