If you want good pediatric care, stay away from retail clinics

They’re everywhere, all of a sudden: little medical kiosks tucked into the back of drug stores, grocery stores, and big box outlets.

With names like “Minute Clinic” or “RediClinic,” they stress speedy, in-and-out service. And of course, you’re already there in the store, ready to buy whatever has been prescribed. A win-win, no?

No.

Everyone knows that if you’re looking for good, wholesome food, you ought to stay away from McWendyKing. If you want good pediatric care, you ought to stay away from these quickie retail clinics, too. They’re the “fast food” of health care providers, offering exactly what your children don’t need.

What’s “good pediatric care”? Care that looks at the whole child, the whole history, and the whole story. To do a good job I have to review the history, the growth charts, the prior blood pressures, the immunization records, and more. Good care means I’m available for every concern—not just the sore throat, but the “Oh, by the way…” worries that are often more significant than the current illness. Things like “He’s not doing so well in school,” or “I think he looks clumsy when he runs,” or “What am I going to do about these headaches every day?” Every encounter is a catch-up on problems and concerns from before, to be reviewed and updated. Children are growing and developing, and every encounter is a snapshot of their over all well-being that can only make sense if it can be placed into a continuous album. At the retail-based clinic, the encounters are just a quick toss-off: an opportunity for genuinely improving health that’s thrown away.

Good pediatric care requires good training. The retail clinics are staffed by midlevel providers who may have minimal pediatric experience. Children are not the same as adults, and without specific, ongoing, significant training in taking care of kids, those well-meaning nurses at the local QuickieCare may not have the skills to adequately assess your child.

Good health care also means keeping up with recommendations and community standards. I recently reviewed two cases of children seen from my practice who were clearly mishandled by the local ZippityDoClinic. One was a child given a vaccine he didn’t need (mom said she brought the records; and even if she didn’t, my state maintains a complete vaccine registry. If they looked, they would have seen that he didn’t need another dose of that vaccine. Did they not look, or do they not know the recommendations?) Another involved treating a urinary tract infection without doing the appropriate testing beforehand (The clinic acknowledged to me that they don’t have the facilities to do the correct test. If they can’t do it right, why are they doing it at all? Are they telling parents that they’re delivering substandard care?)

This week I spoke with the Medical Director of one of the large retail-based chains, a doctor of internal medicine without any particular pediatric experience. She made the following points:

  • “There is a shortage of 40,000 primary care physicians in the USA, and we can fill in the gaps.” While it’s true that there is a shortage of PCPs, that’s primarily a problem in medically underserved areas in rural America and inner cities. Are these retail-based clinics being built where there is the strongest need? Of course not—they’re mostly in affluent suburbs where there’s money to be made. The proliferation of these McSpeedySick places in wealthier neighborhoods will make the imbalance of health resource availability worse, not better.
  • “We are committed to the concept of the medical home.” Right now her chain of clinics is offering special cut-rate sports and camp physicals, dangling cheap rates to lure patients away from their primary care docs for their well-checks. The heart of the well-check is to review all current issues, to look at the big picture, to make sure all health-maintenance tests and immunizations are up-to-date. They can’t possibly offer that service without a thorough review of the past records. A quick physical is cheap, but it is not a fair substitute for a thorough health maintenance visit at a child’s pediatrician.

The existence of a clinic-within-a-store may have another, more underhanded dark side. When I see a patient in my office, I can make whatever suggestions I feel are in the best interest of the child—I don’t make any money off of prescriptions, or medical devices, or anything else I recommend. You can be assured that your doctor isn’t suggesting something or prescribing a medication just because he’s selling it at a profit. At the retail QuickityClinic, families get their prescriptions, march over to the pharmacy, and pay for their white baggie of pills. There’s certainly at least the potential for an odious conflict-of-interest, with increasing profits tied to prescribing more medicines, more expensive medicines, or medicines with a more-favorable markup. Do you want medical decisions being made based on profit?

There’s an old saying: you can have it good, you can have it fast, or you can have it cheap—but you can’t have all three. Retail-based clinics may offer fast care, but you can’t depend on them to offer good care for children. Your kids deserve better.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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  • http://natickpediatrics.net Rob Lindeman

    Dr. Benaroch neglected to mention that retail clinics encroach on our share of the market. Unless we’re honest about this, we risk losing credibility in the debate.

    • http://www.twitter.com/alicearobertson Alice

      You are right. I must say I have six kids and have a lot of experience with doctors I wish I didn’t, but so far Minute Clinic has my vote. The nurse practitioners don’t seem rushed. One got down on her knees to examine my daughter and called in an assistant (it was a swim team injury that was pretty bad and I didn’t feel like waiting until the next day for the doctor who rushes about and acts like they have been on anti-depressants too long…..zombie mode)..

      I may change my mind, but so far the nurse practitioners have given us really great care. Actually, the large hospital system I use is switching to nurse practitioners and when given a choice I choose them….realizing they are limited, but even the specialists there rely on them and give them respect.

  • http://www.theissuewithhealthcare.blogspot.com Shereese Maynard

    I’m going to assume this post is strictly an opinion piece and not based on any actual research. While retail clinics are popping up everywhere they are hardly the antithesis of good care. Retail clinics, while not aimed at replacing comprehensive primary care, offer a service. Most are staffed with highly knowledgeable nurse practitioners whose responsibilities are overseen by licensed physicians. Furthermore, you are wrong to assume that all have no pediatric background. I believe it would depend on which retail clinics you research and how many providers you interview. I find that many physicians are threatened by the existence of retail clinics because of the affects it has on their private practice. It is a little more difficult to charge outrageous fees when a parent can get an ear infection diagnosed just as easily down the street from the home, thereby saving gas, time, and absorbent fees. No one would argue that parents should take their child to the primary pediatrician. However, as more pediatricians change their philosophy regarding just how dedicated they want to be to their practice, and with so many deciding to practice defensively, retail clinics offer a temporary solution at vital times. That is to say, if my pediatrician can’t see my child today, I know I can just run down the road. Doctors shouldn’t be threatened by this phenomenon; they should embrace it. It should be looked upon as a type of partnership with the community. Finally, I have utilized retail clinics once or twice when my son’s allergies were just being discovered. At each appointment I was told by the NP to follow up with the pediatrician. If the retail clinic staff sees their work as an extension of primary care and work to encourage communication with the primary pediatrician, why are you so threatened by them?

    • http://myheartsisters.org Carolyn Thomas

      Very well put. Walk-In clinics would not and could not survive if there weren’t a need for them. Many physicians would rather not take a realistic look at those needs because it impacts their own bottom line – thus their perception of these clinics as a “threat” that patients must be warned about.

      “QuickityClinic. McWendyKing. QuickieCare. McSpeedySick.” Could there be any more contempt shown for these potential threats?

      • Family Doctor

        To address some comments by Ms Maynard and Ms Thomas:
        “Many physicians would rather not take a realistic look at those needs because it impacts their own bottom line – thus their perception of these clinics as a “threat” that patients must be warned about.”

        The realistic look at these clinics is that these NP’s have minimal training and experience compared to a physician. I have 4 years of medical school and 3 years of residency and one year of a fellowship in primary care. These NP’s DO NOT HAVE the experience needed to provide good primary care. It took me EIGHT YEARS to become a competent physician. Yet these NP’s think they can do it in TWO? Impossible.

        “No one would argue that parents should take their child to the primary pediatrician.”
        Then why do you take your child to this substandard clinic?

        “That is to say, if my pediatrician can’t see my child today, I know I can just run down the road.”

        “Doctors shouldn’t be threatened by this phenomenon; they should embrace it. It should be looked upon as a type of partnership with the community.”
        I dont see NP’s as a threat to my practice. They are a threat to the COMMUNITY. THey dont know what they dont know.

        To the readers of this blog: would you want a skilled pilot flying your plane or some with LESS THAN 25% of the training of other pilots?

        • http://natickpediatrics.net Rob Lindeman

          I disagree, respectfully, but vehemently. I have worked side-by-side with NP’s in primary care for 10 years. With very few exceptions, the quality of their work equals or exceeds that of many physicians I’ve worked with. The difference in number of years trained has made no difference. But don’t make my anecdotal word for it: Show me the data that suggests NP work in primary care is inferior!

          The analogy to pilots is strained and suggests desperation on the part of the interlocutor.

          • Family Doctor

            Ok, how about if NP’s take the same board certification we take? If they can demonstrate competence, then we can consider their presence in Family Medicine. Why would anyone want to go see someone who isn’t board certified in a primary care specialty.

            I have also worked alongside many NP’s over the years. I don’t anymore, thank goodness, because their skill was lacking. I saw mistakes, increased amounts of referrals by the NP’s for problems of what a physician would find routine and manage himself, & an overall diminished knowledge base. But how could we anticipate anything different? They have less than 25% of the training of physicians?

            If there were no shortage of primary care doctors, we wouldn’t be having this conversation. The solution is fixing the shortage, not adding sub-optimal providers.

            I stand by my original comments.

        • http://www.twitter.com/alicearobertson Alice

          Yet these NP’s think they can do it in TWO? Impossible. [end quote]

          I disagree also. NP’s get their experience on the job. One is in every visit now with our specialist. They need to rack up loads of on-the-job experience and are trained by…ta da….the specialist. It’s an apprenticeship under the highly trained specialist. But I prefer midwives too….so what’s missing from the equation? It’s not really the level of treatment….hmmm…….could it be a matter of attitude?

        • Vicky Stone-Gale, ARNP

          I have a 3 year nursing Diploma, a 4 year Bachelors in Nursing, a 3 year Masters in Nursing and now a 3 year Doctor or Nursing Practice. This totals 13 years of education and oh did I forget to say I have been practicing for 19 1/2 years as an NP in Family Practice and 5 years before that as a Critical Care Nurse in one of the countries most well-respected hospitals. I am on my 2nd and 3rd generation of patients. I take extreme offense to anyone saying I don’t have the experience to do what I do. I am proud of my nursing education and my practice experience.

          • Fam Med Doc

            Your response is pretty much what I hear from nurses & what gives me serious concern. You nurses INFLATE & MISAPPLY your education & training. Let’s go thru your credentials.
            1) “3 year nursing Diploma”- nurses are AMAZING & an ESSENTIAL part of healthcare. But that training was to be a nurse, not a doctor. Doesn’t apply. This is a misapplied credential.
            2) “a 4 year Bachelors in Nursing”- same as above, doesn’t train you to be a doctor. Misapplied credential.
            3) “a 3 year Masters in Nursing”- a NP program doesn’t compare to the 7 years of training of medical school & residency a primary care doctor experienced. Sorry, it isn’t.
            4) “5 years before that as a Critical Care Nurse in one of the countries most well-respected hospitals”- once again, you were a nurse, not a doctor so it doesn’t help or apply. Inflation of your credentials.
            5) “a 3 year Doctor or Nursing Practice”- ok, this the only part of your training that really helps. But it is missing in rigorous & depth that medical school & residency contains.

            I still maintain that primary care is for physicians trained in a three year residency (which is after a 4 year medical school) in Family Medicine, Internal Medicine, or Peds.

          • http://pediatricinsider.com Roy Benaroch, MD

            Ms. Stone-Gale, if you don’t mind my asking, do you work in a retail-based clinic? Do you think your level of experience is typical of the people who do staff these places? Be honest, here– do you think the retail clinics are looking for the most experienced, seasoned NPs and PAs, or the least expensive? They pay quite poorly compared to what someone with your background could be making in a hospital setting.

          • stitch

            I have worked with some excellent NPs. Excellent. Two in particular, one who was in a primary care position just out of training (and who had gone into an NP program as a second career) and another who had been trained more than 20 years ago as an NP, who had extensive experience. I admired both of them and was happy to work beside them.

            Both of them had a critical attribute: they understood the limits of both their training and their abilities. Neither of them ever equated what they did with any doctor. The latter one, in particular, may have in fact been better at most of what she did than some docs, and there are certainly docs who are not able to admit their own limitations.

            There is an essential difference in how NPs are trained, particularly in the early levels of training (as laid out by Family Doctor above. Nursing education is based primarily on pattern recognition. Medical education is based on deep training in pathophysiology. That’s a critical difference and key to understanding the difference in how NPs and docs approach patient problems. It is not equivalent.

            And I think this is the reason that many primary care docs (and some primary care NPs, too) find this piecemeal “care” provided at Minute Clinics to be lacking. It’s based on protocols, and on being profitable to the center that has the clinic.

            We need to learn how to get along and to recognize the different skills we bring to the table. In the end, it should be about the patients.

    • SueCz

      A good post. All we hear is how overworked and underpaid the PCP and pediatricians are. This is made very clear by the gatekeepers when you call and try to get an appointment for an ear infection or adults the usual sinus infection. They are definitely bad PR to drawing patients back to “home base for your health”. As far as the “by the way” medical worries, I had brought my elderly sister for a congestive heart failure emergent visit. I brought up the fact that new with this flare up was the appearance of confusion and no idea where she was. Not allowed to bring this up during this visit, no time, make another appointment. He gave her IV Lasix and suggested we get her home quickly before it hit. I realize she is a frequent flyer, but jeez her O2 sat was 85%,her legs looked like tree trunks, she is @ home alone as her husband is hospitalized. You know CVS is more user friendly and KIND and COMPASSIONATE. In my opinion that is a good part of what people are responding too. This ended up being more of a vent, then a useful comment. I agree with all these well written posts. Change is upon us.

    • pj

      I have to ask, .. by “absorbent,” did you mean, “exorbitant?”

  • ninguem

    If you want good pediatric care?

    How about if you want good MEDICAL CARE, stay away from the retail clinics.

  • Frank in L.A.

    Dr. Benaroch

    How many people find that after 4:00pm or so (and all day Sat, Sun, and holidays-maybe Friday afternoons also), their only alternative is the walk in clinic or the emergency room?

  • http://drbradcole.com Brad Cole

    Excellent to question whether retail clinics are really filling the primary care gap. It seems (like ninguem wrote) that the cons of retail clinics are not specific to pediatric care.
    It would be interesting to see if patients that seek care at retail clinics do so at the expense of seeking care with a dedicated clinic. And if the major problem of retail clinics is limited clinical history, the EMR system that we all have in 5 years may drastically change our current concept of consistent care.
    The bottom line is that one should “stay away from” poor care in any setting delivered by any provider type.

    • Family Doctor

      Despite what some people are commenting here on this blog, I DO NOT see NP’s or McClinics as a threat to my practice. Seeing a sore throat does not generate much revenue. The revenue loss from seeing a sore throat is small. Seeing complicated diabetics generates much higher revenue. But I am more than happy to see any patient in my panel, for a big or small problem. But what I see is these retail clinics giving antibiotics FOR EVERYONE with a sore throat because they are for-profit. If some parent comes to these McClinics & pays cash, you better believe there is pressure to “get their antibiotics”. Probably most important, the staff at these retail clinics don’t have a relationship with the patients like their primary care doctors have- this takes years to establish. You cant establish that doctor-patient relationship trust in a fast-food like clinic. With this relationship, much can be accomplished- like not over prescribing antibiotics for one. And the over prescribing of antibiotics is a serious, but only one of many problems that NP’s are bringing at these retail clinics.

  • http://emergency-room-nurse.blogspot.com girlvet

    This post is hilarious. These retail clinics have very specific guidelines about what can and can’t be done. Could it be that these NP staffed clinics are taking the profits away from pediatricians and this is what this post is all about? NPs and the flexibility and convenience of these clinics are the future of medicine whether you like it or not. Once again doctors complaining about change instead of embracing it and suggesting improvements.

    • pj

      These comments are less than useful. He IS suggesting an improvement- get the word out that they should be avoided if at all possible!

  • PAULMD

    People, if they are given the facts about the training and credentials, should be able to choose where they seek their care. My thoughts on this is that if you choose course A despite the concerns or frank warnings of the providers of course B, Don’t expect a warm welcome from the providers of course B when you find yourself in trouble. Forgive my possible callousness but, if you made that bed, sleep in it. That would be free market.

    The providers in these kiosk establishments may gleefully tell you to f/u with your primary provider but that is to cover their follow up liability and correct errors they may have made….not a collegial reallignment of long term continued care….please.

    When you blow off your vet appointments for Fido and keep slamming the Petmed products you buy over the internet into him, expect no quarter from your vet when Fido ends up in hepatic failure, stones or a progressive degenerative neurological condition. Remember, you made choices.

    When Grammy falls and breaks a hip or one of us has crushing chest pain do they take you/us to a doc in the box? To the chiropractor? To the naturopath? To the rakii guy’s institute? Is doc in the box foolish enough to purport competency in such cases? I think not.

    If you really want to do the work and are good at it, I welcome the competition, but to date I needent make any aplogies for the care we allopathic and osteopathic physicians provide. Despite any shortfalls we as a profession may have, we are the ones that do the heavy lifting in this medical care world of ours.

    I invite you to share in the often uncompensated, unpredictable, stressful, litigious, and inconvenient world of mandated care and the heavy lifting it involves. Please, either train for it and show up, or bugger off.

    • ninguem

      Well, of course they don’t intend to do the heavy lifting. They’ll leave that for you.

  • Bob

    Really? I have more training so obviously I must be better than you? C’mon people, lets get real. Evidence based medicine. Show me the numbers. You don’t, because you can’t [because its not there]. Sorry these new places are crampin’ your style.

    p.s. I’m not an NP.

  • http://mymayhac.blogspot.com/2010/12/help-weve-fallen-and-cant-get-up.html Shereese Maynard

    Well let’s do some research and meet here another time. One of the greatest areas of errors in primary care comes from treatment orders. Survey your own clinic, hospital, whatever. How many errors were made by physicians? How many from NPs? How many providers have been convicted for fraud? How many NPs? Why is there such a need for malpractice insurance? For physicians or for NPs? Bring the numbers; leave your opinion at the door.

  • http://myheartsisters.org Carolyn Thomas

    Hmmmmm…. I can’t help but compare the regrettably hostile reaction here to the angry furor surrounding the legalization of midwifery in some parts of North America – a similar controversy in which physicians worried that their former monopoly on all facets of health care would be jeopardized by those accused of being woefully under-trained to “replace” an MD. Sound familiar?

    While I don’t mean to hijack the topic here, let me just add that although there are still some physicians who argue against the facts, a four-year study of all home births attended by midwives in my own Canadian province of British Columbia (where home birth midwifery services are fully covered under our health care insurance) found: “Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions/adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.” And an earlier study in the province of Quebec also found that physicians who were more open to midwives had ‘a more client-centered approach to maternity care’. They also had often collaborated with midwives since they had begun practicing.

    So if these walk-in clinics are as patently dangerous as described here, please include research references that confirm this danger to consumers. They’re likely as unavailable as the ones “proving” midwifery to be unsafe, too.

    • gzuckier

      Let us not forget that the whole concept of “germs” hit Semmelweis when he noted that midwives had far lower maternal mortality rates than the doctors of his time. ‘Oh but that was then, we’re so much more advanced now’. As if the doctors of the time would have said ‘We’re just a bunch of primitives now, but by 2011 we’ll have it pretty much under control’.

  • http://pediatricinsider.com Roy Benaroch, MD

    RE: nurse practitioner training: At the local medical school, nurse practitioners are required to spend 2 months of their 2 years of training in pediatrics. I imagine some do extra electives beyond this two months, and many have additional experience as RNs that may have involved pediatrics. Still, that’s it: 2 mos of training specific to pediatrics. Perhaps I am being over-protective of my patients, but I consider this amount of training minimal, and I don’t think most parents would be comfortable with someone with this kind of training evaluating their children.

    I have no problems with mid-levels, per se. In fact, my practice employs one NP who completed a pediatric-specific program of two years, all peds. She is not qualified to treat adult patients.

    RE: providing care that is timely and convenient for my own patients: my office is open 6 days, and I also am affiliated with an after-hours walk-in clinic, staffed by board-certified pediatricians, evenings and weekends. The docs in my group are available for phone consultation for emergencies 24/7/365– no charge (what happens when care from the QuickClinic doesn’t work out? Go ahead, try to call them after hours for followup, let me know how that works out.) I believe we offer excellent care, excellent service, and a very good value for the money. Am I correct? That, the market will decide.

    • http://Www.twitter.com/alicearobertson Alice

      The Minute Clinic I went to was on the border about which treatment to use. I chose the lesser. The NP said if it did not produce results to comeback in three days and she would see her for free. They could not see my son for his eye infection, but knew he needed a doctor’s note and gave it to him for free. I asked my teenagers about this…they prefer NP’s. The patients who are waiting like to chat…many will wait because they prefer the NP over their doctor. I went to the doctor two weeks ago. A simple strep test took two hours. The doc in her best friendly voice told me it was punishment for checking in five minutes late (I told her I was in line almost ten minutes), We waited so long we walked out and she appeared and handed us the prescription that had been printed out a half hour ago. She was passive aggressive in metering out judgement…the lesson I learned? Go to Minute Clinic. Doctors are either tamable or replaceable. I do not like being punished like a bad child, or waiting around to fulfill her mind game when the pharmacy down the street treats me so well and can easily diagnose strep.

      The difference in many cases is going to be how they make you feel…..maybe physicians aren’t getting enough studies in treating beyond the disease? in truth….the vast majority of our problems are not life threatening and can be handled by an NP. In truth, an internist and ENT both misdiagnosed by daughter’s cancer (the delay in treatment has caused a terrible spread which will be biopsied next week and a third operation may become a reality because of doctor error). A tech pulled me aside after viewing the ultrasound and told to get the hell away and find a new ENT. So the lesser surfs in the medical kingdom sometimes know more than the docs, because they become experts at one thing and learn to do it abundantly well without medical school.

      • Fam Med Doc

        the vast majority of our problems are not life threatening and can be handled by an NP

        You are wrong, Alice. If a “vast majority” of health problems could be handled by a NP, medical school & doctors would have phased out long, long ago. A vast majority of health problems CAN NOT be managed by a NP. The problem is you are not experienced enough in healthcare & the diagnoses & management of diseases and it’s complications to know this. Go to medical school. Then residency. You will be humbled, as I was, on the vastness & scope diseases can present & the difficulties in preventing & managing the complications of said diseases. The problem with people like you is you have some interfacing with the medical community & think you can generate a good opinion on how healthcare can be delivered. Please go to med school. Then you will agree. But I’m not concerned as I know most people want an MD & not a NP taking care of them.

        Everyone wants to be a doctor, but no one wants to go to medical school.

        • http://Www.twitter.com/alicearobertson Alice

          You have mislabeled patients claiming they want to be doctors. That is condescending. Informed patients still need doctors….I know I do. Good grief…my kid has cancer…I nearly worship those who care for her. I have a mass….and trust me I do NOT want to be a doctor. I just want a good doctor…one who values their patients input….I need their expertise…I desperately need good doctors…my daughter’s life depends on it.

          • Fam Med Doc

            Dear Alice,

            Ok, you admit “desperately need good doctors” yet you write “the vast majority of our problems are not life threatening and can be handled by an NP”.

            Um, I believe you are the one being condescending when you suggest most doctors are basically unnecessary. But please, I’ll certainly listen if you want to explain better.

          • http://natickpediatrics.net Rob Lindeman

            Fam med doc, I’m a primary care pedie, and most of the “problems” I see in the office can be handled by an individual with common sense and no medical training whatsoever. And I’m REALLY TRYING to keep non-problems out of my office!!! How much more so the folks who put everybody on the schedule! That doesn’t mean that docs aren’t necessary, just that we docs see a lot of stuff that doesn’t require a doc.

            FWIW, there is a glut of primary care pediatricians. In Eastern Mass., where I practice, there is one primary care pedie for roughly 750 children.

          • http://Www.twitter.com/alicearobertson Alice

            Um, I believe you are the one being condescending when you suggest most doctors are basically unnecessary. But please, I’ll certainly listen if you want to explain better.[end quote]

            Um…it is pretty self explanatory. The Minute Clinic thrives and is profitable not because of life threatening illnesses…because of anxiety. sports physicals, sick notes….you know the stuff most of your patients want. But you probably do more immunizations, dispensing blood pressure, cholesterol drugs, check ups. MinuteClinic is successful and that is not happening because they are helping cancer patientsn(I doubt you are treating many cancer paints). Most of what they treat is mundane…stuff the body would heal itself of, but we do not want to wait. Quite frankly….I am of the mindset that I stay away from doctors when at all possible. But I am an educated patient and know when to surrender and go. I do desperately need our specialists…maybe that’s a better clarification.

            Are you saying the majority of your patients would die if they chose not to see you?

          • Primary Care Internist

            “Um…it is pretty self explanatory. The Minute Clinic thrives and is profitable …”

            um, actually no – they are closing, some permamently and some seasonally. so much for “continuity” and a “convenient alternative to your doctor”.

            http://www.wa.regence.com/agent/communication/2009/feb/02252009MinuteClinics.html

            http://www.suite101.com/content/seasonal-closure-of-some-retail-health-clinics-a103109

          • http://Www.twitter.com/alicearobertson Alice

            Six are closing…could that be they were not getting the reimbursement you allude to? If they were they would be opening everywhere.

            So…you have nothing to worry about?

          • ninguem

            Alice – “Six are closing…could that be they were not getting the reimbursement you allude to? If they were they would be opening everywhere.”

            Read the link.
            http://www.suite101.com/content/seasonal-closure-of-some-retail-health-clinics-a103109

            SEASONAL closure. Sheesh, this gets even better. They just close up shop when it’s not profitable enough for them. And then the article author goes on to sing the praises of the retail clinics convenience, completely ignoring what they just finished writing……..convenient for the patient when it’s convenient…..and profitable…..for the retail clinic

            If I just decided I wanted to close up shop and turn off the phones, I’d have my head handed to me. But these ethical rules and responsibilities only work one way.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    “We are committed to the concept of the medical home.”
    Please….. Retail clinics are exactly what medical homes are not supposed to be, with the exception of open access.

    I don’t think physicians should embrace retail clinics. I think they should combat their only reason for existence by offering same day appointments, extended hours and weekend hours. Perhaps get a few practices together and have a virtual coverage agreement to spread the evening and weekend hours in a bearable fashion.

  • Catherine

    The problem is…for kids whose parents don’t have medical benefits (a lot of people) and can’t afford the crazy individual rates (most of the former), the option may be the retail clinic or NO clinic.

    Plus, daycares/schools now seem to require notes from a medical provider of some sort after EVERY illness. I feel so bad for all of the parents in our acute care clinic who have kids in daycare (and, thus, kids who get whatever virus is currently circulating) and have to come in all the time just for us to sign a damn note allowing the kid to go back to school/daycare. I have no idea how these parents get the time off work.

    • http://Www.twitter.com/alicearobertson Alice

      To add to this…it seems about 70 million people will now qualify for Medicaid….but with cuts a huge percentage of doctors will not take it. So the patient will go to the Minute Clinic. The huge hospital system I go to has set up urgent care clinics after hours. When I leave our surgeon’s office they are already signing in (I, purposefully, get the last appointment of the day…he spends a lot of time with you that way). They accept Medicaid, so the hours and type of payment agree with the patients.

      • ninguem

        You think the Minute Clinic is accepting Medicaid?

        You owe me a new screen.

        The Urgent Care will, indeed, see the patient after hours and accept Medicaid. They also charge twice what I charge in my office. Having worked in a neighboring Urgent Care, I’ve seen the fee schedule. They took my fee schedule and I swear just multiplied everything by two.

        Your hospital has an Urgent Care. Don’t you understand they’re charging hospital fees for that? Probably not. Still another Urgent Care in my area slapped on hospital facility fees, double my professional fee, pretty soon a suture removal was a couple hundred dollars. I know, I’ve seen the sticker shock when the patients see the bill, until finally the receptionist got tired of getting yelled at after the fact, so she warned the patients in advance. “Be warned your visit will cost about XX dollars” and she was being truthful.

        That got her fired.

        Been around long enough, did enough moonlighting in Urgent Care clinics while building up my independent practice. You want to talk about threatened? The hospital-based big box places are so threatened by independent practitioners that they hit their doctors with noncompetes, lest the doctor decide to set up independently anywhere near the place.

        That practice is considered the unethical practice of law in every state Bar association in the country. Doctors allow it. Or more to the point, the hospitals want it.

        The ethics only works one way. The primary care doctor hanging out a shingle is the evil money grubber. The people running these places provide no value, in fact they charge far more than I, their leadership makes millions, their doctors are not expected to provide after-hours coverage, and the independent doctor is the bad guy, especially when he refuses to clean up someone else’s mess. Been there, done that, asked to clean it up.

      • Fam Med Doc

        Nonsense Alice. People on Medicaid can’t afford the cash prices of these Quicky Clinics. They will go, for FREE, to the ER. These Quicky Clinics serve the middle class/upper class. The only place I have seen these these clinics is in the nice parts of the large urban city I live in. The poor parts of the city (I live in one of the largest cities in the US) don’t have any of these clinics. Remember, I’m talking bout these Quick Clinics in Rite-Aid, Walgreens etc that were the topic of this blog by Dr Benaroch, not some specific urgent care clinic set up by a hospital.

        • http://Www.twitter.com/alicearobertson Alice

          The quick clinics are not cash only….not nonsense. The government is in a financial bind…..they are seeking cost cutting avenues…this is one.

          In my state the Governor is hitting hard as many other conservatives are. The state cannot afford all the free lunch mentality. The expensive ER visits for non threatening stuff needs to end. The states need control and some will choose to cover quickie clinics.

      • Primary Care Internist

        besides minute clinics the other big scam, with regard to faking altruism, are federally subsidized health centers. they get medicaid rates even much higher than typical private insurance rates for a small solo MD office.

        I’ve heard something like $150 from MEDICAID for an office visit, so they can pay their executives double or triple what their docs make, all courtesy of the shrinking pool of US taxpayers.

  • Solomd

    I think it might be helpful to consider who is benefiting from this arrangement. While it is certainly appropriate to discuss scope of practice, I think we need to realize that the companies running these convenient clinics are clearly in it solely for the money. They employee cheap(er) labor to take care of minor medical problems, while avoiding the liability of comprehensive primary medical care. In essence, they are are skimming the cream of profitability, while boasting their business model augments primary care. I remember when these convenient clinics were getting started how they worked work to get AAFP’s endorsement, only to turn a deaf ear to AAFP’s concerns about scope of practice once they became profitable.

  • http://pediatricinsider.com Roy Benaroch, MD

    Catherine raises two good points:

    For parents without health insurance, rates at doc’s offices can be ridiculous– she’s right about this. For weird, distorted reasons, the “regular rates” at doc offices are way, way out of line high. It’s because of a game player with insurance companies. They “discount” so we raise our prices. It’s a stupid system that hurts the uninsured– I wrote about it a few years ago (http://pediatricinsider.wordpress.com/2008/07/19/the-amish-get-hosed/), and the topic probably deserves a full post here.

    The good news: many docs offer a very substantial discount to cash customers. Ask.

    RE: Daycares insisting on notes for every minor illness, I agree that’s stupid, too. Kids can certainly be sick enough to miss school but not sick enough to go to the doctor. I don’t need to see every cold and sniffle! Parents, if you’re looking at schools and daycares, ask about this kind of policy beforehand. It will cost you plenty, and won’t help keep your kids any healthier.

  • http://natickpediatrics.net Rob Lindeman

    Stepping outside the box for a moment:

    Why don’t we put docs in schools? (or NP’s? with apologies to my colleagues who become apoplectic at the suggestion)

    Schools already perform hearing and vision screens. Some do scoliosis checks, not to mention fitness tests (that no Pediatrician does as far as I know)

    One advantage that my collectivist colleagues will like is that the doc could be paid by the State. The child’s “medical home” could be his school.

    Another advantage is that no parent would be pulled from work to bring a not-so-sick kid to the doctor.

    If not, why not?

    • http://Www.twitter.com/alicearobertson Alice

      Your rhetoric is exactly where we are heading. Great question! Makes us think about what we really want. I do not think the government does anything particularly well. I have home schooled for over 22 years and pay for private classes and oodles of money for sports, and now medical. It is a very slippery slope getting government more involved in healthcare. Some doctors prefer government over insurance companies. I want the government out of my hair and prefer the regulated free market.

      I think as retail clinics pick up the lesser illnesses it will free doctors up for more of what they trained for. But as we get more government it will constrain doctors more than the competitive retail clinics. I prefer competition to more government because I firmly believe quality of care will go down.

      I think some do have a vision of the village school mentality with government at the realm and freedoms surrendered.

  • ninguem

    An entity the size of Wal-Mart or the national pharmacy chains could easily place a physician in one of their offices. They could put a whole Urgent Care in the place.

    They choose not to, and for a reason. They want just the profitable work. Anything that’s even the slightest bit difficult or time consuming, they want sent to the doctor because it’s not profitable. For them.

    Many states don’t allow doctors to dispense from their office. But it’s OK for a nurse-practitioner to prescribe the most profitable medicines for the pharmacy….at the suggestion, direct or indirect, of the pharmacy corporation.

    How about a Stark law prohibiting the pharmacy from filling the prescription written in their building. Tell the patient to go to a competing chain to fill the prescription. We’ll see how the pharmacy chains show their interest in patient care, when they close their in-house clinics in a New York minute..

    This isn’t about the doctor’s profits. It’s about Wal-Mart’s profits. It’s about Walgreen’s profits. It’s about Rite-Aid’s profits.

    • http://Www.twitter.com/alicearobertson Alice

      You are right it is about giving a type of lesser care cheaply. Why does that bother doctors? Money?

      I really do not see how this hurts a good doctor’s business….right now…but the government will look for cheaper ways to dispense non-critical care. These retail clinics are patient friendly. Doctors can learn from their customer care…and you can offer tons of stuff they cannot.

      Minute Clinic offers so little…they would not treat the infected, stray cat bite I had. Urgicare did that for cheaper than the ER would have and much cheaper…and kinder…the doctor was wonderful. I do not consider them in your realm, but consider them a great alternative.

      Alternatives in care by informed or desperate patients are a reality….I think doctors waste their time and energy fighting it. Good doctors have busy practices. It just seems to me…if you are offering the gourmet banquet you say you are you have nothing to worry about if patients want some tacos.

      • Solomd

        “Doctors can learn from their customer care…and you can offer tons of stuff they cannot.”

        There seems to be held an idea (maybe not necessarily yours) that change is happening and that doctors just need to accept it and embrace it. But, if patients want go to these places for the convenience factor, who should be available after hours when a problem or question arises with the treatment that was given? At 2:30am who should mom call if the amoxicillin given to her son by the nurse practitioner for the sore throat is now causing him to break out in an itchy rash? Who should mom talk with if she’s giving the amoxicillin but her son now has a fever and she wants to know how much Tylenol to give him? This gets back to my above post about skimming the cream. These clinics are run purely to make the easy money. They (the owners of the clinics) don’t care if there are complications or problems after hours, because they know the primary care doctor will take care of it. So, the peds or family doctor gets to take care of the problem, for free. I think this is something that the public doesn’t understand. Primary care doctors resent these places being able to take the easy stuff without having to provide follow-through and while passing off the liability. We resent these places pretending to provide needed quality medical care when they aren’t willing to provide continuity – not just on that particular problem, but the whole continuity upon which primary care is based. If you are going to do the things we do 24 hours a day, then you should be there. Maybe we doctors should “embrace” and “accept” that someone else has figured out how to make easy money while doing less than what we consider proper and complete care. Or, maybe these businesses need to come clean and make it clear that they only provide limited care during business hours and that someone else will have to address problems outside of business hours.

        I’m curious, does anyone know if these places offer phone advice during business hours? Will the nurse practitioner take calls about issues arising from a clinic visit (like mom forgot to ask during the visit how much Tylenol to give, or if the rash is from the amoxicillin)?

        • ninguem

          Of course they understand solo. They don’t care. They expect you will do it for free.

          Then they’re shocked when you say no.

          And YOU’RE the bad guy.

          “We should accept it”. The way a restaurant accepts it when you bring your own wine you bought from the liquor store down the street. The way a theater accepts you bringing your own popcorn.

          If they get an amoxicillin rash or a reaction to the flu shot, they don’t go back to the retail clinic, they call you after hours.

          The contractor didn’t install an electrical outlet right when they put up my office. Let me get the competing contractor to fix the competitor’s mistake.

          The ethics only works one way. You’re the evil money grubbing profiteer.

          Wal-Mart is there to serve humanity.

      • ninguem

        Pharmacist makes the profit from lipid testing. Then the patient, correctly, wants to know what to DO about the findings.

        “Call your doctor”.

        So then the pharmacy faxes the results, which I have to file, with that much more overhead added to my office. Patients have actually had the audacity to want me to manage this over the phone.

        Now heck, there are practices that will do that sort of thing. They require their patients to pay annual subscription fees, the Qliance-type or MDVIP-type practices.

        Then the doctors get their ethics questioned for doing that.

        Patient comes to my office, I’ll run the tests again. The real insulting part is I can do the same test for the same price, actually cheaper. Same with the flu shots and the other things they do at these retail clinics.

        You bring a bottle of wine into a restaurant, because it’s cheaper than the restaurant price. You will either get shown the door, or get charged a stiff corkage fee. You bring a bag of popcorn into a movie theatre because you can pop it far cheaper at home, you most certainly will be shown the door.

        And my popcorn and wine is the same price as home-popped corn or wine from the wine store. Still, they buy it elsewhere and ask me to clean up the popcorn crumbs, pop the wine cork, pour the glasses, clean up for them, and dispose of the empty bottle. Oh, and pay the liquor license.

        No, these ethics concerns only go one way. Nobody else on the planet is concerned about making money. It’s really tough being Simon Legree among the chain pharmacies, all run by Mother Teresa.

  • ninguem

    Point of fact, they are NOT cheaper than my office. I see the price list of their office versus my office. Actually, sometimes I’m cheaper.

    So they do virtually nothing and they overcharge for it. Why? Profits……for the chain pharmacies that all but employ the nurses in the place.

    Of course, they can handle the cat bite. It’s not profitable for them to handle the cat bite. Only handle patients who are not ill, for conditions that will require a drug or other medical device that can be sold profitably by the pharmacy. Physician self-referral is limited. How about the opposite? Prohibit the pharmacy from dispensing the drug prescribed by their resident midlevel. See how fast the pharmacies would close the clinics.

    But it’s only the doctors who are motivated by money.

    On this site we have heard from pharmacists who question the ethics of physicians who dispense from their office. But the reverse is OK.

    You keep parroting the same line, moneymoneymoney. They’re the ones who are money-grubbing.

    Am I fighting it? I’m just stating facts.

  • http://Www.twitter.com/alicearobertson Alice

    Ninquem…..if what you say is true you have no problem. You are educated…affordable….and if you are affiable you have no worries…patients will line up for you. I consider myself the average patient…and we just can’t figure out what the whining is about. If it is not money…it certainly isn’t that patients are being poorly treated. From the viewpoint we are at it seems as if you are fearful of losing business and feel there is an unfair advatantage. I think doctor’s families get better treatment that the average patient. So what? That is not going to change no matter how many hussy fits I pull.

    And let me add my doctor does not return calls at 2 am as someone else suggested. Their answering service tells you to go to the ER, or call them in the morning. Now our surgeon will answer email at night. When we found more swollen lymphs recently he had them biopsed within 18 hours, and called me the next day with results. He is splendid and I hope his patent makes him a millionaire.

    • Fam Med Doc

      Alice,

      FYI: Pediatricians are one of the LOWEST paid specialties in the US. In a large city, they might make about $140,000 (docs, please correct me if I’m wrong). This is not in the rural setting. These McQuick Clinics are only in the more affluent parts of town and yes, are taking away much needed revenue from Pediatricians. And giving substandard care. I’m shocked & saddened at the low pay of my Peds collegues. These McClinics are pathetic.

      • http://Www.twitter.com/alicearobertson Alice

        No, we have two types…Minute Clinic with CVS…and Walgreens. The Walgreens clinic gives free care if you bring in something showing you are unemployed. They are in a poor area. I have not visited that one yet..it is far away. But UrgentCare Clinics run by doctors are everywhere. You do not mind them?

        • Fam Med Doc

          1) I have concerns about mid-level providers giving care in the primary care setting
          2) I have concerns and frustration at mid-levels & these Quicki-Clinics (please see all the above comments posted by all the physicians)
          3) I do NOT mind Urgent Care care clinics. Their scope of practice is significantly greater than these ridiculous Quicki-Clinics. BUT I want an MD, not an NP or PA seeing the patients. They are too dangerous-they don’t know what they don’t know.

  • http://Www.twitter.com/alicearobertson Alice

    The NP at the Minute Clinic does answer phone calls and will tell you the wait time, or answer quick questions. But…I do not know if that is protocol or kindness. They train medical assistants there. Some hospitals are phasing out LPN’s.

    The average office visit around here is between $200-400 and up. I go to Minute Clinic for $70. But the last time it was $139 because of flu tests added on.

    If you read Weekly Standard this week there is an article about cash for doctors. A doctor who sells start up kits for retail shops like Minute Clinic for $3500 each. It is the future. This doctor is quite the business.

    Now one wants to ask….are the clinics run by doctors alright or is it the concept?

    • ninguem

      “The average office visit around here is between $200-400 and up. I go to Minute Clinic for $70. But the last time it was $139 because of flu tests added on.”

      If you go to an independent FP office with one straightforward problem, don’t lay on a whole bunch of “oh by the way” side matters that the NP in the retail clinic wouldn’t address anyway, pay cash, don’t involve insurance, that’s what you will pay in an independent FP office.

      Not a big box place where the hospital adds facility fees and urgent care/emergency fees. That’s not just me, I can think of half a dozen independent FP’s in my area who would do the same thing.

      You will NOT get that deal at the big box places. They have to pay for all those billboards and full-page newspaper ads.

      In fact, if it really was just a “flu test”, that seventy dollar markup is excessive. I assume other tests were done.

      $139 in my area for an office visit for a flu-like illness is no bargain. You’d get the same thing in my office, the same evaluation by a real physician instead of a nurse practitioner. Probably cheaper. In fact, I’d have a hard time getting that payment from many private insurances, and definitely would NOT get that much from Medicare and sure as heck not Medicaid.

      My office gets inspected, I have to have the handicapped access, the bathrooms, plumbing in the office, there are retail clinics in my area with no sinks, hand wash dispensers, and you use the store’s restroom. I’ve seen them. You pay the same price as my office, many times less.

      • http://Www.twitter.com/alicearobertson Alice

        If you need to pay cash as I do for this current treatment you cannot get discounts. With little competition in my area an office visit can be really expensive. One visit was billed at almost $700 for under five minutes. When my insurance pays I think the reimbursal is about $100? So, insurers like Minute Clinic….I imagine the government will to.

        I am not a supporter of this administration’s healthcare bill…but the President did a great job sharing how Americans love government programs but hate higher taxes and cuts. We just can’t have it all….but people are going to capitalize on the needs and regulations.

        • ninguem

          Are you saying insurance reimburses for the Minute Clinic visit?

          • http://Www.twitter.com/alicearobertson Alice

            Yes, just about everyone goes in with an insurance card. Before you enter there is a keyboard and monitor…. the patient types info into…it tells how many are in front of you. Stores your info for all future visits and the NP takes your charge card and swipes it if you owe. Somehow she can pull up your prescription list too. I know IT at Cleveland Clinic is hooking up their patient database with Minute Clinic. I was told Minute Clinic uses information from my insurer to get medical information about the patient? Patients must be signing away rights in our electronic agreement we rarely take the time to read for fear we are holding others up?

            But they are basically…boo boo care. Some things are not covered. Like sport’s physicals…I think I paid $35 each for that? I have no idea what insurance companies are reimbursing though. My insurance only jumped on the bandwagon recently. Next time I go I will watch and see what is reimbursable. I am, obviously, drowning in medical bills.

          • Fam Med Doc

            Ninguem,

            Stop. I’m not involving myself in this dialogue anymore. I feel like im wasting my time. You should stop too. A number of doctors have stated quite well why these Quicky Clinics are dangerous & a bad idea. But, as the commenting stream has shown on this post, no matter how eloquently you give the facts to an argument some people have their minds made up. But I have read this Quicki Clinics were struggling too so I’m not surprised of the problems some are having. But I have read your comments ninguem & they are excellent (as usual), but some people will never learn. Even Dr Rob Lindeman who has his mind made up on my comment that NP’s can’t & shouldn’t be delivering primary care (Mcquicky Clinic or primary care, NP’s are bad ideas in primary care). But then again he is biased- instead of employing another Pediatrician, he has working for his clinic a NP. So of course he thinks NPs are great. He has a financial vested interest. Instead of paying a doctor salary, he gets to pay less to a NP.

          • ninguem

            Wonderful. So they charge the same as me for boo-boo care. I get inspected by the insurances for handicapped access, rails in the bathrooms, square footage of the office, my 24/7 access, and the retail clinics get to send the patient to the store bathroom, use hand sanitizers in the rooms in lieu of sinks, and turn their after-hours calls to me.

            Three side problems will be brought up and I’ll be asked about the specialty care received at the Cleveland Clinic for that same $135 flu……if I even get that much.

            “Like sport’s physicals…I think I paid $35 each for that?”
            Same as my office, to the penny. Oh, and there goes any opportunity to do any adolescent counseling in the office. Forget about the meningococcus and HPV vaccines.

            No, I agree, it’s a great business model. Charge the same as a physician for everything easy and leave the doctor holding the bag for anything time-consuming and medicolegally risky. Or for that matter, building something resembling an office, with sinks and toilets.

        • ninguem

          And now you mention the seven hundred dollar five minute visit. I see now, you mention the Cleveland Clinic. I trained there. So I take it we’re comparing the $100 Minute Clinic visit with the Cleveland Clinic?

          Yes, I’m sure they do charge seven hundred dollars for that office visit. You’d be able to get prices like the Minute Clinic in an independent FP office, though I suspect the 800-lb gorilla clinical entities in the area are doing their best to drive independent docs out of business. Obama will drive out the rest.

          • http://Www.twitter.com/alicearobertson Alice

            Ninquem….you are reasonable….but too assumptive. The $700 visit was to get a lab result from a specialist who refuses to discuss results on the phone…will not use MyChart, then did not read the lab notes and wrecked havoc by a delay in treatment.

            I am currently on hold for ten minutes trying to get an appointment with my husband’s internist. We have little chance of an appointment for his swollen cheek. Minute Clinic here we come! Just found out they recommend seeing the NP who runs their urgent care after hours care. They reassured me she can prescribe, etc.

  • http://www.epmonthly.com/whitecoat WhiteCoat

    I proposed a solution to this issue a long time ago. Some thought it was tongue-in-cheek, but I was serious.

    Do away with medical licensing and let anyone who wants to practice medicine hang out a shingle and do so. That would force consumers of medical care to research the background of the medical provider and weigh the medical provider’s bona fides against the cost of seeing the medical provider and the speed with which the medical provider is available to provide care.

    Want to see Lucy on the Peanuts for psychiatric care and pay only 5 cents? She’ll see you today. Want to pay a high school senior 5 bucks to evaluate your nasal congestion? Appointments available after school. Want to pay the NP or pharmacy $50 to get your prescription for antibiotics for runny nose, sore throat, or cough to increase your chance of becoming one of the 1.7 million people to be infected with MRSA each year or one of the 36,000 patients every year who die from MRSA or other drug-resistant infection. Go for it. Just saw a patient last week who was bitten by a dog in the arm. Clinic sewed up the bite wounds and then prescribed Zithromax which doesn’t cover the organisms commonly found in dog bites. Kid had a huge cellulitis/abscess in the arm. Pus squirted out when I removed the sutures.

    None of this harms my business in the emergency department. When patients develop fasciitis, overwhelming sepsis or cholera-like symptoms from Clostridium difficile, the Z-pack won’t help them and they’ll either come see me to be hospitalized or they’ll be buried. All the money they saved at the clinic will go to much more expensive treatment and hospital bills.

    I agree with the author that these clinics fragment care. I also agree that I have seen multiple instances where the care at these clinics is substandard. Antibiotic prescriptions seem to be the norm and in many cases, they are unwarranted. That being said, I have also seen substandard care from physicians’ offices – although in my anecdotal experience I have seen more of the former than the latter.

    I also agree with commenters that there is a conflict of interest with pediatricians and these clinics. If pediatricians want more patients, the make yourself more available or extend your hours.

    The quality of care issue will settle out eventually – once more data is in.

    • Primary Care Internist

      “If pediatricians want more patients, the make yourself more available or extend your hours”

      but pediatricians DON’T want more patients, they’re already working as hard as they can. they just want (and NEED) better pay per patient.

    • gzuckier

      how about taking another look at some of the prescription drugs? is there really a big danger of over the counter high powered diaper rash creme? don’t forget, doctoring didn’t take off as a respectable profession until they got the keys to the drug cabinet.

  • http://Www.twitter.com/alicearobertson Alice

    What do you think about this doctor’s franchise? It is popular with patients, doctors (who see this wave and are either going to sink or swim…some want to capitalize on the trend), and employers. A snippet below…I am not endorsing it…but it is an option that works for some:

    Now, nearly a year later, Forrest says he’s more sure than ever that his business model makes sense. He’s planning to franchise his practice, with six similar doctors’ offices scheduled to open in North and South Carolina this summer, and plans to open others as far north as Baltimore and as far west as Indiana.

    He’s obviously seeing interest from patients. But he’s finding a groundswell of interest from other quarters, too, including from doctors who want to emulate his practice, employers who are looking for less-expensive alternatives to traditional insurance, and even from insurance companies. “I think we’re going to see this model explode,” he says.

    Skeptics say Forrest’s approach—known as “subscription-based” or “direct pay”—wouldn’t work everywhere, and it’s not for every medical practice. A lot of existing practices don’t want to dump insurance cold turkey with no guarantee of success, says Jeffrey J. Denning, a practice management consultant in La Jolla, Calif. “We run into a lot of physicians who are interested in it,” Denning says, “and want to know how to go about it, because they’re angry with what insurance companies are doing to them. They say, ‘How can I get out of the insurance business?’ ”

    Rest of article at Weekly Standard, with comments.

  • http://Www.twitter.com/alicearobertson Alice

    Most people know I am conservative….not Republican…but I do tend to support some of their vision. What if Ryan’s budgetary resolve to go with “premium support” goes through? Vouchers? In eleven years that could be a reality. It will become a medical price war? Does the future of medicine depend on the next election?

  • gzuckier

    I’m not too averse to using them for routine vaccinations. I’m aware of what vaccinations are needed or not, the convenience compared to an office visit is staggering, and frankly, I think the MD has a lot better things to do than routine vaccinations.

  • Angela Caffaratti, MD

    Vicky, I doubt you work in a retail clinic.

    I’ve seen some good care and bad care from retail clinics. Patients seem to know what to expect. When it doesn’t make sense or get better quick, they realize they didn’t seek the best care and go to a doctor. That is okay. I also suspect doctors would care less if we were paid commiserate to both our expertise and our overhead costs. The cherry- picked cases are just easier money than more complicated care. If we were paid to work together, we might even be glad they are seeing sore throats, but physicals should be done by pcps or nurses in pcp practice.

    • Vicky Stone-Gale

      I do work in Retail on a prn basis but in a Family Practice setting full time for 19 years. The HEDIS scores in our retail clinic are in the 97% region. We are proud of those scores. As noted in some of the blogs above–we DO NOT give antibiotics for a sore throat unless there is a positive strep, we DO NOT give antibiotics for Bronchitis, URIs, viruses etc. That is how our scores are so high. Our clinics are very cognizant to the resistance of these meds. When my patients in the FP office come in for follow up after an ER visit they are ALWAYS on antibotics from the ER docs for the above. They require constant continuing education and updates on new meds, treatment etc.

      Also Dr. Benorach asked me about experienced vs unexperienced NPs in the retail clinics. The retail clinic I work for uses experienced and highly seasoned NP’s and the pay is very well. Much more than I could make in a hospital setting and even more than I make in primary care. I chose to stay because I have patients that I have been seeing for 19 years and I can’t let them go.

  • http://innovatorsprescription.com Jason Hwang

    I have written often about retail clinics representing a classic disruptive innovation in health care delivery. Yet I’ve never argued that retail clinics should be replacing clinics, nor that nurses should be the equivalent of doctors. Simply that nurses can do some basic things just as well — if not better (and there’s ample evidence to support this) — and cheaper; and if it can be done in a convenient setting, it just makes sense. I don’t discount the need to have qualified primary care providers coordinating care across the life spectrum, and, in fact, my hope is that disruptive innovations like retail clinics and self-care can give those providers even more time to focus on longitudinal, wellness and prevention care. And other than the broken information systems that permeate health care, there’s no opposition from the retail clinic end to allow information to flow into the pediatrician’s office; in fact, retail clinics have pushed very hard for this linkage into the medical home. But will it ever happen if physician and hospital leaders continue to rail against retail clinics and view that care as inferior and somehow separate from the rest of the health care system?

    • pj

      I keep trying to find a way to point this out without demeaning laypeople or sounding arrogant, but- deep breath, here goes… the avg. american just is not sophisticated enough to pick the right setting for healthcare. Why do so many folks show up at a family Doc’s ofc in the midst of a stroke or MI (even after being advised when they called said ofc, go to the ER)? Why do so many go to the ER with obviously trivial complaints? Why do so few seem to know the diff. between an MD and DO, or a doc vs. a PA or NP?

      That’s why I fear for “market driven” or market based healthcare as our national goal. Far too many citizens have no idea how to assess the market, much less make rational choices about where to seek care.

      • http://Www.twitter.com/alicearobertson Alice

        I think we go where or insurance our government will pay. Medicaid encourages ER abuse because they do not have co-pays attached, while my insurance has a $100 co pay attached and if it is deemed a non-life threatening event I pay the whole bill. So…unless I think it is going to kill one of us we wait on the doctor, or as I shared go to Minute Clinic.

        It may not be our lack of discernment as much as it is our inability to pay out-of-pocket what many on government payments are allowed to abuse because there is no accountability for anything from personal health choices to using up valuable resources on mundane issues I think should be mandatory they use a retail clinic or urgent care center for. Why should we finance irresponsibility under a humanitarian guise. No one wins in a game played with biased rules that ultimately serve no one well. The result? This abuse will cause a catastrophic government smack down that will trickle down to hurt doctors and patients who played by the rules.

      • Fam Med Doc

        Well said PJ. I completely agree.

        The same can be said towards NP’s & PA’s- the lay public is simply not aware of their significant gap in education & training compared to primary care doctors. For that matter, even the NP’s & PA’s don’t recognize their own limitations. A market driven healthcare policy has it’s downside. Just read some of the comments by the NP’s who commented on this topic: very defensive & self impressed with themselves. To the detriment of the patient.

        • http://myheartsisters.org Carolyn Thomas

          “…comments by the NP’s who commented on this topic: very defensive & self impressed with themselves…”

          Not like all the defensive and ‘self-impressed with themselves’ comments from the docs, right?

          Doesn’t this (endless) discussion seem eerily similar to the way many doctors slammed midwifery for the very same “inferior care” reasons in the early days? See comment #24…