Chronic care at Walgreens: Should we see how this plays out?

Walgreens, the country’s largest drugstore chain, announced that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The nurse practitioners (NPs) and physician assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.

A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in accountable care organizations, according to reporting by Forbes’ Bruce Japsen (though it’s not clear how the retailer would share the financial risk or savings in such a model).

But the Walgreens announcement was met with skepticism by physician groups like the American Association of Family Physicians (which has responded defensively in the past to non-physicians’ growing roles as primary care providers). And there are certainly causes for concern, at least based on what we know so far: Such expanded clinics exacerbate the fragmentation in our already piecemeal system. Providers at retail store clinics don’t have access to patients’ medical records, so they might repeat prior efforts or miss key details in caring for these patients.

Per standards set by the American Medical Association, retail clinic providers must establish continuity of care with a patient’s primary care doctor if he has one – this usually takes the form of a faxed note, which can’t compare to real-time communication within an integrated network. Providers at retail clinics are obliged to adhere to rigid protocols for evaluating and treating medical issues, but good chronic care management is customized to a patient’s particular lifestyle and needs. In short, chronic care, more so than one-off medical treatment, is best delivered with consistency by a coordinated team of providers (including NPs and PAs but also primary care doctors and specialists) who have gotten to know the patient over time and have built a relationship of trust.

The idea just might work if established health care systems with specialty providers forge meaningful partnerships with retail clinics – for example, with shared access to electronic health records and staff members who move between settings. If, in other words, the retail clinics are true extensions of the primary care home. It’s hard to say if a retail clinic could or would want to meet these criteria.

While those of us working in more traditional health care settings may have legitimate reservations about how Walgreens-brand chronic care will be delivered, we have to acknowledge that it addresses a need that we are not fulfilling. Walgreens made a savvy business move by targeting a growing population of aging Americans with diabetes and cardiovascular disease and offering services that are truly important and underused.

We can and should learn from how their experiment plays out: Who will opt for this care? Will Americans use it as a stopgap between visits with their primary care doctor or only when they don’t have one to begin with (according to the Salt Lake Tribune, nearly half of current Take Care users don’t have access to one)? Will they come back a second time? What will they like about it? Which locations and hours will be most popular? Will the appeal of cheaper care (compared to paying out of pocket) fade as more Americans are folded into insurance plans? If we can better understand how these nontraditional clinics address gaps in the system, we can work with retail clinic providers more effectively and fill those gaps with truly coordinated chronic care.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared. 

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  • Peter Elias

    “Providers at retail clinics are obliged to adhere to rigid protocols for evaluating and treating medical issues, but good chronic care management is customized to a patient’s particular lifestyle and needs. In short, chronic care, more so than one-off medical treatment, is best delivered with consistency by a coordinated team of providers (including NPs and PAs but also primary care doctors and specialists) who have gotten to know the patient over time and have built a relationship of trust.”

    I understand and largely agree with the point, but I think it fails to acknowledge that the current (mis)understanding and (mis)use of EBM, metrics and standardization, so popular among payors and institutions, is rapidly eliminating the gap that should exist between industrialized recipe-driven care and the care delivered to individuals by individuals. As we are incresingly forced to deliver institution-centric care, we will deliver less and less patient-centric care.

  • ninguem

    The asthmatics can pick their cigarettes on the way out, and the diabetics can pick up their Mountain Dew.

    One-stop shopping.

  • querywoman

    Plan to research in the next few hours what percentage of American doctors are in the AMA. Last I heard it was less than half! What’s the current annual fee to be in the AMA? Over $1000?
    AMA guidelines don’t interest me!

    • ninguem

      WAY less than half.

      It was less than half 30 years ago, and continues to drop.

      • querywoman

        I wouldn’t pay to be a member! When I check my own doctors, I always feel the ones who don’t join are smart! I do have some doctors who are politically and socially active for their type of patients who are AMA members, and I understand it in their case.
        If you are just running a local practice and not interesting in making national impact, it’s a stupid expense!
        Any local or state government entity is more helpful in most causes, anyway! They are right there with us!
        Knowing our city and county reps, being in their offices, etc., will impact our lives more than writing our governor or president!

        A medical license is a STATE license! The AMA was or is a private union for its members!

        • doc99

          Small but important factual point – AMA is not a union.

          • querywoman

            Word quibbling example: it’s illegal for teachers in Texas to have a union. They have an “association.”
            The internet is making a lot of these groups obsolete anyway.. It’s giving little people a voice with posting, Those of us who post on KevinMD have an “association.”
            It’s so easy to exchange and get info on the net without relying on big groups anyway.

          • LeoHolmMD

            Correct. It is a shill group for whoever the current administration is, or whoever pays them. Read JAMA. Every issue pushes the federal agenda of the moment. At least unions attempt to represent the people who belong to them, and have some dignity.

          • querywoman

            Existing labor unions take membership dues and barely represent their members anymore! State labor laws offer more labor protection!

          • querywoman

            The AMA has functioned like a union. It seems that, like most unions, the most important people it protects are its top officers.
            Labor unions used to represent the little person! I was in a traditional union with a phone company in the later 1970s. All I saw was older white men who wanted to protect their own incomes and retirement.
            People said I would be glad to have the retirement money. In the ensuing years, many retirement funds have been squandered. Life has gone downhill for the average worker in their prime years. There’s no such thing as job security. Unions have lost clout and membership, partly due to not courting minorities and women.
            Job growth is now for cashiers and home health aides.
            Did the AMA ever really represent the average doctor? I don’t know that much about it! It obviously didn’t do anything about the ever increasing debt for medical students.

        • Suzi Q 38

          Why should doctors pay NOT to be represented in the manner to which they need to be represented? PCP’s are not paid near as much as specialists. My PCP must love his work.

          • querywoman

            Suzi Q, they are choosing not to pay to be in the AMA. What’s your point?

          • Suzi Q 38

            My point is that I agree with you.
            I don’t think that the AMA has been a good advocate for PCP physicians. I think that they need to be paid more. It is my understanding (maybe I am wrong) that the specialists get paid at least double or sometimes triple of what a PCP makes.
            I see this in my billing, as far as what the insurance will pay my specialists vs. my PCP.
            Hence, if you were a PCP, why would you contribute $$$ to the AMA?

    • doc99

      Estimates of membership by physicians in private practice – excluding Academics and Housestaff – range from 9 – 15%.

      • querywoman

        Doc99, really insignificant percentage now! checked after posting. I think full membership was over $400 annually. Did it used to cost more?

    • Noni

      i know no one in my large physician group who is in the AMA. Does any physician really feel he AMA represents their interests? Why would I blow !k on dues annually for some crappy political group that doesn’t represent the interests of the physicians out there in the trenches?

      • querywoman

        I wouldn’t blow my money on AMA membership.
        The AMA is currently a national joke. Like I said, a few of my doctors who are making “statements” about what they treat are in it.
        For those of you who are embroiled in debt, the staggering loan debt of medical graduates is a recent phenomenon. I suppose when the medical students began graduating with high levels of debt, they didn’t want to join the AMA.
        The AMA probably started losing power then, and nonjoining became the norm!
        Did the AMA used to send you info, etc., via postal mail to keep you update? You don’t need that stuff anymore with the internet, and blogs like these. We don’t need the post office that much anymore.

  • querywoman

    I don’t care what the AMA says. As for their suggestion that you notify your own PCP of a doc-in-a-pharmacy visit, we’ve had doc-in-the-boxes to visit for years.
    In my experience, most doctors don’t care that we went to other doctors. Very few even want medical records.
    If you go to another doctor, just show them whatever med you got.

  • querywoman

    The internet is a great equalizer! The net gives power to the individual, so we don’t need big groups for clout as much anymore.

  • Tom

    If your normal doctor’s office, where you used to have a primary doctor and got to establish a relationship with him or her, is going to morph into a “Patient Centered Medical Home” where you’re going to be shunted around to random midlevels every time you go in and never get to establish a relationship with one primary provider anyway, there’s no reason not to switch to a Walgreens or CVS.

    As I just commented on another post (which was singing the praises of so-called “Patient”-Centered Medical Homes). “If I wanted medical care from miscellaneous providers I have no say in choosing, and where no-one actually knows me and I’d have to repeat my whole story to a new provider every time, I’d just go to a Doc-in-the-Box or those new Walgreens thingies they’re setting up. If I want anonymous care from random midlevels, I don’t need a proper doctor’s office for that.”

    When traditional doctors offices lower their standards to Walgreens-level, don’t be surprised that given the choice, people figure out that they might as well go to Walgreens.

    • ninguem

      All this talk…..empty talk……about wanting to create a “Patient-Centered Medical Home”……and then everyone does their best to BREAK UP that “home”, leaving the doctor to clean up the mess.

      Walgreen’s will only do those parts of medicine that are highly profitable to them, and carry the least medicolegal risk.

      • Tom

        If “Patient Centered Medical Homes” are pay-for-performance-rating kind of places, THEY won’t want complex patients either. Everyone will be cherry picking the young, the healthy, the fit, the compliant, the middle class and well-to-do. The system is disincentivizing medicos from caring for the people who would probably most benefit from a one on one relationship with a primary care physician.

        I’m sorry to sound so ornery, I’m just upset that the whole system seems seems to be going in the wrong direction, just when I had hope that we had someone as President who really cared and was going to put it right. And it’s not getting better, and not even staying the same, but getting worse.

        • Cyndee Malowitz

          I used to work for physicians who cherry picked their patients all the time. Amazing, all that education and for what? You would hope they would want to be challenged.

          • kjindal

            You should ready”freakonomics”- an essential illustrator that EVERYTHING and EVERYONE are primarily influenced by INCENTIVES (not necessarily financial)

  • LeoHolmMD

    Oh, does the AMA have standards they can reinforce? Thats news to me. Perhaps they can have specialists I refer to send me notes without having to repeatedly fax requests for them.

  • D N Block MD, PhD

    Under what conditions might retail establishment care work?

    Well, first would be just as you, Dr Ganguli, post: “if established health care systems with specialty providers forge meaningful partnerships with retail clinics….” It sounds like you envision a technology-based system, since the first thing you point out is an electronic health record. Technology is easy to buy and easy to set up (relatively). It’s hard as hell to get folks to use it, of course, but it makes everybody feel good because it gives people something to point to: a new terminal, a phone app, etc. Just something we can feel awed by because most of us can’t do it, and comfortable with because most of us can use something like it like, maybe, for medical social networking. But, OK, I see the point.

    The second condition is harder: humans who claim to be ‘professionals’ would have to talk to humans who claim to be ‘professionals.’ Nothing snide intended. You have issues of status, clearly, but also of cognitive certainty, autonomy, relationships within and among groups, and fairness. (Mediators recognize these as SCARF-issues by which we humans set our agendas and priorities.) Dr Holm alludes to something like this: he can’t get a consultant to send him back a simple note. (So: consultants are boorish snots; Holm has to provide care without certainty; his autonomy is threatened; there clearly is a lack of relationship; and, how the hell is this all fair?) Matching data bases is easy. Will an RNP at Walgreen’s pick up the phone and tell you, Ganguli, that ‘your’ patient is there and this is what’s been done? (IS there such a thing as a “YOUR PATIENT” any longer?) Will you answer the phone or plead the “doctor is SO busy” excuse? This is not simply “why can’t we all just get along?” This is, can we all be engaged in the success of each? I’m betting, after retirement as a doc, health care consultant, mediator, and a patient, that the answer is: No. Pity.

    Which leads to the 3rd condition: ‘the people who are sick’ have to be let in on this new style and what it means by ‘the people who provide care’ and by ‘the people who pay for the care that THEY deem to be appropriate.’ Tell me, please, very simply: what is each person’s mission and what is each person’s vision? Is your mission to sell a fungible commodity (if we can agree what ‘fungible’ means and what the ‘commodity’ actually is)? Is your mission to provide quantifiable results-per-dollar-cost according to some Platonically defined metric? (Let us have ‘good quality’ or ‘conscious seconds off a ventilator’ or ‘fewer coughs per minute.’ After all, you can’t manage what you can’t measure, and if that works for factories, why shouldn’t it work for doctors and patients? “Just do the math….”) Somebody is going to have to teach patients what to expect, the poor little dears. After all, isn’t that what consumer-education is? But won’t somebody have to educate the providers about realistic expectations, and payers and Systems Overlords as well? (I have residual bitterness, I see.)

    Don’t any of us think this is bloody odd? “Underused care”? That’s BS for lousy patient-doctor engagement and even lousier education: both from the patient AND the doctor. An “idea [that] just might work”? That’s a prayer from a stochastic modeler (which, I guess, we all are) and an awfully weak hypothesis.

    Why not just ask a sick person, “why the hell are you going to Walgreen’s?” Or ask doctors, “what the hell are you going to do about it?” Or ask those MBA’s to whom we have ceded the show, “who the hell are YOU?”

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