Retail Health Clinics- Commentary

As published in the Providence Journal June 18, 2014:

CVS Minute Clinic has applied to the Rhode Island Department of Health once again for a license to operate a retail health clinic (RHC) in Rhode Island, bringing home a national trend in this model of care. RHC arose in the early 2000’s and has grown to over 1600 clinics currently in operation in 42 states. In a recent study by Accenture it is projected that retail clinics will double in the next three years to over 2800.

Weekday evening and weekend visits account for nearly half of retail clinic visits. No appointments are needed and paperwork is minimal for patients. The wait times tend to be under 30 minutes.  RHC primarily service a population age of 18-44 years, patients pay out of pocket and many do not have a primary care physician. They tend to be located in areas of higher income. Repeat visitors tend to be adults who lack health insurance or have unknown insurance status. RHC claim to refer patients to a more appropriate setting such as a primary care office or emergency room if the problem is out of scope of practice. However, only 10 percent of retail visits result in a referral to those locations.

Patients consistently site convenience, short wait times and access as the main reason they visit a RHC. A 2013 survey by the Kaiser Family Foundation and the Health Research and Educational Trust found 56 percent of employers offer health benefits that cover retail health clinic services and many offer financial incentive to visit RHC over primary care offices.

The primary concern from the physician community is the quality, continuity of care and impact on their practices. There are claims that RHC are disruptive to the primary care relationship, especially in light of the expanding model of the Patient Centered Medical Home (PCMH) which provides comprehensive, accessible, longitudinal, quality and lower cost care to patients. There are concerns about missed opportunities for early diagnosis of more complex medical problems, fragmentation of care, missed opportunities for prevention and continuity of care during off hours.  Some states (Massachusetts, Florida, New Hampshire and Texas) have laws that limit the scope of practice, define clinical guidelines, regulate record keeping, physician supervision, referrals and limit repeat visits.

Various organizations (American College of Physicians, American Academy of Family Practice, American Academy of Pediatrics (AAP) and the American Medical Association) have policy around RHC. The AAP is opposed to RHC for pediatric patients. The other organizations have the following common principles:

  • RHC should have a well defined and limited scope of clinical services and be consistent with state scope of practice laws.
  • RHC should have arrangements for health care professionals to have direct access to and supervision by physicians.
  • RHC should have standardized medical protocols based on evidenced based guidelines.
  • RHC should have an electronic record that is shared with the patient’s primary care physician/PCMH.
  • RHC should have a referral system to physician practices for problems beyond the scope of practice and to establish continuity of care.
  • RHC should provide continuous coverage for patients during off hours if they have not been referred to primary care physicians for further care.
  • RHC should not manage chronic medical conditions such as heart disease, hypertension, diabetes, asthma and others.
  • RHC should clearly inform patients in advance of the qualifications of the practitioners and the limitation on types of illness that can be diagnosed and treated.

RHC has been a growing model of care over a decade. They provide convenience and access to care at potentially lower costs to patients and the health care system. They are also a model with potential for fragmentation of care, missed opportunities for early diagnosis of more complex medical problems and lack provisions for continuous team based, comprehensive care. In our free enterprise medical industrial complex it is difficult to argue about their existence, but we can argue for the institution of the above principles to protect the health of our patients.

Nitin S. Damle MD FACP practices general internal medicine in a PCMH in Wakefield RI, past president of the Rhode Medical Society, past president of the South County Hospital Medical Staff, past Governor and current Regent of the American College of Physicians.

 

 

South County Internal Medicine
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